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Title: acute appendicitis

Summary 17 years old Malay gentleman presented with sudden colicky abdominal pain lasted about 1 day at right iliac fossa. It is associated with watery stool and slight abdominal masses at right iliac fossa with palpation.

Introduction a. Background of the study Appendicitis is a common and urgent surgical illness with protean manifestation, generous overlapping with other clinical syndrome. It is a significant morbidity, that increases with diagnostic delay yet no single sign, symptom or diagnostic test can accurately confirms the diagnosis of appendiceal inflammation in all cases. Acute appendicitis remains one of the most common surgical diseases encountered by physicians. When appendicitis manifests in its classic form, it is easily diagnosed and treated. Unfortunately, these classic symptoms occur in just over half of patients with acute appendicitis; therefore, an accurate and timely diagnosis of atypical appendicitis remains clinically challenging and one of the most commonly missed problems in the emergency department. Furthermore, the consequence of missing appendicitis, thus leading to perforation, significantly increases morbidity and prolongs hospitalization b. Rational and significance of choosing the case It is a surgeons goal to evaluate a population of patient referred for suspected appendicitis and to minimize negative appendectomy rate without increasing the rate of perforation. Therefore, identifying the presentation remains a challenge. By choosing this case, it may help the researcher to better understand the clinical presentation of acute appendicitis acute appendicitis as we know remains one of the most common surgical diseases. It may manifest in its classical form yet it can present itself in many ways; atypical appendicitis. When the diagnosis is delayed the consequences may lead to perforation. In the long run, this case definitely will provide a better understanding on disease of surgery; no just for acute appendicitis but also the other acute abdomen diseases; cholecystitis, pancreatitis, intestinal obstruction, renal colic, etc.

History of admission a. Patient biography

Name initials Age Sex Religion Civil status Race Occupation Admission Clerking

: : : : : : : : :

MR. NI 17 y/o Male Islam Single Malay secondary school student 22/2/2009 22/2/2009

b. Chief complaint Patient presented with right abdominal pain. The colicky pain was unbearable that he asked to admit into the hospital

History of presenting illness Mr. NI complains of having sudden excruciating colicky abdominal pain at the right abdomen since one day before the admission. He claimed that he experience such pain a week prior to the admission at the same place right iliac fossa. However, the pain described during this clerking was not radiating to or from umbilical fossa, the pain is not migrating and gradually resolving. The abdominal pain is associated with slight tenderness of the abdomen. But there is no accompanying fever, no nausea and vomit. Mr. NI can tolerate orally. He claimed his bowel output was normal with slight watery stool. When he was asked about the previous episode of the abdominal pain, he claimed that he vomited for a few times accompanied by diarrhoea he suspected a case of food poisoning because during that time keropok lekor contamination was an issue at Kelantan. He also experienced fever and loss of appetite due to the pain.

Review of system system Cardiovascular Endocrine Gastrointestinal Genitourinary Hematopoietic Musculoskeletal Neurologic finding no significant findings such as palpitation, lower limb oedema, orthopnea, syncope, dizziness, etc. No significant findings such as moon features, exophthalmos, tremor, acromegaly, etc. As stated No significant findings such as dysuria, oliguria, haematuria, incontinence, nocturia, etc. No significant findings such as pallor, jaundice or bleeding tendency, etc. No significant findings such as myalgia, arthralgia or arthritis, etc. No significant findings such as recurrent headaches, fits, blurring of vision or drowsiness, etc. No finger clubbing, no accessory muscle used during respiration, no shortness of breath, no noisy breathing, no hemoptysis, no night sweats. No significant findings. The skin colour is normal according to his race; with hair growth distribution is normal. Nail is normal, no clubbing, koilonychia, leukonychia, etc. Normal head size, shape and symmetry; no skull enlargement, bossing, etc. no significant findings of the neck such as webbing, goitre, etc.

Respiratory

Skin, hair, nails

Head and neck

Comprehensive health history a. Past medical/ surgical history This is Mr. NI first hospitalization. Patient has no significant surgical history. He had no other significant medical history, no hypertension or diabetes mellitus. Plus, he completed the immunization according to MoH immunization program, and additional immunization for hepatitis as previous job requirement.

b. Social history Mr. NI was currently studying in final year of secondary school at Tumpat. He staying with his mother she was working a food stall at Tumpat. His father was passed away due to ischemic heart disease. He claimed to not smoke, do not sexually active and do not drink alcohols. c. Family history He is the youngest of 6 siblings. Hi father passed away due to ischemic heart disease after a long life with hypertension died at age of 54. Other than hypertension, he denies of other family history of diabetes mellitus, malignancy, etc. d. Allergy and medication history Patient claimed had no known allergy to food or medication yet.

