CC: ABDOMINAL PAIN
HPI
 23 year old female comes in to the Emergency
Department with abdominal pain that started 4
hours ago and continues to worsen. Now it is
most severe in the right lower quadrant. She
decided to come to the hospital when she could
no longer tolerate bouncing on the new pogo
stick she got for her birthday yesterday. She has
also been nauseated and anorexic for the past
day. Denies fever, rash, diarrhea, vomiting,
hematochezia or melena.
HPI
Past Medical Hx:
 Hx of right humeral
fracture from trampoline
injury.
 Hx of L fibula fracture from
roller blade accident.
 Hx of pelvic inflammatory
disease treated with
antibiotics 7 months ago.
 No past surgical history.
Family and Social Hx:
 Mother has hx of ovarian
cysts and ulcerative colitis.
 Father has hx of
diverticulitis.
 2 Brothers and 2 Sisters are
healthy.
 Lives in apartment with
one roommate. No pets,
no recent travel. Works as a
taste tester for a local
chocolatier.
DIFFERENTIAL DIAGNOSIS

Appendicitis

Ovarian and fallopian tube torsion

Perforated appendix

Endometriosis

Cecal diverticulitis


Meckel's diverticulitis
Ovarian hyperstimulation
syndrome

Acute ileitis

Ectopic pregnancy

Crohn's disease

Acute endometritis

Tubo-ovarian abscess

Renal colic

Pelvic inflammatory disease

Testicular torsion

Ruptured ovarian cyst


Mittelschmerz
Epididymitis Torsion of the
appendix testis or appendix
epididymis
PHYSICAL EXAM
VITALS: BP 130/88, T 38.3, R 28, HR 129
GEN: Appears to be in moderate distress secondary to pain. Speech in
interrupted periodically due to increased abdominal pain.
HEENT: Normocephalic, atraumatic (NCAT), pupils equal, round and reactive
(PERRL) and extraocular movements intact (EOMI). Moist mucous
membranes. Oropharynx clear and patent, no erythema.
CV, RESP: Tachycardic, regular rhythm, no murmurs, rubs or gallops. Breath
sounds are clear to auscultation bilaterally (CTAB), no crackles or ronchi, and
symmetrical chest rise.
ABDOMINAL: Firm, non-distended abdomen, involuntary guarding and
rebound tenderness in the RLQ. Negative Murphy’s sign. Positive Rovsing’s
sign, and tenderness at McBurney’s point.
PELVIC: No bleeding in vaginal vault, bimanual exam exhibits right adnexal
tenderness, no masses appreciated.
RECTAL: DRE is negative for gross and occult blood. Perianal area is intact
without lesions.
NEURO: Alert, awake and oriented to person, place and time. (AAOx3). CN IIVII intact. Strength 5/5 and sensation intact over all extremities.
Commonly associated physical findings:
•MCBURNEY'S POINT TENDERNESS is described as maximal tenderness at 1.5 to 2
inches from the ASIS, on a straight line from the ASIS to the umbilicus. Sens: 50-94%,
Spec 75-86%.
•ROVSING'S SIGN: Pain in the RLQ with palpation of the LLQ. Also known as “indirect
tenderness” and is indicative of right-sided local peritoneal irritation . Sens:22-68%
Spec:58-96%.
•The PSOAS SIGN is associated with a
retrocecal appendix. Manifested by RLQ pain
with passive right hip extension. Due to
appendix lying against the right psoas muscle,
causing the patient to shorten the muscle by
drawing up the right knee. Passive extension of
the iliopsoas muscle with hip extension causes
RLQ pain. Sens: 13 -42%; Spec: 79-97%.
•The OBTURATOR SIGN: associated with a pelvic appendix. Based on the principle
that the inflamed appendix may lay against the right obturator internus muscle. When
the clinician flexes the patient's right hip and knee followed by internal rotation of the
right hip, this elicits RLQ pain, Sens: 8%; Spec: 94%. The sensitivity is low enough that
experienced clinicians no longer perform this assessment.
LABORATORY TESTS
 CBC: normal
 WBC: 14,000
 CMP: normal, LFTs normal
 UA: Negative for WBC, RBC, protein,
leukocyte esterase and nitrites.
 Urine HCG: Negative
 What would you like to do next?
Ultrasound
 The most accurate ultrasound finding for
acute appendicitis is an appendiceal diameter
of >6 mm.
CT Abdomen
CT abdomen with contrast shows:
 Enlarged appendiceal diameter >6 mm with an occluded lumen
 Appendiceal wall thickening (>2 mm)
 Periappendiceal fat stranding
 Appendiceal wall enhancement
 Appendicolith (seen in approximately 25 percent of patients
Appendicitis

Appendicitis is diagnosed based on history and physical examination, Dx can be
supported by laboratory and imaging findings.

