From the Guidelines
The workup for suspected appendicitis should begin with a thorough history and physical examination, focusing on the classic presentation of periumbilical pain migrating to the right lower quadrant, accompanied by nausea, vomiting, anorexia, and fever, as recommended by the most recent guidelines 1. The initial assessment should include laboratory tests such as a complete blood count to check for leukocytosis (elevated white blood cell count), C-reactive protein, and urinalysis to rule out urinary tract infection.
- Imaging is crucial for diagnosis, with ultrasound being the first-line modality for children, pregnant women, and thin adults due to its lack of radiation, as suggested by 1 and 1.
- CT scan with IV contrast is the gold standard for adults, offering 94-98% sensitivity and specificity, although CT without IV contrast also has high diagnostic accuracy in detecting acute appendicitis and may be appropriate, as noted in 1.
- MRI is an alternative for pregnant patients or those who cannot receive CT contrast. While awaiting diagnosis, patients should receive:
- Nothing by mouth
- IV fluids (typically normal saline at maintenance rates)
- Pain management with medications like morphine or hydromorphone
- Broad-spectrum antibiotics such as piperacillin-tazobactam 3.375g IV every 6 hours or ceftriaxone 1-2g IV daily plus metronidazole 500mg IV every 8 hours if perforation is suspected, as recommended by 1. The definitive treatment for appendicitis is typically appendectomy, though some uncomplicated cases may be managed with antibiotics alone, as suggested by 1. Early diagnosis and treatment are essential to prevent complications like perforation, abscess formation, and peritonitis. In cases where initial imaging is inconclusive, subsequent imaging with US, CT, or MRI may be considered, depending on the patient and clinical circumstances, as noted in 1.
From the Research
Suspected Appendicitis Workup
The workup for suspected appendicitis involves a combination of clinical evaluation, laboratory tests, and imaging studies.
- Clinical evaluation: The diagnosis of acute appendicitis is based on history and physical examination, with classic symptoms including vague periumbilical pain, anorexia/nausea/intermittent vomiting, migration of pain to the right lower quadrant, and low-grade fever 2.
- Laboratory tests: Laboratory evaluation is also important in the diagnosis of acute appendicitis, with tests such as complete blood count and blood chemistry helping to confirm the diagnosis 2.
- Imaging studies: Imaging studies, such as computed tomography (CT) scans, can help confirm the diagnosis of appendicitis and identify any complications, such as appendicoliths or perforation 2, 3.
Diagnostic Criteria
The diagnosis of acute appendicitis is made based on a combination of clinical and imaging findings.
- Classic symptoms: The presence of classic symptoms, such as vague periumbilical pain, anorexia/nausea/intermittent vomiting, migration of pain to the right lower quadrant, and low-grade fever, is highly suggestive of appendicitis 2.
- Imaging findings: Specific imaging findings on CT, such as appendiceal dilatation (appendiceal diameter ≥7 mm), or presence of appendicoliths, can help confirm the diagnosis of appendicitis 2.
- Laboratory results: Laboratory results, such as elevated white blood cell count, can also help support the diagnosis of appendicitis 2, 4.
Treatment Options
The treatment of appendicitis depends on the severity of the disease and the presence of any complications.
- Surgical treatment: Laparoscopic appendectomy is the most common treatment for acute appendicitis, and is usually recommended for patients with complicated appendicitis or those who are at high risk of treatment failure with antibiotics 2, 3.
- Antibiotic treatment: Broad-spectrum antibiotics, such as piperacillin-tazobactam monotherapy or combination therapy with either cephalosporins or fluroquinolones with metronidazole, can be used to treat uncomplicated appendicitis in selected patients 2, 3.
- Shared decision-making: In patients with uncomplicated appendicitis, a shared decision-making approach can be used to determine the best course of treatment, taking into account the patient's preferences and values 3.