ATIENZA - CABITAC - CAISIDO

 Case
 History
 Physical Examination
 Salient Features
 Differential Diagnosis
 Assessment

 Background
 Management
General Data:
A. J., 28 years old, Male, admitted for the first time in our
institution on January 18, 2017.

Chief Complaint:
Abdominal pain
1 DAY PRIOR TO ADMISSION
 (+) sudden onset of epigastric pain
 No precipitating factors
 Character: burning pain
 Nonradiating
 Continuous
with a pain scale of 5/10

 (+) self induced vomiting of previously ingested

food amounting to ½ cup per bout, non-bilous, non-
bloody, as well as loss of appetite and dizziness.
(+) epigastric pain
 localized to right lower quadrant
 sudden in onset
 no precipitating factors
 nonradiating
 pain scale of 6/10, continuous.
(-) fever, dysuria, or constipation
(+) self-medicate with Aluminum Hydroxide + Simethicone
+ Magnesium Hydroxide (Maalox liquid), unrecalled
dosage which provided temporary relief
(+) Consult at our ER and was advised admission, however
was not accommodated due to no vacancy of rooms.
FEW HOURS PRIOR TO
ADMISSION
(+) Persistence of signs and symptoms,
(+) Consult at another institution, CBC and Urinalysis
were requested
(+) Consult at our institution and was advised admission.
Thus, was subsequently admitted.
PAST MEDICAL HISTORY
 Unremarkable
FAMILY HISTORY

(+) Hypertension - maternal side

(+) DM paternal side
REVIEW OF SYSTEMS
 Unremarkable
PHYSICAL EXAMINATION
 General:
conscious, coherent, oriented and ambulatory, not in cardio-respiratory distress

 Vital Signs:
BP: 130/100 mmHg, PR: 62 bpm, RR: 21 cpm, T.: 36.5⁰C 02: 98%
PHYSICAL EXAMINATION
 Abdomen:
Flat abdomen, normoactive bowel sounds, soft, (+) tenderness at RLQ, (+) rebound
tenderness at RLQ, (-) Murphy’s sign, (+) Psoas sign, (+) Obturator sign, (-) Rovsing’s
sign, (- ) Kidney punch test

 DRE:
No skin tags, no mass, no discharge, no bleeding, good sphincter tone, (-) pain on
anterior rectal wall
SALIENT FEATURES
 J.A.,
 24 y/o
 Male
 Non hypertensive, non diabetic
 Occasional alcoholic beverage drinker
 Right lower quadrant pain, vomiting, loss of appetite
 PE: (+) direct tenderness RLQ, (+) rebound tenderness, (+) psoas sign, (+)
obturator sign
URETERAL STONE

 RULE IN  RULE OUT

 RLQ pain (pain may simulate  Pain is referred to the labia, scrotum
retrocecal appendicitis) or penis
 Leukocytosis (16.91 x 10^9/L)
 Hematuria (UA = +3)
URINARY TRACT INFECTION
 RULE IN
 Pain and tenderness is usually in
suprapubic area (may present as
hypogastric or flank pain)
 RULE OUT
 No fever/ chills
 No dysuria/burning micturition
 No tenderness at right CVA
 Urine microscopy (increase urine
WBC)
ACUTE CHOLECYSTITIS
 RULE IN  RULE OUT

 Abdominal pain (RLQ)  Unremitting abdominal pain (RUQ

radiating to right upper back)
 Nausea
 Biliary colic
 Loss of appetite/Anorexia
 Jaundice
 Moderate leukocytosis
 (-) murphy’s sign
ACUTE GASTROENTERITIS
(BACTERIAL)
 RULE IN  RULE OUT
 Epigastric pain  History: recent consumption of
possibly tainted food
 Leukocytosis (16.91 x 10^9/L)
 Vomiting
 Diarrhea
 Absence of peritoneal signs and
guarding
 PE: Hyperperistaltic bowel sounds
ACUTE APPENDICITIS
 RULE IN  CANNOT TOTALLY BE RULED OUT
 Epigastric pain
 migrating to RLQ
 Loss of appetite
 Nausea
 (+) Direct and rebound tenderness
RLQ
 (+) Psoas sign
 (+) Obturator sign
 ASSESSMENT
 When should one suspect acute appendicitis?
(+) RLQ abdominal pain

 What clinical findings are most helpful in diagnosing acute

appendicitis?
(+) high intensity of perceived abdominal pain of at least 7-12 hours duration
(+) migratory pain to the RLQ
(+) vomiting
(+) RLQ tenderness
(+) rebound tenderness
(+) guarding
 ETIOLOGY
 Main etiologic factor: Obstruction of the lumen
 Fecaliths
 Hypertrophy of lymphoid tissue

 Other etiologic factors:

 Parasite
 Vegetable / Fruit seeds
 Mass
 Obstruction
 PATHOGENESIS
 Sequence of events
1. Proximal obstruction of the appendiceal lumen produces a
closed loop obstruction
2. Continuing normal secretion by the appendiceal mucosa
rapidly produces distention
3. Distention stimulates the nerve ending of visceral afferent
nerve fibers (vague, dull, diffuse pain in the mid
abdomen or lower epigastrium)
4. Distention increases from continuous secretion and rapid
multiplication of resident bacteria, and the visceral pain
increases (nausea, vomiting)
PATHOGENESIS
4. Pressure in the organ increases, venous
pressure is exceeded resulting into
engorgement and vascular congestion
5. Inflammation process soon involves the
serosa of the appendix and in turn parietal
peritoneum (characteristic shift in pain to
the RLQ)
6. Compromise vascular supply and infarction
progresses
7. Perforation occurs usually in the anti-
mesenteric border just beyond the point of
obstruction
4 STAGES
1. CONGESTION
 Increase intraluminal pressure > Obstruction of
capillaries and venules > vascular engorgement
2. SUPPURATION
 Deposition of cell mediators due to bacterial
proliferation
3. GANGRENOUS
 Obstruction of arterial supply > Ischemia >
Necrosis
4. PERFORATION
 Rupture of appendiceal wall due to necrosis
SIGNS AND SYMPTOMS
 SYMPTOMS
 epigastric or periumbilical (visceral) localizing at the
right lower quadrant (somatic)
 Nausea / vomiting
 Anorexia
 Diarrhea / Constipation
 Location of somatic pain depends on location of appendix
SIGNS AND SYMPTOMS
 SIGNS
 Direct tenderness on RLQ
 Rebound tenderness on RLQ
 Muscle guarding
 Fever
 Psoas sign
 Obturator sign
ALVARADO SCORING
The Alvarado score is the most widespread
scoring system. It is especially useful for
ruling out appendicitis and selecting atients
for further diagnostic workup.
 MIGRATORY RIGHT ILIAC
FOSSA PAIN (1)
 ANOREXIA (1)
 TENDERNESS: RIGHT ILIAC
FOSSA (2)
 REBOUND TENDERNESSS
RIGHT ILIAC FOSSA (1)
 FEVER >/= 36.3 (1)
 LEUKOCYTOSIS (2)
ASSESSMENT
 What diagnostic tests are helpful in the diagnosis of
acute appendicitis?

1. WBC count
 Leukocytosis: 10,000/cc to 18,000/cc
 > 18,000/cc suggests perforation
 predominance of polymorphonuclears
 CBC (01/18/17)
EXAMINATION NORMAL RESULTS EXAMINATION NORMAL RESULTS
VALUES VALUES

RBC 4.60 – 6.20 4.88 x 10^12/L WBC 4.00 – 10.00 16.91 x 10^9/L

HGB 130 – 180 149 g/L Differential Count:

HCT 0.42 – 0.52 0.42 Neu% 0.36 – 0.66 0.81

MCV 80.0 – 97.0 87 Lym% 0.22 – 0.40 0.15

MCH 26.0 – 32.0 31 Mon% 0.04 – 0.08 0.04

MCHC 310 – 360 352 Eos%

PLATELET 150 - 400 ADEQUATE Bas%

COUNT
 URINALYSIS (01/18/17)
EXAMINATION RESULT EXAMINATION RESULT

Color Yellow MICROSCOPIC ANALYSIS

Transparency Hazy Red Blood Cell 2-5 / hpf
CHEMICAL ANALYSIS White Blood Cell 1-3 / hpf
Blood +3 Epithelial cells Few
Urobilinogen Negative Bacteria Rare
Bilirubin Normal Mucus Threads Few
Ketones Trace Amorphous urates/Phosphates Rare
Protein Negative Crystals None
Nitrite Negative Casts None
Glucose Negative Others -
pH 6.0
Specific gravity 1.010
Leukocytes Negative
ASSESSMENT
 What diagnostic tests are helpful in the
diagnosis of acute appendicitis?

