The incidence of appendectomy for acute appendicitis was decreasing in the United Status until the 1990s, at which point the frequency of appendectomy for nonperforated appendicitis began to rise. What is one potential explanation for this observation?
While the true reason is unknown, some have suggested that the quality and usage of diagnostic imaging in the past 20 to 30 years has resulted in the detection of acute appendicitis that would have otherwise spontaneously resolved. While appendectomy may mitigate the clinical symptoms of ulcerative colitis, this is likely not responsible for the broad reduction in observed appendectomy. Obesity is not known to impact appendicitis incidence. Reimbursement patterns should hopefully not impact surgical decision making so directly.
What imaging finding would exclude appendicitis?
Graded compression ultrasonography is inexpensive and rapid. The appendix is identified as a nonperistaltic, blind ending loop of bowel. The compressibility and anteroposterior dimensions are measured. Thickening of the wall as well as peri-appendiceal fluid with a noncompressible appendix are suggestive of appendicitis while an easily compressible, narrow appendix excludes the diagnosis. Failure to identify the appendix on imaging does not definitely rule out appendicitis. A fecalith in the mid appendix may allow proximal filling of the appendix with barium in the presence of appendicitis. Sonographic sensitivity for appendicitis is 55 to 96% while specificity is 85 to 98%.
A 25-year-old man presents with migratory right lower quadrant (RLQ) pain, leukocytosis, and a CT scan consistent with acute, uncomplicated appendicitis. He is physiologically normal and it is 2 AM. You are planning an appendectomy, what difference might be expected in his outcome if his operation is delayed until the next morning?
There have been three retrospective studies comparing urgent versus emergent appendectomy. No difference was found in the incidence of complicated appendicitis, surgical-site infections, abscess formation, or conversion to an open procedure. While hospital length of stay was longer in the urgent group (as might be anticipated given the delay in definitive surgical care) this was not statistically or clinically different from the emergent group. It may be safe in physiologically normal patients with uncomplicated appendicitis to wait 12 to 24 hours and book them as an "urgent" case.
A 55-year-old man has CT evidence of complicated appendicitis with a contained abscess in the RLQ. He is mildly tachycardic, afebrile, and normotensive with focal RLQ tenderness but no peritonitis. What is the optimal approach to this patient?
Conservative management of the physiologically stable patient with complicated appendicitis has been shown to be associated with fewer overall complications, fewer bowel obstructions, fewer intra-abdominal abscesses, and fewer reoperations. While patients with peritonitis or hemodynamic instability should proceed to the operating room, conservative management of more stable patients with complicated appendicitis is favored. This may not necessarily be true in the pediatric population, however, as two prospective randomized trials in children demonstrate equivalent or superior outcomes with early operative intervention.
A 23-year-old woman who is 28 weeks pregnant presents with right -sided abdominal pain, leukocytosis, and an abdominal ultrasound that does not visualize the appendix. What intervention would you recommend?
Appendicitis complicates 1/766 births and is rare in the third trimester. The rate of negative appendectomy in the pregnant patient appears to be about 25% higher than in nonpregnant patients. This is not, however, a benign procedure as a negative appendectomy is associated with a 4% risk of fetal loss and a 10% risk of early delivery. The American College of Radiology recommends the use of nonionizing radiation techniques as front -line imaging in pregnant women. Serial examinations would be inappropriate as rates of fetal loss are considerably higher in patients with complicated appendicitis and the greatest opportunity to improve fetal outcomes is to improve diagnostic accuracy.
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