Episode 43 – Appendicitis Controversies

Emergency Medicine Cases

Dr. Anton Helman

Education, Health & Fitness, Courses, Medicine, Science

4.7 • 602 Ratings

🗓️ 22 April 2014

⏱️ 72 minutes

🔗️ Recording | iTunes | RSS

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Summary

In this episode on Appendicitis Controversies, we have the continuation of our discussion on abdominal pain emergencies with Dr. Brian Steinhart & Dr. David Dushenski. We kick off the discussion with key clinical pearls and pitfalls in the history and physical exam with their respective liklihood ratios when assessing patients with abdominal pain for appendicitis - a diagnosis that is still sometimes missed despite its prevalence. Dr. Dushenski hacks apart the Alvarado and Appendicitis Inflammatory Response Scores and we discuss the value of WBC, CRP and urinalysis in the work-up of appendicitis. Next up are the controversies of imaging algorithms using ultrasound and CT abdomen, as well as the factors affecting which imaging algorithm you might pursue. We wrap up the discussion on Appendicitis Controversies with a critical look at the value of antibiotics in the ED for appendicitis and which patients might be appropriate for non-surgical management.

Transcript

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0:00.0	On to a new case. A 32-year-old otherwise healthy woman presents to your ED with a 16-hour history of vague,
0:08.5	gradual onset, non-radiating, 5 out of 10, periombilical abdominal pain, decreased appetite, and nausea.
0:17.7	She denies fever, vomiting, diarrhea, chest pain, vaginal bleeding, vaginal discharge, dysperunia, or urinary symptoms.
0:26.6	The last menstrual period was one week ago and regular.
0:29.9	On exam, she appears well.
0:32.2	She has slight lower abdominal tenderness with no peritoneal signs.
0:36.7	Her pelvic exam reveals no vaginal discharge,
0:39.6	no adenaxal tenderness or palpable mass, but she does have some cervical motion tenderness.
0:45.4	A rectal exam was not done. Her vital signs are normal, including a temp of 37.2. Her beta
0:52.1	HCG and urinalysis come back with 1 plus RBCs and 1 plus white blood cells.
0:58.0	The serum white blood cell count is 12, with the rest of the routine blood work being normal.
1:04.3	An ultrasound of the abdomen and pelvis is ordered to rule out appendicitis.
1:10.0	Dr. Steinhart, a typical case of appendicitis occurs in a teenager or a young adult who
1:16.2	presents with abdominal pain initially in the mid-epigastric area, migrates down to the right
1:21.5	lower quadrant, progressively worsens over 12 to 24 hours.
1:26.5	In one study, only 6% of appendicitis cases actually presented like this.
1:32.4	So appendicitis typically presents atypically. Can you explain to our listeners, why does
1:38.9	appendicitis so often present atypically? So I think you have to look at both extremes of the spectrum.
1:48.3	Typical cases were harking back to Sir William Osler's days, and you have to look
1:55.2	at their studies where they skewed their population.
1:58.5	They looked at appendicitis cases for which they were operated on
2:02.6	because of migratory lower abdominal pain and they never studied those that present atypically.
	...

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