Several studies have demonstrated diagnostic accuracy without the use of imaging to
be 75-90%. Though this is also found to be dependent on the level of experience of
the examining clinician. Though surgeon dependent it is acceptable to proceed
directly to appendectomy without further imaging based on clinical diagnosis.

The diagnosis of diagnosis can be difficult and delay results in perforation rates that
can be as high as 80%. Most challenging patient populations for this diagnosis include
children <3 years of age, adults >60 years of age and pregnant women.

Imaging modalities have become increasingly utilized to support the diagnosis,
especially US and CT. Some studies have suggested that the increased use of imaging
has minimized the number of nontherapeutic appendectomies.

In acute appendicitis. However many surgeons will and should proceed with surgical
exploration in the absence of imaging if there is strong clinical support, as other
studies have shown that imaging studies do not improve diagnostic accuracy for
acute appendicitis.

Imaging should be performed when the diagnosis of appendicitis is suspected but
unclear, and in more challenging patient groups described in previous slides .
Histological Interpretations
Acute appendicitis is thought to be caused by progressive increase in intraluminal
pressure that compromises venous outflow from the appendix which is a normal true
diverticulum of the cecum. Often caused by a small stone-like mass of stool called a
fecalith. Ischemic injury and luminal stasis causes the structure to become favorable
to bacterial proliferation. This results in an inflammatory response including tissue
edema, neutrophilic infiltration of the lumen and muscular wall and periappendiceal
soft tissue.
Histological Features Cont’d





Congested subserosal vessels
Modest perivascular neutrophilic infiltrate within all layers of the wall
Serosa has a dull, granular and erythematous surface
Diagnosis of appendicitis requires neutrophilic infiltration of the muscularis propria
As the process continues focal abscesses may form within the wall
Treatment

The goal of therapy of acute appendicitis is early diagnosis and prompt
operative intervention. However, this goal is not always easily
accomplished since many patients do not seek medical attention in a
timely manner and the diagnosis of appendicitis can be difficult.
 Many surgeons use an aggressive approach, accepting a certain number
of negative appendectomies, traditionally 15%, although the use of
imaging studies appears to have reduced the negative appendectomy
rate to less than 10 %.
 The preoperative preparation for appendectomy includes intravenous
hydration, correction of electrolyte abnormalities, and perioperative
antibiotics.
 Both open and laparoscopic approaches to appendectomy are
appropriate for all patients. Patients treated with a laparoscopic
appendectomy have significantly fewer wound infections, less pain, and
a shorter duration of hospital stay, but higher rates of readmission,
intra-abdominal abscess formation, and higher hospital costs.
Summary

Classic symptoms of appendicitis: right lower quadrant abdominal pain, anorexia,
fever, nausea and vomiting. Atypical or nonspecific symptoms: indigestion,
flatulence, bowel irregularity, and generalized malaise; and not all patients will have
migratory abdominal pain.

Diagnostic imaging should be performed when the diagnosis of appendicitis is
suspected but unclear. We perform a standard abdominal CT scan with intravenous
and oral contrast

An appendectomy rather than medical management with antibiotics alone is the gold
standard for patients with a history and clinical findings, and radiographic images,
consistent with appendicitis. Although some patients do well with antibiotic therapy
alone, they are at risk of recurrent appendicitis.

Path evaluation of inflammed appendix will involve modest perivascular neutrophilic
infiltrate within all layers of the wall and congested subserosal vessels.

If a normal appearing appendix is identified during surgical exploration for right lower
abdominal pain, an appendectomy should be performed. It is important to search for
other causes of the patient's symptoms, including terminal ileitis, cecal or sigmoid
diverticulitis or a perforating colon carcinoma, Meckel's diverticulitis, mesenteric
adenitis, or uterine, fallopian, or ovarian pathology in a female.
References:

Black, Carrie E., MD, and Ronald F. Martin, MD. "Acute Appendicitis in
Adults: Clinical Manifestations and Diagnosis.” UpToDate, 13 Sept.
2012. Web. 20 Dec. 2012. <http://www.uptodate.com.proxy.
medlib. iupui.edu/contents/acute-appendicitis-in-adults-clinicalmanifestations-and-diagnosis?source=search_result&search=
appendicitis&selected Title=1~150>.
 Kumar, Vinay, Abul K. Abbas, Nelson Fausto, Stanley L. Robbins, and
Ramzi S. Cotran. "Chapter 17 The Gastrointestinal Tract." Robbins
and Cotran Pathologic Basis of Disease. Philadelphia: Elsevier
Saunders, 2005. 826-28. Print.
 Smink, Douglas, MD, MPH, and David I. Soybel, MD. "Acute Appendicitis
In Adults: Management." Acute Appendicitis in Adults: Management.
UpToDate, 27 Aug. 2012. Web. 20 Dec. 2012.<http://www.
uptodate.com.proxy.medlib.iupui.edu/contents/acute-appendicitis
-in-adults-management?source=search_ result&search=
appendicitis &selectedTitle=3~150>.