View Full Chapter Figures Only Tables Only Videos Only Print Share Email Send Email Your Name (required) ! Example: John Doe Email Address (required) ! Please enter a valid sender email address. Example: email@example.com CC Me Recipient Email Address (required) ! Separate multiple email address with semi-colons (up to 5). Subject Subject for your email. Message (Maximum characters: 1,000) Please enter your name Please enter your email address Please enter a valid recipient email address. Example:firstname.lastname@example.org Submit Cancel Thank you! Your email has been sent to: The recipient(s) will receive an email message that includes a link to the selected article. Recipients may need to check their spam filters or confirm that the address is safe. Return to: Send Another Email An error has occurred sending your email(s). Please try again later or contact an administrator at OnlineCustomer_Service@mheducation.com. Return to: Twitter Facebook Linkedin Reddit Get Citation Citation AMA Citation Appendicitis, Acute. In: Doherty GM. Doherty G.M. Ed. Gerard M. Doherty.eds. Quick Answers Surgery New York, NY: McGraw-Hill; 2010. http://accesssurgery.mhmedical.com/content.aspx?bookid=853§ionid=49661995. Accessed June 29, 2017. MLA Citation . "Appendicitis, Acute." Quick Answers Surgery Doherty GM. Doherty G.M. Ed. Gerard M. Doherty. New York, NY: McGraw-Hill, 2010, http://accesssurgery.mhmedical.com/content.aspx?bookid=853§ionid=49661995. Download citation file: RIS (Zotero) EndNote BibTex Medlars ProCite RefWorks Reference Manager © Copyright Tools Search Book Top Return Clip Appendicitis, Acute + Essential Features Print Section + • Abdominal pain• Anorexia, nausea, and vomiting• Localized right lower quadrant pain• Low-grade fever• Leukocytosis ++ Epidemiology + • 7% of people in Western countries have appendicitis at some time in their lives• 200,000 appendectomies for acute appendicitis are performed each year in the United States• Incidence in developing countries has been increasing in proportion to economic gains and changes in lifestyle• Major causes: Obstruction of the proximal lumen by fibrous bands, lymphoid hyperplasia, fecaliths, calculi, or parasites• Evidence of temporal and geographic clustering of cases has suggested a primary infectious etiology• Diagnosis is most difficult in the very young or old• Highest incidence of false-positives occur in women between the ages of 20 and 40, attributable to pelvic inflammatory disease (PID) and other gynecologic conditions + Clinical Findings Print Section ++ Symptoms and Signs + • Classically, abdominal pain develops prior to nausea and vomiting• Peri-umbilical abdominal pain initially, then localizes to the right lower quadrant• Right lower quadrant rebound or percussion tenderness (localized "peritoneal irritation")• Constipation and indigestion are frequent complaints• Patients complain of discomfort with movement, walking, or coughing• Low-grade fever (99 °F-101 °F) unless perforation has occurred ++ Laboratory Findings + • Mild leukocytosis (10,000-15,000) with left shift• Mild elevations in amylase• UA frequently will show a few WBC and RBCs on microscopic exam• Elevated C-reactive protein and ESR levels ++ Imaging Findings + • Plain films may show evidence of localized air fluid levels or localized ileus or increased soft-tissue density in the right lower quadrant -Less common findings include an appendiceal calculus, altered right psoas stripe, or an abnormal right flank stripe• US may demonstrate a dilated tubular structure in the right lower quadrant although this technique is user- and institutional-dependant and is less sensitive in adults than in children• Spiral CT (either abdominal/pelvic or a dedicated "appendiceal protocol") is the most sensitive and specific diagnostic radiographic test -An enlarged appendix with peri-appendiceal fat stranding is demonstrated in 90-95% of cases-CT scans are of greatest value in patients with atypical clinical presentation or laboratory findings + Diagnostic Considerations Print Section + • Acute salpingitis• PID• Regional enteritis/complicated Crohn disease• Viral gastroenterologic infection• Mesenteric adenitis• Dysmenorrhea• Ovarian lesions• Urinary tract infections• Small bowel obstruction• Cecal volvulus• Incarcerated hernia• Mesenteric ischemia• Acute cholecystitis• Right-sided diverticulitis (true cecal or a