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Reviewing patient with RIF pain

Reviewing patient with RIF pain. Colchester general hospital General surgery Wednesday teaching 20/3/2019. Introduction. 17 Y.O. MALE BG: LD, ADHD, Fetal Alcohol Syndrome Presented 4 day hx D+V, 5 day hx abdo pain, slight RIF No prev history, no unwell contacts in school

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Reviewing patient with RIF pain

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  1. Reviewing patient with RIF pain Colchester general hospital General surgery Wednesday teaching 20/3/2019

  2. Introduction 17 Y.O. MALE BG: LD, ADHD, Fetal Alcohol Syndrome Presented 4 day hx D+V, 5 day hxabdo pain, slight RIF No prev history, no unwell contacts in school Seen in SAU, safety netted, discharged on the day Obs normal, bloods WCC13.4, Neut 10.7, CRP305

  3. Timeline Represented to ED 2 days later High temperature + anorexia D+V with RIF pain RE-referred to SAU Abdo tender RIF, percussion tenderness (+) Blood test WCC17.1, Neutrophil 13.3, CRP 423 DDx: Appendicitis. Admitted, IVF, Urine dip, IV Abx, Analgesia Seen by cons on same evening – USS abdo/pelvis tomorrow/CT scan Patient not fasted overnight, no plans for surgery

  4. Timeline • Patient had CT scan the next day: • Request: 17M. Attended due to three days history of RIFpain, vomiting/diarrhoea for five days. Fever, shivers.O/E: abdomen soft, tender RIF, percussion tenderness.BG: learning disability.Bloods01/02: CRP423, WCC17.1, Neut13.3, Creatinine69.? collection ?appendicular mass • “Inflamed appendix with localised necrosis and perforation of the tip. Appendicolithin the tip of the appendix. Periappendiceal inflammatory changes. Extraluminalloculesof gas. Trace of un-encapsulated free fluid with mild thickening of the peritoneal surfaces. Inflammatory changes/free fluid extending up the right paracolicgutter and retroperitoneum. Omentum/mesentery: Extensive inflammatory changes in the right lower quadrant” • Listed for lap appendidectomy • Post-op: drain was inserted, removed when not draining. Continued with IV abx

  5. Timeline • Patient was swapped on oral antibiotics day 2 post op. Patient had a temp spike of 39.5 early hours of that morning, and was tachycardic at 118 during the day. • He was sent home on that day. • It was reported that patient went home without oral antibiotics. • This was on the EDS but not on the drug chart.

  6. Timeline Readmitted the next day with diarrhoea and profuse sweating. Restarted on IV antibiotics for 24hrs and discharged home – when bloods normalised

  7. Discussion + Learning point Why was patient discharged with RIF, raised WCC and CRP? Why was the diagnostic laparoscopy delayed till after the CT scan? – resulted in one day delay

  8. Recommendations Acute appendicitis has been considered to be an irreversible progressive disease although recent studies have questioned this dogma Appendicitis presentation varies wildly and the value of individual clinical variables to determine the likelihood of acute appendicitis in a patient is low C-reactive protein levels render the highest diagnostic accuracy followed by increased numbers of leucocytes with an area under the curve of 0.75 [95 % CI 0.71–0.78] and 0.72 [95 % CI 0.68–0.76], respectively Ultrasonography is therefore reliable to confirm presence of appendicitis but unreliable to exclude appendicitis. Antibiotic prophylaxis has been proven effective in prevention of superficial surgical site infections and intra-abdominal abscesses in patients with appendicitis. Post-op antibiotics supported for complicated appendicitis Diagnosis and management of acute appendicitis. EAES consensus development conference 2015; SurgEndosc (2016) 30:4668–4690 DOI 10.1007/s00464-016-5245-7

  9. Recommendations Antibiotic prophylaxis has been proven effective in prevention of superficial surgical site infections and intra-abdominal abscesses in patients with appendicitis. Prophylaxis should be commenced at the time of establishing the diagnosis of acute appendicitis. The incidence of SSI after appendectomy has been reported to range from 0 to 11 % In patients with complicated appendicitis, post-operative administration of antibiotics significantly reduces the rate of SSI In uncomplicated appendicitis, there is no evidence supporting routine administration of post-operative antibiotics There is no firm evidence on the duration (3, 5, 7, 10 days) and route of administration (usually intravenous administration for 48 h, then oral administration) Diagnosis and management of acute appendicitis. EAES consensus development conference 2015; SurgEndosc (2016) 30:4668–4690 DOI 10.1007/s00464-016-5245-7

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