CE/CME Review Jennifer A. Snyder, PA-C, DFAAPA, Samuel L. Gurevitz, PharmD, CGP, Lindsey S. Rush, MS, PA-S, Laura C. McKeague, PA-S, Chandra Greenlee Houpt, MPAS, PA-C In which patients is the suspicion for appendicitis heightened? Do history and physical exam fi ndings vary with patient age? Who is at increased risk for perforation? What treatments are recommended for uncomplicated versus complicated appendicitis, and are antibiotics alone ever the answer? Primary care clinicians Acute appendicitis, as shown in an must be well prepared to confront these and other questions when abdominal x-ray, frontal view a patient presents with of appendicitis.

CE/CME INFORMATION

TARGET AUDIENCE: This activity has been de- ACCREDITATION STATEMENT: ing objectives and faculty disclosures; 2) study the edu- signed to meet the educational needs of physician as- PHYSICIAN ASSISTANTS cational activity; 3) go to www.clinicianreviews.com/ sistants and nurse practitioners in primary care with This program has been reviewed and is approved for CECourses.aspx, follow links to the posttest for this patients who have signs and symptoms of appendicitis. a maximum of 1.0 hour of American Academy of activity, and provide payment information via our se- • Original Release Date: January 2012 Physician Assistants (AAPA) Category I CME credit cure server; 4) complete the 10-question posttest by • Expiration Date: January 31, 2013 by the Physician Assistant Review Panel. Approval is recording the best answer to each question; and 5) re- • Estimated Time to Complete This Activity: 1 valid for one year from the issue date of January cord their response to each of the additional evaluation hour 2012. Participants may submit the self-assessment at questions. • Medium: Printed journal and online CE/CME any time during that period. If you have any questions, e-mail CR.evaluations@ This program was planned in accordance with AA- qhc.com. Upon successful completion of an online PROGRAM OVERVIEW: The primary objective PA’s CME Standards for Enduring Material Pro- posttest, with a score of 70% or better, and the com- of this educational initiative is to provide clinicians grams and for Commercial Support of Enduring Ma- pletion of the online activity evaluation form, a state- in primary care with the most up-to-date informa- terial Programs. ment of credit will be made available immediately. tion regarding the detection and management of ap- Successful completion of the self-assessment is re- pendicitis. quired to earn Category I CME credit. Successful DISCLOSURE OF UNLABELED USE: This ed- completion is defi ned as a cumulative score of at least ucational activity may contain discussion of published EDUCATIONAL OBJECTIVES: After complet- 70% correct. and/or investigational uses of agents that are not indi- ing this activity, the participant should be better able cated by the FDA. AAPA, The NPA, and Quadrant to: ACCREDITATION STATEMENT: HealthCom Inc. do not recommend the use of any • Describe features in the history, symptomatology, NURSE PRACTITIONERS agent outside of the labeled indications. and physical examination that are most indicative of This program has been approved by the Nurse Practi- The opinions expressed in this educational activity appendicitis in specifi c patient populations. tioner Association New York State (The NPA) for 1.0 are those of the faculty and do not necessarily repre- • List components in the patient evaluation that are contact hour. sent the views of AAPA, The NPA, or Quadrant helpful for ruling out other conditions that may HealthCom Inc. Please refer to the offi cial prescribing mimic appendicitis. DISCLOSURE OF CONFLICTS OF INTER- information for each product for discussion of ap- • Specify the laboratory tests and imaging studies most EST: The faculty reported the following fi nancial proved indications, contraindications, and warnings. likely to support a diagnosis of appendicitis. relationships or relationships to products or devices • Discuss conventional management of uncomplicated they or their spouse/life partner have with commer- DISCLAIMER: Participants have an implied re- and complicated appendicitis, as well as nonopera- cial interests related to the content of this CME ac- sponsibility to use the newly acquired information to tive options that require investigation in reliable tivity: Jennifer A. Snyder, PA-C, DFAAPA, Samuel L. enhance patient outcomes and their own professional clinical trials. Gurevitz, PharmD, CGP, Lindsey S. Rush, MS, PA-S, development. The information presented in this ac- Laura C. McKeague, PA-S, and Chandra Greenlee tivity is not meant to serve as a guideline for patient FACULTY: Jennifer A. Snyder, PA-C, DFAAPA, is an Houpt, MPAS, PA-C, reported no signifi cant fi nan- management. Any procedures, medications, or other Associate Professor and Samuel L. Gurevitz, PharmD, cial relationship with any commercial entity related courses of diagnosis or treatment discussed or sug- CGP, is an Assistant Professor in the Physician Assistant to this activity. gested in this activity should not be used by clinicians Program at Butler University in Indianapolis. Lindsey without evaluation of their patient’s conditions and S. Rush, MS, PA-S, and Laura C. McKeague, PA-S, are METHOD OF PARTICIPATION: The fee for the possible contraindications or dangers in use, re- students in the program. Chandra Greenlee Houpt, participating and receiving CME credit for this activi- view of any applicable manufacturer’s product infor- MPAS, PA-C, is a family practice PA at Center Grove ty is $10.00. During the period January 2012 through mation, and comparison with recommendations of Family Medicine in Greenwood, Indiana. January 31, 2013, participants must 1) read the learn- other authorities.

