Management of abdominal pain in right lower quadrant in A&E

Dr. David Tran20 January 2010FVHospital

Short case report:

Man 76 years old, abdominal pain for 48h.

Physical exam: pain at the right flanck,

right hypochondre and right lower

quadrant (tenderness).

WBC 13.800, CRP 184

ASP Xray: normal,no hydro-aeric level

Abdominal Ultrasound2/ A l'étage pelvien:  L'examen a été réalisé par voie sus-

pubienne.  Vessie anéchogène, à parois fines.  Les coupes réalisées  au niveau du pelvis

montrent une prostate de volume normal, de contours réguliers et nets. Sa structure échographique est homogène. 

FID sans particulariteAu total:  Examen normal. 

Abdominal CT scanner Présence d'une infiltration graisseuse en dessous

du caecum associée aux bulles d'air extradigestives.

Présence de diverticules sigmoidiens. Pas d'épanchement liquidien péritonéal. Pas de pneumoperitoine libre. Le reste de l'examen est sans particularite.

Conclusion: Péritonite localisée de la fosse iliaque

droite, d'origine d'une rupture soit appendiculaire, soit diverticulaire.

Diverticules sigmoidiens.

Suspected appendicitis

Historical management: early laparotomy to

avoid risk of appendix perforation.

In 20% of patients who undergo exploratory

laparotomy, appendix = normal.

Elderly patients and female > the error rate

is about 40%

Strategy if pain at the right lower quadrant

Medical history & physical examination is the

cornerstone in evaluation

3 Common signs of appendicitis may support

the diagnosis:

1. Pain at the right lower quadrant (RLQ)

2. Guarding at palpation RLQ > Abdominal

rigidity

3. Migration of pain from periumbilical region

Se & Sp of clinical signs

Anatomic basis of Psoas sign

Inflate appendix is in the retroperitoneal location in contact with the psoas muscle

The appendix is stretched by the extension of the psoas muscle.

Definition of Psoas sign

Pain on passive extension of the right thigh, patient lies on left side. Examiner extends patient’s right thigh while applying counter resistance to the right hip.

Definition of Obturator sign

Pain on passive internal rotation of the flexed thigh. Examiner moves lower leg laterally while applying resistance to the lateral side of the knee.

Anatomic basis of the Obturator sign

Inflamed appendix in the pelvis is in contact with the obturator internus muscle

The Obturator is stretched by the maneuver

Signs of peritoneal inflammation

Involuntary rigidity or spasm at the

abdominal muscles

Rebound tenderness (It hurts more when

you release pressure)

Coughing increase the abdominal pain

Most common misdiagnosis

Gastroenteritis

Urinary tract infection

Renal colic

Rupture ovarian follicle

Ectopic pregnancyYoung women

Laboratory testing

WBC & CRP are useful to confirm

inflammatory syndrome (but poor specificity

for appendicitis)

Urinalysis must be done (can show blood or

leucocytes)

Beta HCG must be search for all women in

reproductive age (ectopic pregnancy?)

Conventional radiology Law sensitivity and

specificity for the diagnosis of acute appendicitis…

Appendicolith is very rare

ASP shouldn’t be ordered if suspected appendicitis, except if there is an occlusive syndrome.

Ultrasound Ultrasound has Se 75-90

and Sp 86-100 May identify alternative

diagnosis like pyosalpynx or ovarian cyst.

Appendicitis may be rule out if the appendix is normal on ultrasound.

The failure to see the appendix limits the usefulness of ultrasound

Criteria for diagnosis of appendicitis in ultrasound

1. non-compressible sausage appendix with wall

thickening. Ultrasound findings in non-perforated appendicitis

include a muscular wall thickness greater than 2 mm, an appendicial

diameter greater than 7 mm that does not compress, abnormally

thickened bowel wall when viewed in the short axis, and sometimes

distension or obstruction of the appendicial lumen accompanied by

increased echogenicity "oedema" surrounding the appendix.

2. démonstration of an appendicolith, which is seen as

an echogenic focus within the appendix lumen with shadowing.

3. Further signs include fluid around the appendix,

an inflammatory bowel mass and the formation of abscess.

Computed Tomography

Se 90-100%

Sp 91-99%

Distended appendix

Thickened

appendiceal wall

Preiappendiceal

inflammation

CT scanner or ultrasound ?

Greater Se of CT (96% versus 76%)

Higher negative predictive value for CT (95%

versus 76%)

Alternative diagnosis more often with CT.

Appendix often not seen in ultrasound…

Superiority of CT in diagnosis of appendicitis

Algorithm of pain in the RLQ

Conclusion

Physical exam remains the corner stone of the diagnosis of appendicitis

Conventional Xray is useless for diagnosis (except rare appendicolith)

WBC and CRP help the diagnosis but have poor Se & Sp.

If equivocal presentation, CT scanner is better than ultrasound

Thank you, Cam on