Appendicitis: A Case Presentation

8/3/2019 Appendicitis: A Case Presentation

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CASE PRESENTATIONON APPENDICITISEdilberto DB. Santos

SWU – MHAM CM



General Data:

M.A., 27 yrs old/ M/Single, Filipino, RC,Unemployed, currently residing in MJ CuencoAvenue, Cebu City, admitted for the 1st time at

CCMC on June 9, 2011 at 11:45pm due toGeneralized Abdominal pain.



HPI

2 DAYS PTA Patient had onset of abdominalpain which started as vague,crampy, intermittent pain

localized at the left lowerquadrant; associated withnausea and vomiting, anorexia,and fever. Condition wastolerated. No consultation done.



HPI

1 Day PTA Abdominal pain persisted whichshifted to the RLQ, selfmedicated with Omeprazole

but there was no relief.



HPI

Morning PTA The condition persisted,Abdominal pain was noted to beGeneralized which prompted the

patient to seek consultation andwas then subsequently admitted.



Past Medical History

Medications: None

Medical conditions: Non-hypertensive, Non-asthmatic, Non-diabetic

Allergy: No Allergy to Food and Drugs

Surgery: No previous surgeries

Hospitalization: None

Claimed to have complete immunizations.



Family history:

Mother, 58, Diabetic and Hypertensive.

Father, died at 71, due MVA

Birth rank: 6/7

All 6 siblings are apparently healthy



Personal and Social History:

Occasional alcoholic beverage drinker with 1bottle/session

Recently stopped smoking due to health

reason; 5 sticks/day

Has history of illicit drug use

No history of travel outside Cebu.

Elementary level



P.E.

Patient seen and examined alert, awake,conscious, coherent, cooperative, afebrile andNIRD with the following vital signs:

BP: 100/60 mmHg

HR: 90 bpm

RR: 21 cpm

Temp: 36.8 C



P.E

SKIN: warm, dry, good turgor, (-) jaundice

HEENT: Normocephalic, AS, clear cornea, nonasal and ear discharges, PERRLA

Neck: Supple, (-)LAD, no neck veinsengorgement

C/L: CBS, ECE, (-)rales, (-)wheeze

CVS: DHS, NRRR, (-)murmur Abdomen: Soft, tender, (+) Direct and Rebound

Tenderness, (+) Rovsing’s Sign, (+) ObturatorSign, (+) Psoas Sign, (+) Jarring Sign, (+)

Dunphy’s Sign



Rectal: Tight sphincteric tone, (+) slightsuprapubic pain, no mass, prostate not

enlarged, no stool on examining finger. Extremities: SPP, no edema

Musculoskeletal: good muscle tone

CNS: GCS 15 (E4V5M6)Sensory: intact light touch and pain sensation

Motor : R L 5/5 5/5

5/5 5/5

Reflexes : Intact, within normal limits



Impression

Acute Abdomen 2° to Acute Appendicitis,Ruptured



Differential Diagnosis:

Diffuse peritonitis, secondary to PerforatedPeptic ulcer

Colonic Diverticulitis

Acute pancreatitis



Diffuse peritonitis secondary to

Perforated Peptic Ulcer

Sudden pain

Pain Spreads to theentire abdomen

(+) Direct tendernessand rebound

tenderness

(+) Suprapubic pain

(+) Vomiting

No excruciating painwhich makes the patient

collapses. Pain starts at the

Epigastrium

No hypotension (SystolicBP < 100 mmHG)

No hypothermia(temperature should be35.5 and below)

No boardlike regidity ofthe abdomen

To consider: Rule out



Colonic diverticulitis

Pain localized at the

Lower left quadrant

No radiation to the

Right side No history of

previous diverticula

To consider: Rule out



Acute pancreatitis

Presence of pain at theRight lower quadrant

Pain spreads all over theabdomen

(+) Direct tenderness

History of alcohol intake (+) Vomiting

Absent muscle rigidity

No excruciating

epigastric pain The pain doesn’t

radiate to the lumbararea and leftshoulder

Jaundice is notpresent after 1 to 2

days

To consider: Rule out:



Acute Appendicitis

• the primary cause of right lower quadrantinflammation

Etiology and Pathogenesis:

• Obstruction of the lumen is the dominantetiologic factor in acute appendicitis. Fecalithsare the most common cause of appendiceal

obstruction.• Less common causes are hypertrophy of

lymphoid tissue, inspissated barium from

previous x-ray studies, tumors, vegetable andfruit seeds and intestinal arasites.



