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Apendicitis 2
1.
1121 PRINCIPLES Background The appendix was
once considered a vestigial organ; however, it is currently theorized that it serves as a repository for commensal bacteria that assist in normal digestive processes and may allow for recolonization of intestinal flora in times of enteric bacterial destruction. Phylogenetic studies have supported the appendix as likely having a so-called positive fitness value during mammalian evolution, whereas recent clinical research studies have demon- strated a possible increased risk of clostridial infections in patients who have had prior appendectomies.1-3 Appendicitis is the most common cause of acute abdomi- nal pain requiring operative intervention in patients younger than 50 years. It is the most common nonobstetric abdominal emergency in pregnant females, usually occurring in the second trimester. Risk factors for appendicitis include white ethnicity, male gender, and young age (69% of cases occur in patients <30 years). Although males have an increased risk of having appen- dicitis (1.4 : 1), females have an almost twofold increased risk of undergoing an appendectomy, which is partially related to the fact that women have gynecologic conditions that frequently mimic appendicitis. Anatomy and Physiology The vermiform appendix is a blind-ended tube that originates from the cecum, approximately 3 cm from the ileocecal valve. It is considered part of the cecum and has the same histologic arrangement as the large intestine. A unique aspect of the appen- dix is the large masses of lymphoid tissue in the mucosa and submucosa. Although it has an average length of 8 to 10 cm, the appendix may be more than 20 cm in length, thereby allowing it to traverse into the left lower or right upper quadrants of the abdomen. The average diameter of the appendix ranges from 6 to 11 mm; thus, appendiceal diameter alone, in the absence of other radiologic findings, often does not imply appendicitis. Finally, a normal appendix has an average wall thickness of 1.5 mm. The appendix maintains afferent sensory fibers that follow the sympathetic innervation and enter the spinal cord at the 10th thoracic level (T10). It is these nerves that carry the sensation of pain and result in the periumbilical discomfort associated with early appendicitis. There are three important anatomic features of the appendix that determine the site of the patient’s pain and tenderness when the organ is inflamed: (1) the location of the origin of the appen- dix off the cecum; (2) the course the appendix takes from this origin; and (3) the length of the appendix (as described above; Fig. 83.1). All these features are variable, resulting in a wide range of symptoms and signs, which often creates difficulty with the clinical diagnosis of appendicitis. Although the location of the origin of the appendix is generally thought to be positioned at McBurney’s point (exactly between an 1.5 to 2 inches from the right anterior superior iliac spine on a straight line drawn to the umbilicus), the base may be as much as 10 cm away from this site. In fact, only 40% of patients have the base of their appendix within 3m of McBurney’s point, with 36% of patients having the base more than 5m away. Next, there is significant variation involving the course of the appendix from its cecal origin. The frequency with which the appendix is found in various loca- tions is illustrated in Fig. 83.2. Finally, in rare cases, patients may present with left lower quadrant pain or right flank pain due to a very long appendix traveling into the left lower abdomen or a retrocecal location extending into the retroperitoneum, respectively. Pathophysiology The cause of appendicitis is rooted in obstruction of the appen- diceal lumen. The underlying pathophysiology is progressive in nature and best understood in a stepwise fashion—appendiceal obstruction prevents egress of mucus and bacteria from the appendix; continued mucous production and bacterial prolifera- tion result in luminal distention, which stimulates the T10 visceral afferent nerves, creating periumbilical pain typically lasting 4 to 6 hours. Intraluminal pressure eventually exceeds local capillary pressure in the appendiceal wall, preventing arterial perfusion and resulting in tissue ischemia and inflammation; ischemia and inflammation compromise the integrity of the appendiceal wall bacteria and then invade the appendiceal wall. This causes trans- mural inflammation that extends into the surrounding tissues (peritoneal, ileocecal, and pelvic areas), resulting in somatic local- ized pain, typically focused in the right lower quadrant. If this process continues, the appendix becomes necrotic and perforates, releasing enteric contents into the peritoneum and resulting in peritonitis and, typically, diffuse abdominal pain. The length of time from the onset of symptoms to perforation is highly variable. Although obstruction of the appendiceal lumen is thought to be a common inciting factor in appendicitis, the cause of this obstruction is variable and, in many cases, a source of obstruction is not discovered on imaging or pathology. Fecaliths (hard stools) are the most common cause of obstruction in nonperforated appendicitis (65%), followed by appendicoliths (calcified depos- its) and lymphoid hyperplasia (primary or secondary to an enteric infection). Other causes of obstruction are rare; these include fecal stasis, foreign bodies (eg, vegetable matter, inspissated barium), tumors, and intestinal parasites. There are two additional pathologic processes associated with appendicitis. First, so-called tip appendicitis is appendiceal inflammation localized to the distal end of the appendix. The clinical significance of this disorder is that it may be missed on imaging due to the limited extent of disease and the lack of classic findings associated with appendicitis; it has been demonstrated to contribute to the false-negative rate associated with computed tomography (CT) imaging. Second, stump appendicitis is a very rare entity that results from inflammation of the appendiceal remnant that may persist after the appendix has been removed surgically. Timing of its occurrence varies; it has been diagnosed C H A P T E R 83 Acute Appendicitis Michael Alan Cole | Robert David Huang Descargado para Francisco Medina Anderson (fz.medina@hotmail.com) en Organización de Estados Iberoamericanos - Remote Access de ClinicalKey.es por Elsevier en julio 07, 2017. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2017. Elsevier Inc. Todos los derechos reservados.
2.
1122 PART III
Medicine and Surgery | SECTION Five Gastrointestinal System treatment, and disposition. This approach should focus on the history and physical examination findings that have the greatest predictive values. History The history and review of systems provide insight into the patient’s symptoms and help determine alternative diagnoses. A prior history of similar symptoms suggests an alternative diagnosis, because appendicitis is an acute illness. Furthermore, because the pathophysiology of appendicitis is a progressive process,a patient’s symptoms typically worsen over the course of the illness until perforation of the appendix occurs. At this point, the patient may receive some temporary relief due to a decrease of intraluminal pressure, but will subsequently become very ill from the resultant peritonitis. See Table 83.1 for a list common symptoms and their value in predicting the likelihood of appendicitis. Duration of symptoms is variable and often is not useful in the assessment of appendicitis. When considering features that exclude appendicitis, findings that decrease the likelihood of appendicitis include absence of RLQ pain and a history of similar pain in the past. Nevertheless, these findings in isolation do not exclude appendicitis as a pos- sible diagnosis and are best used as part of a comprehensive clini- cal decision making process. Physical Examination All patients with abdominal pain should be fully disrobed, and female patients should ideally be placed in a room in which a pelvic examination can be performed (see Table 83.1). Classic, eponymous examination maneuvers for appendicitis have overall poor sensitivity but, if present, have a modest predictive value (Table 83.2). Although McBurney’s point tenderness has a low correlation with appendiceal location and is not highly sensitive for appendicitis, tenderness at this location does have a modest predictive value for appendicitis. A genitourinary examination should be performed to assess for testicular pathology or hernias in males and pelvic pathology in females. Cervical motion tenderness (CMT) is not specific for pelvic pathology and is noted in 28% of female patient with appendicitis. A rectal examination contributes little toward the assessment of appendicitis and is not routinely recommended.6 DIFFERENTIAL DIAGNOSIS There are many diagnoses that mimic appendicitis; alternatively, appendicitis may present atypically and must be considered in all between 4 days and up to 50 years after the initial appendectomy.4 CLINICAL FEATURES Typical presentations of appendicitis often allow an experienced provider to hone in on a diagnosis in a rather rapid fashion; unfortunately, typical findings are the exception and not the rule. For historical purposes, the constellation findings classically asso- ciated with acute appendicitis include younger age, epigastric pain that migrates to the right lower quadrant (RLQ), and tenderness of the RLQ. However, the combination of these findings occurs in less than 50% of patients with acute appendicitis thus limiting their use in clinical decision making.4a Missed acute appendicitis is one of the most common causes of litigation surrounding emer- gency medicine, which speaks to the challenges in diagnosing this illness in the presence of often ambiguous symptoms.5 No one element of the history or physical examination can reliably be used to diagnose or exclude appendicitis. Therefore, focusing on a single finding may lead to misdiagnosis. Rather, a comprehensive approach using multiple elements of the history, physical examination, and laboratory data should be used to risk- stratify patients to make informed decisions regarding imaging, Fig. 83.1. This figure demonstrates the variation in location of the base of the appendix and its course within the peritoneum. McBurney’s point classically represents the point of maximal tenderness in appendicitis; however, depending on the path, length, and degree of inflammation of the appendix, the true point of maximal tenderness is highly variable. Subcecal (2%) Pelvic (32%) Preilial (1%) Postileal (0.4%) Retrocecal (64%) The origin of the appendix can vary as much as 10 cm from McBurney’s point. TABLE 83.1 Predictive Value of Common Symptoms and Signs in Diagnosing Appendicitis FEATURE MODERATELY USEFUL MILDLY USEFUL NOT USEFUL Historical features RLQ pain Migration of pain to the RLQ Presence of pain prior to vomiting No history of prior similar pain Vomiting Male gender Pain worsened when driving over speed bumps34 Anorexia Nausea Pain worse with cough or movement Physical examination features35 RLQ tenderness Abdominal wall rigidity Pain focused at McBurney’s point Rebound tenderness Guarding Temperature > 38.3°C (101°F) Percussion tenderness Psoas sign Rectal examination Increased skin temperature RLQ, Right lower quadrant. Adapted from Laurell H, Hansson L-E, Gunnarsson U. Manifestations of acute appendicitis: a prospective study on acute abdominal pain. Dig Surg 30:198–206, 2013. Descargado para Francisco Medina Anderson (fz.medina@hotmail.com) en Organización de Estados Iberoamericanos - Remote Access de ClinicalKey.es por Elsevier en julio 07, 2017. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2017. Elsevier Inc. Todos los derechos reservados.
3.
1123CHAPTER 83 Acute
Appendicitis comprehensive assessment of the patient’s condition and further risk-stratify the patient for treatment and disposition purposes. White Blood Cell Count A patient’s white blood cell (WBC) count does not by itself have the sensitivity, specificity, or predictive value necessary to be clini- cally useful in diagnosing or excluding appendicitis. An elevated WBC count (>10,000–12,000/mm3 ) has a sensitivity of 62% to 85%, specificity of 32% to 82%, positive LR of 1.59 to 2.7, and negative LR of 0.25 to 0.46. Even in a subgroup analysis of patients presenting with abdominal pain, not just those with right lower quadrant pain. Table 83.3 lists the most common differen- tial diagnoses for appendicitis. DIAGNOSTIC TESTING Laboratory Data Laboratory data should not be viewed as diagnostic for appendi- citis. Rather, it should be used in association with the patient’s clinical history and physical examination to formulate a more Fig. 83.2. Suggested clinical management pathway for emergency department patients with possible appendicitis. Gen., General; OB, obstetrician. Develop pretest probability for appendicitis based on history, physical examination, and laboratory data Treat symptomatically Low risk • Consider/treat alternative diagnoses • Discharge with precautionary instructions High riskPregnant No Negative/ nondiagnostic Positive Positive Negative/ nondiagnostic Positive Negative Negative Positive Yes Consult OB & Gen. Surgery Moderate risk* No Yes No Yes Operative appendix removal within 12 hours of diagnosis Admit for continued IV antibiotics, serial examinations and observation NoYes CT with IV contrast (no enteric contrast) Is the patient still symptomatic Diagnosis of appendicitis is made Administer IV antibiotics Admit for observation and symptomatic therapy • Consider/treat alternative diagnoses • Discharge with precautionary instructions Admit for observation and symptomatic therapy Surgical consultation Is the patient a candidate for conservative management Is the patient still symptomatic? MRI with no IV contrast (+/- enteric contrast) Consider graded compression ultrasound** Graded compression ultrasound *In moderate pre-test probability patients, the provider may consider admission for serial examinations or discharge in select cases. **In pediatric patients, graded compression ultrasound should always be the first imaging test performed. Descargado para Francisco Medina Anderson (fz.medina@hotmail.com) en Organización de Estados Iberoamericanos - Remote Access de ClinicalKey.es por Elsevier en julio 07, 2017. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2017. Elsevier Inc. Todos los derechos reservados.
