INTRODUCTION: Because of the potential severity of acute appendicitis, many authors recommend the broad use of appendectomy. In this case, 15 to 20% of appendectomies are ultimately found to have been unnecessary. Hospital observation with repeated clinical and laboratory exams can be useful for patients with atypical clinical presentation. This paper assesses our approach, in which some patients with pain in the right iliac fossa (RIF) are admitted for observation before a decision about appendectomy. PATIENTS AND METHODS: All patients (205 cases) admitted from March 2002 through February 2003 for acute abdominal pain of the RIF were included in this prospective study. The 120 women and 85 men (sex ratio=0.7) had a mean age of 27 years. We classified the patients into 3 groups: those who had an emergency appendectomy, those who had surgery after an observation period, and those discharged without appendectomy after observation. RESULTS: The first group included 110 patients: 63% had a (rectal) temperature greater than 38 degrees C; 44% had guarding of the RIF and 87% elevated white blood cell counts (>10000/mm3). At surgery, appendicitis was diagnosed in 92%. After a mean delay of 36 hours of observation, 50 of the patients in the second group underwent surgery: 44% with (rectal) temperature > 38 degrees C, RIF guarding in 8%, and elevated white blood cell count (>10000/mm3) in 74%. In this group, 94% were diagnosed with appendicitis during surgery. Forty-five patients were discharged without surgery after 36 hours of observation. COMMENTARY: In this study, pain and RIF guarding, associated with temperature greater than 38 degrees C and elevated white blood cell counts, were predictive of appendicitis in 96% of cases. Admission for observation of patients with atypical presentation avoided 45 unnecessary appendectomies (22%).
INTRODUCTION: Because of the potential severity of acute appendicitis, many authors recommend the broad use of appendectomy. In this case, 15 to 20% of appendectomies are ultimately found to have been unnecessary. Hospital observation with repeated clinical and laboratory exams can be useful for patients with atypical clinical presentation. This paper assesses our approach, in which some patients with pain in the right iliac fossa (RIF) are admitted for observation before a decision about appendectomy. PATIENTS AND METHODS: All patients (205 cases) admitted from March 2002 through February 2003 for acute abdominal pain of the RIF were included in this prospective study. The 120 women and 85 men (sex ratio=0.7) had a mean age of 27 years. We classified the patients into 3 groups: those who had an emergency appendectomy, those who had surgery after an observation period, and those discharged without appendectomy after observation. RESULTS: The first group included 110 patients: 63% had a (rectal) temperature greater than 38 degrees C; 44% had guarding of the RIF and 87% elevated white blood cell counts (>10000/mm3). At surgery, appendicitis was diagnosed in 92%. After a mean delay of 36 hours of observation, 50 of the patients in the second group underwent surgery: 44% with (rectal) temperature > 38 degrees C, RIF guarding in 8%, and elevated white blood cell count (>10000/mm3) in 74%. In this group, 94% were diagnosed with appendicitis during surgery. Forty-five patients were discharged without surgery after 36 hours of observation. COMMENTARY: In this study, pain and RIF guarding, associated with temperature greater than 38 degrees C and elevated white blood cell counts, were predictive of appendicitis in 96% of cases. Admission for observation of patients with atypical presentation avoided 45 unnecessary appendectomies (22%).