Acute Appendicitis Overview (for an intern at 2:00 am)

 Pathophysiology:

  • Etiology: fecalith obstructing lumen (more common in adults) or lymphatic tissue blocking lumen (kids)
  • Appendix distends as bacteria proliferate

Patient presentation:
  • RLQ pain that begins periumbilical and migrates toward the ASIS. 
    • McBurney's point will have tenderness to deep palpation. It is 2/3rds between umbilicus and ASIS.
  • Anorexia is a key feature in the patient's history. If no anorexia, then it is less likely to be appendicitis. 
  • Diffuse peritonitis indicates perforation. 
  • Fever
  • Nausea/vomiting
    • vomiting → dehydration → increased BUN:Cr ratio

What other signs on exam can point to appendicitis?
  • Roving sign: tenderness in RLQ with palpation of LLQ
  • Psoas sign: tenderness in RLQ with passive extension of the hip
    • Pt lies in left lateral decubitus position
    • May indicate a retrocecal appendix
  • Obturator sign: RLQ tenderness with flexion of knee and hip and internal rotation of hip
    • Indicates a pelvic appendix in close proximity to the obturator internus muscle
Each of these signs have a low sensitivity for acute appendicitis → Their absence does not rule out 

Diagnostic workup
  • Best = CT abdomen/pelvis with IV contrast
  • For pregnant patients or kids = US or MRI
  • Modified Alvarado Score
    • 9 possible points
    • 4 or more indicates evaluate for appendicitis
      • 2 points for RLQ tenderness or WBC > 10,000
      • 1 point for rebound RLQ tenderness, fever (> 99.5°F), migratory RLQ pain, N/V, anorexia
    • Even if Alvarado Score is > 4, get imaging prior to surgery

Differential diagnosis:
  • If female, rule out gynecologic issues (ovarian torsion, ectopic pregnancy, PID)
  • Diverticulitis
  • Psoas abcess
  • Bowel obstruction
  • Cholecystitis
  • Pancreatitis
  • Gastroenteritis
  • UTI
  • Nephrolithiasis

Treatment:
  • Uncomplicated (no abscess, perforation, or necrosis) 
    • non-operative with abx or appendectomy
  • Perforated
    • laparoscopic appendectomy
  • Abscess 
    • +/- percutaneous drainage, abx, interval appendectomy at 6-12 weeks



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