Patient's Details:

Name : X
Age : 12y
Gender : Male
Race : Sarawak Kayan
Address :Sibu
Reference Number :X
TPC Number
:X
Date of Admission :18-10-2016
Time of Admission :1630
____________________________________________________________________________
Chief Complaint
Adrian presented with periumblical pain since three days prior to admission.
History Presenting Illness
The history of present illness started a week ago prior to consult when patient
experienced constipation, his normal bowel frequency ranges between two bowel
movement per day however since a week ago his frequency ranges one in three days only
and lessened to none.
Three days prior to admission patient developed high grade fever with chills and rigor.
The fever started early in the morning and his worried mother gave two tablets of
paracetamol, the fever subside for two hours but did not resolved fully. The second
episodes of fever started again in the afternoon accompanied by periumblical pain.
Regarding the periumblical pain It was described sudden onset as colicky pain in
character and at times the severity increases with a pain score of 7/10 to 10/10 and not
reducing trend,only localized over the periumblical region. Non radiating , lasting for a
20minutes to 1 hour at times The pain was not relieved by paracetamol and bed rest,
and aggravated when he try to moves around. He was totally restless and bedridden. Its
not a satiety pain or hunger pain. His oral intake and urine output reduced since three
days ago as well with loss of appetite, but no vomiting or diarrhea occurred. Persistence
of the noticed pain prompted his mother to bring him to ETD Hospital Sibu. Adrian
treated as gastritis and given lactulose. His bowel output was minimal loose stool after
taken that lactulose and the pain does not improve and he required hospitalization for
further diagnosis here.

Systemic review :
Nervous system : No headache or dizziness
Cardiovascular system : No palpitation
Respiratory system : No shortness of breath
Urinary system : No hematuria
Medical history :
He born full term with normal birth weight SVD. He was admitted for two weeks as
needed for oxygen supply. He was breastfed til 5 months. His vaccination are up to date.
He is a bright student in his class now.
Surgical history :
No relevant history.
Allergy history :
No known drug and food allergies.
Family history :
He has 2 kin and all of them are healthy.
His grandfather has appendicitis and underwent appendicectomy.
Physical examination:
General examination
Adrian a medium built boy was lying comfortably in a supine position. He was awake,
coherent, ambulatory, not in cardiorespiratory distress lying comfortably in a supine
position. Anicteric sclerae, pink palpebral conjunctiva, no palpable cervical
lymphadenopathy, no anterior neck mass noted
Vital signs are as below :
Temperature
: 36.4 C
Blood pressure : 102/62 mmHg
Pulse : 80 beat per minute, good volume, normal rhythm.
Respiratory rate : 20 breaths per minute
Cardiovascular system examination
Normal 1st and 2nd heart sound was heard. There was no additional heart sound or
murmur.
Respiratory system examination
Normal vesicular breath sound was heard with no abnormal sounds.

Abdominal examination
On inspection, the abdomen shape was normal and moves with respiration. There was no
surgical scar, no dilated vein, no visible pulsation and peristalsis noted .
On light palpitation, his abdomen was soft and tender at periumbilical region. There is
guarding and rebound tenderness present. On deep palpation, there was tenderness on
right iliac fossa felt with no hepatosplenomegaly . Both kidneys were not ballotable.
Rovsing sign : negative
Psoas sign : positive
Obturator sign : negative
On percussion, there was no shifting dullness.
On auscultation, normal bowel sound present with no renal bruit
Sumarry:
Adrian Nawan 12years old boy, medium built previously active and healthy boy,
presented with constipation a week prior to admission and a sudden onset of periumblical
pain with high grade fever three days prior to admission.
Diagnosis
12years old boy with appendicitis
Reasons for diagnosis
1. Young onset
2. Acute onset of symptom ( sudden onset )
3. The abdominal tenderness is preceded by symptoms having fever which is the
murphys triad .
4. The clinical examination suggested typical signs of appendicitis.

