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GOOD MORNING

GOOD MORNING. CASE PRESENTATION AND DISCUSSION ON ACUTE APPENDICITIS. by Michael Angelo L.Suñaz Pre-resident Ospital ng Maynila Medical Center. GENERAL DATA. R.P. 35/M. CHIEF COMPLAINT. generalized abdominal pain. HISTORY OF PRESENT ILLNESS.

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GOOD MORNING

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  1. GOOD MORNING

  2. CASE PRESENTATION AND DISCUSSION ON ACUTE APPENDICITIS by Michael Angelo L.Suñaz Pre-resident Ospital ng Maynila Medical Center

  3. GENERAL DATA R.P. 35/M

  4. CHIEF COMPLAINT • generalized abdominal pain

  5. HISTORY OF PRESENT ILLNESS • 6 days PTA - grade 9/10 colicky epigastric pain with radiation to the lower abdomen - followed by 3 episodes of vomiting - abdominal distention - dysuria

  6. HISTORY OF PRESENT ILLNESS • 5 days PTA - on and off abdominal pain of the same characteristics with radiation to the back - 3 episodes of vomiting - (+) BM

  7. HISTORY OF PRESENT ILLNESS • 3 days PTA - persistence of condition - consultation - unrecalled diagnosis and medications

  8. HISTORY OF PRESENT ILLNESS • 1 day PTA - (+) diarrhea and abdominal distention - consultation and the FM OPD - prescribed Lactulose 30cc h.s. and Fibrosine, 1 sachet in the am

  9. HISTORY OF PRESENT ILLNESS • 1 day PTA - CBC: mild leukocytosis  10,400/mm3 (5,000-10,000) Serum K+: hypokalemia  2.7mmol/L (3.6-5.0)

  10. HISTORY OF PRESENT ILLNESS • DOA - persistence of his condition prompted consultation at the Surgery ER with subsequent admission

  11. PAST MEDICAL HISTORY • No known comorbidities

  12. FAMILY HISTORY • No known heredofamilial diseases

  13. PERSONAL/ SOCIAL HISTORY • nonsmoker; no history of alcoholic beverage intake

  14. REVIEW OF SYSTEMS • No decrease in appetite; no fever or chills

  15. PHYSICAL EXAMINATION • G/S: conscious; coherent; not in cardiorespiratory distress; ambulatory • V/S: BP: 110/70 HR: 82 RR: 20 Temp:370C • HEENT:pink conjunctivae; anicteric sclerae; no TPC; no NAD; no CLAD • C/L: SCE; CBS • CVS: NR, RR, no murmurs

  16. PHYSICAL EXAMINATION • Abdomen: globular; HABS; (+) direct tenderness on RUQ; no fluid wave; (+) muscle guarding on RLQ • Extremities: no edema, atrophy, or cyanosis

  17. SALIENT FEATURES • 35/M • 9/10 epigastric pain with radiation to lower abdomenradiation to the back • abdominal distention • vomiting • dysuria • (+) BM diarrhea

  18. SALIENT FEATURES • HABS • direct tenderness on RUQ • muscle guarding on RLQ • hypokalemia • leukocytosis

  19. Generalized abdominal pain inflammatory Non-inflammatory Ileus 20 hypokalemia 20 AGE appendicitis

  20. PARACLINICAL DIAGNOSTIC PROCEDURE • Do I need a paraclinical diagnostic procedure? NO.

  21. GOALS OF TREATMENT • Relieve cause of abdominal pain • Least morbidity and mortality

  22. TREATMENT OPTIONS

  23. PRE-OP PREPARATION • Psychological support • Screen for previous medical problem • Optimize patient’s condition • Consent • Preparation of materials

  24. OPERATIVE TECHNIQUE AND INTRA-OP FINDINGS • Exploratory laparotomy, appendectomy for acute perforative appendicitis with peritonitis • Evacuated >100cc of bloody peritoneal fluid • Meckel’s diveticulum noted at the antimesenteric portion of the small bowel 30 cm from the ileo-cecal valve; nonerythamatous, no signs of diverticulitis

  25. OPERATIVE TECHNIQUE AND INTRA-OP FINDINGS • Serosal tear noted 80cm from the ileo-cecal valve • Repair of tear with silk 4-0 • Release of Ladd bands • Washing of peritoneal cavity • Patient tolerated the procedure well

  26. FINAL DIAGNOSIS • acute perforative appendicitis with peritonitis

  27. POST-OP CARE • 1st POD • Abdomen: distended, soft, nontender, pain on operative site, no rigidity, no guarding • (+) flatus • UO: 45cc/hr in 240 • NPO • D5LR 1L x 60

  28. POST-OP CARE • 1st POD • Maintain NGT and IFC • Cefuroxime 75mg TIV q80 Metronidazole 500mg TIV q80 Famotidine 40mg TIV q120 RTC while on NPO Diclofenac Na+ in 8cc IVF as slow IV push q120 x 3 doses Tramadol 50mg IV q60 x 6 doses • O2at 3-4 Lpm for DOB

