Appendicitis

Clerk Buansay

Identifying Data

K.R.
38 y/o
Female
Married
Filipino

Chief Complaint
Abdominal pain

History of Present Illness

1 day PTC, patient experienced epigastric pain,
9/10 in the pain scale, associated with 5
vomiting episodes of previously ingested food,
non bilous, non projectile, half a cup in volume.
Patient sought consult at a tertiary hospital.
After observation, she was given pantoprazole
and metoclopramide.

History of Present Illness

Few hours before admission, patient still has
epigastric pain (9/10) in radiating to the right
lower quadrant. There was loss of appetite but
no vomiting.

Past Medical History

Hypothyroidism 2007
Laparoscopic oophorecystectomy unrecalled
KSA
Open oophorecystectomy unrecalled - KSA

Family History

(-) Hypertension
(-) DM
(-) asthma
(-) cancer

Personal and Social History

The patient, a government employee, is married
for 10 years to a 40 year old seaman
Denies smoking
Denies alcohol use
Denies drug abuse

OB Gyne History
Last menstrual period September 21, 2015
Gravida 0

M 13 years old
I Regular
D 4 days
A 2 pads per day
S (+) dysmenorrhea

Review of Systems
General: No recent weight changes, no
weakness, no fever
Skin: No rashes
HEENT: No headache, no dizziness, no blurred
vision, no hearing tinnitus, no colds, no
epistaxis, no bleeding gums
Cardiovascular: no shortness of breath, no chest
pain, no cyanosis

Review of Systems
Respiratory: no tachypnea, no dyspnea
Gastrointestinal: (+) loss of appetite, no
diarrhea, no swallowing and chewing difficulties
Genitourinary: no frequency, no dysuria, no
hematuria
Musculoskeletal: no joint pain, no swelling

Physical Examination
General: Awake, alert, conscious, coherent, not in
cardiorespiratory distress
Vital Signs:

BP: 110/60 mm Hg
HR: 104 bpm
RR: 17 cpm
Temperature: 36.7 C
Weight: 53 kg
Height: 1.57 m
BMI: 21.5 (normal)

Physical Examination
Skin: No jaundice, no cyanosis, no pallor. Good
skin turgor.
HEENT: Anicteric sclera, pink palpebral
conjunctivae, no nasal discharge, no ear
discharge, no cervical lymphadenopathy.
Chest: Symmetric chest expansion, no
retractions, clear breath sounds

Physical Examination
Heart: Adynamic precordium, normal rate regular rhythm
Abdomen:

Flat, surgical scars

Normoactive bowel sounds, no bruits,
Tympanitic upon percussion
(+) direct tenderness
(+) Rovsing sign
(+) Psoas sign

Extremities: No edema, full and equal pulses

Neurological Exam: Cranial nerves are intact, no motor and
sensory deficit

At the ER
Complete blood count revealed
Result

Normal Values

19,000

4.4 11

90

56-65

Lymphocytes

25-35

Monocytes

2-8

RBC

4,1

4.3 5.5

Hemoglobin

13.3

12 16

Hematocrit

36.5

37-45

311,000

150,000
450,000

WBC
Neutrophil

Platelets

At the ER
Urinalysis revealed
Color

Yellow

Appearance

Slighlty cloudy

pH

Specific gravity

1.010

Protein

Trace

Glucose

Negative

WBC

12.5

RBC

25.7

At the ER
Ultrasound revealed
1.3 cm luminal diameter

Differential Diagnosis
To consider

Rule out

Pelvic inflammatory
Disease

Female
Vomiting
Abdominal pain
Fever

Bilateral pain

Acid peptic disease

Epigastric pain

Pain not relieved by food

and antacids

Ovarian torsion

Female
Acute onset of RLQ pain
Vomiting
Leukocytosis
Rebound tenderness

Impression
Appendicitis

Discussion

Anatomy
Average length of the appendix is 6 to 9 cm
Can vary in length from <1 to >30 cm
Outer diameter 3 and 88 mm
Luminal diameter 1 and 3 mm

Anatomy
Blood supply
Appendicular branch of ileocolic artery

Anatomy
Nerve supply
Symphatetic: superior mesenteric plexus (T10-L1)
Parasymphatetic: vagus nerve

Anatomy
Histologic layers:

Outer serosa extension of the peritoneum

Muscularis layer
Submucosa
Mucosa crypts, irregularly sized and shaped,
compared to more uniform appearance of crypts
in colon

Epidemiology
Males 8.6% lifetime risk
Females 6.7% lifetime risk
Highest incidence second and third decade of
life

Physiology
function as a reservoir to recolonize the colon
with healthy bacteria

Etiology
Proximal obstruction of appendiceal lumen
closed loop obstruction
continuing normal secretion by the appendiceal
mucosa rapidly produces distension
Nerve endings of visceral fibers produces diffuse
pain

Etiology
Distension increases from
continued secretion and from multiplication of
the bacteria causing nausea and vomiting
Inflammation spreads to serosa and parietal
peritoneum, this time causing right lower
quadrant pain

Clinical Presentation
Upon palpation, there is a tenderness with a
maximum point (McBurneys point)

Clinical Presentation
Indirect tenderness (Rovsings sign) and indirect
rebound tenderness

Medical Vs Surgical Management

Observational studies and controlled trials
revealed 9% short-term (<30 days) failure rate
with nonoperative management of appendicitis
After 1 month, 13% of patients who initially were
successfully treated with nonoperative measures
developed recurrent appendicitis, with an 18%
rate of complicated appendicitis.

Laparoscopic and Open Appendectomy

Laparoscopic Appendectomy

Open Appendectomy

Fewer incisional site infection

Less pain
Shorter length of hospital stay
Quick return to hospital stay

Shorter operative duration

Decreased OR costs

Post Operative Care

Uncomplicated Appendicitis
Diet can be immediately started
Antibiotic is unnecessary

Complicated Appendicitis
Broad spectrum antibiotics for 4 to 7 days
Post op ileus can occur

Complications
Surgical Site Complication
Stump appendicitis
Failure to remove the entire appendix
Can be prevented by using appendiceal critical
view

TY!