Clinico -Pathological Case Conference

June 8, 2011By: Santos, Edilberto DB.

Case Protocol

• A case of B.N.• 28 year old/ F / Married• Filipino, RC, Cebu• Admitted for the 1st time at CCMC• CC: Abdominal Pain

History of Present Illness (HPI)

• The Present condition noted 2 days PTA, as crampy abdominal pain at the epigastric area, associated with vomiting and anorexia. The condition cannot be relieved by rest, no medications nor consultations done.

• A day PTA, condition persisted increasing in severity appreciated more on the RLQ, claimed of no bowel movement for 2 days, also claimed of dysuria and a foul smelling discharge. The patient was referred to OB-Gyne department for evaluation.

Family History

• Unremarkable • No history of Ca or any medical

illness.

Personal and Social History

• Non-smoker • Non-alcoholic drinker

Physical Examination

• Examined conscious, coherent, ambulatory with the following V/S:– BP 110/80 mmHg– HR 89 bpm– RR 26 cpm– Temp 38.2°C

Physical Examination

• HEENT:– Pink, palpebral conjunctivae, anicteric

sclerae• C/L:– ECE, CBS, no rales, no wheeze

• Cardiovascular: – Distinct Heart sounds, no murmur

• ABD– Soft, Flabby, (+) Direct and Rebound

tenderness in all abdominal quadrants, (+) Bilateral KPS

Physical Exam

• Genitourinary: – (+) foul smelling discharges

• Extremities: – strong pulses, no cyanosis

Salient Features

• Age of patient (28 y.o)• Crampy abdominal pain not relieved

by rest• Pain appreciated more at the RLQ • Dysuria, Foul Smelling Discharge• Absent bowel movement for 2 days• Vomiting • Anorexia

• Vital signs– BP 110/80 mm Hg,– HR 89 bpm, – RR 26 cpm, – Temp 38.2 C

• HEENT: pink palpebral conjunctivae• Abd: (+) Direct and Rebound

Tenderness on all quadrants, (+) KPS bilateral

• GUT: (+) foul smelling discharge

Ancillary tests

• 1.Urinalysis:• WBC count= 15-20 /hpf N: 1-2/

hpf• RBC count= 30- 40/hpf N: 1-2/

hpf

• 2. CBC:• WBC: 19,000 x106/L N: 5,000-10,000

x106/L• Hgb: 12 g/L N: 12.5-16.0 g/L• Hct: 38 % N: 37- 47%• Plt: 260/ cu.mm N: 150-400/

cu.mm

• *serum amylase not done

Questions• What is the LMP? • Was pregnancy test done? Result?• Is the patient sexually active?• Was there a history of salpingitis or untreated

Chlamydia or gonorrhea infection?• Was rectal exam done? Result?• Was ESR or CRP done? Was it elevated?• Was there obstipation?• Where in the RLQ is the pain most prominent? Was

pain prominent in the flanks?• Is there hyperesthesia in the RLQ?• How many episodes of vomiting? Character of

vomiting?• Was Rovsing’s sign, Obturator, Psoas, Jarring and

Dunphy’s sign done? Result?

Impression

• Generalized Peritonitis 2° to Acute Appendicitis, Ruptured

Differential Diagnosis

• Acute Pyelonephritis 2°• Ruptured Ectopic Pregnancy• Peritonitis 2° to PID

Ruptured Ectopic Pregnancy

• Ectopic Pregnancy: Pregnancy that develops after implantation of the blastocyst anywhere other than the endometrium lining the uterine cavity

Ectopic Pregnancy

• Physiologic disorder that results in delay of passage of the embryo – Remains in the oviduct at the

gestational age (7 days) when implantation occurs

• Major cause of ectopic pregnancy is salpingitis.– About half of initial episodes of ectopic

pregnancy

• Weström and colleagues – 900 women age 15 to 34 – Laparoscopically confirmed diagnosis of

acute salpingitis – Ectopic pregnancy rate was 68.8 per

1000 conceptions– Sixfold increase in the risk of ectopic

pregnancy after acute salpingitis

• The risk that the first pregnancy after acute salpingitis would be ectopic increased both with the number of episodes of infection and with increasing age of the women at the time of infection

