A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A 19-year-old man comes to the emergency department because of abdominal pain, nausea, and vomiting for 4 hours. Initially, the pain was dull and located diffusely around his umbilicus, but it has now become sharper and moved towards his lower right side. He has no history of serious illness and takes no medications. His temperature is 38.2°C (100.7°F) and blood pressure is 123/80 mm Hg. Physical examination shows severe right lower quadrant tenderness without rebound or guarding; bowel sounds are decreased. His hemoglobin concentration is 14.2 g/dL, leukocyte count is 12,000/mm3, and platelet count is 280,000/mm3. Abdominal ultrasonography shows a dilated noncompressible appendix with distinct wall layers and echogenic periappendiceal fat. Intravenous fluid resuscitation is begun. Which of the following is the most appropriate next step in management?
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A
Begin bowel rest and nasogastric aspirationIncorrect. Bowel rest and NG decompression manage SBO or pancreatitis, not appendicitis — appendicitis without operation progresses to perforation.
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B
Perform percutaneous drainageIncorrect. Percutaneous drainage is for an established periappendiceal abscess; this patient has no abscess, so it is not the next step.
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C
Prescribe oral amoxicillin and clavulanic acidIncorrect. Antibiotics-only treatment is investigational in select uncomplicated cases; it is not the standard of care, and oral amox-clav is inferior to laparoscopic appendectomy.
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D
Perform laparoscopic appendectomyCorrect. Uncomplicated acute appendicitis is treated with prompt laparoscopic appendectomy after fluid resuscitation and a perioperative antibiotic dose.
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E
Administer IV antibiotics and observe without surgeryIncorrect. Nonoperative antibiotic-only management has been studied in select uncomplicated cases but is not yet standard of care; prompt laparoscopic appendectomy remains the gold-standard treatment for acute appendicitis.
↑ Tap an answer to reveal the reasoning
Answer: D. Periumbilical pain that migrates to the right lower quadrant, fever, leukocytosis, and ultrasonography showing a dilated, noncompressible appendix with distinct wall layers and echogenic periappendiceal fat is uncomplicated acute appendicitis. The standard of care is prompt laparoscopic appendectomy after intravenous fluid resuscitation and a single preoperative dose of broad-spectrum antibiotics. Laparoscopic appendectomy has lower wound infection rates, shorter hospitalization, and faster return to activity than open appendectomy, and timely surgery prevents perforation, peritonitis, and abscess formation.
The alternatives are wrong because uncomplicated appendicitis should not be managed expectantly. Bowel rest and nasogastric decompression is supportive care for partial small-bowel obstruction or pancreatitis — not a definitive treatment for appendicitis. Percutaneous drainage is reserved for appendicitis complicated by a well-formed periappendiceal abscess (a phlegmon) where interval appendectomy is planned weeks later; this patient has no abscess. Antibiotic-only therapy is an emerging option in carefully selected uncomplicated cases but is not first-line in the USMLE/NBME context (and the wrong agent here — oral amoxicillin-clavulanate is the older Europe-only outpatient regimen and is associated with high recurrence).
Clinical pearl: dilated noncompressible appendix >6 mm with periappendiceal fat stranding is the imaging triad of uncomplicated appendicitis; proceed to laparoscopic appendectomy.
**Why each option:**
**A.** Bowel rest and NG decompression manage SBO or pancreatitis, not appendicitis — appendicitis without operation progresses to perforation.
**B.** Percutaneous drainage is for an established periappendiceal abscess; this patient has no abscess, so it is not the next step.
**C.** Antibiotics-only treatment is investigational in select uncomplicated cases; it is not the standard of care, and oral amox-clav is inferior to laparoscopic appendectomy.
**D.** Correct. Uncomplicated acute appendicitis is treated with prompt laparoscopic appendectomy after fluid resuscitation and a perioperative antibiotic dose.