How to convince a surgeon to accept a RIF pain referral

I just love gyane on call. A 43 year old woman is brought to A&E complaining of severe right iliac fossa pain for the past day. A pregnancy test is negative. The surgeons think it is a gyane problem. The gyane team think it is appendicitis.

How can you avoid bouncing the patient between the two teams?

In this first post, I’ll go through the features of appendicits that a gyane person could use to convince the surgeons to come take a look.

Appendicitis 

There are two approaches. If the history is classic, you go to theatre. If it’s not but feel there’s enough to make you suspicious (and you have time), you might consider imaging.

Classic presentation

The classic clinical presentation goes through five sequential stages over two to three days:

  1. Vague umbilical colicky pain that does not bother the patient enough to attend

    Stage 1: Non specific colicky abdo pain
    Stage 1: Non specific colicky abdo pain
  2. Anorexia, nausea and gentle vomiting

    Stage 2: Loss of appetite, nausea and mild vomiting
    Stage 2: Loss of appetite, nausea and mild vomiting
  3. Constant right iliac fossa pain that does bother the patient enough to attend (perionitic i.e. worse on coughing/moving, patient keeps still, guarding and rebound tenderness)

    Stage 3: Localisation of pain to RIF with peritonitis features
    Stage 3: Localisation of pain to RIF with peritonitis features
  4. Low grade fever (<38)

    Stage 4: Low grade fever
    Stage 4: Low grade fever
  5. Leucocytosis (12-15*10^9 cells per mm^3)
Stage 5: Leukocytosis
Stage 5: Leukocytosis

This classic history occurs in less than 50% of patients.

Of all the features, the two which really increase the chances of appendicitis are right iliac fossa pain and a migratory history.

There are scoring systems such as the Alvadaro score. However clinical judgement may be superior, especially for more senior clinicians.

Examination tips: Rebound tenderness can be a bit mean if the patient is clearly in pain. Ask the patient to cough and if pain is localised to the right iliac fossa, then this is a good sign.

Is a PR exam helpful? Probably not, especially in the presence of a convincing history and examination. (That said, tenderness on the right side on PR may lead to suspicion of a pelvic appendix so may be worth doing if there is an atypical presentation or if other diagnoses are being considered).

Tests pretty much everyone gets: Urine dipstick (including pregnancy in females), FBC, CRP, U&E.

What to do: If you have a classic history and examination, go to theatre. Go directly to theatre. Do not pass radiology. Do not fill out a CT Abdo request.

Non classic presentation

Who typically presents atypically?

The young, the old and the pregnant. Important atypical presentations include acute confusional state (elderly) and right upper quadrant pain (pregnancy).

What types of appendices present atypically?

Retrocaecal appendix – more right loin pain, less right iliac fossa pain

Pelvic appendix – like a UTI with urinary frequency, suprapubic tenderness and even pyuria/haematuria.

Tenderness on the right side in a PR (or PV) examination is supportive of a pelvic appendix.

What to do: If you have a not quite classic history and examination, think through the differential. If the patient is not acutely unwell, it may be worth organising some imaging (often CT Abdo/Pelvis or a TVUSS gynae scan) to support the diagnosis or look for other causes.

Next week: How to convince a gynaecologist to accept RIF pain

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