Acute Appendicitis: Efficient Diagnosis and Management

1 Acute Appendicitis: Efficient Diagnosis and Management Matthew J. Snyder, DO, Nellis Family Medicine Residency Program, Las Vegas, Nevada Marjorie Guthrie, MD, and Stephen Cagle, MD. Saint Louis University Southwest Illinois Family Medicine Residency, Belleville, Illinois Appendicitis is one of the most common causes of Acute abdominal pain in adults and children, with a lifetime risk of in males and in females. It is the most common nonobstetric surgical emergency during pregnancy. Findings from the history, physical examination, and laboratory studies aid in the Diagnosis of Acute appendicitis. Right lower quadrant pain, abdominal rigidity, and periumbilical pain radiating to the right lower quadrant are the best signs for ruling in Acute appendicitis in adults.

2 Absent or decreased bowel sounds, a positive psoas sign, a positive obturator sign, and a positive Rovsing sign are most reliable for ruling in Acute appendicitis in children. The Alvarado score, Pediatric Appendicitis Score, and Appendicitis Inflammatory Response score incorporate common clinical and laboratory findings to stratify patients as low, moderate, or high risk and can help in making a timely Diagnosis . Recommended first-line imaging consists of point-of-care or formal ultrasonography. Appendectomy via open laparotomy or laparoscopy is the standard treatment for Acute appendicitis. However, intra- venous antibiotics may be considered first-line therapy in selected patients.

3 Pain Illustration by John Karapelou control with opioids, nonsteroidal anti-inflammatory drugs, and acetaminophen should be a priority and does not result in delayed or unnecessary intervention. Perforation can lead to sepsis and occurs in 17% to 32% of patients with Acute appendicitis. Prolonged duration of symptoms before surgical intervention raises the risk. In moderate- to high-risk patients, surgical consultation should be accomplished quickly to reduce morbidity and mortality resulting from perforation. (Am Fam Physician. 2018; 98(1):25-33. Copyright 2018 American Academy of Family Physicians.)

4 Appendicitis is one of the most common causes of Acute Clinical Evaluation abdominal pain, with a lifetime risk of in males and SIGNS AND SYMPTOMS. in It is the most common nonobstetric surgi- Diagnosing Acute appendicitis accurately and efficiently can cal emergency during pregnancy, with an incidence of per reduce morbidity and mortality from perforation and other 10,000 pregnancies during the antepartum period (compared complications. Individual signs and symptoms are more with per 10,000 in nonpregnant persons) and increasing helpful at ruling in the Diagnosis than they are at ruling to per 10,000 More than 300,000 appen- it out when absent.

5 The variable location of the appendix dectomies are performed each year in the United States, and causes variations in the clinical presentation, making diag- less than 10% result in the removal of a normal nosis challenging, especially in pregnant women. Appendicitis is thought to be caused by luminal obstruction Table 1 presents likelihood ratios of various signs and from various etiologies, leading to increased mucus produc- symptoms in adults and ,8 The signs and symp- tion and bacterial overgrowth, resulting in wall tension and, toms that best rule in Acute appendicitis in adults are right eventually, necrosis and potential lower quadrant pain (positive likelihood ratio [LR+] = to ), abdominal rigidity (LR+ = ), and radiation of periumbilical pain to the right lower quadrant (LR+ = ).

6 7. Additional content at https:// w In children, however, absent or decreased bowel sounds CME This clinical content conforms to AAFP criteria for (LR+ = ), a positive psoas sign (LR+ = ), a positive continuing medical education (CME). See CME Quiz on obturator sign (LR+ = ), and a positive Rovsing sign page 18. (LR+ = ) are most reliable for ruling in Acute Author disclosure: No relevant financial affiliations. Physical examination findings specific for Acute appen- dicitis include the psoas sign, the obturator sign, and the Downloaded July 1, 2018 from the American Volume Family1 Physician website at 98, Number Copyright 2018 American Academy of FamilyAmerican For the Physician 25.

7 Private, noncom- mercial use of one individual user of the website. All other rights reserved. Contact for copyright questions and/or permission requests. Acute APPENDICITIS. Rovsing sign (increased right lower quadrant pain occur- , The prevalence of appendicitis in this ring with left lower quadrant palpation). Figures 1 and 2 study was 37%, and the likelihood of appendicitis in high- illustrate how to test for the psoas and obturator signs, risk, moderate-risk, and low-risk groups was 88%, 50%, which significantly increase the likelihood of appendicitis and 5%, respectively. This tool has been compared with when present in the Alvarado score and validated as an accurate clinical decision ,14.

8 CLINICAL DECISION RULES. Several clinical decision rules that TABLE 1. incorporate findings from the patient's history, physical examination, and Accuracy of History and Physical Examination Findings laboratory tests have been developed in the Diagnosis of Acute Appendicitis and validated in a range of popula- tions (Table 2).10-12 These tools typically Adult7 Child8. stratify patients into low-, moderate-, Positive Negative Positive Negative and high-risk categories, and are likelihood likelihood likelihood likelihood incorporated into recommended man- Sign/symptom ratio ratio ratio ratio agement strategies.

9 Right lower quadrant to * 0 to NA. The Alvarado score (https:// w ww. pain appendicitis) is an eight-item, 10-point Rigidity NA NA. tool that is the best studied clinical Migration/periumbilical decision rule in adults and children. pain The Pediatric Appendicitis Score Pain before vomiting NA NA NA. (https:// w appendicitis-score-pas) includes sim- Psoas sign ilar clinical findings in addition to a Fever sign more relevant in children: right lower quadrant pain with coughing, Guarding to 0 to hopping, or percussion. Several studies No similar previous pain NA NA. comparing the Pediatric Appendicitis Score with the Alvarado score have Rebound tenderness to 0 to NA.

10 Validated its use in ,12,13 Like- Anorexia lihood ratios for cutoffs on these scores are listed in Table Vomiting A newer tool, the Appendicitis Rectal tenderness/ to to Inflammatory Response score (https:// obstipation w w w. md c a lc .c om /app e nd ic it i s - inf lammatory-response-air-score), Nausea to to NA NA. includes fewer symptoms than Obturator sign NA NA the Alvarado score and Pediatric Appendicitis Score, but adds an Rovsing sign NA NA inflammatory biomarker (C-reactive Absent/decreased bowel NA NA protein [CRP]) and allows for sounds different severity levels of rebound pain, leukocytosis, CRP, and Pain with hopping/ NA NA coughing/percussion polymorphonucleocytes.