appendicitis

appendicitis

2. Patient Particulars:
Age/Sex: 29/M
Date of admission: 2068/06/27
Chief Complaints:
 Pain in the lower abdomen X 2 days
 Vomiting X 2 days
 Fever X 2 days

3. History of Presenting Illness:
He was apparently well 2 days back when
he suddenly developed pain in the
abdomen (umbilical region).
 Acute in onset, severe, continuous type &
colicky in nature.
The pain was relieved on medication. No
aggravating factors known.
Pain was associated with vomiting, 2
episodes, non-projectile, watery, non-
bilious, contained food particles.

4. The patient also developed fever
associated with chills and rigors. The
temperature was not recorded.
The patient also developed fever
associated with chills and rigors. The
temperature was not recorded.
The patient had no complaints of loss of
appetite or disturbance of sleep.
There was no h/o burning micturition.

5. Past History:
No h/o surgery in the past.
No h/o PTB, HTN, DM.
Personal History:
Non-vegetarian by diet.
Smoker X 10 sticks/day X 3 years.
Consumes alcohol occasionaly.
Family History:
Patient’s mother has PTB at present & is under
medications for the past 3 months as per
DOTS regimen.
No h/o HTN, DM in the family.
Drug & Allergy History: NKTD.

6. On Examination :
General Condition : Fair.
Pallor, Icterus, Lymphadenopathy,
Cyanosis,Oedema, Clubbing,
Oedema : Absent.
Respiratory Examination: B/L Vesicular Breath
Sounds – (+), No added sounds.
Cardiovasular Examination: S1, S2, M0.
Vitals: BP-120/80 mm Hg, Pulse – 80/min,
Temperature- 98.6 F, RR – 22/min.

7. Per Abdomen:
Tenderness (+) at Right Iliac fossa region.
Rovsing’s Sign (+)
Rigidity (-)
Bowel Sounds (+)
No organomegaly.

8. Treatment given in the ER:
Inj. Diclofenac x 1 amp X IM X STAT
Inj. NS 1 pint X IV X STAT
Inj. Ranitidine X 1 amp X IV X STAT
Inj. Buscopan X 1 amp X IV X STAT
Inj. Metoclopramide X 1 amp X IV X STAT
Inj. Metronidazole X 1 amp X IV X STAT

9. Provisional Diagnosis:
Acute Appendicitis
Differential Diagnosis:
Meckel’s Diverticulitis
Urinary Tract Infection
Distal Ilietis
Enteritis

10. Investigation Report:
Hb – 17.7
Total WBC Count – 13,300
Neutrophils – 81
Lymphocytes – 10
Eosinophils – 09
Platelets – 201000
Urine R/E:
Colour – Light Yellow
Transparency – Clear
Reaction – Acidic
Pus Cells – 1-2
Epithelial Cells – 0-1

11. THE ALVARADO SCORE:
Symptoms Score
Migratory RIF Pain 1
Anorexia 1
Nausea and Vomiting 1
Signs
Tenderness (RIF) 2
Rebound Tenderness 1
Elevated Temperature 1
Laboratory
Leucocytosis 2
Shift to left 1
TOTAL 10

12. USG- Abdomen:
Probe compression & Rebound Tenderness
(+).
 A tubular blind ending, aperistaltic, non-
compressible structure measuring 7-8 cm in
length and 12 mm in diameter was noted.
 No mass or fluid collection was seen
adjacent to the structure.

13. Tzankie’s Score:
Ultrasound suggestive of Appendicitis- 6
Tenderness - 4
Rebound Tenderness- 3
Total Count >12,000 - 2
Total Score - 15

14. Pre-Operative Management:
Admission
Nil Per Oral
IV Fluids- Normal Saline & 5% Dextrose
IV Antibiotics – Ceftriaxone 1g
Metronidazole 500 mg
Pantoprazole 40mg
Diagnosis explained
Operative procedure & risks explained
Consent taken from the patient party
Patient shifted to the OT

15. EMERGENCY APPENDICECTOMY
Operative Findings:
Gangrenous Appendix with inflamed
base.
 Caecum – Inflamed.
Early lump formation was noted.
Pyoperitoneum – Around 200 ml of pus
was present.

16. Operative Procedure:
Under all asceptic conditions, the abdomen
was opened in layers.
The mesoappendix was ligated and
divided.
The appendix was then ligated and excised.
Peritoneal lavage was done. The drain was
kept at the pelvis.
The wound was closed in layers.
The pus was sent for C/S.
The appendix was sent for histopathological
examination.

17. Post-operative medications:
Inj. 5% Dextrose III pints X IV X over 24 hrs
Inj. Metronidazole 500 mg X IV X TDS
Inj. Pantoprazole 40 mg X IV X BD
Inj. Pethidine 50 mg X IM X SOS
Inj. Ceftriaxone 1g X IV X BD
Inj. Clavulinic Acid 1.2g X IV X TDS
Tab. Tramadol 50 mg X PO X TDS
The patient is currently on liquid to soft diet.

18. THE
VERMIFORM
APPENDIX

19. Anatomy:

The appendix averages 11 cm in length but
can range from 2 to 20 cm.
The diameter of the appendix is usually
between 4-5 mm.
The appendix is located in the right iliac
fossa.
During childhood growth, the caecum
rotates appendix into a retrocaecal
position. When rotation does not occur it
results in a pelvic, subcaecal or
paracaecal position.

20. Positions of the Appendix:

21. Blood & Lymphatic Supply:
The appendicular artery, branch of the
ileocolic artery enters the mesoappendix
coming to lie in its free border.
Mostly it is an end artery, thrombosis of
which leads to necrosis or gangrenous
appendix.
4 – 6 or more lymphatic channels traverse
the mesoappendix to empty into the
ileocaecal lymph nodes.

22. Aetiology of Acute Appendicitis:
No unifying hypothesis.
Decreased dietary fibre and increased
consumption of refined carbohydrates.
Incidence is lowest in societies with high
dietary fibre intake.
Mixed growth of aerobic and anaerobic
organisms.
Luminal obstruction by faecolith or stricture.

23. Symptoms:
Periumbilical Colic
Pain shifts to Right Iliac Fossa
Anorexia
Nausea and Vomiting
Signs:
Pyrexia (Low Grade)
Abdominal Tenderness localised in the Right
Iliac Fossa
Muscle Guarding
Rebound Tenderness

24. Specific Abdominal Signs:
Rovsing's sign:
Deep palpation in the left iliac fossa causes
pain in the right iliac fossa, by pushing bowel
contents towards the ileocaecal valve and thus
increasing pressure around the appendix.
 Psoas sign:
Right lower-quadrant pain that is produced with
extension of the right hip while supine. Pain is due
to inflammation of the peritoneum or the psoas
muscles, positive in retrocaecal position of
appendix.

25.  Obturator sign:
If an inflamed appendix is in contact with
the obturator internus, spasm of the muscle
can be demonstrated by flexing and
internal rotation of the hip. This indicates the
pelvic position of appendix.
Pointing Sign :
Patient is asked to point to where the pain
began and where it moved.
 Cough sign :
Patient is asked to cough and there is pain
in the right iliac fossa.

26. Investigations:
Blood:
 Leucocytosis
Neutrophilia
Shift to left
 Elevated CRP
Urinalysis :
Abnormal if there is irritation of the urinary
tract.
In females to rule out Ectopic Pregnancy.

27. Radiological:
Plain abdominal X-Ray – may demonstrate
faecolith, to rule out SAIO/IO.
Abdominal Ultrasonography – Detects
Appendicitis with 90% diagnostic accuracy
and gynaecological pathology.
Computed Tomography Scan – Useful when
there is diagnostic uncertainty.95%
accuracy.

28. The Alvarado Score:
Symptoms Score
Migratory RIF Pain 1
Anorexia 1
Nausea and Vomiting 1
Signs
Tenderness (RIF) 2
Rebound Tenderness 1
Elevated Temperature 1
Laboratory
Leucocytosis 2
Shift to left 1
TOTAL 10

29. Tzankie’s Score:
Ultrasound suggestive of Appendicitis- 6
Tenderness - 4
Rebound Tenderness- 3
Total Count >12,000 - 2
Total Score - 15

30. Pre-Operative Management:
Admission
Nil Per Oral
IV Fluids
IV Antibiotics
Analgesics

31. Emergency Appendicectomy:
Position : Supine
 Skin Incision : Gridiron , Lanz.
 Two layers of superficial fascia are cut.
External Oblique aponeurosis is opened in the line of incision.
Internal oblique and Transverse muscles are split .
Peritoneum is opened in the line of incision.
Caecum is identified by the confluence of the 3 taenia coli.
Appendix is held by Babcok’s forceps.
Mesoappendix with appendicular artery is ligated.
Base is cut with artery forceps and transfixed using vicryl.
 Appendix is cut distal to the suture ligature and removed.
 Stump is cleaned with antiseptics.
Purse string suture is tightened to bury the stump.
Abdomen is closed in layers.
.

32. Complications of Appendicitis: