I.

INTRODUCTION

Diseases of the gastrointestinal (GI) tract account for about 10% of the total burden
of illness in the United States. They account for more than 50 million office visits annually
and nearly 10 million hospital admissions. GI diseases probably cost the American public up
to $100 billion yearly and account for 10% of all deaths each year (Goldman & Bennett,
2000). The types of diseases and disorders that affect the lower GI tract are many and
varied. In all age groups, a fast-paced lifestyle, high levels of stress, irregular eating habits,
insufficient intake of fiber and water, and lack of daily exercise contribute to GI problems.
Nurses can have an impact on these chronic problems by identifying behavior patterns that
put patients at risk, by educating the public about prevention and management, and by
helping those affected to improve their condition and prevent complications.

Any part of the lower GI tract is susceptible to acute inflammation caused by

bacterial, viral, or fungal infection. Two such situations are appendicitis and diverticulitis.
These two conditions can lead to peritonitis, an inflammatory process within the abdomen.

The appendix is a small, finger-like appendage about 10 cm (4 in) long that is

attached to the cecum just below the ileocecal valve. The appendix fills with food and
empties regularly into the cecum. Because it empties inefficiently and its lumen is small, the
appendix is prone to obstruction and is particularly vulnerable to infection (ie, appendicitis).
Appendicitis, the most common cause of acute abdomen in the United States, is the most
common reason for emergency abdominal surgery. About 7% of the population will have
appendicitis at some time in their lives; males are affected more than females and
teenagers more than adults. Although it can occur at any age, it occurs most frequently
between the ages of 10 and 30 years (Yamada et al., 1999).

Acute appendicitis does not occur frequently in the elderly population. Classic signs
and symptoms are altered and may vary greatly. Pain may be absent or minimal. Symptoms
may be vague, suggesting bowel obstruction or another process. Fever and leukocytosis
may not be present. As a result, diagnosis and prompt treatment may be delayed, causing
potential complications and mortality. The patient may have no symptoms until the
appendix ruptures. The incidence of perforated appendix is higher in the elderly population
because many of these patients do not seek health care as quickly as younger patients.

Recently it has been hypothesized that some episodes of appendicitis-like symptoms,

especially recurrent symptoms, may be due to an increased sensitivity of the intestine and
appendix from a prior episode of inflammation. That is, the recurrent symptoms are not due
to recurrent episodes of inflammation. Rather, prior inflammation has made the nerves of
the intestines and appendix or the central nervous system that innervate them more
sensitive to normal stimuli, that is, with stimuli other than inflammation. This will be a
difficult, if not impossible, hypothesis to confirm.

A. SIGNIFICANCE OF THE STUDY

A1. Student Centered

1. To be able to come up with a good case analysis to increase our knowledge regarding
the disease.
2. To be knowledgeable about the complications and prevention of the disease.
3. To apply our theoretical knowledge in handling cases like this.
4. To be able to answer our patient’s queries and needs.
A2. Patient Centered
1. To come up with an intervention and management that will benefit the patient pre-
operative and post-operative care.
2. To present facts and information to patient and significant others on the prevention
of further complications.
A3. Course Centered
1. To present an informative and educative output for future references.

B. PREVALENCE / STATISTICS

1 Case Study - Appendicitis

 The case-fatality rate of appendicitis jumps from less than 1 percent to 5 percent or
higher when perforation occurs.

Appendicitis remains the most common acute surgical condition of the abdomen. In
1997, more than 260,000 new cases occurred in the United States. The overall lifetime
occurrence is approximately 12 percent in men and 25 percent in women.1-3.

Because abdominal pain is a common presenting complaint in the outpatient setting,

family physicians serve an important role in the rapid diagnosis of acute appendicitis.
Accurate and timely diagnosis of acute appendicitis is essential to minimize morbidity.
Prompt surgical treatment may reduce the risk of appendix perforation. The case-fatality
rate of appendicitis jumps from less than 1 percent in nonperforated cases to 5 percent or
higher when perforation occurs.4

The diagnosis of appendicitis traditionally has been based on clinical features found
primarily in the patient's history and physical examination.5 An elevated white blood cell
count has a low predictive value for appendicitis because it is present in a number of
conditions.6 While the clinical diagnosis of appendicitis may be straightforward in patients
with classic signs and symptoms, atypical presentations can result in delays in treatment,
unnecessary hospital admissions for observation, and unnecessary surgery.

Unnecessary surgery for suspected appendicitis exposes patients to increased risks,

morbidity, and expense. In 1997, 261,134 patients underwent nonincidental
appendectomies in the United States. However, 39,901 (15.3 percent) of the appendixes
removed showed no pathologic features of appendicitis.

