Appendicitis in the ED: A Gut Feeling

-Case-
A 22-year-old woman presents with abdominal pain that started around her umbilicus and has now migrated to the right lower quadrant. She’s nauseous, hasn’t eaten all day, and has a low-grade fever. On exam, she has tenderness at McBurney’s point and some mild guarding. Labs show a WBC count of 13,000. CT confirms what you already suspected…

-Evaluation-
Appendicitis is one of the most common abdominal emergencies, yet it still manages to fool us regularly. Classically, it begins with vague periumbilical pain that migrates to the RLQ, often accompanied by anorexia, nausea, and low-grade fever. But remember, the textbook case isn’t always what walks through your door!

  • Common symptoms: RLQ pain, anorexia, nausea/vomiting, fever
  • Classic signs: McBurney’s point tenderness, Rovsing’s sign (RLQ pain with LLQ palpation), psoas and obturator signs (less sensitive)
  • Labs: elevated WBC and CRP can support the diagnosis but are not definitive

Imaging:

  • Adults: CT abdomen/pelvis with contrast is the gold standard
  • Children and pregnant patients: ultrasound is the first-line imaging; CT if inconclusive and suspicion remains high

-Management-

  • Surgical consult is a must!
  • NPO and start IV fluids
  • IV antibiotics: Zosyn or Ceftriaxone + metronidazole
  • Pain control is important but don’t delay diagnosis!

-Fast Facts-

  • 1 in 15 people will get appendicitis in their lifetime
  • Up to 30% of patients may have atypical presentations
  • Early imaging and surgical involvement reduce complications

If you’re thinking “this might be appendicitis,” you might just be right. Trust your gut – and your patient’s! The sooner you act, the better their outcome. Don’t let the appendix outsmart you.

Want to learn more? Read our in-depth study guide and listen to our podcast episode on this topic!

Cheers,

Tamir Zitelny, MD

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-References-

  1. Di Saverio S, Podda M, De Simone B, et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg. 2020;15(1):27. doi:10.1186/s13017-020-00306-3
  2. Bhangu A, Søreide K, Di Saverio S, et al. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet. 2015;386(10000):1278-1287. doi:10.1016/S0140-6736(15)00275-5
  3. Howell EC, Dubina ED, Lee SL. Surgical and nonsurgical management of appendicitis in children: a meta-analysis. Pediatrics. 2019;144(1):e20183608. doi:10.1542/peds.2018-3608
  4. Anderson JE, Bickler SW, Chang DC, Talamini MA. Examining a common disease with unknown cause: trends in epidemiology and surgical management of appendicitis in California, 1995-2009. World J Surg. 2012;36(12):2787-2794. doi:10.1007/s00268-012-1776-6
  5. Salminen P, Tuominen R, Paajanen H, et al. Five-year follow-up of antibiotic therapy for uncomplicated acute appendicitis in the APPAC randomized clinical trial. JAMA. 2018;320(12):1259–1265. doi:10.1001/jama.2018.13201
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