Physical Examination and assessment

a. General Patient appearance matches his description of age and race; 17 years old Malay gentleman with light brown skin. His mental status was normal whereas he was alert. Conscious time and place oriented, and comfortable. He was breathing normally and able to communicate with the examiner. He was well nourished and fit; height 167 cm and weight of 59 kg. His body mass index is 21.15kg/m2 ideal. His posture was normal and no abnormal gait pattern can be seen. Inspection of the hand revealed no clubbing, peripheral cyanosis or nicotine stain. No swelling or tenderness of the wrist. No wasting of muscle or flapping tremor. The hand was warm and dry. The radial pulse were palpable, beats per minute, it is regular rhythm and good volume. There was no radio-radial delay or radio-femoral delay and there was also no collapsing pulse.

Examination of the eye shows no sign of ptosis, constricted pupil and loss of sweating. No jaundice noted on the sclera and the conjunctiva was not pale. The tongue was moist and no central cyanosis seen. Oral hygiene was good. Hi vital signs were as recorded; Blood pressure Heart rate Respiratory rate Temperature : : : : 122/76 mmHg 86 beat per minute 26 breaths per minute 37C

Impression: no remarkable findings, patient was stable b. Cardiovascular assessment Inspection JVP demonstrated; no elevation, no chest deformities, no visible pulsation except at the fifth left intercostals space at mid clavicular line apex pulsation, no dilated vein noted. Apex beat palpable at fifth left intercostals space at or medial to mid clavicular line. No loss cardiac dullness, palpable thrills or parasternal heaves. No pulsation at aortic and pulmonic areas, no pulsation at tricuspid area. Full pulsation at apical area. Pulsation at epigastric area. Dullness along the cardiac border Auscultation Full and rapid pulsation. 86 bpm BP: 122/76 mmHg The sounds on aortic and pulmonic areas; lub sound on apex and dub sounds on tricuspid area. 1st and 2nd heart sounds were audible without presence of murmur. All peripheral pulses were present.

Palpation

Percussion

Impression: no remarkable findings

c. Respiratory assessment Inspection Anterior; breathing normally. No chest deformities. There was also no dilated vein. The chest was slightly deviated to the right from the chest symmetry during respiration not asymmetrical. No accessory muscle used while breathing. Posterior; spine is vertically aligned, the shape and symmetry of chest are normal. Anterior; the skin is intact, equal warmth on both side. No masses noted. No tracheal deviation Posterior; no masses or tenderness; equal warmth on each side. Chest expanded symmetrically No significant finding noted. Cardiac dullness and liver dullness at fifth intercostals space. Anterior; no significant finding noted. No crepitation or ronchi, the breathing sound was normal

Palpation

Percussion Auscultation

Impression: no remarkable findings.

d. Abdominal assessment Inspection No distension noted, move symmetry with respiration. Umbilical centrally located and inverted. No previous scar, localized swelling, distended vein, or pulsation noted. Soft, non tender. No organomegaly; liver, spleen are normal. Kidneys are not ballotable renal punch was negative. Mild guarding of the right iliac fossa. Rovsigs sign demonstrated; it is positive. Upon deep palpation, mass can be felt at right iliac fossa appendicular mass noted. No other masses noted. Upper border of the liver was at right fifth intercostals space, with liver span of 12cm. spleen percussion was not demonstrated. No shifting dullness or fluid thrills. Bowel sound present and normal

Palpation

Percussion

Auscultation

Impression: there is a mild guarding reflex of the abdomen during palpation. Appendicular mass was palpable at right iliac fossa. Acute appendicitis that resolved by conservative management usually presented with abdominal mass later.[]

e. Musculoskeletal examination Generally, muscle size and side comparison appears normal. Muscle tone and strength also appears normal. Joints can be moved well and no pain noticed. Impression: no remarkable findings f. Nervous examination Patient was alert and conscious. No slurred speech or abnormal behaviour. He is well oriented to time, place and person. No cerebellar signs present nystagmus, past-pointing. Gait was stable Impression: unremarkable findings

Summary 17 years old Malay gentleman presented with abdominal pain lasted about 1 day at right iliac fossa. It is associated with watery stool and slight abdominal masses at right iliac fossa with palpation.

