CASE CASE PRESENTATIONPRESENTATIONPresented by: Fatma Al-Presented by: Fatma Al-GhaithiGhaithi

ObjectivesObjectivesCase presentationDifferential diagnosisDiscussionHome massage

Fraught with potential pitfalls, because of absence of a pathognomonic sign or symptom.

7% of people will develop it sometime during there lifetime.

Is the 6th most common missed diagnosis.

casecase60 yr old female with rt.

Lower abdominal pain for 2 days.

Concious, in pain.Breathing spontaneouslySat-100% R.ARR-18BP- 120/75 mmHgHR-76/minT-36.8

Known case of HTN. menopaused. RLQ pain for 2 days, started at

periumbilical.Intermittent, colicky.Dysurea.

- No vomiting - No diarrhoea or constipation.

- No fever - No no vaginal discharge or

bleeding. - No hematurea.

Physical examinationPhysical examinationIn painSat-100% R.ARR-18BP- 120/75 mmHgHR-76/minT-36.8Chest: clearCVS: S1, S2 normal, no murmurs.Abdomen:

- no distension, LSCS scar. - RLQ tenderness, ? rebound

tenderness, - Cough reflex absent- No masses felt .

- BS,+

CBC

WBC= 11.7 NEU= 8.9 LYM=1.54 EOS=0.01 RBC=4.5 HGB=12.5 HCT=38% MCV=84 MCH=27.8 MCHC-33 PLT=246

Urea & electrolyte•Urea= 4.0•Creatinine= 86.0•Na=141•K+= 3.9•Cl=103

ESR=40

Urine routine•Suger= NIL•Albumin=trace•WBC=20 per cm2•RBC< 2 per cm2•Epith. Cells= 8 per cm2•CAST=NIL•CRYSTALS=NIL•PH=6.0 (7.35- 7.45)

βHCG-1.22

AMYLASE=39.4

usus

liver, spleen, pancreas, gallbladder and both kidneys are normal in size and echogenicity with no evidence of focal lesions. Mild intrahepatic dilatation with borderline diameter of CBD but no obvious stone seen. Well distended unremarkable urinary bladder.

Impression: mild intrahepatic dilatation and CBD size further evaluation by CT is recommended .

Deferential diagnosisDeferential diagnosis appendicitis AAA Diverticulitis Mesenteric ischemia UTI Biliary tract disease Diabetic ketoacidosis Ovarian cyst Ovarian torsion Pelvic inflammatory

disease

Obstructive bowel disease

Pancratitis Malignancy Renal colic Gastritis, peptic

ulcer disease pneumonia Constipation Herpes zoster

Gyn. Review (ward) -normal vaginal examination. - TVS: endometrial thickness of

13.3 with cystic spaces, rt. Ovary bulky with follicles.

Lt. ovary: cyst 1.7x1.8 cm with echogenic mass inside.

Minimal free fluid +

CT abdomen and pelvisCT abdomen and pelvisPelvis shows diffuse fat stranding and pockets of fluid associated with thickened ileal loops & mesentery.

Picture is suggestive of ruptured appendix or ovarian pathology.

Liver: few scattered tiny hypodense lesions in the liver suggestive of small cysts, for US correlation.

spleen, Gb, pancreas and both kidneys are normal.

Appendicitis in geriatric Appendicitis in geriatric patientpatiento Dx of appendicitis in elderly is

challenging.o Is rare in elderly.o More likely to present atypically.o Is accounts for 7% of abdominal

pain in the elderly.o Higher perforation rate- 72%.o Mortality approaches 15% if

perforated in elderly.

AppendicitisAppendicitis Incidence peaked in 2ed and 3ed decades

of life. The overall mortality rate < 1%, if ruptured

it is 3% and approaches 15% in elderly. In pregnancy: -unruptured appendectomy, fetal loss

3%-5%. -ruptured appendectomy, fetal loss 20-

25%Maternal mortality-4%.

Emerg. Med Clin N Am 28 (2010) 103-118(

AppendicitisAppendicitis

Pathophysiology:Luminal obstruction.Varies with age:

- children: lymphoid hyperplasia due to infection or dehydration

- adults:fecaliths - elderly: neoplasm

Time required for appendix perforation usually occur within 24- 36 hrs from onset of symptomes.

Marx: Rosen's Emergency Medicine, 7th ed.