Clinician Reviews January 2012 • Vol 22, No 1 23

2233 CE-CMECE-CME AppendicitisAppendicitis FINAL.inddFINAL.indd 2323 112/21/112/21/11 12:5712:57 PMPM CE/CME Appendicitis Review

ppendicitis is a trans- cated appendicitis, unless treated PATIENT EVALUATION TABLE 1 mural infl ammatory surgically, eventually evolves into In most cases, a diagnosis of ap- process and a common complicated appendicitis.10 Recent pendicitis can be made with a Possible Symptoms cause of an acute abdo- research refutes this assumption, careful history, systematic physi- of Appendicitis3,8,13,18 Amen. Infl ammation that leads to however, as different etiologies cal exam, and a limited number Anorexia perforation of the appendix, which may be associated with differences of laboratory tests without special Initial periumbilical pain is associated with increased mor- in progression10-12; whether un- diagnostic modalities.13 The pres- bidity and mortality, warrants complicated and complicated ap- ence of symptoms and signs may and/or prompt diagnosis. Etiology, clini- pendicitis are attributable to dif- help to rule in a diagnosis of ap- Migratory right lower quadrant cal presentation, diagnostic stud- ferent etiologies is a question pendicitis, but the absence of pain that is often more ies, and the management of con- requiring further research. Irre- clinical fi ndings often does not continuous and severe fi rmed appendicitis will be spective of the natural progression exclude its possibility.16 While Fever addressed here. of the disease, the current stan- adult and pediatric patients with Sources: Bundy et al. JAMA. 20073; Black and Martin. UpToDate. 20118; Howell et al. Frequently, the etiology of ap- dard of care for appendicitis is still appendicitis share many clinical Ann Emerg Med. 201013; Nance et al. Pediatr pendicitis is luminal obstruction an appendectomy.13 In US hospi- fi ndings (see Table 13,8,13,18), the Emerg Care. 2000.18 by a fecalith (the result of inspis- tals in 2007 (the most recent year occurrence rate of the various sated fecal material and inorganic for which data are available), ap- fi ndings may differ among pa- the anatomical position of the salts1), but the condition may also pendectomy was performed on tient populations.3,15 right lower quadrant (RLQ), with result from parasites, a malignan- 326,000 patients, or 10.9 patients The median time from onset of involvement of the surrounding cy, a foreign body, or fi brosis.1-3 In per 10,000 population.14 symptoms until the patient pres- parietal peritoneum.20 (McBur- some instances, lymphoid hyper- ents for a medical evaluation aver- ney’s point, at the junction of the plasia, resulting from a viral or EPIDEMIOLOGY ages 24 hours or less.16 Diagnosis lateral and middle thirds of a line bacterial infection, has been tar- Appendicitis is most frequently in patients at extremes of age often extending from the anterior su- geted as the cause of luminal ob- seen in the second decade of life proves more diffi cult than in oth- perior iliac spine to the umbili- struction.1,4 Nevertheless, in one- and occurs slightly more often in er patients.20 Thus, a high level of cus, was noted as the point of third to one-half of patients, males than in females.2,15 Further- suspicion must be maintained in maximal tenderness to palpation obstruction is not evident as a more, according to data reported these patient populations. in acute appendicitis by Charles precipitating factor in the devel- to the National Hospital Dis- McBurney in the late 1800s.21) opment of appendicitis. In such charge Survey (1970 to 2004), the The Symptom History This progression of symptoms, cases, the basis for the infl amma- rate of nonperforated appendicitis The appendix is located in the fi rst recognized by John Benja- tion is unknown.5 is much higher in men than in posteromedial wall of the cecum, min Murphy in 1904, is consid- As the obstructed appendix be- women.12 In appendicitis, the risk approximately 3 cm below the il- ered a more reliable indicator of comes congested, the intralumi- for rupture is small within the eocecal valve.1 Initial pain per- appendicitis than RLQ pain nal pressure and venous pressure fi rst 36 hours of symptom onset. ceived around the umbilicus rep- alone3,22; in one large retrospec- increase, leading to stasis and Beyond that point, there is a 5% resents a referred pain resulting tive study, this migratory pain ischemia.1,5-8 The appendix be- increased risk for rupture with from the visceral innervation of had the highest positive predic- comes engorged with secretions. each ensuing 12-hour period.16 the midgut.20 As the infl amma- tive value for pediatric and adult At this stage, the condition is con- In neonates and infants, ap- tory process within the appendix patients (94.2% and 89.6%, re- sidered uncomplicated, but if an pendicitis is rare.3 In children advances, the pain localizes to spectively).15 However, migration infl amed appendix becomes gan- younger than 3 years, however, TABLE 2 grenous or perforates, the condi- the rate of perforation is 80% to 25,26 tion is then referred to as compli- 100%.3,17,18 This high rate may be Age-Specific Clinical Features cated appendicitis. Complicated explained by the very young Neonate Nonspecific with irritability; abdominal appendicitis allows for invasion by child’s limited ability to articu- (birth – 30 d) distention; vomiting; occasional abdominal wall intestinal bacteria of the abdomi- late his or her symptoms, or by cellulitis and palpable mass nal cavity, potentially leading to caregiver reports that are typi- Infancy Vomiting with diffuse abdominal tenderness, , septicemia, abscess, or cally limited to irritability or (age ≤ 2 y) and fever 5,9 3,17,19 fi stula formation. change in diet. According to Preschool Fever and right lower quadrant (RLQ) pain 2 Conventional teaching sup- Marudanayagam et al, who per- (2 – 5 y) reported more commonly; vomiting is often the ports the concept that uncompli- formed a retrospective study of first symptom noted by parents in most patients 2,660 appendectomies during a Jennifer A. Snyder is an Associate Profes- School-age Initial RLQ tenderness reported most commonly six-year period, the perforation sor and Samuel L. Gurevitz is an Assistant (6 – 12 y) Professor in the PA Program at Butler Uni- rate declined from 23.4% in pa- versity in Indianapolis. Lindsey S. Rush tients age 10 or younger to 6.9% Adolescence Periumbilical pain followed by nausea, then and Laura C. McKeague are students in (≥ 13 y) migration of pain to the RLQ and finally, in those in their 20s, then rose the program. Chandra Greenlee Houpt vomiting and fever is a family practice PA at Center Grove steadily to more than 50% in pa- Sources: Rothrock and Pagane. Ann Emerg Med. 200025; Wesson. UpToDate. 2010.26 Family Medicine in Greenwood, Indiana. tients 70 or older.

