Case presentation on acute
appendicitis
BY SADIK.H
PG2 STUDENT.
DEPARTMENT OF PHARMACY
CLINICAL PHARMACY UNIT
May 24/2024
NEKEMTE,ETHIOPIA
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Outline
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Patient demography
Chief compliant
HPI
Physician assessment
Management
DTP identified
Follow up
Patient education
Appendicitis overview
Patient demography
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Name – H.S
Sex- male
Age -18 years
Card no. -225887
Address – G/bila
Date of admission- 19/8/2016
Chief compliant
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Abdominal pain of 4 days duration
History of present illness
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This is 18 years old male patient presented
with history of crampy periumblical
abdominal pain of 4 days duration which
shifts to right lower abdomen associated
nausea and loss of appetite.
Otherwise -no history of vomting, abdominal
distension, cough and SOB
No history of failure to pass feaces and flatus
No history of chronic medical illness
Physical examination
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G/A- well looking
Vital signs on admission
Bp -110/70mmhg
PR -80bm
RR -20
Temp. -37
HEENT –pink conjuctiva
LGS – no LAP
Physical examination
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R/S – clear chest moves with respiration
CVS –s1 & s2 well heard, no murmur &
gallop
Abdomen – flat, moves with respiration
- no papable mass
- there is tenderness over the right
lower quadrant
DRE-normotonic anal sphnictor
-stool on examining finger
MSS – no deformity, no edema
Objective finding
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Abdominal ultrasound
Complex peritoneal collection
CBC
Hgb 12.5g/dl(12-16)
Hct 39.5%(40-54)
Platelete 295*109/L(100-300)
WBC 11.5*109/L(4-10)
RBC 4.23*1012/L(4-5.5)
RBS……….85g/dl
Physician assessment
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Acute abdomen secondary to pelvic
peritonitis secondary to perforated
appendicitis.
Treatment on admission
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MF(1NS,1DNS,1RL/24HR)
Ceftriaxone 1gm iv BID
Metronidazole 500mg iv TID
Take informed consent
Prepare for OR
Treatment…
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Immediate posoperative(laparatomy +
abcess drainage + appendectomy)
MF
ceftriaxone 1gm iv BID
Metronidazole 500mg iv TID
Tramadol 50mg iv TID
Diclofenac 25mg IM BID
Remove cathater after 24hr
On 25/08/2016
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Continue the same management.
Encourage ambulation
0n 29/08/2016
Discontinue iv medication and discharge
the patient.
Vital sign chart
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Date Bp PR RR temp SpO2 Pain
score
20/08/2016 93/80 63 20 36.5 94% 4/10
21/8/2016 91/79 64 20 36.8 95% 3/10
22/8/2016 89/70 67 20 36.5 96% 3/10
23/8/2016 98/57 59 20 36.7 96% 1/10
24/8/2016 106/61 58 20 36 96% 1/10
25/8/2016 100/64 69 20 36 96% 1/10
DTP identified
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Dose too high.
International guidelines recommend 3–5
days of postoperative antibiotics after an
appendicectomy for complex acute
appendicitis.
After appendicectomy for complicated
appendicitis, 3 days of antibiotic treatment
is equally effective as 5 days in reducing
postoperative infections.
van Rossem et al;.Br J Surg. 2023.
monitoring and follow up plan
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Medical Drug Goals of Intervention Status
problems therapy therapy
problems
Acute Dose too Prevent 3–5 days of Not
appendicitis high SSI postoperative accepted
antibiotics
after an
appendicecto
my
Patient education
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Avoid strenuous activities, such as bicycle
riding, jogging, weight lifting, or aerobic
exercise, until you have told it is okay.
Appendicitis
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Epidemiology
The lifetime risk of developing appendicitis
is 8.6% for males and 6.7% for females,
with the highest incidence in the second
and third decades.
The appendix during the 'teens is
particularly liable to obstruct and hence to
become inflamed because of the large
proportion of lymphoid tissue which it
contains.
Appendicitis…
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Etiology and Pathogenesis
The etiology and pathogenesis of
appendicitis are not completely
understood.
Obstruction of the lumen due to fecaliths
or hypertrophy of lymphoid tissue is
proposed as the main etiologic factor in
acute appendicitis.
Microbiology
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Appendicitis may occur in clusters,
suggesting an infectious genesis.
However, an association with various
contagious bacteria and viruses has only
been found in a small proportion of
appendicitis patients.
The flora of the inflamed appendix differs
from that of the normal appendix
About 60% of aspirates of inflamed
appendices have anaerobes compared to
25% of aspirates from normal appendices.
