Clinical Commander

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gi.acute-appendicitis.core.v1

Acute Appendicitis

gastroenterologyacuteadultacuteinpatient
Start encounter →Print handoutPRODUCTION

Manifest is complete with WSES 2020 + SAGES 2024 + CODA + APPAC III evidence; problem-package exists at acute-appendicitis/. Gaps for INTEGRATED: no `_design-brief.md` on disk for this engine (briefs only present for gi.cirrhosis_decompensation.inpatient and gi.gi_bleed.acute); evidence.pmids array is empty (manifest references guideline labels but no numeric PMIDs); no test_files for this engine specifically; AIR score calculator + Pediatric Appendicitis Score not in clinical-tools-registry. No regimen_axes authored — antibiotic regimens (cefazolin, ceftriaxone+metronidazole, pip-tazo, ertapenem) live in manifest.medications but are not wired through regimen-builder with verified RxCUIs.

Entry points (5)

  • symptom
    Right lower quadrant pain (ACG 2024)
    rlq_pain
  • symptom
    Periumbilical pain migrating to RLQ (ACG 2024)
    periumbilical_pain_migration
  • symptom
    Anorexia + nausea/vomiting (ACG 2024)
    anorexia_nausea_vomiting
  • lab_abnormality
    Leukocytosis with left shift (ACG 2024)
    leukocytosis
  • imaging
    CT showing appendiceal inflammation (ACG 2024)
    ct_appendicitis

Required inputs (14)

  • agerequired
    demographic • used at CONTEXT
    Drives Alvarado/AIR scoring, pediatric vs adult pathway, neoplasm risk >40 (ACG 2024)
  • sexrequired
    demographic • used at CONTEXT
    Pregnancy test in females; pelvic differentials (ACG 2024)
  • temperaturerequired
    vital • used at CONTEXT
    Fever as part of Alvarado; sepsis screen (ACG 2024)
  • hrrequired
    vital • used at CONTEXT
    Tachycardia for SIRS/sepsis screen (ACG 2024)
  • sbprequired
    vital • used at CONTEXT
    Hemodynamic stability; sepsis screening (ACG 2024)
  • wbcrequired
    lab • used at INITIAL_WORKUP
    Leukocytosis is core Alvarado/AIR component (ACG 2024)
  • crprequired
    lab • used at INITIAL_WORKUP
    Elevated CRP supports Dx; combined WBC+CRP improves sensitivity (ACG 2024)
  • creatininerequired
    lab • used at CONTEXT
    Renal function for contrast CT, antibiotic dosing (ACG 2024)
  • beta_hcg
    lab • used at CONTEXT
    Pregnancy status changes imaging modality (US/MRI over CT) (ACG 2024)
  • ct_abdomen_pelvisrequired
    imaging • used at INITIAL_WORKUP
    Adult first-line imaging; sens >80%, spec >93% per SAGES 2024
  • us_abdomen
    imaging • used at INITIAL_WORKUP
    First-line in pregnancy and pediatrics to limit radiation (ACG 2024)
  • prior_appendicitis
    history • used at CONTEXT
    Recurrent disease changes nonop vs op decision (CODA 2-year) (ACG 2024)
  • pregnancy_status
    history • used at CONTEXT
    Drives imaging and operative timing (ACG 2024)
  • immunocompromise
    history • used at CONTEXT
    Atypical presentation; lower threshold for surgery (ACG 2024)

12-phase flow (12)

  1. 1FRAME
    Confirm acute abdomen scope — exclude pregnancy/pediatric pathway divergence and ruptured AAA mimics (ACG 2024)
    inputs: age, sex
    advance: patient is hemodynamically assessable and pregnancy status known
  2. 2ENTRY
    Capture chief complaint of RLQ/periumbilical pain with anorexia, nausea, vomiting (ACG 2024)
    advance: one entry trigger present
  3. 3CONTEXT
    Vitals, focused HPI (pain migration, duration), pregnancy/comorbidity screen, allergies (ACG 2024)
    inputs: temperature, hr, sbp, creatinine, pregnancy_status, immunocompromise
    advance: vitals + key history captured
  4. 4RED_FLAGS
    Screen peritonitis, sepsis/SIRS, free air on imaging, hemodynamic instability, pregnancy, appendicolith (ACG 2024)
    inputs: sbp, hr, temperature
    actions: calc.qsofa
    advance: no peritonitis/shock or escalated to OR
  5. 5INITIAL_WORKUP
    CBC + CRP + BMP + urinalysis + beta-hCG; CT abdomen/pelvis with IV contrast (US/MRI in pregnancy/peds) (ACG 2024)
    inputs: wbc, crp, ct_abdomen_pelvis, beta_hcg
    actions: panel.cbc, panel.renal
    advance: imaging + labs returned
  6. 6BRANCHING_WORKUP
    If pregnancy → US first then MRI; if abscess/phlegmon → IR consult; if elderly → broader differential (ACG 2024)
    inputs: us_abdomen
    actions: acute_abdomen
    advance: phenotype identified (uncomplicated / complicated / abscess / pregnancy / elderly)
  7. 7DIFFERENTIAL
    Confirm appendicitis vs mesenteric adenitis, ovarian/ectopic, ureteral colic, cecal diverticulitis, Crohn ileitis (ACG 2024)
    inputs: ct_abdomen_pelvis
    advance: differential narrowed; appendicitis confirmed or alternative routed
  8. 8RISK_STRATIFICATION
    Alvarado / AIR score for pre-test probability; WSES grade 0-4 for severity; sepsis screen (ACG 2024)
    inputs: wbc
    actions: calc.alvarado, calc.news2
    advance: severity grade and operative risk documented
  9. 9TREATMENT
    Laparoscopic appendectomy first-line; antibiotic-first reasonable for selected uncomplicated; IR drainage for abscess; emergent OR for perforation/sepsis (ACG 2024)
    inputs: creatinine
    advance: operative or non-operative plan agreed with shared decision
  10. 10DISPOSITION
    OR same day for uncomplicated/complicated; ICU/step-down for septic; admit for IR drainage of abscess (ACG 2024)
    inputs: sbp
    advance: destination set (OR / ICU / floor / observation)
  11. 11MONITORING
    Serial abdominal exams, vitals q4h, WBC/CRP trend at 48h, diet advancement post-op, wound check (ACG 2024)
    inputs: wbc, crp
    advance: clinical improvement or escalation per protocol
  12. 12FOLLOWUP
    Post-op clinic 2 weeks + path review; interval appendectomy 6-8 weeks for abscess/phlegmon; colonoscopy if ≥40 (ACG 2024)
    advance: follow-up scheduled and return precautions given