4.
1124 PART III
Medicine and Surgery | SECTION Five Gastrointestinal System Urinalysis Urinalysis demonstrates pyuria, hematuria, and/or bacteria in up to 48% of patients with appendicitis. These abnormalities are due to the inflamed appendix abutting the ureter, with resultant ure- teral inflammation. Nevertheless, findings on urinalysis of more than 30 red blood cells (RBCs)/high-power field or more than 20 WBCs/high-power field are more consistent with urinary tract infections than appendicitis. Other Laboratory Tests A serum or urine pregnancy test is recommended for any female of childbearing age with abdominal pain. A basic metabolic panel, liver function tests, and lipase level should be obtained for patients with suspected appendicitis to assess for electrolyte derangements and alternative causes of abdominal pain. Procalcitonin does not currently play a role in the diagnosis of appendicitis due to its poor predictive value.8 The polymorphonuclear count, in isola- tion, has no clinical value in the assessment of appendicitis. Imaging Tests General Principles The decision to pursue imaging is based on the provider’s clinical assessment, which combines the patient’s history, examination, and laboratory data to decide on the likelihood of appendicitis. If the likelihood is low (and other significant disease processes have been excluded), the patient may be discharged from the emergency department (ED) or observed with serial examinations in an observation unit (see Chapter e6) or inpatient setting. However, if there is a concern for appendicitis, imaging should be carried out. Currently, patients rarely undergo surgical removal of the appendix based on clinical features alone. The negative appendec- tomy rate—the number of normal appendices that are surgically removed—is far lower when imaging is used.11 Nevertheless, in rare cases of young men with a classic presentation, the decision to perform an appendectomy in the absence of imaging may be pursued at the surgeon’s discretion. Radiography Due to their poor sensitivity and specificity, routine radiographs are of no clinical value in the evaluation of appendicitis. The only value of radiographs is to assess for other causes of the patient’s symptoms, such as bowel obstruction or bowel perforation. However, an ileus mimicking bowel obstruction may occur in appendicitis due to peritoneal inflammation, and advanced appendicitis may perforate, resulting in intraperitoneal air on TABLE 83.2 Common Maneuvers and Physical Findings Associated With Appendicitis and Their Predictive Valuesa MANEUVER DESCRIPTION SENSITIVITY AND SPECIFICITY (%) Iliopsoas (psoas) sign Increased abdominal pain with patient lying on left side while provider passively extends the patient’s right leg at the hip with both knees extended Sensitivity: 13–42 Specificity: 79–95 Rovsing’s sign Abdominal pain in the RLQ while palpating the left lower quadrant Sensitivity: 7–68 Specificity: 58–96 Obturator sign Increased abdominal pain in the supine patient as the provider internally and externally rotates the right leg as it is flexed at the hip Sensitivity: 8 Specificity: 94 a Overall poor sensitivity decreases the value of these findings. However, if found, these signs moderately increase the likelihood of having appendicitis. RLQ, Right lower quadrant. TABLE 83.3 Differential Diagnosis in Appendicitis ALL PATIENTS FEMALE PATIENTS PEDIATRIC PATIENTS Nonspecific abdominal pain Gastroenteritis Epiploic appendigitis Ureterolithiasis, nephrolithiasis Inflammatory bowel disease Ileus or bowel obstruction Intestinal perforation Testicular torsion (males) Ectopic pregnancy Ovarian torsion Pelvic inflammatory disease Ovarian cyst Henoch-Schönlein purpura Mesenteric lymphadenitis Meckel’s diverticulum increasingly high cutoff values for the WBC count (eg, >15,000 or 20,000/mm3 ), it is still not significant enough to be used in clinical practice to diagnose or exclude acute appendicitis.7,8 C-Reactive Protein The C-reactive protein (CRP) level is a nonspecific, systemic inflammatory marker synthesized by the liver. It has a poor pre- dictive value in diagnosing or excluding acute appendicitis.8 An elevated CRP (>8–10 mg/L) has a sensitivity of 65% to 85%, specificity of 32% to 87%, positive LR of 1.59 to 4.2, and negative LR of 0.11 to 3.2.8,9 Some studies have suggested that CRP may be useful for predicting the severity of appendicitis and likelihood of complications; however, its value in diagnosing appendicitis lies in combining CRP with the WBC (see below).10 Combined Inflammatory Markers The American College of Emergency Physicians clinical policy on patients with suspected appendicitis states that the combination of a WBC more than 10,000/mm3 and CRP more than 8 mg/L has a positive likelihood ratio of 23 and a negative likelihood ratio of 0.03.These combined laboratory findings offer the greatest impact when excluding appendicitis in patients with a low pretest prob- ability of the disease. Although more research is needed, based on the best available evidence, we recommend using the combination of low WBC (<10,000/mm3 ) and CRP (<8 mg/L) in patients deemed to be low risk for appendicitis, based on the provider’s clinical assessment, to exclude appendicitis. Alternatively, we do not believe that there are sufficient data to establish the diagnosis of appendicitis conclusively based on the combination of elevated WBC and CRP levels; rather, these should only assist in the deci- sion making process regarding the need for imaging. Descargado para Francisco Medina Anderson (fz.medina@hotmail.com) en Organización de Estados Iberoamericanos - Remote Access de ClinicalKey.es por Elsevier en julio 07, 2017. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2017. Elsevier Inc. Todos los derechos reservados.
