Internal Medicine

P1: SBT

0521779407-04 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:8

Appendicitis 155

■Crohn disease

■Pelvic inflammatory disease

■Ovarian cyst

■Omental torsion or infarction

■Gastroenteritis

■Cancer of appendix or cecum: be especially wary in older pt or in

presence of iron deficiency anemia

■Urinary tract infection or stone

■Abdominal wall pain (Houdini died of a perforated ulcer after mis-

takenly undergoing operation for appendicitis)

■No clear diagnosis found in many pts thought to have appendicitis

management

What to Do First

■If diagnosis uncertain, may improve accuracy to observe pt in hos-

pital

General Measures

■Uncomplicated appendicitis:

■Early operation usually recommended

■Most resolve w/ antibiotics, but recurrence common

■Complicated appendicitis:

■Perforation w/ peritonitis: proceed to appendectomy

■Abscess/phlegmon: usually treat w/ percutaneous drainage &/or

antibiotics followed by interval appendectomy 6–12 wk later

specific therapy

■Appendectomy:

■Performed either by laparotomy or laparoscopy

■If diagnosis secure, RLQ incision appropriate; if not, midline incision

or laparoscopy provides better exposure of entire abdomen

■Negative appendectomy rates of∼10–15% generally considered

acceptable; diagnosis much more difficult in women of child-

bearing age

■Perioperative antibiotics routinely given: 1 dose or 24 h for uncom-

plicated appendicitis, longer for abscess or perforation

■Third-generation cephalosporin or extended-spectrum penicillin

w/ anaerobic coverage appropriate for most pts

■Percutaneous drainage of appendiceal abscess & antibiotics:

■Treatment of choice for established abscess w/o toxicity

■Antibiotics alone: