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Old 07-10-2010
Ayshee's Avatar
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Unhappy Treatment of appendicitis?

Am confused about this. Some questions say do ultrasound, some questions say do CT scan, some questions say conservative management with IV fluids and antibiotics and stuff, still other questions say immediate surgery!

Would you please explain for me what is the best management of acute appendicitis
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Old 07-11-2010
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After all these centuries that have passed and appendicitis has been one of the most frequent issues of surgical practice, there has not been established a single objective test that confirms or rejects the diagnosis. There are indices of appendiceal inflammation, both imaging --i.e. ultrasonographic evidence of mural thickening of the appendix-- and laboratory --i.e. elevated WBC count-- ones, but none of them is diagnostic; they only come to support clinical suspicion. The definitive diagnosis has always been intra-operational, and this will be the case for the years to come, unless we find a method to directly visualize the appendix through the skin .

The general principle in surgery is that it is much more preferable to "tamper" the abdominal cavity under calm & controlled conditions, rather than "invading" it in the acute phase of any inflammatory process. This is applicable with appendicitis, too. Initial efforts should be directed at "calming down" the abdomen, which is achieved by means of NPO, parenteral fluids and close observation for the development of signs of peritonitis or deterioration of the clinical presentation of the patient in any way. Once the acute phase has eventually gone by, then it is much more preferable to operate under "cold" conditions.
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Old 07-11-2010
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Info Appendicitis USMLE Guidelines

Now that ath.pantelis has given you a "real life" perspective let me give you a "USMLE" guideline for answering appendicitis questions.

Here's the deal;

If the case is an outright obvious clinical acute appendicitis like few hours or maximum few days pain that started centrally and moved to the right lower quadrant with tenderness and rebound and Rovsing's and Psoas signs positive with nausea and vomiting and mild fever and leukocytosis and normal urinalysis then you go for urgent surgery.

If you have any doubt about the diagnosis like with atypical presentation and absence of some of the signs of symptoms mentioned above then it's preferable to confirm the diagnosis before opening the patient's abdomen. Such confirmation can be either an ultrasound or CT scan. Ultrasound is specifically helpful in young females where you might want to exclude ovarian torsion or ectopic pregnancy and in cases where UTI is of high suspicion.

If the case is subacute like it has been there for several days or the patient has been having intermittent symptoms for quite a while or an abscess has already developed with a palpable mass in the right lower quadrant then generally the treatment is conservative with bowel rest, IV fluids, and antibiotics. The ultimate aim is to remove the appendix later electively.
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Old 07-11-2010
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It's true, Dr. lee-usmle, that since the beginning of my Surgery internship, I am urged to see things in a much different way than I used to for the purposes of USMLE.

Thank you for landing me back to USMLE-Earth! I will soon need it for Step 3, although shifting back & forth between USMLE & actual Medicine has started becoming a little bit annoying...!

Thank you for the well-established, evidence-based, to-the-point explanation, anyway!
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