Theories

• Abnormality of embryonic development – Two thirds were abnormal– Half had gross structural abnormalities

Theories

• Cigarette Smoking– Associated twofold increased risk of

ectopic pregnancy– Directly related to the number of

cigarettes smoked per day– Fourfold increased risk noted among

women who smoked 30 or more cigarettes per day

Ectopic Pregnancy

• Incidence– 1 : 28 or 40 pregnancies–Most occur in multigravid

• 97.7% of ectopic pregnancies are tubal– 81% - ampullary portion– 12% - isthmus– 5% - fimbrial

• 1.4% - abdominal• < 1% - ovarian or cervical

• Less than 1% are ovarian or cervical– The tube and fimbria must be intact and

separate from the ovary– The gestational sac must occupy the

normal position of the ovary– The sac must be connected to the

uterus by the ovarian ligament– Ovarian tissue should be demonstrable

in the walls of the sac

Clinical Features

• Abdominal pain 90–100 • Amenorrhea 75–95 • Vaginal bleeding 50–80 • Dizziness, fainting 20–35 • Urge to defecate 5–15 • Pregnancy symptoms 10–25 • Passage of tissue 5–10

Ectopic Pregnancy, Ruptured

Rule In• Strong abdominal pain• Dysuria• Pain of recent onset• Within age group (28

yrs old) – reproductive group

Rule Out• No bowel movement• Foul smelling

discharge

PERITONITIS 2° TO PID

Peritonitis

• A life-threatening event that is often accompanied by bacteremia and sepsis syndrome.

• Either primary (without an apparent source of contamination) or secondary.

Primary (Spontaneous) Bacterial Peritonitis

• occurs most commonly in conjunction with cirrhosis of the liver (frequently the result of alcoholism).

• uncommon event, occurring in 10% of cirrhotic patients.

• cause has not been established definitively but is believed to involve hematogenous spread of organisms in a patient in whom a diseased liver and altered portal circulation result in a defect in the usual filtration function.

• Fever - most common manifestation which is reported in up to 80% of patients.

• Ascites - found but virtually always predates infection.

• Abdominal pain, an acute onset of symptoms, and peritoneal irritation during PE can be helpful diagnostically.

• Nonlocalizing symptoms (such as malaise, fatigue, or encephalopathy) without another clear etiology should also prompt consideration of PBP in a susceptible patient

Primary Bacterial Peritonitis: Treatment

• is directed at the isolate from blood or peritoneal fluid.

• Gram's staining of peritoneal fluid often gives negative res

• until culture results become available, therapy should cover gram-negative aerobic bacilli and gram-positive cocci.

• Third-generation cephalosporins such as cefotaxime (2 g q8h, administered IV) provide reasonable initial coverage in moderately ill patients.

• Broad-spectrum antibiotics, such as penicillin/-lactamase inhibitor combinations (e.g., piperacillin/tazobactam, 3.375 g q6h IV for adults with normal renal function) or ceftriaxone (2 g q24h IV), are also options.

• Patients with PBP usually respond within 72 h to appropriate antibiotic therapy.

• Antimicrobial therapy can be administered for as little as 5 days if rapid improvement occurs and blood cultures are negative, but a course of up to 2 weeks may be required for patients with bacteremia and for those whose improvement is slow

Primary Bacterial Peritonitis: Prevention

• PBP has a high rate of recurrence. Up to 70% of patients experience a recurrence within 1 year.

• Antibiotic prophylaxis reduces this rate to <20%. Prophylactic regimens for adults with normal renal function include fluoroquinolones (ciprofloxacin, 750 mg weekly; norfloxacin, 400 mg/d) or trimethoprim-sulfamethoxazole (one double-strength tablet daily).

