A patient presents with right iliac fossa pain for 48 hours. USG image (shown with Doppler) demonstrates a hyperaemic appendix-region structure with surrounding inflammatory changes. There is no free fluid or evidence of perforation on USG. What is the most appropriate next step?

1. A

   A. Direct surgical management (emergency appendicectomy)

2. B

   B. Contrast-enhanced CT (CECT) of the abdomen and pelvis

3. C

   C. USG-guided biopsy of the lesion

4. D

   D. USG-guided percutaneous drainage

Appeared in: INI-CET EXAM -2026

Explanation

• The patient's symptoms have been present for 48 hours, which increases the risk of complications like an appendiceal phlegmon (a mass of inflamed tissue) or an abscess, even if not obvious on ultrasound.
• A Contrast-Enhanced CT (CECT) scan has higher sensitivity and specificity than ultrasound for diagnosing appendicitis and is far superior for identifying and staging complications.
• CECT provides a detailed anatomical 'roadmap' that is crucial for determining the best course of action: immediate surgery for uncomplicated appendicitis, or a non-operative approach (antibiotics, possible drainage) for a phlegmon or abscess.
• Therefore, obtaining a CECT is the most prudent and appropriate next step to ensure the correct treatment is chosen, minimizing potential surgical complications.

Why Other Options Were Wrong

• Option A: While appendicectomy is the definitive treatment for appendicitis, proceeding directly to surgery without fully assessing for complications like a phlegmon can be risky. Operating on a dense phlegmon can be technically difficult and may lead to increased morbidity.
• Option C: A biopsy is used to obtain a tissue sample for histopathological analysis, typically to diagnose cancer or other specific tissue diseases. It has no role in the diagnosis of an acute inflammatory condition like appendicitis.
• Option D: Percutaneous drainage is a procedure to drain a collection of pus (an abscess). The ultrasound report explicitly states there is 'no free fluid,' and there is no mention of a walled-off abscess, making this intervention inappropriate.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Diagnostic and management pathway for suspected acute appendicitis to guide bedside assessment, documentation, and the next nursing action.
• A nurse's role includes preparing the patient for a CECT scan, which involves ensuring IV access, checking for allergies to contrast media, and assessing renal function (creatinine levels), as contrast can be nephrotoxic.
• Nurses must continuously monitor patients with suspected appendicitis for signs of deterioration, such as increasing fever, worsening pain, or signs of peritonitis (rigid abdomen), and report them immediately, as this could indicate perforation and the need for urgent surgery.
• Understanding the management pathways for uncomplicated versus complicated appendicitis is crucial for patient education and managing expectations regarding treatment plans, which may range from immediate surgery to a course of IV antibiotics.

How to Approach the Question

• First, analyze the patient's clinical presentation: right iliac fossa pain is a classic sign of appendicitis.
• Next, interpret the key information from the stem: the 48-hour duration is significant because it raises the risk of complications.
• Evaluate the imaging findings: The USG with Doppler is highly suggestive of appendicitis ('hyperaemic appendix-region structure'). However, note the limitations of USG in detecting complications.
• Consider the options in the context of the 48-hour timeline. The main decision is between immediate treatment (surgery) and further, more definitive diagnosis/staging (CECT).
• Rule out inappropriate options: Biopsy (for tumors) and drainage (for abscesses, which are not seen) are incorrect.
• Conclude that because of the risk of complications like a phlegmon after 48 hours, a CECT is the most appropriate next step to confirm the diagnosis and guide the choice between immediate surgery and conservative management.

Concept Tested & Keywords

• Concept Tested: Diagnostic and management pathway for suspected acute appendicitis.
• Stem keywords: right iliac fossa pain, 48 hours, USG image, Doppler, hyperaemic appendix, inflammatory changes, no free fluid
• Lead-in keywords: most appropriate next step
• Clinical cues: The 48-hour duration of symptoms is a key clinical cue, as it increases the suspicion for complicated appendicitis (phlegmon or abscess), which may alter the immediate management plan.

Question ID

Qzun1woB43jbgyrUXxeBEG

Copy ID

Reference Book

E6 Medicine Harrison 22e Part 2 p. 500-502

E6 Nelson Textbook of Pediatrics(2024) — Volume 2 p. 182-184