Differential diagnosis :
1.Mesentric lymphadenitis common in children
Point of exclusion : No history of recent upper respiratory tract infections
2.Intussusection
Point of exclusion :He has no palpable 'sausage-shaped' mass (often in the right
upper quadrant)
3.Intestinal obstruction
Point of exclusion : No abdominal distention

Investigation :
1. Urinalysis to exclude urinary tract infection.
2. FBC: there is usually a mild leukocytosis but a normal white cell count does not
exclude appendicitis.
3. Raised inflammatory markers: CRP may be raised but a normal level does not
exclude a diagnosis of appendicitis.
4. Ultrasound may help in some patients where the diagnosis is doubtful and in the
assessment of an appendix mass or abscess.
5. Diagnostic laparoscopy may be considered.
- Normal
Full blood count - Normal
Result
Normal range
Remark
WBC
8.7
4.0 11.0 x10^9 g/L
Normal
RBC
5.28
2.5 5.5 x10^6 /ul
Normal
Hemoglobi
14.3
12.5 17.0 g/dL
Normal
n
Hematocrit
40
35 47 %
Normal
MCV
77.3
76 96 fL
Normal
MCH
27.4
27 32 pg
Normal
MCHC
35.2
30 35 g/dL
High
Platlet
279
150 400 x 10^3 /uL
Normal
Lymphocyt
29.80%
5 55 %
Normal
e%
Neutrophil
76.8 %
45 85 %
Normal
%
Monocyte
6.5 %
Normal
%
Eosinophil
1.3 %
Normal
%
Basophil %
0.1 %
Normal
Lymphocyt
1.06 x 10^3
Normal
e
/ul
Neutrophil
5.30 x 10^3
Normal
/ul
Monocyte 0.45 x10^3 /ul
Normal
Eosinophil
0.09
Normal
Basophil
0.01
Normal
RDW-SD
39.5 fL
37 54 fL
Normal
PDW
11.2 fL
Normal
MPV
10.2 Fl
Normal
P-LCR
26.0 %
Normal

 Renal profile normal

Result
Urea
6
Sodium
145
Potassium
4.2
Chloride
103
Creatinine
78

Normal range
1.7 6.4 mmol/L
135 150 mmol/L
3.5 5.0 mmol/L
98 107 mmol/L
44 88 mmol/L

Coagulation Profile-normal
Result
Prothrombin
13.20
time
Activated Partial
20.0
Thromboplastin
Time

Normal range
10 14 seconds

Remarks
Normal

20 35 seconds

Normal

Blood glucose : 5.1mmol /L

-normal
ECG
-Normal sinus rythm
Management of the patient based on the Hospital Sibu :
1.
2.
3.
4.
5.

Remarks
Normal
Normal
Normal
Normal
Normal

Ravin enema 11/11 stat

Syrup Lactulose 15ml tds
IV Normal Saline & Dextrose 10% maintenance
Observe for abdominal pain severity
Allow orally as tolerated

DISCUSSION:
Inflammation of the appendix is known as the appendicitis. Acute appendicitis is a
common cause of abdominal pain requiring surgery. Appendicitis usually follows
obstruction of the lumen with distal infection and ulceration. The usual causes
are:fecolith, calculi, foreign body, tumor, worms ( ascaris lumbricoides, Oxyuriasis
vermicularis), diffuse lymphoid hyperplasia, vascular occlusion, inadequate dietary fiber
intake, etc.
The lumen of the appendix is relatively wide in the infant and is frequently completely
obliterated in the elderly. Since obstruction of the lumen is the usual precipitating cause
of acute appendicitis it is not unnatural,therefore, that appendicitis should be uncommon
at the two extremes of life. It is seen more commonly in older children and young adults.
Anatomy:
Because of the variation in position, the appendix is said to be the only organ in the body
without anatomy. Also called as vermix, vermiform appendix is a narrow vermin (worm
shaped) tube arising from the posteromedial aspect of the cecum (a large blind sac
forming the commencement of the large intestine) about 1 inch below the iliocecal valve.
Small lumen of appendix opens into the cecum and the orifice is guarded by a fold of
mucous membrane known as valve of Gerlach. The 3 taenia coli (taenia libera, taenia
mesocoli and taenia omental) of the ascending colon and caecum converge on the base of
the appendix.
Although the appendix serves no digestive function, it is thought to be a vestigial remnant
of an organ that was functional in human ancestors.
The length varies from 2 to 20 cm with an average of 9 cm with diameter of about 5mm. It
is longer in children compared to adults. In the fetus it is a direct outpouching of the
caecum, but differential overgrowth of the lateral caecal wall results in its medial
displacement.
The appendix is suspended by a small triangular fold of peritoneum, called the
mesoappendix
Location of Appendix:
Right lower quadrant of abdomen and more specifically right iliac fossa.
McBurneys point lying at the junction of lateral one-third and the medial two-thirds of
the line joining the umbilicus to the right anterior superior iliac spine roughly
corresponds to the position of the base of the appendix.
McBurneys point is the site of maximum tenderness in appendicits.


1.
2.
3.

