GENERAL DATA

 AF
 35 years old
 Male
 Married
 Roman Catholic
 Born on November 11, 1985
 Birthplace – Talisay, Batangas
 Residing at San Gabriel, Laurel, Batangas
 Consult: 2/6/2021 at 9:24am
CHIEF COMPLAINT

 Abdominal Pain

 Informant: Patient
 Reliability: 98%
HISTORY OF PRESENT ILLNESS

10 DAYS PTC

 Patient experienced epigastric pain, dull in character, radiating to right lower

quadrant, pain scale of 10/10 associated with anorexia and 3 episodes of
vomiting. Patient took Hyoscine N-Butylbromide 10mg once which gave
minimal relief for abdominal pain.
HISTORY OF PRESENT ILLNESS

9 DAYS PTC

 Patient sought consult to a faith healer and allegedly underwent

appendectomy. Symptoms were immediately relieved right after the alleged
surgery.
HISTORY OF PRESENT ILLNESS

7 DAYS PTC

 Patient experienced right lower quadrant pain, dull in character,

nonradiating, pain scale of 8/10. Patient was advised by neighbor to take Co-
trimoxazole 400mg/80mg capsule and Hyoscine N-Butylbromide 10mg which
gave moderate relief.
HISTORY OF PRESENT ILLNESS

DURING THE INTERIM

 Patient still had anorexia and on and off abdominal pain, dull in character,
nonradiating, pain scale of 4/10. He continuously took both Co-trimoxazole
400mg/80mg capsule and Hyoscine N-Butylbromide 10mg three times a day.
HISTORY OF PRESENT ILLNESS

ON THE DAY OF CONSULT

 Patient opted to have Whole Abdominal Ultrasound as advised by his neighbor

hence consult.
REVIEW OF SYSTEMS

 General: No fever
 Skin: No jaundice
 Head: No alopecia
 Eyes: No itchiness, no pain, no redness, no excessive lacrimation
 Ears: No hearing loss, no tinnitus, no pain, no itchiness, no excessive
drainage
 Nose: No itchiness, no discharge, no congestion, no pain, no bleeding
 Mouth & Throat: No toothache, no bleeding gums, no dysphagia, no
hoarseness of voice
 Cardiovascular: No easy fatigability, no orthopnea, no palpitations
 Gastrointestinal: -
 Genito-urinary: No dysuria, no hematuria
 Musculoskeletal: No weakness, no stiffness
 Hematologic: No easy bruising, no spontaneous bleeding
 Endocrine: No heat/cold intolerance, no polyuria, no polydipsia, no
polyphagia
 Psychiatric: No behavioral changes, no mood swings
PAST MEDICAL HISTORY

 (-)Hypertension
 (-)Diabetes Mellitus
 (-)Heart Disease
 (-)Thyroid Disorders
 (-)Allergies
 (-)Blood Transfusion
 (-)Hospitalization
 (-)Surgery
 VACCINATION HX: Unrecalled
FAMILY HISTORY

 (+)Hypertension
 (-)Diabetes Mellitus
 (-)Bronchial Asthma
 (-)Pulmonary Tuberculosis
 (-)Thyroid Disorders
 (-)Cancer
GENOGRAM
FAMILY MAP
FAMILY PROFILE

 No. of Family Members: 4

 Family Structure: Extended Family
 Family Residence: Matrilocal
 Family Life Cycle: Family with Young Children
 Family Set-up: Democratic
APGAR I
APGAR II
SCREEM-RES
PERSONAL AND SOCIAL HISTORY

 Married for 11 years  Sleeps 6-7 hours daily

 College Undergraduate  Sedentary life style
 Works as Tricycle Driver
 (-)Smoker
 (+)Occ alcoholic beverage drinker
 (-)Illegal drug use
 (-)History of travel for the last 1
month
 Food preference: none
 Drinking water is tap water
ENVIRONMENTAL HISTORY

