 Hello and welcome to emergency medicine video. In this section, we will talk about appendicitis. Appendicitis is common. It affects about 1 in 1,000 people per year. If you're working in the emergency department even for a short while, chances are you will see a case or two. We want to learn to diagnose it because delayed diagnosis can lead to perforation. And that can lead to increased mortality. But sometimes the signs and symptoms the patients have are not classic and therefore it is tricky to diagnose them. In this video, we'll discuss the classic signs and symptoms of appendicitis. We'll also discuss how sometimes they're not classic. We will also talk about how we diagnose and manage it in the emergency department. What is appendicitis? Let's first look at the cecum and the appendix. Here is the cecum and this is the appendix. Appendicitis occurs when the appendix lumen is blocked, either by food particle, lymphoid tissue, etc. Due to the blocked lumen, the pressure inside increases and blocks vascular drainage. The epithelium then breaks down and allows for bacterial invasion. That leads to inflammation and edema. As this progresses, the tissue infarcts. The perforation then spills the infected material into the peritoneum. Let's first talk about the classic symptoms of appendicitis. The classic pain for appendicitis is a two-step process. The first step often starts with a parambylical or epigastric pain. This happens as the appendix lumen is distended. That triggers visceral pain fibers. The pain is often vague and patient can't describe this as dullness and ache or indigestion. Over the course of the next 4 to 48 hours, the pain can change. It classically migrates to the right lower quadrant. This happens as the inflammation triggers the somatic pain fibers. The pain is less vague and more localized in the right lower quadrant. Other associated symptoms can include fever, nausea vomiting, typically after the pain started, and a loss of appetite. These are the classic symptoms in patients with appendicitis. Unfortunately, these classic symptoms only happen in about 50 to 60% of patients with appendicitis. Why is that? First, the pain may not be where we expect it to be because of changes in anatomy in patients. If the patient's appendix is behind the cecum or retrocecal like here, then the appendicitis will give pain not in the right lower quadrant. It might go up to the right flank instead. Or it could be retroilio. So behind the ilium. If that's the case, then it might irritate the ureter coming down. And that might cause pain in the testicle, in the suprapubic area, or even dysuria. If the appendix is really low down in the pelvis, that can lead to pain not in the right lower quadrant, but in the midline, or even in the left lower quadrant. Sometimes patients can even complain of pain in the rectum. In terms of the associated symptoms, not all patients will have the fever, vomiting, or the anorexia. So what can we use as the most helpful symptoms? Of all the symptoms we talked about, the most helpful, i.e. the one with the highest likelihood ratio, is right lower quadrant pain. The second most helpful is the fact that the pain migrates from paratombolyco area to the right lower quadrant. The third most useful symptom is pain before vomiting. Those are the most useful symptoms. But again, because of the anatomical variation, not all the patients will have pain in where we expect them to be. What about physical examinations? What signs can help us? The classic sign of the patient with appendicitis is someone who is lying still, who does not want to move. They may also have a low grade fever. On examination of the abdomen, there is often tenderness in the right lower quadrant. Specifically, there will be pain in the McBurney's area. The McBurney's area or the McBurney's point can be found by drawing a line from the embolicus to the enteral superior iliac spine. Once you draw a line, the area is about either two-third from the embolicus or about a half from the embolicus, if you bisect this line. This area is known as McBurney's point. When we've helped aid the abdomen, there should be involuntary guarding. That is, the muscle becomes rigid. There should also be rebound as well. Rebound tenderness is when the patient tells you that their pain is worse when you let go of your hand, then deep palpation. There are also other signs that might help us as well. The first one is Rhafsik sign. That is when you palpate the left lower quadrant. Patient has pain in the right lower quadrant. So a sign is pain with either passive extension or active flexion of right hip against some sort of resistance. So it could be your hand pushing against the right hip flexing. That can signify a retrocecal appendicitis. An obturator sign is pain with passive internal rotation of the right hip. That can signify a pelvic appendicitis. But as you can imagine, these signs may not be very helpful. One, they're not in all patients. It all depends on a lot of their own anatomy. Second, if the course of the appendicitis is quite early, they're just not there yet. Out of those, the most helpful on physical examination is involuntary guarding. So you can do the physical examination in patients, but even if the tests are negative, we still cannot rule out appendicitis. Remember, this is a common disease, and if we miss it with a delay diagnosis, it can really increase mortality. We also have a few trickier populations that makes it even harder to diagnose appendicitis. The first group are children and young infants. They tend to not understand and sometimes not able to tell us what it is that's bothering them. Not only do