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Evidence-Based Management of Suspected Appendicitis in The October 2011 Evidence-Based Management Volume 13, Number 10 Of Suspected Appendicitis In Authors Michael Alan Cole, MD Associate Physician, Department of Emergency Medicine, Brigham The Emergency Department and Women’s Hospital; Clinical Instructor, Harvard Medical School, Boston, MA Nicholas Maldonado, MD Abstract Emergency Physician, Brigham and Women’s Hospital/Massachusetts General Hospital, Harvard Affiliated Emergency Medicine Residency, Boston, MA Appendicitis is the most common cause of acute abdominal pain requiring surgical treatment in persons under 50 years of age, Peer Reviewers with a peak incidence in the second and third decades. Women John Howell, MD, FACEP, FAAEM Clinical Professor of Emergency Medicine, The George Washington have a greater risk of misdiagnosis and a higher negative appen- University, Washington, DC; Director of Academics and Risk Management, dectomy rate. Atypical presentations of appendicitis are com- Best Practices, Inc., Inova Fairfax Hospital, Falls Church, VA monly misdiagnosed, resulting in increased morbidity, mortality, Christopher Strother, MD Assistant Professor of Emergency Medicine and Pediatrics, Director, and potential litigation. The variability of presentation relates to Emergency and Undergraduate Simulation, Mount Sinai School of the varied anatomical location and the visceral innervation of the Medicine, New York, NY appendix. Patients presenting with possible appendicitis should Robert Vissers, MD, FACEP be risk stratified based on history, physical examination, and Chief, Emergency Medicine, Quality Director, Legacy Emanuel Hospital, Adjunct Associate Professor, Oregon Health & Science University School laboratory data. An elevated white blood cell (WBC) count alone of Medicine, Portland, OR (> 10,000 cells/mm3) offers poor diagnostic utility; however, CME Objectives combining WBC count > 10 and C-reactive protein (CRP) level > Upon completion of this article, you should be able to: 8 achieves notable predictive power in the diagnosis of acute ap- 1. Recognize the symptoms, signs, and laboratory findings for pendicitis. Imaging studies play a vital role in diagnosis, particu- appendicitis. larly in equivocal presentations. 2. Select the most appropriate imaging techniques and therapeutic options for patients with presumptive appendicitis. 3. Describe the most common medicolegal pitfalls associated with appendicitis. Prior to beginning activity, see “Physician CME Information” on page 32. Editor-in-Chief Nicholas Genes, MD, PhD Keith A. Marill, MD Corey M. Slovis, MD, FACP, FACEP International Editors Assistant Professor, Department of Assistant Professor, Department of Professor and Chair, Department Andy Jagoda, MD, FACEP Peter Cameron, MD Emergency Medicine, Mount Sinai Emergency Medicine, Massachusetts of Emergency Medicine, Vanderbilt Professor and Chair, Department of Academic Director, The Alfred School of Medicine, New York, NY General Hospital, Harvard Medical University Medical Center; Medical Emergency Medicine, Mount Sinai Emergency and Trauma Centre, School, Boston, MA Director, Nashville Fire Department and School of Medicine; Medical Director, Michael A. Gibbs, MD, FACEP Monash University, Melbourne, International Airport, Nashville, TN Mount Sinai Hospital, New York, NY Professor and Chief, Department of Charles V. Pollack, Jr., MA, MD, Australia Emergency Medicine, Maine Medical FACEP Jenny Walker, MD, MPH, MSW Editorial Board Center, Portland, ME; Tufts University Chairman, Department of Emergency Assistant Professor, Departments of Giorgio Carbone, MD Chief, Department of Emergency William J. Brady, MD School of Medicine, Boston, MA Medicine, Pennsylvania Hospital, Preventive Medicine, Pediatrics, and University of Pennsylvania Health Medicine Course Director, Mount Medicine Ospedale Gradenigo, Professor of Emergency Medicine, Steven A. Godwin, MD, FACEP System, Philadelphia, PA Sinai Medical Center, New York, NY Torino, Italy Chair, Resuscitation Committee, Associate Professor, Associate Chair University of Virginia Health and Chief of Service, Department Michael S. Radeos, MD, MPH Ron M. Walls, MD Amin Antoine Kazzi, MD, FAAEM System, Charlottesville, VA of Emergency Medicine, Assistant Assistant Professor of Emergency Professor and Chair, Department of Associate Professor and Vice Chair, Department of Emergency Medicine, Peter DeBlieux, MD Dean, Simulation Education, Medicine, Weill Medical College Emergency Medicine, Brigham and University of California, Irvine; Louisiana State University Health University of Florida COM- of Cornell University, New York; Women’s Hospital, Harvard Medical American University, Beirut, Lebanon Science Center Professor of Clinical Jacksonville, Jacksonville, FL Research Director, Department of School, Boston, MA Emergency Medicine, New York Medicine, LSUHSC Interim Public Gregory L. Henry, MD, FACEP Scott Weingart, MD, FACEP Hugo Peralta, MD Hospital Queens, Flushing, New York Hospital Director of Emergency CEO, Medical Practice Risk Associate Professor of Emergency Chair of Emergency Services, Hospital Medicine Services, LSUHSC Assessment, Inc.; Clinical Professor Robert L. Rogers, MD, FACEP, Medicine, Mount Sinai School of Italiano, Buenos Aires, Argentina Emergency Medicine Director of of Emergency Medicine, University of FAAEM, FACP Medicine; Director of Emergency Dhanadol Rojanasarntikul, MD Faculty and Resident Development Michigan, Ann Arbor, MI Assistant Professor of Emergency Critical Care, Elmhurst Hospital Attending Physician, Emergency Medicine, The University of Center, New York, NY Wyatt W. Decker, MD John M. Howell, MD, FACEP, FAAEM Medicine, King Chulalongkorn Maryland School of Medicine, Professor of Emergency Medicine, Clinical Professor of Emergency Senior Research Editor Memorial Hospital, Thai Red Cross, Baltimore, MD Thailand; Faculty of Medicine, Mayo Clinic College of Medicine, Medicine, The George Washington Joseph D. Toscano, MD Chulalongkorn University, Thailand Rochester, MN University, Washington, DC; Director Alfred Sacchetti, MD, FACEP Emergency Physician, Department Francis M. Fesmire, MD, FACEP of Academic Affairs, Best Practices, Assistant Clinical Professor, of Emergency Medicine, San Ramon Maarten Simons, MD, PhD Director, Heart-Stroke Center, Inc, Inova Fairfax Hospital, Falls Department of Emergency Medicine, Regional Medical Center, San Emergency Medicine Residency Erlanger Medical Center; Assistant Church, VA Thomas Jefferson University, Ramon, CA Director, OLVG Hospital, Amsterdam, Professor, UT College of Medicine, Philadelphia, PA The Netherlands Chattanooga, TN Shkelzen Hoxhaj, MD, MPH, MBA Scott Silvers, MD, FACEP Research Editor Chief of Emergency Medicine, Baylor Chair, Department of Emergency College of Medicine, Houston, TX Matt Friedman, MD Medicine, Mayo Clinic, Jacksonville, FL Emergency Medicine Residency, Mount Sinai School of Medicine, New York, NY Accreditation: EB Medicine is accredited by the ACCME to provide continuing medical education for physicians. Faculty Disclosure: Dr. Cole, Dr. Maldonado, Dr. Howell, Dr. Strother, Dr. Vissers, Dr. Jagoda, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. Commercial Support: This issue of Emergency Medicine Practice did not receive any commercial support. Case Presentations As you ponder these questions, a 62-year-old female presents with an “upset stomach,” suprapubic discomfort, About halfway through your evening shift, you notice a and dysuria over the last 12 hours. She said this feels woman and a young boy walking through the halls, being similar to UTIs that she’s had in the past, so she took a escorted by the triage nurse to one of the ED bays. The ciprofloxacin this morning with no relief. She is afebrile young boy is crouched over and walking slowly. On his- with stable vital signs and a soft abdomen with mild tory, you elicit that this is a 7-year-old boy who has had suprapubic tenderness with trace rebound, no guard- 2 days of mild periumbilical pain that is now localized to ing. Labs returned with WBCs of 10 and RBC of 5, with the RLQ. He wants to eat and is hungry, but his mother negative nitrates, bacteria, and squamous cells. She states brought him in because he vomited twice after coming that she still feels “uncomfortable in her stomach” but home from school, had diarrhea, and has been crying all otherwise is without complaints. What is your next step? night. Two of his friends were recently diagnosed with vi- Next, a 25-year-old male presents with periumbilical/ ral gastroenteritis. On physical examination, he is afebrile midepigastric-area pain for 6 hours, now with RLQ pain with a pulse of 114. Coughing produces notable grimac- and vomiting, a temperature of 39.3°C (102.3°F), and ing, and he has tenderness to deep palpation in most areas RLQ pain. At the request of the surgical resident, you of his abdomen, but is it unclear if it is more prominent in obtain a CT with IV and PO contrast, which is resulted at the RLQ. His abdomen is not rigid, and he lacks a psoas 11 pm and demonstrates nonperforated appendicitis with or obturator sign but has mild rebound tenderness. You no abscess present. The resident is notified and states, think he may have appendicitis, but viral gastroenteritis “Just give him antibiotics and admit to surgery, and we’ll and lower lobe pneumonia are also on your differential. add him on first thing in the morning.” Being the patient You
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