Appendicitis
Clinical Practice Guidelines
Reynaldo O. Joson, MD, MHA, MHPEd, MScSurg
March, 2003
Acute nontraumatic right lower quadrant (RLQ) abdominal pain is a common reason for seeking medical consultation.
The most important concern in patients with acute nontraumatic RLQ abdominal pain is the possibility of acute appendicitis being the cause. If it is present, it must be diagnosed and surgically treated early to avoid the complications of a perforated appendicitis.
The problem is, a definitive diagnosis of acute appendicitis is not possible short of an operation (laparotomy or laparoscopy) to look at and examine the appendix. In the absence of an operation, the diagnosis of acute appendicitis is always only a suspicion, even with the use of the most advanced and most sophisticated diagnostic technologies that may be available. The suspicion that acute appendicitis is present ranges from being possible to, at best, most probable.
The other dilemma in the diagnosis of patients with acute nontraumatic RLQ abdominal pain lies in the difficulty in differentiating acute appendicitis from other diseases or conditions that may also produce RLQ abdominal pain. The more common other diseases and conditions are urinary tract infection, right ureteral stone, gastroenteritis, constipation in males and females and pelvic inflammatory diseases, right ectopic pregnancy, twisted right ovarian tumor, and mittelschmerz in the females. On top of these more specific diseases and conditions is a large group of condition known as “nonspecific RLQ abdominal pain”. Any condition that cannot be given a specific label which causes RLQ abdominal pain and which spontaneously disappears is given the tag of “nonspecific RLQ abdominal pain”. This group of condition is estimated to constitute about 30 to 40% of all causes of acute nontraumatic RLQ abdominal pain.(1-10).
The main reason for the difficulty in differentiation between acute appendicitis and the other diseases and conditions that may produce acute nontraumatic RLQ abdominal pain is the overlapping of symptoms and signs. In other words, they mimic each other.
The diagnostic dilemma in patients with acute nontraumatic RLQ abdominal pain cited above has perennially led to either delay or error in diagnosis of acute appendicitis with its corresponding ill effects. The delay is either on the part of the patient or the physician. The error in diagnosis is on the part of the physician, either in the form of missed or overdiagnosis. The delayed and missed diagnosis has the potential of increasing the incidence of perforated appendicitis with its consequent complication rate. On the other hand, the overdiagnosis has the potential of increasing the rate of normal appendix removal (negative appendectomy rate) to an unacceptable level.
Beside the concerns of perforation and normal appendectomy rates in patients with acute nontraumatic RLQ abdominal pain, which are due to delayed, missed, and overdiagnosis, the other problems observed are the following:
1. Marked variations in the diagnostic and treatment process
2. Costly diagnostic and treatment process
3. Medicolegal suits
Clinical practice guidelines are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances”. (1) Evidence-based clinical practice guidelines are clinical practice guidelines based on a systematic identification, review and synthesis of the best available scientific data and evidence.(2)
The main purpose of guidelines is to achieve better health outcomes by improving the practice of health professionals and by better informing consumers about management options. Guidelines can also be used in the broader education of practitioners and the community and can contribute to quality assurance processes. Finally, they may assist in the resolution of legal disputes and ethical dilemmas. (2)
|
Input |
Throughput |
Output |
|
|
|
|
|
Variations in diagnostic and treatment process Confused patients Confused medical students Costly diagnostic and treatment process Delays in diagnosis and treatment Missed diagnosis Wrong diagnosis Medicolegal suits |
Evidence-basedclinical
practice guidelines on acute
nontraumatic right lower
quadrant abdominal pain and acute appendicitis |
Standardized diagnostic process and treatment process Well-informed patients Well-informed students Cost-effective diagnostic and treatment process Efficient diagnosis and treatment Reduced missed diagnosis Reduced wrong diagnosis Reduced medicolegal suits --------------------------------------------------------------------- Decreased negative appendectomy rate to an acceptable
level without significantly increasing perforation
rate and its morbidity and mortality consequences |
List
of Clinical Issues/Questions
In other words, with what clinical parameters can we say that we are quite certain that the diagnosis is acute appendicitis that we do not have to go through the paraclinical diagnostic process?
4. If the treatment modality is operative, do we need to give antibiotics? 5. If we have to give antibiotics, what, when, and how long? 6. Wound infection is the most common complication after an appendectomy. What is the most cost-effective way of avoiding this? |
|
Format in the formulation of clinical practice guidelines
|
Summary of Answers to Clinical Issue/Recommendations |
|
1.
