A Young Man Presents With Complaints of Abdominal Pain

A 21-year-old man presented to an urgent care center with complaints of abdominal pain. He is an otherwise healthy man with no chronic medical diagnoses and is on no chronic medications. He is from England but moving to the United States to attend college, which will be starting shortly.

History

The patient experienced mild abdominal pain over the previous week, which worsened in the last 24 hours. The pain was originally diffuse, but is recently localized to the right lower part of his abdomen. He has had no appetite for the past 2 days. 

Physical Examination

There was a tenderness in the right lower quadrant with moderate rebound phenomenon.

Laboratory Tests

The test results found a normal metabolic panel, but the complete blood count revealed a white blood count of 18,000 cells/µl with 4% band forms.

Which of the following is the most appropriate for the presented patient?

A. He should be admitted for 24 hours of intravenous antibiotics followed by 7 days of oral ciprofloxacin and metronidazole.
B. He can be discharged on a course of ciprofloxacin and metronidazole with a follow-up appointment in 2 days.
C. He should have an ultrasound study to determine appendicitis. If non-diagnostic, acute appendicitis can be excluded.
D. A CT study is the optimal imaging for diagnosis. If confirmatory, he should proceed to the hospital for immediate laparoscopic appendectomy.

(Answer and discussion on next page)

Correct Answer: A CT study is the optimal imaging for diagnosis. If confirmatory, he should proceed to the hospital for immediate laparoscopic appendectomy.

The patient here exemplifies the current diagnostic and management standards for acute appendicitis, which remains the most common diagnosis requiring emergency abdominal surgery in the United States.^1,2 Clinical and imaging techniques that are currently available should enable the clinician to make or exclude the diagnosis with a high degree of accuracy. 

Alvarado Score

The Alvarado clinical scoring system remains a valuable clinical tool in the initial evaluation of a patient presenting with abdominal pain.^3,4 A patient is assigned a point value (out of 10) based on: 

• Migration of pain to the right lower quadrant (RLQ), anorexia, nausea, or emesis (1 point each)

• RLQ tenderness on exam (2 points)

• Rebound pain or elevated temperature (1 point each)

• Leukocytosis (2 points)

• Left shift (1 point)

A point score of ≤4 is very unlikely to have acute appendicitis whereas the closer the total reaches to 10, the more likely acute appendicitis is present.^3,4 In most situations when appendicitis remains likely, an imaging study will be performed to “corroborate” the diagnosis. Both ultrasound and CT imaging are frequently used with a lot of enthusiasm for the less expensive ultrasound. However, firm data indicates that both the sensitivity and specificity of CT with or without oral contrast is superior (>90%) to those of ultrasonography² and is likely the imaging study of choice. 

Our patient has an Alvarado score of 8, which strongly suggests that acute appendicitis is present. The ultrasound is non-diagnostic, but this study does not have the specificity or sensitivity of CT scanning and in the setting of a high Alvarado score, further imaging should be performed at the least; therefore, Answer C is not optimal here.

Laparoscopic Appendectomy

The management for confirmed cases is emergent surgical removal, although an alternative management is being studied. In the United States, laparoscopic appendectomy is now the most commonly used procedure (in 60%-80% of cases), having replaced an open procedure.^2,5,6 Laparoscopic appendectomy has the advantage of shorter hospital stay (of 1-2 days duration) and lesser complication rates (between 1% and 3%).² 

Of interest, several recent studies from Europe—where laparoscopic appendectomy is less common—have explored an “antibiotic first” regimen somewhat similar to the treatment approach for acute diverticulitis. The reasoning is that the course can be easily aborted in many cases, and an appendectomy can be reserved for cases that do not resolve with the initial treatment. These treatment regimen involve admission to the hospital with clinical and laboratory (eg, white blood cell count) monitoring for 24 hours on intravenous antibiotics, followed by 7 days of oral antibiotics (usually ciprofloxacin and metronidazole).⁵ 

Results of these tightly controlled studies showed most patients were able to avoid appendectomy; 10% to 37% of patients assigned to antibiotics first ultimately required appendectomy within 4.2 to 7 months.^2,5,6 However, other factors to consider include the adherence to the antibiotics as outpatients and the fact that the procedure being compared in these non-US studies is an open appendectomy rather than the safer, less complication-prone laparoscopic approach. This antibiotic-first approach is interesting and likely has utility in selected circumstances (eg, shipboard) but needs further study. 

In the United States, the standard of care remains prompt appendectomy with the laparoscopic method preferred; Answers A and B are not the most appropriate at this time. The next step for the patient is Answer D, to proceed with a CT, the best imaging study, and if acute appendicitis is diagnosed, schedule an appendectomy using a laparoscopic approach.

Outcome of the Case

A lower-dose radiation CT with oral contrast of the abdomen revealed fat stranding surrounding his appendix. He proceeded to an uneventful laparoscopic appendectomy, requiring a 2-day hospitalization. He was discharged without incident and was back in the classroom without delay of his matriculation date. n

Take-Home Message

Acute appendicitis remains the most common cause for emergency abdominal surgery. CT scanning, especially lower-dose radiation protocols, is the most sensitive and specific (compared to ultrasound) and cost-effective (compared to MRI) imaging study to confirm the diagnosis. The Alvarado clinical scoring system remains an excellent clinical tool to formulate likelihood of appendicitis. Although schemes for treating cases with an “antibiotics first” strategy are appearing in the literature, the efficacy and safety of immediate laparoscopic appendectomy in most patients remains the current standard of care.

Ronald Rubin, MD, is a professor of medicine at Temple University School of Medicine and chief of clinical hematology in the department of medicine at Temple University Hospital, both in Philadelphia, PA.

References:

1. Petroianu A. Diagnosing of acute appendicitis. Int J Surg. 2012;10(3):115-119.
2. Flum DR. Clinical practice. Acute appendicitis—appendectomy or the “antibiotics first” strategy. N Engl J Med. 2015:372(20):1937-1943.
3. Alvarado A. A practical score for an early diagnosis of acute appendicitis. Ann Emerg Med. 1986;15(5):557-564.
4. Ohle R, O’Reilly F, O’Brien KK, et al. The Alvarado score for predicting acute appendicitis: a systematic review. BMC Med. 2011;9:139.
5. Vons C, Barry C, Maitre S, et al. Amoxicillin plus clavulanic acid versus appendectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, randomized controlled trial. Lancet. 2011;377(9777):1573-1579.
6. McCutcheon BA, Chang DC, Marcus LP, et al. Long-term outcomes of patients with non-surgically managed uncomplicated appendicitis. J Am Coll Surg. 2014;218(5):905-913.