A 22-year-old male 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 (38.5°C), and there is marked tenderness at McBurney's point with guarding and rebound tenderness. Rovsing's sign is positive. His WBC is 13,500/μL with left shift. Abdominal ultrasound shows a non-compressible, dilated appendix (8 mm) with surrounding free fluid. What is the most appropriate next step in management?

Explanation

## Clinical Diagnosis **Key Point:** This patient has acute appendicitis with classic presentation: periumbilical pain migrating to RLQ, positive McBurney's point tenderness, rebound/guarding, positive Rovsing's sign, fever, and leukocytosis with left shift. **High-Yield:** Ultrasound findings of non-compressible appendix >6 mm with surrounding free fluid confirm acute appendicitis in this clinical context. ## Management Algorithm ```mermaid flowchart TD A[Acute appendicitis confirmed]:::outcome --> B{Complicated or uncomplicated?}:::decision B -->|Uncomplicated| C[Immediate appendectomy]:::action B -->|Complicated: perforation, abscess, peritonitis| D[Percutaneous drainage + antibiotics]:::action D --> E[Interval appendectomy in 6-8 weeks]:::action C --> F[Appendectomy within 24 hrs]:::action ``` **Clinical Pearl:** In uncomplicated acute appendicitis (no perforation, no abscess), immediate appendectomy is the gold standard. Delay increases risk of perforation and peritonitis. **Key Point:** This patient has: - No signs of perforation (localized tenderness, no diffuse peritonitis) - No abscess formation (no palpable mass) - Clear clinical diagnosis (ultrasound-confirmed) - Therefore: **uncomplicated acute appendicitis** → immediate appendectomy ## Why Not the Other Options? | Option | Why Incorrect | |--------|---------------| | Antibiotics + interval appendectomy | Reserved for **complicated appendicitis** (perforation with abscess). Uncomplicated cases require urgent surgery to prevent progression. | | CT for confirmation | Unnecessary delay. Ultrasound + clinical findings are diagnostic in this case. CT is used when diagnosis is uncertain. | | Conservative management | Risks perforation, peritonitis, sepsis, and death. Not indicated in acute appendicitis. | **Mnemonic:** **ACUTE = Appendectomy Urgently in Confirmed uncomplicated Appendicitis** — do not delay with imaging or antibiotics alone. [cite:Sabiston Textbook of Surgery 21e Ch 49]