Rate this Article Email to a Colleague Synonyms and related keywords: acute inflammation of the appendix, abdominal pain AUTHOR INFORATION Section ! o" !! Author Information Introduction Clinical ifferentials !or"up #reatment $edication %ollo&'up $iscellaneous (ictures )ibliograph* Author+ Sandy #rai$, %, Associate (rogram irector, Ad,unct Assistant (rofessor, epartment of Emergenc* $edicine, -ni.ersit* of /orth Carolina at Chapel 0ill, Carolinas $edical Center 1and* Craig, $, is a member of the follo&ing medical societies+ Alpha 2mega Alpha, and 1ociet* for Academic Emergenc* $edicine Editor3s4+ &illiam Lo'er, %, Instructor, epartment of $edical Education, i.ision of )iomedical and 0ealth Informatics, -ni.ersit* of !ashington 1chool of $edicine5 Francisco Tala(era, )*arm%, )*%, 1enior (harmac* Editor, (harmac*, e$edicine5 +u$ene Hardin, %, Chair, epartment of Emergenc* $edicine, $artin 6uther 7ing Jr8Charles R re& $edical Center5 $edical irector, 0ubert 0 0umphre* Comprehensi.e 0ealth Center5 ,o*n Halamka, %, Chief Information 2fficer, Care9roup 0ealthcare 1*stem, Assistant (rofessor of $edicine, epartment of Emergenc* $edicine, )eth Israel eaconess $edical Center5 Assistant (rofessor of $edicine, 0ar.ard $edical 1chool5 and ,onat*an Adler, %, Instructor, epartment of Emergenc* $edicine, $assachusetts 9eneral 0ospital, 0ar.ard $edical 1chool INTRO%U#TION Section - o" !! Author Information Introduction Clinical ifferentials !or"up #reatment $edication %ollo&'up $iscellaneous (ictures )ibliograph* .ack$round: Appendicitis is a common and urgent surgical illness &ith protean manifestations, generous o.erlap &ith other clinical s*ndromes, and significant morbidit*, &hich increases &ith diagnostic dela*: /o single sign, s*mptom, or diagnostic test accuratel* ma"es the diagnosis of appendiceal inflammation in all cases: #he surgeon;s goals are to e.aluate a relati.el* small population of patients referred for suspected appendicitis and to minimi<e the negati.e appendectom* rate &ithout increasing the incidence of perforation: #he emergenc* ph*sician must e.aluate the larger group of patients &ho present to the E &ith abdominal pain of all etiologies &ith the goal of approaching =00> sensiti.it* for the diagnosis in a time', cost', and consultation'efficient manner: )at*op*ysiolo$y: 2bstruction of the appendiceal lumen is the primar* /uick Find Author Information Introduction Clinical ifferentials !or"up #reatment $edication %ollo&'up $iscellaneous (ictures )ibliograph* Clic" for related images: Related Articles Cholec*stitis and )iliar* Colic Constipation i.erticular isease Endometriosis 9astroenteritis Inflammator* )o&el isease $esenteric Ischemia 2.arian C*sts 2.arian #orsion (ediatrics, Intussusception (el.ic Inflammator* isease 1pider En.enomations, !ido& cause of appendicitis: 2bstruction of the lumen leads to distension of the appendix due to accumulated intraluminal fluid: Ineffecti.e l*mphatic and .enous drainage allo&s bacterial in.asion of the appendiceal &all and, in ad.anced cases, perforation and spillage of pus into the peritoneal ca.it*: Fre0uency: In t*e US: Appendicitis occurs in ?> of the -1 population, &ith an incidence of =:=8=000 people per *ear: 1ome familial predisposition exists: Internationally: Incidence of appendicitis is lo&er in cultures &ith a higher inta"e of dietar* fiber: ietar* fiber is thought to decrease the .iscosit* of feces, decrease bo&el transit time, and discourage formation of fecaliths, &hich predispose indi.iduals to obstructions of the appendiceal lumen: ortality1or'idity: 2.erall mortalit* rate of 0:2'0:@> is attributable to complications of the disease rather than to surgical inter.ention: $ortalit* rate rises abo.e 20> in patients older than ?0 *ears, primaril* because of diagnostic and therapeutic dela*: (erforation rates are higher in patients *ounger than =@ *ears and in patients older than A0 *ears, possibl* because of dela*s in diagnosis: Appendiceal perforation is associated &ith an increase in morbidit* and mortalit* rates: Se2: Incidence of appendicitis is approximatel* =:4 times greater in men than in &omen: #he incidence of primar* appendectom* is approximatel* eBual in both sexes: A$e: Incidence of appendicitis graduall* rises from birth, pea"s in the late teen *ears, and graduall* declines in the geriatric *ears: Although rare, cases of neonatal and e.en prenatal appendicitis ha.e been reported: #he emergenc* ph*sician must maintain a high index of suspicion in all age groups: #ontinuin$ +ducation C$E a.ailable for this topic: Clic" here to ta"e this C$E: )atient +ducation Esophagus, 1tomach, and Intestine Center Appendicitis 2.er.ie& Appendicitis Causes Appendicitis 1*mptoms Appendicitis #reatment Abdominal (ain in Adults 2.er.ie& #LINI#AL Section 3 o" !! Author Information Introduction Clinical ifferentials !or"up #reatment $edication %ollo&'up $iscellaneous (ictures )ibliograph* History: Cariations in the position of the appendix, age of the patient, and degree of inflammation ma"e the clinical presentation of appendicitis notoriousl* inconsistent: In addition, man* other disorders present &ith s*mptoms similar to those of appendicitis: #hese include pel.ic inflammator* disease 3(I4, tubo'o.arian abscess, endometriosis, o.arian c*st or torsion, degenerating uterine leiom*omata, di.erticulitis, Crohn disease, colonic carcinoma, rectus sheath hematoma, cholec*stitis, bacterial enteritis, mesenteric adenitis, and omental torsion: #he classic histor* of anorexia and periumbilical pain follo&ed b* nausea, right lo&er Buadrant 3R6D4 pain, and .omiting occurs in onl* A0> of cases: $igration of pain from the periumbilical area to the R6D is the most discriminating historical feature, &ith sensiti.it* and specificit* of approximatel* @0>: !hen .omiting occurs, it nearl* al&a*s follo&s the onset of pain: Comiting that precedes pain is suggesti.e of intestinal obstruction, and the diagnosis of appendicitis should be reconsidered: /ausea is present in E='92> of cases5 anorexia is present in ?4' ?