acute appendicitis - bmj...2020/05/01 · acute appendicitis diagnosis d i a g n o s i s case...

Acute appendicitis

The right clinical information, right where it's needed

Last updated: May 01, 2020

Table of ContentsSummary 3

Basics 4

Definition 4

Epidemiology 4

Etiology 4

Pathophysiology 4

Diagnosis 6

Case history 6

Step-by-step diagnostic approach 6

Risk factors 8

History & examination factors 9

Diagnostic tests 10

Differential diagnosis 12

Diagnostic criteria 14

Treatment 17

Step-by-step treatment approach 17

Treatment details overview 18

Treatment options 19

Emerging 24

Follow up 25

Recommendations 25

Complications 26

Prognosis 27

Guidelines 28

Diagnostic guidelines 28

Treatment guidelines 28

References 29

Images 36

Disclaimer 38

Summary

◊ Acute inflammation of the vermiform appendix.

◊ Typically presents as acute abdominal pain starting in the mid-abdomen and later localizing to theright lower quadrant.

◊ Associated with fever, anorexia, nausea, vomiting, and elevation of the neutrophil count.

◊ Diagnosis is usually made clinically. If investigation is required, computed tomography scan orultrasonography may show dilatation of the appendix outer diameter to more than 6 mm.

◊ Definitive treatment is surgical appendectomy. A nonoperative, antibiotic-only approach may befeasible in select patient populations.

Acute appendicitis BasicsBA

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DefinitionAcute appendicitis is an acute inflammation of the vermiform appendix, most likely due to obstruction of thelumen of the appendix (by fecalith, normal stool, infective agents, or lymphoid hyperplasia).[1] [2][Fig-1]

EpidemiologyAcute appendicitis is one of the most common acute surgical abdominal emergencies.[4] More than 250,000appendectomies are performed each year in the US; however, the incidence is lower in populations where ahigh-fiber diet is consumed.[5] [6] The overall lifetime risk of developing acute appendicitis is 8.6% for malesand 6.7% for females; lifetime risk of appendectomy is around 12% in males and 23% in females.[7] [8]

Globally, the pooled incidence of appendicitis or appendectomy is around 100 per 100,000 person years.[9]Data suggest a rapid increase in incidence in newly industrialized countries.[9] The condition is mostcommonly seen in patients aged between early teens and late 40s. There is a slight male to femalepredominance (1.3:1).

EtiologyObstruction of the lumen of the appendix is the main cause of acute appendicitis. Fecalith (a hard massof fecal matter), normal stool, or lymphoid hyperplasia are the main causes for obstruction. Retrospectiveappendectomy data suggest fecalith prevalence of 14% to 18% (among patients with a clinical indication/clinical syndrome of appendicitis or emergency appendectomy patients, respectively).[10] [11] In emergencyappendectomy patients, fecalith prevalence was 39.4% in perforated appendicitis, but only 14.6% innonperforated appendicitis.[10]

There is evidence suggesting a neuroimmune etiology in some cases, but this is still being investigated.[12]

PathophysiologyThe lumen distal to the appendiceal obstruction starts to fill with mucus and acts as a closed-loopobstruction. This leads to distension and an increase in intraluminal and intramural pressure. As the conditionprogresses, the resident bacteria in the appendix rapidly multiply. The most common bacteria in the appendixare Bacteroides fragilis and Escherichia coli .[13]

Distension of the lumen of the appendix causes reflex anorexia, nausea and vomiting, and visceral painaround the umbilicus, based on the embryonic origins of the appendix.

As the pressure of the lumen exceeds the venous pressure, the small venules and capillaries becomethrombosed but arterioles remain open, which leads to engorgement and congestion of the appendix. Theinflammatory process soon involves the serosa of the appendix, hence the parietal peritoneum in the region,which causes classical right lower quadrant pain at McBurney point.

Once the small arterioles are thrombosed, the area at the antimesenteric border becomes ischemic, andinfarction and perforation ensue. Bacteria leak out through the walls and pus forms (suppuration) within andaround the appendix. Perforations are usually seen just beyond the obstruction rather than at the tip of theappendix.[14]

4 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: May 01, 2020.BMJ Best Practice topics are regularly updated and the most recent versionof the topics can be found on bestpractice.bmj.com . Use of this content is

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Acute appendicitis BasicsBA

SIC

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This PDF of the BMJ Best Practice topic is based on the web version that was last updated: May 01, 2020.BMJ Best Practice topics are regularly updated and the most recent versionof the topics can be found on bestpractice.bmj.com . Use of this content is


5


Acute appendicitis DiagnosisD

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Case historyCase history #1A 22-year-old male presents to the emergency room with abdominal pain, anorexia, nausea, and low-grade fever. Pain started in the mid-abdominal region 6 hours ago and is now in the right lower quadrantof the abdomen. The pain is steady in nature and aggravated by coughing. Physical examination revealsa low-grade fever (100.5°F [38°C]), pain on palpation at right lower quadrant (McBurney sign), andleukocytosis (12,000/microliter) with 85% neutrophils.

Case history #2A 12-year-old girl presents with sudden-onset severe generalized abdominal pain associated with nausea,vomiting, and diarrhea. On exam she appears ill and has a temperature of 104°F (40°C). Her abdomen istense with generalized tenderness and guarding. No bowel sounds are present.

Other presentationsAtypical appendiceal anatomy, such as retrocecal or long appendix, may present with back, hip, or left-sided abdominal pain that is confused with an alternate intra-abdominal diagnosis. Older patients are lesslikely to have classical symptoms and may present with nonspecific abdominal pain without associatedfeatures, or confusion. The delay in presentation or diagnosis in this group results in increased risk ofmorbidity and mortality. The diagnosis of acute appendicitis during pregnancy is often delayed, as thelocation of the pain is affected by displacement of the appendix by the uterus, and symptoms such asnausea and vomiting are frequently associated with pregnancy itself.[3]

Step-by-step diagnostic approachHistory and physical examination form the initial approach in the evaluation of a patient with possibleappendicitis.[2] It is routine practice in the US to request a computed tomography (CT) scan for patientspresenting to the emergency room with features of acute appendicitis.[24]

Validated clinical decision tools such as the Alvarado score demonstrate high sensitivities and are useful forexcluding appendicitis, but lack specificity.[25] [26] [27]

Ultrasound or magnetic resonance imaging (MRI) of the abdomen are recommended if the patient ispregnant.[28] [29] Women of childbearing age should have a pelvic examination to rule out other pelvicpathology.[30]

HistoryAbdominal pain is the main presenting complaint. Pain typically starts at mid-abdominal region and later(1 to 12 hours) shifts to the right lower quadrant. Pain is usually constant in nature and with intermittentabdominal cramps and is usually worse on movement and coughing.

Location of the pain may vary depending upon the position of the appendix:




Acute appendicitis Diagnosis

• Retrocecal appendix may cause flank or back pain• Retroileal appendix may cause testicular pain due to irritation of the spermatic artery or ureter• Pelvic appendix may cause suprapubic pain• A long appendix with tip inflammation in the left lower quadrant may cause pain to that region.

Anorexia is another important symptom almost always associated with acute appendicitis.[31] Withoutanorexia the diagnosis of acute appendicitis is in question. Nausea and vomiting are also present in 75%of patients.[31] Absolute constipation is a late feature.

The sequence of presentation in 95% of patients with acute appendicitis usually starts with anorexia,followed by abdominal pain and then vomiting.[31] However, in pregnant patients, the only featuresshown to be significantly associated with a diagnosis of appendicitis are nausea, vomiting, and localperitonitis.[32]

Complicated appendicitis (perforation or intra-abdominal abscess) is more likely the greater the durationof symptoms and in older patients (>50 years).[33] [34]

Physical examUsually, there are no significant changes in vital signs. Body temperature may be slightly increased (byan average of 1.8°F [1°C]). In patients presenting with a high-grade fever, another diagnosis should beconsidered.[35] Tachycardia may also be present.[36]

A classic sign is right lower quadrant abdominal tenderness (McBurney sign) and localized reboundtenderness, if appendix is anterior. There may also be pain in the right lower quadrant after compressingthe left lower quadrant (Rovsing sign).

