ACUTE ABDOMEN • SENIOR RESIDENT / SURGEON

Acute Appendicitis

A classic migrating-pain presentation that moves from bedside recognition to imaging interpretation and operative strategy.

PROTOTYPE REVIEW REQUIRED

The Call

20-year-old man with 18 hours of abdominal pain

Pain began near the umbilicus and migrated to the right lower quadrant, with anorexia, nausea, low-grade fever, focal right lower quadrant tenderness and guarding.

T 38.0 C • HR 102 • BP 124/72

Migration of pain plus focal peritoneal irritation should make appendicitis a leading diagnosis while dangerous alternatives remain in the differential.

Read the Image • Clinical DataACS VISUAL

CT appearance of acute appendicitis from the ACS image archive.

Make the Decision • Commit to a Plan

A stable 67-year-old has 36 hours of RLQ pain, WBC 18,000, lactate 2.8, an appendicolith, marked inflammatory change and a 4-cm periappendiceal abscess. What is your best initial strategy?

Acute Appendicitis

20-year-old man with 18 hours of abdominal pain

A stable 67-year-old has 36 hours of RLQ pain, WBC 18,000, lactate 2.8, an appendicolith, marked inflammatory change and a 4-cm periappendiceal abscess. What is your best initial strategy?

At laparoscopy the appendix is gangrenous and perforated. A 4-cm abscess is adherent to the cecum and the appendiceal base is friable and unsafe for a routine staple line. What is the best operative principle?

Postoperative day 5 the patient has fever, ileus and rising leukocytosis after perforated appendicitis. Hemodynamics are stable. What is your next move?

Confirm the diagnosis and define the disease burden.

Postoperative care follows disease severity.

Surgical Pearls

Pitfalls

At laparoscopy the appendix is gangrenous with a small perforation and localized purulence. Which feature most changes the postoperative plan compared with uncomplicated appendicitis?