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Acute Abdominal Pain

Nonsurgical causes of acute abdominal pain simulating an acute abdomen


account for up to 30% of patients requiring hospital admission.
_ Multidetector-row computed tomography (MDCT) is the benchmark imaging
modality in the evaluation of acute abdominal pain except in patients with right upper
quadrant (RUQ) pain and abnormal liver function tests (LFTs) or in women who are
or, may be, pregnant
_ Ultrasound is the initial imaging study of choice in patients with RUQ pain,
abnormal LFTs, and suspicion of biliary tract disease.
_ Ultrasound is the preferred initial imaging study for young women and those who
are pregnant.
_ Always perform imaging studies preoperatively in patients with a clinical diagnosis
of acute appendicitis.
_ Irritable bowel syndrome, functional abdominal pain syndrome, and anxiety
disorder may confound accurate diagnosis and are associated with an increased rate
of negative appendectomy.
_ Narcotic pain medication, if indicated, should not be withheld from a patient with
abdominal pain; it will not reduce the recognition of key physical findings and may
improve diagnostic accuracy by relaxing the patient.

Acute appendicitis

It is very common, with a lifetime risk of 7–8% that favours males slightly.
Appendectomy is the most commonly performed emergency operation in the world.
The reported incidence has dropped by more than 50% in the past three decades for
unknown reasons. Over 250,000 patients per year are admitted for the management
of appendicitis, with the highest incidence in the second and third decades of life.
The rate of appendiceal perforation may be up to 80%. Mortality has dropped to less
than 1% with more timely and accurate diagnosis in highrisk groups and
advancements in imaging techniques.

