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ACUTE APPENDICITIS

Roy Phitayakorn, M.D. Christopher Brandt, M.D.


Case Western Reserve University School of Medicine

Ms. Z. Cope
You are called to see a patient in the Emergency Department, who is a 25 year-old female with a 1 day history of right-lower quadrant abdominal pain.

History
What other points of the history do you want to know?

History, Ms. Cope


Consider the Following Characterization of symptoms Temporal sequence Alleviating / Exacerbating factors: Pertinent PMH, ROS, MEDS. Relevant family hx. Associated signs and symptoms

History, Patient ZC
Pain started in the middle of the night and woke the patient from sleep. Felt nauseated and vomited after pain No significant MED.HX. or SURG HX. Negative Family HX Noted some indigestion yesterday Feels urge to have bowel movement, but has been constipated

What is your Differential Diagnosis?

Differential Diagnosis
Based on History and Presentation

Systemic or infectious conditions


Influenza Gastroenteritis Hepatitis Diaphragmatic pleurisy Spinal disease Typhoid Tuberculosis Acute porphyria Diabetic ketoacidosis

Differential Diagnosis
(cont.)

Intra-abdominal conditions
Acute Appendicitis Acute Cholecystitis Diverticulitis (Meckels) Inflammatory Bowel Disease (Crohns) Duodenal Ulcer Intestinal Obstruction Carcinoma of the Cecum Nonspecific adenitis Possible Yersinia infection

Differential Diagnosis
(cont.)

Intra-pelvic conditions
Salpingitis Pelvic Inflammatory Disease Ectopic Pregnancy Ruptured Corpus Luteum Cyst Ruptured Follicular Cyst (Mittelschmerz) Ruptured Ovarian Cyst Ovarian Torsion Pyelonephritis Ureteral/Renal stone

Physical Examination What would you look for?

Physical Examination, Patient ZC


Vital Signs: 39o C, HR=75, RR=15, BP=125/75 Appearance: Patient is lying quietly on bed in fetal position
VAGINAL: nontender, no Discharge

HEENT : No icterus

CV : nl S1S2, no murmurs
PULM : CTA Bilat. no pain with
inspiration

RECTAL: Guaiac neg, uncomfortable during exam


Neuromuscular: Minimal hyperesthesia above umbilicus

ABD : Moderately tender in RLQ between pubic symphysis and ASIS, involuntary guarding, Neg bowel sounds

Would you like to revise your Differential Diagnosis?

Would you like to revise your Differential Diagnosis?


Acute appendicits Diverticulitis (Meckels) Inflammatory Bowel Disease (Crohns) Ovarian pathology Acute cholecystitis Intestinal obstruction Nonspecific adenitis Possible Yersinia infection

Laboratory

What would you obtain?

Labs ordered
CBC Electrolytes

LFTs B-HCG

Amylase /Lipase Urinalysis

Lab Results, Ms. Cope


CBC: 14,500

LFTs : WNL
HCG : WNL

Electrolytes : WNL
Amylase : WNL

U/A: WNL

Interventions at this point?

Interventions at this point?


Consider the following Start IV with Ringers Lactate or similar isotonic crystalloid solution Administer antibiotics Admit to the hospital Go Directly to the OR? Other?

Studies
What further studies would you want at this time?

Radiologic Studies to Consider


Flat/Upright Abdomen CT Scan: Abd/Pelvis CT Scan: Other ? US Abdomen/Pelvis

Considering your Differential Diagnosis


What would you expect to see on a flat/upright abdominal series? What specific abnormalities do you look for on US? What population? Are there specific CT findings in any of your top 3 diagnoses?

Abdominal Film

Abdominal X-ray Findings


Non-specific gas pattern No fecalith No free air

CT Scan Abdomen & Pelvis

CT Scan Results
Acute Appendicitis
Thickened dilated appendix Peri-appendiceal fat stranding Scant free fluid

Incidental small left ovarian cyst

What is the differential diagnosis at this point?

Revised Differential Diagnosis

What next?

Additional Imaging? Observation? OR? Other?

What next?

Discussion of suggested interventions

Management
Surgical Options Pre-operative preparation

Laparoscopic Acute Appendicitis

Discussion
Pathophysiology of the disease process, visceral vs.
parietal abdominal pain, laparoscopy vs. open, antibiotic management, appropriate utilization of resources, etc.

Discussion
Additional teaching points

QUESTIONS ??????

Summary

Alternative scenarios
Acute Appendicitis with perforation/ Abscess or tumor IBD Acute Diverticulitis Ovarian Cyst / Torsion/ Perforated Right colon tumor

CT Cecal Tumor

CT Sigmoid Diverticulitis

CT Ovarian Cystic Mass

CT Terminal Ileal Crohns

CT Acute Appendicitis

Acknowledgment
The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION


In order to improve our educational materials we welcome your comments/ suggestions at: feedbackPPTM@surgicaleducation.com

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