Diagnostic accuracy achieved by history and physical examination has remained at

about 80 percent in men and women (men are diagnosed accurately 78 to 92 percent of the
time, and women 58 to 85 percent of the time).5 Recently, imaging techniques such as
ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) were
evaluated as diagnostic modalities in acute appendicitis and were shown to improve
diagnostic accuracy and patient outcomes. However, the routine use of imaging studies in
all patients is not well established.

II. PATIENT’S PROFILE

A. DEMOGRAPHIC DATA
Client Mark.V.D., was born on June 20, 1996. He is a Filipino, a thirteen-year-
old student presently residing in San Jose, Caba, La Union. His mother,
Adelaida.M., is 57 years old and a farmer. While his father, Jose.D., is a 56
year old farmer. Mark.V.D. is the youngest among the ten children. His family
is a Roman Catholic.

B. PSYCHOSOCIAL DEVELOPMENTAL TASK (ACCORDING TO ERIKSON)

The adolescent is newly concerned with how he or she appears to others.
Superego identity is the accrued confidence that the outer sameness and
continuity prepared in the future are matched by the sameness and continuity
of one's meaning for oneself, as evidenced in the promise of a career. The
ability to settle on a school or occupational identity is pleasant. In later stages
of Adolescence, the child develops a sense of sexual identity.

There are five recognized psychosocial issues that teens deal with during their
adolescent years. These include:

• Establishing an identity. This has been called one of the most important tasks of
adolescents. The question of "who am I?" is not one that teens think about at a
conscious level. Instead, over the course of the adolescent years, teens begin to
integrate the opinions of influential others (e.g. parents, other caring adults, friends,
etc.) into their own likes and dislikes. The eventual outcome is people who have a
clear sense of their values and beliefs, occupational goals, and relationship
expectations. People with secure identities know where they fit (or where they don't
want to fit) in their world.

2 Case Study - Appendicitis

 • Establishing autonomy. Some people assume that autonomy refers to becoming
completely independent from others. They equate it with teen "rebellion." Rather
than severing relationships, however, establishing autonomy during the teen years
really means becoming an independent and self-governing person within
relationships. Autonomous teens have gained the ability to make and follow through
with their own decisions, live by their own set of principles of right and wrong and
have become less emotionally dependent on parents. Autonomy is a necessary
achievement if the teen is to become self-sufficient in society.
• Establishing intimacy. Many people, including teens, equate intimacy with sex. In
fact, intimacy and sex are not the same. Intimacy is usually first learned within the
context of same-sex friendships, then utilized in romantic relationships. Intimacy
refers to close relationships in which people are open, honest, caring and trusting.
Friendships provide the first setting in which young people can practice their social
skills with those who are their equals. It is with friends that teens learn how to begin,
maintain, and terminate relationships; practice social skills; and become intimate.
• Becoming comfortable with one's sexuality. The teen years mark the first time that
young people are both physically mature enough to reproduce and cognitively
advanced enough to think about it. Given this, the teen years are the prime time for
the development of sexuality. How teens are educated about and exposed to
sexuality will largely determine whether or not they develop a healthy sexual
identity. Just over one-third of high school students report being sexually active;
almost half (46 percent) report ever having had sex. Many experts agree that the
mixed messages teens receive about sexuality contribute to problems such as teen
pregnancy and sexually transmitted diseases.
• Achievement. Our society tends to foster and value attitudes of competition and
success. Because of cognitive advances, the teen years are a time when young
people can begin to see the relationship between their current abilities and plans and
their future vocational aspirations. They need to figure out what their achievement
preferences are - what they are currently good at and areas in which they are willing
to strive for success.

Erikson believes that during successful early adolescence, mature time perspective is
developed; the young person acquires self-certainty as opposed to self-consciousness and
self-doubt. He comes to experiment with different - usually constructive - roles rather than
adopting a "negative identity" (such as delinquency). He actually anticipates achievement,
and achieves, rather than being "paralyzed" by feelings of inferiority or by an inadequate
time perspective. In later adolescence, clear sexual identity - manhood or womanhood - is
established. The adolescent seeks leadership (someone to inspire him), and gradually
develops a set of ideals (socially congruent and desirable, in the case of the successful
adolescent). Erikson believes that, in our culture, adolescence affords a "psychosocial
moratorium," particularly for middle - and upper-class American children. They do not yet
have to "play for keeps," but can experiment, trying various roles, and thus hopefully find
the one most suitable for them.