The pathogenesis of acute appendicitis is bacterial proliferation secondary to


luminal obstruction due to one of multiple disorders, including cytomegalovirus or
adenovirus enteritis, Crohn disease, stone, foreign body, or tumor. The presentation
of appendicitis depends on the patient’s age, appendiceal length, body habitus, and
trimester of pregnancy.
The “classic” presentation (acute periumbilical pain migrating to McBurney
point, followed by nausea and vomiting) occurs in only 30–60% of patients. The
perforation rate may reach 50–70% and is directly proportional to a delay in
diagnosis of more than 24 hours. The elderly experience a mortality rate from
appendicitis that is eightfold greater than that of the general population and accounts
for 50% of all deaths from this disorder. Increased body mass index and smoking
have also recently been implicated as risk factors for a complicated course.
Diagnosis is particularly challenging in the young and the elderly, as well as during
pregnancy.
Symptoms and Signs
The history and abdominal examination may vary depending on the location
of the appendix. Diagnosis is delayed, and thus perforation occurs more commonly,
in very young (< 3 years), pregnant, and elderly (> 64 years old) patients, the latter
presenting atypically over 70% of the time.
Socioeconomic status, but not race, may also influence perforation rate. The
atypical location of the appendix in the third trimester of pregnancy represents a
particular diagnostic challenge (see Figure 7–3). Fever may be low grade.
Laboratory Findings
Routine laboratory studies have limited value in the diagnosis of acute
appendicitis. Leukocytosis may be modest or absent. Chemistry studies and
urinalysis are usually normal. A pregnancy test must always be ordered in a woman
of childbearing age.
Imaging Studies
1. Issues and controversies––The pathophysiology and imaging
abnormalities of acute appendicitis are due to luminal obstruction, regardless of
etiology. The advantage of preoperative imaging compared with clinical assessment
alone continues to be challenged by some studies. Several centers have reported
increased time to the operating room, operating time, length of stay, and cost without
a reduction in negative appendectomy rate in patients whose surgery is postponed
for the performance of CT (or ultrasound). On the other hand, even in patients with a
high clinical probability of appendicitis, almost one third of those imaged will be found
to have another diagnosis or a normal scan. The preceding discrepancies are
largely due to variability in institutional experience and recommend that cross-
sectional imaging (CT, MRI, or ultrasound) be performed in all patients suspected of
having acute appendicitis, even those patients with high-probability clinical
presentations.
CT scan with an appendicitis protocol is appropriate in the majority of patients. The
advantage of rectal contrast remains a matter of continued discussion.
2. Ultrasound––Ultrasound has a sensitivity and negative predictive value of
nearly 98% and 100%, respectively, with a specificity of 70–100%. Results are highly
operator dependent. Findings suggestive of acute appendicitis include a thickened,
blind-ended lumen (as opposed to an open-ended salpinx or gonadal vein) with a
diameter greater than 6 mm that is noncompressible and fluid-filled, and the
presence of an appendicolith. There may be tenderness on compression. Ultrasound
should be used as the sole imaging modality only for patients with a high probability
of the disorder. False-positive findings occur commonly (33% of the time) in patients
with inflammatory bowel disease, cecal diverticulitis, and pelvic inflammatory
disease. The value of ultrasound is limited in morbidly obese patients, in the
presence of perforation or a retrocecal position, and when there is inability to
compress the right lower quadrant (RLQ). Ultrasound should be considered as the
study of choice in groups most vulnerable to ionizing radiation, especially children
and women of childbearing age. The additional information gained about the female
pelvic anatomy can also be clinically valuable.
3. CT scan––A contrast-enhanced helical CT scan performed for acute
appendicitis is 96–98% sensitive and 83–89% specific, particularly with the
demonstration of an appendicolith. MDCT may improve specificity even more.
Positive findings include a diameter greater than 6 mm, thickened wall with
enhancement, periappendiceal fat stranding, and appendicolith. An air-filled
appendix on CT essentially excludes acute appendicitis. Focal thickening of the
terminal ileum or cecum may be confused with Crohn disease and appendiceal
dilation may be falsely attributed to an infected right fallopian tube. An ovoid fat-
attenuation focus with hyperattenuating rim near the colonic serosa distinguishes
epiploic appendagitis. Infectious enteritis should be easily differentiated by the
diffuse nature of bowel thickening and enhancement in the presence of a normal
appendix. Less common mimics include mucocele of the appendix, ovarian
disorders, and endometriosis. Advantages of CT over ultrasound are its ability to
visualize the entire abdomen, demonstrating an alternative diagnosis in 15% of
cases. An additional 15% of patients will be found to be normal.
