Republic of the Philippines

UNIVERSITY OF EASTERN PHILIPPINES

University Town, Northern Samar
Web: http://uep.edu.ph Email: uepnsofficial@gmail.com

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

BS NURSING

CASE STUDY:
Acute Appendicitis

CITRINE – SECTION D GROUP 3

Norla Mae Sevilano
Jessyl Siervo
Ryan James Snay
Myra Isabelle Solayao
Daniel Andre Somoray
Steffany Suarez
Czarina Mae Tadeo
Shantelle Tan
Hannah Mae Tagaban

Edgar M. Chan, RN
Clinical Instructor
CASE

Eli Rex Santos, a 38-year-old male residing in Mabuhay, San Isidro, Northern Samar,
was admitted to the hospital with the chief complaint of lower right abdominal pain. Upon
further evaluation, he was diagnosed with acute appendicitis. Mr. Santos reported experiencing
the onset of right lower quadrant (RLQ) abdominal pain for four days, accompanied by vomiting
but not associated with fever. The patient was referred for further investigation and management
of his condition. This case study aims to provide a comprehensive understanding of the clinical
manifestation and management of acute appendicitis, using Mr. Santos as a representative case.

PATIENT PROFILE

Name: Santo Eli, Rex Segarino

Age: 38 years old
Birthday: November 4, 1984
Gender: Male
Address: Brgy. Mabuhay, San Isidro, Northern Samar
Nationality: Filipino
Religion: Catholic
Civil Status: Single
Father’s Name: CrecencioArenia Santo Eli
Mother’s Name: Evelyn Segarino Santo Eli
Case Number: 165013
Ward: Surgery
Date of Admission: January 22, 2023 at 2:55pm
Pre-operative Diagnosis: Acute Abdomen Prob 2^0 to ruptured appendicitis
Post-operative Diagnosis: Gangrenous appendicitis w/ generalized peritonitis
History of present illness: 4 days ptc, onset of RLQ abdominal pain accompanied by
vomiting not associated with fever

FAMILY HISTORY
- No Significant Family Health History is reported.

MEDICAL HISTORY
- No other significant medical/surgical procedure is reported
THE ANATOMY OF THE APPENDIX

The appendix is a small, finger-like projection

attached to the cecum, which is the first part of the
large intestine. The appendix is located in the right
lower quadrant of the abdomen and measures around
10 cm in length in an adult. The cecum and appendix
are part of the digestive system, which is responsible
Source: knowyourbody.net
for breaking down and absorbing nutrients from food.

The anatomy of the appendix consists of

three main layers: the inner mucosal layer, the
muscular layer, and the outer serosal layer. The
mucosal layer is composed of glandular
epithelial tissue and is responsible for secreting
mucus. The muscular layer contains smooth
muscle fibers that contract and relax to propel
contents through the lumen of the appendix. The
serosal layer is a protective layer composed of
Source: moyinbiol3500.blogspot.com
mesothelial cells that line the peritoneal cavity.

The appendix does not have a known physiological function and its role in the human
body remains unclear. Some theories suggest that the appendix may have been involved in the
digestion of plant fibers in our ancestors, or that it may play a role in immunity by acting as a
reservoir for beneficial gut bacteria. However, these theories are not well-supported by scientific
evidence.

The appendix is closely associated with other organs in the digestive system, including
the cecum, the ileum, the ascending colon, and the right ureter. The ileocecal valve, located at
the junction between the ileum and the cecum, regulates the flow of contents between the small
intestine and the large intestine. The right ureter runs close to the appendix and may be involved
in some cases of appendicitis. Inflammation of the appendix can cause pain and tenderness in the
right lower quadrant of the abdomen and may lead to complications if left untreated.
DISEASE PROCESS

Definition

Mr. Santo Eli Rex was diagnosed with acute appendicitis, a common and potentially life-
threatening condition that requires prompt diagnosis and treatment. It is the inflammation of the
appendix, a small, finger-shaped projection
attached to the cecum of the large intestine. The
cause of appendicitis is not well understood, but
it is believed to result from the obstruction of the
appendiceal lumen caused by a fecal mass,
stricture, barium ingestion, or viral infection.
The obstruction leads to inflammation, which
can cause pressure to build up and affect blood
flow to the organ, leading to severe abdominal
pain. If left untreated, appendicitis can be fatal.
Source: reverehealth.com
Ethiology

The exact cause of appendicitis is still not fully understood, but it is thought to occur
when something, such as a fecal mass, growth of bacteria, stricture, or ingestion of barium,
blocks the lumen of the appendix. This obstruction can cause the appendix to become inflamed,
resulting in appendicitis. The obstruction can also lead to ulceration of the mucosa, which can
also cause appendicitis. In some cases, a viral infection may be the cause of the ulceration, but
this is not well understood.

