CASE: RLQ Pain

A 17 year old otherwise healthy female presents to the University Hospital emergency department with a 12 hour history of fever and abdominal pain followed by nausea and vomiting. At home the fever was 101. The abdominal pain began in a periumbilical location but now localizes in the right lower quadrant. The nausea and vomiting began 6 hours after the onset of abdominal pain. The patient denies cough or dysuria. She has not traveled out of the US. She denies consumption of contaminated food. She has not changed her diet recently. She has had unprotected sexual activity with multiple partners over the last few months. No family members are ill. In the emergency department the vital signs are temp 100.7, P110, RR26, and BP110/60. The lungs are clear. The heart has tachycardia but no gallops, rubs or clicks. The abdomen has point tenderness in the right lower quadrant and decreased bowel sounds. There is abdominal pain with rotation of the right hip. The rectal examination shows mild right sided tenderness but is guiac negative.

Slide 1 Radiographs of appendicitis

Slide 2 CT scans of appendicitis

Slide 3 Complications of appendicitis

Slide 4 Laparoscopic appendectomy

Slide 5 Pathology of appendicitis

Key for slidesAcross page from top to bottom

• Slide 1 Radiographs of appendicitis-U/S of inflamed appendix, upright abdominal radiograph with fecolith, close up abdominal radiograph with fecolith, free intraabdominal perforation

• Slide 2 CT scans of appendicitis-inflamed intraperitoneal appendix, another inflamed appendix, inflamed retrocecal appendix, inflamed appendix with fecolith

Key for slidesAcross page from top to bottom

• Slide 3 Complications of appendicitis-hepatic abscess, portal vein gas

• Slide 4 Laparoscopic appendectomy- suppurative appendicitis, endoloop around appendix, cinched endoloop around appendix, ligated and separated appendiceal stump

• Slide 5 inflamed appendix, perforated appendix, fecolith in appendix