Preoperative Management

Figure 74-1 outlines a management strategy for patients suspected to have appendicitis. Early fluid resuscitation is essential, as patients with any intra-abdominal inflammatory process will more than likely present in a dehydrated state. The mainstay of management planning is the level of clinical suspicion for appendicits, which we have divided into three categories requiring continued management.

Any patient with a 1 or 2-day textbook presentation of appendicitis as outlined above and no other distracting conditions should have an appendectomy. Perioperative care should depend on the presence of peritonitis, with broad spectrum antibiotics and bowel restreserved for these patients. Acute appendicitis with peritonitis, even after treatment, can lead to significant morbidity and possible mortality in an elderly or debilitated patient.

The most difficult decisions arise in the patient with high suspicion for appendicitis but an atypical presentation, lack of classic physical findings, potential for gynecological etiology, or confounding medical conditions.

Common masqueraders to consider include perforated cecal or appendiceal tumors in the elderly, typhlitis in neu-tropenic patients, and pelvic inflammatory disease and mittelschmerz in females. It is for these patients that CT scan or ultrasonography should be considered, and transvaginal pelvic ultrasound can also be helpful in ruling out tubo-ovarian disease. The combination of a worrisome CT scan and this level of clinical suspicion would support surgical management, with other patients followed carefully by serial examinations as below.

Patients with some evidence of a right lower quadrant intra-abdominal process but little to implicate the appendix as a source should be admitted for serial observation and rehydration. There is no role for antibiotics in this scenario unless another source of infection has been documented. Most of these patients will improve in 1 to 2 days and can be discharged with precautions to return if symptoms should recur. Serious consideration should be given to operative intervention in a patient who remains undiagnosed but worsens clinically with conservative management.

Abdominal Pain Suspicious for Appendicitis

Careful History and Physical Examination, Basic Laboratory Tests

Very high likelihood of acute appendicitis

High likelihood

Consider: CT scan (elderly, atypical) Ultrasound (child, female) Laparoscopy (female)

Careful History and Physical Examination, Basic Laboratory Tests

High likelihood

Consider: CT scan (elderly, atypical) Ultrasound (child, female) Laparoscopy (female)

Very high likelihood of acute appendicitis

No abcess: Appendectomy

Abcess: Percutaneous drainage Interval appendectomy or

Antibiotics Interval appendectomy or

Appendectomy

No abcess: Appendectomy

Peritonitis: Perioperative resuscitation Full course of antibiotics Postoperative bowel rest

No peritonitis: Immediate surgery Perioperative antibiotics Early refeeding

FIGURE 74-1. Management strategy for patients with suspected appendicitis. CT = computed tomography.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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