C. HEALTH HISTORY
C1. PRESENT HEALTH HISTORY
Three days prior to admission, Mark.V.D.started to have cough and fever, 4-5
times of vomiting of previously ingested food, low appetite and abdominal
pain, no other symptoms noted. Client self medicated with Paracetamol 500
mg 1 tab PRN for fever. Two days prior to admission, client was brought to
Caba Medicare Community Hospital. Urinalysis was done revealing pyuria,
hematuria, and proteinuria. It was treated UTI, given Cefalexin. One day prior
to admission, persistent abdominal pain prompted. ITRMC-ER repeat urinalysis
revealing decrease pyuria, hematuria. Two hours prior to admission, still with
abdominal pain.

Client was brought to ER and was admitted last May 4, 2009 by Dr. Milalyn
Ruth S. Delizo. During the course of hospitalization, ultrasound, hematology,
and X-ray were also performed.

May 5, 2009
12:oo MN – Client on NPO
3:27 p.m - Client was brought to OR
5:16 – operation ended
5:25 – brought to PACU for recovery

3 Case Study - Appendicitis

 C2. PAST MEDICAL HISTORY
He has no previous hospitalization. He has complete immunization. Client has
not undergone any surgical procedure

C3. FAMILY HEALTH HISTORY

No history of hypertension, diabetes mellitus, bronchial asthma and allergy.

C4. SOCIAL DATA

Mark.V.D. is a grade 6 student; not a smoker and alcohol drinker.

D. PATIENT’S ASSESSMENT ACCORDING TO GORDON’S FUNCTIONAL HEALTH

PATTERNS

D1. HEALTH PERCEPTION – HEALTH PATTERN

Client does not go to hospital for a regular check-up. He seeks medical
help only if the signs and symptoms of a certain disease has already
manifested on him or during emergency cases. He does not also go for a
regular dental check-up. When he has fever or headache his mother is self
medicating him with paracetamol. According to the client’s mother, her child
has a complete immunization.
Mark.V.D. has good body hygiene. He takes a bath everyday and
brushes his teeth at least twice a day. He changes his clothes regularly.

D2. NUTRITIONAL – METABOLIC PATTERN

Client states that he is on a consistent carbohydrate diet. Eats
breakfast, lunch, and dinner with a cup or two of rice servings. Skips meal
sometimes. His breakfast, lunch, and dinner meal vary. Typical lunch and
dinner includes small serving of meat, green leafy vegetables (“dinengdeng”),
or sea foods such as fish. Have snack if he feels the urge. Drinks at least 8
glasses of water a day. Drinks coffee, juice, tea, or cola. But due to his UTI his
doctor advices him to avoid drinking cola or concentrated juices. Voices no
food dislikes or intolerances.
Client expresses desire to gain some weight.

D3. ELIMINATION PATTERN

Void five to six times per day with clear yellow urine and has regular
bowel elimination before he got sick. During the disease process, client states
that he had been experiencing pain during urination and elimination with little
amount of urine and stool passing respectively. Complains of urgency during
the colder months with no increase in frequency.

D4. ACTIVITY – EXERCISE PATTERN

Client performs housekeeping for a couple of hours a day. He plays
“bahay-bahayan” and “taguan” with his playmates. Sometimes he helps his
parent in the field work. He spends most of his time playing with his friends.
He walks several blocks when going to school.

D5. SLEEP – REST PATTERN

Goes to bed at 10:00 p.m.. Denies difficulty falling asleep or sleeping.
Feels well rested when he arises at 6:00 a.m. Never used sleep medications.
Sometimes he sleeps 2-3 hours at noon. Denies orthopnea and nocturnal
dyspnea.

D6. COGNITIVE – PERCEPTUAL PATTERN

Understands the state of his condition.

D7. SELF – PERCEPTION – SELF CONCEPT PATTERN

Describes self as a normal person. Friendly, outgoing and likes to be
around people but hates noisy environment. States he is happy with the
person he has become.

4 Case Study - Appendicitis

 D8. ROLE – RELATIONSHIP PATTERN
Client is the youngest in the family. States that he has a harmonious
relationship with his parents, sisters, and brothers. As the youngest he does
lighter work. He helps his older brothers and sisters in doing household chores
and field work.

D9. COPING STRESS PATTERN

Cannot identify major stresses that have occurred in the last years.
Has a grimacing facial expression during hospitalization. Relatives visit him.

D10. VALUE – BELIEF PATTERN

All members of his family are Roman Catholic. Client states that his
parents inculcated in his mind the value of respect and obedience. His parents
taught him to show self discipline always.
He learned from his parents how to use herbal plants.

