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1. Appendicitis: A Case Presentation Overview Student: Eva Hassan To the Department of General Surgery

2. Case Presentation

3. Vitals and Physical Examination Physical Examination General: Alert, oriented ×3 Appears in mild distress due to abdominal pain Abdomen: Soft, non-distended Tenderness localized to the right lower quadrant, maximal at McBurney’s point Rebound tenderness present No guarding or palpable masses Bowel sounds present Vital Signs: at admission (Temp: 37.4, pulse: 82, respiration: 17, blood pressure: 116/76, oxygen sat: 98)

4. Clinical Findings & Preoperative Labs WBC: 16.89 x10³/ μ L (elevated) leukocytosis Neutrophils: 86% (neutrophilia) Lymphocytes: 11% (relative lymphopenia) Hemoglobin: 15.8 g/dL (Normal) Hematocrit: 44.7% (Normal) Platelets: 331 x10³/ μ L (Normal) Glucose: 98 mg/dL (Normal fasting) Creatinine: 0.75 mg/dL (Normal renal function) Sodium: 140 mmol/l (Normal) Chloride: 104 mmol/l (Normal) Potassium: 4.2 mmol/l (Normal)

5. Imaging Findings CT abdomen : Few air fluid levels were noted in the distal small bowel, and submucosal intramural fat deposition was observed at the level of the ileocecal valve. The appendix is enlarged in diameter, measuring up to 17mm, with significant peri-appendiceal fat strandings. Notes are made of the appendicolith at its base and in its center. There is a small localized fluid collection near the tip, suggesting pre-perforating appendicitis . Chest X-ray: - Normal heart, lungs clear - No effusion, dorsal spurring

6. CT ABDOMEN

7. Operative Details The patient was placed in the supine position, and general anesthesia was induced. The abdomen was prepped and draped in sterile fashion. A supraumbilical incision was made, and pneumoperitoneum was established using a Veress needle to an intra-abdominal pressure of 14 mmHg. A 10mm trocar was inserted at the umbilicus, and a 30-degree laparoscope was introduced. Two additional 5 and 10 mm ports were inserted under direct vision—one in the left lower quadrant and one in the suprapubic region. Diagnostic laparoscopy was performed, showing a severely inflamed appendix with pseudomembranes and mild free fluid in the Douglas pouch, confirming the diagnosis of acute appendicitis. The appendix was identified, and the mesoappendix was dissected using electrocautery The base of the appendix was secured with Endoloops (typically 0 PDS), with two applied proximally (to the stump) and one distally (toward the specimen). The appendix was transected between the loops using laparoscopic scissors. The specimen was retrieved via the umbilical port using an endoscopic retrieval bag or directly through the trocar. Hemostasis was confirmed. The peritoneal cavity was irrigated and suctioned as needed. Ports were removed under direct vision. Pneumoperitoneum was released. Skin incisions were closed with absorbable sutures and steri -strips applied.

8. Pathology Findings Appendix of 9 cm covered with pseudo-membrane Necrotic appendix with peri-peritoneal reaction (localized peritonitis). No malignancy identified.

9. Postoperative Course IV Fluids : Normal Saline 0.9% – 2L/day Antibiotics : Rocephin (Ceftriaxone) 2g IV once daily Flagyl (Metronidazole) 500mg IV every 8 hours Gastric Protection : Rizek (Omeprazole) 40mg IV once daily Analgesia : Perfalgan (Paracetamol) 1g IV every 6–8 hours PRN Acupan (Nefopam) 20mg IV every 8 hours PRN Dolosal (Pethidine) 50mg IV/IM every 6–8 hours PRN Antiemetic : Zofran (Ondansetron) 8mg IV every 8 hours PRN Diet : NPO initially → clear liquids → soft/regular as tolerated Mobilization : Encourage early ambulation on Day 0 or Day 1 Lab : CBC to be repeated on Post-op Day 1 Monitoring : Vital signs q4–6h, strict input/output charting Wound & Drain Care : Keep dressing clean and dry Monitor drain (present): color, consistency, volume Report signs of infection or blockage Drain removed on post-operative day 2; the output was serosanguinous Monitoring: Voiding monitored, drain output assessed, symptomatic management provided

