med 18

 

MEDICAL DECISION MAKING

Acute appendicitis is largely a clinical diagnosis and

should be considered in any patient with atraumatic

right-sided abdominal, periumbilical, or flank pain who

has not had an appendectomy. The differential diagnosis

of such a patient is broad and includes diverticulitis, volvulus, colitis, ileitis, bowel obstruction, irritable bowel

disease, incarcerated hernia, intra-abdominal abscess,

intussusception, malrotation, mesenteric lymphadenitis,

ectopic pregnancy, ovarian torsion, ovarian vein thrombosis, pyelonephritis, referred testicular pain, renal colic,

tubo-ovarian abscess, abdominal wall hematoma, and

psoas abscess (Figure 27-2).

TREATMENT

Patients with acute appendicitis typically require appendectomy, so surgical consult should be obtained promptly.

Patients should be kept NPO (nothing by mouth) to avoid

operative delays and be given IV hydration, antiemetics,

and analgesics, including narcotics, as needed. Perioperative

antibiotics should be given once the diagnosis has been

made or if the patient exhibits signs of peritonitis.

Appropriate choices should include broad coverage of

aerobic and anaerobic gram-negative organisms, such as

ciprofloxacin and metronidazole.

CHAPTER 27

Suspicion of append icitis based

on history & physical exam

Classic presentation: acute

onset ( < 48 hours), RLQ

tenderness, migration of

pain, anorexia

Equivocal or late

presentation

(suspected abscess)

Surgical consultation Appendicitis

Figure 27·2. Appendicitis diag nostic algorithm. CT, computed tomog raphy; RLQ, right lower quadrant.

DISPOSITION

� Admission

All patients with appendicitis should be admitted to the hospital after consultation with a general surgeon. Patients with

equivocal diagnoses can be observed with serial examinations.

� Discharge

Stable, nontoxic patients with adequate pain control, toleration of oral fluids, and no significant comorbidities who

have been ruled out for appendicitis and other surgical

conditions may be considered for discharge with timely

follow-up. Discharged patients should be given written instructions that identify signs or symptoms needing earlier return.

SUGGESTED READING

Andersson RE. Meta-analysis of the clinical and laboratory diagnosis of appendicitis. Br J Surg. 2004;9 1 :28-37.

DeKoning EP. Acute appendicitis. In: Tintinalli JE,

Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler

GD. Tintinalli's Emergency Medicine: A Comprehensive

Study Guide. 7th ed. New York, NY: McGraw-Hill, 201 1,

pp. 574-578.

Humes DJ, Simpson J. Acute appendicitis. Br Med /. 2006;333:

530-534.