E. NURSING PHYSICAL ASSESSMENT

May 4, 2009 (2:00 pm)

General Survey - Sex: Male

- Age: 13 years old
- Weight: 30 kg.
- No body odor
- Conscious and oriented
- Cooperative, able to follow instructions
- Cannot sit and has difficulty of breathing
- Clean and neat
- Restless and weak in appearance
Vital Signs - Temp: 39°C
- BP: 110/90
- RR: 48 bpm
- CR: 115 bpm
Skin and Nails

Skin - Light brown, warm and dry to touch

- No rash
- Uniform in color except in areas exposed to sun
- Generalized hyperthermia
- Skin goes back to normal state when pinched
- No jaundice
- No edema
- Erythematous skin.
Nail - Hard and brittle
- No clubbing or Beau’s line
- Pale nailbeds
Head and Neck

Hair - Black, thick and soft

- No scalp lesions or flaking
- Evenly distributed hair
- No hair noted on axilla, chest, back or face
Head - Normocephalic
Eyes - Anticleric sclera
- Pupils equal and constrict from 4mm to 2 mm and are
reactive to light
- Pink palpebral conjunctiva
- No ear discharge and pain
Ears
- Does not wear hearing aid
- Both ears can hear loudly and clearly.
Nose - No nose discharge
Mouth and Throat - Do not wear dentures

5 Case Study - Appendicitis

 - Gums pink with no inflammation.
- Tonsils present with no edema, ulcers, or enlargement
- Moist tongue and oral mucosa
Neck - Muscles equal in size
- Head centered
Thorax and - Skin light brown with no scars and lesions
Lungs - Positive cough
- Rales heard when auscultated.
- RR: 48 bpm; tachypnea
Cardiovascular - CR: 115 bpm; tachycardia
- Normal S1, S2
- No S3, S4 or murmurs heard
- Regular rhythm
Breast and - Skin light to brown with dark brown areola
Axilla - No dimpling or retraction
- Breast even with the chest wall
- No lump discharge, and pain
Abdomen - Abdomen flat, symmetric without masses, lesions or
peristalsis noted.
- Abdomen free of hair, bruising.
- Umbilicus in midline without swelling or discoloration.
- Pain felt at right lower quadrant of the abdomen when
palpated
- With tender abdomen
Genitalia - Pain during urination.
- With dark yellow urine
Anus/Rectum - Has difficulty passing stool

Arms - Warm and dry to touch without edema, or lesions noted.

- With capillary refill of less that 2 seconds
- Radial and brachial pulse strong
- Skin intact, light brown; warm and dry to touch
Legs - Full and equal pulse in lower extremities

Musculoskeletal - Upper and lower extremities with minimal range of motion

- Cannot sit and has difficulty in walking
- Unsteady gait
Neurologic - GCS: 15/15
- Conscious and coherent
- Oriented to time, place and person

III.NORMAL ANATOMY AND PHYSIOLOGY

Vermiform Appendix

Arteries of cecum and vermiform appendix.

6 Case Study - Appendicitis

 (Appendix visible at lower right, labeled as
"vermiform process").

Normal location of the appendix relative to other

organs of the digestive system (frontal view).

In human anatomy, the appendix (or vermiform appendix; also cecal (or caecal)
appendix; also vermix) is a blind ended tube connected to the cecum (or caecum), from
which it develops embryologically. The cecum is a pouch-like structure of the colon. The
appendix is near the junction of the small intestine and the large intestine. The term
"vermiform" comes from Latin and means "worm-shaped". The appendix averages 10 cm in
length, but can range from 2 to 20 cm. The diameter of the appendix is usually between 7
and 8 mm. The longest appendix ever removed measured 26 cm in Zagreb, Croatia. The
appendix is located in the lower right quadrant of the abdomen, or more specifically, the
right iliac fossa. Its position within the abdomen corresponds to a point on the surface
known as McBurney's point (see below). While the base of the appendix is at a fairly
constant location, 2 cm below the ileocaecal valve, the location of the tip of the appendix
can vary from being retrocaecal (74%) to being in the pelvis to being extraperitoneal. In rare
individuals with situs inversus, the appendix may be located in the lower left side.

Given the appendix's propensity to cause death via infection, and the general good
health of people who have had their appendix removed or who have a congenital absence of
an appendix, the appendix is traditionally thought to have no function in the human body.
However, new studies propose that the appendix may harbor and protect bacteria that are
beneficial in the function of the human colon. There have been no reports of impaired
immune or gastrointestinal function in people without an appendix.

