A case presentation onAcute Appendicitis

in the young

Aldwin Ong

MD070061

15 February 2011

General objectives

To present a case of a young patient with Acute Appendicitis

Specific Objectives

To discuss Acute Appendicitis in the young, in particular:

Pathophysiology of appendicitisSigns and symptoms of AP in the youngDiagnosis of APManagement principles of AP

General data• J.T.G.• 18 y/o • Male• Pasig City, Philippines • Primary Informant: Patient (Reliability:

75%)

Chief complaint

• “Sobrang sakit na ng tiyan ko”

History of present illness

Late evening 3 days PTA

Patient had sudden onset intermittent low to mid back pain, PS 4/10, associated with new onset fever, Tmax 39.8. No dysuria, no vomiting no nausea.

Paracetamol taken with temporary relief. No consults done.

History of present illness

2 days PTA

Pain became more pronounced in the epigastric region, PS 6-7/10, still intermittent; back pain now relieved. With 3 episodes of loose watery stool, loss of appetite, still associated with high-grade fever. No vomiting, no dysuria.

Paracetamol continued. No consults done.

History of present illness

1 day prior to consult

Consult done at RMC. CBC and UA done. Impression was Acute Appendicitis, however, no vacant beds

Admission

Epigastric pain persisted, now also with RLQ pain, persistent, PS 8-9/10, associated with fever, anorexia, nausea. No more loose stool.

Review of systemsGeneral: no weight loss, no weakness, no fatigue

MS & Skin: no other lumps/masses, no rashes, no sores, no itching, no arthralgia, no color changes

HEENT: no headache, no dizziness, no enlarged lymph nodes, no cough, no colds

Review of systemsCardiovascular: no palpitations, no chest pain, no syncope

Respiratory: no dyspnea, no hemoptysis, no shortness of breath, no cough, no wheezing

Gastrointestinal: no vomiting, no jaundice

Review of systemsGenitourinary: no edema, no

dysuria, no frequency, no urgency Endocrine: no diaphoresis, no

cold intolerance, no heat intolerance

Nervous: no seizure, no tremor

Past medical history• Born with cleft lip

• Repaired during infancy• Asthma, controlled

• No medications being taken• No DM II• No known allergies• Immunization up-to-date• No other hospitalizations; no other surgeries

Family history

Asthma, DM, HypertensionNo known congenital diseases in the family

Personal & Social History

• Denies smoking• Occasional alcoholic beverage

drinker• Denies illicit drug use

Personal & Social History

• Eldest of 3 children• Good relationship with parents and siblings• Stopped schooling at 2nd yr HS due to

computer gaming• Since then has tried to work as a computer

shop attendant• Attempted to go back to school, but

dropped out soon after due to laziness• Currently not going to school or work

• Likes to play basketball for his pastime

Physical examinationGeneral Survey:

Awake, alert, not in apparent cardiorespiratory distress.

Vital Signs:BP 90/60 HR 98RR 20T 39.2C

Physical examination• Skin:

•Fair and even color, no rashes noted, good turgor

• HEENT: •Pink palpebral conjunctivae, anicteric sclerae. •No TPC, No CLAD. Flat neck veins.

Physical examination• Chest/Lungs:

• symmetrical chest expansion, no retractions, resonant in all LF, clear breath sounds, no rales, no rhonchi, no wheezes

• Heart: • adynamic precordium, no heaves, no lifts,

no thrills, PMI at 5th ICS LMCL, normal rate, regular rhythm, no murmur

Physical examination• Abdomen:

• flat, hyperactive bowel sound, guarding, (+) direct and rebound tenderness at RLQ > epigastric area, (–) Rovsings Sign, (–) CVA tenderness, no hepatosplenomegaly, no palpable masses

• Extremities: • No gross deformities, full and equal pulses, no edema

• Rectum:• Not indicated

• Genitalia: • Not indicated

Physical examination

• Cerebrum: • GCS 15• Conversant. Intact Sensorium.

• Rest of neurologic exam unremarkable.

• 18 y/o Male• 3 day history of migrating, progressive

abdominal pain, noted initially at the lower back, then epigastric area, and eventually localizing at the RLQ, associated with high-grade fever, anorexia, loose bowel movement, and nausea.

• With physical findings of abdominal guarding, hyperactive bowel sounds, direct and rebound tenderness at RLQ.

Salient Features

t/c Acute Appendicitis

r/o Urinary Tract Infectionr/o Acute Gastroenteritis

r/o Dengue Fever

Initial Impression

Diagnostics DoneCBCUrinalysisFecalysisDengue NS1

CBCHgb 160 g/LHct 0.48WBC 7.6

N 0.86L 0.09M 0.05

Plt 193

URINALYSISRBC 4/hpf [0-2]WBC 2/hpf [0-2]EC 7/hpf [0-2]Casts 0/hpfBact 1/hpf [0-20]FECALYSISColor GreenConsistency LooseMucus PositiveBlood (G/O) NegativeNo Ova or Parasite seenNegative for Amoeba

DENGUE NS1 Negative

Final Diagnosis

Acute Appendicitis

ManagementOpen Appendectomy

Case discussion

Acute Appendicitis in the Pediatric Age Group

Statistics• Acute appendicitis is the most common condition

requiring emergency abdominal operation in childhood.