Clinical
Examination of a case of acute appendicitis reveals following physical signs:
Hyperaesthesia in the right iliac fossa
Tenderness at McBurneys point
Muscle guard and rebound tenderness over the appendix
Appendicectomy is usually performed through a muscle-splitting incision in the
right iliac fossa. The caecum is delivered into the wound and, if the appendix is
not immediately visible, it is located by tracing the taeniae coli along the
caecumthey fuse at the base of the appendix. When the caecum is
extraperitoneal it may be difficult to bring the appendix up into the incision;
this is facilitated by first mobilizing the caecum by incising the almost avascular
peritoneum along its lateral and inferior borders.

Variations in Appendix position:

Although the base of the appendix is fixed, the tip can point in any direction. Hence, the
position of the appendix is extremely variable. The appendix is the only organ in the body
which is said to have no anatomy. When compared to the hour hand of a clock, the
positions would be:
12 o clock: Retrocolic or retrocecal (behind the cecum or colon)
2 o clock: Splenic (upwards and to the left Preileal and Postileal)
3 o clock: Promonteric (horizontally to the left pointing the sacral promontory)
4 o clock: Pelvic (descend into the pelvis)
6 o clock: Subcecal (below the cecum pointing towards inguinal canal)
11 o clcok: Paracolic (upwards and to the right)
Most common position of appendix (75% of cases):Retrocecal
Second most common position of appendix (20% of cases):Subcecal
If the appendix is very long, it may actually extend behind the ascending colon and abut
against the right kidney or the duodenum; in these cases its distal portion lies
extraperitoneally.

Clinical
The location of the tip of the appendix determines early signs and symptoms of
appendicitis.
Retrocecal:Extension of the hip joint may cause pain because the appendix is
disturbed by stretching of the psoas major muscle. Pain usually localizes in the
right flank.
Pelvic:Pain may be felt when the thigh is flexed and medially rotated, because
the obturator internus is stretched. Pelvic appendix may irritate the bladder or
rectum causing suprapubic pain, pain with urination, or feeling the need to
defecate.
Retroileal: In some males, it can irritate the ureter and cause testicular pain.
Pregnancy: the appendix can be shifted and patients can present with RUQ
(Right upper quadrant) pain.
Arterial Supply:
1.Appendicular artery:The mesoappendix, containing the appendicular branch of the
ileocolic artery (branch of superior mesenteric artery), descends behind the ileum.
2.Accessory appendicular artery:An accessory appendicular artery can branch from the
posterior cecal artery which is also a branch of ileocolic artery.
Clinical
Acute infection of the appendix may result in thrombosis of the appendicular
artery with rapid development of gangrene and subsequent perforation.
The accessory appendicular artery can lead to significant intraoperative and
postoperative hemorrhage and should be searched for carefully and ligated
once the main appendicular artery is controlled.
Venous drainage:
Appendicular vein > Ileocolic vein > Superior mesenteric vein > Portal vein
Lymphatic drainage:
There is abundant lymphoid tissue in its walls.
From the body and apex of the appendix 8-15 vessels ascend in the mesoappendix and
are ocasionally interrupted by one or more nodes > unite to form 3 or 4 larger vessels >
inferior and superior ileocolic nodes
A few of them pass indirectly through the appendicular nodes situated in the
mesoappendix.

Clinical
Appendicular dyspepsia:Chronic appendicits produces dyspepsia resembling
disease of stomach, duodenum or gall bladder. It is due to passage of infected
lymph to the subpyloric lymph nodes which causes irritation of pylorus.
Nerve supply:
1.Sympathetic nerves:T9 and T10 spinal segments through the celiac plexus
2.Parasympathetic nerves:Vagus
Clinical
Both the appendix and the umbilicus are innervated by segment T10 of the
spinal cord and hence the pain caused by appendicitis is first felt in the region
of umbilicus (referred pain). With increasing inflammation pain is felt in the
right iliac fossa due to involvement of the parietal peritoneum of the region
which is sensitive to pain in contrast to pain insensitive visceral peritoneum.

Pathology:
In acute appendicitis, the microscopy of cross section of appendix reveals:
1. Fibrin on peritoneal surface
2. Neutrophil exudate in lumen
3. Neutrohpil exudate spreads in submucosa and soon affects all layers

Etiology
As refered above, It can be due to obstruction of the appendiceal lumen, typically by
lymphoid hyperplasia, but occasionally by a fecalith, foreign body, or even worms. The
obstruction leads to distention, bacterial overgrowth, ischemia, and inflammation. If
untreated, necrosis, gangrene, and perforation occur. If the perforation is contained by
the omentum, an appendiceal abscess results.
Diagnosis

Clinical evaluation

Abdominal CT if necessary most but always unnecessary due to radiation

Ultrasonography an option to CT and its the best and mobile.