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1125CHAPTER 83 Acute
Appendicitis pelvic US is an important study to help determine ovarian pathol- ogy or tuboovarian abscesses. This should be performed before CT imaging in an attempt to elucidate an alternative diagnosis and may be completed simultaneously with a graded compression US to assess for appendicitis. Computed Tomography CT of the abdomen and pelvis is considered the test of choice for definitive assessment of possible appendicitis in nonpregnant patients. It demonstrates an overall sensitivity of 94% to 100% and specificity of 91% to 99%, with a positive LR of 9.29 to 13.3, negative LR of 0.1 to 0.09, and positive predictive value of 95% to 97%.13 CT is accurate and consistent in diagnosing appendicitis and decreases the negative appendectomy rate. CT is readily avail- able in most hospitals, can be performed in a rapid fashion, is not operator-dependent, can be interpreted by most radiologists and surgeons, and has a greater likelihood of finding an alternative diagnosis (vs. US; Figs. 83.5 and 83.6). abdominal radiographs. Therefore, care must be taken to make the final diagnosis based on radiographic findings, although intra- peritoneal air often expedites the patient’s disposition to the oper- ating room. Graded-Compression Ultrasound Within the medical community, there is a growing awareness of the risks associated with ionizing radiation, and efforts are being made to use methods of diagnosis that reduce or eliminate these risks.12 Graded compression ultrasound (US) is an imaging tool commonly used in evaluating patients for appendicitis. It is a diagnostic technique in which steady pressure is applied with the US probe to the abdomen to reduce bowel gas and collapse normal bowel to promote visualization of the appendix. Studies involving graded compression US for the diagnosis of appendicitis have reported sensitivities of 75% to 90%, specificities of 83% to 95%, positive LRs of 4.5 to 5.8, and negative LRs of 0.19 to 0.27, with an average positive predictive value of 90%.13 Table 83.4 lists US criteria for the diagnosis of appendicitis. The benefits in using US for the diagnosis of appendicitis include decreased cost relative to other imaging modalities, lack of ionizing radiation exposure, and decreased time to diagnosis. Limitations of US use include decreased specificity and increased pain due to the transducer pressure needed for the graded com- pression process. Most importantly, a number of US examinations cannot visualize the appendix (ie, nondiagnostic) for a number of reasons, including lack of operator experience, patient factors (eg, obesity), superimposed bowel gas, or atypically located appen- dix.14 In cases with nondiagnostic US findings, the patient typi- cally requires further imaging with CT (or magnetic resonance imaging [MRI] in pregnancy) or admission for observation and serial examinations. Ultrasound is most useful in children, for whom the risks of ionizing radiation are greatest, and rates of overweight and obese individuals are lower than adults and preg- nant females (Figs. 83.3 and 83.4). A distinction must be made between radiology-based US and bedside (point of care) US examination performed by an emer- gency clinician. Recent studies have demonstrated that bedside US is not as effective at diagnosing appendicitis, with a sensitivity for diagnosis of 60% to 70%, with specificities of 94% to 98%.15,16 Finally, in women with CMT, masses found on pelvic examina- tion, or concern for a gynecologic cause of the patient’s symptoms, TABLE 83.4 Diagnostic Criteria for Appendicitis on Imaging ULTRASOUND COMPUTED TOPOGRAPHY MAGNETIC RESONANCE IMAGING The first two criteria below must be fulfilled: Not all criteria listed below need to be fulfilled but the combination and severity of these findings contribute to a diagnosis: Not all criteria listed need to be fulfilled but the combination and severity of these findings contribute to a diagnosis: • Appendiceal diameter > 6–7 mma Appendiceal diameter (>6 mm with surrounding inflammation or >8 mm without such changes) Appendiceal diameter > 7 mm • Noncompressible appendix Appendiceal circumferential wall thickening >2 mm with mural enhancement (sign of inflammation) Appendiceal circumferential wall thickening > 2 mm Fat stranding (hyperechoic signals associated with periappendiceal inflammation) (secondary finding) and peritoneal fluid Calcified appendicolith Signs of inflammation adjacent to the appendix, such as fat stranding or phlegmon formation Peritoneal fluid surrounding the appendix (secondary finding) Signs of periappendiceal inflammation (eg, fat stranding, clouding of the adjacent mesentery) Presence of an abscess or a fluid filled appendix a It is important to note that the diameter of a normal nondiseased appendix may be up to 11 mm, so the other findings of appendicitis must be factored in when making the diagnosis of appendicitis on CT or MRI. Due to the graded compression technique used in ultrasound, there is more certainty regarding diagnostic criteria for appendiceal diameter. Fig. 83.3. Ultrasound image of appendicitis in an 8-year-girl. Note the dilated noncompressible appendix (thin arrows) and the presence of a fecalith, with posterior acoustic shadowing (thick arrow). (Courtesy Dr. Michael Cole, with permission.) Descargado para Francisco Medina Anderson (fz.medina@hotmail.com) en Organización de Estados Iberoamericanos - Remote Access de ClinicalKey.es por Elsevier en julio 07, 2017. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2017. Elsevier Inc. Todos los derechos reservados.
