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Snapshot
  • A 24-year-old woman presents to the emergency room with abdominal pain for the past 6 hours. The pain was originally located around the umbilical area but has since migrated to the right lower quadrant (RLQ). It is described as a 8/10, stabbing pain that is worse with movement. Her past medical history is unremarkable. A physical examination demonstrates tenderness of the RLQ with moderate guarding.
Introduction
  • Clinical definition
    • medical condition characterized by the inflammation of the appendix, a vestigial structure located at the base of the cecum 
    • it is one of the most common causes of the acute abdomen
  • Epidemiology
    • demographics
      • most commonly occurs during the 2nd and 3rd decades of life
      • incidence of 233/100,000 and highest in the 10-19-year-old age group
  • Pathogenesis
    • the natural process involves initial inflammation of the appendiceal wall followed by local ischemia, perforation, and leading to abscess development or generalized peritonitis
    • obstruction of the appendix is the proposed primary cause
      • fecaliths (hard fecal masses)
      • calculi
      • lymphoid hyperplasia
        • more common in the young
      • infectious process
      • benign/malignant tumors
    • obstruction of the appendix leads to an increase in luminal and intramural pressure leading to the thrombosis and occlusion of the small vessels in the appendiceal wall and stasis of lymphatic flow
      • bacterial overgrowth occurs with predominately aerobic organisms
    • the engorged appendix stimulates the visceral afferent nerve fibers at the T8-T10 level leading to the initial central/periumbilical abdominal pain
      • the latter localized pain at the RLQ occurs due to inflammation of the adjacent parietal peritoneum
Presentation
  • Symptoms 
    • abdominal pain  
      • initial periumbilical pain with migration to the RLQ
    • anorexia
    • nausea
    • vomiting
    • diarrhea
    • indigestion
  • Physical exam 
    • fever
    • McBurney point tenderness 
    • Rovsing sign
      • pain in the RLQ with palpation of the left lower quadrant (LLQ)
    • psoas sign
      • associated with retrocecal appendix
      • RLQ pain with passive right hip extension
    • obturator sign
      • RLQ pain with right hip flexion followed by internal rotation
Studies
  • Diagnostic testing
    • diagnostic approach
      • diagnosis is often based on clinical presentation and supported with imaging
    • imaging 
      • abdominopelvic computed tomography (CT) with IV contrast
        • preferred test in patients suspected with appendicitis as it has the highest diagnostic accuracy when compared to other imaging modalities
        • positive findings include wall thickening (> 2mm), periappendiceal fat stranding, appendiceal wall enhancement, appendicolith, and enlarged appendiceal double-wall thickness (> 6mm) 
      • ultrasound 
        • preferred test in children and pregnant women due to its lack of ionizing radiation and IV contrast and can be performed at bedside
        • though results may be variable, patient- and operator-dependent
        • positive findings include focal pain over appendix with compression, noncompressible appendix with enlarged double-wall thickness (> 6mm), increased echogenicity of inflamed periappendiceal fat, and fluid in the right lower quadrant  
      • magnetic resonance imaging (MRI)
        • indicated for pregnant women or older children who can tolerate the exam
    • studies
      • physical exam
        • digital rectal exam
        • pelvic examination for women of childbearing age
      • laboratory studies
        • serum pregnancy test 
          • should be performed in all women of childbearing age prior to imaging that exposes a potential fetus to radiation and to rule out other causes of acute abdomen
        • white blood cell count with differential
          • often will demonstrate leukocytosis with left shift
    • surgical exploration
      • rare but indicated in a minority of patients with high clinical suspicion with imaging studies that are either negative, undiagnostic, or unavailable
Differential
  • Ectopic pregnancy 
    • differentiating factors
      • will have positive urine pregnancy test and perhaps positive pelvic ultrasound findings
  • Ovarian/fallopian tube torsion
    • differentiating factors
      • will appear on CT imaging
  • Renal colic 
    • differentiating factors
      • will appear on CT of the abdomen and will generally present with hematuria
  • Psoas abscess
    • pain to palpation
    • pain with stretching of the psoas muscle
    • diagnose with CT 
Treatment
  • Non-perforated appendicitis
    • appendectomy (laparoscopic or open) 
      • should be performed within 12 hours of diagnosis
      • laparoscopic approach is more common and popular
    • antibiotics
      • though there is growing popularity with antibiotic-alone therapy
  • Perforated appendicitis with hemodynamic instability, sepsis, free perforation, or peritonitis
    • emergency appendectomy
    • irrigation and drainage of peritoneal cavity
    • bowel resection if needed
  • Stable perforated appendicitis
    • initial nonoperative management
      • IV antibiotics
      • percutaneous drainage of abscess if present
    • rescue appendectomy for patients who do not respond to antibiotics
Complications
  • Appendiceal abscess
  • Perforation
  • Sepsis
  • Peritonitis
  • Hemodynamic instability
  • Death
 

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(M2.GI.16.4694) A 23-year-old college student presents to the emergency room with severe abdominal pain, nausea, vomiting, and anorexia for the last 24 hours. She reports that she was in her usual state of health, until yesterday when she began to have abdominal pain which she describes near her belly button. This morning, she woke up with her pain much increased, and shifted to the right lower quadrant. Vitals are T 102.0 F HR 98 bpm BP 138/94 mmHg RR 18 Sat 100%. Exam is notable for exquisite right lower quadrant pain that is worse with rebound. When the examiner presses on the left lower quadrant, the patient complains of pain in the right lower quadrant. Psoas signs is present, with a negative obturator sign. Lab studies show a white blood cell count of 15.3, beta HCG is negative. Abdominal CT with contrast is shown in Figure A. Which of the follow pathophysiologies most likely lead to this patient's condition? Tested Concept

QID: 107823
FIGURES:
1

Telescoping of hollow viscus into adjacent segment due to a lead point resulting in vascular compromise

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2

Rotation of adnexa about ligamentous structures leading to venous and arterial compromise

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3

Implantation of zygote within the fallopian tubes leading to tubular dilation and rupture

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4

Luminal obstruction of hollow viscus by fecolith or lymphoid tissue leading to venous outflow obstruction

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(1/1)

5

Viral infection with hyperplasia of lymphoid tissue, and inflammation of mesenteric nodes

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L 2 D

Select Answer to see Preferred Response

(M3.GI.16.26) A 12-year-old boy is brought in by his mother to the emergency department. He has had abdominal pain, fever, nausea, vomiting, and loss of appetite since yesterday. At first, the mother believed it was just a "stomach flu," but she is growing concerned about his progressive decline. Vitals include: T 102.3 F, HR 110 bpm, BP 120/89 mmHg, RR 16, O2 Sat 100%. Abdominal exam is notable for pain over the right lower quadrant. What is the next best step in management in addition to IV hydration and analgesia? Tested Concept

QID: 103317
1

Abdominal CT scan with IV and PO contrast

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Abdominal CT scan with IV contrast

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3

Upright and supine abdominal radiographs

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4

Right lower quadrant ultrasound

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5

Abdominal MRI with gadolinium contrast

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L 2 C

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