The approach to a patient with potential appendicitis varies with the nature of the initial presentation, and it is a paradox in time management. Given the spectrum of appendicitis presentations, the overall goal is to eliminate delay to definitive care in clear cases of appendicitis but to allow time for other potential subtle presentations to evolve into more diagnostic certainty. In general, patients with abdominal pain can be stratified into four groups with respect to their potential for appendicitis. The first group is composed of patients who demonstrate the classic presentation for acute appendicitis. The management of these patients is straightforward, involving prompt surgical consultation and subsequent appendectomy. The emergency department course is focused on preoperative preparation, as outlined previously.

The second group includes those patients with signs and symptoms that are suspicious but not diagnostic for appendicitis. These patients are the most difficult to manage. This group of patients would most likely benefit from imaging studies, either CT or ultrasound, to elucidate the diagnosis. Observation for a 4- to 6-h period with serial examinations may clarify the evolution of the underlying pathologic condition. Surgical consultation is clearly indicated in cases where the examination becomes progressively more characteristic of appendicitis or if a surgical finding is identified on an imaging study.

The third group involves those patients with presentations minimally evoking appendicitis as a diagnostic possibility or for whom appendicitis is not a consideration in the cause of their abdominal complaint. These patients represent the highest medicolegal risk for the emergency practitioner. These patients should be observed in the emergency department for a period, with serial examinations. If the course remains benign and no other contraindications to discharge exist, they should be sent home with no diagnostic label (e.g., nonspecific abdominal pain). Clear follow-up instructions are critical to ensuring optimal outcomes for patients.

For patients with abdominal pain cleared for discharge, follow-up instructions are paramount. Patients should be told that no clear cause for their symptoms was found but that over time their symptoms will either abate or coalesce into a recognizable pattern. Follow-up instructions should include a description of worrisome symptoms that suggest progressive disease and warrant return to the emergency department. Patients should be reevaluated in 12 to 24 h by their primary physician or by the emergency department to ensure resolution of symptoms. Patients should be cautioned to avoid strong analgesics that might mask evolving pathologic processes; instead, they should be instructed to return if their pain increases. In this fashion, the emergency physician establishes a clear continuity of care for the patient with guidelines that minimize the likelihood of an adverse outcome.

The last group is composed of all high-risk special populations presenting with abdominal pain. This group includes elderly, pediatric, pregnant, and immunocompromised patients. As emphasized earlier, these patients require a high index of clinical suspicion and a low threshold for surgical consultation to avoid morbidity and mortality from undetected appendicitis.

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