 Lives with family and in-laws in a bungalow concrete house

 Well-ventilated house
 Own dumping site for waste disposal
SOCIO-ECONOMIC HISTORY

 His father-in-law is a jeepney driver

 Mother-in-law and his wife used to have a small piggery
 They are helping each other in household expenses
 Whole family experience financial setbacks during ASF and Covid-19 crises
PSYCHOSOCIAL CONCERN

 “Doc sayang yung limang libo sa albularyo. Pangdagdag ospital na sana. San po
kaya pwede magpa-opera na mura lang? Walang-wala kami sa ngayon.”
PHYSICAL EXAMINATION

 General Survey: conscious, coherent, NICRD

 Vital Signs:
 BP 120/70 mmHg
 Temp 36.8 °C
 PR 93/min
 RR 21/min
 sp02 97%
PHYSICAL EXAMINATION

 Skin: warm to touch, (-)rash, good skin turgor

 HEENT: (-)periorbital edema, anicteric sclera, (+)pale palpebral conjunctiva,
(-)nasoaural discharge, (+)pale lips, (-)tonsillopharyngeal congestion,
 (-)cervilymphadenopathy
 Chest & Lungs: symmetric chest expansion, (-)retractions, clear breath sounds
 Heart: adynamic precordium, normal rate regular rhythm, (-)murmur
 Abd: flat, normoactive bowel sounds, (+)abdominal rigidity, (+)tenderness,
RLQ (+)rebound tenderness (+)obturator sign (+)psoas sign (+)rovsing sign
 Extremities: grossly normal, full and equal pulses, (-)cyanosis, (+)pallor, (-
)edema
NEUROLOGIC EXAMINATION

I Olfactory Not done

II, Pupils 2-3mm, Pupils equally round and reactive to light,
Optic
III Grossly normal vision
III, Oculomotor, Intact extraocular muscles
IV Trochlear
VI Abducens
Able to clench teeth and raise or lower his jaw.
Jaw movement was also symmetric and without
difficulty.
V Trigeminal
Sensations (pinprick and light touch) on the forehead,
cheeks, and chin could be correctly and equally
identified on both sides
NEUROLOGIC EXAMINATION

Facial symmetry and bilateral movements were observed

VII Facial during smiling, frowning, closing both eyes tightly, lifting
the eyebrows, showing teeth and puffing the cheeks
VIII Acoustic Can hear soft, spoken words on both ears equally
IX Glossopharyngeal The uvula and the soft palate rose symmetrically in the
X , Vagus midline
Able to shrug the shoulders with equal strength on both
XI Spinal Accessory
sides, against resistance
No atrophy, deviation, fasciculation, or tremors of the
XII Hypoglossal tongue present
MOTOR FUNCTION

 All the muscle groups on both the upper and lower

extremities were observed to be symmetrical in size and


bulk.
No muscle wasting, hypertrophy, or fasciculation present.
5/5 5/5
 No involuntary movements and tremors observed.
 No dysdiadochokinesia



No dysmetria
No gait problems
5/5 5/5
SENSORY FUNCTION

100% 100%

100% 100%
SALIENT FEATURES

 35 year old male

 History of dull epigastric pain, radiating to right lower quadrant, pain scale of 10/10 associated with
anorexia and 3 episodes of vomiting, minimally relieved by HNBB 10mg 10 days ptc
 Allegedly underwent appendectomy thru faith healer which gave immediate relieve of symptoms 9
days ptc
 Right lower quadrant pain, dull in character, nonradiating, pain scale of 8/10, started taking Co-
trimoxazole 400mg/80mg capsule and Hyoscine N-Butylbromide 10mg which gave moderate relief 7
days ptc
 Anorexia and on and off abdominal pain, dull in character, nonradiating, pain scale of 4/10,
continuously took both Co-trimoxazole 400mg/80mg capsule and Hyoscine N-Butylbromide 10mg
three times a day during the interim
 Vital Signs: PR 93/min, RR 21/min
 PE: (+)pale palpebral conjunctiva (+)pale lips (+)pallor (+)abdominal rigidity, (+)tenderness, RLQ
(+)rebound tenderness (+)obturator sign (+)psoas sign (+)rovsing sign
 No fever, lower back pain, dysuria, increased urinary frequency
DIFFERETIAL DIAGNOSIS

