Appendicitis: Clinical sciences

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Introduction0:00–0:47

Appendicitis refers to inflammation of the appendix, which is usually caused by obstruction of the appendiceal lumen by tumors, fecaliths, or hard fecal masses, and lymphoid hyperplasia.
When the appendix is obstructed, the pressure inside it increases. This causes local stasis of lymphatic flow, occlusion of small vessels, and bacterial overgrowth, which can eventually lead to ischemia and necrosis of the appendix.
Now, appendicitis can be classified as uncomplicated or complicated. In uncomplicated appendicitis, the appendix is only inflamed; while in complicated appendicitis, it may develop perforation, phlegmon, or abscess.If you suspect appendicitis the first thing you should do is an ABCDE assessment, to determine if your patient is unstable or stable.

Unstable0:47–1:21

If the patient is unstable, which usually results from sepsis, you should first stabilize their airway, breathing, and circulation.
This means that you may need to intubate the patient, establish IV access, or administer fluids before continuing with your assessment.

History and Physical1:21–3:19

However, if your patient is stable, your next step is to obtain a focused history and physical examination, as well as labs such as a CBC and CRP.
Now, history typically reveals abdominal pain, which starts around the umbilicus and migrates to the right lower quadrant.
Additionally, the patient might report fever, nausea, vomiting, and anorexia. On physical examination, individuals usually present with tenderness in the affected area, most commonly the right lower quadrant, especially at a region called McBurney point, located one-third of the distance from the anterior superior iliac spine to the umbilicus.
Some additional physical exam findings that can help you recognize appendicitis include the Rovsing, psoas, and obturator signs.
A Rovsing sign is positive when you palpate your patient’s left lower quadrant and your patient feels pain in the right lower quadrant.
This indicates peritoneal irritation of the right side of the abdomen. On the other hand, a psoas sign is positive when passive extension of the patient’s right hip causes right lower quadrant pain.
This indicates an inflammation of an appendix that is retrocecal, or situated behind the cecum. Finally, the obturator sign is positive if internal rotation of the hip with the knee and hip flexed causes pain in the patient’s right lower quadrant.
This may indicate an appendix located in the pelvis. Lastly, it’s extremely important to evaluate for peritoneal signs, such as local or diffuse rebound tenderness, as well as rigidity, and guarding.
Now, when it comes to labs, you might see leukocytosis with a left shift, and an elevated CRP. These lab findings are not specific for acute appendicitis but may support the diagnosis.
Alright, if you suspect acute appendicitis based on the history, physical examination, and lab findings, make sure to initiate acute management.

Acute management3:19–5:51

This includes starting IV fluids as well as administering antiemetics and pain medications as needed. Additionally, you should keep the patient NPO.After initiating the acute management, your next step is to confirm the diagnosis.
To do this, order a CT scan of the abdomen and pelvis with IV contrast to assess the appendiceal diameter and wall thickness, and whether any fat stranding is present.
A high yield fact to remember is that some institutions prefer starting with an ultrasound because it’s quicker, more cost efficient, and avoids radiation exposure.
This is especially important in the pediatric population. If the imaging reveals an appendiceal diameter of less than 6 mm; appendiceal wall thickness of less than 3 mm; and no fat stranding around the appendix, then appendicitis is unlikely, so you should consider other diagnoses, such as mesenteric adenitis.On the other hand, if the imaging reveals a dilated appendix with a diameter greater than 6 mm; thickening of the appendiceal wall greater than 3 mm; and fat stranding around the appendix, it confirms the diagnosis of uncomplicated appendicitis!
Sometimes imaging reveals appendicitis with either an abscess, phlegmon, or extraluminal air, or a combination of these findings.
In all of these cases, think of complicated appendicitis! Additionally, you might even see a small calcified deposition within the appendiceal lumen, which is also referred to as appendicolith.
Keep in mind that appendicolith is not a complication, but an important risk factor that can eventually lead to perforation!Here is some high-yield information to keep in mind!
When deciding on the appropriate imaging modality for your patient, you should pay attention to two groups: pediatric and pregnant individuals.
In these cases, you should try to avoid radiation exposure, so you’d first do an ultrasound of the right lower quadrant.
An ultrasound may reveal a non-compressible appendix with an increased reflection of the fat around the appendix. If the ultrasound findings are still unclear, you can order an MRI of the abdomen.
Alright, now that imaging is all clear, pun intended, let’s talk about treatment. First, let’s start with uncomplicated appendicitis, which can be treated either non-surgically or surgically.

Uncomplicated appendicitis5:51–7:08

Typically, the initial treatment is with non-surgical management, which includes IV antibiotics for 1 to 3 days, followed by oral antibiotics for a total of 7 to 10 days.
Make sure to choose an antibiotic that covers intestinal flora and anaerobes, so possible options include penicillin with a beta-lactamase inhibitor, or a combination of metronidazole with either a fluoroquinolone or a third-generation cephalosporin.
After giving non-surgical management, serial abdominal exams should be performed to check if the antibiotics are working.
In fact, the main indication for surgical management in patients with uncomplicated appendicitis is a worsening of serial abdominal exams despite antibiotics, which means it’s progressing to complicated appendicitis.
Other indications for surgical management include being immunocompromised, having a history of IBD, or pregnancy; as well as the presence of appendicolith on imaging.
If your patient falls into any of these categories, they require an urgent appendectomy. Now that we are done with uncomplicated appendicitis, what should you do if the CT reveals findings of complicated appendicitis, such as perforation, phlegmon, or abscess?

Complicated appendicitis7:08–8:59

First, let’s focus on appendicitis associated with perforation. You should start the patient on IV antibiotics and consult surgery for a potential emergency appendectomy.
Next up, if appendicitis is associated with a phlegmon, you can usually treat it non-surgically with IV antibiotics while monitoring your patient’s response.
If the patient improves, you can discharge them and continue oral antibiotics to complete a total of 7 to 10 days. Also, don’t forget to schedule an appendectomy in 6 to 8 weeks.
On the other hand, if the patient’s symptoms don’t improve, or even worsen, the patient should get an urgent appendectomy and continue IV antibiotics to complete 7 to 10 days.Finally, if a patient has appendicitis complicated by an abscess, you can treat them with IV antibiotics and abscess drainage, either percutaneously or surgically.
If the abscess is small, or less than 3 cm, it might be too challenging to reach the abscess percutaneously. So, in that case, the patient should get an urgent appendectomy and IV antibiotics.
Once the patient is released from the hospital, you can switch them to oral antibiotics for a total of 7 to 10 days. In contrast, if the abscess is large, or greater than 3 cm, it’s often possible to drain the abscess percutaneously.
Now, sometimes the abscess can be located in an area that can’t be reached percutaneously. In this case, consider an urgent appendectomy.
Regardless of the procedure, make sure to continue antibiotics for a total of 7 to 10 days. Alright, as a quick recap… Once you suspect appendicitis based on history and physical findings, obtain a CT scan to confirm the diagnosis.

Review8:59–9:56

Uncomplicated appendicitis is typically treated with IV antibiotics; however, individuals with risk factors might need an urgent appendectomy.
On the other hand, complicated appendicitis can be associated with perforation, phlegmon, or abscess. All patients with complicated appendicitis should receive IV antibiotics.
Additionally, individuals that present with perforation require emergent appendectomy, while patients with a phlegmon can respond well to IV antibiotics only.
If the patient with phlegmon improves, you can switch them to oral antibiotics and schedule an appendectomy in 6 to 8 weeks, but if they don’t improve, they might need an urgent appendectomy.
Finally, depending on the size and location, an abscess can be treated with either appendectomy or drainage.