Moderator EMEDPA Posted March 27, 2011 Moderator Share Posted March 27, 2011 just saw a 66 yr old with ct proven appendicitis. I know this can happen at any age but generally I think of appendicitis as a disorder of folks under 50. hope path is neg for malignancy. also on a related note juist heard a lecture by a peds em doc from LA county/usc med ctr. they are no longer doing abd ct on kids for r/o appy they are doing limited mri of the rlq. sounds like a good idea to me. I have seen this utilized in pregnant pts before but I think making it standard in kids would be a good first step in diminishing lifetime radiation exposure and associated risks of later malignancy. Link to comment Share on other sites More sharing options...
rcdavis Posted March 27, 2011 Share Posted March 27, 2011 E. Oldest for me was somewhere in 46-ish Not sure I agree with MRI protocol. Appreciate radiation concern, but cost is still too great. Old school Copes... Repeated exams, surgery based on hx and pe ( more and more Peds surgery doing this and getting away from any imaging except for U/S) ... Vr davis Link to comment Share on other sites More sharing options...
andersenpa Posted March 28, 2011 Share Posted March 28, 2011 E.Oldest for me was somewhere in 46-ish Not sure I agree with MRI protocol. Appreciate radiation concern, but cost is still too great. Old school Copes... Repeated exams, surgery based on hx and pe ( more and more Peds surgery doing this and getting away from any imaging except for U/S) ... Vr davis I don't deal with abd stuff any more. Is there any evidence out there for clinical presentation vs imaging for appys? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 28, 2011 Author Moderator Share Posted March 28, 2011 I only know 2 surgeons who will consider doing an appy without an imaging study. one guy has an interesting philosophy which I think is a great way to do things. he sticks in the scope, if the appendix appears nl he leaves it in and they get a much smaller bill. the other guy wants young males with fever+ rlq pain+ elevated wbc+ anorexia+ positive rebound/heel jar, etc most of the guys won't even talk to you without a + u/s or ct and the u/s techs at my primary facility only see the appendix maybe 10% of the time. at one of my per diem jobs they only don't see the appendix 10% of the time...it's all operator dependent. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 28, 2011 Author Moderator Share Posted March 28, 2011 I don't deal with abd stuff any more.Is there any evidence out there for clinical presentation vs imaging for appys? the problem is mesenteric adenitis vs appy. very hard to tell the difference clinically. one of my attendings swears by the crp as a good indicator. his theory : nl crp+ neg u/s or indeterminate u/s = d/c home with close f/u or obs prn. he hasn't been burned yet. of course other things can cause a + crp but a neg crp seems to have some value. I have been ordering them in addition to imaging and I have yet to see a nl crp with a + ct or u/s for appy. Link to comment Share on other sites More sharing options...
LESH Posted March 28, 2011 Share Posted March 28, 2011 just saw a 66 yr old with ct proven appendicitis. I know this can happen at any age but generally I think of appendicitis as a disorder of folks under 50. I did too until I had one at 50+. Was not pretty..lol. Link to comment Share on other sites More sharing options...
browndog Posted March 28, 2011 Share Posted March 28, 2011 I had a 58 y/o female with CT proven acute appy. Pretty rare indeed. Link to comment Share on other sites More sharing options...
marilynpac Posted March 28, 2011 Share Posted March 28, 2011 I had a 58 y/o female with CT proven acute appy. Pretty rare indeed. You know we women just don't always read the book b/f we come down with our illnesses... Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 28, 2011 Author Moderator Share Posted March 28, 2011 I did too until I had one at 50+. Was not pretty..lol.they had ct scans when you were 50?.....:)probably didn't need one anyway because that dr osler was one sharp diagnostician....of course the open procedure using just ether must have been rough... Link to comment Share on other sites More sharing options...
LESH Posted March 28, 2011 Share Posted March 28, 2011 they had ct scans when you were 50?.....:)probably didn't need one anyway because that dr osler was one sharp diagnostician....of course the open procedure using just ether must have been rough... Use of ether came 10 years later. I was given a stick to bite on. I hear things are better now. Link to comment Share on other sites More sharing options...
eze8923 Posted March 28, 2011 Share Posted March 28, 2011 chose to do a presentation on the alvarado score during my 2nd year to review its efficacy as a risk stratification tool for appys. pretty interesting, but its success appears to be largely dependent on the circumstances during which it is applied. Link to comment Share on other sites More sharing options...
hrjames Posted March 28, 2011 Share Posted March 28, 2011 My first appy (as a student on surg rotation) was ~85 y/o male (no kidding). I did my long-student intake and he gave me a classic presentation of sx, had a fever ~103 but no elevated WBCs. I thought it was an appy but the surgeon & PA didn't believe me (which I DO understand - it was my first rotation, after all) and it wasn't well visualized on CT. He went to the OR late in the evening after he had perfed & became septic. It gave me an interesting case presentation. Interesting thought about limited MRI on kiddos. We try to go with serial exams when possible, but I've ordered my share of CTs on kids. Link to comment Share on other sites More sharing options...
icthus13 Posted March 29, 2011 Share Posted March 29, 2011 I had a 52 y/o lady a few weeks ago. Classic presentation. As for the kiddo's, I've ordered my fair share of CT's too but I usually try not to unless they have leukocytosis, fever, etc, but our surgeon's won't touch anyone without imaging. I haven't had much luck with RLQ ultrasound at our facility unless I'm looking for ovarian cysts. They never seem to be able to find the appendix. I'll have to talk to our rads dept about RLQ MRI; I don't think anyone here has tried it. Link to comment Share on other sites More sharing options...