Provisional diagnosis Acute appendicitis Patient presented with symptom of acute colicky abdominal pain at right iliac fossa. From the history taking, patient also claimed experiencing similar pain a week prior to the second episode; the first episode were associated with right iliac fossa pain, fever, loss of appetite, nausea and vomiting classical symptoms for acute appendicitis. Physical examination and assessment revealed that the patient had mild guarding of the abdomen and have an appendicular mass palpable at the right iliac fossa. Patient was positive for Rovsigs sign. There is no tenderness or any other reflex suggestive for other diseases.

Differential diagnosis Diagnosis Cholecystitis Positive relevant Nausea vomiting, fever, abdominal pain may radiated, spontaneous resolves, etc. Colicky abdominal pain, reduced bowel movement, loss of appetite, nausea vomiting, Fever, colicky pain depending on area affected, Negative relevant Relieved by move around appendicitis patient usually bed-rest, precipitate with fatty meal, positive murphys sign No fever, constipation associated with painful bowel movement, duration of symptom lasted longer. No Nausea vomiting, bowel movement remains, no loss of appetite

Constipation

Renal calculi

Investigation

Investigation

Reason to support The total white cell count is raised above normal in 85% of patients and three quarters have an abnormal differential white cell count, having more than 75% neutrophils. Only 4% of patients with appendicitis have both a normal white cell count and a normal Neutrophil count. The white cell count, however, is raised in many other conditions, so although highly sensitive, it has poor specificity for appendicitis. To exclude severe urinary tract infections, but an increase in the numbers of leucocytes and bacteria is often seen in acute appendicitis. To rule out pancreatitis specific test to diagnose pancreatitis by serum amylase level elevation more than 10u/dL

Full blood count

Urinalysis

Serum amylase

Full blood count Blood Count WCC RBC Hb HCT MCV MCH MCHC Platelet Neutrophil Result 17.9 5.1 13.1 38.8 77.5 25.5 30.8 240 Interpretation High Normal Normal Normal Normal Normal Normal Normal High Normal Normal Normal Normal Normal range 4.5-13.5 4.0-5.4 11.5-14.5 37.0-45.0 76.0-92.0 24.0-30.0 28.0-33.0 150-400 40.0-75.0 2.9-7.9 20.0-45.0 1.8-4.0 2.0-10.0 0.2-0.8 0.0-5.0 0.04-0.44 0.0-2.0 0.0-0.2 x 109 /L x 1012 /L g/dL Ratio fL Pg g/dL 109 /L % 109/L % 109/L % 109/L % 109/L % 109/L

76.3 13.7 Lymphocyte 21.0 3.8 2.1 Monocyte 0.38 0.3 Eosinophil 0.05 0.2 Basophil 0.04

Impression: white blood cell and neutrophil are elevated. The elevation might be due to the inflammatory reaction of the body. As mentioned, 85% of patient with appendicitis presented with an increased in white blood count, neutrophil. []

Serum amylase Patient result was 6.9 u/dL Impression: no significant findings. It is not pancreatitis

Urinalysis Blood Count Specific gravity Osmolality Urobilinogen Erythrocytes RBC cast Leukocytes pH Protein Glucose Ketones Bilirubin Blood Nitrite Na K Ca P Creatinine Result 1.030 850 0.8 1 Nil Nil 7 0 Nil Nil Nil Nil Nil 180 50 3.4 19 7.3 Interpretation normal Normal Normal Normal Normal Normal Normal Normal normal Normal Normal Normal Normal normal Normal Normal Normal Normal Normal range 1.003-1.030 >800 0.2-1.0 <2-3 Nil Nil 5-7 Trace Nil Nil Nil Nil Nil 150-300 40-90 2.5-8.0 <38 4.8-19 mmol/H mmol/H mmol/H mmol/H mmol/H Per high field power g/mL mOsm/kg Mg/dL

Impression: no significant findings

Final diagnosis Acute appendicitis 1) Based on history, Mr. NI presented with sudden colicky abdominal pain at right iliac fossa for a day before it resolved gradually. The pain was associated with watery stool. From the history as well, he claimed to have the same abdominal pain a week before with association of fever, nausea vomiting, loss of appetite, and abdominal tenderness 2) Based on assessment, patient presented mild guarding at the right iliac fossa. Upon deep palpation, it revealed that there was an appendicular mass noted at right iliac fossa region approximately at area of ileocaecal junction. Rovsigs sign demonstrated and it was positive. 3) Full blood count revealed a slight elevation of white blood count and neutrophil inflammatory markers. The urinalysis shows no unremarkable findings this serve to rule out any genitourinary factors.

