Appendicitis
by Chanda McDaniel 1/08
Objectives
 To
review 3 cases of appendicitis (that
presented to AUCC at DH)
 To discuss how we could improve the care
of these patients
 To review the presentation, work-up, and
differential diagnosis of appendicitis
Case 1 HPI
 37yo
female presents to PCP (seen by
resident) for 6 wk postpartum check up
with abdominal pain x 5-7 days.
 No
N/V. Pain is achy/diffuse. Subjective fever
yesterday.
 No appetite. Drinking. Nl BMs. No dysuria or
abnormal vaginal discharge. Stopped bleeding
1 ½ weeks ago.
Case 1 Physical
 37.5
128
124/81
22
 NAD
H
- RRR w/o M
 A - TTP midline, RLQ, LLQ, NABS, soft,
non-distended, + guarding
 Pelvic - midline tenderness, no adnexal
tenderness, no foul-smelling discharge
Case 1 Labs
 U/A-1.025,
pH 5, 1+pro, 1+Hgb, 1-5
WBCs, 6-10 RBCs
 UHCG
- negative
Case 1 PCP Dx, Plan
 Late
postpartum endometritis
 Doxycycline 100mg po BID x 14 days
 Vicodin, Colace, Ibuprofen
 RTC 1 week
3 days later
 Pt
presents to AUCC with worsening
abdominal and low back pain.
 Dizzy.
Decreased appetite. Fever. Pain 5/10.
Nausea x 1 wk.
 No emesis, diarrhea, dysuria, vaginal
discharge or URI sxs.
AUCC Physical
 38.3
113 16 113/70 99% RA
 HEENT – pale conjunctiva, nl o/p
 H – RRR w/o M (90)
 L – CTAB
 A – NABS, soft, tender in suprapubic area,
less in RLQ, no rebound, no obturator or
psoas sign
 GU – no CMT, min. discharge, uterus TTP
AUCC Labs/xray
 UA
– 1-5 WBC, 1-5 RBC, 1+ bacteria
 WBC 12.6, Hb 12.5, Hct 38.9, plts 323
 Chem 7 – nl, Calcium – nl
 Pelvic US – nl
 CT – 9.6x7cm mass abuts cecum with
surrounding fat stranding most likely
perforated appendicitis with associated
abscess
AUCC course

Pt seen by surgery who wanted to admit & take
pt to OR. She refused and left AMA, but said she
would return in AM.

Pt returned the next day and said that she
refused admission due to a religious holiday and
was admitted to surgery.

She was discharged on Levo and Flagyl post op.
Endometritis
Most cases develop within the 1st week after
delivery
 15% present between 1-6 weeks postpartum
 May present as late postpartum hemorrhage
 Clinical criteria




Fever and uterine tenderness occurring in a
postpartum woman
foul lochia, chills, and lower abdominal pain
Admit for IV antibiotics (Clinda/Gent)
What could we (at DH) have done
differently?

PCP could have considered appendicitis in the
differential

Pt presentation was atypical for endometritis

Late onset

No VB or discharge

Abnormal vitals (HR 128) not addressed

No labs were drawn (even for baseline)

Needed admission/IV Abx (?), if diagnosis of
endometritis was correct
Case 2 HPI
 21
yo female presents with abd. pain and
vaginal bleeding x 3 days.
 Not using pad – just on TP.
 Recently had IUD removed.
 No N/V.
 PMH – Depression
 Meds – Prozac
 NKDA
Case 2 Physical
 36.3
119 110/63 18
 NAD
 Chest
– clear
 H – RR
 A – soft, marked tenderness in RLQ,
tender in suprapubic area & LLQ, no
rebound, NABS
 Pelvic – blood in vault, cervix/uterus
tender, adnexa tender R>L
Case 2 Labs

UA – mod ketones, 1.015, 2+pro, tr blood, tr
leu, 11-20 WBC, no RBC, 1+crystals

UHCG – negative

CBC – WBC 26.6, hb 14.9, hct 42.9, plt 406,
87% segs

Chem 7 normal except Na 133
Case 2 Dx & Plan
 Abdominal
pain with elev. WBCs, some
WBCs in urine
 R/O PID vs UTI, doubt appy
 Urine cx P
 Gonorrhea/Chlamydia P
 Levofloxacin 500mg BID, Flagyl 500mg
BID x 14 days
Case 2 AUCC f/u
 Seen
1 day later in AUCC – “Pt did not
want CT yesterday. Feels better.” Meds
upset stomach. Ate some breakfast. No
nausea now.
 VS 38.4
113/69
124
20
 A - +BS, soft, tender in RLQ w/ guarding
 WBC 20.7, Hb 13.7, Hct 40.2, Plts 333
 CT – RLQ 11x4cm abscess, adj to cecum
Case 2 Hosp. course
 Pt
admitted for perforated appendix
(approximately 7-10 days old) and placed
on IV Timentin.
 IR placed drain on hosp. day 1 and
removed on day 7 after 2nd CT scan
(although I can’t find the report of 2nd
CT).
 Discharged on Augmentin, Colace, Vicodin.
What could we have done
differently?
 If
appendicitis was in the differential and it
was not visualized on US  consider CT or
surgery consult.
 If
patient refused CT, we could have
improved our documentation on her initial
visit.
Case 3 HPI
 51
yo male with epigastric pain since this
am. N/V x 3. No diarrhea. No fever.
 PMH – No hospitalizations.
 Meds – Tylenol flu
 All – none
 SHx – no exposures, ETOH yesterday
Case 3 Physical