medic25 Posted March 29, 2011 Share Posted March 29, 2011 I haven't had much luck with RLQ ultrasound at our facility unless I'm looking for ovarian cysts. They never seem to be able to find the appendix. I'll have to talk to our rads dept about RLQ MRI; I don't think anyone here has tried it. We've actually had a fair number of positive appy's on ultrasound, especially in our pedi population. I suspect like most ultrasounds, there is a component of operator proficiency. The strangest finding we had was two sisters with positive appy's within the course of a month; both were around 12-13 (don't recall but they may have actually been twins), and they were both imaged by the same ultrasound tech. Very strange coincidence! Link to comment Share on other sites More sharing options...
physasst Posted March 30, 2011 Share Posted March 30, 2011 This comes up frequently with us, and we are doing FAR, FAR more US for appy. Appendicitis is still, for the most part, a clinical diagnosis. E, I think I told you this story, but recently I had a young 21 year old female come in with classic appendicitis. Periumbilical pain, migrating....n/v/anorexia/fever/cramping...exam was consistent. Anyway, I called the surgery resident, who said "What did the CT show?" I said, I'm not getting a CT, this is an appendix....they got upset, and said, "It could be ovarian".....I said, It's not ovarian, pain pattern isn't right......They demand a CT...I say No.....Then as we were at a stalemate, I tell him "Look, you need to come see her....come see her first, and if you STILL want a CT AFTER you examine her, I'll order it"......He isn't happy, but comes down.....10 minutes later comes out of the room....."yeah, we'll take her to the OR"..... Most appendicitis cases can still be diagnosed clinically...NOT all mind you. Some patients as we all know are just poor historians, sometimes the presentation isn't straightforward, etc.etc.etc. Anyway, I'd say we use ultrasound more than CT (practitioner dependent to a degree) for appy...here at least. Oldest appy patient= 74...surprised the hell out of me. Had an elevated lactate, WBC, and crampy abdominal pain, I was more concerned about mesenteric ischemia.....got the CT, and BAM....there it was. Link to comment Share on other sites More sharing options...
marilynpac Posted March 30, 2011 Share Posted March 30, 2011 Thank God it was appy>ovarian, that surgeon would have been ramming it up your nose until you retired....just saying. Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 30, 2011 Moderator Share Posted March 30, 2011 64 female ct proved appy Link to comment Share on other sites More sharing options...
kargiver Posted March 30, 2011 Share Posted March 30, 2011 Had me an 85 yo female CT-proven appy without abscess or rupture 4 days ago... of course, her INR was 3.7 due to her mechanical heart valve so she needed to wait a little bit for her INR reversal to kick in before the General Surgeon took her to the OR (36 hours later). This is second one over 80 in the past 2 months. Prior to that the oldest I had seen mas mid 60s. I coulda sworn in both cases they were diverticulitis or colitis... G Link to comment Share on other sites More sharing options...
andersenpa Posted March 31, 2011 Share Posted March 31, 2011 http://www.jaapa.com/imaging-the-appendix/article/197449/?DCMP=EMC-JAAPA_Perspectives# Link to comment Share on other sites More sharing options...
jwells78 Posted March 31, 2011 Share Posted March 31, 2011 They demand a CT...I say No.....Then as we were at a stalemate, I tell him "Look, you need to come see her....come see her first, and if you STILL want a CT AFTER you examine her, I'll order it"......He isn't happy, but comes down.....10 minutes later comes out of the room....."yeah, we'll take her to the OR"..... Awesome. E- interesting stuff, limited MRI for RLQ pain in Peds. Our facility is going through such a struggle right now with US vs CT; our protocol is SUPPOSED to be US anyone under 14 y/o, but about 3/4 of our surgeons don't care what the US shows anyway- the consensus is always "just get a CT." So then we've called in an US tech to do a scan that in the end was useless, and we end up scanning anyway. Cluster. Anyway, who is the driving force behind the limited MRI at your facility? Surgeons or the ER Attendings? If the cost/sensitivity numbers are good or acceptable- why not? Link to comment Share on other sites More sharing options...
pahopeful Posted May 11, 2011 Share Posted May 11, 2011 I had an 85 yr old male about 2 months ago. White count was "normal", but had a shift, no bands. Mild ttp in rlq, with guarding. Scanned him to cya b/c abd pain and old almost always is something bad! :) Link to comment Share on other sites More sharing options...
PAstudentCanada Posted May 11, 2011 Share Posted May 11, 2011 Interesting for me as a Canadian PA-S to read through this thread. We order U/S to r/o appendicitis in kids/young folks. MRI is too expensive and too long a wait/not usually available and CT, of course, carries the risk of radiation. I was with a doc once who ordered an abdo CT on a 22 yr old female to r/o an appendicitis and the radiologist called down to emerg and gave him an earful. He never ordered one at that hospital again lol. In every emerg I've been in now, including community hospitals and major teaching hospitals I have found u/s to be the go-to diagnostic test when there is clinical suspicion of appendicitis. Link to comment Share on other sites More sharing options...
pahopeful Posted May 11, 2011 Share Posted May 11, 2011 There are many places where there is not an US tech that is trained to diagnose appy via US. That is the case at my current location. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted May 11, 2011 Author Moderator Share Posted May 11, 2011 U/S for appy is very operator dependent. at one of my jobs they never se the appy and at another they always do. mri for appy is probably what's coming down the pike, at least in kids. Link to comment Share on other sites More sharing options...
mostrike1 Posted May 12, 2011 Share Posted May 12, 2011 During PA school, I was able to see a 66 year old female patient who had a perforated appendix. The more interesting part was what was next to her perforated appendix...her VP shunt! pretty neat case to follow. Link to comment Share on other sites More sharing options...
Recommended Posts
Archived
This topic is now archived and is closed to further replies.