Acute Appendicitis

Diagnosis 
Alvarado scoring for diagnosis of acute appendicitis
Treatment

Diagnosis

Consider the diagnosis of acute appendicitis when a patient presents with right lower quadrant abdominal pain. This is not common in females presenting with lower abdominal pain in Emergency Unit.  Always think of PID (pelvic inflammatory disease, ectopic pregnancy, urinary tract infection, acute cholecystitis etc.).  By contrast, the most common cause of right sided lower abdominal pain in young males is acute appendicitis.

Acute appendicitis should be suspected in any patient (especially male) who presents with a high intensity of perceived abdominal pain of at least 7-12 hours duration, with migration to the right lower quadrant, and followed by vomiting. Although symptoms alone have a low discriminating power, the diagnosis of acute appendicitis becomes more certain when the physical examination findings include right lower quadrant tenderness, guarding, rebound tenderness and other signs of peritoneal irritation. Diagnostic score such as the Alvarado score can be helpful.

Although the diagnosis of acute appendicitis is primarily based on the clinical findings, a WBC with differential is indicated.

Alvarado Scoring for Diagnosis of Acute Appendicitis

*— Total score of 1 to 4 = appendicitis unlikely; 5 or 6 = appendicitis possible; 7 or 8 = appendicitis probable; 9 or 10 = appendicitis very probable.

Equivocal Appendicitis in adults can be evaluated by a CT scan, ultrasound or repeated clinical evaluation. If feasible, CT scan should be preferred over ultrasonography in clinically equivocal appendicitis in adults because of its superior accuracy. Abdominal X-Ray is not routine, but may be helpful in doubtful cases; an abdominal ultrasound is helpful in either excluding appendicitis or confirming the diagnosis of PID.

Diagnostic Laparoscopy is an invasive procedure requiring anaesthesia and having risks similar to appendectomy. It should be utilised at this time only in selected cases.

Treatment

Appendectomy is the appropriate treatment for acute appendicitis. Open appendectomy is the recommended primary approach to the treatment of acute appendicitis in our setting, either via a RIF incision or via laparotomy. This is left to the surgeon’s discretion. Therapeutic laparoscopic appendectomy is an alternative for selected cases, such as young women, and patients with a high BMI.

Antibiotic prophylaxis is effective in the prevention of surgical site infection for patients who undergo appendectomy and should be considered for routine use. 

The following antibiotics are recommended for prophylaxis in uncomplicated appendicitis : Cefazolin, IV, 1gr and metronidazole, IV,500mg as a single dose.

For gangrenous appendicitis, the recommended form of surgical management is to treat in the same manner as uncomplicated appendicitis. Therapeutic antibiotic regime is Pen G 1-2  million units 6 hourly IVI (Use Clindamycin if allergic), Flagyl 500mg 8 hourly IVI, Gentamycin 3-5mg/Kg daily IVI (Ciprofloxacin may be an alternative in patients with renal dysfunction, orally or IVI). The antibiotic therapy may be maintained for 5-7 days, but the duration of antibiotic therapy may vary depending on the clinician’s assessment after the operation. 

Sequential therapy to oral antibiotics may be considered when gastrointestinal function has returned. The absence of fever for 24 hours (temperature < 38 C), the ability to tolerate oral intake, and a normal WBC count with 3 per cent or less band forms are useful parameters for the discontinuation of antibiotic therapy.