ACUTE APPENDICITIS!

DATE: 30TH OCT. 2012

Time of interview: 1-5 PM Date of interview: 23rd Oct.12

General Data:
Allan macapagal, 37 y/o, married, Roman Catholic, works as a welder in Manila, from Arayat Pampanga.

Source and Reliability: The patient himself. Seems Reliable (90%)

Chief Complaint:
Epigastric pain.

History of present illness:

On Oct 22nd, 10 AM, he experienced remitting epigastric pain of pain scale 5/10 (10 being the most severe pain the patient has ever experienced), that later generalized starting from suprapubic radiating to upward. There were no associated vomiting, fever or body malaise. He thought it will just go off by sometime and continued working. He did not get any rest. At 5:30 PM, the pain still persisted of pain scale 7/10. The pain continued with vomiting. He tried drinking water (hot and then cold) but afforded no relief. He started feeling numbness on the extremities also. He tried resting for a while but still not relieved. At 9:30 pm, he was admitted at the V Luna Hospital in Manila because of the severe pain scale of 10/10. Laboratory tests were done and he was diagnosed with acute appendicitis. He was told that he needs emergency operation but he requested for transfer to his home town because his relatives were here only. He was given a referral slip and was transferred and admitted to JBLMRH at 1 am oct 23rd and was scheduled for operation.

Past Medical History:

Childhood illnesses and immunization status: He had childhood illnesses like

chickenpox and measles. He had complete childhood immunizations

Allergies: The patient does not have any known allergies to drugs or food. Medical: He does not have any known illness or co morbidities such as

hypertension, cancer, thyroid problems, tuberculosis, asthma or diabetes. He is not taking any maintenance drugs.
Surgical: None Previous hospitalization: 17 years ago due to accident in Quezon province. Psychiatric: None

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ACUTE APPENDICITIS!

DATE: 30TH OCT. 2012

Family History:
His father is 63 years old and diabetic and mother is 58 years old and is healthy. The patient has 9 other siblings. He has 4 siblings, all of them are healthy.

Personal and Social History:

The patient currently works as a welder in Manila. He completed high school. He smokes 12-15 sticks per day for 12 years. He drinks alcoholic beverages thrice a week. He has a stable nancial condition. He doesnt take any supplements and doesnt take coffee also. He drinks soft drinks. The source of water is from the faucet. His form of relaxation is watching TV. He sleeps for 7 hours a day.

Environmental History:
He lives in a concrete building has 2 oors. The rooms are well ventilated and well lit. There are 8 people residing there including his cousins and coworkers. The garbage is collected twice a week.

Diet History:
He takes a mixed type of diet and eats three times a day. He gets his food from the market and drinks distilled water.

Review of Systems:
General: The patient denies of weight loss or gain, fever, chills or loss of appetite. Skin: No jaundice, no rashes, no lumps, no sores, no itching, no dryness and no change in hair & nails. Head, Eyes, Ears, Nose, Throat (HEENT): Head: He denies of headache, dizziness and lightheadedness. Eyes: No pain, eye irritation and blurring of vision, no excessive tearing, no ashes of light. Ears: No hearing loss. No tinnitus, vertigo, infections. Nose: No nose bleeds, sinus trouble, no nasal stufness. Throat (or mouth and pharynx): No gum bleeding, no sore throat, no difculty on swallowing. Neck: He has pain on the anterior neck region. No swollen glands, No stiffness Respiratory: No cough, wheezing, dyspnea. Cardiovascular: No orthopnea and palpitations, no chest pains, no edema.

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ACUTE APPENDICITIS!

DATE: 30TH OCT. 2012

Gastrointestinal: No indigestion, heartburn. Generalized abdominal pain. No diarrhea, constipation. Urinary: Urine is light yellow, no frequency/urgency in urination, no dysuria, no gross hematuria and no nocturia. Genital: No pain, sores, discharge and rashes Peripheral Vascular: No cramps and intermittent claudication. Musculoskeletal: No joint stiffness, and muscle pain but numbness in the extremities. Psychiatric: No history of depression or treatment for psychiatric disorders. No nervousness and suicidal attempts. Neurologic: No fainting, seizures, motor or sensory loss. Hematologic: No easy bleeding and bruising, not anemic. Endocrine: No or cold intolerance, excessive thirst, hunger and polyuria. Sweats averagely.

Physical Examinations:
General Survey: On interview, the patient is conscious, coherent, appropriate and ambulatory. He is sthenic, not in respiratory distress and well oriented to time, person and place. He also has a guarding behavior on his abdomen Vital Signs: BP:110/80 mmHg ! PR:67 bpm! RR:19 cpm ! Temp:! 37.1C (Right axilla) Skin, Hair and Nails: Patient has brown skin, no jaundice, cyanosis noted. There were also no edema, contractures or lesions seen. He has a good skin turgor; return within few seconds upon skin pinching in the forehand. Patient has black hair. The nails were dirty and there were no clubbing or koilonychias noted. HEENT: Head: Grossly the head is symmetrical to body. There were no scars, lesions, masses or alopecia present. There was no deviation of the jaw from the midline upon opening of the mouth. Good quality of temporal pulse was noted with no area of tenderness throughout the cranium and facial areas upon palpation.