The most common explanation is that the human appendix is a vestigial structure
which does absolutely nothing for the body. (There has been little study of its function in the
other animals in which it occurs - apes, wombats and some rodents - or comparison with
animals in which it does not occur.) In The Story of Evolution, Joseph McCabe argued: The
vermiform appendage—in which some recent medical writers have vainly endeavoured to
find a utility—is the shrunken remainder of a large and normal intestine of a remote
ancestor. This interpretation of it would stand even if it were found to have a certain use in
the human body. Vestigial organs are sometimes pressed into a secondary use when their
original function has been lost. One potential ancestral purpose put forth by Charles Darwin
was that the appendix was used for digesting leaves as primates. Over time, we have eaten
fewer vegetables and have evolved, over thousands of years to consume meats, hence this
organ may have evolved to be smaller to make room for our stomach. It may be a vestigial
organ of ancient humans that has degraded down to nearly nothing over the course of
evolution. Evidence can be seen in herbivorous animals such as the Koala. The cecum of the
koala is very long, enabling it to host bacteria specific for cellulose breakdown. Human
ancestors may have also relied upon this system and lived on a diet rich in foliage. As
people began to eat more easily digested foods, they became less reliant on cellulose-rich
plants for energy. The cecum became less necessary for digestion and mutations that
previously had been deleterious were no longer selected against. These alleles became
more frequent and the cecum continued to shrink. After thousands of years, the once-
necessary cecum has degraded to what we see today, with the appendix. Evolutionary
theorists have suggested that natural selection selects for larger appendices because
smaller and thinner appendices would be more susceptible to inflammation and disease.

Loren G. Martin, a professor of physiology at Oklahoma State University, argues that

the appendix has a function in fetuses and adults. Endocrine cells have been found in the

7 Case Study - Appendicitis

appendix of 11 week old fetuses that contribute to "biological control (homeostatic)
mechanisms." In adults, Martin argues that the appendix acts as a lymphatic organ. The
appendix is experimentally verified as being rich in infection-fighting lymphoid cells,
suggesting that it might play a role in the immune system. Zahid suggests that it plays a
role in both manufacturing hormones in fetal development as well as functioning to 'train'
the immune system, exposing the body to antigens in order that it can produce antibodies.
He notes that doctors in the last decade have stopped removing the appendix during other
surgical procedures as a routine precaution, because it can be successfully transplanted into
the urinary tract to rebuild a sphincter muscle and reconstruct a functional bladder.

Although it was long accepted that the immune tissue, called gut associated
lymphoid tissue, surrounding the appendix and elsewhere in the gut carries out a number of
important functions, explanations were lacking for the distinctive shape of the appendix and
its apparent lack of importance as judged by an absence of side-effects following
appendectomy. William Parker, Randy Bollinger, and colleagues at Duke University proposed
that the appendix serves as a haven for useful bacteria when illness flushes those bacteria
from the rest of the intestines. This proposal is based on a new understanding of how the
immune system supports the growth of beneficial intestinal bacteria, in combination with
many well-known features of the appendix, including its architecture and its association with
copious amounts of immune tissue. Such a function is expected to be useful in a culture
lacking modern sanitation and healthcare practice, where diarrhea may be prevalent.
Current epidemiological data show that diarrhea is one of the leading causes of death in
developing countries, indicating that a role of the appendix as an aid in recovering beneficial
bacteria following diarrhea may be extremely important in the absence of modern health
and sanitation practices.

IV. DISEASE ENTITY/ PATHOPHYSIOLOGY

Appendicitis means inflammation of the appendix. It is thought that appendicitis

begins when the opening from the appendix into the cecum becomes blocked. The blockage
may be due to a build-up of thick mucus within the appendix or to stool that enters the
appendix from the cecum. The mucus or stool hardens, becomes rock-like, and blocks the
opening. This rock is called a fecalith (literally, a rock of stool). At other times, the lymphatic
tissue in the appendix may swell and block the appendix. After the blockage occurs, bacteria
which normally are found within the appendix begin to invade (infect) the wall of the
appendix. The body responds to the invasion by mounting an attack on the bacteria, an
attack called inflammation. An alternative theory for the cause of appendicitis is an initial
rupture of the appendix followed by spread of bacteria outside the appendix.. The cause of
such a rupture is unclear, but it may relate to changes that occur in the lymphatic tissue, for
example, inflammation, that line the wall of the appendix.)

If the inflammation and infection spread through the wall of the appendix, the
appendix can rupture. After rupture, infection can spread throughout the abdomen;
however, it usually is confined to a small area surrounding the appendix (forming a peri-
appendiceal abscess).

Sometimes, the body is successful in containing ("healing") the appendicitis without

surgical treatment if the infection and accompanying inflammation do not spread
throughout the abdomen. The inflammation, pain and symptoms may disappear. This is
particularly true in elderly patients and when antibiotics are used. The patients then may
come to the doctor long after the episode of appendicitis with a lump or a mass in the right
lower abdomen that is due to the scarring that occurs during healing. This lump might raise
the suspicion of cancer.