@> of cases: /either finding is statisticall* different from findings in E patients &ith other etiologies of abdominal pain: iarrhea or constipation is noted in as man* as =@> of patients and should not be used to discard the possibilit* of appendicitis: uration of s*mptoms is less than 4@ hours in approximatel* @0> of adults but tends to be longer in the elderl* and in those &ith perforation: Approximatel* 2> of patients report duration of pain in excess of 2 &ee"s: 0istor* of prior similar pain is reported in as man* as 2F> of cases: 0istor* of similar pain should not, in and of itself, be used to discard the possibilit* of appendicitis: An inflamed appendix located in proximit* to the urinar* bladder or ureter can gi.e rise to irritati.e .oiding s*mptoms and hematuria or p*uria: Remember that c*stitis in males is rare in the absence of instrumentation: Consider the possibilit* of an inflamed pel.ic appendix in males &ith apparent c*stitis: )*ysical: R6D tenderness is present in 9E> of patients but is a .er* nonspecific finding: #he most specific ph*sical findings are rebound tenderness, pain on percussion, rigidit*, and guarding: Ro.sing sign 3ie, R6D pain &ith palpation of the 66D4, obturator sign 3ie, R6D pain &ith internal rotation of the flexed right hip4, and psoas sign 3ie, R6D pain &ith h*perextension of the right hip4 are present in a minorit* of patients &ith acute appendicitis: #heir absence ne.er should be used to rule out appendiceal inflammation: A positi.e cough sign 3ie, sharp pain in the R6D elicited b* a .oluntar* cough4 ma* be helpful in ma"ing the clinical diagnosis of locali<ed peritonitis: 1imilarl*, R6D pain in response to percussion of a remote Buadrant of the abdomen, or to firm percussion of the patient;s heel, suggests peritoneal inflammation: 6iterature is inconsistent as to &hether rectal examination is helpful in ma"ing the diagnosis5 ho&e.er, failure to perform a rectal examination is cited freBuentl* in successful malpractice claims: #auses: Appendicitis is usuall* precipitated b* obstruction of the appendiceal lumen: Causes of luminal obstruction include fecaliths, l*mphoid follicle h*perplasia, foreign bodies 3eg, shotgun pellet, intrauterine de.ice4, and tumors: o %ecaliths form &hen calcium salts and fecal debris become la*ered around a nidus of inspissated fecal material located &ithin the appendix: o 6*mphoid h*perplasia is associated &ith a .ariet* of inflammator* and infectious disorders including Crohn disease, gastroenteritis, amebiasis, respirator* infections, measles, and mononucleosis: %IFF+R+NTIALS Section 4 o" !! Author Information Introduction Clinical ifferentials !or"up #reatment $edication %ollo&'up $iscellaneous (ictures )ibliograph* Cholec*stitis and )iliar* Colic Constipation i.erticular isease Endometriosis 9astroenteritis Inflammator* )o&el isease $esenteric Ischemia 2.arian C*sts 2.arian #orsion (ediatrics, Intussusception (el.ic Inflammator* isease 1pider En.enomations, !ido& Ot*er )ro'lems to 'e #onsidered: #*philitis Epiploic appendagitis $esenteric adenitis &OR5U) Section 6 o" !! Author Information Introduction Clinical ifferentials !or"up #reatment $edication %ollo&'up $iscellaneous (ictures )ibliograph* La' Studies: Complete blood count o 1tudies consistentl* sho& that @0'@A> of adults &ith appendicitis ha.e a !)C count greater than =0,000: /eutrophilia greater than ?A> occurs in ?@> of patients: %e&er than 4> of patients &ith appendicitis ha.e a !)C count less than =0,000 and neutrophilia less than ?A>: o C)C is inexpensi.e, rapid, and &idel* a.ailable5 ho&e.er, it is nonspecific and misses 4> of cases: It costs approximatel* GA0: o 6iterature is inconsistent &ith regard to !)C count parameters in children and elderl* patients &ith appendicitis: C'reacti.e protein test o C'reacti.e protein 3CR(4 is an acute'phase reactant s*nthesi<ed b* the li.er in response to bacterial infection: 1erum le.els begin to rise &ithin E'=2 hours of acute tissue inflammation: A rapid assa* is &idel* a.ailable: o 1e.eral prospecti.e studies ha.e concluded that in adult patients &ho ha.e had s*mptoms for longer than 24 hours, a normal CR( has a negati.e predicti.e .alue of approximatel* =00> for the presence of appendicitis: 1pecificit* has ranged from A0'@?> in se.eral series: #&o other studies in adults found that a combination of a !)C count of less than =0,A00, neutrophilia less than ?A>, and a normal CR( had =00> negati.e predicti.e .alue for the diagnosis of acute appendicitis: In =9@9, #himsen et al noted that a normal CR( after =2 hours of s*mptoms &as =00> predicti.e of benign, self'limited illness: o CR( does not distinguish bet&een .arious t*pes of bacterial infection: o Cost is approximatel* GEE: Ima$in$ Studies: Computed tomograph* o Abdominal C# has become the most important imaging stud* in the e.aluation of patients &ith at*pical presentations of appendicitis: 1e.eral studies ha.e sho&n a decrease in negati.e laparotom* rate and appendiceal perforation rate &hen abdominal C# is used in selected patients &ith suspected appendicitis: Ad.antages of C# scanning include superior sensiti.it* and accurac* compared &ith other imaging techniBues, read* a.ailabilit*, nonin.asi.eness, and potential to re.eal alternati.e diagnoses: isad.antages include radiation exposure, potential for anaph*lactoid reaction if intra.enous 3IC4 contrast is used, length* acBuisition time if oral contrast is used, and patient discomfort if rectal contrast is used: A .ariet* of C# techniBues ha.e been studied: o Initial studies e.aluated seBuential 3nonhelical4 C# scanning in the diagnosis of appendicitis: $alone, in =99F, e.aluated unenhanced, seBuential C# scanning in 2== patients and reported a sensiti.it* of @?> and specificit* of 9?>: Addition of IC and oral contrast increases sensiti.it* to 9E'9@>, but it increases cost to approximatel* G900: 1eBuential C# &ith oral and IC contrast is highl* accurate but time consuming and expensi.e5 it is best used for eBui.ocal presentations &hen helical C# is not a.ailable: o In =99?, 6ane e.aluated helical C# scanning &ithout contrast and found a sensiti.it* of 90> and specificit* of 9?>: $ore recent studies 36ane, =9995 Ege, 20024 of noncontrast helical C# in adult patients &ith suspected appendicitis found the sensiti.it* to be 9E> and the specificit* to be 9@'99>: o Rao, in =99?, found that focused 3lo&er abdomen and upper pel.is4 helical C# scanning &ith F> 9astrografin contrast instilled into the colon 3&ithout IC contrast4 has a superior sensiti.it* of 9@> and specificit* of 9@>: %ocused helical scanning &ith a.oidance of IC contrast eliminates the ris" of anaph*lactoid contrast reaction and reduces the cost to approximatel* G2F0: AcBuisition time is less than =A minutes: Radiation exposure is less than that of a standard obstruction series: Alternati.e diagnoses are re.ealed in up to E2> of patients and include di.erticulitis, nephrolithiasis, adnexal patholog*, R6D tumor, small bo&el hernias, and ischemia: o Current literature suggests that limited helical C# &ith rectal contrast is a highl* accurate, time'efficient, cost'effecti.e &a* to e.aluate adult patients &ith eBui.ocal presentations for appendicitis: #&o studies of focused helical C# in children suggest sensiti.it* of 9A'9?