AppendicitisAppendicitisWhy pain of appendicitis referred to periumbilical area?

-afferent fibers that conduct visceral pain from the appendix accompany the sympathetic nerves and enter the spinal cord at the level of the 10TH thoracic segment.

Clinical signsClinical signs-Rebound tenderness:

- -sensitivity:63 to 82%, specificity: 69 to 90%, respectively. (1)

- A positive cough sign has been found to be

- 80 to 95% sensitive in diagnosing acute peritonitis.

LRs for specific symptoms in LRs for specific symptoms in appendicitisappendicitis

Historical symptom

Positive LRIncrease in posttest

probability

Negative LR

RLQ pain7.31-8.46Moderate probability

0-0.28

Migration 3.18Small increase0.50

Pain before vomiting

2.76Small increase-

No past similar pain

1.50Not helpful0.323

anorexia1.27Not helpful0.64

nausea0.69-1.20Not helpful0.70-0.84

vomiting0.92Not helpful1.12

LR of 5–10, presence moderately increases probability of disease.LR of 2–5, may increase probability of the disease.LR of <2, not likely to change the probability of the disease.

LRs for specific signs in LRs for specific signs in appendicitisappendicitis

Physical signPositive LRIncrease in posttest

probability

Negative LR

Rigidity3.76Small increase0.82

Tender RLQ2.30Small increase0.0-0.1

Psoas sign2.38Small increase0.90

Rebound tenderness

3.70Small increase0.43

Fever1.94Not helpful0.58

Guarding1.65-1.78Not helpful0.27

Rectal tenderness

0.83-5.34Not helpful0.76

LR of 5–10, presence moderately increases probability of disease.LR of 2–5, may increase probability of the disease.LR of <2, not likely to change the probability of the disease

Laboratory testsLaboratory tests WBCcount:

-it is not a reliable independent predictor of

appendicitis .-positive LR ( 1.59- 2.7) and

a negative ratio ( 0.25- 0.50).

-Repeating WBC counts is not beneficial.

urinalysisurinalysis is obtained to rule out possible UTI.

urinalysis can represent a potential pitfall, because the proximate location of the appendix to the ureter and bladder can cause microscopic pyuria or hematuria in up to a third of patients with appendicitis

CRPCRP poor specificity; however, when

combined with a WBC count, it may be more useful.

( LR - 4.24) but when combined with an elevated WBC count, the positive LR of the combination was a significant 23.32.

Have high negative predictive value when the combination of the WBC count, C-reactive protein, and the neutrophil count were normal.

Diagnostic scoresDiagnostic scoresscoring systems yield inconsistent results when prospectively evaluated and appear to be particularly inaccurate when applied to female patients.

Scoring systemsScoring systemsThe most common is the Alvarado

score, also known as the MANTRELSMANTRELS: Migration of pain Anorexia Nausea/vomiting Tenderness in the RLQ Rebound tenderness Elevated T Leukocytosis Shift to the left).

ImagingImagingUS can be helpful in possible appendicitis, particularly in children, pregnant women, and women of childbearing age.

CT has a greater accuracy than US.

specificity was similar between CT and ultrasound (94% and 93%, respectively), the sensitivity was better for CT (94% vs 83%).

CTCT findings suggestive of appendicitis include :

an appendix greater than 6 mm

wall thickening RLQ inflammatory changes, such as fat stranding

the presence of appendicoliths

CTCT A systematic review of 23 studies of CT in suspected

appendicitis found a weighted sensitivity and specificity of 93% and 98%, respectively, for noncontrast CT compared with CT with IV and oral contras

Am J Surg 190. 474-478.2005

In a prospective randomized study compared 3 different techniques, CT with oral and IV contrast, CT with rectal contrast, and CT without contrast showed: - CT with oral and IV contrast was more sensitive than CT with rectal contrast and not significantly different from noncontrast CT. Dis Colon Rectum 50. 1223-1229.2007

USUSFindings suggestive of appendicitis include:

thickened wall noncompressible lumendiameter greater than 6 mmabsence of gas in the lumen appendicoliths

Home massageHome massageNot all patients require imaging to

diagnose appendicitis.Patients with a low risk for

appendicitis may be sent home with close follow-up and education about progressive symptoms.

Patients with equivocal findings should undergo advanced diagnostic imaging or in-hospital serial examinations.

Pain medication should be offered to all patients with suspected appendicitis.