Pain may be elicited in the right lower quadrant with the patient lying on their left side and slowlyextending the right thigh to cause a stretch in the iliopsoas muscle (psoas sign) or by internal rotation ofthe flexed right thigh (obturator sign).

Bowel sounds may be reduced, particularly on the right side compared with on the left.

Classical abdominal findings may not be present if the appendix is in an atypical position.

Patients with perforation may present acutely ill with hypotension, tachycardia, and a tense, distendedabdomen with generalized guarding and absent bowel sounds.

A palpable mass may be felt with appendiceal perforation that has been contained by the omentum,resulting in a periappendiceal abscess.

InvestigationAll patients with abdominal discomfort should have a complete blood count taken. Mild leukocytosis(10,000 to 18,000/microliter) with increased neutrophils is usually present.

Some form of imaging is usually warranted. Most nonpregnant patients presenting to the emergency roomwith abdominal pain suggestive of appendicitis will have a CT scan of the abdomen and pelvis.[28] [29]Preoperative imaging with a CT scan of the abdomen (ultrasound or MRI for pregnant women) now formsthe usual standard of care. Women and children, in particular, may benefit from preoperative imaging.[24][37] [38]

Choice of imaging modality

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Although CT scan has greater sensitivity and specificity than ultrasound in diagnosing appendicitis, thelatter is readily available, rapid, and able to be performed at the bedside.[39] [40] [41] [39] In children,ultrasound may be preferred over CT scan in order to limit radiation exposure. There is evidence tosuggest enhanced sensitivity and specificity of ultrasound in children compared with adults.[37] [42][43] If, on ultrasound, a normal appendix is visualized in its full length, then acute appendicitis can beexcluded. However, this is rarely the case, and the greatest utility for ultrasound is to detect an alternativecause of abdominal pain that excludes appendicitis.[44]

Appendiceal CT scan is increasingly used as the initial diagnostic test for acute appendicitis, and it isroutine practice in the US to request a CT for patients presenting to the emergency room with features ofacute appendicitis.[24] A CT is also indicated in atypical presentations.[28] [45] However, delayed surgerysubsequent to CT scan for presumed appendicitis is associated with an increased rate of appendicealperforation.[46] Intravenous contrast-enhanced CT scan with or without oral contrast has up to 100%sensitivity compared with 92% sensitivity in nonintravenous contrast-enhanced CT scan.[47] [48][Fig-2]

In pregnant women presenting with features of appendicitis, an abdominal sonogram should beperformed to identify the appendix. If the sonogram examination is inconclusive, an abdominal MRI(particularly in early pregnancy) may be appropriate.[30] [28]

Tests to exclude other causesA urinalysis should be performed to exclude possible urinary tract infection or renal colic. Sexually activewomen of childbearing age should have a urinary pregnancy test.

[VIDEO: Venepuncture and phlebotomy: animated demonstration ]

Risk factorsWeak<6 months of breastfeeding• Affects immunologic responses to certain microbial organisms. Children who received <6 months of

breastfeeding had a higher incidence of acute appendicitis compared with those who received >6months of breastfeeding.[15] [16]

low dietary fiber• Known to cause constipation. Children with appendectomies have low fiber in their diet compared with

controls.[6] [17] However, this theory is controversial.[18]

improved personal hygiene• A higher incidence of acute appendicitis in Western society may be related to the living conditions and

improved personal hygiene.[19]• A balance of gastrointestinal microbial flora is important for prevention of infection, for digestion, and

providing important nutrients.[20] Frequent use of antibiotics and improved hygienic conditions lead todecreased exposure and/or imbalance of gastrointestinal microbial flora that may eventually lead to amodified response to viral infection and thereby trigger appendicitis.[21]



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smoking• Children exposed to passive smoking have significantly increased incidence of acute appendicitis.[22]

There is also an increased incidence of acute appendicitis in adult patients who smoke compared withadults who never smoked.[22] [23]

History & examination factorsKey diagnostic factorsabdominal pain (common)• Constant mid-abdominal pain which later (1 to 12 hours) shifts to right lower quadrant. Usually worse

on movement and coughing.

anorexia (common)• An important symptom almost always associated with acute appendicitis.[31] Without anorexia the

diagnosis of acute appendicitis is in question.

right lower quadrant tenderness (common)• A classic sign is right lower quadrant abdominal tenderness (McBurney sign). There may be localized

rebound tenderness, especially if the appendix is anterior. Compressing the left lower quadrant mayalso elicit pain in the right lower quadrant (Rovsing sign). Pain may also be elicited with the patientlying on their left side and slowly extending the right thigh to cause a stretch in the iliopsoas muscle(psoas sign) or by internal rotation of the flexed right thigh (obturator sign).

Other diagnostic factorsadolescence or early adulthood (common)• May occur at any age but is most commonly seen in early teens to late 40s.

nausea (common)• Nausea and vomiting are present in 75% of patients.[31]

fever (common)• Low-grade, usually 1.8°F (1°C) increase in body temperature.

diminished bowel sounds (common)• Bowel sounds may be reduced, particularly on the right side compared with the left.

tachycardia (common)• Tachycardia may be present, particularly in patients with perforation.[36]

vomiting (uncommon)• Nausea and vomiting are present in 75% of patients.[31]

Rovsing sign (uncommon)• Pressing the left side of the abdominal cavity elicits pain in right lower quadrant.

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psoas sign (uncommon)• Extending the right thigh on left lateral position elicits pain in right lower quadrant.

obturator sign (uncommon)• Pain is elicited in the right lower quadrant of abdomen by internal rotation of the flexed right thigh.

Diagnostic tests1st test to order

Test ResultCBC

• Increased polymorphonuclear leukocytes (>75%). High discriminatorypower when combined with history.[49]

mild leukocytosis (10,000to 18,000/microliter)

abdominal and pelvic CT scan• Wall thickening, wall enhancement, and inflammatory changes in

the surrounding tissues are additional findings seen in a CT scan ofabdomen and pelvis.[50][Fig-2]

• Appendiceal CT scan is increasingly used as the initial diagnostictest for acute appendicitis, and it is routine practice in the US torequest a CT for patients presenting to the emergency room withfeatures of acute appendicitis.[24] A CT is also indicated in atypicalpresentations.[28] [45]

• Intravenous contrast-enhanced CT scan with or without oralcontrast has up to 100% sensitivity compared with 92% sensitivity innonintravenous, contrast-enhanced CT scan.[47] [48]

• In pregnant women presenting with features of appendicitis, anabdominal sonogram should be performed to identify the appendix.If the sonogram examination is inconclusive, abdominal MRI(particularly in early pregnancy) may be appropriate.[28] [45]

abnormal appendix(diameter >6 mm)identified or calcifiedappendicolith seenin association withperiappendicealinflammation, fatstranding

urinary pregnancy test• If positive, the possibility of ectopic pregnancy should be considered.

negative





Other tests to consider

Test Resultabdominal ultrasound

• May be preferred in children in order to limit radiation exposure withCT scan. Sensitivity and specificity of ultrasound may be higher inchildren compared with adults.[40] [42] [43]

aperistaltic ornoncompressiblestructure with outerdiameter >6 mm, fluidcollection if perforated, fatstranding, appendicolith

urinalysis• If positive for red cells, white cells, or nitrates, an alternative diagnosis

such as renal colic or urinary tract infection should be considered.

negative

abdominal and pelvic MRI in pregnancy• In pregnant women presenting with features of appendicitis, an

abdominal sonogram should be performed to identify the appendix.If the sonogram examination is inconclusive, abdominal MRI(particulary in early pregnancy) may be appropriate.[28] [45]

abnormal appendix(diameter >6 mm)identified and evidenceof periappendicialinflammatory changes,appendicolith, fatstranding

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Differential diagnosis

Condition Differentiating signs /symptoms

Differentiating tests

Acute mesenteric adenitis • Usually presents in childrenwith a recent history of upperrespiratory infection.

• Pain in the abdomenis usually diffuse withtenderness not localized tothe right lower quadrant.

• Guarding may be present,but rigidity is usually absent.

• Generalizedlymphadenopathy may benoted.

• There is no specific test toconfirm the diagnosis.

• Relative lymphocytosis inWBC differential counts issuggestive.

• Negative ultrasound or CTfindings help exclude otherdiagnoses.

Viral gastroenteritis • Common in children; causedby viruses, bacteria, or toxin.

• Characterized by profusewatery diarrhea, nausea,and vomiting.

• Crampy abdominal painoften precedes the diarrhea,and no localizing signs arepresent.

• If caused by typhoid fever,intestinal perforationmay cause localizedabdominal pain and/orgeneralized and reboundtenderness. In this scenario,associated maculopapularrash, inappropriatebradycardia, and leukopeniawill differentiate fromappendicitis.

• No specific test unless dueto typhoid ( Salmonellatyphi from stool or blood willconfirm the diagnosis).

Meckel diverticulitis • Usually asymptomatic.• Clinical presentation of

diverticulitis is similar toacute appendicitis.

• Technetium pertechnetatescan may show theenhancement of diverticulumif gastric mucosa is present.

Intussusception • Occurs in young children(age <2 years).

• Sudden onset of colickypain; between episodes ofpain the child is calm.

• A sausage-shaped massmay be palpable in the rightlower quadrant.

• Barium enema maydemonstrate theintussusception with a coil-spring sign at the point ofbowel invagination.

Crohn disease • Young adult with fever,nausea, vomiting, diarrhea,right lower quadrant pain,and localized tenderness.

• CT scan may show intra-abdominal abscess.

• Contrast study of the smallbowel and colon may show







stricture or a series of ulcersand fissures (cobblestoneappearance) of mucosa.

Peptic ulcer disease • May or may not have ahistory of peptic ulcerdisease.

• Pain is abrupt, severein intensity, and may belocalized to right lowerquadrant.

• Erect chest x-ray andabdominal x-ray may showfree air under the diaphragm

Right-sided ureteric stone • Pain is usually colickyin nature and severe inintensity. May be referredto the labia, scrotum, orpenis and associated withhematuria.

• Fever usually absent.

• Urinalysis positive for blood.• Leukocytosis usually absent.• Abdominal x-rays or

tomogram may showcalcified stone.

• Pyelography and CTscan without oral andintravenous contrast confirmthe diagnosis.

Cholecystitis • Pain and tenderness areusually in the right upperquadrant. In one third ofpatients the gallbladder canbe palpable.[51]

• Abdominal ultrasound showsthick wall with pericholecysticcollection, and tendernessis present over gallbladderarea (Murphy sign).

• Hepatobiliary iminodiaceticacid scan will shownonvisualization ofgallbladder at >4 hours.

Urinary tract infection • Pain and tenderness isusually in suprapubic areaassociated with burningmicturition.

• Acute right-sidedpyelonephritis may presentwith fever, chills, andtenderness at the rightcostovertebral angle.

• Urine microscopy and cultureconfirm presence of bacteria.

Primary peritonitis • Most patients present withabrupt abdominal pain, fever,distension, and reboundtenderness.

• History of advanced cirrhosisor nephrosis.

• CT scan may show fluid inthe abdomen.

• Peritoneal fluid shows>500/microliter count and>25% polymorphonuclearleukocytosis.

Pelvic inflammatorydisease

• Occurs in females usuallyaged between 20 and 40years.

• Presents with bilateral lowerquadrant tenderness, usuallywithin 5 days of the lastmenstrual period.

• Endocervical swabmay confirm the pelvicinflammatory disease due to Chlamydia trachomatis .[52]

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• Purulent discharge fromcervical os.

Ruptured Graafian follicle(mittelschmerz)

• Midmenstrual cycle, briefperiod of lower abdominalpain not usually associatedwith nausea and vomitingand fever.

• Tenderness is usuallydiffuse, not localized.

• Clinical diagnosis. Noinvestigation indicated.

Ectopic pregnancy • Female within childbearingage presents with missedmenstrual period, right lowerquadrant pain, or pelvicpain with some degree ofvaginal bleeding or spotting.Cervical motion tendernessmay be present on pelvicexamination.

• Human chorionicgonadotropin hormone levelis high in serum and in urine.

• Ultrasound reveals presenceof mass in fallopian tubes.

Ovarian torsion • Female with right lowerquadrant pain. Occasionallypresents with mass in theright lower quadrant.

• Ultrasonography showsovarian cyst and decreasedblood flow.

Diagnostic criteria

There are multiple validated decision tools utilized in the diagnosis of appendicitis. These include theAlvarado, AIR, and RIPASA scoring systems.

The Alvarado score is commonly used and has undergone the most validation studies. The AIR scoreperformed well in one systematic review of clinical prediction rules. The RIPASA score was more sensitivethan the Alvarado score, with improved diagnostic odds ratio, but lower specificity.[26] [27]

Alvarado (MANTRELS) score[25]Score is based on clinical characteristics of the patients. The higher the score out of a possible total of 10,the greater the chance of having acute appendicitis.

M: Migration of pain to right lower quadrant = 1 point.

A: Anorexia = 1 point.

N: Nausea and vomiting = 1 point.

T: Tenderness in right lower quadrant = 2 points.

R: Rebound tenderness = 1 point.

E: Elevated temperature = 1 point.





L: Leukocytosis = 2 points.

S: Shift of WBC count to left = 1 point.

Appendicitis Inflammatory Response (AIR) score[53]Vomiting = 1 point.

Pain in right inferior fossa = 1 point.

Rebound tenderness: light = 1 point; medium = 2 points; strong = 3 points.

Body temperature ≥38.5 = 1 point.

Polymorphonuclear leukocytes: 70% to 84% = 1 point; ≥85% = 2 points.

WBC count: 10.0 to 14.9 ×10⁹/L = 1 point; ≥15.0 ×10⁹/L = 2 points.

CRP concentration: 10g/L to 49 g/L = 1 point; ≥50 = 2 points.

(Maximum 12 points.)

Sum 0 to 4 = low probability. Outpatient follow-up if unaltered general condition.

Sum 5 to 8 = indeterminate group. In-hospital active observation with rescoring/imaging or diagnosticlaparoscopy according to local traditions.

Sum 9 to 12 = high probability. Surgical exploration is proposed.

RIPASA Score for Acute Appendicitis[54]The higher the score out of a possible total of 16, the greater the chance of having acute appendicitis. Thescoring system was developed for Asian populations.

Female = 0.5 points.

Male = 1 point.

Age <39.9 years = 1 point.

Age >40 years = 0.5 points.

Right iliac fossa (RIF) pain = 0.5 points.

Migration of pain to RIF = 0.5 points.

Anorexia = 1 point.

Nausea and vomiting = 1 point.

Duration of symptoms <48 hours = 1 point.

Duration of symptoms >48 hours = 0.5 points.

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RIF tenderness = 1 point.

Guarding = 2 points.

Rebound tenderness = 1 point.

Rovsing sign = 2 points.

Fever = 1 point.

Raised WBC = 1 point.

Negative urine analysis = 1 point.

(Maximum 16 points.)

Acute Physiology and Chronic Health Evaluation II (APACHE II)score[55]The APACHE score is commonly used to establish illness severity in the intensive care unit (ICU) and predictthe risk of death.

[VIDEO: APACHE II scoring system ]There is a high risk of death if the score is 25 or above.

There are several other models that have been developed for use in the ICU, including APACHE III, Mortalityin Emergency Department Sepsis score, Simplified Acute Physiology Score, Sepsis-related Organ FailureAssessment, and Mortality Probability Model II.[56] [57] [58]



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Acute appendicitis Treatment

Step-by-step treatment approachThe usual standard of care for the management of uncomplicated appendicitis continues to be operative.