  29. POST-OP CARE • 2nd POD • Continue IVF and IV meds • NGT pulled out • encourage ambulation • Moderate to high back rest • Paracetamol 300mg TIV q40 RTC for 240 then q40 prn for temp > 38.50C

  30. POST-OP CARE • 3rd POD • (+) BM • IFC pulled out • Abdominal binder applied • General liquids • IVF and IV meds continued

  31. POST-OP CARE • 4th POD • Abdomen: no d/c from operative sit, good coaptation and granulation, nontender, no pain • (+) watery stool • (+) frequent flatus • Soft diet • Increase OFI

  32. POST-OP CARE • 5th POD • IVF and IV meds to consume • Start Metronidazole 500mg qid p.o. Cefuroxime 500mg tid p.o. • DAT with SAP

  33. POST-OP CARE • 6th POD • MGH

  34. DISCUSSION • Vermiform appendix - a blind-ending tubular, worm-like structure arising from the inferior part of the cecum -in adults, a normal vermiform appendix varies in length from 5-35 cm (average 8 cm). • Appendicitis - an acute inflammation of the appendix

  35. APPENDICITIS • Pathophysiology - obstruction of the appendiceal lumen is the primary cause  distention of the appendix due to accumulated intraluminal fluid. - obstruction may be due to: • Fecalith (most common) • Strictures • Parasite infection • Kinks • Adhesions • Foreign bodies

  36. APPENDICITIS - ineffective lymphatic and venous drainage  bacterial invasion of appendiceal wall  perforation  spillage of pus  peritonitis

  37. APPENDICITIS • Early stage appendicitis - obstruction of the appendiceal lumen mucosal edema, ulceration, diapedesis of bacteria, distention of the appendix stimulation of the visceral afferent nerve fibers visceral periumbilical or epigastric pain lasting 4-6 hours.

  38. APPENDICITIS • Suppurative appendicitis - increasing intraluminal pressures exceed capillary perfusion pressure obstructed lymphatic and venous drainage bacterial and inflammatory fluid invasion of the tense appendiceal wall transmural spread of bacteria -inflamed serosa of the appendix comes in contact with the parietal peritoneumclassic shift of pain to the right lower quadrant (RLQ)

  39. APPENDICITIS • Gangrenous appendicitis - due to intramural venous and arterial thromboses

  40. APPENDICITIS • Perforated appendicitis - persisitent ischemia  infarction perforation

  41. APPENDICITIS • Phlegmonous appendicitis - inflamed or perforated appendix is walled off by the greater omentum or by bowel loops

  42. APPENDICITIS • Clinical presentation • colicky abdominal pain initially located periumbilically or epigastrically then subsequently shifts to the RLQ (50%), where it becomes progressively more severe. • Nausea (61-92%), vomiting, anorexia (74-78%), and low-grade fever --When vomiting occurs, it almost always follows the onset of pain. • Diarrhea or constipation is observed in 18% of patients.

  43. APPENDICITIS • Clinical presentation • Rebound tenderness (96%), pain on percussion, rigidity, and guarding • RLQ pain with palpation of the left lower quadrant (Rovsing sign), RLQ pain with hyperextension of the right hip (psoas sign), and RLQ pain with internal rotation of the flexed right hip (obturator sign) rarely are present with acute appendicitis.

  44. APPENDICITIS • Laboratory findings • Leukocytosis (>10,000/mm3) is observed in 80% of patients. • high level C-reactive protein (>0.8 mg/dL) with leukocytosis and neutrophilia are the most sensitive laboratory findings, with a sensitivity of approximately (97-100%; Graffeo, 1996; Gronroos, 1999). Therefore, the probability of acute appendicitis is low in the absence of these 3 laboratory findings. • A urine test may be performed to exclude urinary tract infection as the cause.

  45. INTERVENTION • Immediate (emergent) appendectomy - historically, recommended for all patients with appendicitis, whether perforated or not

  46. INTERVENTION • Percutaneous or transrectal drainage - used in conjunction with IV antiboitics in patients with perforated appendicitis with mild symptoms and localized abscess or phlegmon on abdominopelvic CT scans -if the patient's symptoms, WBC count, and fever satisfactorily resolve, therapy can be changed to oral antibiotics and the patient can be sent home.

  47. INTERVENTION • Delayed (interval) appendectomy - performed 4-8 weeks after percutaneous or transrectal drainage - may not be necessary unless patient presents with recurrent symptoms

  48. REFERENCES Craig, S. Acute appendicitis. Available through the worldwide web (http://www.emedicine.com). 24 October 2006. Incesu, L and Taylor, C. Appendicitis. Available through the worldwide web (http://www.emedicine.com). 10 June 2004.

  49. THANK YOU

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