URINARY TRACT INFECTION

CRITERIA FOR RULING IN CRITERIA FOR RULING OUT

 Right lower quadrant dull abdominal  No dysuria

pain
 No increased urinary frequency
 Nausea and vomiting
 No urinary urgency
 Anorexia
 No lower back pain
 Signs of Sepsis: PR 93/min, RR
21/min, (+)pale palpebral
conjunctiva (+)pale lips (+)pallor

DECISION: DIAGNOSIS NOT LIKELY

DIFFERETIAL DIAGNOSIS

NEPHROLITHIASIS

CRITERIA FOR RULING IN CRITERIA FOR RULING OUT

 Right lower quadrant dull abdominal  Anorexia

pain
 Abdominal PE: (+)abdominal rigidity
 Nausea and vomiting (+)tenderness, RLQ (+)rebound
tenderness (+)obturator sign (+)psoas
sign (+)rovsing sign

DECISION: DIAGNOSIS NOT LIKELY

DIFFERETIAL DIAGNOSIS

RUPTURED APPENDECITIS

CRITERIA FOR RULING IN CRITERIA FOR RULING OUT

 Epigastric to right lower quadrant dull abdominal pain
 Nausea and vomiting
 Anorexia
 Abdominal PE: (+)abdominal rigidity (+)tenderness, RLQ
(+)rebound tenderness (+)obturator sign (+)psoas sign
(+)rovsing sign
 Signs of Sepsis: PR 93/min, RR 21/min, (+)pale
palpebral conjunctiva (+)pale lips (+)pallor

DECISION: DIAGNOSIS NOT LIKELY

DIAGNOSIS/WORKING IMPRESSION:

 To Consider Ruptured Appendicitis

MANAGEMENT

 Initial Management
 NPO
 Discontinue Hyoscine N-Butylbromide
 Complete Blood Count with Platelet Count now
 Urinalysis now
 Whole Abdominal Ultrasound now
MANAGEMENT

 Follow-up (after 1 hr)

 Complete Blood Count with Platelet Count
 HGB 38.1, HCT 15.2, RBC 4.84, PC 346, WBC 12.3, SEG 73, LYM 17, MIXED 10
 Urinalysis
 Light yellow, clear, pH 6, SG 1.010, sug -, alb trace, pus 0-2, rbc 0-1, ec rare
 Whole Abdominal Ultrasound
 Poorly circumscribed irregular complex mass at the right lower quadrant region, may
relate to abscess formation. Calcific component may represent an appendicolith.
Contrast-enhanced CT scan is suggested for further evaluation. Hepatomegaly. Normal
study of pancreas, gallbladder, spleen, and bilateral kidneys.

 Referral letter given

APPENDICITIS
APPENDIX: Historical Background

 1492 – Leonardo da Vinci depicted the appendix in his anatomic drawings but
were not published until the 18 th century.

 1544 – Jean Fernel published a paper describing the first appendiceal disease.

 1711 – Lorenz Heister provided the first description of classic appendicitis.

 1736 – Claudius Amyand performed the first known appendectomy in London.

APPENDIX: Embryology

 6th week – Appendix and cecum appear as outpouchings from the caudal limb
of the midgut.

 8th week – The appendiceal outpouching is initially noted.

 5th month – Appendix begins to elongate at about the to achieve a vermiform

appearance.
APPENDIX: Anatomy

 Average length – 6 to 9 cm

 Arterial supply – Appendicular branch of the ileocolic artery

 Lymphatic drainage – Lymph nodes that lie along the ileocolic artery

 Innervation – Sympathetic elements by the superior mesenteric plexus (T10-

L1); parasympathetic elements via the vagus nerves

 Location – Posterior medial wall, just below the ileocecal valve.