> in that population: Continued impro.ements in helical C# technolog* and interpretation ma* allo& noncontrast helical C# to be the imaging test of choice in the future: -ltrasonograph* o In =9@E, (u*laert described a graded compression techniBue for e.aluation of the appendix using transabdominal ultrasonograph*: A A'$0< transducer is used, appl*ing gentle but firm pressure in the R6D to displace inter.ening bo&el gas and to decrease the distance bet&een the transducer and the appendix, thereb* impro.ing image Bualit*: An outer diameter of greater than E mm, noncompressibilit*, lac" of peristalsis, or presence of a periappendiceal fluid collection characteri<es an inflamed appendix: #he normal appendix is not .isuali<ed in most cases: A posterolateral approach is suggested to e.aluate the retrocecal area: 1cattered case reports endorse trans.aginal ultrasonograph* for &omen &ith lo& pel.ic tenderness if the appendix is not .isuali<ed on transabdominal sonograph*: o /umerous studies ha.e documented a sensiti.it* of @A'90> and a specificit* of 92' 9E>: %i.e studies using graded compression ultrasonograph* in children reported sensiti.ities of @A'9A> and specificities ranging from 4?'9E>: #he cost is approximatel* G22A: o Ad.antages include nonin.asi.eness, short acBuisition time, lac" of radiation exposure, and potential for diagnosis of other causes of abdominal pain, particularl* in the subset of females of childbearing age: $an* authorities feel that ultrasonograph* should be the initial imaging test in pregnant &omen and in pediatric patients because radiation exposure is particularl* undesirable in those groups: o #he principal disad.antage is that ultrasonographic examination is operator dependent: )ecause non.isuali<ation is interpreted as a noninflamed appendix, technical expertise and commitment to a thorough examination are essential in obtaining maximum sensiti.it*: o If graded compression ultrasonograph* of the right lo&er Buadrant is positi.e for appendicitis, appendectom* should be performed: If negati.e, this finding is not sufficientl* sensiti.e to rule out the possibilit* of appendicitis: Consideration should be gi.en to further obser.ation and focused helical C# &ith rectal contrast: Abdominal radiograph* o 7idne*s'ureters'bladder 37-)4 .ie& used t*picall*: o Cisuali<ation of an appendicolith in a patient &ith s*mptoms consistent &ith appendicitis is highl* suggesti.e of appendicitis, but this occurs in fe&er than =0> of cases: o #he consensus in the literature is that plain radiograph* is insensiti.e, nonspecific, and not cost'effecti.e: )arium enema o A single contrast stud* can be performed on an unprepared bo&el: /onfilling or incomplete filling of the appendix coupled &ith pressure effect or spasm in the cecum suggests appendicitis: #he cost is approximatel* G420: o $ultiple studies ha.e found that the sensiti.it* of a barium enema is in the range of @0'=00>: 0o&e.er, as man* as =E> of examinations in adults 3and 22'F9> of examinations in children4 &ere technicall* unsuitable for interpretation and &ere excluded from data anal*sis: o Ad.antages of barium enema are its &ide a.ailabilit*, use of simple eBuipment, and potential for diagnosis of other diseases 3eg, Crohn disease, colon cancer, ischemic colitis4 that ma* mimic appendicitis: o isad.antages include its high incidence of nondiagnostic examination, radiation exposure, insufficient sensiti.it*, and in.asi.eness: #hese disad.antages ma"e barium enema a poor screening examination for use b* emergenc* ph*sicians: )arium enema has essentiall* no role in the diagnosis of acute appendicitis in the era of ultrasonograph* and C#: Radionuclide scanning o !hole blood is &ithdra&n: /eutrophils and macrophages are labeled &ith technetium 99m albumin and administered intra.enousl*: Images of the abdomen and pel.is are obtained seriall* o.er 4 hours: 6ocali<ed upta"e of tracer in the R6D suggests appendiceal inflammation: #he cost is approximatel* G4A0: o %our earl* studies in adults &ith suspected appendicitis sho&ed a sensiti.it* of 90> and specificit* of 92'9E>: #&o recent studies of ne&er labeling techniBues achie.ed sensiti.ities of 9@> for the presence of appendicitis: o !hile future studies ma* confirm sensiti.it* as high as 9@>, the acBuisition time of A hours and the lac" of a.ailabilit* are disad.antages to its use as a high'sensiti.it* E screen for appendicitis: Ot*er Tests: Clinical diagnostic scores o 1e.eral in.estigators ha.e created diagnostic scoring s*stems in &hich a finite number of clinical .ariables is elicited from the patient and each is gi.en a numerical .alue: #he sum of these .alues is used to predict the li"elihood of acute appendicitis: o #he best "no&n of these is the $A/#RE61 score, &hich tabulates presence or absence of migration of pain, anorexia, nausea8.omiting, tenderness in the R6D, rebound tenderness, ele.ated temperature, leu"oc*tosis, and shift to the left: o Clinical scoring s*stems are attracti.e because of their simplicit*5 ho&e.er, none has been sho&n prospecti.el* to impro.e upon ph*sician ,udgment in the subset of patients e.aluated in the E for abdominal pain suggesti.e of appendicitis: #he $A/#RE61 score, in fact, &as based on a population of patients hospitali<ed for suspected appendicitis, &hich differs mar"edl* from the population seen in the E: Computer'aided diagnosis o A retrospecti.e database of clinical features of patients &ith appendicitis and other causes of abdominal pain is entered into a computer: It is then utili<ed in prospecti.el* assessing the ris" of appendicitis: o Computer'aided diagnosis can achie.e sensiti.it* greater than 90> &hile reducing rates of perforation and negati.e laparotom* b* as much as A0>: o #he principle disad.antages are that each institution must generate its o&n uniBue database to reflect local population characteristics: 1peciali<ed eBuipment and significant initiation time are reBuired: o Computer'aided diagnosis is not &idel* a.ailable in -1 emergenc* departments: TR+AT+NT Section 7 o" !! Author Information Introduction Clinical ifferentials !or"up #reatment $edication %ollo&'up $iscellaneous (ictures )ibliograph* +mer$ency %epartment #are: #reatment guidelines for patients &ith suspected acute appendicitis include the follo&ing+ o Establish IC access and administer aggressi.e cr*stalloid therap* to patients &ith clinical signs of deh*dration or septicemia: o o not gi.e an*thing b* mouth to patients &ith suspected appendicitis: o Administration of analgesics to patients &ith acute undifferentiated abdominal pain has historicall* been discouraged and critici<ed because of concerns that the* &ould render the ph*sical examination less reliable: At least @ randomi<ed controlled studies no& report that administering opioid analgesic medications to adult and pediatric patients &ith acute undifferentiated abdominal pain is safe5 no stud* has found that analgesics ad.ersel* effect the accurac* of the ph*sical examination: o Consider ectopic pregnanc* in &omen of childbearing age and obtain a Bualitati.e beta'hC9 in all cases: o Administer IC antibiotics to those &ith signs of septicemia and those &ho are to proceed to laparotom*: /onsurgical treatment of appendicitis o Anecdotal reports describe the success of IC antibiotics in treating acute appendicitis in patients &ithout access to surgical inter.ention 3eg, submariners, indi.iduals on ships at sea4: In one prospecti.e stud* of 20 patients &ith ultrasound'pro.en appendicitis, 9A> had resolution of s*mptoms &ith antibiotics alone, but F?