Appendicitis: Diagnosis and Management

00:01 What imaging modality would you like to pursue for further diagnosis of appendicitis or the right lower quadrant abdominal pain? I would like to point to the audience that if the findings are classic both on history and physical exam, there’s no need for further imaging studies. However, if you need to get an imaging study, we have a lot of modalities that are available to us: CT scans, ultrasound, and MRI.

00:28 Let’s visit CT scans. Clearly, CT scans introduce radiation to the patient which is of concern particularly if the patient has had recent radiation or is pregnant. Modern CT scanners are multislice detectors which introduce less radiation. Nevertheless, it’s not zero. That’s why ultrasound has gained some favor recently.

00:51 Ultrasound is very operator-dependent. So, if you have a good technician who is experienced in doing ultrasounds for right lower quadrant pain, the results are very helpful and trustworthy.

01:01 Concurrently, ultrasounds do not give any radiation to the patient and may be a good first diagnostic tool in a young patient who you have very high suspicion of appendicitis. Lastly, don’t forget about MRIs.

01:16 MRIs are particularly helpful for pregnant patients as both CT scans introduce radiation which we don’t want for the infant and ultrasound may be difficult to obtain useful images. Therefore, we can offer an MRI.

01:31 Now that you decided that the patient needs surgery, how do we prepare a patient for surgery? Well, everybody gets preoperative antibiotics. Specifically, we want to cover enteric content, enteric, meaning intestines. In the colon, gram negatives and anaerobes predominate. This means our antibiotic choice can be a first generation cephalosporin or fluoroquinolone attached to an anaerobic coverage. Here on the slide, you see ciprofloxacin and metronidazole which is a classic combination.

02:07 This is a high definition image of a laparoscopic appendectomy. Through this trocar, we are looking at the right lower quadrant of the abdomen. In the lower third of the screen, you notice that the appendix is lying horizontally. Laparoscopic appendectomy is now standard of care. The way that we divide the appendix is using a linear titanium stapler. We divide the appendix and detach it from its cecum as well as taking its blood supply called the mesoappendix. High-yield fact: intraoperatively, even though you are 100% certain that the patient had acute appendicitis, if you are presented with this scenario, you’re in the operating room and there’s no appendicitis, one should consider some other potential differential diagnosis.

02:54 In this age group, inflammatory bowel disease is very, very common. Always think about inflammatory disease when the appendix appears normal intraoperatively. How do we care for the patient postoperatively? Well, it depends on if the patient is perforated or non-perforated. In perforated patients, one should consider to continue antibiotics longer than if the patient was not perforated. Advance diet based on the clinical picture, what does that mean? Has the patient result under bowel function, had bowel movements, passing gas? Have their fever trends been downwards? Have their leukocytosis or white blood cell count returned to normal? Remember to counsel the patient that with the perforated appendicitis, they’re a higher risk for developing an abdominal postoperative abscess. This is all different than a patient who has a non-complicated, non-perforated appendicitis. Luckily for me, this is the vast majority of the patients. These patients can usually have their antibiotics discontinued within 24 hours of surgery. We rapidly advance their diet.

04:03 And they’re less likely to have an intraabdominal postoperative abscess though not zero percent.

04:09 These patients typically go home within 24 hours of surgery. Some important clinical pearls to keep in mind.

04:17 Although earlier I said that imaging is not necessary if classic findings in history are present, it may be necessary in patients with a classic history and exam that’s not present. This is particularly true in women.

04:31 Again, ultrasound is increasingly used for diagnosis because it gives no radiation to the patient.

04:37 High-yield facts for your examination: if the scenario presents a patient who you’re pretty certain has appendicitis, you're in the operating room and yet the appendix appears normal to you, I would recommend that you still do a completion laparoscopic appendectomy.

04:53 Remember, always consider GYN pathology particularly in child-bearing aged women.

05:00 Thank you very much for joining me on this module on acute appendicitis.