ImagingImaging is often utilized to confirm a diagnosis of appendici-tis because a negative operation rate is acceptable in <10% ofmale patients and <20% of female patients. Routine use of cross-sectional imaging somewhat reduces the rate of negative laparot-omies. Imaging studies are most appropriate for patients in whoma diagnosis of appendicitis is unclear or who are at high risk fromoperative intervention and general anesthesia, such as pregnantpatients or patients with multiple comorbidities. Commonlyutilized imaging modalities include computerized tomography(CT), ultrasound (US), and magnetic resonance imaging (MRI).CT Scan. A contrast-enhanced CT scan has a sensitivity of0.96 (95% confidence interval [CI] 0.95–0.97) and specificity of0.96 (95% CI 0.93–0.97) in diagnosing acute appendicitis. 16,17Features on a CT scan that suggest appendicitis includeenlarged lumen and double wall thickness (greater than 6 mm)

ainful for patients with peritonitis. A comparison of the effi-cacy of ultrasound v. CT scan is found in Table 30-2.MRI. MRI of the abdomen has a sensitivity of 0.95 (95% CI0.88–0.98) and specificity of 0.92 (95% CI 0.87–0.95) for iden-tification of acute appendicitis. 22 MRI is an expensive test thatrequires significant expertise to perform and interpret and isusually recommended in patients for whom the risk of ionizingradiation outweighs the relative ease of obtaining a contrastCT scan, i.e., pregnant or pediatric patients

MANAGEMENT OF APPENDICITISUncomplicated AppendicitisThe preferred approach to manage patients with uncomplicatedappendicitis is an appendectomy. Several recent randomizedtrials and cohort studies have examined the role of nonopera-tive management of adult patients with appendicitis. 23,24,25 Ineach of these well-designed studies with noninferiority as theendpoint, patients were randomized to either receiving antibiot-ics or undergoing an appendectomy, which was frequently per-formed open. A majority of the patients in the nonoperative armreceived intravenous antibiotics for a short course followed bya course of a fluoroquinolone and metronidazole, or oral amoxi-cillin/clavulanic acid. 23,26,27 Meta-analysis of the published datafound that 26.5% of patients in the nonoperative group requiredan appendectomy within 1 year. In addition, the rate of adverseevents following antibiotics therapy was higher (relative risk[RR] 3.18, 95% CI 1.63–6.21, P = 0.0007), and patients whorecurred presented more frequently with complicated appen-dicitis (RR 2.52, 95% CI 1.17–5.43, P = 0.02). 28,29 Currently,conservative management can be offered to informed patientsusing techniques of shared decision-making, but it is not thestandard modality of management of appendicitis, except inpatients with significant phobia of surgery. 30 Societal costs andlong-term implications of the conservative strategy have not yetbeen completely evaluated.Timing of Surgery. Emergent surgery is often performed inpatients with appendicitis, but studies have evaluated the perfor-mance of urgent surgery (waiting less than 12 hours) in a semi-elective setting after administering antibiotics upon admission.The studies did not reveal any significant difference in outcomes,except for a slightly longer hospital stay in those undergoingurgent surgery.31-33 Currently, delaying surgery less than 12 hoursis acceptable in patients with short duration of symptoms (lessthan 48 hours) and in nonperforated, nongangrenous appendicitis.Approach of Surgery. Numerous meta-analyses comparinglaparoscopic to open appendectomy have demonstrated relativeequivalence of the techniques, with laparoscopic appendec-tomy resulting in a shorter length of stay (LOS), faster return towork, and lower superficial wound infection rates, especiallyin obese patients. 34,35 Open appendectomy results in shorteroperative times and lower intra-abdominal infection rates.36Costs of the two techniques are relatively similar because ofthe offset of costs in laparoscopic techniques by shorter LOS.In the United States, laparoscopic appendectomies are increas-ingly utilized. 37Complicated AppendicitisPerforated and gangrenous appendicitis and appendicitis withabscess or phlegmon formation are considered complicatedconditions. Patients with perforated appendicitis usually pres-ent after 24 hours of onset, although 20% of patients presentwithin 24 hours. Such patients are often acutely ill and dehy-drated and require resuscitation. Usually, the perforated abscessis walled off in the right lower quadrant, although retroperito-neal abscesses including psoas abscess, liver abscesses, fistu-las, and pylephlebitis (portal vein inflammation) can also occurwhen left untreated.Perforated appendicitis can be managed either operativelyor nonoperatively. Immediate surgery is necessary inpatients that appear septic, but this is usually associatedwith higher complications, including abscesses and enterocuta-neous fistulae due to dense adhesions and inflammation.The management of long-duration, complicated appendici-tis is often staged.38,39 Patients are resuscitated and treated withIV antibiotics. 40,41 Patients with longstanding perforation arebetter treated with adequate percutaneous image-guided drain-age.42 This strategy is successful in 79% of patients who achievecomplete resolution, which occurs more often in lower-gradeabscesses, transgluteal drainage, and with CT- (vs. ultrasound-)guided drainage43 Operative intervention is performed in patientswho fail conservative management and in patients with free intra-peritoneal perforation.Interval Appendectomy. The majority of patients with perfo-rated appendicitis (80%) have resolution of their symptoms withdrainage and antibiotics. There remains debate about the valueof performing an interval appendectomy 6 to 8 weeks after theoriginal inflammatory episode. 44-46 Proponents of this approachcite the incidence of recurrent appendicitis (7.4%–8.8%) and thepresence of appendiceal neoplasms detected on the appendec-tomy (relevant benign lesions 0.7%, malignant lesions 1.3%).47Opponents cite the high incidence of no future events after amedian follow-up of 34 months in 91% of patients. Currently,shared decision-making is necessary before proceeding with aninterval appendectom

Which of given imaging modalities is preferred for evaluating soft tissue abscesses in abdomen?Question 19Select one:a.CT scanb.PET scanc.Ultrasoundd.X-ray

A week after open appendectomy for perforated appendicitis, the Lanz incision is noted to be erythematous, slightly swollen and tender. The appropriate treatment is:Question 45Select one:a.Incision and drainageb.Systemic antibioticsc.Topical antibiotics’d.Local heat therapye.Regional ultrasound

Which imaging modality is preferred for diagnosing a herniated disc?Question 37Select one:a.Ultrasoundb.CT scanc.MRId.X-ray