View source for Appendicitis

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{{Adult top}} [[Special:MyLanguage/appendicitis (peds)|appendicitis (peds)]]
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==Background==

[[File:Appendix locations.png|thumb|Drawing of colon with variability of appendix locations as seen from anterior view.]]
*Acute inflammation of the vermiform appendix
*Most common non-obstetric surgical emergency in pregnancy 
*Most common abdominal surgical emergency in patients <50
*Most common between 10-30 years, but no age is exempt
*Most commonly caused by luminal obstruction by a fecalith 
*There are no historical or physical exam findings that can definitively rule out appendicitis



==Clinical Features==

[[File:McBurney's point.jpg|thumb|Location of McBurney's point (1), located two thirds the distance from the umbilicus (2) to the right anterior superior iliac spine (3).]]


===History===

*Early on primarily malaise, indigestion, anorexia 
**Later patient develops [[Special:MyLanguage/abdominal pain|abdominal pain]] 
***Initially vague, periumbilical (visceral innervation) 
***Later migrates to McBurney point (parietal innervation)
*** <50% of patients have this typical presentation 
*[[Special:MyLanguage/Nausea|Nausea]], with or with out emesis, typically follows onset of pain 
*[[Special:MyLanguage/Fever|Fever]] may or not occur 
*Urinary symptoms common given proximity of appendix to urinary tract (sterile pyuria) 
*Sudden improvement suggests perforation 
*33% of patients have atypical presentation 
**Retrocecal appendix can cause [[Special:MyLanguage/flank pain|flank]] or [[Special:MyLanguage/pelvic pain|pelvic pain]] 
**Gravid uterus sometimes displaces appendix superiorly → [[Special:MyLanguage/RUQ pain|RUQ pain]]



===Physical Exam===

*McBurney's: maximal tenderness to palpation 2/3 of the way between umbilicus and right anterior superior iliac spine
*Rovsing sign (palpation of LLQ worsens RLQ pain) 
*Psoas sign (extension of right leg at hip while patient lies on left side elicits abdominal pain) 
*Obturator sign (internal and external rotation of thigh at hip elicits pain 
*[[Special:MyLanguage/Peritonitis|Peritonitis]] suggested by: 
**Right heel strike elicits pain 
**Guarding
**Rebound
**Rigidity



===Clinical Examination Operating Characteristics===

{| class="wikitable"
|-
| Procedure
| LR+
| LR-
|-
| RLQ pain
| 7.3-8.4
| 0-0.28
|-
| Rigidity
| 3.76
| 0.82
|-
| Migration
| 3.18
| 0.50
|-
| Pain before vomiting
| 2.76
| NA
|-
| Psoas sign
| 2.38
| 0.90
|-
| Fever
| 1.94
| 0.58
|-
| Rebound
| 1.1-6.3
| 0-0.86
|-
| Guarding
| 1.65-1.78
| 0-0.54
|-
| No similar pain previously
| 1.5
| 0.32
|-
| Anorexia
| 1.27
| 0.64
|-
| Nausea
| 0.69-1.2
| 0.70-0.84
|-
| Vomiting
| 0.92
| 1.12
|}



==Differential Diagnosis==

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{{Abd DDX RLQ}}
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==Evaluation==

[[File:Appendicitis_Jarrett_Subramaniam.gif|thumbnail|Dilated, non-compressible appendix with appendicolith and surrounding free fluid<ref>http://www.thepocusatlas.com/pediatrics/</ref>]]
[[File:AppendicitisMark.png|thumb|Peri-appendiceal fat stranding in the setting of acute appendicitis.]]
[[File:X-ray showing fecalith which has caused appendicitis.jpg|thumb|Fecalith (arrow) and stranding in the setting of acute appendicitis.]]
[[File:CAT scan demonstrating acute appendicitis.jpg|thumb|Dialated appendix and stranding in the setting of acute appendicitis.]]


