Appendicitis

Three Stages of Appendicitis

Stage 1: ~12 hours of “gastroenteritis” like symptoms
Stage 2: Direct somatic irritation
- This is when pain over McBurney’s develops!
Stage 3: Perforation
- Patient is now sick and septic

Approach to Appendicitis

Step 1: Consider getting labs
- Always remember “The white blood cell count is the last refuge of the intellectually destitute”
- The WBC count has both low sensitivity and low specificity for acute appendicitis
Step 2: Get a detailed history
- When did the pain start?
  - How many HOURS into their syndrome are they (remember stages of appendicitis)
  - Is the pain migrating?
- Objective fever?
- Did the pain start before the vomiting started?
- Does the patient have decreased appetite?
Step 3: Perform a physical exam
- Pain over McBurney’s point
  - Right lower quadrant
  - 1/3 the distance from the ASIS to the umbilicus
- Peritoneal signs (Rigidity, Rebound, Guarding)
- Psoas sign
  - Lie patient on left side with legs extended
  - Extend their hip behind them
  - Pain = Suspected retroperitoneal inflammation
- Obturator sign
  - Have patient lie on back with hip/knee flexed at 90 degrees
  - Internally rotate hip (move ankle away from body)
  - Pain = Suspected obturator internus inflammation
Step 4: Imaging
- Most adults
  - CT scan +/- IV contrast
- Pregnant women
  - MRI abdomen
- Pediatric patients
  - RLQ ultrasound
Step 5: Disposition
- Perform a repeat abdominal exam
- Even if CT is negative, consider followup in ED in 12-24 hours

Additional Reading