Appendicitis

Madrid
Identifying Data

● JQ
● 45 y/o
● Female
● Roman Catholic
● Filipino
● Mandaluyong City
Chief Complaint:
Abdominal Pain
History of Present Illness

3 days Hours
In the
prior to prior to
interim
consult consult

Sudden Onset Generalized Crampy

Abdominal Pain
7/10 Severity Persistence of generalized crampy Migration of crampy abdominal pain
abdominal pain to RLQ with increased severity
(-) Anorexia
(+) Nausea (-) Anorexia
(-) Vomiting (-) Fever
(-) Nausea (+) Nausea
(-) Changes in bowel movement
(-) Vomiting (-) Anorexia
(-) Fever
(-) Changes in bowel movement (-) Vomiting
Consulted at another institution (-) Fever (-) Changes in bowel movement
Sent home with ketorolac, omeprazole
and domiperidone Symptoms prompted consult
Review of Systems

General (-) Easy Fatigability, (-) Weight Gain, (-) Weight Loss

HEENT (-) Blurring of Vision, (-) Epistaxis, (-) Headache, (-) Seizure, (-)
Deafness, (-) Vertigo (-) Jaundice

MSK/Integumentary (-) Erythema, (-) Joint Pains, (-) Joint Swelling, (-) Muscle Pains, (-
) Rashes, (-) Weakness

Cardiovascular (-) Syncope, (-) Orthopnea, (-) Heaves, (-) Distended Neck Veins, (-)
Palpitation, (-) Edema
Review of Systems

Respiratory (-) Colds, (-) Cough, (-) Hemoptysis,

Gastrointestinal (-) Constipation, (-) Loose stools, (-) Nausea, (-) Vomiting, (-) Bleeding

Genitourinary (-) Dysuria, (-) Hematuria, (-) Nocturia, (-) Frequency

Endocrine (-) Polyuria, (-) Excessive sweating, (-) Heat intolerance, (-) Excessive
thirst, (-) Cold intolerance
Past Medical History
● No known drug or food allergies
● Known case of Peptic Ulcer Disease
● No previous hospitalizations
● No previous surgeries
Family History
● (-) Diabetes
● (-) Hypertension
● (-) Cancer
● (-) Heart Disease
● (-) Tuberculosis
● (-) Asthma
OB-GYN History
● G6P6 (6-0-0-6)
● LMP: 1/17/19
● M - 14 y/o
● I - Irregular
● D - 3-4 days
● A - 2-3 pads per day
● S - Occasional Dysmenorrhea
Physical Exam
● General survey: Awake, alert, coherent, uncomfortable, in pain
● Vital signs: BP 100/70, HR 81, RR 20, Temp 36.9
● HEENT: Pink palpebral conjunctivae, anicteric sclerae, non-distended neck
veins, no CLADs
● Cardiovascular: Normal rate, regular rhythm, no murmurs
● Respiratory: Symmetric chest expansion, clear breath sounds, fair air entry
Physical Exam
● Abdominal
○ (-) gross deformities, scars nor lesions
○ Soft, nondistended abdomen
○ Normoactive bowel sounds
○ (+) Direct tenderness on RLQ
○ (+) Rebound tenderness on RLQ
○ (+) Psoas Sign
○ (+) Rovsing’s Sign
○ (-) Obturator Sign
○ (-) Fluid Wave
○ (-) Murphy’s sign
○ (-) CVA tenderness
● DRE
○ (-) Blood, (-) Tissues, (-) Fissure, (-) Soft Stools, (-) Masses, (-) Tenderness
Physical Exam
● Extremities
○ Full and equal pulses, fair skin color, no cyanosis, no edema, CRT < 2 secs
● Neurologic
○ Cranial nerves intact
○ Motor: 5/5, with spontaneous movement
○ Sensory: 100%
Assessment
Problem List
1. Right Lower Quadrant Abdominal Pain
 Primary Acute Appendicitis
Impression
Primary Impression
More Likely Less Likely

Pelvic Inflammatory Disease Female (+) Nausea

(+) RLQ pain (-) Mucopurulent discharge

Ovarian/Fallopian Tube Torsion (+) Sudden onset lower (-) Fever

abdominal pain (-) Vomiting
(+) Nausea Usually presents with
pelvic/adnexal mass (but cannot
be totally assessed due to
guarding)

Diverticulitis (+) Abdominal pain Pain more common in LLQ

(+) Rebound tenderness (-) Vomiting
(-) Changes in bowel habits
(-) Fever
Plan
Diagnostic Plan
● CBC (Check if WBC levels are elevated)
● Urinalysis (Abnormal result may suggest alternative cause)
● Pregnancy test
● Creatinine (Screening before CT contrast imaging)
● CT scan
Laboratory Test - CBC

Hgb 137 g/L Differential Count

Hct 0.39 Band 0.00 (L)

RBC 4.66 x 1012/L Neutrophils 0.85 (H)

WBC 18.2 x 109/L (H) Lymphocytes 0.15

Thrombocytes Adequate Monocytes 0.02

Eosinophils 0.00

Basophils 0.00
Laboratory Test - Pregnancy Test
Negative
Laboratory Test - Urinalysis

Color Light yellow Leucocytes Negative

Transparency Hazy Ketones Negative

Reaction Acidic Urobilinogen Normal

Specific gravity 1.020 Bilirubin Negative

Blood Negative Nitrites Negative

Protein Trace

Glucose Negative
Laboratory Test - Urinalysis

Red cells 2

White cells 1

Epithelial cells 3

Casts 0

Bacteria 118 (H)

Laboratory Test - Blood Chemistry

Sodium 134.00 mmol/L

Potassium 4.09 mmol/L

BUN 6.22 umol/L

Radiologic Exam – CT Scan
● Diffuse haziness and fat stranding seen in the RLQ with a localized fluid collection
● Collection measures 2.3 x 3.3 x 2.3cm
● Cecum and distal/terminal ileal segments exhibit diffuse wall thickening
● Multiple varied sized nodularities also appreciated with largest measuring 0.8cm

Impression: Constellation of findings in the RLQ may suggest ruptured appendicitis with
early abscess formation. Probable appendicolith still present with proximal portion of the
appendix.
Therapeutic Plan
● For exploratory laparotomy, appendectomy
Operative Technique
Operative Technique
● Incise through superficial (Campers) and
deep (Scarpa) fascia
● External oblique is exposed and incised in
the direction of the fibers
Operative Technique
● Exposed external oblique aponeurosis
● Split external oblique muscles bluntly
Operative Technique
● Visualization of the transversalis fascia and
the peritoneum
Operative Technique
● Incision on the peritoneum in a
craniocaudal direction
● There would be access to the peritoneal
cavity
● Fluid aspirated and sent of gram staining
and culture
Operative Technique
● Removal of appendix

● Free appendix-mesoappendix from inflamed

tissue

● Mesoappendix containing appendiceal

artery is ligated and separated from the
appendix
Operative Technique
Operative Diagnoses

Pre-operative diagnosis: Acute surgical abdomen probably

secondary to ruptured appendicitis

Post-operative diagnosis: Ruptured appendicitis

Discussion
Epidemiology

● Lifetime risk of developing appendicitis is 8.6% for males and 6.7% for females

● Highest incidence in the second and third decades

● Most common abdominal surgical emergency in the world
Pathophysiology

● Appendicitis is caused by non-specific obstruction of the appendiceal lumen

● Fecal material, undigested food, other foreign material, etc. may accumulate in
the appendix
● Obstruction causes colic which produces poorly localized periumbilical
abdominal pain typical in early appendicitis
○ Also causes appendiceal lumen to dilate and its wall to thicken
Pathophysiology