> of these patients experienced recurrent appendicitis &ithin =4 months: o #his ma* be useful &hen appendectom* is not accessible or &hen it is temporaril* a high'ris" procedure: (reoperati.e antibiotics o (reoperati.e antibiotics ha.e a demonstrated efficac* in decreasing postoperati.e &ound infection rates in numerous prospecti.e controlled studies: o )road'spectrum gram'negati.e and anaerobic co.erage is indicated: o #hese should be gi.en in con,unction &ith the surgical consultant: #onsultations: 9eneral surgeon +%I#ATION Section 8 o" !! Author Information Introduction Clinical ifferentials !or"up #reatment $edication %ollo&'up $iscellaneous (ictures )ibliograph* #he goals of therap* are to eradicate the infection and pre.ent complications: rug Categor*+ Antibiotics '' #hese agents ha.e pro.en effecti.e in decreasing the rate of postoperati.e &ound infection and in impro.ing outcome in patients &ith appendiceal abscess or septicemia: %ru$ Name $etronida<ole 3%lag*l4 '' -sed in combination &ith an aminogl*coside, such as gentamicin, pro.ides broad gram' negati.e and anaerobic co.erage: Appears to be absorbed into cells, and intermediate'metaboli<ed compounds that are formed bind /A and inhibit protein s*nthesis, causing cell death: Adult %ose ?:A mg8"g IC before surger* )ediatric %ose =A'F0 mg8"g8d IC di.ided bid8tid for ? d, or 40 mg8"g (2 once5 not to exceed 2 g8d #ontraindications ocumented h*persensiti.it* Interactions $a* increase toxicit* of anticoagulants, lithium, and phen*toin5 cimetidine ma* increase toxicit*5 disulfiram reaction ma* occur &ith orall* ingested ethanol )re$nancy ) ' -suall* safe but benefits must out&eigh the ris"s: )recautions Ad,ust dose in hepatic disease5 monitor for sei<ures and de.elopment of peripheral neuropath* %ru$ Name 9entamicin 39entacidin, 9aram*cin4 '' Aminogl*coside antibiotic for gram'negati.e co.erage: -sed in combination &ith both an agent against gram'positi.e organisms and one that co.ers anaerobes: /ot the 2C: Consider if penicillins or other less toxic drugs are contraindicated, &hen clinicall* indicated, and in mixed infections caused b* susceptible staph*lococci and gram'negati.e organisms: osing regimens are numerous5 ad,ust dose on the basis of CrCl and changes in .olume of distribution: $a* be gi.en IC8I$: Adult %ose 2 mg8"g IC loading dose before surger*5 F'A mg8"g8d di.ided tid8Bid thereafter )ediatric %ose Infants8neonates+ ?:A mg8"g8d IC di.ided tid Children+ E'?:A mg8"g8d IC di.ided tid #ontraindications ocumented h*persensiti.it*, nonHdial*sis'dependent renal insufficienc* Interactions Coadministration &ith other aminogl*cosides, cephalosporins, penicillins, and amphotericin ) ma* increase nephrotoxicit*5 aminogl*cosides enhance effects of neuromuscular bloc"ing agents5 thus, prolonged respirator* depression ma* occur5 coadministration &ith loop diuretics ma* increase ototoxicit* of aminogl*cosides, &hich ma* cause irre.ersible hearing loss of .ar*ing degrees 3monitor regularl*4 )re$nancy C ' 1afet* for use during pregnanc* has not been established: )recautions /arro& therapeutic index 3not intended for long'term therap*45 caution in renal failure 3not on dial*sis4, m*asthenia gra.is, h*pocalcemia, and conditions that depress neuromuscular transmission5 ad,ust dose in renal impairment %ru$ Name Cefotetan 3Cefotan4 '' 1econd'generation cephalosporin used as single'drug therap* to pro.ide broad gram'negati.e co.erage and anaerobic co.erage: 0alf'life is F:A h: 9i.e &ith cefoxitin to achie.e effecti.eness of single'dose: Adult %ose 2 g IC once before surger* )ediatric %ose 20'40 mg8"g IC8I$ once before surger* #ontraindications ocumented h*persensiti.it* Interactions Consumption of alcohol &ithin ?2 h of cefotetan ma* produce disulfiramli"e reactions5 ma* increase h*poprothrombinemic effects of anticoagulants5 coadministration &ith potent diuretics 3eg, loop diuretics4 or aminogl*cosides ma* increase nephrotoxicit* )re$nancy ) ' -suall* safe but benefits must out&eigh the ris"s: )recautions Reduce dosage b* half if CrCl =0'F0 m68min and b* three Buarters if I=0 m68min5 bacterial or fungal o.ergro&th of nonsusceptible organisms ma* occur &ith prolonged or repeated therap* %ru$ Name Cefoxitin 3$efoxin4 '' 1econd'generation cephalosporin indicated for management of infections caused b* susceptible gram'positi.e cocci and gram'negati.e rods: 0alf'life is 0:@ h: Adult %ose 2 g IC before surger*, follo&ed b* F doses of 2 g B4'Eh for 24 h )ediatric %ose IF months+ /ot established JF months+ F0'40 mg8"g IC before surger*, follo&ed b* F doses of 2 g B4'Eh for 24 h #ontraindications ocumented h*persensiti.it* Interactions (robenecid ma* increase effects5 coadministration &ith aminogl*cosides or furosemide ma* increase nephrotoxicit* 3closel* monitor renal function4 )re$nancy ) ' -suall* safe but benefits must out&eigh the ris"s: )recautions )acterial or fungal o.ergro&th of nonsusceptible organisms ma* occur &ith prolonged use or repeated treatment5 caution in patients &ith pre.iousl* diagnosed colitis %ru$ Name $eropenem 3$errem4 '' )actericidal broad'spectrum carbapenem antibiotic that inhibits cell'&all s*nthesis: Effecti.e against most gram'positi.e and gram'negati.e bacteria: Adult %ose = g IC B@h )ediatric %ose 40 mg8"g IC B@h #ontraindications ocumented h*persensiti.it* Interactions (robenecid ma* inhibit renal excretion of meropenem, increasing meropenem le.els )re$nancy ) ' -suall* safe but benefits must out&eigh the ris"s: )recautions (seudomembranous colitis and thromboc*topenia ma* occur, reBuiring immediate discontinuation of medication rug Categor*+ Analgesics '' #hese agents can be used to relie.e acute undifferentiated abdominal pain in patients presenting to the emergenc* department: %ru$ Name $orphine sulfate 3Astramorph, uramorph, $1 Contin, $1IR, 2ramorph4 '' 2C for analgesia because of reliable and predictable effects, safet* profile, and ease of re.ersibilit* &ith naloxone: Carious IC doses are used5 commonl* titrated until desired effect obtained: Adult %ose 1tarting dose+ 0:= mg8"g IC8I$81C $aintenance dose+ A'20 mg8?0 "g IC8I$81C B4h Relati.el* h*po.olemic patients+ 1tart &ith 