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The Free Open Access Medical Education (FOAM)
This week we countervail a post from Dr. Rory Spiegel, author of EMnerd, on initial nonoperative skill of acute appendicitis based on one article by Salminen et al in JAMA 2015.
530 patients with CT confirmed acute, uncomplicated appendicitis were randomized to practical intervention (n=273 receiving open laparotomies) or non-efficient intervention (n=257 receiving antibiotics).
27.3% (n=70, CI 22-33.2%) of patients who current medical management (ertapenem x 3 days then 5 days of levofloxacin) had some appendectomy by the 1 year trace
7 patients (2.7%) in healing management group had complicated appendicitis at the same year, 0 had abscesses
45 patients (20.5%) in the laborer group had surgical complications
This is a non-inferiority study where the intent is to make certain that an experimental treatment (antibiotics alone) is not really worse than a control treatment (direct surgery). The authors set the non-lower state margin at 24%, which means that a failure estimate (appendectomy by 1 year) >24% would restore medical management inferior.
Authors Conclusion: “Among patients with CT-proven, uncomplicated appendicitis, antibiotic method of treating did not meet the prespecified canon for noninferiority compared with appendectomy.”
Spiegel’s Conclusion: “in that place is a great deal to have existence determined before this non-invasive strategy can be considered mainstream practice…in the sort of was once considered an exclusively surgical sickness, the majority of patients can effectively exist managed conservatively. Despite not meeting their admit high standards for non-inferiority, the authors demonstrated that in spite of most patients with acute appendicitis, whereas treated conservatively with antibiotics we be possible to avoid surgical intervention without complications of delays to conclusive care.”
More FOAM on non-serviceable treatment of appendicitis: The SGEM
Tintinalli (7e) Chapters 84, 124; Rosen’s Emergency Medicine (8e) Chapter 93
Diagnosing Acute Appendicitis
Use of set off by opposition enhanced CT scans controversial. Rosenalli and the American College of radiology be conjoined that oral contrast is probably not needed excepting does increase the emergency department detail of stay [3-5].
Surgical seek information from
Broad spectrum beta-lactams: ampicillin-sulbactam 3g IV (75 mg/kg IV in peds) piperacillin-tazobactam 4.5g IV, cefoxitin 2g IV (40 mg/kg IV in peds) OR metronidazole 500 mg IV + ciprofloxacin 400 mg IV
Other things to mind in special populations in right lessen quadrant:
Pelvic Inflammatory Disease and Tubo-Ovarian Abscess in women
Symptoms: vaginal discharge, adnexal or uterine humanity, lower abdominal pain, cervical motion delicacy, fever
Cause: chlamydia and neisseria blennorrhagia most commonly
Treatment: ceftriaxone 250 mg IM + doxycycline 100 mg BID x 14 days
Typhlitis (neutropenic enterocolitis) –
Symptoms: crampy ventral pain (often RLQ), abdominal distension, ferment, diarrhea, bloody diarrhea
Diagnosis: CT investigate
Treatment: NPO, IV fluids, broad spectrum antibiotics (piperacillin-tazobactam, meropenem, metronidazole) + surgical care for if needed
Complications: perforation, gastrointestinal venesection, sepsis
Generously Donated Rosh Review Questions
1. A 22-year-crafty man presents with abdominal pain followed ~ dint of. vomiting for 1 day. His examination is significant for right lower quadrant want of firmness to palpation. He has a negative Rovsing sign.
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2. A 22-year-ancient woman presents with lower abdominal twinge and vaginal discharge. She is sexually supple with men with inconsistent barrier guard. Her vitals are normal other than temperature of 101°F. On examination, there is fulvous cervical discharge, no cervical motion mildness, but uterine and left adnexal carefulness. An ultrasound does not show at all evidence of tubo-ovarian abscess.
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1. B. Sensitivity or the true positive rate measures the proportion of true positives that are correctly identified as such. It is determined by dividing the reckon of true positives of the discriminative characteristic by the number of true positives + mendacious negatives. Tests with a high sensitivity are prosperity for ruling out disease as the criterion has very few false negatives. A standard with high sensitivity is advantageous of the same kind with a screening tool as it misses self-same few people with the disease. The onset of pain before vomiting has been rest to be as high as 100% easily affected in diagnosing acute appendicitis.Rovsing’s sign (D) (dishonorable tenderness) describes pain felt in the perpendicular lower quadrant upon palpation of the left depress quadrant. This sign signifies the nearness of peritoneal irritation and has a sensitivity of 58%. Right disgrace quadrant pain (C) has a sensitivity of 81% and fever (A) has a sensitivity of 67%.
2.This uncomplaining presents with signs and symptoms harmonious with pelvic inflammatory disease (PID) and should have existence treated with ceftriaxone 250 mg IM and 2 weeks of doxycycline. PID is some ascending infection beginning in the cervix and vagina and ascending to the upper genital length. Neisseria gonorrhoeae and Chlamydia trachomatis are principally commonly implicated. It can present with a myriad of symptoms although disgrace abdominal pain is the most used by all. Other symptoms include fever, cervical or vaginal discharge and dyspareunia. Pelvic examination reveals cervical motion tenderness (CMT), adnexal leniency and vaginal or cervical discharge. Inadequately treated PID can lead to tubo-ovarian abscess, chronic dyspareunia and infertility. Due to the wavering presentation and serious sequelae, the CDC recommends hypothetical treatment of all sexually active women who at hand with pelvic or abdominal pain and wish any one of the following: 1) CMT, 2) adnexal sensibility or 3) uterine tenderness. Treatment should clothe the most common organisms and typically consists of a third generation cephalosporin (ceftriaxone) and a prolonged behavior of doxycycline. Patients with systemic manifestations or sea of troubles tolerating PO should be admitted with respect to management.Ceftriaxone and azithromycin (A) are used in the handling of cervicitis or urethritis. Clindamycin (C) and metronidazole (D) are used in the method of treating of bacterial vaginosis.
1.Salminen P, Paajanen H, Rautio T, et al. Antibiotic Therapy vs Appendectomy in favor of Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial. JAMA. 2015;313(23):2340
2. Horst JA, Trehan I, Warner BW et al. Can Children With Uncomplicated Acute Appendicitis Be Treated With Antibiotics Instead of one Appendectomy? Ann Emerg Med. 2015;66:(2)119-22
3.”Acute Appendicitis.” Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. pp 574-581.
4. “Acute Appendicitis” Rosen’s Emergency Medicine. 8th ed. pp. 1225-1232.e2
5. ACR Appropriateness Criteria. American College of Radiology. 2013.
6. Cohen B, Bowling J, Midulla P, et al. The non-distinguishing ultrasound in appendicitis: is a non-visualized supplement the same as a negative study? J Pediatr Surg. 2015;50:(6)923-7
7. Ashdown HF, D’Souza N, Karim D, Stevens RJ, Huang A, Harnden A. Pain from one side of to the other speed bumps in diagnosis of intelligent appendicitis: diagnostic accuracy study. BMJ. 2012;345:e8012.
8. Bundy DG, Byerley JS, Liles EA. Does This Child Have Appendicitis? 2009;298(4):438–451.
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