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

• Characterization of symptoms

• Temporal sequence• Alleviating /

Exacerbating factors:

• Pertinent PMH, ROS, MEDS.

• Relevant family hx.• Associated signs and

symptoms

Consider the Following

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 DiagnosisBased 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 (Meckel’s)

• Inflammatory Bowel Disease (Crohn’s)

• 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 icterusVAGINAL: nontender, no Discharge

CV : nl S1S2, no murmurs RECTAL: Guaiac neg, uncomfortable during exam

PULM : CTA Bilat. no pain with inspiration

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 (Meckel’s)• Inflammatory Bowel Disease (Crohn’s)• Ovarian pathology• Acute cholecystitis• Intestinal obstruction• Nonspecific adenitis – Possible Yersinia infection

Laboratory

What would you obtain?

Labs ordered

CBC Electrolytes

LFT’s Amylase /Lipase

B-HCG Urinalysis

Lab Results, Ms. Cope

CBC: 14,500CBC: 14,500

LFTs LFTs : : WNLWNL

HCG HCG : : WNLWNL

Electrolytes Electrolytes : : WNLWNL

Amylase Amylase : : WNLWNL

U/A: U/A: WNLWNL

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 Crohn’s

CT Acute Appendicitis

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