APPENDIX: Physiology

 An immunologic organ that actively participates in the secretion of

immunoglobulins, particularly immunoglobulin A.

 May function as a reservoir to recolonize the colon with healthy bacteria.

Appendicitis: Epidemiology

 Lifetime risk of developing appendicitis is 8.6% for males and 6.7% for
females.

 Highest incidence in the second and third decades.

Appendicitis: Pathophysiology

1. Closed-loop obstruction of the appendiceal lumen.

2. Distension caused by continuing normal secretion and rapid multiplication of
the resident bacteria stimulates the nerve endings of the appendix
producing vague, dull, diffuse pain in the mid-abdomen or lower
epigastrium. As distension continues, reflex nausea and vomiting occurs and
the visceral pain increases.
3. Increasing pressure in the organ results in engorgement and vascular
congestion.
4. The inflammatory process soon involves the serosa of appendix and parietal
peritoneum which shifts the pain to the right lower quadrant.
5. As distension, bacterial invasion, compromise of the vascular supply, and
infarction progress, perforation occurs.
Appendicitis: Microbiology

 The flora of the inflamed appendix differs from that of the normal appendix.

 Inflamed appendix – Escherichia coli, Bacteroides species, Fusobacterium

nucleatum/necrophorum

 Normal Flora – Peptostreptococcus, Pseudomonas, Bacteroides splanchnicus,

Bacteroides intermedius, Lactobacillus
Appendicitis: Clinical Presentation

 Abdominal pain – Usually starts with periumbilical and diffuse pain that
eventually localizes to the right lower quadrant.
 Nausea
 Vomiting
 Anorexia
Appendicitis: Clinical Presentation

 Right lower quadrant pain is one of the most sensitive signs

of appendicitis.

 Tenderness with a maximum at or near McBurney’s point.

 Gastrointestinal symptoms that develop before the onset of

pain suggest a different etiology.

 Diarrhea may occur in association with perforation,

especially in children.
Appendicitis: Clinical Presentation

 Early in presentation, vital signs may be minimally altered.

 The body temperature and pulse rate may be normal or slightly elevated.
Appendicitis: Clinical Presentation

 Rebound tenderness – Patient feels a sudden pain when the pressure of the
examining hand is quickly relieved.

 Rovsing’s sign – Pain in the right lower quadrant when the left lower quadrant
is palpated. Strong indicator of peritoneal irritation.

 Psoas sign – Pain with extension of the right leg; Indicates a focus of irritation
in the proximity of the right psoas muscle.

 Obturator sign – Stretching of the obturator internus through internal rotation

of a flexed thigh suggests inflammation near the muscle.
Appendicitis: Laboratory Findings

 Complete Blood Count

 Mild leukocytosis in acute, uncomplicated appendicitis accompanied by a
polymorphonuclear prominence.
 White blood cell count above 18,000 cells/mm3 raise the possibility of a perforated
appendix with or without an abscess.
 White blood cell counts can be low due to lymphopenia or septic reaction, but in
this situation, the proportion of neutrophils is usually very high.
Appendicitis: Laboratory Findings

 C-reactive protein (CRP)

 Increased CRP concentration is a strong indicator of appendicitis.
 Can have up to a 12-hour delay.

 Urinalysis
 Several white or red blood cells can be present from irritation of the ureter or
bladder.
 To rule out the urinary tract as the source of infection.