redundant sigmoid that flops over into the right lower quadrant)• Complicated peptic ulcer disease (with enteric contents collecting in the right paracolic gutter)• Infarcted epiploic appendage ++ Rule Out + • Nonsurgical etiology of right lower quadrant abdominal pain-Acute salpingitis-Dysmenorrhea-Urinary tract infections-Viral gastroenterologic infection-Mesenteric adenitis-Others• Complicated appendicitis manifested by right lower quadrant abscess formation + Work-up Print Section + • Thorough history and physical exam (including rectal and pelvic in all females)• CBC• Basic chemistries and liver profile• Amylase and lipase• UA• Chest and abdominal films• Obtain CT scans when clinical presentation or laboratory findings are atypical ++ When to Admit + • All patients with acute appendicitis or complicated appendicitis for definitive treatment• In equivocal clinical presentations, 24-hour admission for serial abdominal exams is helpful in making the diagnosis of acute appendicitis• Reliable patients that live close to the hospital may be sent home and asked to return to the emergency department if their pain worsens ++ When to Refer + • Referral to gynecology, gastroenterology, etc as clinically indicated• Patients who present in a delayed fashion with a formed right lower quadrant abscess may be best managed by percutaneous drainage via interventional radiology + Treatment and Management Print Section + • CT scan or 24-hour admission for serial abdominal exams or diagnostic laparoscopy for "nonclassic" presentation• Appendectomy mainstay of treatment for uncomplicated acute appendicitis• Appendectomy can be performed open or laparoscopically• Patients with complicated appendicitis can be treated operatively with appendectomy and drainage or with percutaneous drainage followed by delayed appendectomy• Abdominal drainage only for established abscesses• Culturing abdominal fluid has no practical value as organisms are the usual fecal flora• If a patient with appendicitis cannot be taken to a surgical facility for care, treatment should consist of antibiotics alone ++ Surgery ++ Indications + • Uncomplicated acute appendicitis• Diagnostic laparoscopy, especially in young women• Interval appendectomy for patients with right lower quadrant abscess formation and who were treated initially with percutaneous drainage ++ Medications + • Prophylactic antibiotics are indicated preoperatively only• Single-drug regimen, usually a cephalosporin, is as effective as multidrug combinations ++ Treatment Monitoring + • Clinical improvement in symptoms• Resolution of fever• Normalization of WBC ++ Complications + • Wound complications• Right lower quadrant abscess formation (up 30% in perforated appendicitis)• Tubal infertility in complicated appendicitis ++ Prognosis + • Mortality 0.1% for uncomplicated appendicitis• Mortality 5% for perforated appendicitis + Resources Print Section ++ References ++Andersen BR, Kallehave FL, Andersen HK: Antibiotics versus placebo for prevention of postoperative infection after appendicectomy. Cochrane Database Syst Rev 2005;3:CD001439. ++Blomqvist PG et al: Mortality after appendectomy in Sweden, 1987â1996. Ann Surg 2001;233:455. [PubMed: 11303128] ++Brown CV et al: Appendiceal abscess: immediate operation or percutaneous drainage? Am Surg 2003;69:829. [PubMed: 14570357] ++Carr NJ: The pathology of acute appendicitis. Ann Diagn Pathol 2000;4:46. [PubMed: 10684382] ++Choi D et al: The most useful findings for diagnosing acute appendicitis on contrast-enhanced helical CT. Acta Radiologica 2003;44:574. [PubMed: 14616200] ++Lee SL et al: Computed tomography and ultrasonography do not improve and may delay the diagnosis and treatment of acute appendicitis. Arch Surg 2001;136:556. [PubMed: 11343547] ++Long KH et al: A prospective randomized comparison of laparoscopic appendectomy with open appendectomy: clinical and economic analyses. Surgery 2001;129:390. [PubMed: 11283528] ++Mourad J et al: Appendicitis in pregnancy: new information that contradicts long-held clinical beliefs. Am J Obstet Gynecol 2000;182:1027. [PubMed: 10819817] ++Pinto Leite N et al: CT evaluation of appendicitis and its complications: imaging techniques and key diagnostic findings. Am J Roentgenol 2005;185:406. [PubMed: 16037513] ++Sauerland S, Lefering R, Neugebauer EA: Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev 2004;4:CD001546.