CAUSES

On the basis of experimental evidence, acute appendicitis seems to be the end result
of a primary obstruction of the appendix lumen. Once this obstruction occurs the appendix
subsequently becomes filled with mucus and swells, increasing pressures within the lumen
and the walls of the appendix, resulting in thrombosis and occlusion of the small vessels,
and stasis of lymphatic flow. Rarely, spontaneous recovery can occur at this point. As the
former progresses, the appendix becomes ischemic and then necrotic. As bacteria begin to
leak out through the dying walls, pus forms within and around the appendix (suppuration).

8 Case Study - Appendicitis

The end result of this cascade is appendiceal rupture (a 'burst appendix') causing peritonitis,
which may lead to septicemia and eventually death.

Among the causative agents, such as foreign bodies, trauma, intestinal worms, and
lymphadenitis, the occurrence of an obstructing fecalith has attracted attention. The
prevalence of fecaliths in patients with appendicitis is significantly higher in developed than
in developing countries, and an appendiceal fecalith is commonly associated with
complicated appendicitis. Also, fecal stasis and arrest may play a role, as demonstrated by a
significantly lower number of bowel movements per week in patients with acute appendicitis
compared with healthy controls. The occurrence of a fecalith in the appendix seems to be
attributed to a right sided fecal retention reservoir in the colon and a prolonged transit time.
From epidemiological data it has been stated that diverticular disease and adenomatous
polyps were unknown and colon cancer exceedingly rare in communities exempt for
appendicitis. Also, acute appendicitis has been shown to occur antecedent to cancer in the
colon and rectum. Several studies offer evidence that a low fiber intake is involved in the
pathogenesis of appendicitis. This is in accordance with the occurrence of a right sided fecal
reservoir and the fact that dietary fiber reduces transit time.

CLINICAL MANIFESTATIONS

Symptoms of acute appendicitis can be classified into two types, typical and atypical.
The typical history includes pain starting centrally (periumbilical) before localizing to the
right iliac fossa (the lower right side of the abdomen); this is due to the poor localizing
(spatial) property of visceral nerves from the mid-gut, followed by the involvement of
somatic nerves (parietal peritoneum) as the inflammation progresses. The pain is usually
associated with loss of appetite and fever, although the latter isn't a necessary symptom.
Nausea or vomiting may occur, and also the feeling of drowsiness and the feeling of general
bad health. With the typical type, diagnosis is easier to make, surgery occurs earlier and
findings are often less severe.

Atypical symptoms may include pain beginning and staying in the right iliac fossa,
diarrhea and a more prolonged, smoldering course. If an inflamed appendix lies in contact
with the bladder, there is frequency of urination. With post-ileal appendix, marked retching
may occur. Tenesmus or "downward urge" (the feeling that a bowel movement will relieve
discomfort) is also experienced in some cases.

Unlike acute appendicitis, chronic appendicitis symptoms can vary from patient to
patient—so much so that "There are no typical findings or routine diagnostic modalities to
diagnose chronic relapsing appendicitis. It is a diagnosis of exclusion.

The signs include localized findings in the right iliac fossa. The abdominal wall
becomes very sensitive to gentle pressure (palpation). Also, there is rebound tenderness. In
case of a retrocecal appendix, however, even deep pressure in the right lower quadrant may
fail to elicit tenderness (silent appendix), the reason being that the cecum, distended with
gas, prevents the pressure exerted by the palpating hand from reaching the inflamed
appendix. Similarly, if the appendix lies entirely within the pelvis, there is usually complete
absence of the abdominal rigidity. In such cases, a digital rectal examination elicits
tenderness in the rectovesical pouch. Coughing causes point tenderness in this area
(McBurney's point) and this is the least painful way to localize the inflamed appendix. If the
abdomen on palpation is also involuntarily guarded (rigid), there should be a strong
suspicion of peritonitis requiring urgent surgical intervention.

Other signs are:

Rovsing's sign - Deep palpation of the left iliac fossa may cause pain in the right iliac fossa.
This is the Rovsing's sign, also known as the Rovsing's symptom. It is used in the diagnosis
of acute appendicitis. Pressure over the descending colon causes pain in the right lower
quadrant of the abdomen.

Psoas sign - Occasionally, an inflamed appendix lies on the psoas muscle and the patient will
lie with the right hip flexed for pain relief.

Obturator sign - If an inflamed appendix is in contact with the obturator internus, spasm of
the muscle can be demonstrated by flexing and internally rotating the hip. This maneuver
will cause pain in the hypogastrium.

9 Case Study - Appendicitis

DIAGNOSTIC FINDINGS

The diagnosis of appendicitis begins with a thorough history and physical

examination. Patients often have an elevated temperature, and there usually will be
moderate to severe tenderness in the right lower abdomen when the doctor pushes there. If
inflammation has spread to the peritoneum, there is frequently rebound tenderness.
Rebound tenderness is pain that is worse when the doctor quickly releases his hand after
gently pressing on the abdomen over the area of tenderness.

