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Appendicitis

Clinical Practice Guidelines

 

 

Reynaldo O. Joson, MD, MHA, MHPEd, MScSurg

March, 2003

rjoson@maniladoctors.com.ph

 

 

The Health Problem and its Importance

 

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

           

 

Evidence-based Clinical Practice Guidelines

 

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)

 

 

 

conceptual framework of guideline development

 

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-based

clinical 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

 

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?

 

2.      If paraclinical diagnostic procedure(s) is/are needed, what is/are the most cost-effective ones and how do we interpret the results?

 

3.      With a definite diagnosis of acute appendicitis, what is the most cost-effective treatment, operative or non-operative?

 

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?

 

7.      What do we do when we encounter a grossly normal appendix when we operate with a diagnosis of acute appendicitis?

 

 

 

 

 

Format in the formulation of clinical practice guidelines

 

  • Cliinical Issue or Question
  • Statement of Premises
  • Operational Definition of Terms
  • Evidence Appraisal Plan
  • Search Methodology
  • Search and Tracking Outcome
  • Presentation of Primary Evidences
  • Distillation of all Available Evidences to come out with recommendations or answers to the clinical issue/question
  • Summary of Answers to Clinical Issue/Recommendations
  • Future Research Issues/Questions
  • References
  • Quick Reference Guide or Algorithm

 

 

 

 

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 Report

1999

 

The 1998 Normal Appendectomy and Perforated Appendicitis Rate in Manila Doctors Hospital

[Abstract][Text]

 

 Variations and Tendencies in the Clinical Decision-Making of MDH Hospital Staff in Patients with Acute Nontraumatic RLQ Abdominal Pain

[Abstract][Text]

 

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

Female

Male

5-14 years old

5-14 years old

15-50 years old

15-50 years old

More than 50 years old

More than 50 years old

 

 

 

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.