It is important to note that while the presence of an obstruction is a common cause of

appendicitis, it can also occur without an obstruction. In these cases, it is believed that the
inflammation and ulceration of the appendix are caused by some other underlying factor, such as
a viral infection or an autoimmune reaction. Regardless of the cause, it is clear that the
inflammation and swelling of the appendix can cause severe pain and other symptoms that
require prompt medical attention.

Epidemiology
Source: duttongregory.co.uk
 Appendicitis can occur at any age and affects both males and females equally, although it
is more common in males between puberty and age 25. The incidence and mortality of
appendicitis have declined since the advent of antibiotics.

Pathophysiology

The Pathophysiology of appendicitis is not well understood, but it is believed to occur in

the following steps:

1. Ulceration of the mucosa in the appendix, which may be caused by a viral infection or
other unknown factors.
2. Inflammation accompanies the ulceration and temporarily obstructs the appendix.
3. If present, the obstruction is caused by stool accumulation around vegetable fibers
(fecalith).
4. Mucus outflow is blocked, causing the appendix to distend.
5. Pressure within the appendix increases, and the appendix becomes obstructed.
6. Bacteria multiply and inflammation and pressure continue to increase, leading to
decreased blood flow to the organ and severe abdominal pain.

The obstruction of the appendix leads to an accumulation of mucus and bacteria within
the appendix, causing the organ to become distended and inflamed. This inflammation causes
pressure to build up within the appendix, leading to decreased blood flow and oxygenation to the
organ. This decreased blood flow and oxygenation can cause the appendix to become necrotic, or
die, leading to the development of an abscess, which is a collection of pus surrounded by
inflamed tissue.

The inflammation and swelling of the

appendix cause pressure to be applied to the
surrounding tissues, leading to severe pain in the
right lower quadrant of the abdomen just as what
Mr. Santo had experienced. This pain is usually
accompanied by other symptoms, such as nausea,
Source: plus100years.com
vomiting, fever, loss of appetite, and changes in bowel movements, such as constipation or
diarrhea.
CLINICAL MANIFESTATION

The symptoms of acute appendicitis can vary in intensity and duration, but typically include the
following:

1. Abdominal pain: This is the most common and consistent symptom of acute appendicitis.
It starts as a vague discomfort and then becomes more severe and localized to the right
lower quadrant. The pain may be severe and worsening, especially with movement or
deep breathing.
2. Nausea and vomiting: Nausea and vomiting may occur along with abdominal pain and
are often a result of the pain and discomfort associated with appendicitis.
3. Loss of appetite: Loss of appetite is common in patients with acute appendicitis, as they
may feel uncomfortable or experience abdominal pain when trying to eat.
4. Fever: A low-grade fever may be present in some cases of acute appendicitis, indicating
an infection.
5. Changes in bowel movements: Some patients may experience constipation or diarrhea
along with abdominal pain and other symptoms of acute appendicitis.
6. Abdominal tenderness: Physical examination may reveal tenderness in the right lower
quadrant, which is the location of the appendix.
7. Rebound tenderness: This is a physical finding in which pain increases when pressure is
applied and then released, indicating the presence of inflammation.

Eli Rex Santos, came in with a complaint of lower right abdominal pain that started 4 days
prior to presentation. He reported onset of right lower quadrant (RLQ) abdominal pain
accompanied by vomiting, but without associated fever. Vital signs were taken, with a blood
pressure of 130/80 mmHg, temperature of 36.5 degrees Celsius, heart rate of 95 bpm, and
respiratory rate of 24.
 Laboratory examination showed increased
white blood cell count of 13.24 and a NEUT
value of 81.3. The results of the serum
electrolytes, urine analysis, and urea nitrogen and
creatinine were all normal. A sonogram was
performed and showed a blind-ended aperistaltic
and non-compressible tubular structure in the
right lower quadrant originating from the base of
the cecum, most likely representing the appendix.
This is a sample image of a sonogram
The tip of the appendix was prominent, measuring illustrating appendix diameter greater than
17.7mm in the widest diameter, with minimal peri- 6mm indicating inflammation of the appendix

appendiceal fluid. Source: ultrasound-cases.blogspot.com

These clinical manifestations, along with the patient's history, are highly indicative of acute
appendicitis, which is a medical emergency requiring prompt attention and treatment.

MEDICAL/SURGICAL MANAGEMENT

"Eli Rix Santo," a 38-year-old male, was experiencing pain in the right lower quadrant
(RLQ) and was diagnosed with appendicitis, confirmed by accompanying lab results. The patient
was advised to undergo an appendectomy to remove the inflamed appendix and chose to proceed
with the operation.
Before the surgery, the patient was prepared and anesthetized. At the discretion of the
lead surgeon, considering the appendix was in the late stages of appendicitis, a midline incision
was made instead of a McBurney's point incision, in case the appendix had already perforated.
This led to an exploratory laparotomy appendectomy.
Once the incision was made and the appendix was visible, the surgeon quickly assessed
its state and discovered that it had burst and spilled its contents into the abdominal cavity. The
surgeon swiftly flushed and rinsed the cavity of any residue and then resumed the removal of the
perforated appendix.
 Upon removal, the surgeon observed that the cecum had started to become perforated due
to the inflammation of the appendix and decided to initiate a cecorraphy procedure to repair the
cecum. The lead surgeon inserted a Jackson-Pratt drain to help with fluid collection inside the
abdomen after the incision was closed.
The surgeon then continued to suture each appropriate layer of the abdomen, including
inserting a makeshift fenestrated Penrose drain from a surgical glove finger to facilitate fluid
drainage at the incision site, before suturing the subcutaneous layer.
After successfully completing the operation, the patient was admitted to the surgical ward
for postoperative care, with a diagnosis of exploratory laparotomy appendectomy with
cecorraphy.

Surgical Operations

Exploratory laparotomy is a procedure that is used when the diagnosis of acute

appendicitis is uncertain or the inflamed appendix had already perforated. This procedure is
necessary to further inspect the extent of the condition that might be affecting other organs, also
in some cases, the symptoms of acute appendicitis can be similar to other medical conditions,
such as gastrointestinal disorders or gynecological problems. By making an incision in the
abdomen and inspecting the abdominal organs, the surgeon can rule out other conditions and
confirm the diagnosis of acute appendicitis.

Appendectomy is the definitive treatment for acute appendicitis and is necessary because
removing the inflamed appendix will relieve the patient's symptoms and prevent potential
complications. The choice between an open incision and laparoscopic appendectomy will depend
on several factors, including the patient's medical history, the severity of the inflammation, and
the surgeon's experience and preference.

Cecorraphy is a procedure that is necessary in cases where the appendix is severely

inflamed and adherent to the cecum. In these cases, removing only the appendix may not address
the underlying cause of the inflammation and can lead to recurrent inflammation. By removing a
portion of the cecum along with the appendix, the surgeon can ensure that the underlying cause
of the inflammation is addressed and prevent recurrent inflammation.
 In conclusion, exploratory laparotomy, appendectomy, and cecorraphy are necessary
procedures for the treatment of Mr. Santo. These surgical proceedures help diagnose and treat the
condition, relieve symptoms, and prevent potential complications.

LABORATORY RESULTS AND INTERPRETATION

Hematology Analysis

The purpose of a hematology analysis in the

evaluation of acute appendicitis is to measure the levels
of white blood cells (WBC) in the patient's blood.
Elevated levels of WBC can indicate an infection or
inflammation in the body, which is often present in
patients with acute appendicitis. The hematology
analysis can provide important information about the
patient's immune system response to the inflammation,
which can help to confirm the diagnosis of appendicitis
and guide treatment decisions. In particular, the
percentage of neutrophils, a type of white blood cell, may be elevated in patients with acute
appendicitis.

Urine Analysis

The purpose of a urine analysis in the evaluation of acute appendicitis is to rule out other
potential causes of abdominal pain and to assess the patient's overall health. A urine analysis can
help to detect any urinary tract infections, which may have similar symptoms to acute
appendicitis but require a different treatment approach. The presence of pus cells and red blood
cells in the urine can indicate a urinary tract
infection or other underlying medical conditions
that may be contributing to the patient's symptoms.
By conducting a urine analysis, healthcare providers
can ensure that the patient's symptoms are not being
caused by a urinary tract infection or other medical condition, and that the patient is not at
increased risk for complications from the appendicitis.

Serum Electrolytes

The purpose of a serum electrolyte laboratory test in the evaluation of acute appendicitis
is to assess the patient's fluid and electrolyte balance and to rule out other potential causes of
abdominal pain. Electrolytes, such as sodium and potassium, play a crucial role in maintaining
fluid balance and proper cellular function in the body. Abnormal levels of electrolytes can
indicate various medical conditions, such as dehydration or kidney disease, that may have similar
symptoms to acute appendicitis and require a different treatment approach. By measuring the
patient's serum electrolyte levels,
healthcare providers can ensure that the
patient's symptoms are not being caused
by an electrolyte imbalance or other
medical condition and that the patient is
not at increased risk for complications
from the appendicitis.

Urea Nitrogen and Creatinine

The purpose of measuring urea nitrogen and creatinine levels in the evaluation of acute
appendicitis is to assess the patient's kidney function. Urea nitrogen and creatinine are waste
products that are produced by the body and normally excreted by the kidneys. High levels of
these substances in the blood can indicate that the kidneys are not functioning properly, which
may be a sign of kidney disease, dehydration, or other medical conditions.

