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 Pertinent PMH, ROS,

symptoms MEDS.
Temporal sequence Relevant family hx.
Alleviating / Associated signs and
Exacerbating factors: symptoms
 History, Patient ZC
Pain started in the middle of the Noted some indigestion
night and woke the patient from yesterday
sleep.

Felt nauseated and vomited Feels urge to have bowel

after pain
movement, but has been
No significant MED.HX. or
constipated
SURG HX.

Negative Family HX
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

HEENT : No icterus
CV : nl S1S2, no murmurs
PULM : CTA Bilat. no pain with
inspiration
ABD : Moderately tender in RLQ
between pubic symphysis and
ASIS, involuntary guarding, Neg
bowel sounds
VAGINAL: nontender, no
Discharge
RECTAL: Guaiac neg,
uncomfortable during exam
Neuromuscular: Minimal
hyperesthesia above umbilicus
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 Amylase /Lipase

B-HCG 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
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