From the Guidelines
The most appropriate management for this 27-year-old obese woman is urgent surgical consultation for suspected acute appendicitis, followed by diagnostic imaging, preferably ultrasound (US) as the first-line diagnostic tool, 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 (commonly a combination of cefuroxime 1.5g IV and metronidazole 500mg IV). Some key points to consider in the management of suspected acute appendicitis include:
- The use of clinical scoring systems, such as the Alvarado score or the Adult Appendicitis Score (AAS), to stratify patients into low, intermediate, and high risk of appendicitis 1
- The value of diagnostic imaging, including ultrasound (US) and computed tomography (CT) scan, in confirming the diagnosis of acute appendicitis 1
- The importance of early surgical intervention to prevent progression to perforation, abscess formation, or peritonitis, which would significantly increase morbidity and prolong hospitalization 1
- The preference for laparoscopic appendectomy over open surgery, especially in obese patients, due to its benefits in terms of visualization, post-operative pain, and recovery time 1. Given the patient's obesity, a low-dose CT scan may be considered if the US is inconclusive, as recommended by the 2020 update of the WSES Jerusalem guidelines 1. However, the initial diagnostic approach should prioritize US as the first-line imaging modality, due to its satisfactory sensitivity and specificity in diagnosing acute appendicitis, as well as its advantages in terms of ease of use, speed, and lack of radiation exposure 1.
From the Research
Diagnosis and Management of Acute Appendicitis
The patient's symptoms, such as right iliac fossa pain, anorexia, nausea, vomiting, and leucocytosis, suggest acute appendicitis. The most appropriate management for this condition involves:
- Diagnostic imaging to confirm the diagnosis
- Consideration of the patient's age, sex, and body mass index (BMI) in choosing the imaging modality
Imaging Modalities for Acute Appendicitis
The following imaging modalities can be used to diagnose acute appendicitis:
- Ultrasonography (US): US is the first-line imaging modality for children and non-obese young adults, including women of reproductive age 2
- Computed Tomography (CT): CT is a valuable diagnostic tool, especially in adults with suspected appendicitis 3, 4, 5
- Diagnostic Laparoscopy: Diagnostic laparoscopy can be useful in the early stages of the diagnostic work-up, especially in women of reproductive age 3
Considerations for the Patient's Condition
Given the patient's age (27 years) and obesity, CT scan may be a more appropriate imaging modality than US 4, 5. However, US should still be considered as the first-line imaging modality, especially if the patient is a woman of reproductive age 2.
Most Appropriate Management
Based on the patient's symptoms and condition, the most appropriate management would be to start with:
- Ultrasonography (US) as the first-line imaging modality, considering the patient's age and sex 2
- If the US findings are equivocal or do not correlate with the clinical assessment, a CT scan may be considered as a follow-up imaging modality 2, 4, 5
The options can be evaluated as follows:
- A. Open surgery: Not the most appropriate initial management, as diagnostic imaging should be performed first to confirm the diagnosis
- B. CT: May be considered as a follow-up imaging modality if US findings are equivocal
- C. US: The most appropriate first-line imaging modality for this patient
- D. Diagnostic laparoscopy: May be considered in certain cases, but not as the first-line diagnostic approach 3