Incidence

most frequently seen in patients in their secondthrough fourth decades of life, with a mean age

of 31.3 years and a median age of 22 years.There is a slight male:female predominance(1.2 to 1.3:1)



Clinical Manifestations

1. Abdominal pain is the prime symptom of

acute appendicitis

The pain is initially diffusely centered in thelower epigastrium or umbilical area, is

moderately severe, and is steady, sometimeswith intermittent cramping superimposed

After a period varying from 1 to 12 hours, butusually within 4 to 6 hours, the pain localizes tothe right lower quadrant



2. Anorexia

• Anorexia nearly always accompanies

appendicitis3. Vomiting

• occurs in nearly 75% of patients, it is neither

prominent nor prolonged, and most patientsvomit only once or twice. Vomiting is caused byboth neural stimulation and the presence ofileus.

4. Obstipation

usually occurs before the onset of abdominalpain



SIGNS:

-Vital signs are minimally changed byuncomplicated appendicitis

-Temperature elevation is rarely >1°C (1.8°F) andthe pulse rate is normal or slightly elevated

-usually prefer to lie supine, with the thighs,particularly the right thigh, drawn up, becauseany motion increases pain. If asked to move,

they do so slowly and with caution



The classic right lower quadrant physical signsare present when the inflamed appendix lies in

the anterior position. Tenderness often is maximal at or near the

McBurney point.

Direct rebound tenderness usually is present.In addition, referred or indirect reboundtenderness is present.

This referred tenderness is felt maximally in the

right lower quadrant, which indicates localizedperitoneal irritation



• Rovsing sign—pain in the right lowerquadrant when palpatory pressure is exerted in

the left lower quadrant—also indicates the siteof peritoneal irritation

• Palpation:

- Early in the disease, resistance, if present,consists mainly of voluntary guarding.

-As peritoneal irritation progresses, musclespasm increases and becomes largely

involuntary, that is, true reflex rigidity due tocontraction of muscles directly beneath theinflamed parietal peritoneum.



• Rectal Exam

As the examining finger exerts pressure on

the peritoneum of Douglas' cul-de-sac, pain isfelt in the suprapubic area as well as locallywithin the rectum

• Psoas sign

The psoas sign indicates an irritative focus inproximity to that muscle.

The test is performed by having the patient lieon the left side as the examiner slowlyextends the patient's right thigh, thusstretching the iliopsoas muscle. The testresult is positive if extension produces pain



Obturator sign

hypogastric pain on stretching the obturator

internus indicates irritation in the pelvis. Thetest is performed by passive internal rotation ofthe flexed right thigh with the patient supine.



Laboratory Findings

Mild leukocytosis, ranging from 10,000 to18,000 cells/mm3, usually is present in patientswith acute, uncomplicated appendicitis andoften is accompanied by a moderate

polymorphonuclear predominance.

It is unusual for the white blood cell count to be>18,000 cells/mm3 in uncomplicated

appendicitis.



White blood cell counts above this level raisethe possibility of a perforated appendix with orwithout an abscess.

Urinalysis can be useful to rule out the urinarytract as the source of infection. Although

several white or red blood cells can be presentfrom ureteral or bladder irritation as a result ofan inflamed appendix



Imaging studies

Abdominal film

-In patients with acute appendicitis, one oftensees an abnormal bowel gas pattern, which is

a nonspecific finding. The presence of afecalith is rarely noted on plain films but, ifpresent, is highly suggestive of the diagnosis

-plain radiographs can be of significant benefitin ruling out other pathology



• chest radiograph

-sometimes indicated to rule out referred pain

from a right lower lobe pneumonic process.• Sonograph

-Sonographic demonstration of a normal

appendix, which is an easily compressible,blind-ending tubular structure measuring ≤5

mm in diameter, excludes the diagnosis ofacute appendicitis.



Graded compression sonography has been

suggested as an accurate way to establish thediagnosis of appendicitis. The technique isinexpensive, can be performed rapidly, doesnot require a contrast medium, and can be

used even in pregnant patients-The sonographic diagnosis of acuteappendicitis has a reported sensitivity of 55 to

96% and a specificity of 85 to 98%



Non compression Compression



The presence of an appendicolith establishesthe diagnosis. Thickening of the appendiceal

wall and the presence of periappendiceal fluidis highly suggestive

CT Scanan excellent technique for identifying other

inflammatory processes masquerading as

appendicitis.



Alvarado scoring method

This scoring system was designed toimprove the diagnosis of appendicitis andwas devised by giving relative weight to

specific clinical manifestation.



Alvarado scoring method

Patients with scores of 9 or 10 are almostcertain to have appendicitis; there is littleadvantage in further work-up, and they shouldgo to the operating room. Patients with scores

of 7 or 8 have a high likelihood of appendicitis,whereas scores of 5 or 6 are compatible with,but not diagnostic of, appendicitis. CT scanningis certainly appropriate for patients with

Alvarado scores of 5 and 6, and a case can bebuilt for imaging for those with scores of 7 and8.



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Appendicitis: A Case Presentation