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)?

Management of Suspected Acute Appendicitis in an Obese Young Woman

Point-of-care ultrasound (POCUS) is the most appropriate first-line diagnostic tool for this 27-year-old obese woman presenting with right iliac fossa pain, anorexia, nausea, vomiting, moderate right iliac fossa tenderness, and leucocytosis. 1

Diagnostic Approach Algorithm

1. Initial Clinical Assessment

   • The patient's presentation is highly suggestive of acute appendicitis with:
     • Right iliac fossa pain
     • Anorexia, nausea, and vomiting
     • Moderate right iliac fossa tenderness
     • Leucocytosis
   • These findings represent several of the key predictive factors for acute appendicitis 2

2. First-line Imaging

   • POCUS (Point-of-care Ultrasound) should be the initial imaging modality
   • The 2020 WSES Jerusalem guidelines strongly recommend POCUS as the most appropriate first-line diagnostic tool in adults with suspected appendicitis 1
   • POCUS offers satisfactory sensitivity and specificity while enabling swift decision-making by emergency physicians or surgeons 1

3. If POCUS is inconclusive or negative

   • Proceed to contrast-enhanced low-dose CT scan
   • The WSES guidelines strongly recommend low-dose CT over standard-dose CT in patients with negative US findings 1
   • CT has higher sensitivity and specificity than ultrasound 1
   • In obese patients, ultrasound may have limitations due to body habitus 1

4. If imaging is inconclusive but clinical suspicion remains high

   • Proceed to diagnostic laparoscopy
   • The WSES guidelines recommend explorative laparoscopy for patients with progressive or persistent pain after negative imaging 1
   • Diagnostic laparoscopy allows for both diagnosis and immediate treatment 1

Rationale for Diagnostic Laparoscopy When Indicated

Diagnostic laparoscopy is particularly valuable in this case for several reasons:

1. Diagnostic accuracy: Laparoscopy allows direct visualization of the appendix and other pelvic organs, which is crucial in young women where gynecological conditions may mimic appendicitis 3, 4, 5

2. Therapeutic potential: If appendicitis is confirmed, immediate appendectomy can be performed during the same procedure 1

3. Alternative diagnoses: Laparoscopy can identify other causes of right iliac fossa pain such as tubal pathology, which may present similarly 3, 5

4. Obesity consideration: In obese patients, imaging techniques may have limitations, making direct visualization more reliable 1

5. Reduced negative appendectomy rate: The Cochrane review cited in the WSES guidelines showed that laparoscopy was associated with a significant reduction in the rate of removal of normal appendix compared to open surgery 1

Important Considerations

• Obesity impact: Ultrasound sensitivity may be reduced in obese patients, potentially necessitating progression to CT or diagnostic laparoscopy more quickly 1

• Appendix removal during laparoscopy: Even if the appendix appears normal during laparoscopy, removal should be considered as studies show that 19-40% of visually normal appendices have pathological abnormalities on histological examination 1

• Timing: Early intervention is crucial to prevent progression to complicated appendicitis, which increases morbidity and mortality 1

• Leucocytosis interpretation: While leucocytosis supports the diagnosis of appendicitis, its absence does not rule out the condition, especially in immunocompromised patients 1, 6, 7

In conclusion, while POCUS is the recommended first-line diagnostic tool, the clinical presentation strongly suggests appendicitis, and if imaging is inconclusive, diagnostic laparoscopy would be the appropriate next step to both confirm the diagnosis and provide definitive treatment.