A high clinical index of suspicion for acute appendicitis mandates the use of a
dedicated appendicitis protocol with intravenous and rectal contrast alone, reducing
the time of study to only 15 minutes by eliminating the administration of oral contrast.
CT scan during pregnancy must be used with great discretion; ultrasound or MRI is
recommended. The lack of a reduction in the published rate of negative
appendectomy since the introduction of CT most likely reflects inconsistent
performance standards.
Differential Diagnosis
The differential diagnosis of acute appendicitis is broad, reflecting classic and
atypical presentations of the disorder. It includes mesenteric lymphadenitis, bacterial
enteritis, acute diverticulitis, ureteral calculus, Crohn disease, cholecystitis,
appendagitis epiploica, Meckel diverticulitis, and several gynecologic disorders
including acute salpingitis (pelvic inflammatory disease), ruptured ovarian follicle
(mittelschmerz), and ruptured ectopic pregnancy.
Treatment
A. Overview
Surgery has been recognized since 1886 as the definitive treatment for
appendicitis.Active debate continues regarding the proper timing and choice of
technique (ie, open appendectomy vs laparoscopic appendectomy), and what
variables influence these decisions. The incidence of negative appendectomy
remains as high as 20% in some patient groups, especially young women and
patients with preexisting irritable bowel syndrome. Women aged 15–45 years have a
20% negative appendectomy rate, two to five times that of the general population,
attributed to the multiple other causes for acute pelvic pain and the atypical location
of the appendix in late pregnancy.
B. Antibiotics
A third-generation intravenous cephalosporin may be initiated preoperatively
in patients who are mildly ill. Sicker patients with signs of perforation and sepsis
require broader coverage for anaerobes, including bacteroides. Continuation of
antibiotics postoperatively will depend on the surgical findings and the patient’s
clinical response. Antibiotic therapy as the sole treatment for acute appendicitis must
be
undertaken with great circumspection and extreme caution based on the current
literature.
C. Interventional Radiology
Appendiceal rupture or abscess is found in 25% of patients at presentation.
When an abscess is found on imaging, CTguided drainage and dedicated parenteral
antibiotic therapy should be considered the preferred alternative to immediate
appendectomy. Interval appendectomy after resolution of the collection should then
be performed at a later date. The final decision must be made by the surgeon after
consultation with the gastroenterologist and radiologist.
D. Surgery
Surgery remains the treatment of choice for acute appendicitis. The timing
and type of surgical approach for acute appendicitis is now the most debated aspect
of management, with a balance sought between the desire for accurate diagnosis
and stabilization of the patient versus prevention of perforation. Prevention of
perforation remains a major goal, and the rate of perforation has become a quality-
of-care indicator in some institutions. The identification of predictors more reliable
than patient age and gender has been a challenge. A brief voluntary delay to perform
diagnostic studies, begin antibiotics, or accommodate staffing needs has not been
proven to increase the risk of complications, including perforation. A patient with a
late or atypical presentation may actually benefit from a period of observation with
the administration of antibiotics, while the gastroenterologist obtains additional
history and reviews the imaging studies and the response to therapy with the
surgeon, or gynecologist/obstetrician. Primary therapy of acute appendicitis with
antibiotics has been utilized when surgical intervention is not readily available or if
antibiotics are deemed necessary by a surgeon prior to operation. Laparoscopic
appendectomy has gained increasing support as the operation of choice. Patients
have fewer wound infections, less pain, and shorter hospital stays compared with
those undergoing open cholecystectomy. The surgeon must first consider the degree
of diagnostic certainty, imaging evidence for complicating disease, stage of
appendicitis, and experience with the technique. Recent retrospective data suggest
that race and insurance status may affect the decision. Debate continues over which
procedure is medically appropriate, but in women, particularly during pregnancy,
there appears to be a clear advantage to laparoscopic appendectomy associated
with the ability to identify other gynecologic pathology and reduce the rate of
negative appendectomy. Negative appendectomy rate, in women inversely
proportional to fetal health, is becoming another benchmark for determining the
proper procedure in any given institution. In men, the benefit of laparoscopic
appendectomy is less well established. As noted earlier, the surgical experience in
an institution must always be considered before a final choice of laparoscopic versus
open cholecystectomy is made.
The resected appendix may reveal unexpected and clinically useful data in
2% of cases and therefore should always be submitted for histologic analysis. It is
recommended, therefore, that surgeons continue to submit the resected
appendix for histologic analysis.