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1126 PART III
Medicine and Surgery | SECTION Five Gastrointestinal System To this end, there have been recent studies of low-dose CT protocols for the diagnosis of appendicitis. These low-dose pro- tocols decrease the average dose to approximately 2 mSv, with no detriment in the negative appendectomy rate. However, there is less diagnostic certainty by radiologists about the diagnosis of appendicitis with these studies. These are relatively new protocols that show promise but require more studies before they can be universally adopted.17,18 Table 83.4 lists CT findings diagnostic of appendicitis. In some cases, the appendix cannot be visualized. In these cases, if CT demonstrates no findings of inflammation in the RLQ, it has been found that appendicitis is unlikely. However, patients with low amounts of intra-abdominal body fat may not display secondary signs of inflammation; consequently, these patients may lack this important marker of appendicitis on CT imaging, leading to false- negative study results. The term tip appendicitis refers to obstruc- tion and inflammation limited to the distal tip of the appendix and is a subtle finding on CT that is a common cause of false- negative interpretation.19 To assess for appendicitis, CT should be performed with IV contrast only. Enteric contrast of any type, oral or rectal, contrib- utes little to the assessment of appendicitis. In addition, studies have demonstrated that non–contrast-enhanced CT has accept- able accuracy in diagnosing appendicitis. Furthermore, according to the American College of Radiology’s appropriateness criteria for imaging suspected appendicitis, CT imaging with or without IV contrast are acceptable imaging modalities, with the use of enteric contrast being deferred to institutional preference. There- fore, if there are contraindications to IV contrast, there should be little hesitation to move forward with non–contrast-enhanced CT for the evaluation of appendicitis.17 Magnetic Resonance Imaging When considering the evaluation for appendicitis, current evi- dence supports the use of MRI for assessment in pregnant females if US is nondiagnostic. MRI has the advantage of not using ion- izing radiation and is not operator-dependent. However, its use is limited by its increased cost, increased time required to acquire images,limited availability,and need for the radiologist or surgeon The greatest disadvantage of CT is the ionizing radiation. A CT scan of the abdomen exposes the patient to an average dose of ionizing radiation equivalent to 8 examination 10 mSv. To put this in perspective, the average ionizing radiation dose associated with an abdominal x-ray is 0.7 mSv, and the average dose associated with coronary angioplasty is 15 mSv. An abdominal CT carries an excess risk of fatal cancer of 1 in 2000, a value that is even greater in children. However, this value must be tempered by the fact that the general population has a lifetime risk of being diagnosed with cancer of 1 in 3. The risk of radiation increases conversely with age, with children and fetuses having the greatest risk of adverse outcomes of radiation due to their smaller body habitus, more rapidly developing cells, and increased incubation time for genetic mutations to manifest. Fig. 83.5. CT scan with typical findings of acute appendicitis. thick arrow, thin arrows, dashed line arrow. Fig. 83.6. Oral contrast CT scan showing discrete abscess from appen- diceal perforation, with periappendiceal fat streaking. (Courtesy Jefferson Radiology, Avon, CT.) Fat stranding Discrete abscess from perforated appendix Fig. 83.4. Graded compression ultrasound scan demonstrating a dilated noncompressible appendix (thin arrow) representing appendicitis. Descargado para Francisco Medina Anderson (fz.medina@hotmail.com) en Organización de Estados Iberoamericanos - Remote Access de ClinicalKey.es por Elsevier en julio 07, 2017. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2017. Elsevier Inc. Todos los derechos reservados.
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1127CHAPTER 83 Acute
Appendicitis IV fluids, antipyretics, and antibiotics (see below). The patient’s pain and nausea should be treated with parenteral opiate analgesia and antiemetics, respectively. There have been a number of good- quality studies that support the concept that opiate analgesia does not negatively affect a patient’s abdominal examination when the patient has an abdominal condition that requires surgery.26,27 Therefore, parenteral opiate analgesia should not be withheld from the patient unless there are contraindications to its use (eg, severe hypotension, allergies). In rare cases, acute appendicitis can cause severe sepsis or septic shock. Antibiotic Therapy Antibiotic therapy should be promptly administered on making the diagnosis of appendicitis or in patients with suspected appen- dicitis and severe sepsis or septic shock. The choice of antibiotics should include broad-spectrum gram-negative and anaerobic coverage. For nonperforated appendicitis, we recommend cipro- floxacin, 400 mg IV, and metronidazole (Flagyl), 500 mg IV; or ceftriaxone, 1g IV, and metronidazole, 500 mg IV; or ampicillin- sulbactam, 3g IV monotherapy. For perforated appendicitis, we recommend broader spectrum antibiotics, such as piperacillin- tazobactam, 3.375 to 4.5g IV, cefepime, 2 g IV, or imipenem- cilastatin, 500 mg IV. Methicillin-resistant Staphylococcus aureus (MRSA) coverage is not typically needed to treat appendicitis but may be considered if the patient has previously known MRSA colonization.28 Definitive Treatment Definitive treatment of acute appendicitis will depend on whether there are associated complications, and all decisions should be made in consultation with the surgical service. Nonperforated appendicitis with a well-circumscribed abscess should be treated with IV antibiotics and percutaneous drainage. Perforated appen- dicitis with or without abscess is treated with IV antibiotics and urgent operative intervention.28 Nonperforated appendicitis without abscess (ie,uncomplicated appendicitis) is traditionally treated with IV antibiotics and surgi- cal removal of the inflamed appendix. However, recent and his- torical data have demonstrated that conservative treatment of appendicitis with antibiotic therapy and a period of inpatient observation may be a viable treatment option for certain patients. There is historical precedence for nonoperative management of appendicitis,and recent studies have found that there may be value in risk-stratifying patients with appendicitis based on their CT findings. In appendicitis with low-risk features, antibiotic therapy with a period of inpatient observation is a feasible option.29,30 Features associated with failed conservative management include the presence of a fecalith, abscess, tumor, or fluid collection or appendiceal diameter of more than 1.1 cm.31 In patients with any of these features, operative intervention is preferred. A minority of patients treated conservatively may fail the inpa- tient observation period and still require surgery; a minority of those discharged after conservative treatment carry the risk of recurrence of appendicitis. However, with a negative appendec- tomy rate of 3.6% to 10% and a complication rate as high as 18%—including small bowel obstruction, adhesions, surgical site infection, and abscess formation—nonoperative care is an option worth considering.32 The decision regarding definitive treatment of acute appendicitis should be made in consultation with the surgical service and the risks and benefits of conservative treat- ment versus surgical intervention should be frankly discussed with the patient, surgeon, and emergency clinician. When the decision is made to proceed with surgical removal of the appendix, in uncomplicated appendicitis, delaying surgery up to 12 hours after diagnosis is made (eg, “waiting until the to be skilled in