they not have the typical signs and symptoms, they have other symptoms such as diarrhea or a limp that can lead us astray into other diagnosis. The second group are the elderly. They often have more subtle signs and symptoms. They can often present late in the disease course. The elderly also tend to be on medication that can make their vital signs normal looking, even if they're not well. So let's say they're on a beta blocker. Even though they might be having appendicitis and their heart rate might be high, the beta blocker will make it look normal. The next group are the pregnant patient. In the pregnant patient, the uterus might be moving the appendix to an area that's no longer where it usually is, making the pain more atypical. The last group are the patients that we always worry about infection. They're the patient who are on medications that immunosuppress them. Either they're steroids or other drugs that suppress the immune system. Those patients may not mount the same typical response they would have if they have appendicitis. Those are the tricky population that we would want to spend a lot more time and probably more imaging on. Let's talk about diagnostic testing. First, we'll talk about blood work. Blood work can sometimes help us. Most patients with appendicitis will have a high white blood cell count. However, as we talked about before, not everybody will have it especially elderly and patients who are immunosuppressed, probably not. Also, a high white blood cell count can be due to other infections as well. And therefore, it's not sensitive or specific enough to be the only test that rules in or out appendicitis. We often do one, but you shouldn't rest on that. What other lab tests should we order? We should order a beta-xcg to check pregnancy status. A urine dip to rule out UTI. Although, you might remember a few slides back that sometimes the retro-elio appendicitis can irritate the ureter to make you think that the patient's having UTI. And in those cases, you might even see a few white blood cells in the urine. Other tests we might see done also include things like a CBC, electrolytes, and the ability to measure renal function. Let's move on to imaging. There's no role for x-ray unless there's a suspicion for bowel obstruction or a foreign body. Really, for appendicitis, the imaging choice boils down to between ultrasound and CT. How do these tests compare and how do we choose? Ultrasound will give us the answer whether there is appendicitis or not in about 80% of the patients. The radiologist will be looking for an appendix that's more swollen, the tip is non-compressable, remember it's obstructed, the wall which is thickened, or there is inflammation surrounding the appendix. Sometimes, tenderness on scanning that area can also help them decide. Ultrasound has a big advantage of no ionizing radiation, making it a perfect choice for pregnant patient and younger patients. The problem with ultrasound is that it's very dependent upon the body habitus of the patient. The ultrasound waves have to get to the appendix. If the patient's body habitus is obese, then the ultrasound waves have difficulty penetrating through adipose tissue. The higher the BMI, the more likely that the appendix is not well seen by ultrasound. Therefore, ultrasound would be the first choice for patients who are pregnant and younger patients with a normal BMI. CT is more sensitive than ultrasound in diagnosing appendicitis. The sensitivity is about 95%. The big advantage of CT is that in addition to diagnosing appendicitis it can also diagnose other intra-abdominal conditions at the same time as well. The problem for CT is that of course it has radiation and it often needs intravenous contrast and therefore allergy and renal impairment can be a relative contraindication for CT scan. It has to be discussed on a case-by-case basis. How do we put this together for the diagnosis of appendicitis? If you have a patient who has classic symptoms with paraumblycopane to the right lower quadrant and when you examine them they have true involuntary guarding. Once other causes have been ruled out, in some centers a surgeon might be involved at this point and they can decide whether they want imaging or not. These patients are relatively easy to diagnose. What about the patient who has a few atypical symptoms? We often will need imaging to help us. If the patient is young or pregnant we will start with an ultrasound. If the ultrasound is not conclusive and we're still worried about appendicitis CT will be a next step in non-pregnant patient. In some centers they would choose to MRI patients who are pregnant. That should be done in conjunction with consulting radiology and general surgery. For all others particular people with a higher BMI CT might be the first choice of imaging. How do we treat it? Once a diagnosis is made we give IV antibiotics that cover gram positive gram negative and n-ropes. A surgeon also needs to be involved. In most cases the patient will have surgery. In some cases the surgeon might offer antibiotics only as an option will be surgeon and center specific and so you would definitely want to discuss it with your consultants. In summary we discuss the diagnosis and management of appendicitis. Keep in mind that even though typical symptoms are easy to spot many patients have atypical signs and symptoms and can be very tricky. Remember the specific population the elderly, the young the pregnant patient and the immunocompromised patient. We rely on one clinical test or lab value to rule out the diagnosis. To confirm we'll either need ultrasound or CT scan. We hope you enjoy it. Thank you for watching.