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
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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
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
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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
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NB: patients with hypersensitivity (HS):
post-op care:
ongoing antibiotics post-op:
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:
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 practical
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references
appendicitis.txt · Last modified: 2019/01/21 12:43 (external edit)