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appendicitis

appendicitis

clinical features

  • pain initially epigastric and migrated to RIF with anorexia, nausea +/- low grade fever
  • max. tenderness over McBurney's point
  • +/- Rovsing's sign - rebound tenderness LIF
  • +/- psoas sign (pain on passive extension of the right hip) - esp. likely in retrocaecal appendicitis
  • +/- obturator sign (pain on passive internal rotation of the flexed right thigh) - esp. pelvic appendicitis
  • remember, pelvic appendicitis may have few abdo signs and present with diarrhoea
  • clinical diagnosis can be very difficult in young children, the elderly, the pregnant patient or those with atypical presentations

Mx of the patient thought to have appendicitis going to theatre

  • nil orally
  • iv fluids - 0.9% saline
  • baseline FBE, U&E plus HCG if female
  • consider blood culture if temp > 38.5deg C
  • urinalysis
  • commence fluid balance chart
  • analgesia as needed
  • consider PR exam if atypical history or findings as it maybe helpful in diagnosing a pelvic appendicitis which tends to present with minimal abdominal findings and often some diarrhoa
    • PR exam is generally NOT indicated in children
  • ensure pregnancy and gynaecologic causes of the pain have been reasonably excluded

pre-op care

  • surgical team to obtain consent, book theatre
  • pre-op CXR, ECG if comorbidities or elderly
  • fast for minimum 6 hours if clinically possible
  • maintain iv therapy
  • surgical shave in theatre
  • DVT prophylaxis as per surgical protocol
  • if signs of peritonitis, commence antibiotics as below ASAP rather than just at induction of anaesthesia

prophylactic antibiotic cover:

  • Aust. Therapeutic Guidelines recommend prophylactic dual Rx for appendicitis with metronidazole AND either cephazolin or gentamicin
  • however, many surgeons will prefer triple Rx (as per peritonitis) with:
    • amoxycillin/ampicillin 2g (child: 50mg/kg up to 2g) 6h iv, PLUS,
    • gentamicin 4mg/kg (usually 320mg in an adult for 1st dose and 6mg/kg for children > 10yrs) iv daily and adjust for renal function, PLUS
    • metronidazole 500mg (child: 12.5mg/kg up to 500mg) iv 12h
  • NB: patients with hypersensitivity (HS):
    • immediate HS to penicillins:
    • non-immediate HS to penicillin &/or HS to gentamicin:
      • use ceftriaxone instead of both amoxycillin and gentamicin

post-op care:

  • ongoing antibiotics post-op:
    • not needed if normal appendic or only mildly inflamed appendix
    • if necrotic/purulent appendix or signs of peritonitis then:
      • iv ampicillin 1g qid plus iv gentamicin 4-6mg/kg daily (subsequent doses according to age, CRN levels, gentamicin levels) plus iv metronidazole 500mg tds
      • if gentamicin C/I, then use iv timentin 3.1g 6hrly
      • complete 5-7 day course depending on clinical response - cease when afebrile > 24hrs and normalising WCC
      • if responding well, consider changing to oral augmentin duo forte i bd after 48 hours
  • routine post-op obs
  • diet when tolerated, iv fluids until then
  • encourage mobilisation
  • encourage regular analgesia to allow mobilisation

discharge planning:

  • written and verbal discharge instructions:
    • no vigorous exercise or lifting > 10kg for 4 weeks, then increase exercise slowly
    • can shower
    • can drive a motor vehicle when able to move comfortably (eg. 2-3 weeks)
    • normal diet as tolerated
    • contact LMO or hospital if fevers, wound inflammation or excessive nausea occurs
  • sick certificate
  • surgical team to check histopathology within 2 weeks
  • outpatient follow up appt within 2 weeks if complicated case, otherwise at 6 weeks

non-operative Mx of the patient with atypical features for appendicitis

  • patients with atypical history and examination findings may be considered for admission under the general surgical unit and monitored rather than going to theatre initially
  • continue initial Mx as above but no antibiotics
  • at least bd reassessment by surgical team
  • iv fluids
  • fluid balance chart
  • 4/24 obs
  • record bowel movements / passage of flatus
  • repeat WCC
  • mobilise as tolerated
  • educate why patient needs to rest gut - ice chips only or fast until decision regarding surgery has been made
  • if pain settles and not for surgery, diet as tolerated
  • if pain does not settle within 24 hours, consider CT abdomen with contrast (after excluding pregnancy and gynaecologic conditions)
  • discharge when:
    • tolerating diet
    • haemodynamically stable
    • bowel function returning to normal
  • discharge planning:
    • advise patient to see GP within 7 days
    • provide written and verbal discharge instructions to patient
    • check if outpatient appointment is required
    • check if sick certificate is required

non-operative Mx of acute appendicitis

  • currently this is NOT practiced in most Western centres but an Italian study in 2010 suggests it may be practical1):
    • patients with severe illness or complications ⇒ surgery
    • other patients admitted for short term observation and Rx with amoxycillin/clavulanic acid:
      • if worse or no improvement ⇒ surgery
      • otherwise home on antis:
        • within 7 days 12% had failed Rx and required surgery
        • of the remainder over 2 years, 14% had recurrence of appendicitis (none after the initial 15 days?):
          • 2/3rds settled with antibiotics
          • 1/3rd went to surgery
          • did not appear to increase mortality or morbidity

references

  • derived from South Australia's Flinders Medical Centre surgical guidelines 2007 for Mx of appendicitis
appendicitis.txt · Last modified: 2019/01/21 12:43 (external edit)