2 mg IC8I$81C5 reassess hemod*namic effects of dose )ediatric %ose Infants and children+ 0:='0:2 mg8"g dose IC8I$81C B2'4h prn5 not to exceed =A mg8dose5 ma* initiate at 0:0A mg8"g8dose #ontraindications ocumented h*persensiti.it*5 h*potension5 potentiall* compromised air&a* in &hich establishing rapid air&a* control &ould be difficult Interactions (henothia<ines ma* antagoni<e analgesic effects of opiate agonists5 tric*clic antidepressants, $A2Is, and other C/1 depressants ma* potentiate ad.erse effects of morphine )re$nancy C ' 1afet* for use during pregnanc* has not been established: )recautions Caution in h*potension, respirator* depression, nausea, emesis, constipation, urinar* retention, atrial flutter, and other supra.entricular tach*cardias5 has .agol*tic action and ma* increase .entricular response rate FOLLO&9U) Section : o" !! Author Information Introduction Clinical ifferentials !or"up #reatment $edication %ollo&'up $iscellaneous (ictures )ibliograph* Furt*er Inpatient #are: 2pen .ersus laparoscopic appendectom* o Initiall* performed in =9@?, laparoscopic appendectom* has been performed in thousands of patients and is successful in 90'94> of attempts: o Ad.antages of laparoscopic appendectom* include increased cosmetic satisfaction and a decrease in the postoperati.e &ound infection rate: 1ome studies find a shorter con.alescent period compared to open appendectom* and a trend to&ard shorter hospital sta*s: o isad.antages of laparoscopic appendectom* include a slightl* longer operating time 3approximatel* 20 min4 and increased cost: o Contraindications to laparoscopic appendectom* include significant intra'abdominal adhesions and pregnanc* be*ond the first trimester: #omplications: !ound infection ehiscence )o&el obstruction Abdominal8pel.ic abscess eath 3rare4 )ro$nosis: Excellent )atient +ducation: %or excellent patient education resources, .isit e$edicine;s Esophagus, 1tomach, and Intestine Center: Also, see e$edicine;s patient education articles, Appendicitis and Abdominal (ain in Adults: IS#+LLAN+OUS Section ; o" !! Author Information Introduction Clinical ifferentials !or"up #reatment $edication %ollo&'up $iscellaneous (ictures )ibliograph* edical1Le$al )it"alls: Approximatel* =0> of adults &ho de.elop appendicitis are not diagnosed correctl* at the first ph*sician encounter: %ailure to diagnose appendicitis is the leading cause of successful malpractice claims and the fifth most expensi.e source of claims against emergenc* ph*sicians: Special #oncerns: (regnanc* o #he incidence of appendicitis is unchanged in pregnanc*, but the clinical presentation becomes e.en more .ariable: uring pregnanc* the appendix migrates in a countercloc"&ise direction to&ard the right "idne*, rising abo.e the iliac crest at about 4:A months gestation: R6D pain and tenderness dominate in the first trimester, but in the latter half of pregnanc*, right upper Buadrant 3R-D4 or right flan" pain must be loo"ed upon as a possible sign of appendiceal inflammation: /ausea, .omiting, and anorexia are common in uncomplicated first trimester pregnancies, but their reappearance later in gestation should be .ie&ed &ith suspicion: o (h*siologic leu"oc*tosis during pregnanc* ma"es the !)C count less useful in the diagnosis, and no reliable distinguishing !)C parameters are cited in the literature: 2ne stud* of 22 pregnant &omen in the first and second trimesters found that graded compression ultrasound had a sensiti.it* of EE> and specificit* of 9A>: iagnostic laparoscop* also has been suggested for pregnant patients in the first trimester &ith suspected appendicitis: o !hile negati.e appendectom* does not appear to affect maternal or fetal health ad.ersel*, diagnostic dela* &ith perforation does increase fetal and maternal morbidit*: #herefore, aggressi.e e.aluation of the appendix is &arranted in this group: /onpregnant &omen of childbearing age o (atients in this group &ho de.elop appendicitis are misdiagnosed in FF> of cases: #he most freBuent misdiagnoses are (I, follo&ed b* gastroenteritis and urinar* tract infection: o In distinguishing appendiceal pain from (I, presence of anorexia and onset of pain more than =4 da*s after menses fa.ors appendicitis: (re.ious (I, presence of .aginal discharge, or presence of urinar* s*mptoms indicates the diagnosis of (I: o 2n ph*sical examination, tenderness outside the R6D, cer.ical motion tenderness, .aginal discharge, and positi.e urinal*sis fa.or the diagnosis of (I: Children o Children &ith appendicitis are misdiagnosed in 2A'F0> of cases o.erall, and the rate of initial misdiagnosis is in.ersel* related to the age of the patient: o #he most common misdiagnosis is gastroenteritis, follo&ed b* upper respirator* infection and lo&er respirator* infection: o $isdiagnosed children are more li"el* than their correctl* diagnosed counterparts to ha.e .omiting before pain onset, diarrhea, constipation, d*suria, signs and s*mptoms of upper respirator* infection, and letharg* or irritabilit*: o (h*sical findings less li"el* to be documented in the children &ho are misdiagnosed include findings of ear, nose, and throat exam5 bo&el sounds5 peritoneal signs5 and findings of rectal examination: Elderl* patients o Appendicitis in patients older than E0 *ears accounts for =0> of all appendectomies: o #he incidence of misdiagnosis is increased in the elderl*: o In those patients &ith comorbid conditions, diagnostic dela* does correlate &ith increased morbidit* and mortalit*: o 2lder patients tend to see" medical attention later in the course of illness5 therefore, duration of s*mptoms in excess of 24'4@ hours should not dissuade the ph*sician from the diagnosis: )I#TUR+S Section !< o" !! Author Information Introduction Clinical ifferentials !or"up #reatment $edication %ollo&'up $iscellaneous (ictures )ibliograph* #aption: (icture =: C# scan &ith colonic contrast re.eals an enlarged appendix &ith thic"ened &alls, &hich do not fill &ith contrast, l*ing ad,acent to the right psoas muscle: Cie& %ull 1i<e Image e$edicine Koom Cie& 3Interacti.eL4 )icture Type: C# #aption: (icture 2: 9raded compression transabdominal ultrasound sho&s a sagittal .ie& of an acutel* inflamed appendix: #he tubular structure is noncompressible, lac"s peristalsis, and measures greater than E mm in diameter: A thin rim of periappendiceal fluid is present: Cie& %ull 1i<e Image e$edicine Koom Cie& 3Interacti.eL4 )icture Type: (hoto #aption: (icture F: 9raded compression transabdominal ultrasound sho&s a trans.erse .ie& of an acutel* inflamed appendix: /ote the targetli"e appearance due to thic"ened &all and surrounding loculated fluid collection: Cie& %ull 1i<e Image e$edicine Koom Cie& 3Interacti.eL4 )icture Type: (hoto #aption: (icture 4: 7idne*s'ureters'bladder 37-)4 x'ra* sho&s an appendicolith in the right lo&er Buadrant: #his is seen in fe&er than =0> of patients &ith appendicitis but, &hen present, is essentiall* pathognomonic: Cie& %ull 1i<e Image e$edicine Koom Cie& 3Interacti.eL4 )icture Type: M'RAN #aption: (icture A: #echnetium 99m radionuclide scan of the abdomen sho&s focal upta"e of labeled &hite blood cells in the right lo&er Buadrant consistent &ith acute appendicitis: Cie& %ull 1i<e Image e$edicine Koom Cie& 3Interacti.eL4 )icture Type: (hoto Acute Appendicitis: Re(iew and Update D. MIKE HARDIN, JR., M.D., Texas A&M University Health Science Center, Te!le, Texas Appendicitis is common, &ith a lifetime occurrence of ? percent: Abdominal pain and anorexia are the predominant s*mptoms: #he most important ph*sical examination finding is right lo&er Buadrant tenderness to palpation: A complete blood count and urinal*sis are sometimes helpful in determining the diagnosis and supporting the presence or absence of appendicitis, &hile appendiceal computed tomographic scans and ultrasonograph* can be helpful in eBui.ocal cases: ela* in diagnosing appendicitis increases the ris" of perforation and complications: Complication and mortalit* rates are much higher in children and the elderl*: 3Am %am (h*sician =9995E0+202?'F4:4 Appendicitis is the most common acute surgical condition of the abdomen: =
Approximatel* ? percent of the population &ill ha.e appendicitis in their lifetime, 2
&ith the pea" incidence occurring bet&een the ages of =0 and F0 *ears: F espite technologic ad.ances, the diagnosis of appendicitis is still based primaril* on the patient;s histor* and the ph*sical examination: (rompt diagnosis and surgical referral ma* reduce the ris" of perforation and pre.ent complications: 4 #he mortalit* rate in nonperforated appendicitis is less than = percent, but it ma* be as high as A percent or more in *oung and elderl* patients, in &hom diagnosis ma* often be dela*ed, thus ma"ing perforation more li"el*: = )at*o$enesis #he appendix is a long di.erticulum that extends from the inferior tip of the cecum: A Its lining is interspersed &ith l*mphoid follicles: F $ost of the time, the appendix has an intraperitoneal location 3either anterior or retrocecal4 and, thus, ma* come in contact &ith the anterior parietal peritoneum &hen it is inflamed: -p to F0 percent of the time, the appendix ma* be OhiddenO from the anterior peritoneum b* being in a pel.ic, retroileal or retrocolic 3retroperitoneal retrocecal4 position: E #he OhiddenO position of the appendix notabl* changes the clinical manifestations of appendicitis: 2bstruction of the narro& appendiceal lumen initiates the clinical illness of acute appendicitis: 2bstruction has multiple causes, including l*mphoid h*perplasia 3related to .iral illnesses, including upper respirator* infection, mononucleosis, TA.L+ ! Common 1*mptoms of Appendicitis #ommon symptoms= Fre0uency >?@ Abdominal pain P=00 Anorexia P=00 /ausea 90 Comiting ?A (ain migration A0 Classic s*mptom seBuence 3.ague periumbilical pain to anorexia8nausea8unsustained .omiting to migration of pain to right lo&er Buadrant to lo&' grade fe.er4 A0 "##$nset %& sy!t%s ty!ically 'ithin !ast () t% *+ h%,rs. In&%rati%n &r% re&erences * thr%,-h .. gastroenteritis4, fecaliths, parasites, foreign bodies, Crohn;s disease, primar* or metastatic cancer and carcinoid s*ndrome: 6*mphoid h*perplasia is more common in children and *oung adults, accounting for the increased incidence of appendicitis in these age groups: =,A History and )*ysical +2amination Abdominal pain is the most common s*mptom of appendicitis: F In multiple studies, F'A specific characteristics of the abdominal pain and other associated s*mptoms ha.e pro.ed to be reliable indicators of acute appendicitis 3Table 14: A thorough re.ie& of the histor* of the abdominal pain and of the patient;s recent genitourinar*, g*necologic and pulmonar* histor* should be obtained: Anorexia, nausea and .omiting are s*mptoms that are commonl* associated &ith acute appendicitis: #he classic histor* of pain beginning in the periumbilical region and migrating to the right lo&er Buadrant occurs in onl* A0 percent of patients: = uration of s*mptoms exceeding 24 to FE hours is uncommon in nonperforated appendicitis: = TA.L+ - 1ignificant 6i"elihood Ratios for 1*mptoms and 1igns of Acute Appendicitis Symptom1si$n )ositi(e likeli*ood ratio >LRA@ Symptom1si$n Ne$ati(e likeli*ood ratio >LR9@ Right lo&er Buadrant 3R6D4 pain @:0 R6D painQ 0 to 0:2@R (ain migration F:2 /o similar pain pre.iousl*SS 0:F (ain before .omiting 2:@ (ain migration 0:A Anorexia, nausea and .omitingT $uch lo&er 6RU than R6D pain, pain migration and pain before .omiting 9uarding 0 to 0:A4R Rigidit* F:?E Rebound tenderness 0 to 0:@ER (soas sign 2:F@ %e.er, rigidit* and psoas signV Rebound tenderness =:= to E:FR %e.er =:9W 9uarding and rectal tendernessT $uch lo&er 6RU than rigidit*, psoas sign and rebound tenderness /2#E+ 6R is the amount b* &hich the odds of a disease change &ith ne& information, as follo&s+ Likeli*ood ratio %e$ree o" c*an$e in pro'a'ility J=0 or I0:= 6arge 3often conclusi.e4 A to =0 or 0:= to 0:2 $oderate 2 to A or 0:2 to 0:A 1mall 3but sometimes important4 = to 2 or 0:A to = 1mall 3rarel* important4 "##These sy!t%s an/ si-ns have ,ch l%'er 0R1. 2##Rati%s are !resente/ in ran-es &%r si-ns an/ sy!t%s that ha/ 'i/ely varyin- res,lts in st,/ies. 3##4ever ha/ %nly 5%r/erline 0R1. 6##That is, the a5sence %& R07 !ain si-ni&icantly l%'ers the %//s %& havin- a!!en/icitis. 88##That is, the hist%ry %& ex!eriencin- a siilar !ain !revi%,sly l%'ers the %//s %& havin- a!!en/icitis. 9##These si-ns have hi-her 0R#. In&%rati%n &r% re&erences :, ; an/ <= In a recent meta'anal*sis, ? li"elihood ratios &ere calculated for man* of these s*mptoms 3Table 24: A li"elihood ratio is the amount b* &hich the odds of a disease change &ith ne& information 3e:g:, ph*sical examination findings, laborator* results4: @ #his change can be positi.e or negati.e: 1*mptoms such as anorexia, nausea and .omiting commonl* occur in acute appendicitis5 ho&e.er, the presence of these s*mptoms does not necessaril* increase the li"elihood of appendicitis nor does their absence decrease the li"elihood of the diagnosis: $oreo.er, other s*mptoms ha.e more notable positi.e and negati.e li"elihood ratios 3Table 24: A careful, s*stematic examination of the abdomen is essential: !hile right lo&er Buadrant tenderness to palpation is the most important ph*sical examination finding, other signs ma* help confirm the diagnosis 3Table 34: #he abdominal examination should begin &ith inspection follo&ed b* auscultation, gentle palpation 3beginning at a site distant from the pain4 and, finall*, abdominal percussion: #he rebound tenderness that