Emergency medicine updates: Acute appendicitis in the adult patient

Acute appendicitis is a condition commonly seen in the emergency department (ED). Therefore, it is important for emergency medicine clinicians to be aware of the current evidence regarding the diagnosis and management of this disease.

This paper evaluates key evidence-based updates concerning appendicitis in the adult patient for the emergency clinician.

Acute appendicitis can present with a variety of signs and symptoms in adults, and no single history or examination finding can exclude the diagnosis of appendicitis. The presence of right lower quadrant pain or tenderness, migrating pain, Rovsing's sign, psoas sign, and obturator sign are suggestive of the diagnosis. A combination of normal white blood cell count, neutrophil distribution, and c-reactive protein suggest appendicitis is less likely. Several risk stratification tools are available, including the original and modified Alvarado score, the Appendicitis Inflammatory Response (AIR) score, the Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) score, and the Adult Appendicitis Score (AAS). Current evidence and guidelines suggest the AIR, AAS, and RIPASA have the highest diagnostic accuracy. Patients determined to be low risk on these scores may not require further diagnostic evaluation when used with shared decision-making. Patients who are not low risk warrant further investigation. A variety of imaging tests are available, including computed tomography (CT), ultrasound (US), and magnetic resonance imaging (MRI). US or CT may be used as the first-line imaging modality in adults. US and MRI are the recommended imaging tests in pregnant females. All patients with acute appendicitis should receive surgical consultation, and antibiotics should be administered. Evidence suggests that non-operative management with antibiotics alone may be safe in select patients with uncomplicated appendicitis, particularly those without appendicolith. Surgical intervention is recommended in pregnancy.

An understanding of literature updates can improve the ED care of patients with appendicitis.