How to manage a patient with right lower quadrant (RLQ) abdominal pain, guarding, fever, toxicity, and leukocytosis (white blood cell count (WBC) elevated)?

Management of Patient with RLQ Abdominal Pain, Guarding, Fever, and Leukocytosis

CT abdomen (option B) is the most appropriate initial management step for a patient presenting with right lower quadrant pain, guarding, fever, and elevated white blood cell count of 22,000 to confirm the diagnosis before proceeding to surgical intervention. 1

Rationale for CT Abdomen

• CT abdomen has superior diagnostic yield for suspected appendicitis with sensitivity of 85.7-100% and specificity of 94.8-100% 1
• Can identify key findings including:
  • Appendiceal dilatation
  • Presence of appendicoliths
  • Wall thickening
  • Periappendiceal fat stranding
  • Complications such as perforation or abscess formation

Clinical Assessment

The patient's presentation strongly suggests acute appendicitis with potential complications:

• RLQ abdominal pain and guarding
• Fever and toxic appearance
• Markedly elevated WBC count (22,000)

These findings represent the classic triad of appendicitis with potential perforation, which requires prompt evaluation and management 1.

Management Algorithm

1. Initial step: CT abdomen to confirm diagnosis and assess for complications
2. If uncomplicated appendicitis: Proceed to appendectomy (laparoscopic preferred) with appropriate antibiotics
3. If complicated appendicitis (perforation/abscess):
   • Antibiotics with possible appendectomy
   • Percutaneous drainage followed by interval appendectomy
   • Urgent exploratory laparotomy if peritonitis is present

Why Not Other Options?

• Exploratory laparotomy (option A): While sometimes necessary for perforated appendicitis with peritonitis, proceeding directly to surgery without imaging confirmation is not recommended by current guidelines 1
• MRI abdomen (option C): Has longer acquisition times and is less readily available than CT for emergency situations 1
• Conservative management (option D): Not appropriate for a patient with signs of severe infection (fever, toxicity, leukocytosis) and potential perforation

Important Considerations

• The American College of Radiology recommends CT as the initial step in management for patients with this clinical presentation 1
• Prompt diagnosis and treatment are essential to reduce morbidity and mortality
• Patients with perforated appendicitis are at risk for intra-abdominal abscess formation requiring drainage 1
• Markedly elevated WBC count (22,000) suggests severe inflammation and possible perforation, which requires urgent intervention

CT abdomen provides the most accurate diagnosis and helps determine the appropriate surgical approach, making it the best initial management step for this patient with suspected complicated appendicitis.