In the context of acute appendicitis, urea nitrogen and creatinine levels are measured to
ensure that the patient's
symptoms are not being
caused by a kidney problem,
and to rule out potential
complications related to
kidney function, such as
kidney failure. Additionally, in some cases, the treatment of acute appendicitis may involve the
use of medications or fluids that could affect the kidney function. By measuring urea nitrogen
and creatinine levels, healthcare providers can monitor the patient's kidney function and adjust
the treatment approach accordingly, if needed.

Sonograph

The purpose of sonography for acute appendicitis is to visually examine the patient's
appendix and surrounding tissue to identify any potential abnormalities or signs of inflammation.
A sonographic report can help in diagnosing acute appendicitis by providing information on the
size, shape, and location of the appendix and any surrounding fluid or inflammation.
Additionally, a sonogram can help determine if the appendix is the cause of a patient's abdominal
pain and guide the healthcare provider in making treatment decisions, such as whether or not
surgery is necessary.

Results and Interpretation

Mr. Santo Eli Rex underwent laboratory tests to help diagnose his condition. The results
of the hematology analysis showed an elevated white blood cell count of 13.24 x 10^9/L and a
high percentage of neutrophils at 81.3%. The urine analysis showed the presence of pus cells in
the range of 10-15/HPF and red blood cells in the range of 4-8/HPF. The serum electrolyte
levels, including sodium at 137.2 mmol/L and potassium at 4.16 mmol/L, were within normal
range. The urea nitrogen level was 5.4 mmol/L and the creatinine level was 82 umol/L, both of
which were also within normal range. The sonographic report showed that the right lower
quadrant had a blind-ended, non-compressible tubular structure originating from the base of the
cecum, which was most likely the appendix. The tip of the structure was more prominent and
measured 17.7mm in its widest diameter with minimal fluid around it.

The elevated white blood cell count, presence of pus cells and red blood cells in the urine,
and the findings from the sonographic report all suggest an acute inflammatory process, such as
appendicitis, in Mr. Santo Eli Rex. The normal electrolyte, urea nitrogen, and creatinine levels
help to confirm that his kidney function is normal.
MEDICATIONS

Drugs are usually prescribed prior to and after surgery in appendectomy to address
different medical concerns of the patient. Before surgery, antibiotics such as cefuroxime may be
prescribed to prevent or treat any potential infection. Antiemetics such as metoclopramide may
be used to prevent nausea and vomiting, which are common side effects of general anesthesia.
Other medications, such as omeprazole and ranitidine, may be prescribed to manage any
symptoms of acid reflux or gastroesophageal reflux disease.

After surgery, pain management is typically a top priority. Medications such as tramadol
and ketorolac may be prescribed to help relieve pain and reduce inflammation. Antibiotics may
also be continued post-operatively to prevent or treat any infections. Metronidazole may be
prescribed to treat any potential bacterial infections in the surgical area. Additionally,
medications such as omeprazole and ranitidine may be used to manage any symptoms of acid
reflux or gastroesophageal reflux disease. These medications are important in ensuring a smooth
and comfortable recovery for the patient after surgery.

Cefuroxime: is a type of antibiotic that belongs to the cephalosporin group. It is often prescribed
to patients before undergoing surgery, such as an appendectomy, to prevent bacterial infections
and other complications.
Metoclopramide: is a medication that is commonly used to treat symptoms of gastroesophageal
reflux disease (GERD) and other digestive problems. It is also used to enhance the speed and
efficiency of gastric emptying, which can help prevent nausea and vomiting before and after
surgery.
Metronidazole: is an antibiotic that is used to treat various types of infections caused by
bacteria, such as anaerobic bacteria and protozoa. This drug may be prescribed to patients with
acute appendicitis to prevent post-operative infections.
Omeprazole: is a type of proton pump inhibitor that is used to treat GERD and other digestive
problems. It works by reducing the amount of acid produced by the stomach, which can help
prevent acid reflux and other symptoms of GERD before and after surgery.
Ranitidine: is a histamine H2 receptor antagonist that is used to treat GERD, peptic ulcers, and
other digestive problems. This drug works by reducing the amount of acid produced by the
stomach, which can help prevent acid reflux and other symptoms of GERD before and after
surgery.
Tramadol: is a pain reliever that is often used to treat moderate to severe pain, including pain
associated with surgery. It works by changing the way the brain and body respond to pain.
Ketorolac: is a nonsteroidal anti-inflammatory drug (NSAID) that is used to relieve pain, reduce
inflammation, and lower fever. It is often prescribed to patients before and after surgery, such as
an appendectomy, to help manage pain and reduce the risk of other complications.