There is emerging evidence to suggest that a nonoperative, antibiotic-only approach may be feasible inselect patient populations. The evidence supporting nonoperative management of appendicitis continues tobe conflicting, and further research is warranted. There is more evidence to support a nonoperative approachin children than in adults.[61] [62] [63] [64] [65] [66] [67] [68]

Uncomplicated presentationOnce the diagnosis of acute appendicitis is made, patients should be given nothing by mouth.

Intravenous fluids, such as lactated Ringer solution, should be started. Use of prophylactic intravenousantibiotics postoperatively is controversial; however, the use of a broad-spectrum antibiotic such ascefoxitin (one dose preoperatively and 2 doses postoperatively) is recommended for uncomplicatedappendicitis to reduce the risk of wound infection.[69] Prompt appendectomy remains the treatment ofchoice in international guidelines and should be recommended in most cases.

An antibiotic-only approach may be reasonable for select groups, where patients understand the risk ofrecurrence appendicitis.[68] [66]

Complicated presentationComplications of acute appendicitis occur in 4% to 6% of patients and include gangrene with subsequentperforation or intra-abdominal abscess.[14]

Initial management includes keeping the patient nothing by mouth and starting intravenous fluids. Patientswho are in shock should be given a bolus of intravenous fluid, such as lactated Ringer solution, in order tomaintain a stable pulse rate and BP.[70] [71]

Intravenous antibiotics (e.g., cefoxitin or piperacillin/tazobactam) should be started immediately andcontinued until the patient becomes afebrile and the leukocytosis is corrected. For more severe infections,a carbapenem antibiotic may be used as a single agent. Combination antibiotic regimens may also beused based on local sensitivities and protocols.[14]

In patients with acute peritonitis, appendectomy should be performed without delay. Patients presentingwith right lower quadrant abscess should be managed with intravenous antibiotics and drainage eitherby interventional radiology (computed tomography-guided drainage) or by operative drainage. If there isclinical improvement and the signs and symptoms are completely resolved, interval appendectomy maybe unnecessary.[72] [73] [74]

Interval appendectomy is performed after 6 weeks if the symptoms are not completely resolved.[75]There is evidence to suggest that laparoscopic appendectomy may be a feasible first-line optionover conservative treatment for appendiceal phlegmon/abscess in adults and children; however, onesystematic review was unable to find evidence for either benefit or harm from early appendectomy(laparoscopic or open) versus conservative treatment.[76] [77] Unplanned interim analysis of 60 patientsincluded in one small, randomized controlled trial (subsequently terminated), suggested that patients>40 years of age with periappendiceal abscess may be at increased risk for appendiceal tumor.[78] Untilfurther information becomes available from future studies, routine interval appendectomy should bepreferred in these patients.[78] [79]

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Surgical optionsThere are 2 operative options for appendectomy: open and laparoscopic. Most procedures are nowundertaken laparoscopically.

In adults, the choice of appendectomy generally depends upon the experience of the surgeon. Studieshave shown laparoscopic appendectomy to have better cosmetic results, shorter length of hospital stay,reduced postoperative pain, and reduced risk of wound infection, compared with open appendectomy.[80] Laparoscopic appendectomy is recommended for uncomplicated appendicitis, as well as complicatedand perforated appendicitis.[81] [82] It is also considered the safest approach in obese patients.[83]

In children, laparoscopic appendectomy decreases the incidence of overall postoperative complications,including wound infection and duration of total hospital stay.[84] [85] [80] However, another study hasshown no significant difference.[86]

[VIDEO: Peripheral venous cannulation: animated demonstration ]

[VIDEO: Practical suturing techniques: animated demonstrations ]

The surgical approach in pregnant women is controversial. Meta-analyses report significantly greater riskof fetal loss with a laparoscopic approach, but length of hospital stay and overall complications may belower than for open surgery.[88] [89]

Antibiotic-only therapyAntibiotics alone for the treatment of uncomplicated appendicitis can be successful in selected patientswho wish to avoid surgery, and who accept the risk of up to 39% recurrence. In such cases, it isrecommended that the diagnosis of uncomplicated appendicitis is confirmed by imaging, and that patientexpectations are managed via a shared decision-making process.[29] [90] [66] [68]

Treatment details overviewPlease note that formulations/routes and doses may differ between drug names and brands, drugformularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

Acute ( summary )uncomplicated acute appendicitis

1st appendectomy + supportive care

adjunct intravenous antibiotic therapy

2nd antibiotic-only therapy

ill with perforation or abscess

1st intravenous antibiotic therapy +supportive care

perforation plus appendectomy

abscess plus drainage ± interval appendectomy



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Treatment optionsPlease note that formulations/routes and doses may differ between drug names and brands, drugformularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

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Acuteuncomplicated acute appendicitis

1st appendectomy + supportive care

» Once the diagnosis of acute appendicitisis made, patients should be given nothing bymouth.

» Intravenous fluids, such as lactated Ringersolution, should be started.

» Appendectomy should be performed withoutdelay, as early appendectomy reduces thechances of perforation and intra-abdominalabscess.[Fig-1]

» There are 2 operative options forappendectomy: open and laparoscopic. Inadults, the choice of appendectomy generallydepends upon the experience of the surgeon.

» Studies have shown laparoscopicappendectomy to have better cosmetic results,shorter length of hospital stay, reducedpostoperative pain, and reduced risk ofwound infection, when compared with openappendectomy. [80]

» Laparoscopic appendectomy is recommendedfor uncomplicated appendicitis.[81] It is alsoconsidered the safest approach in obesepatients.[83] The surgical approach in pregnantwomen is controversial. Meta-analyses reportsignificantly greater risk of fetal loss with alaparoscopic approach, but length of hospitalstay and overall complications may be lower thanfor open surgery.[88] [89]

» In children, laparoscopic appendectomydecreases the incidence of overall postoperativecomplications, including wound infection andduration of total hospital stay.[84] [85] [80]However, another study has shown no significentdifference.[86]

[VIDEO: Peripheral venouscannulation: animateddemonstration ]

[VIDEO: Practical suturingtechniques: animateddemonstrations ]

» Patients with higher APACHE (AcutePhysiology and Chronic Health Evaluation)











Acutescores seem to be at higher risk of developmentof postoperative complications.

[VIDEO: APACHE II scoring system ]

adjunct intravenous antibiotic therapy

Treatment recommended for SOME patients inselected patient group

Primary options

» cefoxitin: 1-2 g intravenously as a singledose before surgery, followed by 1-2 g every8 hours for 2 doses postsurgery

» Given for 24 hours for uncomplicatedappendicitis.

2nd antibiotic-only therapy

» Antibiotics alone for the treatment ofuncomplicated appendicitis can be successful inselected patients who wish to avoid surgery, andwho accept the risk of up to 39% recurrence.In such cases, it is recommended that thediagnosis of uncomplicated appendicitisbe confirmed by imaging, and that patientexpectations be managed via a shared decision-making process.[29] [90] [66] [68]

ill with perforation or abscess

ill with perforation or abscess 1st intravenous antibiotic therapy +supportive care

Primary options

» cefoxitin: 1-2 g intravenously every 8 hours

OR

» piperacillin/tazobactam: 3.375 gintravenously every 6 hoursDose consists of 3 g piperacillin plus 0.375 gtazobactam.

OR

» meropenem: 1 g intravenously every 8hours

» These patients have evidence of perforation,mass, or abscess.

» Initial management includes keepingthe patient nothing by mouth and startingintravenous fluids. Patients who are in shock

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Acuteshould be given a bolus of intravenous fluid,such as lactated Ringer solution, in orderto maintain a stable pulse rate and bloodpressure.[70] [71] Following on, maintenanceintravenous fluids should be given until thecondition of the patient improves and an oral dietcan be tolerated.