is associated &ith peritoneal irritation has been sho&n to be more accuratel* identified b* percussion of the abdomen than b* palpation &ith Buic" release: = As pre.iousl* noted, the location of the appendix .aries: !hen the appendix is hidden from the anterior peritoneum, the usual s*mptoms and signs of acute appendicitis ma* not be present: (ain and tenderness can occur in a location other than the right lo&er Buadrant: E A retrocecal appendix in a retroperitoneal location ma* cause flan" pain: In this case, stretching the iliopsoas muscle can elicit pain: #he psoas sign is elicited in this manner+ the patient lies on the left side &hile the examiner extends the patient;s right thigh 3Figures 1a and 1b4: In contrast, a patient &ith a pel.ic appendix ma* sho& no abdominal signs, but the rectal examination ma* elicit tenderness in the cul'de'sac: In addition, an obturator sign 3pain on passi.e internal rotation of the flexed right thigh4 ma* be present in a patient &ith a pel.ic appendix F 3Figures 2a and 2b4: TA.L+ 3 Common 1igns of Appendicitis X Right lo&er Buadrant pain on palpation 3the single most important sign4 X 6o&'grade fe.er 3F@YC Zor =00:4Y%[4'' absence of fe.er or high fe.er can occur X (eritoneal signs X 6ocali<ed tenderness to percussion X 9uarding X 2ther confirmator* peritoneal signs 3absence of these signs does not exclude appendicitis4 X (soas sign''pain on extension of right thigh 3retroperitoneal retrocecal appendix4 X 2bturator sign''pain on internal rotation of right thigh 3pel.ic appendix4 X Ro.sing;s sign''pain in right lo&er Buadrant &ith palpation of left lo&er Buadrant X unph*;s sign''increased pain &ith coughing X %lan" tenderness in right lo&er Buadrant 3retroperitoneal retrocecal appendix4 X (atient maintains hip flexion &ith "nees dra&n up for comfort In&%rati%n &r% re&erences * thr%,-h .. FIBUR+ !AC #he psoas sign: (ain on passi.e extension of the right thigh: (atient lies on left side: Examiner extends patient;s right thigh &hile appl*ing counter resistance to the right hip 3asteris"4: FIBUR+ !.C Anatomic basis for the psoas sign+ inflamed appendix is in a retroperitoneal location in contact &ith the psoas muscle, &hich is stretched b* this maneu.er: FIBUR+ -AC #he obturator sign: (ain on passi.e internal rotation of the flexed thigh: Examiner mo.es lo&er leg laterall* &hile appl*ing resistance to the lateral side of the "nee 3asteris"4 resulting in internal rotation of the femur: FIBUR+ -.C Anatomic basis for the obturator sign+ inflamed appendix in the pel.is is in contact &ith the obturator internus muscle, &hich is stretched b* this maneu.er: #he differential diagnosis of appendicitis is broad, but the patient;s histor* and the remainder of the ph*sical examination ma* clarif* the diagnosis 3Table 44: )ecause man* g*necologic conditions can mimic appendicitis, a pel.ic examination should be performed on all &omen &ith abdominal pain: 9i.en the breadth of the differential diagnosis, the pulmonar*, genitourinar* and rectal examinations are eBuall* important: 1tudies ha.e sho&n, ho&e.er, that the rectal examination pro.ides useful information onl* &hen the diagnosis is unclear and, thus, can be reser.ed for use in such cases: A La'oratory and Radiolo$ic +(aluation If the patient;s histor* and the ph*sical examination do not clarif* the diagnosis, laborator* and radiologic e.aluations ma* be helpful: A clear diagnosis of appendicitis ob.iates the need for further testing and should prompt immediate surgical referral: La'oratory Tests #he &hite blood cell 3!)C4 count is ele.ated 3greater than =0,000 per mm F Z=00 TA.L+ 4 ifferential iagnosis of Acute Appendicitis Bastrointestinal Abdominal pain, cause un"no&n Cholec*stitis Crohn;s disease i.erticulitis uodenal ulcer 9astroenteritis Intestinal obstruction Intussusception $ec"el;s di.erticulitis $esenteric l*mphadenitis /ecroti<ing enterocolitis /eoplasm 3carcinoid, carcinoma, l*mphoma4 2mental torsion (ancreatitis (erforated .iscus Col.ulus Bynecolo$ic Ectopic pregnanc* Endometriosis 2.arian torsion (el.ic inflammator* disease Ruptured o.arian c*st 3follicular, corpus luteum4 #ubo'o.arian abscess Systemic iabetic "etoacidosis (orph*ria 1ic"le cell disease 0enoch' 1ch\nlein purpura )ulmonary (leuritis (neumonia 3basilar4 (ulmonar* infarction Benitourinary 7idne* stone (rostatitis (*elonephritis #esticular torsion -rinar* tract infection !ilms; tumor Ot*er (arasitic infection (soas abscess Rectus sheath hematoma Re!rinte/ 'ith !erissi%n &r% >ra&&e% CS, C%,nselan 40. A!!en/icitis. Eer- Me/ Clin N%rth A <==+?<)@+.*#:<. F =0 9 per 6[4 in @0 percent of all cases of acute appendicitis: 9 -nfortunatel*, the !)C is ele.ated in up to ?0 percent of patients &ith other causes of right lo&er Buadrant pain: =0 #hus, an ele.ated !)C has a lo& predicti.e .alue: 1erial !)C measurements 3o.er 4 to @ hours4 in suspected cases ma* increase the specificit*, as the !)C count often increases in acute appendicitis 3except in cases of perforation, in &hich it ma* initiall* fall4: A In addition, 9A percent of patients ha.e neutrophilia = and, in the elderl*, an ele.ated band count greater than E percent has been sho&n to ha.e a high predicti.e .alue for appendicitis: 9 In general, ho&e.er, the !)C count and differential are onl* moderatel* helpful in confirming the diagnosis of appendicitis because of their lo& specificities: A more recentl* suggested laborator* e.aluation is determination of the C' reacti.e protein le.el: An ele.ated C'reacti.e protein le.el 3greater than 0:@ mg per d64 is common in appendicitis, but studies disagree on its sensiti.it* and specificit*: 4,A An ele.ated C'reacti.e protein le.el in combination &ith an ele.ated !)C count and neutrophilia are highl* sensiti.e 39? to =00 percent4: #herefore, if all three of these findings are absent, the chance of appendicitis is lo&: A In patients &ith appendicitis, a urinal*sis ma* demonstrate changes such as mild p*uria, proteinuria and hematuria, = but the test ser.es more to exclude urinar* tract causes of abdominal pain than to diagnose appendicitis: Radiolo$ic +(aluation #he options for radiologic e.aluation of patients &ith suspected appendicitis ha.e expanded in recent *ears, enhancing and sometimes replacing pre.iousl* used radiologic studies: (lain radiographs, &hile often re.ealing abnormalities in acute appendicitis, lac" specificit* and are more helpful in diagnosing other causes of abdominal pain: FIBUR+ 3C -ltrasonogram sho&ing longitudinal section 3arro&s4 of inflamed appendix: 6i"e&ise, barium enema is no& used infreBuentl* because of the ad.ances in abdominal imaging: A -ltrasonograph* and computed tomographic 3C#4 scans are helpful in e.aluating patients &ith suspected appendicitis: == -ltrasonograph* is