Microbiology…
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Tissue specimens from the inflamed
appendix wall (not luminal aspirates)
virtually all grow Escherichia coli and
Bacteroides species on culture.
Fusobacterium nucleatum/necrophorum,
which is not present in the normal cecal
flora, has been identified in 62% of
inflamed appendices.
Clinical Presentation
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periumbilical and diffuse pain that
eventually localizes to the right lower
quadrant (sensitivity, 81%; specificity,
53%).
Although right lower quadrant pain is one
of the most sensitive signs of appendicitis,
pain in an atypical location or minimal
pain will often be the initial presentation.
Variations in the anatomic location of the
appendix may account for the differing
presentations of the somatic phase of
Antibiotic
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Patients undergoing nonoperative
treatment should receive IV antibiotics in
hospital for 24–72 hours to monitor for
worsening pain or clinical deterioration.
A common regimen is IV ceftriaxone for 24
hours followed by 5–10 days of
ciprofloxacin and metronidazole.
Operative versus Non-operative
Management of Uncomplicated
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Appendicitis
Antibiotic therapy proved to be safe, less
expensive, but also less effective than
surgical treatment.
A meta-analysis and trial
sequential analysis of RCT
A Systematic Review and Meta-analysis
point to the general safety and efficacy of
nonoperative management of
uncomplicated acute appendicitis.
However, this strategy may be associated
with an increase in duration of hospital
Operative versus Non-operative
Management of Complicated
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Appendicitis
Surgical treatment of patients presenting
with complicated appendicitis is preferable
to non-operative, antibiotic oriented
treatment in reduction of LOS and need
for readmissions
Helling TS, et al; cohort study; Am
J Surg. 2017
Laparoscopic versus Open
Appendectomy
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prospective randomized trial revealed
that there was no difference in morbidity,
and both groups had a median time to
discharge of 3 days.
Laparoscopic appendectomy is as safe as
open appendectomy; and despite the
longer operating time, the advantages
such as fewer wound infections and earlier
return to normal activity make it a
worthwhile alternative for patients with a
clinical diagnosis of acute appendicitis.
Acute Appendicitis in the Young
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In children, the physical examination
findings of
maximal tenderness in the right lower
quadrant,
the inability to walk or walking with a limp,
and
pain with percussion, coughing, and
hopping were found to have the highest
sensitivity for appendicitis
Acute Appendicitis in the Young…
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The treatment regimen for perforated
appendicitis generally includes immediate
appendectomy.
Antibiotic coverage is limited to 24 to 48
hours in cases of nonperforated
appendicitis.
For perforated appendicitis, intravenous
antibiotics usually are given until the
white blood cell count is normal and the
patient is afebrile for 24 hours.
Laparoscopic appendectomy has been
Acute Appendicitis in the Elderly
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Compared with younger adults, elderly
patients with appendicitis often pose a
more difficult diagnostic problem because
of the atypical presentation, expanded
differential diagnosis, and communication
difficulty.
Elderly patients usually present with lower
abdominal pain, but on clinical
examination, localized right lower quadrant
tenderness is not as common as in younger
patients.
Elderly…
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laparoscopic appendectomy offers elderly
patients with appendicitis a shorter length
of hospital stay, a reduction in
complication and mortality rates, and a
greater chance of discharge to home
Acute Appendicitis during
Pregnancy
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Acute appendicitis can occur at any time
during pregnancy but is rare in the third
trimester.
many abdominal symptoms may be
considered pregnancy related.
In addition, during pregnancy, there are
anatomic changes in the appendix and
increased abdominal laxity that may
further complicate clinical evaluation.
Pregnancy…
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In an analysis of outcomes in California
using administrative databases,
laparoscopy was found to be associated
with a 2.31 times increased risk of fetal
loss compared with open surgery.
Complications
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Peritonitis: When the appendix bursts and
bacteria spill into your abdominal cavity,
the lining can become infected and
inflamed.
This is known as peritonitis.
It can be very serious and even fatal.
Treatment includes antibiotics and surgery
to remove the appendix.
Complications…
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Abscesses: An abscess is a painful pocket
of pus that forms around a burst appendix.
These white blood cells are your body’s
way of fighting the infection.
The infection must be treated with
antibiotics, and the abscess will need to
be drained.
Sepsis: In rare cases, bacteria from a
ruptured abscess may travel through your
bloodstream to other parts of your body.
Sepsis is a medical emergency.
Thank you!
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