2. Imaging studies: CT Scan and Ultrasound

 Adults: CT Scan > Ultrasound
 Pediatric: Ultrasound > CT Scan
ASSESSMENT
ULTRASOUND CT SCAN
Blind-ending, non peristaltic
Dilated (>5mm)
bowel loop
Thickened of the appendiceal Thickened of the appendiceal
wall wall
Perieppendiceal fluid Periappendiceal fat stranding
Non compressible appendix ,
Thickened mesoappendix
>5mm
Fecaliths Periappendiceal phlegmon
Free fluid
Fecaliths
TREATMENT
 What is the appropriate treatment for acute appendicitis?

Appendectomy is the appropriate treatment for acute

appendicitis.
SURGICAL MANAGEMENT
 What is the recommended approach to the surgical
management of acute appendicitis?

Open appendectomy is the recommended primary to the

treatment of acute appendicitis in our setting. Therapeutic
laparoscopic appendectomy is an alternative for selected
cases.
ANTIBIOTIC PROPHYLAXIS
 What is the recommended antibiotic prophylaxis, dose and
route in uncomplicated appendicitis?

Cefoxitin 2g IV single dose (Adult)

40mg/kg IV single dose (Children)
ANTIBIOTIC PROPHYLAXIS
 Alternative:
Ampicillin-Sulbactam 1.5-3g IV dose (Adults)
75 mg/kg IV dose
(Children)
Amoxicillin-clavulanate 1.2-2.4 g IV single dose
(Adults)
45 mg/kg IV single dose (Children)
ANTIBIOTIC PROPHYLAXIS
 Gentamycin 80-120mg IV single dose +
Clindamycin 600 mg IV single dose (Adults)

 Gentamycin 2.5mg/kg IV single dose +

Clindamycin 7.5-10mg/kg IV single dose
(Children)
ANTIBIOTIC PROPHYLAXIS
 What antibiotics are recommended for the
treatment of complicated appendicitis, route and
dose?
ANTIBIOTIC PROPHYLAXIS
Adults
 Ertapenem 1g IV q24
 Piperacillin tazobactam 3.375-4.5g IV q6 or q8

Alternative:
 Ciprofloxacin 400mg IV q12 plus Metronidazole 500mg
IV q6
ANTIBIOTIC PROPHYLAXIS
Pediatrics:
Ticarcillin –clavulanic acid 75mg/kg IV q6

Alternative
 Imipenem- Cilastin 15-25mg/kg IV q6
 Gentamycin 5mg/kg IV q24 plus clindamycin 7.5-
10mg/kg IV q6
ANTIBIOTIC PROPHYLAXIS
 For gangrenous appendicitis, recommended
management is to treat as uncomplicated
appendicitis.

 Duration of antibiotic therapy depends on

clinician’s post-op assessment. Therapy may be
maintined for 5-7 days. Sequential therapy to oral
antibiotics may be considered when GI function has
returned.
ANTIBIOTIC PROPHYLAXIS
Parameters for discontinuance of antibiotics:

 Absence of fever for 24 hours

 Ability to tolerate oral intake
 Normal WBC count with 3% or less band forms
LOCALIZED PERITONITIS
 How should localized peritonitis be managed?

No necrotic tissue should be left behind.

Intraperitoneal drains while most useful in well-
established and localized abcess activity should be
selectively used.
WOUND CLOSURE
 What is the appropriate wound method closure in
patients with complicated appendicitis?

Incision may be closed primarily.

PERIAPPENDICEAL
ABSCESS
 What is the optimal timing of surgery in periappendiceal
abscess?

As soon as the diagnosis is made.

 Brunicardi, et. al. Schwartz Principles of Surgery 10th edition (2016)
 Bongal, et. al. Evidence-based Clinical Practice Guidelines on Diagnosis and
Treatment of Acute Appendicitis (2002)