MRI scan interpretation. MRI demonstrates a sensitivity of 85% to 100%, specificity of 95% to 99.2, average positive predictive value of 92.4, and average negative predictive value of 99.7.20 Table 83.4 lists MRI criteria for the diagnosis of appendicitis. In pregnant patients, IV gadolinium contrast should not be used when evaluating for appendicitis due to potentially harmful effects on the fetus.21 Enteric contrast may be used at the discre- tion of the interpreting radiologist or per institutional protocol. Combined Imaging Pathways An imaging pathways that combine US and CT, in which abdomi- nopelvic CT is performed if the graded compression US is non- diagnostic or negative, have demonstrated combined sensitivities of 94% to 99%, specificities of 91% to 97.5%, and significant reductions in CT utilization.22,23 It has been projected that this pathway would save $547/patient in imaging costs and $25 million/year in aggregate by reducing imaging costs, unnecessary surgeries, and unnecessary hospitalizations, not to mention decreased radiation exposure.24 As institutions increase their experience with the use of US to diagnose appendicitis, we think that a combined US-CT pathway will gain acceptance and improve health care delivery. Interestingly, a so-called radiation-free imaging pathway that combines US and MRI, in which abdominopelvic MRI is per- formed if the US is nondiagnostic or negative, has been recently studied in the emergency pediatric population, with outcomes similar to those of the combined US-CT pathway. However, at this time, there is a paucity of sufficient data and lack of institutional resources to suggest the routine use of this approach.25 Summary of Imaging Methods Fig. 83.2 illustrates a suggested pathway regarding imaging. For nonpregnant patients, graded compression US may be first con- sidered. In nonpregnant females, a pelvic US may also be consid- ered to assess for pelvic pathology. The ability to visualize the appendix on US is institution-dependent, and the provider’s deci- sion to use US initially may depend on the institution’s level of experience with this modality. If the US studies are negative or nondiagnostic (ie, no appendix is visualized and no alternative pathology is noted), the patient may undergo CT imaging of the abdomen and pelvis with IV contrast (no PO contrast). An alter- native to CT imaging in low-risk cases with nondiagnostic US is admission for observation and serial examinations. If the patient is pregnant, graded compression and pelvic US should always be the initial studies of choice, followed by MRI of the abdomen without IV contrast in cases of nondiagnostic or negative US findings. If MRI is not available, and transfer to a facility with MRI capabilities is not feasible, then, after consulta- tion with a radiologist, general surgeon, and obstetrician, abdomi- nal CT scanning with IV contrast may be considered. However, in low-risk cases, admission for observation and serial examinations is an acceptable alternative. MANAGEMENT Supportive Care Decisions surrounding supportive care will depend on the patient’s condition and needs. Supportive care should be initiated prior to a definitive diagnosis and should continue until the patient leaves the ED. Patients should remain NPO. IV fluids (normal saline or lactated Ringer’s) may be administered to maintain hydration and support hypotensive patients. Systemic signs of infection are more common in perforated appendicitis and should be supported by Descargado para Francisco Medina Anderson (fz.medina@hotmail.com) en Organización de Estados Iberoamericanos - Remote Access de ClinicalKey.es por Elsevier en julio 07, 2017. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2017. Elsevier Inc. Todos los derechos reservados.
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1128 PART III
Medicine and Surgery | SECTION Five Gastrointestinal System based on imaging or, rarely, clinical assessment alone. In this case, antibiotics should be initiated, surgical consultation should be obtained, and the patient should be admitted for operative inter- vention or, in select cases, IV antibiotics and observation. Based on clinical and laboratory assessment, the risk of appendicitis is low, and no imaging study was performed. In this case, the patient may be discharged home if he or she is reliable, has improved clinical status (ie, feels better), and understands the provider’s thought process and precautionary instructions. Alternatively, if these criteria are not met, the patient may be transferred to an observation unit or hospitalized for serial examinations. If the patient’s imaging results are inconclusive, or if they are negative but the patient is still symptomatic, the patient may be admitted for observation, symptomatic treatment, serial examinations, and kept NPO, although select patients in this category may still be discharged at the provider’s discretion. morning”) is acceptable and does not lead to worse clinical out- comes; one recent study has demonstrated that inpatient delay of appendectomy by up to 24 hours does not result in worse out- comes.33 Although limited in-hospital delay of operative care has not been shown to increase perforation risk or morbidity, delay by patients initially seeking care does increase the risk of perfora- tion and associated morbidity. Lack of insurance, male gender, and a greater number of comorbid conditions are factors associ- ated with increased perforation risk. The choice of laparoscopic versus open appendectomy is made by the surgeon; however, lapa- roscopic appendectomy has become the current method of choice. DISPOSITION There are three possible disposition pathways when a diagnosis of appendicitis is considered. A diagnosis of appendicitis is made • Appendicitis is a progressive illness caused by appendiceal luminal distention followed by appendiceal wall ischemia, transmural inflammation, and eventual perforation, with resultant peritonitis. • Clinical history, physical examination, and laboratory findings need to be combined to formulate a comprehensive assessment. No one finding can definitively diagnose or exclude appendicitis. • The most useful historical features in evaluating appendicitis are RLQ pain, pain preceding vomiting, and migration of pain to the RLQ. • The most useful physical findings in evaluating appendicitis are RLQ tenderness and rigidity. • Cervical motion tenderness is not specific for pelvic pathology and is found in up to 28% of females with appendicitis. • A rectal examination contributes little and should not be routinely performed in the evaluation of appendicitis. • The white blood cell count alone is neither sensitive nor specific for appendicitis and offers little in the evaluation of appendicitis. • When clinicians have a low pretest possibility for appendicitis, the combination of a WBC count below 10,000/mm3 and CRP level below 8 mg/L support the exclusion of appendicitis as a likely diagnosis. • Nonoperative management of acute appendicitis (IV antibiotics, admission) is gaining support. The patient should not have high-risk features (eg, presence of a fecalith, abscess, tumor, or fluid collection or appendiceal diameter >1.1 cm) and should be made aware of the risk of failed observation as an inpatient or recurrent appendicitis once discharged, both of which would then require surgical removal of the appendix. • Once the diagnosis of appendicitis is made, in-hospital delay of appendectomy of up to 12 hours has not demonstrated negative outcomes when compared to emergent operative care. KEY CONCEPTS The references for this chapter can be found online by accessing the accompanying Expert Consult website. Descargado para Francisco Medina Anderson (fz.medina@hotmail.com) en Organización de Estados Iberoamericanos - Remote Access de ClinicalKey.es por Elsevier en julio 07, 2017. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2017. Elsevier Inc. Todos los derechos reservados.
