A case presentation on Acute Appendicitis in the young Aldwin Ong MD070061 15 February 2011.
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Transcript of A case presentation on Acute Appendicitis in the young Aldwin Ong MD070061 15 February 2011.
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A case presentation on
Acute Appendicitisin the young
Aldwin Ong
MD070061
15 February 2011
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General objectives
To present a case of a young patient with Acute Appendicitis
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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
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General data
• J.T.G.
• 18 y/o
• Male
• Pasig City, Philippines
• Primary Informant: Patient (Reliability: 75%)
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Chief complaint
• “Sobrang sakit na ng tiyan ko”
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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.
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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.
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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.
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Review of systems
General: 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
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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
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Review of systems
Genitourinary: no edema, no dysuria, no frequency, no urgency
Endocrine: no diaphoresis, no cold intolerance, no heat intolerance
Nervous: no seizure, no tremor
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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
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Family history
Asthma, DM, Hypertension
No known congenital diseases in the family
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Personal & Social History
• Denies smoking
• Occasional alcoholic beverage drinker
• Denies illicit drug use
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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
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Physical examination
General Survey:
Awake, alert, not in apparent cardiorespiratory distress.
Vital Signs:
BP 90/60 HR 98
RR 20 T 39.2C
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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.
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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
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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
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Physical examination
• Cerebrum: • GCS 15• Conversant. Intact Sensorium.
• Rest of neurologic exam unremarkable.
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• 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
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t/c Acute Appendicitis
r/o Urinary Tract Infection
r/o Acute Gastroenteritis
r/o Dengue Fever
Initial Impression
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Diagnostics DoneCBC
Urinalysis
Fecalysis
Dengue 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
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Final Diagnosis
Acute Appendicitis
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Management
Open Appendectomy
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Case discussion
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Acute Appendicitis in the Pediatric Age Group
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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
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Epidemiology
• 6% of population, M>F
• 80% between 5-35 years of age
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Operative Definitions
Uncomplicated 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
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Pathogenesis
luminal obstruction bacterial overgrowth inflammation/swelling increased pressure localized ischemia gangrene/perforation localized abscess (walled off by omentum) or peritonitis
In young children, the omentum is poorly developedPerforation is not usually confined
Bacterial invasion of mesenteric veins
Portal vein sepsis and subsequent liver abscess may form
Inflammatory process intestinal obstruction or paralytic ileus
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Etiology
Children or young adult: hyperplasia of lymphoid follicles, initiated by infection
Adult: fibrosis/stricture, fecolith, obstructing neoplasm
Other causes: parasites, foreign body
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Symptoms
Common symptoms of appendicitisabdominal pain
anorexia
nausea
constipation
vomiting
Vomiting less common with uncomplicated appendicitis
Profuse vomiting may indicate generalized peritonitis associated with perforation
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Symptoms
Appendicitis 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
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Symptoms
Children 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
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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
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Laboratory Tests
CBCMild leukocytosis with left shift
(may have normal WBC counts)
Higher leukocyte count with perforation
UrinalysisTo rule out urinary tract infection
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Clinical Decision Rule
Clinical 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
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Pediatric Appendicitis Score (PAS)
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Pediatric Appendicitis Score (PAS)
The PAS predicts appendicitis in > 70% children if score ≥ 7 andRules out appendicitis in > 99% patients with score < 2
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Alvarado/MANTRELS
9-10: almost certain, little advantage for further work-up7-8: high likelihood5-6: compatible but not diagnostic0-4: Unlikely
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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
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CT Images
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UTZ Image
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Therapeutic Management
Definitive management for Acute Appendicitis in the Pediatric age group is Appendectomy via (PCS, 2002):
1. Open Appendectomy
2. Laparoscopic Appendectomy
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Prophylaxis
Antibiotic prophylaxis (Adults vs. Children)Uncomplicated AP
Cefoxitin 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)
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Prophylaxis
For 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
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Complications
Occurs 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
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Psycho-social
Unfounded belief that running after eating causes appendicitis
Absences in school
Appendicitis is a common condition that must be anticipated and/or understood by lay people
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Public health
Reducing mortality through campaigns to recognize symptoms
Proper referral systems to reduce delays in transfer of patient
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Thank You !
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Reference
Brunicardi, 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
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A case presentation on
Acute Appendicitisin the young
Aldwin Ong
MD070061
15 February 2011