What is the most appropriate management for a 27-year-old obese woman presenting with right iliac fossa pain, anorexia, nausea, vomiting, moderate right iliac fossa tenderness, and leucocytosis (elevated white blood cell count)?

From the Guidelines

The most appropriate management for this 27-year-old obese woman is urgent surgical consultation for suspected acute appendicitis, followed by appendectomy, with initial diagnostic imaging preferably using ultrasound (US) as the first-line imaging modality, as recommended by the 2020 update of the WSES Jerusalem guidelines 1. The clinical presentation of right iliac fossa pain, anorexia, nausea, vomiting, localized tenderness, and leucocytosis strongly suggests acute appendicitis. Initial management should include keeping the patient nil by mouth, providing intravenous fluids (typically normal saline at 1-2 L initially), administering analgesia (such as morphine 0.1 mg/kg IV), and starting broad-spectrum antibiotics (such as cefuroxime 1.5g IV and metronidazole 500mg IV). The use of US as the first-line imaging modality is supported by a recent meta-analysis, which reported a mean sensitivity and specificity of 90% and 95%, respectively, for diagnosing acute appendicitis 1. If US is inconclusive, a contrast-enhanced low-dose CT scan may be performed to confirm the diagnosis, as recommended by the 2020 update of the WSES Jerusalem guidelines 1. Laparoscopic appendectomy is generally preferred over open appendectomy, particularly in obese patients, as it offers better visualization, less post-operative pain, shorter hospital stay, and faster recovery. The patient's obesity is a risk factor that may complicate both diagnosis and surgical management, potentially increasing the risk of complications such as wound infections. Early surgical intervention is crucial to prevent progression to perforation, abscess formation, or peritonitis, which would significantly increase morbidity. Clinical scoring systems, such as the Alvarado score or the Adult Appendicitis Score (AAS), may be used to guide decision-making and reduce the need for imaging and negative surgical explorations 1. However, these scoring systems should be used in conjunction with clinical judgment and imaging findings to ensure accurate diagnosis and appropriate management. In addition to surgical management, the patient's obesity should be addressed through weight management options, such as diet and lifestyle modifications, to reduce the risk of future complications 1. Key points to consider in the management of this patient include:

• Urgent surgical consultation for suspected acute appendicitis
• Initial diagnostic imaging using US as the first-line modality
• Use of broad-spectrum antibiotics and analgesia
• Laparoscopic appendectomy as the preferred surgical approach
• Addressing the patient's obesity through weight management options
• Early surgical intervention to prevent complications and improve outcomes.

From the Research

Diagnosis and Management

The patient's symptoms, such as right iliac fossa pain, anorexia, nausea, vomiting, and leucocytosis, are suggestive of acute appendicitis 2. The diagnosis of acute appendicitis is typically based on a combination of clinical evaluation, laboratory tests, and imaging studies.

Imaging Studies

Imaging studies, such as ultrasonography (US) and computed tomography (CT), play a crucial role in diagnosing acute appendicitis. According to a study, US should be the first-line imaging modality for all ages, particularly for children and non-obese young adults, including women of reproductive age group 3. However, in obese patients, CT may be more accurate than US 4.

Appropriate Management

Given the patient's symptoms and laboratory results, the most appropriate management would be to perform imaging studies to confirm the diagnosis. Considering the patient's obesity, a CT scan may be more suitable than US 4. If the CT scan confirms acute appendicitis, the patient may be a candidate for either appendectomy or antibiotics as first-line therapy, depending on the presence of high-risk CT findings 2.

Key Points

• Acute appendicitis is a common abdominal surgical emergency 2
• Imaging studies, such as US and CT, are essential for diagnosing acute appendicitis 3, 4
• CT may be more accurate than US in obese patients 4
• The management of acute appendicitis depends on the presence of high-risk CT findings and the patient's overall condition 2

Possible Next Steps

• Perform a CT scan to confirm the diagnosis of acute appendicitis
• Consider appendectomy or antibiotics as first-line therapy, depending on the CT scan results and the patient's condition 2
• Monitor the patient's symptoms and laboratory results to determine the best course of treatment