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Appendicitis REFERENCES 1. Smith HF, Parker W, Kotzé SH, et al: Multiple independent appearances of the cecal appendix in mammalian evolution and an investigation of related ecological and anatomical factors. Comptes Rendus Palevol 12:339–354, 2013. 2. Im GY, Modayil RJ, Lin CT, et al: The appendix may protect against Clostridium difficile recurrence. Clin Gastroenterol Hepatol 9:1072–1077, 2011. 3. Clanton J, Subichin M, Drolshagen K, et al: Fulminant Clostridium difficile infection: an association with prior appendectomy? World J Gastrointest Surg 5:233–238, 2013. 4. Hendahewa R, Shekhar A, Ratnayake S: The dilemma of stump appendicitis—a case report and literature review. Int J Surg Case Rep 14:101–103, 2015. 4a. Laméris W, van Randen A, Go PM, et al: Single and combined diagnostic value of clinical features and laboratory tests in acute appendicitis. Acad Emerg Med 16(9): 835–842, 2009. 5. Brown TW, McCarthy ML, Kelen GD, et al: An epidemiologic study of closed emer- gency department malpractice claims in a national database of physician malpractice insurers. Acad Emerg Med 17:553–560, 2010. 6. Takada T, Nishiwaki H, Yamamoto Y, et al: The role of digital rectal examination for diagnosis of acute appendicitis: a systematic review and meta-analysis. PLoS ONE 10:e0136996, 2015. 7. Howell JM, Eddy OL, Lukens TW, et al: Clinical policy: critical issues in the evaluation and management of emergency department patients with suspected appendicitis. Ann Emerg Med 55:71–116, 2010. 8. Yu C-W, Juan L-I, Wu M-H, et al: Systematic review and meta-analysis of the diag- nostic accuracy of procalcitonin, C-reactive protein and white blood cell count for suspected acute appendicitis. Br J Surg 100:322–329, 2013. 9. Farooqui W, Pommergaard H-C, Burcharth J, et al: The diagnostic value of a panel of serological markers in acute appendicitis. Scand J Surg 104:72–78, 2015. 10. Shindoh J, Niwa H, Kawai K, et al: Diagnostic power of inflammatory markers in predicting severity of appendicitis. Hepatogastroenterology 58:2003–2006, 2011. 11. Bachur RG, Hennelly K, Callahan MJ, et al: Diagnostic imaging and negative appen- dectomy rates in children: effects of age and gender. Pediatrics 129:877–884, 2012. 12. Miglioretti DL, Johnson E, Williams A, et al: The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk. JAMA Pediatr 167:700–707, 2013. 13. van Randen A, Laméris W, van Es HW, et al: A comparison of the accuracy of ultra- sound and computed tomography in common diagnoses causing acute abdominal pain. Eur Radiol 21:1535–1545, 2011. 14. Abo A, Shannon M, Taylor G, et al: The influence of body mass index on the accuracy of ultrasound and computed tomography in diagnosing appendicitis in children. Pediatr Emerg Care 27:731–736, 2011. 15. Mallin M, Craven P, Ockerse P, et al: Diagnosis of appendicitis by bedside ultrasound in the ED. Am J Emerg Med 33:430–432, 2015. 16. Elikashvili I, Tay ET, Tsung JW: The effect of point-of-care ultrasonography on emergency department length of stay and computed tomography utilization in chil- dren with suspected appendicitis. Acad Emerg Med 21:163–170, 2014. 17. Smith MP, Katz DS, Lalani T, et al: ACR Appropriateness Criteria® right lower quad- rant pain—suspected appendicitis. Ultrasound Q 31:85–91, 2015. 18. Kim K, Kim YH, Kim SY, et al: Low-dose abdominal CT for evaluating suspected appendicitis. N Engl J Med 366:1596–1605, 2012. 19. Gaetke-Udager K, Maturen KE, Hammer SG: Beyond acute appendicitis: imaging and pathologic spectrum of appendiceal pathology. Emerg Radiol 21:535–542, 2014. 20. Burke LMB, Bashir MR, Miller FH, et al: Magnetic resonance imaging of acute appendicitis in pregnancy: a 5-year multiinstitutional study. Am J Obstet Gynecol 213:693.e1–693.e6, 2015. 21. Expert Panel on MR Safety, Kanal E, Barkovich AJ, et al: ACR guidance document on MR safe practices: 2013. J Magn Reson Imaging 37:501–530, 2013. 22. Thirumoorthi AS, Fefferman NR, Ginsburg HB, et al: Managing radiation exposure in children—reexamining the role of ultrasound in the diagnosis of appendicitis. J Pediatr Surg 47:2268–2272, 2012. 23. Polites SF, Mohamed MI, Habermann EB, et al: A simple algorithm reduces com- puted tomography use in the diagnosis of appendicitis in children. Surgery 156:448– 454, 2014. 24. Bachur RG, Levy JA, Callahan MJ, et al: Effect of reduction in the use of computed tomography on clinical outcomes of appendicitis. JAMA Pediatr 169:755–760, 2015. 25. Aspelund G, Fingeret A, Gross E, et al: Ultrasonography/MRI versus CT for diagnos- ing appendicitis. Pediatrics 133:586–593, 2014. 26. Manterola C,Vial M, Moraga J, et al: Analgesia in patients with acute abdominal pain. Cochrane Database Syst Rev (1):CD005660, 2011. 27. Poonai N, Paskar D, Konrad S-L, et al: Opioid analgesia for acute abdominal pain in children: A systematic review and meta-analysis. Acad Emerg Med 21:1183–1192, 2014. 28. Solomkin JS, Mazuski JE, Bradley JS, et al: Diagnosis and management of compli- cated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis 50:133–164, 2010. 29. Salminen P, Paajanen H, Rautio T, et al: Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis: the APPAC randomized clinical trial. JAMA 313:2340–2348, 2015. 