Acute Appendicitis: Efficient Diagnosis and Management

 

Am Fam Physician. 2018 Jul 1;98(1):25-33.

Author disclosure: No relevant financial affiliations.

Appendicitis is one of the most common causes of acute abdominal pain in adults and children, with a lifetime risk of 8.6% in males and 6.7% 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. 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, intravenous antibiotics may be considered first-line therapy in selected patients. Pain 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.

Appendicitis is one of the most common causes of acute abdominal pain, with a lifetime risk of 8.6% in males and 6.7% in females.1 It is the most common nonobstetric surgical emergency during pregnancy, with an incidence of 6.3 per 10,000 pregnancies during the antepartum period (compared with 9.6 per 10,000 in nonpregnant persons) and increasing to 9.9 per 10,000 postpartum.2 More than 300,000 appendectomies are performed each year in the United States, and less than 10% result in the removal of a normal appendix.25 Appendicitis is thought to be caused by luminal obstruction from various etiologies, leading to increased mucus production and bacterial overgrowth, resulting in wall tension and, eventually, necrosis and potential perforation.6

WHAT IS NEW ON THIS TOPIC

A meta-analysis of five randomized controlled trials found that antibiotic treatment for adults with appendicitis resulted in decreased complications, less sick leave or disability, and less need for pain medication compared with initial appendectomy. However, 40% of patients who received antibiotic therapy required appendectomy within one year.

In a study of 375 children, risk factors for appendiceal perforation included fever, vomiting, longer duration of symptoms, elevated C-reactive protein level or white blood cell count, and ultrasound findings of free abdominal fluid, visualized perforation, or a mean appendix diameter of 11 mm or more.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

The Alvarado score, Pediatric Appendicitis Score, or Appendicitis Inflammatory Response score can be used with point-of-care or formal ultrasonography and laboratory testing to help diagnose acute appendicitis and reduce the use of computed tomography.

B

1012, 14, 15, 18, 27

When skilled sonographers are available, first-line imaging for patients with suspected acute appendicitis consists of point-of-care or formal ultrasonography, especially in children and pregnant women.

C

18, 24, 25

Opioids, nonsteroidal anti-inflammatory drugs, or acetaminophen should be provided to patients with suspected acute appendicitis.

A

28, 29

Open and laparoscopic appendectomies are effective surgical techniques for the treatment of acute appendicitis.

A

1

Intravenous antibiotics can be used as first-line therapy in children and adults with acute appendicitis.

A

4, 31


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

The Alvarado score, Pediatric Appendicitis Score, or Appendicitis Inflammatory Response score can be used with point-of-care or formal ultrasonography and laboratory testing to help diagnose acute appendicitis and reduce the use of computed tomography.

B

1012, 14, 15, 18, 27

When skilled sonographers are available, first-line imaging for patients with suspected acute appendicitis consists of point-of-care or formal ultrasonography, especially in children

The Authors

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MATTHEW J. SNYDER, DO, FAAFP, is program director of the Nellis Family Medicine Residency Program, Nellis Air Force Base, Las Vegas, Nev....

MARJORIE GUTHRIE, MD, is program director at Saint Louis University Southwest Illinois Family Medicine Residency, Belleville.

STEPHEN CAGLE, MD, is an assistant clinical professor in the Department of Family and Community Medicine at Saint Louis University Southwest Illinois Family Medicine Residency.

Address correspondence to Matthew J. Snyder, DO, 4700 N. Las Vegas Blvd., Nellis AFB, NV 89191 (e-mail: mdrnsnyder@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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