medical case presentation on APPENDICITIS.pptx

A condition in which the appendix becomes inflamed and filled with faecoliths, causing pain.
The appendix is a pouch-like structure attached at the start of the large intestine, believed to serve immunological purpose.
Appendicitis begins with fever and pain near the belly button and then moves toward the lower-right side of the abdomen. This is often accompanied by nausea, vomiting, loss of appetite, fever and chills.
Appendicitis is usually treated with antibiotics and surgery is required within 24 hours of its diagnosis. If untreated, the appendix can rupture and cause an abscess or systemic infection (sepsis).
Common
More than 1 million cases per year (India)
Requires a medical diagnosis
Lab tests or imaging often required
Treatable by a medical professional
Short-term: resolves within days to weeks
Critical: needs emergency care
Symptoms
Pain in the lower right abdomen that starts near the middle of the abdomen and becomes constant and severe. Other symptoms include nausea, vomiting, decreased appetite, fever, malaise, and swollen belly.
Causes
An obstruction in the appendix can be caused by appendicoliths, tumors, intestinal parasites, or hypertrophied lymphatic tissues.
Diagnosis
A doctor will review your medical history and symptoms, perform a physical exam, and may order blood tests, urinalysis, or imaging tests.
Treatment
Treatment usually involves antibiotics and surgery to remove the appendix, known as an appendectomy. If the appendix has burst, the surgeon will drain the abdominal cavity of pus.
Risk
If left untreated, the appendix can burst, which can lead to more infection and even death.
Although anyone can develop appendicitis, it's most common in people between the ages of 10 and 30.

1. APPENDICITIS 1 Presented by :JISHA JAMES

2. What is appendicitis? 2 Appendicitis is inflammation of the appendix. Appendicitis is the leading cause of emergency abdominal operations.

3. What is appendix? 3 The appendix is a close ended , narrow tube attached to the cecum. The appendix does not appear to have a specific function in the body, and removing it does not seem to affect a person’s health.

4. Anatomy & physiology 4 Anatomical name : Vermiform appendix meaning worm-like appendage Anatomical location : Right lower quadrant (RLQ) less commonly retro-colic The inside of the appendix is called the appendiceal lumen. Normally, mucus created by the appendix travels through the appendiceal lumen and empties into the cecum. The wall of appendix contains lymphatic tissues that is a part of the immune system for making antibodies.

5. Pathogenesis 5 An obstruction/blockage, of the appendiceal lumen. Mucosal secretions continue to increase intra luminal pressure

6. Who gets appendicitis? 6 APPENDICITIS An inflamed appendix will likely burst if not removed. Eventually the pressure exceed capillary perfusion pressure and venous and lymphatic drainage are obstructed Vascular compromise , bacterial invasion by bowel flora Arterial stasis and tissue infarction . Peroration and spillage of infected appendiceal contents into peritoneum Inflammation of serosa and adjacent structures Triggering somatic pain fibers , innervating peritoneal structures. Pain felt in RLQ

7. pathophysiology 7 Organism lodge in sub mucosa , proliferate , wall becomes red and turgid. Inflammation ∞ obstruction Obstruction + infection distention with pus venous occlusion, oedema, gangrene and perforation . defence by greater omentum & coiling appendix mass appendix abscess Free perforation following obstruction and infection spread to peritoneal cavity intense peritoneal reaction with outpouring of fluid.

