What's the Diagnosis? By Dr. Loran Hatch

40 yo F presents to the ED w/ 12 hours of GI symptoms. She had nausea and vomiting, then developed right lower quadrant abomdinal pain. Labs were significant for an elevated WBC count. A CT A/P was obtained. What's the diagnosis? (scroll down for answer) 




Answer: Acute Appendicitis

  • due to luminal obstruction (most commonly by fecalith); increase in intraluminal pressure leads to vascular insufficiency--> bacterial proliferation and inflammation
  • other causes: obstruction by lymphatic tissue, tumor, parastic infection
  • early: poorly localized/periumbilical discomfort (due to viserval innervation)
  • classic finding is migration of pain to RLQ (at McBurney's point) due to somatic innervation of peritoneum
    • Mc Burney's point-- 1/3 distance from ASIS to umbilicus
  • up to 50% can have atypical presentation: r pelvic/flank pain (retrocecal appendix), L sided pain (due to malrotation), RUQ pain (due to gravid uterus in pregnancy) 
  • lab findings: elevated wbc and/or CRP, sterile pyuria
  • CT findings- appendix > 6mm in diameter, wall thinkening > 2mm and fat stranding


  • treatment: surgical consult and appendectomy (standard of care per American College of Surgeons)
    • Pre-op antibiotics to cover aerobic and anaerobic gram negative organisms
    • Antibiotics for non-operative management ?
      • several RTC studies have addressed- consider in select patients (those refusing surgery, high risk surgical candidates)
      • surgery still considered standard of care
      • the Eastern Associated for the Surgery of Trauma conducted a systematic review and meta-analysis of non-operative management as an approach to acute appendicits and were unable to make a recommendation for or against the use of an antibiotics first approach as the primary treatment of acute uncomplicated appendicitis



DeKoning E. Acute Appendicitis. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e New York, NY: McGraw-Hill

Rushing A, Bugaev N, Jones C, et al. Management of acute appendicitis in adults: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surgery. 2019;87(1):214-224