A 22-year-old male from Delhi presents to the emergency department with a 36-hour history of periumbilical pain that migrated to the right lower quadrant. He reports anorexia, nausea, and one episode of vomiting. On examination, he is febrile (38.2°C), and has tenderness at McBurney's point with a positive Rovsing's sign. His WBC is 13,500/μL with left shift. Ultrasound shows a non-compressible, dilated appendix measuring 8 mm with periappendiceal free fluid. What is the most appropriate immediate management?

Explanation

## Diagnosis and Management of Acute Appendicitis ### Clinical Presentation This patient has classic acute appendicitis with: - Migration of pain from periumbilical to RLQ (pathognomonic) - Fever, anorexia, nausea, vomiting - Rovsing's sign positive (pain in RLQ on palpation of LLQ) - McBurney's point tenderness - Elevated WBC with left shift - Ultrasound findings: non-compressible appendix >6 mm with periappendiceal fluid **Key Point:** The combination of clinical signs (Rovsing's, McBurney's), fever, elevated WBC, and imaging confirmation (US showing dilated non-compressible appendix) is diagnostic of acute appendicitis. ### Management Algorithm ```mermaid flowchart TD A[Acute appendicitis diagnosed]:::outcome --> B{Perforation or periappendiceal abscess?}:::decision B -->|No| C[Immediate appendicectomy]:::action B -->|Yes| D[Abscess >4 cm?]:::decision D -->|Yes| E[Percutaneous drainage + IV antibiotics]:::action D -->|No| F[IV antibiotics + appendicectomy]:::action C --> G[Appendicectomy within 6-12 hours]:::action E --> H[Interval appendicectomy after 6-8 weeks]:::action ``` ### Why Immediate Surgery? **High-Yield:** In uncomplicated acute appendicitis (no perforation, no abscess), immediate appendicectomy is the gold standard. The risk of perforation increases with time, and delay increases morbidity. - **Perforation risk:** ~20% at 24 hours, ~40% at 48 hours - **Morbidity:** Perforation leads to peritonitis, sepsis, and higher mortality - **Timing:** Appendicectomy should be performed within 6–12 hours of diagnosis **Clinical Pearl:** The presence of periappendiceal free fluid on ultrasound does NOT indicate perforation or abscess formation if the appendix itself is not perforated and there is no localized collection. This is reactive peritoneal fluid from inflammation. ### Why NOT the Other Options? | Option | Why Wrong | |--------|----------| | IV antibiotics + observation | Delays definitive treatment; increases perforation risk; not standard of care for uncomplicated appendicitis | | CT abdomen | Unnecessary when ultrasound is diagnostic; delays surgery; CT is reserved for equivocal cases or suspected complications | | Percutaneous drainage + interval appendicectomy | Indicated only for localized abscess (>4 cm) or perforation with contained collection; this patient has no abscess | **Mnemonic: APPENDICITIS Management — ASAP** - **A**cute uncomplicated → **S**urgery **A**SAP - **P**erforation/abscess → **P**ercutaneous drainage, then interval surgery [cite:Sabiston Textbook of Surgery Ch 50]