10. Discharge Medications Ceftriaxone (Rocephin) – 1 g IV/IM once daily (Continue as outpatient parenteral antibiotic therapy ) Metronidazole (Flagyl) – 500 mg orally every 8 hours (To complete a 5–7 day total antibiotic course) Pain Medications (PRN): Paracetamol ( Perfalgan ) – 500–1000 mg every 6–8 hours

11. Summary of the case

12. Differential Diagnosis

13. Anatomy of the Appendix

14. The appendix is also called the vermiform appendix , meaning "worm-like" (from vermis = worm). Its length is highly variable among individuals. The average length of the appendix is 8–10 cm . The base of the appendix is attached to the cecum (part of the large intestine).

15. Layers of the appendix are similar to the layers of the large bowel

16. Nervous supply Sympathetic and parasympathetic branches of the autonomic nervous system innervate the appendix. Nerves are carried by the ileocolic branch of the superior mesenteric plexus. Sympathetic afferent nerve fibers of the appendix arise at the spinal cord’s T10 (umbilical ) level. Patients with early appendicitis experience initial visceral pain – periumbilical. The pain then localizes to the RLQ.

17. Arterial Blood Supply of the Appendix

18. Appendix Anatomy & Clinical Relevance Appendix Tip Position Highly variable in location (retrocecal, pelvic, subcecal , etc.) Not reliable for consistent clinical signs Appendix Base More anatomically consistent Located at the posteromedial cecum, below the ileocecal valve McBurney’s Point Located one-third the distance from the ASIS to the umbilicus Marks the surface projection of the appendix base Common site of maximal tenderness in acute appendicitis

19. Location of the tip varies while the base is constant, and this variation can give a wide range of symptoms in acute appendicitis .

20. Acute Appendicitis - Epidemiology

21. Acute Appendicitis-Etiology Obstruction of the lumen of the appendix Faecolith They are composed of inspissated fecal materials, calcium and Magnesium phosphates and carbonates, bacteria and epithelial debris, and rarely a foreign body. Stricture Worms: Round worm/Thread worm Foreign body Infective Viral infections - responsible for clustering of cases among children Distal obstruction of the colon Colon cancer, Carcinoma ceacum

22. Pathophysiology of acute appendicitis

23. Gangrenous appendix

24. Perforation of the appendix

25. Perforated appendix

26. Symptoms Anorexia ( loss of appetite, Burger’s sign ) Nausea/ vomiting Classical visceral-somatic sequence of pain

27. Signs Pyrexia: Low grade after 6 hours Tenderness (localized) in the RLQ Muscle guarding Rebound Tenderness (Blumberg Sign) Tachycardia: Perforation, Gangrene & Peritonitis

28. Physical Exam

29. Physical Exam

30. Physical Exam

31. Summary of Physical Exam Signs Rovsing's Sign Psoas Sign Obturator Sign Dunphy's Sign: Any movement (Coughing) causes Pain. Mc Burney's Point -Tenderness

32. Atypical Features Retrocecal (65%): pain poorly localized, flank or back pain reported, mild or absent Mc Burney point tenderness, Psoas sign positive. It mimics renal colic pain. Pelvic (30%): Suprapubic pain (lower), urinary symptoms, diarrhea; usually, the obturator sign is positive. Subcecal , Postileal , Preileal : Periumbilical pain associated with vomiting and diarrhea.

33. Investigations The diagnosis of acute appendicitis is essentially clinical.

34. Diagnostic Scoring Systems

35. Other investigations WBC- Raised: 10000 to 18000 (Neutrophils >75%). If WBC >18000 (suspect perforation) Elevation in serum bilirubin may suggest perforation Abdominal Ultrasound (operator dependent) CT Scan (gold standard, more than 6mm dilation ) MRI ( in children and in pregnancy)

36. Management NPO IV Fluids Supplements Analgesics Antibiotics Appendectomy (within 24 hours ASAP)

37. Treatment Conservative Operative ➤ Open appendectomy ➤ Laparoscopic appendectomy

38. Open VS Laparoscopic Surgery

39. Conservative Management of Acute Appendicitis

40. Algorithm for perforated appendicitis

41. Thank you!