A 32-year-old man presents to the emergency department with acute onset severe right lower abdominal pain, fever (38.5°C), and guarding. On examination, he has rebound tenderness and a positive Rovsing sign. His WBC count is 14,500/μL with left shift. Imaging confirms acute appendicitis with no perforation. What is the most appropriate immediate next step in management?

Question

Accepted Answer

C. Perform emergency appendectomy after resuscitation and preoperative optimization. ## Clinical Context
This patient has acute appendicitis confirmed by imaging with signs of acute inflammation (fever, elevated WBC with left shift, peritoneal signs). The absence of perforation does not change the standard management approach.

## Management Principle in Acute Appendicitis

**Key Point:** Acute appendicitis is a surgical emergency requiring appendectomy regardless of whether perforation is present. Delayed surgery increases morbidity and mortality from perforation and peritonitis.

**High-Yield:** The inflammatory cascade in acute appendicitis progresses rapidly — bacterial translocation across the inflamed mucosa leads to transmural inflammation, and perforation can occur within 24–48 hours if untreated. Surgical intervention is the definitive management, not observation or medical therapy alone.

## Rationale for Correct Answer

Emergency appendectomy after appropriate resuscitation (IV fluids, electrolyte correction, analgesia) is the standard of care. Preoperative optimization includes:
- IV fluid resuscitation
- Broad-spectrum antibiotics (ceftriaxone + metronidazole or piperacillin-tazobactam)
- Analgesia and anxiolysis
- NPO status
- Urinary catheterization if prolonged surgery anticipated

Surgery should proceed urgently (within 6–12 hours) to prevent progression to perforation and sepsis.

**Clinical Pearl:** Even uncomplicated acute appendicitis has a ~30% risk of perforation if surgery is delayed beyond 48 hours. The inflammatory mediators (IL-6, TNF-α, prostaglandins) released during acute inflammation drive tissue destruction and bacterial invasion.

## Why Surgery Is Superior to Conservative Management

| Aspect | Emergency Appendectomy | Conservative Management |
|--------|------------------------|------------------------|
| Perforation risk | <1% if done promptly | 20–30% if delayed |
| Mortality | <0.1% in uncomplicated cases | Increases with perforation |
| Morbidity | Surgical site infection risk | Risk of abscess, sepsis, peritonitis |
| Definitive treatment | Yes | No — addresses only inflammation, not underlying pathology |

**Mnemonic:** **ASAP** — **A**ppendicitis requires **S**urgical **A**ction **P**romptly.

Answer

A. Administer NSAIDs to reduce inflammation and defer surgery pending response

Answer

B. Start broad-spectrum antibiotics and observe for 48 hours with serial clinical examination

Answer

D. Obtain CT abdomen with contrast to rule out other causes of acute abdomen

Explanation

Clinical Context

Management Principle in Acute Appendicitis

Rationale for Correct Answer

Why Surgery Is Superior to Conservative Management

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Aspect	Emergency Appendectomy	Conservative Management
Perforation risk	<1% if done promptly	20–30% if delayed
Mortality	<0.1% in uncomplicated cases	Increases with perforation
Morbidity	Surgical site infection risk	Risk of abscess, sepsis, peritonitis
Definitive treatment	Yes	No — addresses only inflammation, not underlying pathology