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Abdominal Pain: Update on Emergency Department Management of Appendicitis and Diverticulitis

Abdominal Pain: Update on Emergency Department Management of Appendicitis and Diverticulitis
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Publication Date: October 2024 (Volume 26, Number 10)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-B CME credits. CME expires 10/01/2027.

Author

Liza Hartofilis, MD
Assistant Medical Director, New York Presbyterian-Westchester Emergency Department, Bronxville NY; Assistant Professor and Attending Physician in Emergency Medicine, New York Presbyterian-Columbia University Medical Center, New York, NY
John K. Riggins, Jr., MD, MHA, FACEP
Assistant Professor of Emergency Medicine, Assistant Medical Director, New York Presbyterian-Allen Emergency Department; New York Presbyterian-Columbia University Medical Center; Columbia University Vagelos College of Physicians and Surgeons, New York, NY

Peer Reviewers

Marc Andrews, MD
Emergency Medicine Physician, Kaiser Permanente San Leandro Medical Center, San Leandro, CA
Randy Sorge, MD, FACEP
Clinical Associate Professor of Emergency Medicine, Louisiana State University Health Science Center, New Orleans, LA

Abstract

Abdominal pain is one of the most common presenting complaints to the emergency department, and appendicitis and diverticulitis are common causes. Intra-abdominal infections have historically been managed with admission to the hospital, antibiotics, and surgical interventions, and best-practice pathways are an important part of quality programs. Advances in diagnostics and management, supported with outcome data, are impacting care pathways. This review provides an update on best practices related to the management of appendicitis and diverticulitis, with the goal of improving patient care, minimizing risk, and maximizing the patient experience.

Case Presentations

CASE 1
A 24-year-old man presents to the ED complaining of 2 days of abdominal pain that has moved to his right lower quadrant…
  • The patient says he’s had a slight fever at home. His current vital signs are: temperature, 38.2ºC; heart rate, 108 beats/min; blood pressure, 122/70 mm Hg; and respiratory rate, 14 breaths/min.
  • On palpation, his abdomen is soft and not distended, with tenderness to palpation in the periumbilical area and right lower quadrant. Bowel sounds are present.
  • You order a urinalysis, complete blood cell (CBC) count, basic metabolic panel (BMP), liver function tests (LFTs), and lipase level, and administer IV morphine, IV crystalloid fluids, and antipyretics.
  • You have high suspicion for appendicitis and consider what type of imaging should be ordered. You wonder: do scoring systems really work? And if it is appendicitis, can you send this patient home on oral antibiotics?
CASE 2
A 50-year-old woman presents with left-sided abdominal pain, nausea, and some diarrhea. She has no comorbidities, but she says this feels like a prior episode of diverticulitis…
  • Her vital signs are: temperature, 37.4ºC; heart rate, 93 beats/min; blood pressure, 145/84 mm Hg; and respiratory rate, 16 breaths/min.
  • You order a urinalysis, CBC, BMP, LFTs, and lipase level, and give her pain medication and antiemetics.
  • Her laboratory results return as normal, and her symptoms improve slightly.
  • You consider whether you should order a CT scan to look for complications, or discharge her, without antibiotics, for outpatient follow-up…
CASE 3
A 40-year-old woman who is 15 weeks’ pregnant presents to the ED with right-sided abdominal pain…
  • The patient reports subjective fever, chills, nausea, and decreased appetite over the last 3 days.
  • Her current vital signs are: temperature, 37.9ºC; heart rate, 112 beats/min; blood pressure, 118/82 mm Hg; and respiratory rate, 18 breaths/min.
  • You suspect acute appendicitis, and consider what the best imaging options are. Should you start with ultrasound, or order an MRI? What if she has a contraindication to MRI?

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

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