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ACUTE APPENDICITIS

Roy Phitayakorn, M.D.


Christopher Brandt, M.D.
Case Western Reserve University
School of Medicine

Ms. Z. Cope
You are called to see a patient in the
Emergency Department, who is a 25 year-old
female with a 1 day history of right-lower
quadrant abdominal pain.

History
What other points of the history do you
want to know?

History, Ms. Cope


Consider the Following
Characterization of
symptoms
Temporal sequence
Alleviating /
Exacerbating factors:

Pertinent PMH, ROS,


MEDS.
Relevant family hx.
Associated signs and
symptoms

History, Patient ZC
Pain started in the middle of the
night and woke the patient from
sleep.

Noted some indigestion


yesterday

Felt nauseated and vomited


after pain

Feels urge to have bowel


movement, but has been
constipated

No significant MED.HX. or
SURG HX.
Negative Family HX

What is your Differential Diagnosis?

Differential Diagnosis
Based on History and Presentation

Systemic or infectious conditions

Influenza
Gastroenteritis
Hepatitis
Diaphragmatic pleurisy
Spinal disease
Typhoid
Tuberculosis
Acute porphyria
Diabetic ketoacidosis

Differential Diagnosis
(cont.)

Intra-abdominal conditions

Acute Appendicitis
Acute Cholecystitis
Diverticulitis (Meckels)
Inflammatory Bowel Disease (Crohns)
Duodenal Ulcer
Intestinal Obstruction
Carcinoma of the Cecum
Nonspecific adenitis Possible Yersinia infection

Differential Diagnosis
(cont.)

Intra-pelvic conditions

Salpingitis
Pelvic Inflammatory Disease
Ectopic Pregnancy
Ruptured Corpus Luteum Cyst
Ruptured Follicular Cyst (Mittelschmerz)
Ruptured Ovarian Cyst
Ovarian Torsion
Pyelonephritis
Ureteral/Renal stone

Physical Examination
What would you look for?

Physical Examination, Patient ZC


Vital Signs: 39o C, HR=75, RR=15, BP=125/75
Appearance: Patient is lying quietly on bed in fetal position
HEENT : No icterus

VAGINAL: nontender, no
Discharge

CV : nl S1S2, no murmurs

RECTAL: Guaiac neg,


uncomfortable during exam

PULM : CTA Bilat. no pain with

Neuromuscular: Minimal
hyperesthesia above umbilicus

inspiration

ABD : Moderately tender in RLQ


between pubic symphysis and
ASIS, involuntary guarding, Neg
bowel sounds

Would you like to revise your


Differential Diagnosis?

Would you like to revise your


Differential Diagnosis?

Acute appendicits
Diverticulitis (Meckels)
Inflammatory Bowel Disease (Crohns)
Ovarian pathology
Acute cholecystitis
Intestinal obstruction
Nonspecific adenitis Possible Yersinia infection

Laboratory

What would you obtain?

Labs ordered
CBC

Electrolytes

LFTs

Amylase /Lipase

B-HCG

Urinalysis

Lab Results, Ms. Cope


CBC: 14,500
LFTs : WNL
HCG : WNL
Electrolytes : WNL
Amylase : WNL
U/A: WNL

Interventions at this point?

Interventions at this point?


Consider the following
Start IV with Ringers Lactate or similar
isotonic crystalloid solution
Administer antibiotics
Admit to the hospital
Go Directly to the OR?
Other?

Studies
What further studies would
you want at this time?

Radiologic Studies to Consider

Flat/Upright Abdomen
CT Scan: Abd/Pelvis
CT Scan: Other ?
US Abdomen/Pelvis

Considering your Differential Diagnosis


What would you expect to see on a flat/upright
abdominal series?
What specific abnormalities do you look for on
US? What population?
Are there specific CT findings in any of your
top 3 diagnoses?

Abdominal Film

Abdominal X-ray Findings


Non-specific gas pattern
No fecalith
No free air

CT Scan Abdomen & Pelvis

CT Scan Results
Acute Appendicitis
Thickened dilated appendix
Peri-appendiceal fat stranding
Scant free fluid

Incidental small left ovarian cyst


What is the differential diagnosis at this point?

Revised Differential Diagnosis

What next?

Additional Imaging?
Observation?
OR?
Other?

What next?

Discussion of suggested interventions

Management
Surgical Options
Pre-operative preparation

Laparoscopic Acute Appendicitis

Discussion
Pathophysiology of the disease process, visceral vs.
parietal abdominal pain, laparoscopy vs. open,
antibiotic management, appropriate utilization of
resources, etc.

Discussion
Additional teaching points

QUESTIONS ??????

Summary

Alternative scenarios
Acute Appendicitis with perforation/ Abscess or
tumor
IBD
Acute Diverticulitis
Ovarian Cyst / Torsion/
Perforated Right colon tumor

CT Cecal Tumor

CT Sigmoid Diverticulitis

CT Ovarian Cystic Mass

CT Terminal Ileal Crohns

CT Acute Appendicitis

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