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 surgeon’s 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 : MR. NI

Age : 17 y/o
Sex : Male
Religion : Islam
Civil status : Single
Race : Malay
Occupation : secondary school student
Admission : 22/2/2009
Clerking : 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 finding

no significant findings such as palpitation, lower limb oedema,

Cardiovascular
orthopnea, syncope, dizziness, etc.
No significant findings such as moon features, exophthalmos,
Endocrine
tremor, acromegaly, etc.

Gastrointestinal As stated

No significant findings such as dysuria, oliguria, haematuria,

Genitourinary
incontinence, nocturia, etc.
No significant findings such as pallor, jaundice or bleeding
Hematopoietic
tendency, etc.

Musculoskeletal No significant findings such as myalgia, arthralgia or arthritis, etc.

No significant findings such as recurrent headaches, fits, blurring

Neurologic
of vision or drowsiness, etc.
No finger clubbing, no accessory muscle used during respiration,
Respiratory no shortness of breath, no noisy breathing, no hemoptysis, no
night sweats.
No significant findings. The skin colour is normal according to his
Skin, hair, nails race; with hair growth distribution is normal. Nail is normal, no
clubbing, koilonychia, leukonychia, etc.
Normal head size, shape and symmetry; no skull enlargement,
Head and neck bossing, etc. no significant findings of the neck such as webbing,
goitre, etc.

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 : 122/76 mmHg

Heart rate : 86 beat per minute
Respiratory rate : 26 breaths per minute
Temperature : 37°C

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.
Palpation 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.
Percussion
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.

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.
Palpation 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
Percussion No significant finding noted. Cardiac dullness and liver
dullness at fifth intercostals space.
Auscultation Anterior; no significant finding noted. No crepitation or
ronchi, the breathing sound was normal

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.
Palpation Soft, non tender. No organomegaly; liver, spleen are
normal. Kidneys are not ballotable –renal punch was
negative. Mild guarding of the right iliac fossa. –Rovsig’s
sign demonstrated; it is positive.
Upon deep palpation, mass can be felt at right iliac fossa
–appendicular mass noted. No other masses noted.
Percussion 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.
Auscultation Bowel sound present and normal

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 Rovsig’s sign. There is no tenderness or any other reflex suggestive for other
diseases.
Differential diagnosis

Diagnosis Positive relevant Negative relevant

Cholecystitis Relieved by move around –

Nausea vomiting, fever,
abdominal pain may
radiated, spontaneous
resolves, etc.
Constipation Colicky abdominal pain,
reduced bowel movement,
loss of appetite, nausea
vomiting,
Renal calculi
Fever, colicky pain –
depending on area affected,
appendicitis patient usually
bed-rest, precipitate with
fatty meal, positive
murphy’s sign
No fever, constipation
associated with painful
bowel movement, duration
of symptom lasted longer.
No Nausea vomiting, bowel
movement remains, no loss
of appetite

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
Full blood count
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
Urinalysis in the numbers of leucocytes and bacteria is often seen in
acute appendicitis.
To rule out pancreatitis –specific test to diagnose
Serum amylase pancreatitis by serum amylase level elevation more than
10u/dL
Full blood count

Blood Result Interpretation Normal range

Count
WCC 17.9 High 4.5-13.5 x 109 /L
RBC 5.1 Normal 4.0-5.4 x 1012 /L
Hb 13.1 Normal 11.5-14.5 g/dL
HCT 38.8 Normal 37.0-45.0 Ratio
MCV 77.5 Normal 76.0-92.0 fL
MCH 25.5 Normal 24.0-30.0 Pg
MCHC 30.8 Normal 28.0-33.0 g/dL
Platelet 240 Normal 150-400 109 /L
Neutrophil 76.3 High 40.0-75.0 %
13.7 2.9-7.9 109/L
Lymphocyte 21.0 Normal 20.0-45.0 %
3.8 1.8-4.0 109/L
Monocyte 2.1 Normal 2.0-10.0 %
0.38 0.2-0.8 109/L
Eosinophil 0.3 Normal 0.0-5.0 %
0.05 0.04-0.44 109/L
Basophil 0.2 Normal 0.0-2.0 %
0.04 0.0-0.2 109/L

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 Result Interpretation Normal range

Count
Specific 1.030 normal 1.003-1.030 g/mL
gravity
Osmolality 850 Normal >800 mOsm/kg
Urobilinogen 0.8 Normal 0.2-1.0 Mg/dL
Erythrocytes 1 Normal <2-3
Per high
RBC cast Nil Normal Nil field
Leukocytes Nil Normal Nil power

pH 7 Normal 5-7
Protein 0 Normal Trace
Glucose Nil normal Nil
Ketones Nil Normal Nil
Bilirubin Nil Normal Nil
Blood Nil Normal Nil
Nitrite Nil Normal Nil
Na 180 normal 150-300 mmol/H
K 50 Normal 40-90 mmol/H
Ca 3.4 Normal 2.5-8.0 mmol/H
P 19 Normal <38 mmol/H
Creatinine 7.3 Normal 4.8-19 mmol/H

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. Rovsig’s 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) Admission into surgical ward

2) Continuous observation
3) To nil by mouth
4) IV drip
5) To keep in view for appendectomy
6) To keep in view for interval appendectomy
7) 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 Q4-
6H 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;333:530–4

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.