Principal management 1) 2) 3) 4) 5) 6) 7) Admission into surgical ward Continuous observation To nil by mouth IV drip To keep in view for appendectomy To keep in view for interval appendectomy To look out for a. Increase in pain b. Peritonitis c. Increase mass d. Worsening condition 8) Prophylaxis antibiotic 9) Pain killers

Clinical course and progression On admission, patient was came in presented with abdominal pain and had to bed rested. Patient was assessed through Alvarado score, with result of 6/10 therefore, he was put under observation for 24 hours. The patient was unable to eat by mouth and had to be given liquid food. He was then prescribed with antibiotic; ampicillin 1-2g IV Q46H and flagyl IV 500mg Q 8H. He was given pain killer to ease the abdominal pain, to help him rest. He is then evaluated by surgeon whether it is necessary to undergo appendectomy by Alvarado score patient was to be observed for further changes. On the second day, patient claimed the pain has subsided. Palpation of abdomen revealed that there was appendicular mass noted at the right iliac fossa. The patient is now comfortable and able to tolerate solid food properly doctor starts to encourage solid fluid slowly. Doctor plans to continue conservative management and to observe for further changes. The third day, the patient was comfortable, and is now well ambulated. He can tolerate solid food very well and there was no abdominal pain killer prescription has been stop. Mr. NI was scheduled for discharge on the evening doctor plans is for patient to come to the hospital as soon as possible if the pain reoccur, to come again for interval appendectomy, to continue antibiotics prescription for 1 week.

Discussion Acute appendicitis remains as one of the most common surgical diseases encountered by physicians. The diagnosis of acute appendicitis is predominantly a clinical. Classical presentation of acute appendicitis includes, epigastric or periumbilical pain followed by brief nausea, vomiting, and anorexia; after a few hours, the pain shifts to the right lower quadrant. Association with low grade fever is very common. The etiology of appendicitis is likely that luminal obstruction by external (lymphoid hyperplasia) or internal (inspissated fecal material, appendicoliths) compression that leads to increased mucus production, bacterial overgrowth, and stasis, which increase appendiceal wall tension. Consequently, blood and lymph flow is diminished, and necrosis and perforation follow. In this case, patient presented with abdominal pain lasted more than 24 hour before admitted into the ward. It is not radiating to or from umbilical fossa, the pain is not migrating and gradually resolving. The pain accompanied with fever and abdomen tenderness. This is in fact classical presentations of acute appendicitis. However, as mentioned in study by Humes et al1 suggested that patient with a delayed presentation may present itself with palpable mass can be confirmed on ultrasonography or computer tomography scan. A study done by Blomqvist et al3 in Sweden shows that in most cases the mass will decrease in size over the subsequent days as the inflammation resolves, although patients need careful observation to detect early signs of progress of the inflammatory process. As appendicitis can recur, management after resolution of the mass is usually an interval appendicectomy; a conservative approach with outpatient follow-up has been suggested, but no definitive evidence exists to support this.

Conclusion Appendicitis is inflammation of vermiform appendix whereas patient presented with abdominal pain migrating from periumbilical or epigastric to right iliac fossa, associated with fever, nausea vomiting, anorexia, and abdominal tenderness . The gold-standard treatment for appendicitis is appendicectomy or conservative treatment depending on the presentation of the patient.

References 1. Humes D.J, Simpson J. Clinical Review: acute appendicitis. BMJ 2006;333:5304 2. Campbell MR, Johnston SL III, Marshburn T, et al. Nonoperative treatment of suspected appendicitis in remote medical care environments: implications for future spaceflight medical care. J Am Coll Surg. 2004;198:822 830. 3. Blomqvist PG, Andersson RE, Granath F, Lambe MP, Ekbom AR. Mortality after appendectomy in Sweden, 1987-1996. Ann Surg 2001;233:455- 60.