36.7 142/85 66 20 (not orthostatic)
General - Alert, NAD
HEENT – NCAT, anicteric, o/p -, neck supple w/o
LAD
H – RRR w/o m
L – CTAB
A – NABS, soft, mild epigastric tenderness to
palpation, more TTP in RLQ, + rebound, - heel
tap, - obturator, + psoas, nl rectal
Case 3 Labs
 WBC
16.4, Hb 16.1, Hct 47.8, Plts 221,
91% Segs
 Chem 7 – normal
 LFT’s – normal
 Amylase – 27
 U/A – 1.038, 2+pro, 1+Hb, 2+glc, - WBC,
- RBC
 Guaiac - negative
Case 3 CT
 Verbal
report – Equivocal for appendicitis
 Written report – There is considerable
fecal material within the cecum, but the
terminal ileum is not dilated and the
appendix is normal. Moderate thickening
of sigmoid colon, which may indicate a
prior inflammatory process. No evidence
of acute diverticulitis.
Case 3 Surgery Consult
 51
yo w/ epigastric pain – better now. N/V
x 1.
 A – NTTP
 CT – poorly visualized appendix
 A/P – resolved Abd pain, with elevated
WBC. Would like to admit for obs, but pt
would like to go home. Return to AUCC in
am for recheck, CBC.
Case 3 AUCC f/u
 51
yo w/ abd pain seen yesterday. N/V x2
this am. Constant pain. No appetite.
 37.3 64 20 128/74
 A – RLQ tenderness
 WBC 20.3, Hb 15.7, Hct 46, plts 225, 87S
 Admitted to surgery. Laproscopic eval –>
partially necrotic appendix (ruptured per
path)  open appendectomy. Discharged
on Levo/Flagyl.
What could we have done
differently?
 Talked
pt into staying the night in the
hospital? This may have prevented
rupture?
Appendicitis Epidemiology






250,000 cases/yr in US
most common in 2nd/3rd decades of life
highest incidence in 10-19 yo age group
no age is exempt
males > females
rate of negative appendectomies (15-20%) has
not declined in the last 15 years despite the
increasing use of US and CT


DH: 1-2 carcinoids, 2-3 parasitic infections, TB, TOA/several hundred
surgeries (<1%)
Mortality <1% (nonperf)%5> , (perf)
Pathophysiology
 1)
Obstruction of lumen
 young
= lymphoid follicular hyperplasia (due to
viral or bacterial infection and dehydration)
 older = fibrosis, fecalith, neoplasm
 2)
Fills with mucusdistendsincreases
intraluminal pressurethrombosis
ischemianecrosis (<24hrs) and
perforation (>48hrs)
Organisms
 E.
coli
 Peptostreptococcus
 Bacteriodes Fragilis
 Pseudomonas
Appendix Anatomy
 normal
= lies in RLQ
 retrocecal
 pelvic
(65%)
(30%)
 intestinal
malrotation = LUQ
 pregnant
= RUQ
Symptoms

Initial




indigestion
flatulence
bowel irregularity
Epigastric or periumbilical pain

visceral - constant, not very severe in intensity, poorly
localizable
Then, N/V (not usually 1st symptoms)
 Fever (higher suggests perf)
 Sxs may subside (temporarily) after rupture

Abdominal Pain
 Visceral
 Parietal
 Referred
Visceral pain

Stretching, distention, torsion, or contraction of
abdominal organs

Carried on slow-conducting fibers

Dull ache

Location correspond to dermatomes that match the
innervation of the injured organ

Epigastrium organs proximal to ligament of treitz
(hepatobiliary, spleen)

Periumbilicalligament of treitz to hepatic flexure of colon

Midline lower abdorgans distal to hepatic flexure
Parietal Pain
 Well-localized
 Results
from direct irritation of the
peritoneal lining
A
delta fibersrapid conduction
 Sharp
pain sensation
Referred pain
 Occurs
when visceral afferents carrying
stimuli from a diseased organ enter the
spinal cord at the same level as somatic
afferents from a remote anatomic location.
 Typically
 Gall
well-localized
bladder inflammation to R shoulder
 Diaphragmatic
 Heart
rupture to shoulder
attack to L arm
Physical Exam: Appendicitis

