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Appendicitis
Seen in 60 %
Anorexia
Periumbilical pain, nausea, vomiting
RLQ pain developing over 24 hrs.
Anorexia and pain are most frequent
Usually nausea, sometimes vomiting
Diarrhea, esp. with pelvic location
Usually tender to palpation
Rebound is a later finding
Physical Exam
Established in 1986
Migration of pain
Anorexia
Nausea / vomiting
Tenderness RLQ
Rebound
Elevated temp.
Leukocytosis
Shift to left
MANTRELS Score, cont'd.
Ovulating women
PID, TOA, ovarian cyst rupture can mimic
appendicitis
Look for cervical motion tenderness,
adnexal tenderness, history of STD’s
Can have CMT with pelvic appendix
High Risk Patients, cont'd.
Pregnancy
Most common surgical emergency in
pregnancy
Mortality rate if missed = 2 % for mother,
up to 35 % for fetus
WBC elevated in pregnancy
Appendix changes location
Differential Diagnosis
Gastroenteritis TOA
Mesenteric Ectopic pregnancy
lymphadenitis UTI
PID Pyelonepritis
Mittelschmertz Otherprocesses
Crohn's disease involving appendix
Diverticulitis
Endometriosis
Imaging Studies
Plain films
Low sensitivity and specificity
Appendicolith specific, but seen in only 2 %
May see local air-fluid levels, psoas
obliteration, soft tissue mass, gas in
appendix : all nonspecific
Imaging Studies, cont'd.
Ultrasound
75 to 90 % sensitive, 86 to 100 % specific
Noninvasive, low cost, but operator-
dependent
Good for diagnosing GYN disorders
3 criteria for diagnosis
ƒ Tender, noncompressible appendix
ƒ No peristalsis of appendix
Ultrasound (US)
Appendix may not be seen, due to obesity,
guarding, bowel gas, perforation,
retrocecal location
2.4 to 56 % of normal appendixes seen
One study of 736 pediatric patients
showed 36.6 % without preop US had
negative appendectomy vs. 9.8 % who had
US
Imaging Studies, cont'd.
Ultrasound
Study from Australia showed total WBC
and neutrophil count were more accurate
than US. They recommended pts. with
unequivocal presentation go to OR. If
equivocal, obtain CBC. If WBC > 15,000,
go to OR. If < 11,000, obtain CT (US only
in pregnancy).
Imaging Studies, cont'd.
CT
Early studies showed low yield, but helical
CT much more accurate
Sensitivity 97 to 100 %, specificity 95 %
(similar no matter what type or whether
contrast is used)
Often shows alternative diagnosis
More expensive, radiation exposure
Imaging Studies, cont'd.
CT
Criteria for appendicitis :
ƒ Diameter > 6 mm
ƒ Failure to completely fill with contrast or
air
ƒ Appendicolith
CT
One study showed negative laparotomy
rates of 4 % in men, 8 % in ovulating
women with CT (typical is 20 % and 45 %
respectively), but no change in perforation
rate
Another study showed increase in CT use
led to earlier diagnosis, less severe
pathologic findings, and decreased length
of stay
Imaging Studies, cont'd.
CT
Study from Dept. of Surgery, Stamford,
Connecticut : use of CT markedly
increased from 1994 to 2000, without
change in rate of negative appendectomy.
They concluded use of CT by
nonsurgeons leads to increased E.D. LOS
without improving accuracy. They
recommend mandatory surgical consult if
CT considered.
Do We Need Imaging Studies?
Literature conflicting
Pediatric Imaging -Evidence-Based
Guidelines
Imaging most useful in clinically equivocal
cases
Costs of imaging minor compared to cost
of unnecessary surgery or delayed
diagnosis
US and CT both specific enough to rule in
appendicitis, but only CT sensitive
enough to rule it out
Do We Need Imaging Studies?