ACUTE APPENDICITIS

Roy Phitayakorn, M.D. Christopher Brandt, M.D.Case Western Reserve University School of Medicine

Ms. Z. Cope

You are called to see a patient in the Emergency Department, who is a 25 year-old female with a 1 day history of right-lower quadrant abdominal pain.

History What other points of the history do you want to know?

History, Ms. CopeCharacterization of symptomsTemporal sequenceAlleviating / Exacerbating factors:

Pertinent PMH, ROS, MEDS.Relevant family hx.Associated signs and symptoms

Consider the Following

History, Patient ZCPain started in the middle of the night and woke the patient from sleep.

Felt nauseated and vomited after pain

No significant MED.HX. or SURG HX.

Negative Family HX

Noted some indigestion yesterday

Feels urge to have bowel movement, but has been constipated

What is your Differential Diagnosis?

Differential DiagnosisBased on History and PresentationSystemic or infectious conditionsInfluenzaGastroenteritisHepatitisDiaphragmatic pleurisySpinal diseaseTyphoidTuberculosisAcute porphyriaDiabetic ketoacidosis

Differential Diagnosis(cont.)Intra-abdominal conditionsAcute AppendicitisAcute CholecystitisDiverticulitis (Meckels)Inflammatory Bowel Disease (Crohns)Duodenal UlcerIntestinal ObstructionCarcinoma of the CecumNonspecific adenitis Possible Yersinia infection

Differential Diagnosis(cont.)Intra-pelvic conditionsSalpingitisPelvic Inflammatory DiseaseEctopic PregnancyRuptured Corpus Luteum CystRuptured Follicular Cyst (Mittelschmerz)Ruptured Ovarian CystOvarian TorsionPyelonephritisUreteral/Renal stone

Physical Examination

What would you look for?

Physical Examination, Patient ZCVital Signs: 39o C, HR=75, RR=15, BP=125/75Appearance: Patient is lying quietly on bed in fetal position

HEENT : No icterusVAGINAL: nontender, no DischargeCV : nl S1S2, no murmursRECTAL: Guaiac neg, uncomfortable during examPULM : CTA Bilat. no pain with inspirationNeuromuscular: Minimal hyperesthesia above umbilicusABD : Moderately tender in RLQ between pubic symphysis and ASIS, involuntary guarding, Neg bowel sounds

Would you like to revise your Differential Diagnosis?

Would you like to revise your Differential Diagnosis?Acute appendicitsDiverticulitis (Meckels)Inflammatory Bowel Disease (Crohns)Ovarian pathologyAcute cholecystitisIntestinal obstructionNonspecific adenitis Possible Yersinia infection

Laboratory What would you obtain?

Labs ordered

CBCElectrolytesLFTsAmylase /LipaseB-HCGUrinalysis

Lab Results, Ms. CopeCBC: 14,500LFTs : WNLHCG : WNLElectrolytes : WNLAmylase : WNL U/A: WNL

Interventions at this point?

Interventions at this point?Consider the followingStart IV with Ringers Lactate or similar isotonic crystalloid solutionAdminister antibioticsAdmit to the hospitalGo Directly to the OR?Other?

StudiesWhat further studies would you want at this time?

Radiologic Studies to ConsiderFlat/Upright AbdomenCT Scan: Abd/PelvisCT Scan: Other ?US Abdomen/Pelvis

Considering your Differential DiagnosisWhat would you expect to see on a flat/upright abdominal series?What specific abnormalities do you look for on US? What population?Are there specific CT findings in any of your top 3 diagnoses?

Abdominal Film

Abdominal X-ray FindingsNon-specific gas patternNo fecalithNo free air

CT Scan Abdomen & Pelvis

CT Scan ResultsAcute Appendicitis Thickened dilated appendix Peri-appendiceal fat stranding Scant free fluid Incidental small left ovarian cyst

What is the differential diagnosis at this point?

Revised Differential Diagnosis

What next?Additional Imaging?Observation?OR?Other?

What next?Discussion of suggested interventions

ManagementSurgical OptionsPre-operative preparation

Laparoscopic Acute Appendicitis

Discussion Pathophysiology of the disease process, visceral vs. parietal abdominal pain, laparoscopy vs. open, antibiotic management, appropriate utilization of resources, etc.

Discussion Additional teaching points

QUESTIONS ??????

Summary

Alternative scenariosAcute Appendicitis with perforation/ Abscess or tumorIBDAcute DiverticulitisOvarian Cyst / Torsion/Perforated Right colon tumor

CT Cecal Tumor

CT Sigmoid Diverticulitis

CT Ovarian Cystic Mass

CT Terminal Ileal Crohns

CT Acute Appendicitis

Acknowledgment

The preceding educational materials were made available through the ASSOCIATION FOR SURGICAL EDUCATION

In order to improve our educational materials we welcome your comments/ suggestions at: feedbackPPTM@surgicaleducation.com

****************************Value of 1 intervention over another? Interject EBM where appropriateValue of 1 intervention over another? Interject EBM where appropriate

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