![Perforated appendicitis: Treat with antibiotics and either percutaneous drainage (for stable patients with a contained RLQ abscess [ie, contained perforation]) or emergency appendectomy (for patients with diffuse intraabdominal contamination [ie, free perforation or peritoneal signs]).](https://s3-us-west-2.amazonaws.com/secure.notion-static.com/2e54de83-e334-4d07-a50a-9fbf04a16158/foo.jpg)
develops after obstruction of the appendiceal lumen from a fecalith, cancer, or lymphoid follicular hyperplasia.
obstruction→ increases appendiceal intraluminal pressure→ high venous pressure→ edema→ occludes blood flow→ ischemia.
| Clinical presentation | • Nausea, vomiting, anorexia • Initially (referred): diffuse abdominal pain (visceral pain) can be periumbilical • Later: localized RLQ pain (somatic pain) • Mild leukocytosis | | --- | --- | | Examination | • McBurney point tenderness • Psoas sign: pain with right hip extension seen with retroccecal appendix • Obturator sign: pain with right hip internal rotation seen with pelvic appendix • Rovsing sign: RLQ pain with LLQ palpation | | Diagnosis (READ BELOW) | • Clinical presentation (Modified Alvarado score ) • CT scan or ultrasound (distended and edematous appendix + periappendiceal fat stranding | | Treatment | • Surgical appendectomy |
<aside> 💡 in patients with recent abdominal surgery (eg, cesarean delivery), periumbilical pain may be masked.
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Perforated appendicitis: Treat with antibiotics and either percutaneous drainage (for stable patients with a contained RLQ abscess [ie, contained perforation]) or emergency appendectomy (for patients with diffuse intraabdominal contamination [ie, free perforation or peritoneal signs]).
A high clinical suspicion of appendicitis was historically considered sufficient to proceed to appendectomy, and a negative appendectomy (ie, removed appendix was noninflamed on pathology) rate (NAR) of approximately 10% was deemed acceptable. However, given its widespread availability and rapidity, diagnostic imaging is now typically performed when appendicitis is suspected (eg, modified Alvarado score ≥4). Imaging decreases the NAR and directs definitive management
| Modified Alvarado score | |
|---|---|
| Points (each) | Clinical feature |
| 1 | • Migratory RLQ pain |
| • Anorexia | |
| • Nausea or vomiting | |
| • Fever >37.5 C (>99.5 F) | |
| • RLQ rebound tenderness | |
| 2 | • RLQ tenderness |
| • Leukocytes >10,000/mm3 | |
| 9 | Total possible score |
| • 0-3: Appendicitis unlikely. | |
| • ≥4: Evaluate for appendicitis. |
Appendectomy is indicated to prevent appendiceal rupture, which can lead to peritonitis or an intra-abdominal abscess. In equivocal cases with negative imaging, serial abdominal examinations are often performed to evaluate for the development of the condition.
The Modified Alvarado Score adjusts the original by excluding the "left shift of neutrophils" as a factor which was included in the orginal score. This change makes the score more practical in resource-limited settings where a detailed differential count may not be available. It also simplifies the score to 9 points.