Clinician Reviews January 2012 • Vol 22, No 1 24

2233 CE-CMECE-CME AppendicitisAppendicitis FINAL.inddFINAL.indd 2424 112/21/112/21/11 12:5712:57 PMPM exams may yield normal fi ndings TABLE 4 TABLE 3 or may elicit tenderness.32 The rec- Possible Physical Possible Peritoneal Signs Due to tal examination should be per- Exam Findings in an Inflamed Appendix3,8,20 formed with considerable care, us- Uncomplicated Rebound tenderness, especially referred to the RLQ ing the smallest digit possible for 3,8,20 an adequate assessment, especially Appendicitis Cutaneous hyperesthesia at T10-12 in the younger patient.33 Variation in number of Guarding Several scoring systems have physical findings from Rovsing’s sign (pain in RLQ with palpation of left lower quadrant) been designed for adults and chil- patient to patient dren with suspected appendicitis, Fever (pain with flexing and internal and external rotation of the hip) using fi ndings from the history, Tachycardia the physical exam, and laboratory (pain on extension of the right hip due to Localized tenderness to 34 inflammation of the peritoneum overlying the iliopsoas muscles) testing (see Table 5, page 26, for percussion example). Despite their protocol- Markle sign (pain elicited in the when the standing Right lower quadrant based approach, the scoring sys- patient drops from standing on toes to the heels with a jarring tenderness tems have yielded mixed results in landing) Sources: Bundy et al. JAMA. 20073; Black clinical practice,34-36 and there is no and Martin. UpToDate. 20118; Humes and Abbreviation: RLQ, right lower quadrant. scoring system for evaluation of Simpson. BMJ. 2006.20 Sources: Bundy et al. JAMA. 20073; Black and Martin. UpToDate. 20118; Humes and Simpson. BMJ. 2006.20 the pregnant patient.37 Neither has of pain occurs in only 50% to nant or elderly, RLQ pain re- However, Bundy et al3 report that there been any recommendation 60% of patients, and therefore mains a signifi cant historical the presence of RLQ tenderness for or endorsement of a diagnostic may not be helpful.1,23 fi nding.30 In the pregnant woman, on palpation is of minimal value in guideline from any medical or According to results from oth- a diagnosis of appendicitis is often children; rather, fever is the single professional organization.38 Thus, er studies, unfortunately, this overlooked because of the dis- most useful sign among pediatric clinical gestalt is usually relied progression of symptoms is not comforts common to pregnancy patients and conversely, its ab- upon instead. often present in pediatric pa- and the expanding gravid uter- sence reduces the risk. tients.17 The somatic RLQ pain is us.31 Elderly patients often present Tachycardia is associated with Conditions to Rule Out continuous and more severe than with vague or atypical symptoms, risk for rupture.16,20 In the elderly The patient with is the early visceral periumbilical such as mild pain.20 In these pa- patient, fever (> 38°C) is also and suspected appendicitis should pain.1 Since the anatomic posi- tient populations, the diagnosis of strongly correlated with an in- be evaluated for other causes dur- tion of the appendix can vary, a appendicitis is often delayed. creased risk for rupture.30 ing the physical examination (see number of patients do not neces- In addition to obtaining a thor- To alleviate pain, a patient with Table 6, 2,8,39-42 page 26). In addi- sarily present with pain in the ough history of the presentation appendicitis may maintain the tion to investigation for other ab- RLQ but elsewhere.24 of pain, it is important to conduct hips and knees in a slightly fl exed dominal etiologies, auscultation to Certain clinical fi ndings ap- a complete review of the gastroin- position. While asking distract- the heart and lungs and an assess- pear to be relatively age-depen- testinal, genitourinary, pulmo- ing questions, the examiner ment of the peripheral vasculature dent (see Table 2,25,26 page 24). nary, musculoskeletal, neurologic, should observe the patient’s facial are imperative. Auscultation of the Classic fi ndings in the adult diag- and reproductive systems for pos- expressions to detect involuntary lungs is important to rule out a nosed with appendicitis, as de- sible alternate etiologies. guarding.3 RLQ tenderness to right lower lobe pneumonia that scribed by Becker et al,27 begin percussion is often positive. may generate referred pain to the with periumbilical pain, then Physical Examination The patient may experience RLQ due to a shared T9 derma- nausea, followed by migration of The number of physical fi ndings tenderness on palpation of the tome distribution.20,25 the pain to the RLQ, then vomit- varies among patients who present posterior abdominal wall (K sign) In males, the patient with ab- ing and fever. Abdominal pain with appendicitis3,8,20 (see Table or right-side fl ank tenderness.24 dominal pain should be assessed and anorexia are the most com- 33,8,20). A thorough physical exami- Increased pain with coughing for a testicular etiology, and a pel- mon presenting symptoms.20 nation is thus required to help the (Dunphy’s sign) or fi rm percussion vic examination is indicated in Nausea and vomiting that begin clinician exclude other diseases of the heel (the heel jar test) may be any female with abdominal pain, after the onset of abdominal pain and establish the diagnosis of ap- elicited.8,25 A number of addition- to rule out a gynecologic origin.1,3 are typical; in isolation, however, pendicitis. It is important to tailor al peritoneal signs, resulting from In the infant with suspected ap- these manifestations have weak the exam according to the patient’s an infl amed appendix, may occur pendicitis, a diagnosis of Hirsch- diagnostic predictability for ap- age and developmental stage.19 (see Table 43,8,20), but examination sprung’s disease (a congenital ob- pendicitis.28 In adults, if nausea The cooperation of children techniques that elicit these signs struction of the colon) should also and vomiting precede abdominal undergoing the physical examina- should be minimized so as to not be considered.17 pain, consideration should be giv- tion for appendicitis may vary. It cause the patient any unnecessary en to a diagnosis of gastroenteritis may be helpful to instruct a young pain. LABORATORY WORK-UP rather than appendicitis.29 child to “show me with your fi n- Depending on the location of Based on the patient’s history and Among patients who are preg- ger where it hurts the most.”3 the appendix, rectal and vaginal physical exam fi ndings, certain

Clinician Reviews January 2012 • Vol 22, No 1 25

2233 CE-CMECE-CME AppendicitisAppendicitis FINAL.inddFINAL.indd 2525 112/21/112/21/11 12:5712:57 PMPM CE/CME Appendicitis Review

laboratory and imaging studies or ectopic pregnancy, this test CT and ultrasound are cur- TABLE 6 can be useful in confi rming the should be ordered for all women rently considered the imaging diagnosis of appendicitis. A white capable of pregnancy who pres- studies of choice.13 Of the two, Differential blood cell (WBC) count with dif- ent with acute abdominal pain.20 multidetector CT is more accu- Diagnosis of ferential is helpful in both diagno- Urinalysis may be indicated to rate for detecting infl ammation of Appendicitis2,8,39-42 sis and exclusion of appendicitis: exclude abdominal pain of uri- the appendix (sensitivity, 98.5%; Gastroenteritis Appendicitis often leads to mod- nary tract etiology.3,46 specifi city, 98%; 99.5% negative B owel obstruction/ erate leukocytosis (WBC, 10,000 predictive value),47 especially in perforation to 20,000/μL) with neutrophilia.13 Imaging Studies the obese patient.48 While CT use Similarly, the fi nding of a normal Not all patients with a presump- has increased, the overall negative Mesenteric lymphadenitis or low WBC and absent left shift tive diagnosis of appendicitis re- appendectomy rate was similar in helps to rule out appendicitis.43 quire imaging. Such studies can be some clinical trials with or with- Crohn’s disease A C-reactive protein (CRP) val- foregone in patients with low clin- out CT use.49,50 Additionally, the Diverticulitis ue greater than 3.0 mg/dL, when ical suspicion for appendicitis, al- cost, availability, length of test, Intussusception combined with moderate leukocy- though they should be instructed and radiation exposure associated Pancreatitis tosis, may increase the likelihood to return if the pain worsens, with CT have raised concern of appendicitis and rule out other changes, or does not resolve. Like- about this imaging choice. Ectopic pregnancy conditions (eg, gastroenteritis, wise, patients with a high clinical Ultrasound is useful to confi rm Pelvic inflammatory disease mesenteric adenitis, pelvic infl am- suspicion for appendicitis may be appendicitis, particularly in pa- Endometriosis matory disease).15,44 Additionally, referred to a surgeon as early as tients with limited abdominal fat, Ovarian cyst/abscess/torsion 13 an elevated CRP may be sensitive possible (without imaging). but it has limitations in ruling out Testicular torsion (83% to > 90%) for detecting ap- In children, however, the clas- the condition.51 These include its Pneumonia pendiceal perforation and abscess sic clinical and laboratory fi nd- operator-dependent nature, limit- Volvulus formation.44 The role of cytokine ings are often less reliable in diag- ed ability to allow visualization of levels, such as interleukin-6 (IL-6) nosing appendicitis. Positive the appendix in obese patients, and B enign or malignant and IL-10, may be helpful but re- results on CT or ultrasound— lack of sensitivity in cases in which neoplasia Sources: Marudanayagam et al. main under investigation and are that is, infl ammation and disten- the appendix is perforated or only 2 7 J Gastroenterol. 2006 ; Black and Martin. not typically used in the diagnosis tion of the appendix or free fl uid the distal tip is involved. UpToDate. 20118; Harrison et al. Cases of appendicitis.45 in the abdomen—are associated Plain radiographs are not used J. 200939; Pirie. Clin Pediatr Emerg Med. 201040; Yokota et al. Gastrointest Endosc. Because negative fi ndings in with confi rmed appendicitis more to diagnose appendicitis, although 201041; Purysko et al. Radiographics. 15 the β-hCG rule out intrauterine than 90% of the time. they may be helpful to evaluate 2011.42 patients with atypical symptoms1 TABLE 5 or to rule out other causes of ab- proach should be taken, up to Alvarado Scoring System (MANTRELS Criteria)34 dominal pain. For example, a 76% of appendectomies are per- chest x-ray may be used to rule formed using a laparoscopic pro- Migration of pain to the right lower quadrant 1 out pneumonia or to look for free cedure rather than open surgery.55 Anorexia 1 air under the diaphragm, sug- Patients with uncomplicated 20,25 Nausea/vomiting 1 gesting a different etiology. appendicitis should be given noth- Imaging studies can be helpful ing by mouth, but adequate hy- Tenderness in the right lower quadrant 2 when differentiating between dration should be provided with Rebound pain 1 complicated versus uncomplicated IV fl uids. IV analgesia should be Elevation of temperature (≥ 37.3°C) 1 appendicitis and ruling out other considered if pain is causing dis- Leukocytosis (WBC > 10 000/μL) 2 causes of the (eg, tress to the patient. Current evi- Shift of WBC count to the left (≥ 75% neutrophils) 1 gastroenteritis, diverticulitis, pel- dence suggests that administra- Maximum score: 10 vic infl ammatory disease). Alter- tion of opioids does not alter the natively, watchful observation is clinician’s diagnostic accuracy.56 Scoring 1 – 4: Patient is not considered likely to have appendicitis essential until the diagnosis be- The treatment of a patient with comes clearer or exploratory lapa- complicated appendicitis who is 5 – 6: Diagnosis compatible with appendicitis but roscopic surgeries have been used hemodynamically stable is less does not appear to require an immediate 52 operation. Continue observation or further to evaluate the acute abdomen. clear. The conventional treatment testing to rule out appendicitis is antibiotics and drainage, fol- MANAGEMENT OF lowed by appendectomy at a later 7 – 8: Probable appendicitis; surgical consultation APPENDICITIS 6 needed date ; this procedure is referred to Appendectomy remains the stan- as interval appendectomy. Some au- 9 – 10: Very probable appendicitis and surgery dard of care for appendicitis.13,53,54 thorities suggest that in cases of should be performed While the clinical presentation appendicitis resolved with antibi- Source: Alvarado. Ann Emerg Med. 1986.34 often dictates what surgical ap- otics, interval appendectomy

Clinician Reviews January 2012 • Vol 22, No 1 26

2233 CE-CMECE-CME AppendicitisAppendicitis FINAL.inddFINAL.indd 2626 112/21/112/21/11 12:5712:57 PMPM should no longer be recommend- ed.57,58 In 2011, Blakely et al59 re- TABLE 7 ported that in children with perfo- Selected Antibiotics and Dosage for Surgical Prophylaxis rated appendicitis, early surgery and Antibiotic Therapy of Complicated Appendicitis62-65 results in reduced recovery time and fewer adverse events, com- Medication Pediatric dosing Adult dosing pared with delayed appendectomy. Prophylaxis Cefoxitin 20 – 40 mg/kg 1 –2 g IV Preoperative antibiotics have Cefotetan — 1 – 2 g IV demonstrated effi cacy in decreas- Cefotaxime 25 – 50 mg/kg — ing postoperative wound infec- Ampicillin/sulbactam — 3 g IV tions; the timing of antibiotic ad- Penicillin- Metronidazole 10 mg/kg/d 500 mg IV ministration is critical to its allergic: effi cacy.60,61 The fi rst dose should plus gentamicin 2 mg/kg/d 2 mg/kg be given within 60 minutes before Treatment Piperacillin/tazobactam 200 – 300 mg/kg/d divided for 3.375 g/6 h the incision is made to achieve ad- administration every 6 – 8 h equate antibiotic serum and tissue Ceftriaxone 50 – 75 mg/kg/d, divided for 1 – 2 g/12 to 24 h levels. The antibiotic should be administration every 12 – 24 h discontinued 24 hours after the 30 – 40 mg/kg/d, divided for 500 mg/8 to 12 h or 60,62 plus metronidazole surgery has been completed. administration every 8 h 1500 mg/24 h The agent selected for antibi- Penicillin- Metronidazole 30 – 40 mg/kg/d, divided for 500 mg/8 to 12 h or otic prophylaxis should be effec- allergic: administration every 8 h 1500 mg/24 h tive against the most likely infect- 3 – 7.5 mg/kg/d, divided for 5 – 7 mg/kg/24 h 17,61,62 plus gentamicin ing organism. In a patient administration every 2 – 4 h with uncomplicated appendicitis, the antibiotic of choice should be Sources: Bucher et al. Curr Opin Pediatr. 201162; American Society of Health-Systems Pharmacists. Am J Health Syst Pharm. 199963; Treat Guidel Med Lett. 200964; Solomkin et al. Clin Infect Dis. 2010.65 effective against gram-negative bacilli, such as Escherichia coli and needed to determine the effi cacy trials with children enrolled, clear .uptodate.com/contents/acute-appendicitis-in- 46,61,62 adults-clinical-manifestations-and-diagnosis. Bacteroides fragilis. A single of antibiotic therapy alone, with inclusion criteria, and outcome re- Accessed December 14, 2011. dose of cefoxitin, cefotetan, cefo- consideration of the surgical risks porting with an intention-to-treat 9. Pittman-Waller VA, Myers JG, Stewart RM, et al. Appendicitis: why so complicated? Analysis of 5755 taxime, or ampicillin/sulbactam is associated with appendectomy. basis will help validate this ap- consecutive appendectomies. Am Surg. 2000; typically prescribed to prevent proach as an alternative to current 6(66):548-554. postsurgical site infections in pa- POSTOPERATIVE CARE practice. CR 10. Mazuski JE, Solomkin JS. Intra-abdominal infec- tions. Surg Clin North Am. 2009;89(2):421-437. tients with uncomplicated appen- Adequate pain control, advance- 11. Andersson RE. The natural history and tradi- dicitis (Table 762-65). For β-lactam– ment of diet, and monitoring for REFERENCES tional management of appendicitis revisited: spon- taneous resolution and predominance of prehospi- allergic patients, an alternative development of complications 1. Birnbaum BA, Wilson SR. Appendicitis at the tal perforations imply that a correct diagnosis is antibiotic regimen is metronida- constitute typical postoperative millennium. Radiology. 2000;215(2):337-348. more important than an early diagnosis. World J zole with an aminoglycoside.61,62 care. Complications of appendec- 2. Marudanayagam R, Williams GT, Rees BI. Review Surg. 2007;31(1):86-92. of the pathological results of 2660 appendicectomy 12. Livingston EH, Woodward WA, Sarosi GA, Haley tomy include both short- and long- specimens. J Gastroenterol. 2006;41(8):745-749. RW. Disconnect between incidence of nonperfo- In Lieu of Surgery term risks (eg, infection, adhe- 3. Bundy DG, Byerley JS, Liles EA, et al. Does this child rated and perforated appendicitis: implications for have appendicitis? JAMA. 2007;298(4):438-451. As an alternative to surgery, sev- sions, obstruction) associated with pathophysiology and management. Ann Surg. 4. Alder AC, Fomby TB, Woodward WA, et al. Asso- 2007;245(6):886-892. eral randomized studies have sug- any surgical intervention. ciation of viral infection and appendicitis. Arch Surg. 13. Howell JM, Eddy OL, Lukens TW, et al; American gested that antibiotics alone can be 2010;145(1):63-71. College of Emergency Physicians. Clinical policy: 5. Rubin R. The gastrointestinal tract. In: Rubin R, critical issues in the evaluation and management of used to treat uncomplicated ap- CONCLUSION Strayer DS, eds. Rubin’s Pathology: Clinicopatho- emergency department patients with suspected pendicitis.66-68 Recent evidence Primary care providers should be logic Foundations of Medicine. 6th ed. Lippincott, appendicitis. Ann Emerg Med. 2010; 55(1):71-116. Williams and Wilkins; 2012: 671. suggests that a nonsurgical antibi- well versed in identifying the 14. CDC. Number, rate, and standard error of all- 6. McQuaid KR. Gastrointestinal disorders. In: listed surgical and nonsurgical procedures for dis- otic approach may result in signifi - symptoms and signs of appendici- McPhee SJ, Papadakis MA, eds. 2011 Current Med- charges from short-stay hospitals, by selected pro- cant cost savings,69 attributable to tis. In cases with equivocal fi nd- ical Diagnosis and Treatment. 50th ed. McGraw Hill; cedure categories: United States, 2007. www.cdc 2011: 606-608. .gov/nchs/data/nhds/4procedures/2009 pro4_num eliminating surgery and a reduced ings, imaging studies and/or labo- 7. Brennan GD. Pediatric appendicitis: pathophysiol- berrate.pdf. Accessed December 14, 2011. risk for complications. Of addi- ratory tests should be ordered to ogy and appropriate use of diagnostic imaging. 15. Lee SL, Ho HS. Acute appendicitis: is there a CJEM. 2006;8(6):425-432. tional benefi t is eliminating sur- help confi rm the diagnosis. The difference between children and adults? Am Surg. 8. Black C, Martin R. Acute appendicitis in adults: 2006;5(72):409-413. gery-associated morbidity and standard of care is appendectomy; clinical manifestations and diagnosis (2011). www 16. Bickell NA, Aufses AH Jr, Rojas M, Bodian C. mortality. therefore, a surgical consult is How time affects the risk of rupture in appendicitis. Our CE/CME posttest can J Am Coll Surg. 2006;202(3):401-406. Because design limitations less- needed. Recent evidence suggests 17. Morrow SE, Newman KD. Current management of en the reliability of the studies cit- that a nonsurgical, antibiotic ap- be taken or viewed at appendicitis. Semin Pediatr Surg. 2007; 16(1):34-40. ed, however, appendectomy is still proach in the treatment of uncom- www.clinicianreviews 18. Nance ML, Adamson WT, Hedrick HL. Appendi- citis in the young child: a continuing diagnostic chal- preferred, based on the current plicated appendicitis may be bene- .com/CECourses.aspx lenge. Pediatr Emerg Care. 2000; 16(3):160-162. evidence.53,54 More studies are fi cial. However, large, randomized 19. Feinberg AN, Feinberg LA. The gastrointestinal

Clinician Reviews January 2012 • Vol 22, No 1 27

2233 CE-CMECE-CME AppendicitisAppendicitis FINAL.inddFINAL.indd 2727 112/21/112/21/11 12:5712:57 PMPM CE/CME Appendicitis Review

tract, , gallbladder, and pancreas. In: Greydanus overview#a1. Accessed December 14, 2011. 47. Pickhardt PJ, Lawrence EM, Pooler D, Bruce RJ. mass: is it necessary? Surgeon. 2007;5(1):45-50. D, Feinberg A, Patel D, Homnick D, eds. The Pedi- 34. Alvarado A. A practical score for the early diag- Diagnostic performance of multidetector computed 59. Blakely ML, Williams R, Dassinger MS, et al. Early atic Diagnostic Examination. McGraw-Hill Profes- nosis of acute appendicitis. Ann Emerg Med. tomography for suspected acute appendicitis. Ann vs interval appendectomy for children with perfo- sional; 2008:267. 1986;15(5):557-564. Intern Med. 2011:154(12):789-796. rated appendicitis. Arch Surg. 2011;146 (6):660-665. 20. Humes DJ, Simpson J. Acute appendicitis. BMJ. 35. Schneider C, Kharbanda A, Bachur R. Evaluating 48. Coursey CA, Nelson RC, Moreno RD, et al. 60. Salkind AR, Rao KC. Antibiotic prophylaxis to 2006;333(7567):530-534. appendicitis scoring systems using a prospective pedi- Appendicitis, body mass index, and CT: is CT more prevent surgical site infections. Am Fam Physician. 21. Yale SH, Musana KA. Charles Heber McBurney atric cohort. Ann Emerg Med. 2007; 49(6):778-784. valuable for obese patients than thin patients? Am 2011;83(5):585-590. (1845-1913). Clin Med Res. 2005;3(3):187-189. 36. Kharbanda AB, Taylor GA, Fishman SJ, Bachur Surg. 2011;77(4):471-475. 61. James M. Antibiotics and perioperative infec- 22. Murphy JB. Two thousand operations for RG. A clinical decision rule to identify children at low 49. Petrosyan M, Estrada J, Chan S, et al. CT scan in tions. Best Pract Res Clin Anaesthesiol. 2008; appendicitis with deductions from his personal risk for appendicitis. Pediatrics. 2005; 116(3):709–16. patients with suspected appendicitis: clinical impli- 22(3):571-584. experience. Am J Med Sci. 1904;128:187-211. 37. Brown JJ, Wilson C, Coleman S, Joypaul BV. cations for the acute care surgeon. Eur Surg Res. 62. Bucher BT, Warner BW, Dillon PA. Antibiotic 23. Andersson RE. Meta-analysis of the clinical and Appendicitis in pregnancy. Colorectal Dis. 2009; 2008;40(2):211-219. prophylaxis and the prevention of surgical site infec- laboratory diagnosis of appendicitis. Br J Surg. 11(2):116 -122. 50. Huynh V, Lalezarzadeh F, Lawandy S, et al. tion. Curr Opin Pediatr. 2011;23(3):334-338. 2004;91(1):28-37. 38. Richardson E, Paulson C, Hitchcock K. Clinical Abdominal computed tomography in the evaluation 63. American Society of Health-Systems Pharma- 24. Wani I. K-sign in retrocaecal appendicitis: a case inquiries. History, exam, and labs: is one enough to of acute and perforated appendicitis in the com- cists. ASHP therapeutic guidelines on antimicrobial series. Cases J. 2009;2:157. diagnose acute adult appendicitis? J Fam Practice. munity setting. Am Surg. 2007;73(10):1002-1005. prophylaxis in surgery. Am J Health Syst Pharm. 25. Rothrock SG, Pagane J. Acute appendicitis in 2007;56(6):474-476. 51. Fox JC, Solley M, Anderson CL, et al. Prospective 1999;56(18):1839-1888. children: emergency department diagnosis and 39. Harrison S, Mahawar K, Brown D, et al. Acute evaluation of emergency physician performed bed- 64. Antimicrobial prophylaxis for surgery. Treat management. Ann Emerg Med. 2000;36(1):39-51. appendicitis presenting as small bowel obstruction: side ultrasound to detect acute appendicitis. Eur J Guidel Med Lett. 2009;7(82):47-52. 26. Wesson DE. Acute appendicitis in children: two case reports. Cases J. 2009;2:9106. Emerg Med. 2008;15(2):80-85. 65. Solomkin JS, Mazuski JE, Bradley JS, et al. Diag- clinical manifestations and diagnosis (2010). www 40. Pirie J. Management of constipation in the 52. Al-Mulhim AS, Nasser MA, Abdullah MM, et al. nosis and management of complicated intra- .uptodate.com/contents/acute-appendicitis-in-chil emergency department. Clin Pediatr Emerg Med. Emergency laparoscopy for acute abdominal condi- abdominal infection in adults and children: guide- dren-clinical-manifestations-and-diagnosis? 2010;11(3):182-188. tions: a prospective study. J Laparoendosc Adv Surg lines by the Surgical Infection Society and the source=related_link. Accessed December 14, 2011. 41. Yokota S, Togashi K, Kasahara N, et al. Crohn’s Tech A. 2008;18(4):599-602. Infectious Diseases Society of America. Clin Infect 27. Becker T, Kharbanda A, Bachur R. Atypical clini- disease confined to the appendix. Gastrointest 53. Varadhan KK, Humes DJ, Neal KR, Lobo DN. Dis. 2010;50(2):133-164. cal features of pediatric appendicitis. Acad Emerg Endosc. 