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ACUTE APPENDICITIS
Roy Phitayakorn, M.D.
Christopher Brandt, M.D.Case Western Reserve University
School of Medicine
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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.
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History
What other points of the history do you want to know?
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History, Ms. Cope
• Characterization of symptoms
• Temporal sequence• Alleviating /
Exacerbating factors:
• Pertinent PMH, ROS, MEDS.
• Relevant family hx.• Associated signs and
symptoms
Consider the Following
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History, Patient ZC
• Pain started in the middle of the night and woke the patient from sleep.
• Felt nauseated and vomited after pain
• No significant MED.HX. or SURG HX.
• Negative Family HX
• Noted some indigestion yesterday
• Feels urge to have bowel movement, but has been constipated
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What is your Differential Diagnosis?
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Differential DiagnosisBased on History and Presentation
• Systemic or infectious conditions• Influenza• Gastroenteritis• Hepatitis• Diaphragmatic pleurisy• Spinal disease• Typhoid• Tuberculosis• Acute porphyria• Diabetic ketoacidosis
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Differential Diagnosis(cont.)
• Intra-abdominal conditions• 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
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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
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Physical Examination
What would you look for?
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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 icterusVAGINAL: nontender, no Discharge
CV : nl S1S2, no murmurs RECTAL: Guaiac neg, uncomfortable during exam
PULM : CTA Bilat. no pain with inspiration
Neuromuscular: Minimal hyperesthesia above umbilicus
ABD : Moderately tender in RLQ between pubic symphysis and ASIS, involuntary guarding, Neg bowel sounds
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Would you like to revise your Differential Diagnosis?
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Would you like to revise your Differential Diagnosis?
• Acute appendicits• Diverticulitis (Meckel’s)• Inflammatory Bowel Disease (Crohn’s)• Ovarian pathology• Acute cholecystitis• Intestinal obstruction• Nonspecific adenitis – Possible Yersinia infection
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Laboratory
What would you obtain?
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Labs ordered
CBC Electrolytes
LFT’s Amylase /Lipase
B-HCG Urinalysis
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Lab Results, Ms. Cope
CBC: 14,500CBC: 14,500
LFTs LFTs : : WNLWNL
HCG HCG : : WNLWNL
Electrolytes Electrolytes : : WNLWNL
Amylase Amylase : : WNLWNL
U/A: U/A: WNLWNL
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Interventions at this point?
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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?
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Studies
What further studies would
you want at this time?
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Radiologic Studies to Consider
Flat/Upright Abdomen CT Scan: Abd/Pelvis CT Scan: Other ? US Abdomen/Pelvis
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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?
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Abdominal Film
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Abdominal X-ray Findings
• Non-specific gas pattern
• No fecalith
• No free air
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CT Scan Abdomen & Pelvis
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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?
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Revised Differential Diagnosis
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What next?
• Additional Imaging?• Observation?• OR?• Other?
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What next?
Discussion of suggested interventions
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Management
• Surgical Options
• Pre-operative preparation
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Laparoscopic Acute Appendicitis
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Discussion
Pathophysiology of the disease process, visceral vs.
parietal abdominal pain, laparoscopy vs. open,
antibiotic management, appropriate utilization of
resources, etc.
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Discussion
Additional teaching points
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QUESTIONS ??????
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Summary
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Alternative scenarios
• Acute Appendicitis with perforation/ Abscess or tumor
• IBD
• Acute Diverticulitis
• Ovarian Cyst / Torsion/
• Perforated Right colon tumor
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CT Cecal Tumor
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CT Sigmoid Diverticulitis
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CT Ovarian Cystic Mass
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CT Terminal Ileal Crohn’s
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CT Acute Appendicitis
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