UNIQUE PRESENTATIONS OF APPENDICITIS


1. Appendicitis in Pregnancy
Appendicitis occurs in approximately 1 in 800–1500 pregnancies and
appendectomy is the most common nonobstetric operation performed during
pregnancy. The presence of the fetus and altered appendiceal location provide a
major clinical challenge. Preoperative diagnosis is inaccurate 25–50% of the
time.Maternal death is now virtually zero but fetal loss is 2–3% without and 20% with
appendiceal perforation. Appendiceal rupture is reported in 12–55% of pregnant
women.
The proper choice of imaging in women with appendicitis has been discussed
earlier. The risk of fetal harm from exposure to ionizing radiation of CT must be
compared with the relatively reduced accuracy of ultrasound, especially in the third
trimester. The imaging expertise in one’s own institution, particularly in view of the
increasing role of MRI, remains very important and should factor into the clinician’s
final choice of study. Negative appendectomy is higher in pregnant (23%) than
nonpregnant (18%) women and carries a 2.69 increased odds ratio for fetal loss. The
goal of eliminating negative appendectomy during pregnancy with improvement in
preoperative assessment must be balanced with the delay in surgical therapy and
expected increase in complicated appendicitis and perforation. Laparoscopic
appendectomy for the experienced surgeon appears safe and effective.
2. Atypical Appendicitis
Retrocecal (ileal) appendicitis presents with less pain and rigidity due to
shielding from the abdominal wall. Localization of discomfort may be ill defined as
well due to the lack of appendix contact with the peritoneum, and it is less common
in the RLQ Pelvic appendicitis is characterized by severe, constant pain usually in
the LLQ, with fecal and urinary urgency. Abdominal tenderness is variable but
severe tenderness on pelvic and rectal examination may be present. Atypical
appendicitis is more common in the elderly but is considered less frequently as a
cause for acute abdominal pain. Pain is vague and is present in the RLQ in only 20%
of patients. There may be no fever. The abdominal examination may yield only a
nontender mass. The white blood cell count can be lower than expected. Proper
management relies on a high index of suspicion, careful patient assessment, and CT
findings.
3. Late (“Delayed”) Appendicitis
Late appendicitis is defined as presentation following more than 72 hours of
symptoms. It occurs most often in the young, the elderly, and in women of
childbearing age since accurate diagnosis is most difficult in these groups. A
phlegmon may be palpable in the RLQ or be seen on CT, usually with an abscess
component. Accurate diagnosis is difficult due to the surrounding inflammatory
response. Crohn disease, infection, and neoplasm are part of the differential
diagnosis. Malignancy (carcinoid, colonic adenocarcinoma, lymphoma, and ovarian
cancer) may be present in 1% of cases. Studies of late appendicitis are
retrospective, occurring before advanced CT imaging was widely available. Thirty %
of patients required a drainage procedure as their initial surgery and appendectomy
was usually postponed until abdominal sepsis could be controlled. Patients should
be kept NPO (nothing by mouth) with intravenous fluids and antibiotics. A nontoxic
patient (without tachycardia, abdominal rigidity or oliguria) should avoid immediate
surgical intervention, if possible, to improve diagnostic accuracy and prevent
recurrent episodes.
The indications for percutaneous drainage of an abscess depend on the
collection, size, consistency and accessibility as well as the patient’s stability.
Percutaneous drainage as the sole treatment for delayed appendicitis is not
recommended because the recurrence rate for abscess without appendectomy is 5–
20%. Colonoscopy has a role in the preoperative and postoperative management of
patients who are stable and have both clinical and radiographic features of
ileocolonic Crohn disease. Note that the appendix can be involved in ileocolonic
Crohn disease and obfuscate the diagnosis in patients with acute RLQ abdominal
pain. No clinical criteria have been developed to predict the clinical outcome of
delayed appendectomy or the ideal timing of appendectomy. Curative surgery,
ideally by laparoscopy, is usually performed within 2–3 months.
4. Chronic (“Recurrent,” “Subacute”) Appendicitis
Five to ten percent of patients with a surgical diagnosis of acute appendicitis
may have had a previous attack, and 1.5% will have had symptoms for more than 3
weeks. Such observations have led to the description of a subset of patients with so-
called chronic appendicitis. The literature is entirely retrospective and no clinical
distinction has been drawn between patients found to have a normal appendix at
appendectomy and those with an inflamed appendix. Fibrosis with luminal
obliteration has been described but not fistula or abscess. The role of appendectomy
for such patients is controversial as they appear to represent a distinct clinical group
without the poor prognosis associated with “late” or “delayed” appendicitis.
5. Epiploic Appendagitis
Epiploic appendagitis is very uncommon. In 70% of patients, illness is
triggered by torsion with ischemia and pain in one or more of the approximately 100
epiploic (or omental) appendages that arise from the serosal surface of the colon.
These appendages are oriented in two rows and are composed of adipose tissue
and a vascular stalk, 0.5–5 cm in length. Less common manifestations are
incarceration (20%) and obstruction (10%). The condition occurs more often in men,
primarily in the fourth to fifth decades, and mimics acute appendicitis, diverticulitis,
mesenteritis, and omental infraction with the acute onset of RLQ or LLQ pain often
after eating or exercises in a previously healthy person. Risk factors are obesity,
hernia, and physical inactivity. Fever and obstructive symptoms are uncommon. The
white blood cell count is normal. Preoperative diagnosis is uncommon even with the
availability of sensitive ultrasound and CT technology. CT findings, when present,
consist of 2–4 cm oval fat-density lesions with surrounding inflammation and central
attenuation. Unlike diverticulitis, colon wall thickness and diameter are normal. It is
important to make the diagnosis so as to avoid unnecessary surgery. The prognosis
is considered benign, but one study reported a 40% recurrence rate. Surgery, when
performed for recurrent symptoms, involves resection of the inflamed appendages.