From the Guidelines
The patient's presentation of moderate to severe right lower quadrant abdominal pain (8/10), elevated white blood cell count (11.1 × 10^9/L), and elevated C-reactive protein (37.5 mg/L) strongly suggests acute appendicitis, and urgent surgical consultation is recommended for evaluation for appendectomy. The clinical presentation is consistent with an inflammatory process in the right lower abdomen, and the elevated inflammatory markers indicate a high risk of appendiceal inflammation, which can progress to perforation if not treated promptly, leading to peritonitis and increased morbidity 1.
The diagnostic performance of imaging modalities varies, but CT scan with contrast of the abdomen and pelvis is an excellent diagnostic imaging modality for the evaluation of patients with nonspecific RLQ pain, with a high diagnostic yield for detection of appendicitis as well as suggesting alternative diagnoses 1. The use of CT scan has been shown to decrease the negative appendectomy rate and reduce the risk of perforation 1.
While awaiting surgical assessment, the patient should remain NPO (nothing by mouth), receive IV fluids for hydration, and be given appropriate pain management with medications such as morphine 2-4mg IV or hydromorphone 0.5-1mg IV as needed. Broad-spectrum antibiotics should be initiated promptly, such as piperacillin-tazobactam 3.375g IV every 6 hours or ceftriaxone 1g IV plus metronidazole 500mg IV every 8 hours. Additional diagnostic tests should include a complete blood count with differential, comprehensive metabolic panel, urinalysis, and imaging studies (preferably CT scan with contrast of the abdomen and pelvis, or ultrasound if the patient is pregnant or a child) 1.
Key considerations in the management of this patient include:
- Urgent surgical consultation for evaluation for appendectomy
- Imaging studies to confirm the diagnosis and rule out alternative diagnoses
- Broad-spectrum antibiotics to reduce the risk of perforation and peritonitis
- Pain management and hydration to reduce the patient's discomfort and prevent dehydration
- Monitoring for signs of perforation or peritonitis, such as increased pain, fever, or abdominal tenderness.
From the Research
Patient Presentation
The patient presents with 8/10 right lower quadrant (RLQ) abdominal pain, a white blood cell (WBC) count of 11.1 x 10^9/L, and a C-reactive protein (CRP) level of 37.5 mg/L.
Diagnostic Considerations
- The clinical presentation suggests acute appendicitis, which is the most common abdominal surgical emergency in adults, with an annual incidence of 96.5 to 100 cases per 100,000 adults 2.
- The diagnosis of acute appendicitis is based on history, physical examination, laboratory evaluation, and imaging studies.
- Classic symptoms of appendicitis include vague periumbilical pain, anorexia, nausea, intermittent vomiting, migration of pain to the RLQ, and low-grade fever 2.
Laboratory Findings
- The patient's elevated WBC count and CRP level are consistent with an inflammatory process, such as acute appendicitis 2, 3.
- Laboratory test results, including WBC count and CRP, are valuable in assessing the patient's condition and guiding further management 3.
Imaging Studies
- Computed tomography (CT) is a highly accurate, non-invasive test for diagnosing appendicitis, with a sensitivity of 0.95 and specificity of 0.94 4.
- CT findings, such as appendiceal dilatation and presence of appendicoliths, can help identify patients who are more likely to fail antibiotic treatment and require surgical management 2, 5.
Management Options
- Laparoscopic appendectomy remains the most common treatment for acute appendicitis, but increasing evidence suggests that broad-spectrum antibiotics can successfully treat uncomplicated acute appendicitis in approximately 70% of patients 2, 6.
- The decision to use antibiotics or surgery as first-line therapy should be based on individual patient factors, including the presence of high-risk CT findings, such as appendicolith, mass effect, or a dilated appendix greater than 13 mm 2.