This is a very common question in both the certifying and recertifying exam that can go in many different directions and different findings at laparotomy asking you what to do.

Usually, this question is presented as a young patient (male or female) with RLQ pain, some fever and leukocytosis, some cervical motion tenderness in females, etc. Everything is borderline - like usual!

Many times, it was mentioned in the context of this question that the patient is homosexual or HIV positive to see if you would handle the case differently.

After appropriate history and physical exam, your blood and urine tests should include pregnancy test in women of childbearing age, then plain abdominal x-ray (fecalith, mass, localized ileus...) then ultrasound to the pelvis and appendix can be very helpful. CT scan with p.o. and IV contrast in borderline cases is also indicated.

Whenever you have peritonitis signs you have to operate. Observation for 6-12 hours is probably acceptable only if you are not sure of the peritonitis signs on physical exam and overall picture. The HIV status of the patient does not change this logic, although HIV positive patients have probably higher incidence of negative laparotomy for acute appendicitis and higher incidence of CMV enteritis, T.B. enteritis, lymphoma and localized colitis.

Once you decide to operate(especially borderline cases), an initial diagnostic laparoscopy is a safe option. What can you find besides acute appendicitis?

Terminal ileitis ( Yersinia, Typhlitis, CMV, T.B., Crohn's disease, mesenteric lymphadenitis...).
Meckel's diverticulitis.
Lymphoma (small intestine).
Colitis (ischemic, bacterial, Neutropenic, CMV colitis, diverticulitis in a redundant sigmoid...).
Tubo-ovarian pathology most of it should have been diagnosed by ultrasound or CT scan such as ectopic pregnancy, PID, tubo-ovarian abscess, ruptured ovarian cyst or twisted ovarian cyst.
Cecal CA (perforated or associated with appendicitis).
Carcinoid tumor in the appendix.
Mucocele (ruptured or intact).
Other remote sources (mainly: acute cholecystitis, acute diverticulitis, perforated peptic ulcer, Ureteral colic and pyelonephritis).

1-You should be prepared with a plan of action for each of these findings.

2- Some of the above mentioned Ileitis and lymphoma diagnosis are especially relevant to HIV positive patients and the treatment is mostly medical unless there is a perforation or obstruction.

3- If you find terminal ileitis or Crohn's in terminal ileum, do appendectomy if the base of the appendix is healthy and not involved.

4- In Meckel's diverticulitis limited segmental bowel resection with primary anastomosis is recommended, especially in "wide-mouth" diverticulum. Incidental diverticulectomy of a non-pathologic diverticulum is generally not recommended in adults. It has some justification in children.

5- You should know how to handle tubo-ovarian pathologies (your dilemma will be in the oral exam is to decide whether to open the patient or continue the procedure laparoscopically, my inclination would be to do the appendectomy and come out unless the patient has another life threatening pathology which needs to be addressed, in this case ,if you are familiar with laparoscopic management of that condition ,fine, do it laparoscopically. If not, you have to open the patient.):

a. Ectopic pregnancy
Unruptured => salpingotomy + evacuate the content + hemostasis and repair.
Ruptured => unilateral salpingectomy (keep the ovary in either case).

b. Pelvic inflammatory disease with some swelling in the tubes and hyperemia =>medical treatment (Rocephin + Doxycycline).
If the patient has an advanced and necrotic tubo-ovarian abscess with peritonitis signs => Unilateral salpingo- oophorectomy + lavage and drain.

c.Ruptured ovarian cyst => lavage (send to pathology) + cystectomy and repair the ovary. Most are corpus luteum cysts (see GYN surgery section).

d.Twisted ovarian cyst => Untwist and observe, if ok transfix + lavage ( send to pathology). Do unilateral salpingo-oophorectomy only if the ovary is infarcted.

Note: See chapter "Notes on GYN Surgery" for more information

Acute cholecystitis can be treated with laparoscopic cholecystectomy in addition to the appendectomy and sigmoid diverticulitis if found can be treated medically but you can proceed with the appendectomy you came for.

Finally, one last note about a question that was brought up several times on the Board exam.

What would you do if you find acute appendicitis, with acutely inflamed cecum and necrotic appendiceal base?

The safest answer is: Perform a partial cecum resection through a healthy area in the cecum avoiding the necrotic portion of it using the stapler with or without lateral cecostomy (avoid the ileocecal valve).

Recently, a question regarding the management to periappendicular abscess was raised; if the abscess is well localized and the patient has minimal systemic symptoms, percutaneous CT guided drainage with antibiotics.... followed in 2-3 months by an elective appendectomy is a safe approach.
If the patient is looking sick, has generalized peritonitis signs or the etiology of the abscess is unclear then surgical exploration under antibiotic coverage with appendectomy and drainage of pus and leaving a drain in the wound which should be left partially open in both the subcutaneous and skin level is the safest answer. The antibiotic coverage should be continued until the drain is removed and the patient is looking good and afebrile for more than 24 hours.

What if the same patient is 2 months S/P MI and frail ? well, in such a patient you should be conservative and consider percutaneous drainage guided by CT or U/S with antibiotics...followed in 2 - 3 months by appendectomy (for there is 60% recurrence rate in this case).


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