Oral Board Case: Acute Appendicitis

What is your differential diagnosis for this young man's right lower quadrant pain?

Expected answer

Acute appendicitis is most likely given the classic migratory periumbilical-to-RLQ pain with anorexia and rebound. Other considerations include mesenteric adenitis, Meckel's diverticulitis, Crohn's/terminal ileitis, infectious gastroenteritis, ureteral colic, epididymitis/testicular torsion, and cecal diverticulitis. In a female I would add ovarian cyst/torsion, tubo-ovarian abscess, PID, and ectopic pregnancy.

What initial workup do you want?

Expected answer

Vital signs, a focused exam, and labs—CBC with differential, BMP, and a urinalysis. In a male of reproductive age I do not need a pregnancy test, but I would obtain a beta-hCG in any female. I'd start IV fluids for resuscitation. A WBC >10 supports appendicitis; a WBC >15 with high fever raises concern for complicated, perforated, or gangrenous disease.

This patient has a WBC of 13, a temperature of 38.5°C, and clear rebound at McBurney's point. Do you need imaging before operating?

Expected answer

No. A young male with a classic history, fever, RLQ rebound, and leukocytosis is high-suspicion acute uncomplicated appendicitis. In males, imaging is not required—I would resuscitate, give preoperative antibiotics, and proceed to laparoscopic appendectomy. Imaging is reserved for females (to exclude gynecologic causes) and for equivocal presentations.

When would imaging change your approach, and what study would you order?

Expected answer

If the presentation is equivocal—WBC under 15, afebrile, only mild RLQ tenderness—I'd image to clarify. In adults a CT abdomen/pelvis is preferred (cost-effective and accurate). In children or pregnant patients I'd start with ultrasound, and use MRI if ultrasound is non-diagnostic. CT findings supporting appendicitis include an appendix >10 mm, wall thickening, fat stranding, and periappendiceal fluid without perforation.

Describe how you would perform a laparoscopic appendectomy.

Expected answer

After preoperative antibiotics and general anesthesia, I place a periumbilical camera port and two working ports (commonly suprapubic and left lower quadrant). I inspect the abdomen, identify the appendix and mesoappendix, divide the mesoappendix with energy device or clips, and divide the appendiceal base with an endoscopic stapler at the cecum, ensuring no residual stump. I retrieve the specimen in a bag, irrigate, confirm hemostasis, and close. I also inspect for Meckel's and other pathology if the appendix looks normal.

Intraoperatively the appendix looks grossly normal. What do you do?

Expected answer

I still perform an appendectomy because a grossly normal appearance does not exclude early inflammation and leaving it causes diagnostic confusion later. But first I run the terminal ileum for a Meckel's diverticulum or Crohn's, inspect the cecum for masses, and in a female examine the adnexa. If I find another clear source such as Crohn's involving the cecal base, I avoid stapling across diseased bowel and tailor management accordingly.

CT in an equivocal patient instead shows a contained periappendiceal abscess. How do you manage this?

Expected answer

A contained perforation with abscess is best managed nonoperatively—IV antibiotics, bowel rest/NPO, IV fluids, and CT-guided percutaneous drainage of the collection. This carries lower morbidity than immediate appendectomy in an inflamed, hostile field. I'd plan interval appendectomy in 6–8 weeks to prevent recurrence (>10% risk) and to exclude malignancy or Crohn's. Patients over 40–50 should undergo colonoscopy before the interval appendectomy to rule out cecal cancer.

The patient managed nonoperatively develops persistent fever, worsening leukocytosis, and signs of sepsis despite antibiotics and drainage. What now?

Expected answer

Failure of nonoperative management mandates source control with immediate appendectomy. I'd resuscitate, broaden antibiotics, and take the patient to the OR. Given the inflammation I should be prepared for a more extensive operation—potentially ileocecal resection or right hemicolectomy if the cecal base is involved or unsafe to staple. Laparoscopy is reasonable if I'm comfortable, with a low threshold to convert to open.

What are the major complications of appendectomy you would counsel this patient about?

Expected answer

Surgical site/wound infection, intra-abdominal abscess, small bowel obstruction from adhesions, ileus, and bleeding. Wound infection risk is notably higher with complicated appendicitis (around 20%). I'd also counsel about the small possibility of needing a larger bowel resection and the rare finding of an appendiceal neoplasm on pathology.