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ACUTE APPENDICITIS!

DATE: 30TH OCT. 2012

Eyes: Patient has anicteric sclerae without any swelling, paleness, cataracts, excessive tearing, discharge upon inspection. The eyebrows and eyelashes are evenly distributed. Pupils were equally round and reactive to light and accommodation. With positive direct reex and consensual light reactions. Pupil size is 2-3 mm. Extraocular movement in all direction and peripheral vision were intact. Ears: There is no redness, swelling, masses, deformities or discharge upon inspection of the ears; positive cone of light. The patient has pearly white intact tympanic membrane. There was no tragal, auricular or mastoid tenderness upon palpation. Nose and Sinuses: Grossly, the nose and nasal septum are located midline with symmetrical external nasal structures There were no observed external deformities, masses or lesions. There were no complaint of tenderness and pain upon palpation. Mouth and Pharynx: The lips, gum, teeth, tongue and oor of the mouth do not have lesions. There is no bleeding nor any deviations. There is positive protrusion and retraction of the tongue.

Neck and Thyroid Gland: There was no cervical lymphadenopathy. The thyroid gland is not palpable upon swallowing. Carotid pulse was of good quality without carotid bruit upon auscultation. Chest and Lungs: Thorax is symmetrical without any deformities, chest retraction or local lag in the respiratory movement; no masses and lesions present. There were no areas of tenderness noted. Tactile fremitus and sounds are transmitted on an equal intensity on both sides. Areas of the lungs are resonant on percussion. Normal clear breath sounds were heard upon auscultation of both lung elds. Cardiovascular: There is adynamic precordium. The point of maximal impulse at the 5th intercostal space left midclavicular line. Good S1 and S2 without any S3, S4 or cardiac murmurs upon auscultation. Regular Rhythm. There are no lifts, thrills and heaves. Radial, brachial and dorsalis pedis pulses are full and equal. No cyanosis or edema.
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ACUTE APPENDICITIS!

DATE: 30TH OCT. 2012

Abdomen: Inspection: The abdomen of the patient was at, symmetrical and not distended. There were no visible peristalses nor visible pulsations. Auscultation: Bowel sounds were hypoactive. No bruits or friction rub Percussion: The abdomen was tympanitic on all 4 quadrants. Palpation: There were no masses palpated. The spleen was not palpable. No abdominal pain. Liver span is 8cm. There was rebound tenderness and was positive for Rovsings, psoas and obturator sign. The liver edge was rm, non-tender and non-nodular. Genito-Urinary: Kidneys were not palpable and there was no CVA tenderness. Musculoskeletal/extremities: There were no joint deformities. Good range of motion in hands, wrists, elbows, shoulders, spine, hips, knees, ankles. There were no limitations in extension of the extremities. 5/5 muscular strength on the left and right arm and lower extremities. ! Peripheral Vascular:! No cyanosis. There were no trace edema or varicosities seen upon inspection of the lower extremities. There was good quality of brachial, ulnar and radial pulses as well as the popliteal, posterior tibial and dorsalis pedis pulses. Pulses were brisk or normal with same intensity on both right and left extremities. Good capillary rell time (<2sec) Neurologic Exam: Patient was conscious, alert and cooperative. Patient was oriented to person, place and time. Immediate, recent and past memories were intact. Attention was adequate and has no easy distractibility. 5/5 strength on both upper and lower extremities (patient has good motor strength upon application of full resistance) without any involuntary motor movements or tics observed. Cranial nerves: I not examined II pupils dilated at 2-3mm, Equal reactive to light, isocoric, able to count ngers III, IV, VI Extra Ocular Movement intact, full and equal conjugate eye movements, no ptosis V Intact V1-V3 patient can clench jaw
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ACUTE APPENDICITIS!

DATE: 30TH OCT. 2012

VII intact, able to do facial expression VIII gross intact hearing, able to lateralize sound and air greater than bone conduction, no nystagmus, IX, X Gag reex not examine, uvula at midline XI intact, able to raise shoulder XII tongue in midline, able to do phonation and protrusion of the tongue

Salient Features:
Subjective:
37yearold male, with abdominal pain that started at the supra pubic area and was

generalized later for last 28 hours. Associated with vomiting. Objective:

Abdomen with tenderness and was positive for Rovsings, psoas and obturator sign.

Patient is conscious.

