Appendicitis

Appendicitis - Acute

Definition  

Acute inflammation of the vermiform appendix

 

Medical History  

* Low fiber diet

* Family history of Appendicitis

* Smoking

 

Findings  

* Abdominal mass

* Pain in scrotum

* Abdominal guarding

* Abdominal pain - Acute

* Abdominal tenderness

* Bowel sounds hyperactive

* Decreased bowel sounds

* Obturator sign

* Psoas sign

* Rebound tenderness

* Diarrhea

* Sinus tachycardia

* Urinary retention

* Appetite loss - anorexia

* Constipation

* Fever

* Irritability

* Vomiting

 

Tests  

 

Suspected appendicitis  

* White blood cell count: Although the presence of leukocytosis may suggest appendicitis, its low sensitivity limits its usefulness as a reliable diagnostic marker .

 

Suspected appendicitis  

* Serum C reactive protein level: C-reactive protein is elevated in relation to severity of appendiceal inflammation .

 

Suspected appendicitis  

* Microscopic urinalysis: Pyuria and microscopic hematuria may be present in 7% to 25% of patients with appendicitis .

 

Suspected appendicitis  

* Abdominal ultrasound: Ultrasound is less accurate than CT for the diagnosis of appendicitis .

 

Suspected appendicitis  

* CT of abdomen: CT is more accurate than ultrasound for the diagnosis of appendicitis .

 

Suspected appendicitis  

* Diagnostic laparoscopy: Diagnostic laparoscopy may decrease the number of unnecessary appendectomies and unestablished diagnoses, particularly in fertile women .

 

Differential Diagnosis  

* Ectopic pregnancy - Acute

* Torsion of ovary

* Intussusception of intestine - Acute

* Pelvic inflammatory disease - Acute

* Cyst of ovary

* Follicular cyst of ovary

* Corpus luteum cyst

* Urinary tract infectious disease - Acute

* Crohn's disease

* Ulcerative colitis

* Mesenteric adenitis, acute

* Gastroenteritis - Acute

* Nephrolithiasis - Acute

* Occlusive mesenteric ischemia

* SPIDER-LATRODECTUS SPECIES

* Peptic ulcer with perforation

* Diverticulitis - Acute

* Pyelonephritis AND Pregnancy

* Pyelonephritis

* Testicular torsion - Acute

* Cholecystitis - Acute

* HELLP syndrome

* Pancreatitis - Acute

* Right lower lobe pneumonia

* Omental infarction

* Diabetic ketoacidosis - Acute

* Meckel's diverticulum - Acute

 

Treatment  

 

Drug Therapy  

 

Preoperative antibiotic prophylaxis in patients with nonperforated appendicitis  

 

CEFOXITIN SODIUM  

Adults: 1 to 2 g IV preoperatively

Pediatrics: 40 mg/kg IV preoperatively

 

CEFOTETAN DISODIUM  

Adults: 1 to 2 g IV preoperatively

Pediatrics: 40 mg/kg IV preoperatively

 

 

Preoperative antibiotic prophylaxis in children with appendicitis at high risk  

 

GENTAMICIN SULFATE - CLINDAMYCIN PHOSPHATE - AMPICILLIN  

Pediatrics: Gentamicin 2 mg/kg IV AND clindamycin 10 mg/kg IV AND ampicillin 50 mg/kg IV

 

GENTAMICIN SULFATE - CLINDAMYCIN PHOSPHATE  

Pediatrics: Gentamicin 2 mg/kg IV AND clindamycin 10 mg/kg IV

 

 

Children with appendicitis and/or peritonitis who are ?2 months of age  

 

PIPERACILLIN SODIUM/TAZOBACTAM SODIUM  

Pediatrics (2 to 9 months): 80 mg piperacillin/10 mg tazobactam per kg every 8 hours

Pediatrics (?9 months and weight ?40 kg): 100 mg piperacillin/12.5 mg tazobactam per kg every 8 hours

Pediatrics (weight >40 kg): 3.375 g every 6 hours

 

 

Ruptured appendicitis (mild to moderate disease) in a hospitalized adult patient  

 

AMPICILLIN SODIUM/SULBACTAM SODIUM  

Adults: 3 g IV every 6 hours

 

PIPERACILLIN SODIUM/TAZOBACTAM SODIUM  

Adults: 3.375 g IV every 6 hours or 4.5 g IV every 8 hours

 

TICARCILLIN DISODIUM/CLAVULANATE POTASSIUM  

Adults: 3.1 g IV every 6 hours

 

ERTAPENEM SODIUM  

Adults: 1 g IV once daily

 

CIPROFLOXACIN - METRONIDAZOLE

Adults: Ciprofloxacin 400 mg IV every 12 hours AND metronidazole 1 g IV every 12 hours

 

LEVOFLOXACIN - METRONIDAZOLE

Adults: Levofloxacin 750 mg IV every 24 hours AND metronidazole 1 g IV every 12 hours

 

CEFEPIME HYDROCHLORIDE - METRONIDAZOLE

Adults: Cefepime 2 g every 12 hours AND metronidazole 1 g IV every 12 hours

 

 

Ruptured appendicitis (severe, life-threatening disease) in an intensive care unit adult patient  

 

IMIPENEM/CILASTATIN  

Adults: 500 mg IV every 6 hours

 

MEROPENEM

Adults: 1 g IV every 8 hours

 

AMPICILLIN - METRONIDAZOLE

Adults: Ampicillin 2 g IV every 6 hours AND metronidazole 500 mg IV every 6 hours AND ciprofloxacin 400 mg IV every 12 hours

 

AMPICILLIN - METRONIDAZOLE

Adults: Ampicillin 2 g IV every 6 hours AND metronidazole 500 mg IV every 6 hours AND levofloxacin 750 mg IV every 24 hours

 

AMPICILLIN - METRONIDAZOLE

Adults: Ampicillin 2 g IV every 6 hours AND metronidazole 500 mg IV every 6 hours AND gentamicin [2 mg/kg load, then 1.7 mg/kg every 8 hours or 5.1 (7 if critically ill) mg/kg every 24 hours]

 

 

Acute pain  

 

MORPHINE SULFATE  

Adults: 2 to 10 mg IV every 5 to 10 minutes titrated to effect OR 10 mg IM or subQ every 3 to 4 hours as needed

Pediatrics: 0.1 to 0.2 mg/kg subQ, IM, or IV every 2 hours as needed (maximum 15 mg/dose)

 

FENTANYL  

Adults: 1 mcg/kg IV slowly every 3 to 5 minutes titrated to effect

Pediatrics: 0.5 to 1 mcg/kg IV every 30 to 60 minutes as needed

 

HYDROMORPHONE HYDROCHLORIDE  

Adults: 1 mg IV every 10 minutes titrated to effect OR 1 to 2 mg subQ or IM every 3 to 4 hours as needed

Pediatrics: 10 to 20 mcg/kg IV every 3 to 4 hours as needed

 

KETOROLAC TROMETHAMINE  

Adults (<65 years): 60 mg IM or 30 mg IV as a single dose OR 30 mg IV or IM every 6 hours (maximum 120 mg/day for  5 days)

 

Procedural Therapy  

 

Appendicitis  

* Appendectomy: Compared with open appendectomy, laparoscopy is associated with a decreased risk of wound infection but an increased risk of intra-abdominal abscess .

 

Dehydration  

* Intravenous fluid replacement: Intravenous fluid replacement is indicated for patients with dehydration when oral replacement cannot be accomplished .