What are reliable clinical parameters that we can use
to make a confident primary clinical diagnosis of acute appendicitis in
patients presenting with an acute nontraumatic right lower quadrant (RLQ)
abdominal pain and tenderness? In other words, with what
clinical parameters can we say that we are quite certain that the diagnosis
is acute appendicitis that we do not have to go through the paraclinical
diagnostic process? The reliable clinical parameters that we can use for making a primary clinical diagnosis of acute appendicitis (of 90% or more probability) in patients with acute RLQ abdominal pain consist of the following: RLQ abdominal pain and tenderness with signs of
peritoneal irritation No alternative diagnosis of the RLQ signs of peritoneal
irritation RLQ Signs of Peritoneal Irritation: ·
Definite (persistent progressive) direct
tenderness with at least guarding ·
Rigidity |
|
2.
If paraclinical
diagnostic procedure(s) is/are needed, what is/are the most cost-effective ones
and how do we interpret the results? In patients suspected to have acute appendicitis, if
paraclinical diagnostic procedure(s) is/are needed, the most cost-effective is active
observation and monitoring. Diagnostic parameter in active observation and monitoring for acute appendicitis: Definite, persistent, progressive, RLQ tenderness signifying peritonitis (direct tenderness with at least guarding or rigidity) With no alternative diagnosis |
|
3.
With a definite
diagnosis of acute appendicitis, what is the most cost-effective treatment,
operative or non-operative? With a definite diagnosis of acute appendicitis, the most cost-effective
treatment is operation – removing the
inflamed appendix. |
|
4.
If the treatment modality is operative, do we need to
give antibiotics? No definite answers yet. |
|
5.
If we have to give antibiotics, what, when, and how
long? NO definite answers yet. |
|
6.
Wound infection is the most common complication after
an appendectomy. What is the most
cost-effective way of avoiding this? No definite answers yet. |
|
7.
What do we do
when we encounter a grossly normal appendix when we operate with a diagnosis
of acute appendicitis? When we encounter a grossly normal appendix during an operation for acute appendicitis, in the absence of an alternative diagnosis, REMOVE THE APPENDIX. |
|
|
|
|
|
|
||||||||
|
Goal
in the management of patients with right lower quadrant abdominal pain |
||||||||
|
|
||||||||
|
|
||||||||
|
Manila Doctors Hospital
Quality Assurance Program on Patients with RLQ Abdominal Pain and Acute
Appendicitis |
||||||||
|
Evidence-based Clinical
Practice Guidelines in Patients with Acute Nontraumatic Right Lower Quadrant
Abdominal Pain and Acute Appendicitis Manila Doctors Hospital Setting A Preliminary Quality Assurance Practice Guideline Development Report1999 |
||||||||
|
|
||||||||
|
The
1998 Normal Appendectomy and Perforated Appendicitis Rate in Manila Doctors
Hospital |
||||||||
|
Variations and Tendencies in the Clinical Decision-Making of MDH Hospital Staff in Patients with Acute Nontraumatic RLQ Abdominal Pain |
||||||||
|
Clinical
Decision-Making of Medical Staff in Patients with Acute Nontraumatic Right
Lower Quadrant Abdominal Pain Manila Doctors
Hospital Department of Surgery, Ospital ng Maynila Medical Center |
||||||||
|
|
||||||||
Clinical Decision-Making in Patients with RLQ Abdominal Pain
|
||||||||
|
|
||||||||
|
|
||||||||
|
|
||||||||
R.O. Joson’s Writings on Acute Appendicitis Active observation in the evaluation of patients with possible acute appendicitis [1990, PJSS 45 (3): 108-111] {p1} {p2} {p3} {p4} Evaluation of
Patients with Possible Acute Appendicitis [1991, JMMSI 27(1&2):35-38] {p1}
{p2} {p3} {p4} Evaluation of Patients with Possible Acute
Appendicitis (1990, UPCM-PGH Consultants’ Forum) |
||||||||
How to manage appendiceal abscess |
1. Institute of Medicine (1990). Clinical practice guidelines: directions for a new program. (eds. Field, MJ and Lohr, KN). Institute of Medicine, National Academy Press, Washington, DC.
2. Quality of Care and Health Outcomes Committee. Office of the National Health and Medical Research Council (Australia). Guidelines for the development and implementation of clinical practice guidelines. October, 1995.