» Intravenous antibiotics (e.g., cefoxitin orpiperacillin/tazobactam) should be startedimmediately. For more severe infections, acarbapenem antibiotic may be used as a singleagent. Combination antibiotic regimens mayalso be used based on local sensitivities andprotocols.[14]

» Antibiotics should be continued until the patientbecomes afebrile and leukocytosis is corrected.

» Patients with higher APACHE (AcutePhysiology and Chronic Health Evaluation)scores seem to be at higher risk of developmentof postoperative complication.

[VIDEO: APACHE II scoring system ]perforation plus appendectomy

Treatment recommended for ALL patients inselected patient group

» There are 2 operative options forappendectomy: open and laparoscopic. Inadults, the choice of appendectomy generallydepends upon the experience of the surgeon.

» Studies have shown laparoscopicappendectomy to have better cosmetic results,shorter length of hospital stay, reducedpostoperative pain, and reduced risk ofwound infection, when compared with openappendectomy. [80]

» Laparoscopic appendectomy is recommendedfor complicated and perforated appendicitis.[82]It is also considered the safest approach inobese patients.[83] The surgical approach inpregnant women is controversial. Meta-analysesreport significantly greater risk of fetal loss witha laparoscopic approach, but length of hospitalstay and overall complications may be lower thanfor open surgery.[88] [89]

» In children, laparoscopic appendectomydecreases the incidence of overall postoperativecomplications, including wound infection andduration of total hospital stay.[84] [85] [80]However, another study has shown no significantdifference.[86]






Acute[VIDEO: Peripheral venouscannulation: animateddemonstration ]

[VIDEO: Practical suturingtechniques: animateddemonstrations ]

abscess plus drainage ± interval appendectomy

Treatment recommended for ALL patients inselected patient group

» Abscess usually occurs as a progression of thedisease process, particularly after perforation.

» Presents with tender right lower quadrantmass, swinging fever, and leukocytosis.Ultrasonography or computed tomography (CT)scan will show the abscess.

» Initial treatment includes intravenousantibiotics and CT-guided or operative drainageof the abscess.

» If there is clinical improvement and the signsand symptoms are completely resolved, intervalappendectomy may be unnecessary.[72] [73][74] Interval appendectomy is performed after6 weeks if the symptoms are not completelyresolved.[75]

» There is evidence to suggest that laparoscopicappendectomy may be a feasible first-line optionover conservative treatment for appendicealphlegmon/abscess in adults and children;however, one systematic review was unable tofind evidence for either benefit or harm fromearly appendectomy (laparoscopic or open)versus conservative treatment.[76] [77]

» Unplanned interim analysis of one randomizedcontrolled trial (subsequently terminated)suggested that patients >40 years of age withperiappendiceal abscess may be at increasedrisk for appendiceal tumor.[78] Routine intervalappendectomy should be preferred in thesepatients.[78] [79]

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EmergingEravacycline#Eravacycline is a novel antibiotic of the tetracycline class. One clinical trial indicated that it is at least aseffective as ertapenem in treating complicated intra-abdominal infections (cIAIs).[91] Eravacycline mayhave a role in the treatment of complicated appendicitis. The Food and Drug Administration (FDA) and theEuropean Medicines Agency have approved eravacycline (Xerava, Tetraphase Pharmaceuticals) for thetreatment of cIAIs in adults.

Meropenem/vaborbactamMeropenem/vaborbactam is a carbapenem beta-lactamase inhibitor combination that has demonstratedhigher clinical cure rates, versus best available therapy, for the treatment of carbapenem-resistantEnterobacteriaceae, among other infections.[92] The Committee for Medicinal Products for Human Use ofthe European Medicines Agency has recommended granting authorisation for meropenem/vaborbactam forthe treatment of several types of infection, including cIAIs. Meropenem/vaborbactam is approved by the FDAfor the treatment of complicated urinary tract infections in adults.

Imipenem/cilastatin/relebactamImipenem/cilastatin/relebactam is a three-drug combination containing imipenem-cilastatin, a previouslyFDA-approved antibiotic, and relebactam, a new beta-lactamase inhibitor. The FDA has approved thiscombination to treat adults with complicated urinary tract infections and cIAIs.




Acute appendicitis Follow up

RecommendationsMonitoringPatients are usually discharged from hospital 1 day after surgery for uncomplicated appendicitis.Complicated appendicitis may require a longer hospital stay depending on the response to treatment.In some countries, patients are followed up postoperatively regardless of complicated or uncomplicatedappendicitis; for example, 1 week after discharge, with further follow-up visits arranged as needed.

Patient instructionsPatients can be started on a clear liquid diet on the same day as the operation if there is no nauseaor vomiting and can start a regular diet the next day. Patients are usually given at least 1 week offwork or school. Future level of activity, driving, or return to work should be determined at the follow-upappointment.

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Complications

Complications Timeframe Likelihoodperforation short term low

May occur after >12 hours of progressive appendiceal inflammation.

Usually a consequence of a delay in seeking medical treatment.

Presents with more severe abdominal pain, high fever (>101°F [38.3°C]), localized tenderness, anddecreased bowel sounds.

Appendectomy should be performed in all cases. Procedure can be open or laparoscopic.

generalized peritonitis short term low

Large perforation of acutely inflamed appendix results in generalized peritonitis.

Presents with an acute abdomen (high fever, diffuse abdominal pain, generalized tenderness, and absentbowel sounds).

If the diagnosis is suspected as acute appendicitis, appendectomy can be performed. If diagnosis is indoubt, exploratory laparotomy should be performed through midline incision, and the appendix, if inflamed,should be removed.

appendicular mass short term low

Usually due to delay in medical treatment.

Presents with tender right lower quadrant mass. Ultrasonography or computed tomography scan will showa mass.

If the patient appears otherwise well, the initial management is conservative treatment with intravenousfluids and broad-spectrum antibiotics. If there is clinical improvement and the signs and symptoms arecompletely resolved, then there is no need for interval appendectomy.[72] [73] [74] Interval appendectomyis performed after 6 weeks if the symptoms are not completely resolved.[75]

In older patients, carcinoma should be excluded.

appendicular abscess short term low

Usually occurs as a progression of the disease process, particularly after perforation.

Presents with tender right lower quadrant mass, swinging fever, and leukocytosis.

Ultrasonography or computed tomography (CT) scan will show the abscess.

Initial treatment includes intravenous antibiotics and CT-guided drainage of abscess.

If there is clinical improvement and the signs and symptoms are completely resolved, then there is noneed for interval appendectomy.[72] [73] [74] Interval appendectomy is performed after 6 weeks if thesymptoms are not completely resolved.[75] There is evidence to suggest that laparoscopic appendectomymay be a feasible first-line option over conservative treatment for appendiceal abscess in adults; however,




Acute appendicitis Follow up

Complications Timeframe Likelihoodone systematic review was unable to find evidence for either benefit or harm from early appendectomy(laparoscopic or open) versus conservative treatment for appendiceal abscess.[76] [77]

surgical wound infection short term low

Decreased incidence if laparoscopic approach and prophylactic antibiotic used.[69]

Prognosis

If patients are treated in a timely fashion, the prognosis is good. Wound infection and intra-abdominalabscess are potential complications associated with appendectomy. Laparascopic appendectomy has beenshown to decrease the incidence of overall complications.[93]

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Acute appendicitis GuidelinesG

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Diagnostic guidelines

International

ACR Appropriateness Criteria: right lower quadrant pain - suspectedappendicitis [28]Published by: American College of Radiology Last published: 2018

ACR Appropriateness Criteria: acute nonlocalized abdominal pain and fever [45]Published by: American College of Radiology Last published: 2018

ACR Appropriateness Criteria: fever without source or unknown origin - child [59]Published by: American College of Radiology Last published: 2015

Critical issues: evaluation and management of emergency departmentpatients with suspected appendicitis [60]Published by: American College of Emergency Physicians Last published: 2010

WSES Jerusalem guidelines for diagnosis and treatment of acuteappendicitis [29]Published by: World Society of Emergency Surgery Last published: 2016