appropriate in patients in &hich the diagnosis is eBui.ocal b* histor* and ph*sical examination: It is especiall* &ell suited in e.aluating right lo&er Buadrant or pel.ic pain in pediatric and female patients: A normal appendix 3E mm or less in diameter4 must be identified to rule out appendicitis: An inflamed appendix usuall* measures greater than E mm in diameter 3Figure 34, is noncompressible and tender &ith focal compression: 2ther right lo&er Buadrant conditions such as inflammator* bo&el disease, cecal di.erticulitis, $ec"el;s di.erticulum, endometriosis and pel.ic inflammator* disease can cause false'positi.e ultrasonograph* results: =2 C#, specificall* the techniBue of appendiceal C#, is more accurate than ultrasonograph* 3Table 54: Appendiceal C# consists of a focused, helical, appendiceal C# after a 9astrografin'saline enema 3&ith or &ithout oral contrast4 and can be performed and interpreted &ithin one hour: Intra.enous contrast is unnecessar*: =2 #he accurac* of C# is due in part to its abilit* to identif* a normal appendix better than ultrasonograph*: =F An inflamed appendix is greater than E mm in diameter, but the C# also demonstrates periappendiceal inflammator* changes =4 3Figures 4 and 54: If appendiceal C# is not a.ailable, standard abdominal8pel.ic C# &ith contrast remains highl* useful and ma* be more accurate than ultrasonograph*: =2 Treatment #he standard for management of nonperforated appendicitis remains appendectom*: )ecause prompt treatment of appendicitis is important in pre.enting further morbidit* and mortalit*, a margin of error in o.er'diagnosis is acceptable: Currentl*, the national rate of negati.e appendectomies is approximatel* 20 percent: =A 1ome studies ha.e in.estigated nonoperati.e management &ith parenteral antibiotic treatment, but 40 percent of these patients e.entuall* reBuired appendectom*: F Appendectom* ma* be performed b* laparotom* 3usuall* through a limited right lo&er Buadrant incision4 or laparoscop*: iagnostic laparoscop* ma* be helpful in eBui.ocal cases or in &omen of childbearing age, &hile therapeutic laparoscop* ma* be preferred in certain subsets of patients 3e:g:, &omen, obese patients, athletes4: =E !hile laparoscopic inter.ention has the ad.antages of decreased postoperati.e pain, earlier return to normal acti.it* and better cosmetic results, its TA.L+ 6 Comparison of -ltrasound and Appendiceal C# E.aluation of 1uspected Appendicitis #omparison $raded ultrasound Appendiceal computed tomo$rap*ic scan 1ensiti.it* @A> 90 to =00> 1pecificit* 92> 9A to 9?> -se E.aluate patients &ith eBui.ocal diagnosis of appendicitis E.aluate patients &ith eBui.ocal diagnosis of appendicitis Ad.antages 1afe Relati.el* inexpensi.e Can rule out pel.ic disease in females )etter for children $ore accurate )etter identifies phlegmon and abscess )etter identifies normal appendix isad.antages 2perator dependent #echnicall* inadeBuate studies due to gas (ain Cost Ioni<ing radiation Contrast In&%rati%n &r% re&erences <<, <*, (A. disad.antages include greater cost and longer operati.e time: 4 2pen appendectom* ma* remain the primar* approach to treatment until further cost and benefit anal*ses are conducted: FIBUR+ 4C Computed tomographic scan sho&ing cross'section of inflamed appendix 3A4 &ith appendicolith 3a4: FIBUR+ 6C Computed tomographic scan sho&ing enlarged and inflamed appendix 3A4 extending from the cecum 3C4: #omplications Appendiceal rupture accounts for a ma,orit* of the complications of appendicitis: %actors that increase the rate of perforation are dela*ed presentation to medical care, =? age extremes 3*oung and old4 =@ and hidden location of appendix: E A brief period of in'hospital obser.ation 3less than six hours4 in eBui.ocal cases does not increase the perforation rate and ma* impro.e diagnostic accurac*: =@ iagnosis of a perforated appendix is usuall* easier 3although immediatel* after rupture, the patient;s s*mptoms ma* temporaril* subside4: #he ph*sical examination findings are more ob.ious if peritonitis generali<es, &ith a more generali<ed right lo&er Buadrant tenderness progressing to complete abdominal tenderness: An ill'defined mass ma* be felt in the right lo&er Buadrant: %e.er is #he classic histor* of pain beginning in the periumbilical region and migrating to the right lo&er Buadrant occurs in onl* A0 percent of patients: more common &ith rupture, and the !)C count ma* ele.ate to 20,000 to F0,000 per mm F 3200 to F00 F =0 9 per 64 &ith a prominent left shift: F A periappendiceal abscess ma* be treated immediatel* b* surger* or b* nonoperati.e management: 4 /onoperati.e management consists of parenteral antibiotics &ith obser.ation or C#'guided drainage, follo&ed b* inter.al appendectom* six &ee"s to three months later: = Special #onsiderations !hile appendicitis is uncommon in *oung children, it poses special difficulties in this age group: Noung children are unable to relate a histor*, often ha.e abdominal pain from other causes and ma* ha.e more nonspecific signs and s*mptoms: #hese factors contribute to a perforation rate as high as A0 percent in this group: = In pregnanc*, the location of the appendix begins to shift significantl* b* the fourth to fifth months of gestation: Common s*mptoms of pregnanc* ma* mimic appendicitis, and the leu"oc*tosis of pregnanc* renders the !)C count less useful: !hile the maternal mortalit* rate is lo&, the o.erall fetal mortalit* rate is 2 to @:A percent, rising to as high as FA percent in perforation &ith generali<ed peritonitis: As in nonpregnant patients, appendectom* is the standard for treatment: F
Elderl* patients ha.e the highest mortalit* rates: #he usual signs and s*mptoms of appendicitis ma* be diminished, at*pical or absent in the elderl*, &hich leads to a higher rate of perforation: $ore freBuent perforation combined &ith a higher incidence of other medical problems and less reser.e to fight infection contribute to a mortalit* rate of up to A percent or more: = Final #omment (rompt diagnosis of appendicitis ensures timel* treatment and pre.ents complications: )ecause abdominal pain is a common presenting s*mptom in outpatient care, famil* ph*sicians ser.e an important role in the diagnosis of appendicitis: 2b.ious cases of appendicitis reBuire urgent referral, &hile eBui.ocal cases &arrant further e.aluation and, man* times, surgical consultation: #he techniBue of appendiceal computed tomograph* is more accurate than ultrasonograph* in confirming the diagnosis of appendicitis: #he author than"s 9len Cr*er, epartment of (ublications, 1cott and !hite $emorial 0ospital, #emple, #ex:, for help &ith the manuscript: %igures F through A &ere pro.ided b* $ichael 6: /ipper, $::, epartment of Radiolog*, 1cott and !hite $emorial 0ospital, #emple, #ex: