EPISODE #43: APPENDICITIS & DIVERTICULITIS - EMERGENCYMEDICINECASES.COM EPISODE 43: ADULT APPENDICITIS CONTROVERSIES WITH DR. Appendicitis STEINHART & DR. DUSHENSKI Alvarado score NOT Laboratory Values: recommended by our experts as - WBC > 10: (Pos Likelihood Clinical Decision Scores: 1) ALVARADO score: it underperforms in elderly, Ratio (+LR)) = 2.4; (MANTRELS) children and women, and Neg LR = 0.25) as good or Migration of pain RLQ (1) physician judgment may better than any single clinical Anorexia (1) outperform the score. history/physical factor(2) N/V (1) 2) Appendicitis Inflammatory - Sensitivity of WBC increases Tenderness in RLQ (2) Response Score with duration of illness Rebound pain (1) Vomiting (1) - Combining WBC and CRP Elevated temp >= 37.3 (1) Pain right inferior fossa (1) increases predictive power Leukocytosis >=10 (2) Rebound tenderness (1-3) - Urinalysis – in appendicitis, Shift of WBC to left (1) Temp >=38.5 (1) inflamed appendix can abut Score of 7 or more has positive PMN (1-2) the ureter and cause ureter LR of 4.0. Score of less than 7 WBC (1-2) CRP (1-2) inflammation, resulting in a has negative LR of 0.2. Score 0-4 is low probability of significant WBC (don’t appendicitis, 9-12 high probability. assume UTI!) History and Physical Examination - Migration of pain, RLQ pain, psoas sign, fever, pain before vomiting, rebound tenderness all increase likelihood of appendicitis Does Delay in Dx Increase the Rate of - Recurrent pain decreases the likelihood of Appendix Perforation? appendicitis but does not rule it out - Delay in seeking care is a risk factor for perforation - Pain while traveling over speed bumps increases the - Multiple studies have shown that in-hospital delay to likelihood of appendicitis (3) OR <12 h does not affect perforation rates (5,6). - DRE has limited role in diagnosis of acute, undifferentiated abdominal pain (4) - Important to consider pelvic exam in females with undifferentiated abdominal pain. Remember, cervical motion tenderness does not rule out appendicitis! - Atypical presentations: obese, immunocompromised, extremes of age, diabetics Imaging for Appendicitis Factors Affecting Imaging: Fig 1: Distended appendix on found to be non-inferior to 1. Duration of Pain: Ultrasound emergency appendectomy. - Ultrasound sensitivity However, associated with increases with duration of One option after equivocal increased risk for recurrent pain ultrasound for appendicitis: disease. - CT sensitivity unchanged with observe patient for 8hrs, then re- - Candidates for medical duration of pain examine +/- re-ultrasound management (decision best (remember that ultrasound made in conjunction with 2. Body Habitus: sensitivity increases with time) surgical colleagues): Early, - Ultrasound accuracy is non-perforated, < 24h from increased in slim patients CT Scan: onset of symptoms, no - CT accuracy is increased in - Contrast may increase appendicolith or masses obese patients sensitivity (8) causing persistent obstruction 3. Number of ultrasounds done - IV contrast: accentuates of the appendix at your institution for appendicitis periappendiceal and luminal inflammation Modalities: - Oral contrast: demarcates References Ultrasound: appendix from surrounding (click for abstract) - First line in: young, non-obese structures, opacifies ileocecal patients with symptoms > 12h portion of bowel in 45-60min 1) Andersson. 2004. Br J Surg, - Dependent on operator skill. - Rectal contrast: also helps 91(1): 28-37 More impact of patient’s body demarcate appendix, can habitus. Bowel gas can hinder administer just prior to CT, 2) Cardall et al. 2004. Acad image acquisition thereby reducing time to wait Emerg Med, 11(10):1021-7. - Diagnostic Criteria: for CT (9). 3) Ashdown et al. 2012. BMJ, - Non-compressible - Studies have failed to 345: e8012. appendix demonstrate reduction in - No peristalsis negative appendectomy rate 4) Kessler & Bauer. 2012. J - Diameter > 6mm in men despite increased CT Emerg Med, 43)6):1196-204. - Other suggestive findings: use - Appendicolith 5) Ingraham et al. 2010. Arch - Hyperechoic fat Treatment Surg, 145(9): 886-92. - Free fluid in males 6) Clyde et al. 2008. Am J Surg, - Appendix not visualized (7): Antibiotics: 195(5): 590-2. - Indicator for observation - No good evidence for routine vs. further imaging administration of antibotics in 7) Steward et al. 2012. J Clin - NPV 85-95% ED for appendicitis Ultrasound, 40(8): 455-61. - Consider your pre-test - Patients should receive 8) Chiu et al. 2013. Acad Radiol, probability and other prophylactic antibitoics within 20(1): 73-8. ultrasound findings 60min window prior to 9) Rao et al. 1997. Am J incision Raoentgenol, 169(5): 1275-80. - Consider antibiotics if there is delay to OR 10) Vons et al. 2011. Lancet, 377(9777): 1573-9. Medical vs Surgical Management: SUBSCRIBE TO EMCASES - Oral antibiotics vs. immediate OR for acute, uncomplicated appendicitis (10). Amox-Clav .