Case Summary

Radiological discordance: The USG (done first) shows a dilated 10 mm appendix with appendiculoliths — the hallmark of acute appendicitis. The CECT (done later) calls the appendix "normal in size" but notes subtle omental fat stranding. This discordance likely reflects early/resolving appendicitis or a decompressed appendix on CECT, but the USG diagnosis of acute appendicitis takes clinical precedence given the appendiculoliths and 10 mm diameter.

Diagnosis: Acute Appendicitis (Uncomplicated) with Appendiculoliths

Management

1. Initial Resuscitation & Pre-operative Steps

• IV access + blood investigations: CBC (leukocytosis expected), CRP, LFT, RFT, coagulation profile, blood group & cross-match
• Urinalysis/urine culture (USG also showed cystitis — irregular bladder wall)
• β-hCG to exclude ectopic pregnancy (26F, corpus luteum seen)
• IV crystalloid resuscitation (normal saline/Ringer's lactate)
• NPO status, IV antiemetics, analgesia (IV paracetamol ± opioid)
• Foley catheter for urine output monitoring

2. Antibiotic Therapy

In this young woman, narrow-spectrum regimens (ceftriaxone + metronidazole) are preferred to minimize antibiotic resistance risk — evidence shows no difference in outcomes vs. extended-spectrum agents for uncomplicated appendicitis.

3. Timing of Surgery

• Uncomplicated appendicitis is no longer a surgical emergency requiring immediate OR
• Surgery can be safely delayed up to 24 hours from presentation without increased risk of progression to complicated appendicitis (Van Dijk et al.; NSQIP data)
• WSES Jerusalem 2025 Guidelines: Operate within 24 hours of presentation in adults with uncomplicated acute appendicitis
• ⚠️ Delay to hospital day 3 is associated with increased 30-day mortality and major complications

4. Surgical Management — Laparoscopic Appendectomy (Preferred)

• Patient supine; Foley catheter
• Pneumoperitoneum via Veress needle or Hasson trocar (12–15 mmHg CO₂)
• Three-port technique: umbilical 10–12 mm camera port + two 5 mm working ports (suprapubic + LIF or RIF)

1. Identify appendix at base of taenia coli
2. Window through mesoappendix with energy device
3. Divide mesoappendix (vessels controlled with LigaSure/clips)
4. Place two Endoloops or endostapler across base of appendix; transect
5. Retrieve specimen in bag through umbilical port
6. Irrigate/suction peritoneal cavity if soiled
7. Close fascia at 10+ mm ports; skin closure

5. Open Appendectomy

• McBurney's incision (gridiron) or lower midline for complicated disease
• Identify appendix → ligate base → purse-string suture (invagination optional)

6. Non-operative Management (Antibiotics Alone)

• Now an accepted option for uncomplicated appendicitis without appendicoliths in suitable patients
• However, this patient has appendiculoliths — associated with higher failure rates of antibiotic therapy (~40% at 1 year) and higher perforation risk → surgical management is strongly preferred

7. Management of Concurrent Cystitis

• Urine culture before starting antibiotics
• Empirical antibiotics: Nitrofurantoin 100mg BD × 5 days OR Trimethoprim-sulfamethoxazole for uncomplicated UTI
• The broad-spectrum antibiotics given for appendicitis (ceftriaxone/piperacillin-tazobactam) will also cover urinary organisms — dual treatment may not be needed

8. Post-operative Care

• Mobilize early (POD 1)
• Resume diet when bowel sounds return
• Wound care; DVT prophylaxis (LMWH)
• Discharge typically 24–48 hours post laparoscopic appendectomy
• Histopathology of specimen is mandatory (to exclude carcinoid tumor, mucocele)

Summary Algorithm

Diagnosis confirmed (USG: 10mm appendix + appendiculoliths)
           ↓
IV access → bloods → β-hCG → NPO → IV fluids
           ↓
Broad-spectrum IV antibiotics (ceftriaxone + metronidazole)
           ↓
Schedule laparoscopic appendectomy within 24 hours
           ↓
Post-op: no further antibiotics needed (uncomplicated)
Treat cystitis separately with urine culture-guided therapy