White Blood Cell Count - The white blood cell count in the blood usually becomes
elevated with infection. In early appendicitis, before infection sets in, it can be
normal, but most often there is at least a mild elevation even early. Unfortunately,
appendicitis is not the only condition that causes elevated white blood cell counts.
Almost any infection or inflammation can cause this count to be abnormally high.
Therefore, an elevated white blood cell count alone cannot be used as a sign of
appendicitis.

Urinalysis - Urinalysis is a microscopic examination of the urine that detects red blood
cells, white blood cells and bacteria in the urine. Urinalysis usually is abnormal when
there is inflammation or stones in the kidneys or bladder. The urinalysis also may be
abnormal with appendicitis because the appendix lies near the ureter and bladder. If
the inflammation of appendicitis is great enough, it can spread to the ureter and
bladder leading to an abnormal urinalysis. Most patients with appendicitis, however,
have a normal urinalysis. Therefore, a normal urinalysis suggests appendicitis more
than a urinary tract problem.

Abdominal X-Ray - An abdominal x-ray may detect the fecalith (the hardened and
calcified, pea-sized piece of stool that blocks the appendiceal opening) that may be
the cause of appendicitis. This is especially true in children.

Ultrasound - An ultrasound is a painless procedure that uses sound waves to identify

organs within the body. Ultrasound can identify an enlarged appendix or an abscess.
Nevertheless, during appendicitis, the appendix can be seen in only 50% of patients.
Therefore, not seeing the appendix during an ultrasound does not exclude
appendicitis. Ultrasound also is helpful in women because it can exclude the
presence of conditions involving the ovaries, fallopian tubes and uterus that can
mimic appendicitis.

Barium Enema - A barium enema is an x-ray test where liquid barium is inserted into
the colon from the anus to fill the colon. This test can, at times, show an impression
on the colon in the area of the appendix where the inflammation from the adjacent
inflammation impinges on the colon. Barium enema also can exclude other intestinal
problems that mimic appendicitis, for example Crohn's disease.

Computerized tomography (CT) Scan - In patients who are not pregnant, a CT Scan of
the area of the appendix is useful in diagnosing appendicitis and peri-appendiceal
abscesses as well as in excluding other diseases inside the abdomen and pelvis that
can mimic appendicitis.

Laparoscopy - Laparoscopy is a surgical procedure in which a small fiberoptic tube

with a camera is inserted into the abdomen through a small puncture made on the
abdominal wall. Laparoscopy allows a direct view of the appendix as well as other
abdominal and pelvic organs. If appendicitis is found, the inflamed appendix can be
removed with the laparascope. The disadvantage of laparoscopy compared to
ultrasound and CT is that it requires a general anesthetic.

A number of clinical and laboratory based scoring systems have been devised to
assist diagnosis. The most widely used is Alvarado score.

Symptoms
Migratory right iliac fossa pain 1 point
Anorexia 1 point
Nausea and vomiting 1 point
Signs
Right iliac fossa tenderness 2 points

10 Case Study - Appendicitis

 Rebound tenderness 1 point
Fever 1 point
Laboratory
Leucocytosis 2 points
Shift to left (segmented
1 point
neutrophils)
10
Total score
points

A score below 5 is strongly against a diagnosis of appendicitis, while a score of 7 or

more is strongly predictive of acute appendicitis. In patients with an equivocal score
of 5-6, CT scan further reduces the rate of negative appendicectomy.

There is no one test that will diagnose appendicitis with certainty. Therefore, the approach
to suspected appendicitis may include a period of observation, tests as previously discussed,
or surgery.

COMPLICATIONS

The most frequent complication of appendicitis is perforation. Perforation of the

appendix can lead to a periappendiceal abscess (a collection of infected pus) or diffuse
peritonitis (infection of the entire lining of the abdomen and the pelvis). The major reason
for appendiceal perforation is delay in diagnosis and treatment. In general, the longer the
delay between diagnosis and surgery, the more likely is perforation. The risk of perforation
36 hours after the onset of symptoms is at least 15%. Therefore, once appendicitis is
diagnosed, surgery should be done without unnecessary delay.

A less common complication of appendicitis is blockage of the intestine. Blockage

occurs when the inflammation surrounding the appendix causes the intestinal muscle to
stop working, and this prevents the intestinal contents from passing. If the intestine above
the blockage begins to fill with liquid and gas, the abdomen distends and nausea and
vomiting may occur. It then may be necessary to drain the contents of the intestine through
a tube passed through the nose and esophagus and into the stomach and intestine.

