Appendicitis case presentation

DEPARTMENT OF SURGERYNORTHERN MINDANAO MEDICAL

CENTER“Towards Excellence in Patient Care and Safety”

Clerk’s Presentation

SC Ian Christian A. GonzalesXU JPRSM



GENERAL OBJECTIVE:• To present a case of a 28 year old male

presenting with abdominal pain

SPECIFIC OBJECTIVES:• to present the history and physical examination • to discuss anatomy, functions, incidence,

pathogenesis, and management of the diagnosis

M.E.28 year old maleFilipinoRoman Catholic Manticao, Misamis Oriental March 2, 2014.

General Data



Abdominal pain

Chief Complaint



Morning PTASudden abdominal pain in the epigastric area, persistent, diffuse in quality, non-radiating, with a pain score of 8/10 aggravated by physical activity and unrelieved by rest

History of Present Illness



Associated anorexia and nausea(-) fever, change in BM, dysuria, flank pain




12 hours PTAAbdominal pain now localized to the right lower quadrant with a pain score of 10/10.




(-) hypertension(-) diabetes(-) bronchial asthma(-) previous hospitalization(-) previous surgery

Past Medical History



hypertension on the paternal side Family History

Personal/Social History laborer high school graduatenon smoker, non alcoholic



Physical Examination

awake, coherent, afebrile, not in respiratory distressGeneral Survey

Vital Signs BP: 100/70 mmHg Wt: 50kg HR: 82 bpm BMI: 20kg/m2 RR: 20 cpm Temp: 36.9 C



acyanotic(-) jaundice(-) pallorwarmgood turgor

Skin



anicteric scleraepinkish palpebral conjunctivae(-) alar flaring moist lips, tongue, and oral mucosae (-) oropharyngeal lesions

HEENT



trachea in midline non palpable thyroid gland (-) cervical lymphadenopathy Neck



symmetric chest expansion (-) retractions clear breath sounds

Chest and Lungs



normal rateregular rhythm (-) heaves/thrills (-) murmur

Cardiovascular System



flat normoactive bowel sounds soft (+) direct tenderness, RLQ (+) rebound tenderness, RLQ (+) Rovsing’s sign

Abdomen



(-) costovertebral angle tendernessGenitourinary System

symmetric, brisk pulses (-) edema CRT < 2 secExtremities



(-) perianal lesions good sphincter tone (-) rectal mass non palpable prostate gland (+) greenish fecal mater examining finger (-) pararectal tenderness (-) blood on examining finger

Rectal Exam



Salient Features

sudden, severe abdominal pain of localizing RLQ area anorexia nausea

History



Physical Examination (+) RLQ tenderness (+) RLQ rebound tenderness(+) rovsing sign



Impression

Acute Appendicitis

Differentials

Rule In Rule OutUrinary tract infection

- sudden onset abdominal pain-nausea- vomiting

- No dysuria- No urinary

frequency- No hematuria

Acute gastroenteritis

-abdominal pain - No episodes of loose watery stool

Mesenteric adenitis

-right lower quadrant pain-nausea

- No history upper respiratory infection

Course in the Ward

At the wards... admitted at surgical ward NPO plan:For E AppendectomyCefoxitin 1gm IVTT



Labs: CBCHb 13.5 g/dLHct 41%WBC 9,500/uLNeutrophils 79%Plt 312,000



Labs: UAYellowClearSpGrav 1.020pH 6.5(-) sugar, (-) proteinWBC 0-1, RBC 0-1, Epith rare



Labs: ChemistryNa 144.30 mEq/LK 4.5 mEq/L



Intraop findings:Gangrenous appendicitis



Case Discussion

first becomes visible in the eighth week of embryologic developmentdisplaced medially toward the ileocecal valve (growth rate of the cecum exceeds that of the appendix) Relationship of base is relatively fixed Tips may be variable (retrocecal, pelvic, subcecal, preileal, or right pericolic)

Anatomy



taeniae coli converge – important landmark to identify the appendix Length varies from length <1 cm to >30 cm (Average: 6 to 9 cm)Blood supply: appendiceal artery ileocolic artery superior mesenteric artery



Lymphoid tissue first appears in the appendix approximately 2 weeks after birthimmunologic organ secretes immunoglobulins (IgA)Appendectomy may have a protective role against IBD (mechanism unclear)

Functions



second through fourth decades of lifemean age of 31.3 years median age of 22 years male:female predominance (1.2 to 1.3:1)rate of misdiagnosis (15.3%)lifetime rate of appendectomy is 12% for men and 25% for women

Incidence



Obstruction of the lumenFecaliths hypertrophy of lymphoid tissueinspissated barium from previous x-ray studiestumorsvegetable and fruit seedsintestinal parasites

Etiology



Pathogenesis

proximal obstruction of the appendiceal lumen

closed-loop obstruction

continuous normal secretion by the appendiceal mucosa

lumen distension

Stimulation of the nerve endings of visceral afferent

stretch fibers

vague, dull, diffuse pain in the midabdomen or lower

epigastrium

peristalsis

cramping

continuous normal secretion by the appendiceal mucosa

Increased magnitude of lumen distension

continued mucosal secretion & rapid multiplication

bacteria

Venous pressure is exceeded

more severe diffuse visceral

pain

Reflex nausea and vomiting

Occlusion of capillaries and venules; arteriolar inflow continues

Inflammation of the appendiceal serosa

Compromise of arteriolar outflow

Peritoneal irritation with shift of pain in the

region of inflammation

engorgement and vascular congestion

Progressive distension

ellipsoidal infarcts @ antimesenteric border

Perforation

Escherichia coliBacteroides fragilisprincipal organisms seen in the normal appendix, in acute appendicitis, and in perforated appendicitis

Bacteriology





Abdominal pain Epigastric then localizing to the RLQ within 1-12 hoursVariations: Retrocecal – flank/back painPelvic – suprapubic painRetroileal – testicular pain

Symptoms



Anorexia nearly always accompanies appendicitisvomiting occurs in nearly 75% of patients (neural or ileus) Usual sequence :Anorexia abdominal pain vomiting



RLQ tendernessRLQ rebound tendernessRovsing’s sign Psoas sign Obturator sign

Signs



CBC (WBC count): 10,000 to 18,000 cells/mm3 (acute, uncomplicated appendicitis)>18,000 cells/mm3 (complicated appendicitis., possible perforated appendix +/- abscess)

Laboratory Findings



designed to improve the diagnosis of appendicitis and was devised by giving relative weight to specific clinical manifestation

Alvarado’s Scoring

importance of early operative intervention (appendectomy) should not be minimizedAdequate hydration Correct electrolyte abnormalities Stabilize comorbidities

Management



Antibiotics simple acute appendicitis – no need to extend coverage beyond 24 - 48 hours (single-agent therapy with cefoxitin, cefotetan, or ticarcillin-clavulanic acid)



• perforated or gangrenous appendicitis – continued until afebrile or has decreasing white count , 7-10 days (single-agent therapy with carbapenems or combination therapy with a third-generation cephalosporin, monobactam, or aminoglycoside plus anaerobic coverage with clindamycin or metronidazole)



EndDEPARTMENT OF SURGERY

NORTHERN MINDANAO MEDICAL CENTER

“Towards Excellence in Patient Care and Safety”

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Appendicitis case presentation