30. Vons C, Barry C, Maitre S, et al: Amoxicillin plus clavulanic acid versus appendicec- tomy for treatment of acute uncomplicated appendicitis: an open-label, non- inferiority, randomised controlled trial. Lancet 377:1573–1579, 2011. 31. Shindoh J, Niwa H, Kawai K, et al: Predictive factors for negative outcomes in initial non-operative management of suspected appendicitis. J Gastrointest Surg 14:309– 314, 2010. 32. Seetahal SA, Bolorunduro OB, Sookdeo TC, et al: Negative appendectomy: a 10-year review of a nationally representative sample. Am J Surg 201:433–437, 2011. 33. Drake FT, Mottey NE, Farrokhi ET, et al: Time to appendectomy and risk of perfora- tion in acute appendicitis. JAMA Surg 149:837–844, 2014. 34. Ashdown HF, D’Souza N, Karim D, et al: Pain over speed bumps in diagnosis of acute appendicitis: diagnostic accuracy study. BMJ 345:e8012, 2012. 35. Laurell H, Hansson L-E, Gunnarsson U: Manifestations of acute appendicitis: a prospective study on acute abdominal pain. Dig Surg 30:198–206, 2013. CHAPTER 83: QUESTIONS & ANSWERS 83.1. What percentage of women with acute appendicitis have accompanying cervical motion tenderness (CMT)? A. 10% B. 15% C. 20% D. 25% E. 30% Answer: D. Prior to the advent of routine imaging of the appen- dix, as many as 25% of women with acute appendicitis were ini- tially misdiagnosed because of the presence of CMT. 83.2. Which of the following statements regarding ultrasonographic visualization of the appendix is true? A. A compressible appendix is a positive finding. B. An appendiceal diameter greater than 6 or 7 mm is a positive finding. C. The sensitivity of ultrasound for appendicitis is 94% to 98%. D. Ultrasonography has good reliability for detecting a retrocecal appendix. E. Ultrasonography compares favorably with computed tomography (CT) scanning for the detection of appendicitis. Answer: B. A noncompressible appendix with a diameter greater than 6 or 7 mm in a setting of clinical appendicitis is considered a positive finding. Ultrasound sensitivities are 75% to 90%. It is a less useful modality in the obese, those with peritoneal adhesions, and those with a retrocecal appendix. The sensitivity of helical CT scanning with rectal contrast approaches 98%, much higher than ultrasonography. 83.3. A 27-year-old G3P2 woman at 22 weeks of gestation presents with 2 days of right lower quadrant (RLQ) abdominal pain. It began midline and later became more pronounced in the RLQ. The physical examination was remarkable for RLQ tenderness without rebound. The gynecologic examination was negative except for a nontender gravid uterus, with good fetal movement by transabdominal ultrasound. Urinalysis showed 8 to 10 white blood cells (WBCs)/high-power field (HPF) and occasional bacteria. Complete blood count (CBC) showed a WBC count of 12,700/mm3 with 77% neutrophils. Hemoglobin level was 11 g/dL. RLQ ultrasound was limited, with no visualization of a normal or abnormal appendix, and transvaginal ultrasound did not show an obvious gynecologic or obstetric problem. Repeat examination showed continued RLQ tenderness. What is the most appropriate intervention? A. Administer cephalexin for urinary tract infection and schedule a 48-hour clinic recheck B. Admit for observation and serial examination Descargado para Francisco Medina Anderson (fz.medina@hotmail.com) en Organización de Estados Iberoamericanos - Remote Access de ClinicalKey.es por Elsevier en julio 07, 2017. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2017. Elsevier Inc. Todos los derechos reservados.
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1128.e2 PART III
Medicine and Surgery | SECTION Five Gastrointestinal System C. Obtain surgical consultation for laparotomy D. Order a CT scan of the abdomen. E. Order a magnetic resonance imaging (MRI) scan Answer: E. MRI scanning for appendicitis may be helpful in preg- nant women, in whom the avoidance of radiation exposure is a significant consideration, and exploratory surgery carries addi- tional risks. 83.4. In men and children with classic symptoms and signs of appendicitis, what is the most appropriate initial intervention? A. Antibiotics and serial abdominal examinations B. CT scan of the abdomen C. MRI scan of the abdomen D. Surgery E. Ultrasonography Answer: E. In men and children with classic appendicitis, imaging adds little to the evaluation and only exposes patients to unneces- sary radiation. However, it has become less and less common for a patient with a history and examination concerning for appen- dicitis to undergo surgery without further imaging. Ultrasound is the most appropriate initial intervention because it uses no radia- tion and can often visualize and diagnose appendicitis without significant delay. Graded compression ultrasound for appendicitis is specific but lacks the sensitivity of CT scan so, if the appendix is not visualized, a discussion can be had with the general surgeon to determine if it is necessary to obtain further information (via CT or MRI). Descargado para Francisco Medina Anderson (fz.medina@hotmail.com) en Organización de Estados Iberoamericanos - Remote Access de ClinicalKey.es por Elsevier en julio 07, 2017. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2017. Elsevier Inc. Todos los derechos reservados.
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