A feared complication of appendicitis is sepsis, a condition in which infecting bacteria

enter the blood and travel to other parts of the body. This is a very serious, even life-
threatening complication. Fortunately, it occurs infrequently.

PROGNOSIS

Most appendicitis patients recover easily with surgical treatment, but complications
can occur if treatment is delayed or if peritonitis occurs. Recovery time depends on age,
condition, complications, and other circumstances, including the amount of alcohol
consumption, but usually is between 10 and 28 days. For young children (around 10 years
old) the recovery takes three weeks.

The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment. The patient may have to undergo a medical
evacuation. Appendectomies have occasionally been performed in emergency conditions
(i.e. outside of a proper hospital), when a timely medical evaluation was impossible.

Typical acute appendicitis responds quickly to appendectomy and occasionally will

resolve spontaneously. If appendicitis resolves spontaneously, it remains controversial
whether an elective interval appendectomy should be performed to prevent a recurrent
episode of appendicitis. Atypical appendicitis (associated with suppurative appendicitis) is
more difficult to diagnose and is more apt to be complicated even when operated early. In
either condition prompt diagnosis and appendectomy yield the best results with full recovery
in two to four weeks usually. Mortality and severe complications are unusual but do occur,
especially if peritonitis persists and is untreated. Another entity known as appendicular lump
is talked about quite often. It happens when appendix is not removed early during infection
and omentum and intestine get adherent to it forming a palpable lump. During this period
operation is risky unless there is pus formation evident by fever and toxicity or by USG.
Medical management treats the condition.

11 Case Study - Appendicitis

 An unusual complication of an appendectomy is "stump appendicitis": inflammation
occurs in the remnant appendiceal stump left after a prior, incomplete appendectomy.

PATHOPHYSIOLOGY

The main thrust of events leading to the development of acute appendicitis lies in the
appendix developing a compromised blood supply due to obstruction of its lumen and
becoming very vulnerable to invasion by bacteria found in the gut normally.

Obstruction of the appendix lumen by faecolith, enlarged lymph node, worms, tumour, or
indeed foreign objects, brings about a raised intra-luminal pressure, which causes the wall of
the appendix to become distended.

Normal mucus secretions continue within the lumen of the appendix, thus causing further
build up of intra-luminal pressures. This in turn leads to the occlusion of the lymphatic
channels, then the venous return, and finally the arterial supply becomes undermined.

Reduced blood supply to the wall of the appendix means that the appendix gets little or no
nutrition and oxygen. It also means a little or no supply of white blood cells and other
natural fighters of infection found in the blood being made available to the appendix.

The wall of the appendix will thus start to break up and rot. Normal bacteria found in the gut
gets all the inducement needed to multiply and attack the decaying appendix within 36
hours from the point of luminal obstruction, worsening the process of appendicitis.

This leads to necrosis and perforation of the appendix. Pus formation which is a combination
of dead white blood cells, bacteria, and dead tissue occurs when nearby white blood cells
are recruited to fight the bacterial invasion.

The content of the appendix (faecolith, pus and mucus secretions) are then released into the
general abdominal cavity, bringing causing peritonitis.

So, in acute appendicitis, bacterial colonisation follows only when the process have
commenced. These events occur so rapidly, that the complete pathophysiology of
appendicitis takes about one to three days. This is why delay can be deadly

Pain in appendicitis is thus caused, initially by the distension of the wall of the appendix,
and later when the grossly inflamed appendix rubs on the overlying inner wall of the
abdomen (parietal peritoneum) and then with the spillage of the content of the appendix
into the general abdominal cavity (peritonitis).

Fever is brought about by the release of toxic materials (endogenous pyrogens) following
the necrosis of appendicael wall, and later by pus formation.

Loss of appetite and nausea follows slowing and irritation of the bowel by the
inflammatory process.

Gender: Common in men

Age: Peak incidence in the early teens and

early twenties

Fecalith causing obstruction of the

lumen

Raised intra-luminal
pressure
Abdominal
Distended wall of Pain
Persistent appendix
Abdomina May 1,09
l Pain Fatigue Weaknes Low of
Little or no supply
Fever N/V
Appendix gets 12little
Case StudyOcclusion of the
- Appendicitis lymphatic
Bacteria will into
Released channel
multiply
the and the s
WBC and otherappetite
May May May
no1,09
or Perforation
nutritionofand Mayvenous return
Appendix
and Pus
will
attack
Impaired
general startdecaying
Peritoniti
the
arterial to break upDead
blood
abdominal
inflammati Bacteri natural
1,09 May
Necrosiof
fighters
May 1,09
1,09
13 Case Study - Appendicitis