Appendicitis

Surgery - Appendicitis

1. Appendicitis M. Kamil (DP- Surgery)

2. Case Mr. Y is a 20 year old Chinese male previously healthy who presented to ED at 5.30 am due to sudden sharp abdominal pain on RLQ since 3.00 am. The onset was at 11.00 pm but at 3.00 am the pain caused him to wake up from sleep . The pain was sharp, continuous and non-radiating in nature. There was nothing that can be done to relieve the pain. He rated the pain during the attack as 7/10 in the scale 0 to 10. The pain was also associated with dizziness and vomiting 3x (food particles) but denied diarrhea. At ED he rated the pain as 8/10. He denied any abnormal stool.

3. PMH: Not significant No childhood/ adulthood illness. Allergy: NKDA Vaccination: cannot recall No prior h/o hospitalization and surgery. No h/o recent trauma. Family History: Not significant He is a second son out of 3. All his siblings are healthy. Mother: healthy Father: has diabetes and amputation of the big toe was done. Both his grandparents are healthy.

4. Physical examination findings. Vital signs: Normal BP: 120/78 Pulse: 80 RR: 20 T: 37.1 General: Alert, conscious, pink, not tachypnic, good hydration. Hand: No scar, no deputyrene contracture, no pallor, no palmar erythema, joint- non tender, crt <2sec. Head: no scar. Forehead normal. Eye brows symmetry.

5. Physical examination findings. Abdominal exam: Inspection: Shape- flat. No scar of prior surgery. Umbilicus inverted. Flank not full. All quadrants moving symmetry with breathing. Auscultation: bowel sound present but hypoactive. No renal bruit. Palpation (light): Guarding, Tenderness at RLQ Percussion: resonance in all quadrants No rebound tenderness

6. Investigations. FBC: Hb 15.7 g/dL (13.5 – 17) Normal WBC 15.7 /L (4.5 – 10.0) Elevated Plt 328 mm 3 (150 – 400) Normal Diagnosis Acute appendicitis Plan: Admit to surgical NBM IV tramadol 50 mg TDS + IV maxalon 10 mg stat IV metronidazole 500 mg stat TDS IV cefuroxime 1.5 stat TDS IVD 4 pints NS/24H To inform surgical

7. Operation: Open appendectomy Intra-op finding: Normal cecum Normal small bowel No pus/ slough No Meckel's diverticulum Retrocecal appendix – grossly inflamed Post – op plan: Allow clear fluid Continue abx T PCM 1 g QID WI D3

8. Acute appendicitis – Clinical presentation Acute appendicitis is inflammation of vermiform appendix.

9. Epidemiology Commonly occur between 10 to 20 year old and predominantly male (M: F, 1.4:1) Mortality rate: 20 fold decline from that reported 50 years ago. In general population : 4/1 000 000 For infant increase to 9%, For patient above 65 year old is 15% For ruptured appendicitis: 4-5% For non-ruptured appendicitis: 0.1% For women, RIF pain with normal Gynae exam and normal leukocyte count, the 90 - 99% of cases usually reveal acute appendicitis.

10. Differential Diagnosis The differential diagnosis of acute appendicitis depends on 4 major factors: the anatomic location of the inflamed appendix; the stage of the process (i.e., simple or ruptured); the patient's age ; and the patient's sex Acute Mesenteric Adenitis (in kids) Gynecologic disorders (female) Acute gastroenteritis Other intestinal disorders Renal calculi

11. Classic presentation : Periumbilical abdominal pain which progress to intense pain over 24 hours, become constant, sharp and migrates to right iliac fossa and associated with: loss of appetite, (help to diagnose in pediatric group) nausea, vomiting and constipation

12. Other signs and symptoms Migrating pain - Pain in the umbilical region that moves to the right iliac fossa Maximal tenderness at a McBurney’s point Rovsing’s sign – Palpation of LIF causes pain in RIF

13. Other signs Psoas sign – Hip extension Obturator sign – Rotation of right flexed hip

14. Atypical presentation – depend on the anatomic variations of location of appendix retrocecal appendix Absent of muscular rigidity and tenderness to deep palpation. Exacerbation of pain on hip extension (psoas sign) may occur. If the appendix is subcecal/pelvic Present of rectal or vaginal tenderness on right side. Absent of abdominal tenderness. If appendix is pre- ileal or post- ileal, The patient may present with vomiting or diarrhea Appendix can also be found on the left side in 0.2% of population.

15. Clinical prediction rules ALVARADO/MANTREL SCORE M igratory abdominal pain to RLQ (1) A norexia (1) N ausea/vomiting (1) T enderness in the right iliac fossa (2) R ebound tenderness (1) E levated temp >37.5°C (1) L eukocytosis >10 (2) L eft Shift (Neutrophils) (1) Maximum score: 10 0-4: Low probability 5-6: Moderate probability >7: High probability 95% sensitivity, 83% diagnostic accuracy (M>F) PATIENT FROM THE CASE: M igratory abdominal pain to RLQ (1) A norexia (1) N ausea/vomiting (1) T enderness in the right iliac fossa (2) R ebound tenderness (1) E levated temp >37.5°C (1) L eukocytosis >10 (2) L eft Shift (Neutrophils) (1) Score: 6 (Moderate probability)

16. Clinical algorithm for the management for suspected acute appendicitis History and physical examination Refer to surgical unit Admit: Observe and Serial abdominal examination and r/o other differentials e.g. hernia, PID, pregnancy, renal calculi etc ± diagnostic laparoscopy Features persistent for appendicitis Refer to surgical unit Possible appendicitis A score: 5 to 6 Alvarado Score Clinical appendicitis (possible) A score: 7 to 10 Unlikely appendicitis A score: 0 to 4 Discharge with advice or for follow- up at appropriate clinic e.g. Obgyn , Urology. Features not persistent for appendicitis Appendectomy

17. Open appendectomy Traditional approach is Gridiron incision over McBurney’s point, at 90° to line from umbilicus to the anterior superior iliac spine. Lanz incision is more horizontal in Langer’s lines (skin creases) and gives a better scar. Divide subcutaneous fat and superficial/Scarpa’s fascia. Fibers of external oblique, internal oblique and transversus abdominus divided with muscle splitting incision. Incise pre-peritoneal fat and peritoneum to reveal caecum. Deliver caecum through incision. Appendix located at convergence of taenia coli. Mesoappendix (blood vessels and mesentery) and appendix divided, ligated and excised (stump may be inverted). In case of a normal looking appendix, excise (may be histologically if not macroscopically inflamed); look for Meckel’s diverticulum. Wash, close in layers, dress wound. Oxford, clinical medicine, 9 th edition (2014)

18. References Alvarado, A (May 1986). "A practical score for the early diagnosis of acute appendicitis.". Annals of emergency medicine 15 (5): 557–64 Kyung Won, PhD. Chung (2005). Gross Anatomy (Board Review) . Hagerstown, MD: Lippincott Williams & Wilkins. p. 255.

19. Thank you 