8. Who gets appendicitis? 8 Anyone can get appendicitis, although it is more common among people 10 to 30 years old.

9. Signs & Symptoms 9 The symptoms of appendicitis are typically easy for a health care provider to diagnose. The most common symptom of appendicitis is abdominal pain . Abdominal pain with appendicitis usually • occurs suddenly, often waking a person at night • occurs before other symptoms • begins near the belly button and then moves lower right • is unlike any pain felt before • gets worse in a matter of hours when moving around, taking deep breaths, coughing, or sneezing

10. Signs & Symptoms 10 Other symptoms of appendicitis may include • loss of appetite • nausea /vomiting • constipation / diarrhea • bloating • a low-grade fever that follows other symptoms • abdominal swelling • the feeling that passing stool will relieve discomfort

11. Signs & Symptoms 11 Symptoms vary and can mimic the following conditions that cause abdominal pain: Intestinal obstruction IBD Pelvic inflammatory disease Abdominal adhesions mesentric adenitis Urolithiasis Constipation

12. DIAGNOSIS 12 A health care provider can diagnose most cases of appendicitis by taking a person’s medical history and performing a physical exam. Physical exam: Details about the person’s abdominal pain are key to diagnosing appendicitis. The health care provider will assess the pain by touching or applying pressure to specific areas of the abdomen. Responses that may indicate appendicitis include:

13. DIAGNOSIS 13 • Obturator sign. The right obturator muscle also runs near the appendix. A health care provider tests for the obturator sign by asking the patient to lie down with the right leg bent at the knee. Moving the bent knee left and right requires flexing the obturator muscle and will cause abdominal pain if the appendix is inflamed.

14. DIAGNOSIS 14 • Rovsing’s sign: A health care provider tests for Rovsing’s sign by applying hand pressure to the lower left side of the abdomen. Pain felt on the lower right side of the abdomen upon the release of pressure on the left side indicates the presence of Rovsing’s sign.

15. DIAGNOSIS 15 • Guarding: Guarding occurs when a person subconsciously tenses the abdominal muscles during an exam. Voluntary guarding occurs the moment the health care provider’s hand touches the abdomen. Involuntary guarding occurs before the health care provider actually makes contact and is a sign the appendix is inflamed.

16. DIAGNOSIS 16 Rebound tenderness: A health care provider tests for rebound tenderness by applying hand pressure to a person’s lower right abdomen and then letting go. Pain felt upon the release of the pressure indicates rebound tenderness and is a sign the appendix is inflamed. A person may also experience rebound tenderness as pain when the abdomen is jarred—for example, when a person bumps into something or goes over a bump in a car.

17. Diagnosis 17 3.Laboratory Tests Laboratory tests can help confirm the diagnosis of appendicitis or find other causes of abdominal pain. • Blood tests. show signs of infection, dehydration or fluid and electrolyte imbalances. • Urinalysis. used to rule out a urinary tract infection or a kidney stone. 4.Imaging Tests Imaging tests can confirm the diagnosis of appendicitis or find other causes of abdominal pain. • Abdominal ultrasound can show signs of inflammation , a burst appendix, a blockage in the appendiceal lumen, and other sources of abdominal pain. • MRI/CT scan

18. BURST APPENDIX 18 A burst appendix spreads infection throughout the abdomen—a potentially dangerous condition called peritonitis. A person with peritonitis may be extremely ill and have nausea, vomiting, fever, and severe abdominal tenderness. This condition requires immediate surgery through laparotomy to clean the abdominal cavity and remove the appendix. Without prompt treatment, peritonitis can cause death. Sometimes an abscess forms around a burst appendix—called an appendiceal abscess. A surgeon may drain the pus from the abscess during surgery or, more commonly, before surgery. To drain an abscess, a tube is placed in the abscess through the abdominal wall. The drainage tube is left in place for about 2 weeks while antibiotics are given to treat infection. Six to 8 weeks later, when infection and inflammation are under control, surgeons operate to remove what remains of the burst appendix.

19. MANAGEMENT 19 Surgical intervention • Laparotomy - single incision in the lower right area of the abdomen. • Laparoscopic surgery - uses several smaller incisions and special surgical tools fed through the incisions to remove the appendix. Laparoscopic surgery leads to fewer complications, such as hospital-related infections, and has a shorter recovery time. Surgeons recommend limiting physical activity for the first 10 to 14 days after a laparotomy and for the first 3 to 5 days after laparoscopic surgery.

20. MANAGEMENT 20 2.Nonsurgical treatment may be used if surgery is not available, a person is not well enough to undergo surgery, or the diagnosis is unclear. Nonsurgical treatment includes antibiotics to treat infection. However once appendicitis is diagnosed, antibiotics should be started and surgery should be consulted emergently. Antibiotics for acute appendicitis include: Piperacillin +tazobactam Metronidazole/tinidazole+ cephalosporins Ertapenem

21. MANAGEMENT 21 Eating, Diet, and Nutrition Researchers have not found that eating, diet, and nutrition play a role in causing or preventing appendicitis. If a health care provider prescribes nonsurgical treatment for a person with appendicitis, the person will be asked to follow a liquid or soft diet until the infection subsides. A soft diet is low in fiber and is easily digested in the GI tract. A soft diet includes foods such as milk, fruit juices, eggs, puddings, strained soups, rice, fish, and mashed, boiled, or baked potatoes .

22. KEYNOTE 22 Appendicitis is a medical emergency that requires immediate care. People who think they have appendicitis should see a health care provider or go to the emergency room right away. Swift diagnosis and treatment can reduce the chances the appendix will burst and improve recovery time.

23. CASE PRESENATATION 23

24. SUBJECTIVE 24 Patient’s name : Mr. XYZ Presenting Complaints: Abdominal pain , vomiting, fever *2 days acute onset, intermittent in nature loss of appetite. no h/o myalgia , throat pain , cough, breathing difficulty, diarrhoea . Age : 22 Sex :Male Date of admission : 28/03/2021 Date of discharge : 03/04/2021 Department: General surgery

25. OBJECTIVE 25 GENERAL EXAMINATION : SYSTEMIC EXAMINATION: Conscious ,oriented Pulse : 92/min B.P:120/80mmHg RR : 18/min RS: NVBS , No added sound P/A: soft, non-distended, tenderness in right iliac fossa, rebound tenderness(+) , ill defined mass in right iliac fossa CVS: S1S2 heard , no murmur CNS: HMF – normal ,no FND

26. LABORATORY DATA 26 PARAMETER 28/3 30/3 1/5 3/5 REFERENCE INFERENCE Hb 13.9 13.2 13.6 - 13-17gm% Normal PCV 41 40.1 41 - 40-54% Normal Total WBC 10200 11500 12400 - 4000-1100cumm ELEVATED DC poly 89 87 79 - 40-75% ELEVATED DC lymph 5 7 12 - 20-40% LOW DC esinophil 1 1 2 - 1-6% Normal DC mono 5 5 7 - 2-10% Normal ESR 41 45 55 - 3-15mm/hr ELEVATED PLATELET 90000 80000 75000 1.2 1.5-4 lakh/ cumm LOW Sodium 131 132 135 135 135-144mmol/L Normal Potassium 3.7 3.4 3.8 4 3.2-5.5mmol/L Normal

27. LABORATORY DATA 27 PARAMETER 28/4 30/4 1/5 3/5 REFERENCE INFERENCE urea 30 - 22 - 10-50mg/dl Normal creatinine 1.1 - 0.7 - 0.6-1.5mg/dl Normal T.Bilirubin 2.4 1.7 2.2 - 0.3-1mg/dl ELEVATED D.Bilirubin 0.6 0.5 0.6 - 0.1-0.3mg/dl ELEVATED SGOT 30 18 22 - <37IU/L Normal SGPT 24 33 33 - <40IU/L Normal ALP 73 - - - 30-120U/L Normal T.P 7 - - - 6.6-8.7g/dl Normal Albumin 4 - - - 3.5-5 g/dl Normal Globulin 3 - - - 2.2-3.6 g/dl Normal A/G ratio 1.3 - - - 1.2-1.5 g/dl Normal

28. OBJECTIVE 28 RADIOLOGICAL INVESTIGATION: USG ABDOMEN : Heterogeneously hypoechoic area in right iliac fossa with adjacent mesentery appearing hyperechoic – suggestive of formation in right iliac fossa ? secondary to appendicitis --- possibilities of appendicular mass formation. No obvious well defined mass ,hyperechoic lesion in right iliac fossa present oedematous with mild wall thickening ,probably inflammatory sequalae , minimised inter-bowel free fluid noted in right iliac fossa.