 Appendicitis is very unlikely if the white blood cell count, proportion of

neutrophils, and CRP are all normal.
Appendicitis: Clinical Scoring Systems
Appendicitis: Imaging Studies

 Xray
 Benefit in ruling out other pathology.
 Abdominal Xray – Can show the presence of a fecalith and fecal loading in the
cecum associated with appendicitis but are rarely helpful in diagnosing acute
appendicitis
 Chest Xray – Helpful to rule out referred pain from a right lower lobe pneumonic
process.
Appendicitis: Imaging Studies

 Barium Enema
 Not indicated in the acute setting.
 If the appendix fills on barium enema, appendicitis is unlikely.
Appendicitis: Imaging Studies

 Ultrasonography
 Sensitivity 55-96%; Specificity 85-98%.
 Inexpensive, rapid, does not require a contrast medium, and can be used in
pregnant patients.
 Thickening of the appendiceal wall and the presence of periappendiceal fluid are
highly suggestive of appendicitis.
 Easily compressible appendix measuring <5 mm in diameter excludes the diagnosis
of appendicitis.
Appendicitis: Imaging Studies

 CT Scan
 Sensitivity 92-97%; Specificity 85-94%; Accuracy 90-98%; Positive predictive value
75-95%; Negative predictive value 95-99%.
 Inflamed appendix appears dilated (>5 mm) and the wall is thickened.
 Evidence of inflammation – Periappendiceal fat stranding, thickened
mesoappendix, periappendiceal phlegmon, and free fluid.
 Fecaliths can be often visualized however, their presence is not pathognomonic of
appendicitis.
 Additional use of rectal contrast does not improve the results.
 Disadvantages – Expensive, exposes the patient to significant radiation, limited use
during pregnancy, allergy to iodine or contrast limits the administration of contrast
agents
Appendicitis: Differential Diagnosis

 Differential diagnosis depends on:

 Anatomic location of the inflamed appendix
 stage of the process
 Patient’s age
 Patient’s gender

 Most common findings in erroneous preoperative diagnosis of appendicitis –

Acute mesenteric adenitis, no organic pathologic condition, acute pelvic
inflammatory disease, twisted ovarian cyst or ruptured graafian follicle, and
acute gastroenteritis.
Appendicitis: Differential Diagnosis

 Pediatric Patient
 Acute mesenteric adenitis
 Self-limited disease
 Most often confused with acute appendicitis in children.
 Upper respiratory tract infection is present or has recently subsided.
 Pain is diffuse, tenderness is not sharply localized, and rigidity is rare.
 Generalized lymphadenopathy may be noted.
 Laboratory procedures are of little help in arriving at the correct diagnosis.
Appendicitis: Differential Diagnosis

 Elderly Patient
 Diverticulitis or perforating carcinoma of the cecum or of a portion of the sigmoid
 CT scan is often helpful
Appendicitis: Differential Diagnosis

 Female Patient
 Misdiagnosis remains higher among female patients.
 Pelvic inflammatory disease – Usually bilateral, nausea and vomiting are present in
only approximately 50%, pain and tenderness are usually lower, and motion of the
cervix is exquisitely painful.
 Right-sided cysts – When rupture or undergo torsion, the manifestations are similar
to appendicitis: right lower quadrant pain, tenderness, rebound, fever, and
leukocytosis. Transvaginal ultrasonography and CT scanning can be diagnostic.
 Ectopic Pregnancy – Rupture of right tubal or ovarian pregnancies can mimic
appendicitis. History of abnormal menses, presence of pelvic mass, elevated HCG,
leukocyte count rises slightly, hematocrit level falls, cervical motion, and adnexal
tenderness.
Appendicitis: Initial Management

 Uncomplicated Appendicitis
 Operative versus Nonoperative Management
 Concept of nonoperative treatment for uncomplicated appendicitis
1. Surgical treatment is not available (e.g., submarines, expeditions in remote areas), treatment
with antibiotics alone was noted to be effective.
2. Patients who did not pursue medical treatment would occasionally have spontaneous resolution
of their illness.