2010;72(5):1063-1064. Antibiotic therapy versus appendectomy for acute 66. Vons C, Barry C, Maitre S, et al. Amoxicillin plus Med. 2007;14(2):124-129. 42. Purysko AS, Remer EM, Filho HM, et al. Beyond appendicitis: a meta-analysis. World J Surg. clavulanic acid versus appendicectomy for treatment 28. Laméris W, van Randen A, Go P, et al. Single and appendicitis: common and uncommon gastrointesti- 2010;34(2):199-209. of acute uncomplicated appendicitis: an open-label, combined diagnostic value of clinical features and nal causes of right lower quadrant abdominal pain at 54. Fitzmaurice GJ, McWilliams B, Hurreiz H, Epano- non-inferiority, randomized controlled trial. Lancet. laboratory tests in acute appendicitis. Acad Emerg multidetector CT. Radiographics. 2011;31(4):927-947. meritakis E. Antibiotics versus appendectomy in the 2011;377(9777):1573-1579. Med. 2009;16(9):835-842. 43. Wang LT, Prentiss KA, Simon JZ, et al. The use management of acute appendicitis: a review of the 67. Hansson J, Körner U, Khorram-Manesh A, et al. 29. McCollough M, Sharieff G. Abdominal pain in of white blood cell count and left shift in the diag- current evidence. Can J Surg. 2011; 54(5):307-314. Randomized clinical trial of antibiotic therapy versus children. Pediatr Clin N Am. 2006;53:107-137. nosis of appendicitis in children. Pediatr Emerg Care. 55. Ingraham AM, Cohen ME, Bilimoria KY, et al. appendicectomy as primary treatment of acute 30. Sheu BF, Chiu TF, Chen JC, et al. Risk factors 2007;23(2):69-76. Comparison of outcomes after laparoscopic versus appendicitis in unselected patients. Br J Surg. associated with perforated appendicitis in elderly 44. Kwan KY, Nager AL. Diagnosing pediatric open appendectomy for acute appendicitis at 222 2009;96(5):473-481. patients presenting with signs and symptoms of appendicitis: usefulness of laboratory markers. Am ACS NSQIP hospitals. Surgery. 2010;148(4): 625-635. 68. Styrud J, Eriksson S, Nilsson I, et al. Appendec- acute appendicitis. ANZ J Surg. 2007;77(8):662-666. J Emerg Med. 2010;28(9):1009-1015. 56. Manterola C, Vial M, Moraga J, Astudillo P. tomy versus antibiotic treatment in acute appendi- 31. Borst AR. Acute appendicitis: pregnancy compli- 45. Yildirim O, Solak C, Koçer B, et al. The role of Analgesia in patients with acute abdominal pain. citis: a prospective multicenter randomized control cates this diagnosis. JAAPA. 2007; 20(12):36-38. serum inflammatory markers in acute appendicitis Cochrane Database Syst Rev. 2011;(1):CD005660. trial. World J Surg. 2006;30(6):1033-1037. 32. Sedlak M, Wagner OJ, Wild B, et al. Is there still and their success in preventing negative laparotomy. 57. Puapong D, Lee SL, Haigh PI, et al. Routine inter- 69. Sakorafas GH, Mastoraki A, Lappas C, et al. a role for rectal examination in suspected appendici- J Invest Surg. 2006;19(6):345-352. val appendectomy in children is not indicated. J Conservative treatment of acute appendicitis: her- tis in adults? Am J Emerg Med. 2008;26 (3):359-377. 46. Spirt MJ. Complicated intra-abdominal infec- Pediatr Surg. 2007;42(9):1500-1503. esy or an effective and acceptable alternative to 33. Ylitalo AW. Digital rectal examination. http:// tions: a focus on appendicitis and diverticulitis. Post- 58. Deakin DE, Ahmed I. Interval appendectomy surgery? Eur J Gastroenterol Hepatol. 2011;23 emedicine.medscape.com/article/1948001- grad Med. 2010;122(1):39-51. after resolution of adult inflammatory appendix (2):121-127.

RADIOLOGY Review Nandan R. Hichkad, PA-C, MMSc

fter accidentally being run over by a vehicle, a 54-year-old man presents to the emer- gency department for evaluation of pain in his elbow and left arm. He was leaning Adown behind the vehicle and was not seen when the driver backed up. The patient states that one of the tires went over his left shoulder and arm. Primary complaint is pain and decreased range of motion. He denies any signifi cant medical history, except for medication-controlled hypertension and gallbladder surgery. His vital signs are stable. Examination of the left arm demonstrates some abrasions and contusions over the shoul- der and forearm, as well as some swelling over the elbow. The patient has good color, distal pulses, and sensation. There is localized tenderness over the elbow and midforearm. Flexion of the elbow is somewhat limited secondary to pain. Radiograph of the forearm is obtained and shown. What is your impression?

see answer on page 32 >>

Nandan R. Hichkad practices at the Georgia Neurosurgical Institute in Macon.

Clinician Reviews January 2012 • Vol 22, No 1 28

2233 CE-CMECE-CME AppendicitisAppendicitis FINAL.inddFINAL.indd 2828 112/21/112/21/11 12:5712:57 PMPM