===Appendicitis Risk Scores===

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{{Alvarado scoring system}}
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===Labs===

*Abdominal panel
**CBC
***Normal WBC does not rule-out appendicitis
***Only 80% of patients will have leukocytosis with left shift<ref>Khan MN, Davie E, Irshad K. The role of white cell count and C-reactive protein in the diagnosis of acute appendicitis. J Ayub Med Coll Abbottabad. 2004;16(3):17-19.</ref>
**Chemistry
**Consider LFTs + lipase
**Consider coagulation studies (PT, PTT, INR), as a marker of liver function
*Urine pregnancy
*[[Special:MyLanguage/Urinalysis|Urinalysis]]
**Leukocytes will be present in 40% of patients<ref>Baird DLH, Simillis C, Kontovounisios C, Rasheed S, Tekkis PP. Acute appendicitis. BMJ. 2017;357:j1703. Published 2017 Apr 19. doi:10.1136/bmj.j1703</ref>
*Consider [[Special:MyLanguage/serum lactate|serum lactate]]
**Does not necessarily define level of severity (if appendicitis is present.) 
**Can aid in trending effective resuscitation once the diagnosis is made.
*Consider CRP
**Normal CRP AND WBC makes appendicitis unlikely



===Imaging===

*Early surgical consultation should be obtained before imaging in straightforward cases
*Not universally necessary; consider in:
**Women of reproductive age
**Men with equivocal presentation
*Perforation may result in false negative study
*Imaging modalities
**[[Ultrasound: Abdomen|Ultrasound]]
***First choice for pregnant women and children
***Limitations: operator-dependent, difficult to visualize with obesity, gravid uterus, bowel gas, guarding, lack of patient cooperation
***Findings: noncompressible appendix >6mm in diameter, wall thickness greater or equal to 3 mm
***Other supportive findings: aperistalsis, distinct wall layers, target appearance in axial view, appendicolith, periappendiceal fluid, prominent echogenic periappendiceal fat
**CT
***First choice for adult males and nonpregnant women with equivocal cases
***Women derive the greatest benefit from preoperative imaging (lower neg appy rate)
***Contrast (both PO and IV) is unnecessary but typically ordered
**MRI
***When unable to identify appendix in children or pregnant women



==Management==


===Supportive Management===

#NPO status
#[[Special:MyLanguage/Fluid resuscitation|Fluid resuscitation]]
#[[Special:MyLanguage/Analgesia|Analgesia]]/[[Special:MyLanguage/antiemetics|antiemetics]]



===[[Special:MyLanguage/Antibiotics|Antibiotics]]===

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{{Appendicitis Antibiotics}}
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===Surgery===

*Open laparotomy or laparoscopy
**Patients who present <72 hours after the onset of symptoms usually undergo immediate appendectomy
**Patients who present >72hrs and have perforated appendix may be treated initially with antibiotics, intravenous fluids, and bowel rest



==Disposition==

*Admission



==Complications==


===Infection===

*Either a simple wound infection or an intraabdominal abscess
**Typically in patients with perforated appendicitis



===Recurrent appendicitis===

*Occurs in approximately 1:50,000 appendectomies <ref>Hendahewa R. et al. The dilemma of stump appendicitis - a case report and literature review. Int J Surg Case Rep. 2015; 14: 101-3.</ref>
*Typically caused by inflammation of the remaining appendiceal stump
**Can also be caused by a retained piece of the appendix not removed during surgery <ref>Boardman T. et al. Recurrent appendicitis caused by a retained appendiceal tip: A case report. The Journal of Emergency Medicine. 2019; 57: 232-4.</ref>
*Can present similar to primary appendicitis
*Treatment similar to that of primary appendicitis and likely requires surgical revision of the appendiceal stump or removal of retained tissue
*Delay in diagnosis and treatment can result in perforation and sepsis



==See Also==

*[[Special:MyLanguage/Appendicitis (Peds)|Appendicitis (Peds)]]



==External Links==

*[http://www.chop.edu/clinical-pathway/appendicitis-without-known-gi-disease-clinical-pathway CHOP Appendicitis Pathway]
*[https://www.acep.org/patient-care/clinical-policies/appendicitis/ ACEP Clinical Policy Statement]
*[http://www.emdocs.net/appendicitis-why-do-we-miss-it-and-how-do-we-improve/ emDocs - Appendicitis: Why Do We Miss It, and How Do We Improve?]



==References==

<references/>
[[Category:GI]]
[[Category:Surgery]]
[[Category:ID]]
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