 Urgent versus Emergent Appendectomy

 No statistically significant increase in the number of complicated appendicitis cases in the
urgent group when compared to the emergent group.
 Rates of surgical site infection, intra-abdominal abscesses, conversion to an open
procedure, or operative time showed no difference.
Appendicitis: Initial Management

 Complicated Appendicitis
 Refers to perforated appendicitis associated with an abscess or phlegmon.
 Children <5yo and patients >65yo have the highest rates of perforation.
 The proportion of perforation increases with increasing duration of symptoms.
 Signs of sepsis and generalized peritonitis should be taken to the operating room
immediately.
Appendicitis: Initial Management

 Interval Appendectomy
 Performing an appendectomy following initial successful nonoperative management
in patients with no further symptoms.
 Done 2-4 months after acute presentation.
 To prevent future attacks of appendicitis or to identify other disease.
 Close clinical follow-up, a complete history searching for persistent symptoms, and
screening colonoscopy
Appendicitis: Operative Interventions

 Open Appendectomy
 Nonperforated appendicitis – Right lower quadrant incision at McBurney’s point is
commonly used. A McBurney (oblique) or Rocky-Davis (transverse) right lower
quadrant muscle splitting incision is made.
 Perforated appendicitis – If suspected or the diagnosis is in doubt, a lower midline
laparotomy is considered.
 If appendicitis is not found, the cecum and mesentery should be inspected. The
small bowel should be evaluated in a retrograde fashion beginning at the ileocecal
valve. Concerns for Crohn’s disease or Meckel’s diverticulum should be of priority.
Appendicitis: Operative Interventions

 Laparoscopic Appendectomy
 First performed in 1983 by Semm.
 Surgeon and assistant should be
standing on the patient’s left
facing the appendix while
laparoscopic screens should be
positioned on the patient’s right or
at the foot of the bed.
 Uses three ports – 10- or 12-mm
port at the umbilicus, two 5-mm
ports at suprapubic and left lower
quadrant.
Appendicitis: Operative Interventions

 Laparoscopic Appendectomy
 Appendiceal critical view – Taenia libera at 3 o’clock position, terminal ileum at 6
o’clock, and appendix at 10 o’clock.
Appendicitis: Operative Interventions

 Laparoscopic Appendectomy
 Advantages:
 Fewer incisional surgical site infections
 Less pain
 Shorter length of stay
 Quicker return to normal activity

 Disadvantages
 Increased risk of intra-abdominal abscess
 Increased operative duration
Appendicitis: Post-operative Care

 Uncomplicated appendectomy
 Complication rates are low
 Diet can quickly be started on a
 Discharged home the same day or the following day
 Postoperative antibiotic therapy is unnecessary.
 Complicated appendectomy
 Complication rates are increased
 Broad-spectrum antibiotics for 4 to 7 days
 Diet should be started based on daily clinical evaluation
 Increased risk for surgical site infections
Appendicitis: Post-operative
Complications
 Surgical Site Infection
 Treatment – opening of the incision and obtaining a culture
 The cultured organisms are typically bowel flora.
 Postoperative intra-abdominal abscesses
 Fever, leukocytosis, and abdominal pain are common presentations
 Small abscesses – Treated with antibiotics
 Larger abscesses – Require drainage. Most commonly, percutaneous drainage with CT or
ultrasound guidance.
 Abscess not amenable to percutaneous drainage, laparoscopic abscess drainage is a viable
option.
Appendicitis: Post-operative
Complications
 Stump Appendicitis
 Recurrent symptoms of appendicitis approximately 9 years after their initial
surgery.
 More likely to have complicated appendicitis, have an open procedure, and
undergo colectomy.
 Prior appendectomy should not be an absolute criterion in ruling out acute
appendicitis.
REFERENCES:

 Brunicardi et.al. (2015). Schwartz’s Principles of Surgery Tenth Edition

 Frasetto, L. & Kohlstadt, I.(2011). Treatment and Prevention of Kidney
Stones: An Update. American Academy of Family Physicians, 84 (11), pp 1234-
1242.
 Philippine Clinical Practice Guidelines on the Diagnosis and Management of
Urinary Tract infections in Adults (2013)