Beginner•5 min read•High Yield

Acute Appendicitis - CCS Case Guide

Key Takeaway: Acute appendicitis is the most common surgical emergency of the abdomen. Classic presentation involves periumbilical pain migrating to the right lower quadrant.

Acute appendicitis is the most common surgical emergency of the abdomen. Classic presentation involves periumbilical pain migrating to the right lower quadrant. Prompt surgical consultation and appendectomy are the standard of care.

Recognizing the Appendicitis Presentation

  • History: Periumbilical pain migrating to RLQ over 12-24 hours, anorexia, nausea, vomiting, low-grade fever
  • Physical Exam: RLQ tenderness at McBurney point, guarding, rebound tenderness, positive Rovsing sign, psoas sign, obturator sign
  • Vital Signs: Low-grade fever (often < 38.5°C initially), tachycardia, higher fever suggests perforation

Immediate Actions (First 5 Minutes)

These orders should be placed immediately — timing is scored:

Critical First Orders

  • ✓ IV access and fluid resuscitation
  • ✓ NPO status
  • ✓ Pain management (IV morphine or ketorolac)
  • ✓ Stat CBC and BMP
  • ✓ CT abdomen and pelvis with IV contrast (if diagnosis uncertain)
  • ✓ Surgical consultation

Complete Workup

After initial stabilization, complete the diagnostic workup:

  • CBC with differential (leukocytosis with left shift)
  • BMP
  • Urinalysis (rule out UTI or kidney stone)
  • Pregnancy test in women of reproductive age
  • CT abdomen and pelvis with IV contrast (sensitivity > 95%)
  • Ultrasound (first-line in children and pregnant patients)
  • CRP (often elevated)
  • Lipase (rule out pancreatitis if needed)

Treatment

Surgical

  • Laparoscopic appendectomy (preferred)
  • Open appendectomy if laparoscopic not feasible
  • Urgent surgery recommended within 24 hours of diagnosis

Perioperative

  • IV antibiotics preoperatively (cefoxitin or cefazolin + metronidazole)
  • IV fluid resuscitation
  • NPO
  • Pain management
  • VTE prophylaxis

Perforated or Complicated

  • Broad-spectrum antibiotics (piperacillin-tazobactam or meropenem)
  • Percutaneous drainage of abscess if present
  • Interval appendectomy 6-8 weeks later if initial drainage performed

Common Pitfalls

Scoring Tip: These are the most commonly missed actions for Appendicitis cases.

  • Missing the diagnosis in elderly patients (atypical presentation)
  • Not obtaining a pregnancy test in women of childbearing age
  • Delaying surgical consultation
  • Withholding pain medication (does not mask peritoneal signs per current evidence)
  • Failing to recognize perforation (higher fever, more diffuse tenderness, tachycardia)

Disposition

  • Admit for surgical management
  • Discharge 1-2 days post-laparoscopic appendectomy if uncomplicated
  • Longer admission for perforated appendicitis with IV antibiotics
  • Surgical follow-up in 1-2 weeks

Key Orders Checklist

  • ☐ CT abdomen and pelvis with contrast
  • ☐ Surgical consult
  • ☐ NPO
  • ☐ IV antibiotics (preoperative)
  • ☐ IV fluids
  • ☐ Pain management
  • ☐ Pregnancy test (women of reproductive age)

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