● Intraluminal bacterial overgrowth follows with breakdown of the mucosal

barrier, bacterial invasion of the wall, inflammation, ischemia, and gangrene,
eventually leading to perforation
● Inflammation of the wall of the appendix causes peritonitis causing the localized
pain on the right lower quadrant of the abdomen
Classic Presentation of Appendicitis
● Anorexia ● Signs of peritoneal irritation
● Periumbilical pain (early) ○ Involuntary muscle guarding
● Migration of pain to RLQ (within 24 with palpation
hours of onset of symptoms) ○ (+) Rovsing’s sign
● Pain with movement ○ (+) Obturator sign
● Vomiting ○ (+) Psoas sign
● Fever (24-48 hours after onset of ○ (+) Rebound tenderness
symptoms) ○ (+) McBurney’s Point
● RLQ tenderness
Clinical Presentation
● Symptoms
○ Usually starts with periumbilical and diffuse pain that eventually localizes to the right lower
quadrant
○ Associated with gastrointestinal symptoms like nausea, vomiting, and anorexia
Clinical Presentation
● Signs
○ Body temperature and pulse rate may be
normal or slightly elevated
○ Tenderness with a maximum at or near
McBurney’s point
○ Muscular resistance (guarding) in the right
iliac fossa
○ Rebound tenderness
○ Indirect tenderness (Rovsing’s sign)
○ Psoas sign → proximity to the right psoas
muscle
○ Obturator sign → inflammation near the
obturator muscle
Clinical Presentation
Clinical Presentation
● Laboratory findings
○ Mild leukocytosis accompanied by a polymorphonuclear prominence
○ Counts > 18,000 cells/mm3 → possibility of perforated appendix with or without an abscess
○ Increases CRP concentration → strong indicator of appendicitis
○ Urinalysis to rule out UTI as a source of infection
Clinical Presentation
1 point: Migratory Right Iliac Fossa Pain
Clinical Scoring System: Alvarado Scoring
1 point: Anorexia ● Used to identify the likelihood of
acute appendicitis
1 point: Nausea/vomiting
● A score of 0 - 3 means there is a
2 points: Tenderness in the Right Iliac Fossa small likelihood of resulting into acute
1 point: Rebound Tenderness in the Right Iliac Fossa appendicitis
● A score of > 4 should be evaluated
1 point: Elevated Temperature > 37.5 degrees Celsius
further for high likelihood of
2 points: Leukocytosis appendicitis
1 point: Shift of WBC Count
Clinical Presentation
● Imaging studies
○ Ultrasonography and CT scan are most commonly used
○ CT scan is more sensitive and specific than ultrasonography in diagnosing appendicitis
■ Enlarged appendiceal diameter of > 5mm with an occluded lumen
■ Appendiceal wall thickening >2mm
■ Periappendiceal fat stranding thickened mesoappendix, periappendiceal phlegmon, and free
fluid
■ Appendicolith
Stages of Appendicitis
1. Early stage
○ Obstruction of lumen → mucosal edema, mucosal ulceration, bacterial diapedesis, appendiceal
distention
○ Stimulation of visceral afferent nerve fibers → mild visceral periumbilical/epigastric pain
2. Suppurative appendicitis
○ Intraluminal pressure > capillary perfusion → obstructed lymphatic and venous drainage
○ Bacterial and fluid invasion of the appendiceal wall
○ Inflamed serosa in contact with parietal peritoneum → RLQ migration
3. Gangrenous appendicitis
○ Intramural venous and arterial thromboses
4. Perforated appendicitis
○ Persistent tissue ischemia → appendiceal infarction, perforation
○ Localized or generalized peritonitis
Perforated vs Nonperforated Appendicitis
Nonperforated Perforated

● Also known as simple appendicitis ● Appears more ill (significant

or non-complicated appendicitis dehydration if fever and vomiting
● Without clinical or radiological signs have been present for a long time)
of perforation ● Can localize to RLQ or can be
diffuse if there is general peritonitis
Management
● Surgical treatment has been the standard of treatment
○ Open appendectomy
○ Laparoscopic appendectomy
Management
Open Appendectomy Laparoscopic Appendectomy

● When the diagnosis is in question, ● Fewer incisional surgical site

such as in female patients of infections
reproductive age, older patients in ● May be associated with increased
whom malignancy is suspected, and risk of intra-abdominal abscess
morbidly obese patients, larger open ● Less pain, shorter length of stay,
appendectomy incisions may be quicker return to normal activities
required ● Increased operative duration and
increased operating rooms costs
Post-Operative Care
● Uncomplicated appendectomy
○ Low complication rates
○ Most patients can quickly be started on a diet and discharged home the same day or the following
day
○ Postoperative antibiotic therapy is unnecessary
● Complicated appendectomy
○ Continued on broad-spectrum antibiotics for 4 to 7 days
○ Postoperative ileus may occur, so diet should be started based on daily clinical evaluation
○ Increased risk for surgical site infections