Appendicitis

• Infectious
  • Gastroenteritis
  • Streptococcal pharyngitis (children)
• Endocrine
  • Diabetic Ketoacidosis  
• Gastrointestinal
  
  • Appendicitis
  • Diverticulitis
  • Intestinal obstruction
  • Biliary disease
  • Volvulus
  • Meckel diverticulum
  • Epiploic appendicitis
• OBGYN
  • PID
  • Ectopic pregnancy
  • Ovarian cyst/torsion
  • Tubo-ovarian abscess
  • Endometriosis
• Vascular
  • Abdominal aortic aneurysm
  • Henoch–Schonlein purpura
• Urine
  • UTI
  • Pyelonephritis
  • Renal stone
• Men
  • Testicular torsion
• Immunology 
  • Mesenteric adenitis
  • Crohn’s disease

• Abdomen: tender to palpation greatest in right lower quadrant, with voluntary guarding, slight rigidity, and no rebound, bowel sounds present, no pulsatile masses, no masses, no hernia, negative Murphy’s sign, + tenderness at McBurney’s point, (+) Rovsing sign, negative Psoas sign, Obturator signs
• Rectal: no rectal mass, no gross blood, hemoccult negative brown stool
• Pelvic: external vaginal normal, no blood or lesions in vaginal vault, no cervical motion tenderness

• Two large-bore peripheral IV lines
• 1 L NS bolus
• Monitor
• Nothing by mouth (NPO)

• Basic Labs
  • CBC
  • BMP
  • LFT
  • Lipase
• Urine
  • Urinalysis
  • Urine Pregnancy

• CT Abdomen and Pelvis with IV Contrast
• An ultrasound or MRI can be done if pregnancy is considered and urine pregnancy test results are delayed.

General Surgery

• Analgesics
  • Fentanyl 1 to 2 μg/kg IV every 1 to 4 hours or morphine 0.1 mg/kg.
  • Administration of analgesics, including narcotics, does not adversely affect abdominal exam or mask pathology
• IV Fluids – resuscitation with LR or 0.9% NS
• Surgery Consult – Immediate surgical consult for convincing history and physical exam
• Antibiotics to cover anaerobes, enterococci, and gram-negative intestinal flora
  • Single-Agent Regimen
    • Piperacillin/tazobactam 3.375 g IV  
    • Ertapenem: 1 g IM/IV q24h 
  • Combination regimen with metronidazole 
    
    • ONE of the following:
      • Cefoxitin: 2 g IV q6h
      • Ceftriaxone: 1 g IV q24h
      • Ciprofloxacin: 400 mg (peds: 20–40 mg/kg) IV q12h
    • PLUS
      • Metronidazole: 500 mg (peds: 30–50 mg/kg/24 h)

▢  Urine pregnancy test

▢  UA

▢  Pelvic examination in woman of child-bearing age

▢  Pain management

▢  Antibiotics preoperatively

▢  Serial abdominal examination

▢  CT abdomen/pelvis with enteric contrast

▢  Surgery consult