Secondary Peritonitis

• develops when bacteria contaminate the peritoneum as a result of spillage from an intraabdominal viscus.

• The organisms found almost always constitute a mixed flora in which facultative gram-negative bacilli and anaerobes predominate, especially when the contaminating source is colonic.

• Gram-negative bacilli, particularly E. coli, are common bloodstream isolates, but Bacteroides fragilis bacteremia also occurs.

• Secondary peritonitis can result primarily from chemical irritation and/or bacterial contamination.

Secondary Peritonitis: Treatment

• includes early administration of antibiotics aimed particularly at aerobic gram-negative bacilli and anaerobes.

• Mild to moderate disease can be treated with many drugs covering these organisms, including broad-spectrum penicillin/-lactamase inhibitor combinations (e.g., ticarcillin/clavulanate, 3.1 g q4–6h IV) or cefoxitin (2 g q4–6h IV).

• Secondary peritonitis usually requires both surgical intervention to address the inciting process and antibiotics to treat early bacteremia, to decrease the incidence of abscess formation and wound infection, and to prevent distant spread of infection.

• While surgery is rarely indicated in PBP in adults, it may be life-saving in secondary peritonitis.

Pelvic Inflammatory Disease

• PID is an infection in the upper genital tract not associated with pregnancy or intraperitoneal pelvic operations

• it may include infection of any or all of the following anatomic locations: the endometrium (endometritis); the oviducts (salpingitis), the ovary (oophoritis), the uterine wall (myometritis), the uterine serosa and broad ligaments (parametritis), and the pelvic peritoneum

• Acute PID results from ascending infection from the bacterial flora of the vagina and cervix in more than 99% of cases. This ascending infection occurs along the mucosal surface, resulting in bacterial colonization and infection of the endometrium and fallopian tubes

• Acute PID is rare in a woman without menstrual periods, such as the pregnant, premenarcheal, or postmeno-pausal woman. In less than 1% of cases, acute PID results from transperitoneal spread of infectious material from a perforated appendix or intraabdominal abscess

Incidence:

• acute PID occurs in 1% to 2% of all young, sexually active women. It is the most common serious infection of women ages 16 to 25.

• Approximately 85% of infections are spontaneous in sexually active females. The other 15% of infections develop following procedures that break the cervical mucus barrier, allowing the vaginal flora the opportunity to colonize the upper genital tract.

Risk Factors

• Risk factors are important considerations in both the clinical management and prevention of upper genital tract infections.

• sexually active,• inner city adolescents, • younger age at first intercourse,• older sex partners, • alcohol use before intercourse, • and current C. trachomatis infection were

all significant risk factors for the development of PID

Symptoms and Signs

Diagnosis

• Direct visualization via the laparoscope is the most accurate method of diagnosing acute PID.

• Laparoscopy also has been indispensable in the clinical research of the disease.

• In several presentations of acute PID laparoscopy or laparotomy is strongly indicated, such as impending septic shock, acute surgical abdomen, and in a complicated differential diagnosis in a postmenopausal woman

Management

• Treatment of the patient with PID encompasses more than just prescribing the appropriate antimicrobial regimen.

• Determining the need for hospitalization, patient education, treatment of sexual partners, and careful follow-up are key treatment issues.

• The two most important goals of the medical therapy of acute PID are the resolution of symptoms and the preservation of tubal function.

• Antibiotic therapy should be started as soon STD screening has been obtained and the diagnosis is suggested.

Generalized Peritonitis 2° to Acute Appendicitis,

Ruptured with concomitant Urinary Tract

Infection

Final Diagnosis

Differential Diagnosis

• Acute Appendicitis probably Ruptured

• Ruptured Ectopic Pregnancy

Acute Appendicitis• the primary cause of right lower quadrant

inflammation

Etiology and Pathogenesis:• Obstruction of the lumen is the dominant

etiologic factor in acute appendicitis. Fecaliths are the most common cause of appendiceal obstruction.