The Alvarado score was assessed as to its accuracy in the preoperative diagnosis of acute
appendicitis
Alvarado scoring: Diagnostic scoring of clinical presentations and laboratory
interpretation for acute appendicitis
Symptoms:
Score
1. Migratory right iliac fossa 1
pain
1
2. Aneroxia
1
3. Nausea and vomiting
Signs:
1. Rebound tenderness
2
2. Tenderness
1
3. Fever
1
Laboratory
result:
indicating
inflammation
1
1. Leukocytosis
2
2. Neutrophilia
Total
10

 >7 indicates appendicitis and management appropriated

4-6 suggests suspicion of appendicitis. Patient should be warded and observed for
development of presentations of appendicitis and repeated examination of 2-hourly.
Observe for abdominal changes and sign and symptoms of infection. Limit food
intake as it can lower the risk of progression of peritonitis as gastric hormone
increases peristalsis. Give IV fluid and antibiotics.
<4 indicates that it is less likely to be appendicitis and patient can be discharged
Modified Alvarado scoring: Lab results are excluded
Laparoscopy can be used for diagnosis as well as definitive treatment; it may be especially
helpful in women with lower abdominal pain of unclear etiology. Laboratory studies
typically show leukocytosis (12,000 to 15,000/L), but this finding is highly variable; a
normal WBC count should not be used to exclude appendicitis
Prognosis
Without surgery or antibiotics (eg, in a remote location or historically), mortality is>50%.
With early surgery, the mortality rate is<1%, and convalescence is normally rapid and
complete. With complications (rupture and development of an abscess or peritonitis)
and/or advanced age, the prognosis is worse: Repeat operations and a long convalescence
may follow.

Management Discussion:
1. All suspected cases should be admitted to hospital.
2. Appendicectomy is the treatment of choice and this is increasingly done as a
laparoscopic procedure.
3. Spontaneous resolution of early appendicitis can occur.
4. However, because of relatively low morbidity and mortality associated with
appendicectomy, and concern about possible readmission rates, early operative
intervention remains the treatment of choice.
5. Medical treatment including antibiotics may be an alternative to surgery.In cases
of diagnostic doubt a period of 'active observation' can be useful.
6. Intravenous fluids and opiate analgesia are also required.
7. Pre-operative antibiotics are associated with a reduction in surgical site infections.
Transabdominal ultrasound is to aid in excluding other causes such as ureteric
stone.
Management of appendicular mass:
Conservative management (wait at least 48 hours until fever subsides)
Nil-per-oral (NPO) in preparation of surgery
Intravenous fluid due to NPO
Intravenous broad spectrum antibiotics to treat both gram positive and negative
bacterial infections
Daily continuous observation of:
1. Abdominal tenderness decreasing
2. Size of mass decreasing
3. Abdominal girth decreasing (if increaseas, ileus occurs or fluid increases)
4. Guarding decreasing (if increases and moves to other side, peritonitis occurs)
5. Temperature decreasing
6. Pulse rate decreasing
7. Nasogastric suction decreasing
If all signs show of increase, abcess may be forming

Treatment

Surgical removal

IV fluids and antibiotics

Appendectomy is surgical removal of vermiform of appendix which can be

performed laparoscopically (this is called minimally invasive surgery) or as an open
operation. Laparoscopy is often used if the diagnosis is in doubt, or if it is desirable to
hide the scars in the umbilicus or in the pubic hair line. Recovery may be a little quicker
with laparoscopic surgery; the procedure is more expensive and resource-intensive than
open surgery and generally takes a little longer, with the (low in most patients) additional
risks associated with pneumoperitoneum (inflating the abdomen with gas).

 Removed appendix should be sent for HPE to exclude carcinoid tumour which
needs right hemicolectomy
If appendix appears normal during appendicectomy, it still should be removed as
there is no grave consequences that can occur if it is removed
During appendicectomy, surrounding structures should be examined:
Caecum: inflamed caecum is a contraindication of appendicectomy as it can cause
fecal fistula
Tubo-ovary: tubal pregnancy, abcess, mass etc
Lymph nodes: mass
Appendectomy should be preceded by IV antibiotics. Third-generation
cephalosporins are preferred. For nonperforated appendicitis, no further
antibiotics are required. If the appendix is perforated, antibiotics should be
continued until the patient's temperature and WBC count have normalized .

(SURGERY CASE WRITE UP)

Submitted by RAHUL AUDENESEN

Date : 24th October 2016

Tittle : APPENDICITIS