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Chapter 26: Acute Abdomen and the Appendix

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A 23-year-old man presents to the emergency department (ED) with crampy, nonradiating abdominal pain in the right lower quadrant. He is taken to the operating room and found to have a normal-appearing appendix. On further evaluation, the distal ileum appears inflamed with fat wrapping. You notice the cecum is not involved. What is your management at this time?

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(A) Perform appendectomy

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(B) Close and consult gastroenterology

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(C) Perform appendectomy and resect the distal ileum

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(D) Perform appendectomy and stricturoplasty of the terminal ileum

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(E) Run the small bowel to rule out Meckel diverticulum

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(A) Historically, 20% of all explorations for appendicitis turn out to be negative; however, the negative appendectomy rate has decreased to less than 10% at some centers (possibly related to improvement in CT imaging). If appendicitis is not found at operation, other sources of pain must be sought. On exploration, the patient had classic findings of Crohn disease, including fat wrapping, which is pathognomonic for Crohn disease. Clinically, differentiating Crohn disease from appendicitis can be difficult, especially without preoperative imaging. If the history discloses previous episodes of colicky abdominal pain with bouts of diarrhea, it should lead to a suspected diagnosis of Crohn disease. Management of the disease intraoperatively is to perform an appendectomy if there is no cecal involvement in order to eliminate the diagnostic confusion of appendicitis versus Crohn flare in the future. If the cecum is involved, an appendectomy is not performed because of the risk of fistula formation. Stricturoplasty is not indicated secondary to the lack of obstructive symptoms.

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BIBLIOGRAPHY

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Maa J, Kirkwood KS. The appendix. In: Townsend CM, Beauchamp RD, Evers M, Mattox KL (eds.), Sabiston Textbook of Surgery, 19th ed. Philadelphia, PA: WB Saunders Co.; 2012.

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A 42-year-old man presents to the ED with complaints of abdominal pain, nausea, and vomiting. He states the pain is 8/10 in intensity and began early in the morning. The pain is located in the left upper quadrant (LUQ) without radiation and is described as being achy and dull. He also complains of a low-grade fever and having no bowel movements in the last 2 days. There is no other significant medical history. Lab work reveals white blood cell (WBC) count of 16,000 with left shift; urinalysis (UA) is negative. Physical examination reveals tenderness in the lower border of the LUQ, with some guarding but no rebound or rigidity. There are no palpable masses and no hepatosplenomegaly. A computed tomography (CT) of the abdomen revealed malrotation with appendicitis. What is the most appropriate surgical option?

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