Treatment guidelines

International

WSES Jerusalem guidelines for diagnosis and treatment of acuteappendicitis [29]Published by: World Society of Emergency Surgery Last published: 2016

The management of intra-abdominal infections from a global perspective:2017 WSES guidelines for management of intra-abdominal infections [90]Published by: World Society of Emergency Surgery Last published: 2013



http://www.acr.org/Quality-Safety/Appropriateness-Criteria/




https://www.acep.org/patient-care/clinical-policies/

https://www.acep.org/patient-care/clinical-policies/

https://www.wses.org.uk/guidelines


www.wses.org.uk/guidelines

www.wses.org.uk/guidelines




Acute appendicitis References

Key articles

• Hardin DM. Acute appendicitis: review and update. Am Fam Physician. 1999 Nov 1;60(7):2027-34.Abstract

• Temple CL, Shirley AH, Temple WJ. The natural history of appendicitis in adults. A prospective study.Ann Surg. 1995 Mar;221(3):278-81. Full text Abstract

• Andersson RE. Meta-analysis of the clinical and laboratory diagnosis of acute appendicitis. Br J Surg.2004 Jan;91(1):28-37. Abstract

• Salminen P, Tuominen R, Paajanen H, et al. Five-year follow-up of antibiotic therapy for uncomplicatedacute appendicitis in the APPAC randomized clinical trial. JAMA. 2018 Sep 25;320(12):1259-65. Fulltext Abstract

References

1. Fitz RH. Perforating inflammation of the vermiform appendix with special reference to its earlydiagnosis and treatment. Am J Med Sci. 1886;92:321-46.

2. Itskowitz MS, Jones SM. Appendicitis. Emerg Med. 2004;36:10-5.

3. Andersen B, Nielsen TF. Appendicitis in pregnancy: diagnosis, management and complications. ActaObstet Gynecol Scand. 1999;78:758-762. Abstract

4. Koepsell TD. In search of the cause of appendicitis. Epidemiology. 1991 Sep;2(5):319-21. Abstract

5. Owings MF, Kozak LJ. Ambulatory and inpatient procedures in the United States, 1996. Vital HealthStat 13. 1998 Nov;(139):1-119. Full text Abstract

6. Arnbjornsson E. Acute appendicitis and dietary fiber. Arch Surg. 1983 Jul;118(7):868-70. Abstract

7. Korner H, Sondenaa K, Soreide JA, et al. Incidence of nonperforated and perforated appendicitis: age-specific and sex-specific analysis. World J Surg. 1997 Mar-Apr;21(3):313-7. Abstract

8. Addiss DG, Shaffer N, Fowler BS, et al. The epidemiology of appendicitis and appendectomy in theUnited States. Am J Epidemol. 1990 Nov;132(5):910-25. Abstract

9. Ferris M, Quan S, Kaplan BS, et al. The global incidence of appendicitis: a systematic review ofpopulation-based studies. Ann Surg. 2017 Aug;266(2):237-41. Abstract

10. Singh JP, Mariadason JG. Role of the faecolith in modern-day appendicitis. Ann R Coll Surg Engl.2013 Jan;95(1):48-51. Full text Abstract

11. Ramdass MJ, Young Sing Q, Milne D, et al. Association between the appendix and the fecalith inadults. Can J Surg. 2015 Feb;58(1):10-4. Full text Abstract

REFER

ENC

ES



29

http://www.ncbi.nlm.nih.gov/pubmed/10569505?tool=bestpractice.bmj.com


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1234570/pdf/annsurg00049-0078.pdf



https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6233612/





http://www.cdc.gov/nchs/data/series/sr_13/sr13_139.pdf











Acute appendicitis ReferencesR

EFER

ENC

ES

12. Di Sebastiano P, Fink T, di Mola FF, et al. Neuroimmune appendicitis. Lancet. 1999 Aug7;354(9177):461-6. Abstract

13. Soffer D, Zait S, Klausner J, et al. Peritoneal cultures and antibiotic treatment in patients withperforated appendicitis. Eur J Surg. 2001 Mar;167(3):214-6. Abstract

14. Brunicardi FC, Andersen DK, Billiar TR, et al, eds. The appendix. In: Schwartz's principles of surgery.8th ed. New York, NY: McGraw-Hill; 2005:1119-37.

15. Gomez-Alcala AV, Hurtado-Guzman A. Early breastfeed weaning as a risk factor for acute appendicitisin children [in Spanish]. Gac Med Mex. 2005 Nov-Dec;141(6):501-4. Abstract

16. Pisacane A, de Luca U, Impagliazzo N, et al. Breast feeding and acute appendicitis. BMJ. 1995 Apr1;310(6983):836-7. Full text Abstract

17. Adamidis D, Roma-Giannikou E, Karamolegou K, et al. Fiber intake and childhood appendicitis. Int JFood Sci Nutr. 2000 May;51(3):153-7. Abstract

18. Naaeder SB, Archampong EQ. Acute appendicitis and dietary fibre intake. West Afr J Med. 1998 Oct-Dec;17(4):264-7. Abstract

19. Barker DJ, Osmond C, Golding J, et al. Acute appendicitis and bathrooms in three samples of Britishchildren. Br Med J (Clin Res Ed). 1988 Apr 2;296(6627):956-8. Full text Abstract

20. Huis in 't Veld JH. Gastrointestinal flora and health in man and animal [in Dutch]. TijdschrDiergeneeskd. 1991 Mar 1;116(5):232-9. Abstract

21. Walker AR, Segal I. What causes appendicitis? J Clin Gastroenterol. 1990 Apr;12(2):127-9. Abstract

22. Montgomery SM, Pounder RE, Wakefield AJ. Smoking in adults and passive smoking in children areassociated with acute appendicitis. Lancet. 1999 Jan 30;353(9150):379. Abstract

23. Oldmeadow C, Wood I, Mengersen K, et al. Investigation of the relationship between smoking andappendicitis in Australian twins. Ann Epidemiol. 2008 Aug;18(8):631-6. Abstract

24. Bendeck SE, Nino-Murcia M, Berry GJ, et al. Imaging for suspected appendicitis: negativeappendectomy and perforation rates. Radiology. 2002 Oct;225(1):131-6. Abstract

25. Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med. 1986May;15(5):557-64. Abstract

26. Kularatna M, Lauti M, Haran C, et al. Clinical prediction rules for appendicitis in adults: which is best?World J Surg. 2017 Jul;41(7):1769-81. Abstract

27. Frountzas M, Stergios K, Kopsini D, et al. Alvarado or RIPASA score for diagnosis of acuteappendicitis? A meta-analysis of randomized trials. Int J Surg. 2018 Aug;56:307-14. Abstract

28. American College of Radiology. ACR appropriateness criteria: right lower quadrant pain - suspectedappendicitis. 2018 [internet publication]. Full text






http://www.bmj.com/cgi/content/full/310/6983/836




http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2545433/pdf/bmj00279-0012.pdf










https://www.acr.org/Quality-Safety/Appropriateness-Criteria



29. Di Saverio S, Birindelli A, Kelly MD, et al. WSES Jerusalem guidelines for diagnosis and treatment ofacute appendicitis. World J Emerg Surg. 2016 Jul 18;11:34. Full text Abstract

30. Basaran A, Basaran M. Diagnosis of acute appendicitis during pregnancy: a systematic review. ObstetGynecol Surv. 2009 Jul;64(7):481-8; quiz 499. Abstract

31. Hardin DM. Acute appendicitis: review and update. Am Fam Physician. 1999 Nov 1;60(7):2027-34.Abstract

32. Brown JJ, Wilson C, Coleman S, Joypaul BV. Appendicitis in pregnancy: an ongoing diagnosticdilemma. Colorectal Dis. 2009 Feb;11(2):116-22. Abstract

33. Temple CL, Shirley AH, Temple WJ. The natural history of appendicitis in adults. A prospective study.Ann Surg. 1995 Mar;221(3):278-81. Full text Abstract