Differential Diagnoses:
Diverticulitis: Rule In Abdominal Pain first started at supra pubic area. Accompanied by anorexia, nausea, and vomiting Rule Out Pain is not present for several days prior to presentation. No altered bowel habits, especially constipation, is seen in the patient

Peptic Ulcer Disease Rule In Epigastric pain Alcoholic and smoker Rule Out No bleeding, hematemesis or melena No relation of pain with the intake of foods.

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ACUTE APPENDICITIS!

DATE: 30TH OCT. 2012

Acute Appendicitis Rule In Started with epigastric pain, followed by vomitting Positive for rosvings, psoas and obturator signs.

Final Diagnosis:
Acute Appendicitis

Epidemiology
Appendicitis is one of the more common surgical emergencies, and it is one of the most common causes of abdominal pain. In the United States, 250,000 cases of appendicitis are reported annually, representing 1 million patient-days of admission. The incidence of acute appendicitis has been declining steadily since the late 1940s, and the current annual incidence is 10 cases per 100,000 population. Appendicitis occurs in 7% of the US population, with an incidence of 1.1 cases per 1000 people per year. Some familial predisposition exists. In Asian and African countries, the incidence of acute appendicitis is probably lower because of the dietary habits of the inhabitants of these geographic areas. The incidence of appendicitis is lower in cultures with a higher intake of dietary ber. Dietary ber is thought to decrease the viscosity of feces, decrease bowel transit time, and discourage formation of fecaliths, which predispose individuals to obstructions of the appendiceal lumen. In the last few years, a decrease in frequency of appendicitis in Western countries has been reported, which may be related to changes in dietary ber intake. In fact, the higher incidence of appendicitis is believed to be related to poor ber intake in such countries. There is a slight male preponderance of 3:2 in teenagers and young adults; in adults, the incidence of appendicitis is approximately 1.4 times greater in men than in women. The incidence of primary appendectomy is approximately equal in both sexes. The incidence of appendicitis gradually rises from birth, peaks in the late teen years, and gradually declines in the geriatric years. The mean age when appendicitis occurs in the pediatric population is 6-10 years. Lymphoid hyperplasia is observed more often among infants and adults and is responsible for the increased incidence of appendicitis in these age groups. Younger children have a higher rate of perforation, with reported rates of 50-85%. The median age at appendectomy is 22 years. Although rare, neonatal
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ACUTE APPENDICITIS!

DATE: 30TH OCT. 2012

and even prenatal appendicitis have been reported. Clinicians must maintain a high index of suspicion in all age groups.

Etiology:
Appendicitis is caused by obstruction of the appendiceal lumen. The most common causes of luminal obstruction include lymphoid hyperplasia secondary to inammatory bowel disease (IBD) or infections (more common during childhood and in young adults), fecal stasis and fecaliths (more common in elderly patients), parasites (especially in Eastern countries), or, more rarely, foreign bodies and neoplasms. Fecaliths form when calcium salts and fecal debris become layered around a nidus of inspissated fecal material located within the appendix. Lymphoid hyperplasia is associated with various inammatory and infectious disorders including Crohn disease, gastroenteritis, amebiasis, respiratory infections, measles, and mononucleosis. Obstruction of the appendiceal lumen has less commonly been associated with bacteria (Yersinia species, adenovirus, cytomegalovirus, actinomycosis, Mycobacteria species, Histoplasma species), parasites (eg, Schistosomes species, pinworms, Strongyloides stercoralis), foreign material (eg, shotgun pellet, intrauterine device, tongue stud, activated charcoal), tuberculosis, and tumors.

CLINICAL APPROACH: Diagnostic Workup

Patients with appendicitis may not have the reported classic clinical picture 37-45% of the time, especially when the appendix is located in an unusual place. In such cases, imaging studies may be important but not always available. However, patients with appendicitis usually have accessory signs that may be helpful for diagnosis. For example, the obturator sign is present when the internal rotation of the thigh elicits pain (ie, pelvic appendicitis), and the psoas sign is present when the extension of the right thigh elicits pain (ie, retroperitoneal or retrocecal appendicitis). Laboratory tests are not specic for appendicitis, but they may be helpful to conrm diagnosis in patients with an atypical presentation. LABS:

mild leukocytosis with left shift (may have normal WBC counts) higher leukocyte count with perforation urinalysis

IMAGING:

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ACUTE APPENDICITIS!

DATE: 30TH OCT. 2012

CT scan: This is considered the gold standard for diagnosing appendicitis. The observations here could be thick wall, appendicolith, inammatory changes. The overall accuracy rate is 94-100%. Ultrasound: It may visualize appendix. But is not really the choice of the modality. Overall accuracy is about 90-94%. It can rule in but cannot rule out appendicitis (if >6 mm.) Chest X-ray: Upright CXR, AXR: This is usually nonspecic. One can observe free air if perforated (rarely). Calcied facecloth if present can be seen. The other possible x-ray observations could be loss of psoas shadow and RLQ ileum.

