How to manage suspected appendicitis in a patient with overlapping menses?

Management of Suspected Appendicitis with Overlapping Menses

For patients with suspected appendicitis and overlapping menstruation, proceed with standard diagnostic workup while considering gynecologic causes, as menstruation does not alter the need for prompt evaluation and management of appendicitis.

Diagnostic Approach

Initial Assessment

• Use validated clinical scoring systems (AIR score, Alvarado score, AAS) to stratify risk 1
• Assess for classic appendicitis symptoms despite menstruation:
  • Periumbilical pain migrating to right lower quadrant
  • Nausea/vomiting
  • Fever
  • Anorexia
  • Rebound tenderness at McBurney's point

Imaging

1. First-line imaging: Point-of-care ultrasound (POCUS) 1, 2

   • Allows visualization of appendix and pelvic organs
   • Can identify gynecologic pathology that may mimic appendicitis
   • Pooled sensitivity 83.1%, specificity 93.6% 1

2. Second-line imaging: Low-dose contrast-enhanced CT scan if ultrasound is negative or inconclusive 1, 2

   • Higher sensitivity and specificity than ultrasound
   • Can identify alternative diagnoses

Laboratory Testing

• Complete blood count with differential (leukocytosis with left shift)
• C-reactive protein (elevated in appendicitis)
• Pregnancy test (mandatory in women of childbearing age) 1

Important Differential Considerations During Menses

Gynecologic Conditions to Consider

• Ectopic endometriosis of the appendix 3
  • May cause cyclic pain during menstruation
  • Can mimic or potentially trigger appendicitis
• Pelvic inflammatory disease
• Ovarian cyst/torsion
• Mittelschmerz (mid-cycle pain)

Management Algorithm

1. High clinical suspicion of appendicitis (high scores on validated scales):

   • Proceed with surgical consultation
   • Administer broad-spectrum antibiotics covering aerobic and anaerobic organisms 1, 2
   • Plan for appendectomy within 24 hours 1

2. Intermediate suspicion:

   • Obtain imaging (POCUS first, then CT if needed)
   • If imaging confirms appendicitis: proceed with antibiotics and appendectomy
   • If imaging is negative but symptoms persist: observe for 24 hours with repeat evaluation 1, 2

3. Low suspicion with gynecologic symptoms predominant:

   • Consider gynecologic consultation
   • Observe with serial examinations
   • Repeat imaging if symptoms worsen or fail to improve

Surgical Considerations

• Laparoscopic approach preferred (better visualization of pelvic organs) 1
• Timing: appendectomy should be performed within 24 hours of admission to minimize complications 1
• Delaying beyond 24 hours increases risk of perforation and adverse outcomes 1

Potential Pitfalls

1. Misattribution of symptoms to menstruation

   • Menstrual pain should not be assumed to explain acute abdominal pain
   • Appendicitis requires prompt diagnosis and treatment regardless of menstrual status

2. Overlooking gynecologic pathology

   • Endometriosis involving the appendix can cause cyclic symptoms 3
   • Careful examination and appropriate imaging help distinguish causes

3. Delayed diagnosis

   • Delays in diagnosis increase risk of perforation
   • Perforation significantly increases morbidity and mortality

Follow-up

• For patients with negative workup but persistent symptoms:
  • Re-evaluate within 24 hours 1, 2
  • Consider additional imaging or diagnostic laparoscopy if symptoms worsen
  • Document resolution of symptoms before discharge

Remember that menstruation does not protect against appendicitis, and the presence of menses should not delay appropriate diagnostic workup and management of suspected appendicitis.