34. Franz MG, Norman J, Fabri PJ. Increased morbidity of appendicitis with advancing age. Am Surg.1995 Jan;61(1):40-4. Abstract

35. Berry J, Malt RA. Appendicitis near its centenary. Ann Surg. 1984 Nov;200(5):567-75. Full text Abstract

36. Humes DJ, Simpson J. Acute appendicitis. BMJ. 2006 Sep 9;333(7567):530-4. Full text Abstract

37. Bachur RG, Callahan MJ, Monuteaux MC, et al. Integration of ultrasound findings and a clinical scorein the diagnostic evaluation of pediatric appendicitis. J Pediatr. 2015 May;166(5):1134-9. Abstract

38. Benabbas R, Hanna M, Shah J, et al. Diagnostic accuracy of history, physical examination, laboratorytests, and point-of-care ultrasound for pediatric acute appendicitis in the emergency department: asystematic review and meta-analysis. Acad Emerg Med. 2017 May;24(5):523-51. Full text Abstract

39. Fox JC, Solley M, Zlidenny A, et al. Bedside ultrasound for appendicitis. Acad Emerg Med.2005;12:76.

40. Terasawa T, Blackmore CC, Bent S, et al. Systematic review: computed tomography andultrasonography to detect acute appendicitis in adults and adolescents. Ann Intern Med. 2004 Oct5;141(7):537-46. Abstract

41. Dahabreh IJ, Adam GP, Halladay CW, et al. Diagnosis of right lower quadrant pain and suspectedacute appendicitis. In: Agency for Healthcare Research and Quality (US). AHRQ Comparativeeffectiveness reviews report no. 15(16)-EHC025-EF. 2015. Rockville, MD: Agency for HealthcareResearch and Quality (US). Full text Abstract

42. Eng KA, Abadeh A, Ligocki C, et al. Acute appendicitis: a meta-analysis of the diagnostic accuracy ofUS, CT, and MRI as second-line imaging tests after an initial US. Radiology. 2018 Sep;288(3):717-27. Full text Abstract

43. Zhang H, Liao M, Chen J, et al. Ultrasound, computed tomography or magnetic resonance imaging- which is preferred for acute appendicitis in children? A Meta-analysis. Pediatr Radiol. 2017Feb;47(2):186-96. Abstract

REFER

ENC

ES



31
















https://onlinelibrary.wiley.com/doi/full/10.1111/acem.13181



https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0086388/


https://pubs.rsna.org/doi/10.1148/radiol.2018180318?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&

https://pubs.rsna.org/doi/10.1148/radiol.2018180318?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&





EFER

ENC

ES

44. Puylaert JB. Imaging and intervention in patients with acute right lower quadrant disease. BaillieresClin Gastroenterol. 1995 Mar;9(1):37-51. Abstract

45. American College of Radiology. ACR Appropriateness Criteria: acute nonlocalized abdominal pain.2018 [internet publication]. Full text

46. Musunuru S, Chen H, Rikkers LF, et al. Computed tomography in the diagnosis of acute appendicitis:definitive or detrimental? J Gastrointest Surg. 2007 Nov;11(11):1417-21; discussion 1421-2. Abstract

47. Chiu YH, Chen JD, Wang SH, et al. Whether intravenous contrast is necessary for CT diagnosis ofacute appendicitis in adult ED patients? Acad Radiol. 2013 Jan;20(1):73-8. Full text Abstract

48. Hlibczuk V, Dattaro JA, Jin Z, et al. Diagnostic accuracy of noncontrast computed tomography forappendicitis in adults: a systematic review. Ann Emerg Med. 2010 Jan;55(1):51-9.e1. Abstract

49. Andersson RE. Meta-analysis of the clinical and laboratory diagnosis of acute appendicitis. Br J Surg.2004 Jan;91(1):28-37. Abstract

50. Choi D, Park H, Lee YR, et al. The most useful finding for the diagnosing acute appendicitis oncontrast-enhanced helical CT. Acta Radiol. 2003 Nov;44(6):574-82. Abstract

51. Sabiston D. The biliary system. In: Sabiston D, Lyerly HK, eds. Textbook of surgery: the biologicalbasis of modern surgical practice. 15th ed. Philadelphia, PA: W.B. Saunders Company; 1997:1127.

52. Vincelette J, Schirm J, Bogard M, et al. Multicenter evaluation of the fully automated COBASAMPLICATOR PCR test for detection of Chlamydia trachomatis in urogenital specimens. J ClinMicrobiol. 1999 Jan;37(1):74-80. Full text Abstract

53. Andersson M, Andersson RE. The appendicitis inflammatory response score: a tool for the diagnosisof acute appendicitis that outperforms the Alvarado score. World J Surg. 2008 Aug;32(8):1843-9.Abstract

54. Chong CF, Adi MI, Thien A, et al. Development of the RIPASA score: a new appendicitis scoringsystem for the diagnosis of acute appendicitis. Singapore Med J. 2010 Mar;51(3):220-5. Full text Abstract

55. Knaus WA, Draper EA, Wagner DP, et al. APACHE II: a severity of disease classification system. CritCare Med. 1985 Oct;13(10):818-29. Abstract

56. Shapiro NI, Wolfe RE, Moore RB, et al. Mortality in Emergency Department Sepsis (MEDS) score:a prospectively derived and validated clinical prediction rule. Crit Care Med. 2003 Mar;31(3):670-5.Abstract

57. Knaus WA, Wagner DP, Draper EA, et al. The APACHE III prognostic system. Risk prediction ofhospital mortality for critically ill hospitalized adults. Chest. 1991 Dec;100(6):1619-36. Abstract

58. Rivers EP, Nguyen HB, Amponsah D. Sepsis: a landscape from the emergency department to theintensive care unit. Crit Care Med. 2003 Mar;31(3):968-9. Abstract




https://acsearch.acr.org/docs/69467/Narrative/


https://www.academicradiology.org/article/S1076-6332(12)00385-6/fulltext





http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=9854067




http://smj.sma.org.sg/5103/5103a4.pdf










59. American College of Radiology. ACR appropriateness criteria: fever without source or unknown origin -child. 2015 [internet publication]. Full text

60. Howell JM, Eddy OL, Lukens TW, et al. Clinical policy: critical issues in the evaluation andmanagement of emergency department patients with suspected appendicitis. Ann Emerg Med. 2010Jan;55(1):71-116. Full text Abstract

61. Georgiou R, Eaton S, Stanton MP, et al. Efficacy and safety of nonoperative treatment for acuteappendicitis: a meta-analysis. Pediatrics. 2017 Mar;139(3). Abstract

62. Gorter RR, The SML, Gorter-Stam MAW, et al. Systematic review of nonoperative versus operativetreatment of uncomplicated appendicitis. J Pediatr Surg. 2017 Aug;52(8):1219-27. Abstract

63. Podda M, Cillara N, Di Saverio S, et al. Antibiotics-first strategy for uncomplicated acute appendicitisin adults is associated with increased rates of peritonitis at surgery. A systematic review with meta-analysis of randomized controlled trials comparing appendectomy and non-operative managementwith antibiotics. Surgeon. 2017 Oct;15(5):303-14. Abstract

64. Kessler U, Mosbahi S, Walker B, et al. Conservative treatment versus surgery for uncomplicatedappendicitis in children: a systematic review and meta-analysis. Arch Dis Child. 2017Dec;102(12):1118-24. Abstract

65. Harnoss JC, Zelienka I, Probst P, et al. Antibiotics versus surgical therapy for uncomplicatedappendicitis: systematic review and meta-analysis of controlled trials (PROSPERO 2015:CRD42015016882). Ann Surg. 2017 May;265(5):889-900. Abstract

66. Salminen P, Tuominen R, Paajanen H, et al. Five-year follow-up of antibiotic therapy for uncomplicatedacute appendicitis in the APPAC randomized clinical trial. JAMA. 2018 Sep 25;320(12):1259-65. Fulltext Abstract