Pathophysiology/ Pathogenesis:
The probable sequence of events in acute appendicitis is: 1. Luminal obstruction.
In young patients, more commonly by lymphoid tissue hyperplasia. In older patients, fecalith is an increasingly common cause of obstruction.

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ACUTE APPENDICITIS!

DATE: 30TH OCT. 2012

2. Distention and increased intraluminal pressure.

The appendiceal mucosa continues to secrete normally despite being obstructed. The resident bacteria multiply rapidly, further increasing intraluminal pressure.

3. Venous congestion.
The intraluminal pressure eventually exceeds capillary and venule

pressures.
Arteriolar blood continues to ow in, causing vascular congestion and

engorgement. 4. Impaired blood supply renders the mucosa ischemic and susceptible to bacterial invasion. 5. Inammation and ischemia progress to involve the serosal surface of the appendix.

Clinical Course:
The development of appendicitis generally begins with luminal obstruction by a fecalith, lymphoid hyperplasia, or food matter. With this obstruction there is an increase in mucous secretion, venous and lymphatic congestion, and bacterial overgrowth. When unabated, this process leads to ischemic necrosis and perforation. The classic history of acute appendicitis begins with vague pain in the periumbilical region, nausea, vomiting, and the urge to defecate; these symptoms are followed by localization of the pain in the right lower quadrant associated with localized peritonitis. Approximately 20% of patients with acute appendicitis experience perforation within 24 hours of the onset of symptoms. Recognition of appendicitis can be delayed because of atypical presentations caused by retrocolic or pelvic locations. Similarly, antibiotic administration during the early course of appendicitis may alter the clinical course. Only approximately 50% of patients with acute appendicitis show a classic presentation.

Prognosis:
Acute appendicitis is the most common reason for emergency abdominal surgery. Appendectomy carries a complication rate of 4-15%, as well as associated costs and the discomfort of hospitalization and surgery. Therefore, the goal of the surgeon is to make an accurate diagnosis as early as possible. Delayed diagnosis and treatment account for much of the mortality and morbidity associated with appendicitis. The overall mortality rate of 0.2-0.8% is attributable to complications of the disease rather than to surgical intervention. The mortality rate in children ranges from 0.1% to 1%; in patients older than 70 years, the rate rises above 20%, primarily because of diagnostic and therapeutic delay. Appendiceal perforation is associated with increased morbidity and mortality compared with nonperforating appendicitis. The mortality risk of acute but not gangrenous appendicitis is less than 0.1%, but the risk rises to 0.6% in gangrenous appendicitis.
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DATE: 30TH OCT. 2012

The rate of perforation varies from 16% to 40%, with a higher frequency occurring in younger age groups (40-57%) and in patients older than 50 years (55-70%), in whom misdiagnosis and delayed diagnosis are common. Complications occur in 1-5% of patients with appendicitis, and postoperative wound infections account for almost one third of the associated morbidity.

Plan of Management:
Hydrate, correct electrolyte abnormalities Surgery (gold standard, 20% mortality with perforation especially in elderly) along

with the antibiotic coverage

If localized abscess (palpable mass or large phlegmon on imaging and often pain

>4-5 d), consider radiologic drainage with antibiotics for 14 days interval appendectomy in 6 wks
appendectomy:

laparoscopic vs. open complications: spillage of bowel contents, pelvic abscess, enterocutaneous stula perioperative antibiotics: - ampicillin +gentamicin+ metronidazole (antibiotics x 24 h only if non-perforated) - other choices: 2nd/3rd generation cephalosporin for aerobic gut organisms
colonoscopy in the elderly

Medications:
The following antibiotics are recommended for prophylaxis in uncomplicated appendicitis : Cefoxitin: 2 grams IV single dose (Adults) Alternative agents: Ampicillin-sulbactam:! 1.5-3 grams IV single dose (Adults) ! ! ! Amoxicillin-clavulanate 1.2 2.4 grams IV single dose For patients with allergy to beta-lactam antibiotics: Gentamicin 80-120 mg IV single dose plus Clindamycin 600 mg IV single dose The recommended antibiotics for therapy of complicated appendicitis in adults are ! ! ! 1) Ertapenem 1 gram IV every 24 hours 2) Tazobactam-piperacillin 3.375 grams IV every 6 hours or 4.5 grams IV every 8 hours

For adults with beta-lactam allergy: ! Ciprooxacin 400 mg IV every 12 hours plus !
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Metronidazole 500 mg IV every 6 hours

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ACUTE APPENDICITIS!

DATE: 30TH OCT. 2012

References:
Schwartzs Principles of Surgery, 9th Edition Toronto Notes 2012 Acute Appendicitis from http://emedicine.medscape.com/article/773895-overview

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