Transcript acute appendicitis

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
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Systemic or infectious conditions
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Influenza
Gastroenteritis
Hepatitis
Diaphragmatic pleurisy
Spinal disease
Typhoid
Tuberculosis
Acute porphyria
Diabetic ketoacidosis
Differential Diagnosis
(cont.)
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Intra-abdominal conditions
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Acute Appendicitis
Acute Cholecystitis
Diverticulitis (Meckel’s)
Inflammatory Bowel Disease (Crohn’s)
Duodenal Ulcer
Intestinal Obstruction
Carcinoma of the Cecum
Nonspecific adenitis – Possible Yersinia infection
Differential Diagnosis
(cont.)
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Intra-pelvic conditions
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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?
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Acute appendicits
Diverticulitis (Meckel’s)
Inflammatory Bowel Disease (Crohn’s)
Ovarian pathology
Acute cholecystitis
Intestinal obstruction
Nonspecific adenitis – Possible Yersinia infection
Laboratory
What would you obtain?
Labs ordered
CBC
Electrolytes
LFT’s
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
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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?
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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 Crohn’s
CT Acute Appendicitis
Acknowledgment
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