67. Rollins KE, Varadhan KK, Neal KR, et al. Antibiotics versus appendicectomy for the treatment ofuncomplicated acute appendicitis: an updated meta-analysis of randomised controlled trials. World JSurg. 2016 Oct;40(10):2305-18. Abstract

68. Sakran JV, Mylonas KS, Gryparis A, et al. Operation versus antibiotics--The "appendicitis conundrum"continues: A meta-analysis. J Trauma Acute Care Surg. 2017 Jun;82(6):1129-37. Abstract

69. Liberman MA, Greason KL, Frame S, et al. Single-dose cefotetan or cefoxitin versus multiple-dosecefoxitin as prophylaxis in patients undergoing appendectomy for acute nonperforated appendicitis. JAm Coll Surg. 1995 Jan;180(1):77-80. Abstract

70. National Institute for Health and Care Excellence. Intravenous fluid therapy in adults in hospital.December 2016 [internet publication]. Full text

71. Lobo DN, Awad S. Should chloride-rich crystalloids remain the mainstay of fluid resuscitation toprevent 'pre-renal' acute kidney injury? Kidney Int. 2014 Dec;86(6):1096-105. Full text Abstract

72. Mason RJ. Surgery for appendicitis: is it necessary? Surg Infect (Larchmt). 2008 Aug;9(4):481-8.Abstract

REFER

ENC

ES



33

https://www.acr.org/Quality-Safety/Appropriateness-Criteria

https://www.annemergmed.com/article/S0196-0644(09)01644-8/fulltext













https://www.nice.org.uk/guidance/cg174

http://www.sciencedirect.com/science/article/pii/S0085253815304403






EFER

ENC

ES

73. Deakin DE, Ahmed I. Interval appendicectomy after resolution of adult inflammatory appendix mass -is it necessary? Surgeon. 2007 Feb;5(1):45-50. Abstract

74. Andersson RE, Petzold MG. Nonsurgical treatment of appendiceal abscess or phlegmon: a systematicreview and meta-analysis. Ann Surg. 2007 Nov;246(5):741-8. Abstract

75. Garba ES, Ahmed A. Management of appendiceal mass. Ann Afr Med. 2008 Dec;7(4):200-4. Full text Abstract

76. Mentula P, Sammalkorpi H, Leppäniemi A. Laparoscopic surgery or conservative treatment forappendiceal abscess in adults? A randomized controlled trial. Ann Surg. 2015 Aug;262(2):237-42.Abstract

77. Cheng Y, Xiong X, Lu J, et al. Early versus delayed appendicectomy for appendiceal phlegmon orabscess. Cochrane Database Syst Rev. 2017 Jun 2;(6):CD011670. Full text Abstract

78. Mällinen J, Rautio T, Grönroos J, et al. Risk of appendiceal neoplasm in periappendicular abscessin patients treated with interval appendectomy vs follow-up with magnetic resonance imaging:1-year outcomes of the peri-appendicitis Acuta randomized clinical trial. JAMA Surg. 2019 Mar1;154(3):200-7. Full text Abstract

79. Kristo G, Itani KMF. Settling the controversy-appendectomy as the criterion for appendicitis diagnosis.JAMA Surg. 2019 Mar 1;154(3):207-8. Abstract

80. Jaschinski T, Mosch CG, Eikermann M, et al. Laparoscopic versus open surgery for suspectedappendicitis. Cochrane Database Syst Rev. 2018 Nov 28;(11):CD001546. Full text Abstract

81. Wei HB, Huang JL, Zheng ZH, et al. Laparoscopic versus open appendectomy: a prospectiverandomized comparison. Surg Endosc. 2010 Feb;24(2):266-9. Abstract

82. Yau KK, Siu WT, Tang CN, et al. Laparoscopic versus open appendectomy for complicatedappendicitis. J Am Coll Surg. 2007 Jul;205(1):60-5. Abstract

83. Woodham BL, Cox MR, Eslick GD. Evidence to support the use of laparoscopic over openappendicectomy for obese individuals: a meta-analysis. Surg Endosc. 2012 Sep;26(9):2566-70.Abstract

84. Katkhouda N, Mason RJ, Towfigh S, et al. Laparoscopic versus open appendectomy: a prospectiverandomized double-blind study. Ann Surg. 2005 Sep;242(3):439-48; discussion 448-50. Full text Abstract

85. Billingham MJ, Basterfield SJ. Pediatric surgical technique: laparoscopic or open approach? Asystematic review and meta-analysis. Eur J Pediatr Surg. 2010 Mar;20(2):73-7. Abstract

86. Lintula H, Kokki H, Vanamo K, et al. Laparoscopy in children with complicated appendicitis. J PediatrSurg. 2002 Sep;37(9):1317-20. Abstract





http://www.annalsafrmed.org/article.asp?issn=1596-3519;year=2008;volume=7;issue=4;spage=200;epage=204;aulast=Garba















http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=16135930







87. Webster J, Osborne S, Rickard CM, et al. Clinically-indicated replacement versus routine replacementof peripheral venous catheters. Cochrane Database Syst Rev. 2019 Jan 23;(1):CD007798. Full text Abstract

88. Wilasrusmee C, Sukrat B, McEvoy M, et al. Systematic review and meta-analysis of safety oflaparoscopic versus open appendicectomy for suspected appendicitis in pregnancy. Br J Surg. 2012Nov;99(11):1470-8. Full text Abstract

89. Prodromidou A, Machairas N, Kostakis ID, et al. Outcomes after open and laparoscopicappendectomy during pregnancy: A meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2018Jun;225:40-50. Abstract

90. Sartelli M, Chichom-Mefire A, Labricciosa FM, et al. The management of intra-abdominal infectionsfrom a global perspective: 2017 WSES guidelines for management of intra-abdominal infections.World J Emerg Surg. 2017 Jul 10;12:29. Full text Abstract

91. Solomkin J, Evans D, Slepavicius A, et al. Assessing the efficacy and safety of eravacycline vsertapenem in complicated intra-abdominal infections in the investigating gram-negative infectionstreated with eravacycline (IGNITE 1) trial: a randomized clinical trial. JAMA Surg. 2017 Mar1;152(3):224-32. Full text Abstract

92. Zhanel GG, Lawrence CK, Adam H, et al. Imipenem-relebactam and meropenem-vaborbactam: twonovel carbapenem-β-lactamase inhibitor combinations. Drugs. 2018 Jan;78(1):65-98. Abstract

93. Wei HB, Huang JL, Zheng ZH, et al. Laparoscopic versus open appendectomy: a prospectiverandomized comparison. Surg Endosc. 2010;24:266-269. Abstract

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https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007798.pub5/full



http://onlinelibrary.wiley.com/doi/10.1002/bjs.8889/full





https://jamanetwork.com/journals/jamasurgery/fullarticle/2580504





Acute appendicitis ImagesIM

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Images

Figure 1: Acute appendicitis - intraoperative specimen.

Nasim Ahmed, MBBS, FACS; used with permission




Acute appendicitis Images

Figure 2: CT abdomen - thickened appendix.

Nasim Ahmed, MBBS, FACS; used with permission

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Contributors:

// Authors:

Ali Tavakkoli, MBBS, FRCS, FACSAssociate Professor of SurgeryHarvard Medical School, Brigham and Women's Hospital, Boston, MADISCLOSURES: AT is a consultant for Medtronic.

Peter Szasz, MD, PhD, FRCSCClinical FellowSurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MADISCLOSURES: PS declares that he has no competing interests.

// Acknowledgements:Professor Ali Tavakkoli and Dr Peter Szasz would like to gratefully acknowledge Professor Dileep N. Loboand Dr Nasim Ahmed, previous contributors to this topic. DNL is the author of an article cited in the topic.NA declares that he has no competing interests.

// Peer Reviewers:

John M. Davis, MDGeneral SurgeryJersey Shore Medical Center, Neptune, NJDISCLOSURES: JMD declares that he has no competing interests.

acute appendicitis - bmj...2020/05/01 · acute appendicitis diagnosis d i a g n o s i s case...

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