• Perforation rates in children = 30-60%

• Greatest risk of perforation is in children 1-4 year old (70-75%)

• Lowest risk of perforation is in the adolescent age group

• The adolescent age group has the highest age-specific incidence of appendicitis in childhood

Epidemiology• 6% of population, M>F

• 80% between 5-35 years of age

Operative DefinitionsUncomplicated Appendicitis - includes the acutely inflamed, phlegmonous, suppurative, or mildly inflamed appendix with or without peritonitis  Complicated Appendicitis - includes gangrenous appendicitis, perforated appendicitis, localized purulent collection at operation, generalized peritonitis and periappendiceal abscess Equivocal Appendicitis – a patient with right lower quadrant abdominal pain who presents with an atypical history and physical examination and the surgeon cannot decide whether to discharge or to operate on the patient

Pathogenesisluminal obstruction bacterial overgrowth inflammation/swelling increased pressure localized ischemia gangrene/perforation localized abscess (walled off by omentum) or peritonitisIn young children, the omentum is poorly developed

Perforation is not usually confinedBacterial invasion of mesenteric veinsPortal vein sepsis and subsequent liver abscess may formInflammatory process intestinal obstruction or paralytic ileus

EtiologyChildren or young adult: hyperplasia of lymphoid follicles, initiated by infection Adult: fibrosis/stricture, fecolith, obstructing neoplasmOther causes: parasites, foreign body

SymptomsCommon symptoms of appendicitis

abdominal painanorexia nauseaconstipation vomiting

Vomiting less common with uncomplicated appendicitis Profuse vomiting may indicate generalized peritonitis associated with perforation

SymptomsAppendicitis in children is more difficult to recognize clinically than in adults:

abdominal pain is often poorly localized small children are rarely able to describe their symptoms clearly

SymptomsChildren with appendicitis may have atypical history

Based on (2007) diagnostic cohort study 755 children enrolled over 20 month periodcommon clinical features reported in only 50%-68% children

pain migration in 50% anorexia in 60% maximal pain in right lower quadrant in 68%

45% had abrupt onset of pain

In (1997) series of 63 children < 3 years old with appendicitis, 57% initially misdiagnosed

33% had diarrhea as presenting symptom 84% had perforation and/or gangrene

Diagnostic Management

Diagnosis of appendicitis is still highly based on history, and physical examinationImaging modalities may be helpfulBlood parameter including CBC and CRP may also help

Mild leukocytosis with left shift (may have normal WBC counts) Higher leukocyte count with perforation

Laboratory TestsCBC

Mild leukocytosis with left shift (may have normal WBC counts)

Higher leukocyte count with perforation

UrinalysisTo rule out urinary tract infection

Clinical Decision RuleClinical decision rule:

absolute neutrophil count > 6,750/mcL, OR combination of nausea PLUS maximal tenderness in right lower quadrant

This rule appears sufficiently sensitive for appendicitis that children without these features can be observed without CT imaging

Pediatric Appendicitis Score (PAS)

Pediatric Appendicitis Score (PAS)

The PAS predicts appendicitis in > 70% children if score ≥ 7 andRules out appendicitis in > 99% patients with score < 2

Alvarado/MANTRELS

9-10: almost certain, little advantage for further work-up7-8: high likelihood5-6: compatible but not diagnostic0-4: Unlikely

Equivocal Appendicitis in

Pediatric Age GroupImaging modalities that may be used: • Ultrasound (Sensitive but not specific)

•to confirm acute appendicitis but not to definitively rule out acute appendicitis

• CT Scan (Sensitive and specific)•if diagnosis uncertain after ultrasound, use abdominal and pelvic CT to confirm or rule out acute appendicitis

For pediatric patients, UTZ is preferred because of its:• lack of radiation • cost-effectiveness • availability compared to CT scan

CT Images

UTZ Image

Therapeutic Management

Definitive management for Acute Appendicitis in the Pediatric age group is Appendectomy via (PCS, 2002):

1. Open Appendectomy2. Laparoscopic Appendectomy

ProphylaxisAntibiotic prophylaxis (Adults vs. Children)

Uncomplicated APCefoxitin 2 grams IV single dose (Adults)

40 mg/kg IV single dose (Children)Ampicillin-sulbactam 1.5-3 grams IV single dose (Adults)

75 mg/kg IV single dose (Children)Amoxicillin-clavulanate 1.2 –2.4 grams IV single dose (Adults)

45 mg/kg IV single dose (Children)

ProphylaxisFor therapy of complicated appendicitis in pediatric patients:

Ticarcillin-clavulanic acid 75 mg/kg IV every 6 hours

Alternative agents for pediatric patients include:

Imipenem-Cilastatin 15-25 mg/kg IV every 6 hours

For children with beta-lactam allergyGentamicin 5 mg/kg IV every 24 hours plus Clindamycin 7.5 –10 mg/kg IV every 6 hours

ComplicationsOccurs in 25-30% of children with appendicitis, especially those with perforations. Includes:

Wound infectionsIntra-abdominal abscessLiver abscess from portal vein sepsisIntestinal obstructionInfertility from post-op adhesions

Psycho-socialUnfounded belief that running after eating causes appendicitisAbsences in schoolAppendicitis is a common condition that must be anticipated and/or understood by lay people

Public healthReducing mortality through campaigns to recognize symptomsProper referral systems to reduce delays in transfer of patient

Thank You !

ReferenceBrunicardi, FC, et. al. 2010. Schwartz’s principles of surgery.Toronto Notes 2010.Nelson’s Textbook of Pediatrics.Dynamed. Ebscohost.The Diagnosis of Appendicitis in Children: Outcomes of a Strategy Based on Pediatric Surgical Evaluation Ann M. Kosloske, C. Lance Love, James E. Rohrer, Jane F. Goldthorn and Stuart R. Lacey. Am Ac of Pediatrics 2004;113;29-34

A case presentation onAcute Appendicitis

in the young

Aldwin Ong

MD070061

15 February 2011