Pain is subjective

Tenderness is objective;
local tenderness in RLQ

McBurney’s point (1/3 of
distance of line from
anterior iliac spine to
umbilicus)

May have tenderness in
RLQ during rectal and
pelvic
Common Signs of Appendicitis
• Right lower quadrant pain on palpation (the single most important sign)
• Low-grade fever (38°C [or 100.4°F])--absence of fever or high fever can
occur
• Peritoneal signs
• Localized tenderness to percussion
• Guarding
• Other confirmatory peritoneal signs (absence of these signs does not
exclude appendicitis)
• Psoas sign--pain on extension of right thigh (retroperitoneal retrocecal
appendix)
• Obturator sign--pain on internal rotation of right thigh (pelvic appendix)
• Rovsing's sign--pain in right lower quadrant with
palpation of left lower quadrant
• Dunphy's sign--increased pain with coughing
• Flank tenderness in right lower quadrant (retroperitoneal retrocecal
appendix)
• Patient maintains hip flexion with knees drawn up for comfort
3 PE findings with highest
predictive value of appendicitis
 1)
RLQ pain
 2)
Abdominal rigidity
 3)
Migration of a pain from periumbilical
region to the RLQ
 Occur
in about 50% of patients
Retrocecal appendix
 Appendix
doesn't
touch
parietal
peritoneum
 Sxs
 not
localized
 dull ache
 +psoas sign
 flank pain
Psoas sign
 Inflamed
appx is in
retroperitoneal
location in contact
with psoas
Pelvic Appendix
 May
have no abdominal signs
 Urinary frequency
 Dysuria
 Tenesmus
 Diarrhea
 Tenderness with rectal exam
 Positive obturator sign
Obturator sign
 Inflamed
appx is in
pelvis, in contact
with obturator
muscle
 UA

Labs

r/o UTI (micro hematuria/pyuria in 30% appys)

>30 RBC or >20 WBC - urinary
UHCG

r/o ectopic

Pelvic cultures

CBC

leukocytosis

30% have normal WBC (95% have left shift)
Radiology (CT or US)
 Obtain
if diagnosis is unclear.
 A population based study suggested that
the rates of negative appendectomies have
not changed between 1980 and 1999.
CT Appy

Sensitivity 94%

Specifity 95%

Air or contrast in appendix – excludes dx

Diameter 6 mm or less - normal

Non-visualized appx

does not rule out appendicitis

If pt with sxs for a short duration, only min.
inflammation may be present

IV contrast (?) -
may improve wall appearance/inflammation
Normal Appendix on CT
Appendicitis on CT
 Dm
>6mm
 Appendicolith
 Cecal thickening
 Arrowhead sign
 abscess
formation
 cecal thickening
Arrowhead sign
An axial CT image in the upper pelvis shows edema of the cecal wall which, along with
barium in the cecum (C), contributes to the "arrowhead sign" of appendicitis. A dilated
fluid filled appendix (large arrow) is seen with adjacent stranding of retroperitoneal fat
(arrowheads). The appendix follows a retrocecal course (small arrows).
CT radiation
 “There
is direct evidence from
epidemiologic studies that the organ doses
corresponding to a common CT study (2-3
scans, dose 30-90 mSv) result in an
increased risk of cancer.”
 10,000 adults, 35 yrs old, US instead of CT
 Appendicitis would be missed in 480 cases
 2 patients could be prevented from
developing cancer in the future
Differential Diagnosis

Cecal diverticulitis

Meckel's diverticulitis

Ilietis (bacterial infection)

Yersinia

Campylobacter

Salmonella

Crohn's

PID

Ob/Gyn

UTI/Nephrolithiasis
Treatment
 NPO
 IVF
 Antibiotics
 nonperforated
preop – Cefazolin, Flagyl,
(Timentin or Cefotetan at DH)
 perforated – Levo + Flagyl (x 7-10 days)
Bibliography

1) Brenner, D. Computed Tomography – An Increasing Source of Radiation
Exposure. NEJM. Nov. 2oo7;2277-84.

2) Doria, A. US or CT for diagnosis of appendicitis in Children and adults? A
meta-analysis. Radiology. Aug. 2006:241:83-94.

3) Flaser, M. Acute Abdominal Pain. Medical Clinics of North America. May
2006:90;3.

4) Goldberg, J. Appendicitis in adults. Uptodate. August 2007.

5) Hardin, M. Acute appendicitis: Review and Update. American Family
Physician 1999;60:2027-2034.

6) Humes, D. Acute appendicitis. BMJ. Sept 2006;333:530-534.

7) Morino, M. Acute Nonspecific Abdominal Pain. Ann Surg. Dec.
2006;244(6):881-888.

8) Old, J. Imaging for Suspected Appendicitis. American Family Physician.
Jan. 2005;71(1).

9) Paulson, E. Suspected appendicitis. NEJM. Jan 2003;348:236-242.