• Less common causes are hypertrophy of lymphoid tissue, inspissated barium from previous x-ray studies, tumors, vegetable and fruit seeds, and intestinal parasites.

Incidence• most frequently seen in patients in

their second through 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 Manifestations1. Abdominal pain is the prime

symptom of acute appendicitisThe pain is initially diffusely centered in the lower epigastrium or umbilical area, is moderately severe, and is steady, sometimes with intermittent cramping superimposed

After a period varying from 1 to 12 hours, but usually within 4 to 6 hours, the pain localizes to the 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 patients vomit only once or twice. Vomiting is caused by both neural stimulation and the presence of ileus.

4. Obstipation usually occurs before the onset of

abdominal pain

SIGNS:-Vital signs are minimally changed by

uncomplicated appendicitis-Temperature elevation is rarely >1°C

(1.8°F) and the pulse rate is normal or slightly elevated

-usually prefer to lie supine, with the thighs, particularly the right thigh, drawn up, because any motion increases pain. If asked to move, they do so slowly and with caution

• The classic right lower quadrant physical signs are 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 rebound tenderness is present.

• This referred tenderness is felt maximally in the right lower quadrant, which indicates localized peritoneal irritation

• Rovsing sign—pain in the right lower quadrant when palpatory pressure is exerted in the left lower quadrant—also indicates the site of peritoneal irritation

• Palpation:- Early in the disease, resistance, if

present, consists mainly of voluntary guarding.

-As peritoneal irritation progresses, muscle spasm increases and becomes largely involuntary, that is, true reflex rigidity due to contraction of muscles directly beneath the inflamed parietal peritoneum.

• Rectal ExamAs the examining finger exerts pressure on the peritoneum of Douglas' cul-de-sac, pain is felt in the suprapubic area as well as locally within the rectum

• Psoas signThe psoas sign indicates an irritative focus

in proximity to that muscle. The test is performed by having the

patient lie on the left side as the examiner slowly extends the patient's right thigh, thus stretching the iliopsoas muscle. The test result is positive if extension produces pain

• Obturator signhypogastric pain on stretching the obturator internus indicates irritation in the pelvis. The test is performed by passive internal rotation of the flexed right thigh with the patient supine.

Laboratory Findings• Mild leukocytosis, ranging from

10,000 to 18,000 cells/mm3, usually is present in patients with acute, uncomplicated appendicitis and often 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 raise the possibility of a perforated appendix with or without an abscess.

• Urinalysis can be useful to rule out the urinary tract as the source of infection. Although several white or red blood cells can be present from ureteral or bladder irritation as a result of an inflamed appendix

Imaging studies

• Abdominal film-In patients with acute appendicitis, one often sees an abnormal bowel gas pattern, which is a nonspecific finding. The presence of a fecalith is rarely noted on plain films but, if present, is highly suggestive of the diagnosis-plain radiographs can be of significant benefit in 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 of acute appendicitis.

Graded compression sonography has been suggested as an accurate way to establish the diagnosis of appendicitis. The technique is inexpensive, can be performed rapidly, does not require a contrast medium, and can be used even in pregnant patients-The sonographic diagnosis of acute appendicitis has a reported sensitivity of 55 to 96% and a specificity of 85 to 98%

Non compression Compression

• The presence of an appendicolith establishes the diagnosis. Thickening of the appendiceal wall and the presence of periappendiceal fluid is highly suggestive

• CT Scanan excellent technique for

identifying other inflammatory processes masquerading as appendicitis.

Alvarado scoring method

• This scoring system was designed to improve the diagnosis of appendicitis and was devised by giving relative weight to specific clinical manifestation. Table 30-2 lists the eight specific indicators identified.

Alvarado scoring method• Patients with scores of 9 or 10 are almost

certain to have appendicitis; there is little advantage in further work-up, and they should go 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 scanning is certainly appropriate for patients with Alvarado scores of 5 and 6, and a case can be built for imaging for those with scores of 7 and 8.