29. ASSESSMENT 29 Based on the subjective and objective data , the patient is diagnosed with – APPENDICITIS WITH ABSCESS FORMATION THROMBOCYTOPENIA UNDER EVALUATION? PLAN FOR APPENDECTOMY

30. MEDICATION CHART 30 BRAND NAME DOSE FREQ ROA DURATION 28/4 29/4 30/4 31/4 1/5 2/5 3/5 Inj. Cefomed S 1.5g Q12H I.V + + + + + + + Inj.Metrogyl 5oomg Q8H I.V + + + + + + + Inj.Pantop 40mg O.D I.V + + + + + Inj.Tramadol 50mg Q8H I.V + + + + + Operative procedure: Open appendicetomy and adhesiolysis under GA Operative findings: Retro- caecal appendix with dense adhesions to the peritoneum and ileal mesentry

31. DISCHARGE 31 TO BE TAKEN FOR 3 DAYS MEDICATIONS POST SURGERY T.Ciplox TZ 500/600mg 1-0-1 P/O T.Pantop 40mg 1-0-1 P/O T.Triolytic - 1-1-1 p/o T.Calpol 650mg 1-1-1 P/0 Ensure adequate hydration , ambulation , soft diet . Review in Gen surgery on 7/5/21

32. ASSESSMENT 32 BRAND NAME GENERIC NAME CLASS INDICATION S IDE EFFECTS Inj. Cefomed S Ceftriaxone (1000mg) +sulbactam(500mg) 3 rd generation cephalosporin+ beta lactamase inhibitor Appendicitis Rash , diarrhea, nausea Inj.Metrogyl Metronidazole Nitroimidazole antibiotic Appendicitis Stomach upset, Nausea Inj.Pantop Pantoprazole Ppi GI irritation Diarrhea,abdominal upset Inj.Tramadol Tramadol hydrochloride Centrally acting opioid agonist Abdominal pain Nausea,constipation,sleepiness,dizziness

33. ASSESSMENT 33 BRAND NAME GENERIC NAME CLASS INDICATION S IDE EFFECTS T.Ciplox TZ Ciprofloxacin(500mg)+Tinidazole (600mg) Fluoroquinolone+ nitroimadzole Appendicitis Stomach upset, NAUSEA, CONSTIPATION T.Triolytic Rutin (100mg)/ trypsin(48mg)/ bromelain(90mg) Antioxidant/enzymes Aid healing process post appendicetomy nil

34. PHARMACIST INTERVENTION 34 Patient’s temperature was not documented . CULTURE and sensitivity test prior to beginning of tinidazole is essential , here it is not performed. PHARMACOECONOMIC ANALYSIS: DRUG PRESCRIBED BRAND COST /TAB (Rs) COST EFFECTIVE BRAND COST /TAB (Rs) Ciprofloxacin(500mg)+Tinidazole (600mg) Ciplox TZ ( cipla ) 10.6 Citizol (Aristo) 4

35. PATIENT COUNSELLING 35 ABOUT DISEASE: Appendicitis is a condition in which your appendix gets inflamed. The appendix is a small pouch attached to the large intestine. ABOUT DRUGS: 1.T.Ciplox T2: This medication is a combination of two antibiotics Tell doctor immediately if you experience constipation or blood in stool, or if your experience pain in tendons, numbness or tingling sensations 2.T.Pantop: Take it one hour before meal. Avoid alcohol and smoking. Swallow it as a whole, do not crush, chew or break the tablet.

36. PATIENT COUNSELLING 36 3.T.Triolytic: Triolytic tablet helps relieve pain and inflammation due to surgery Take with plenty of water /fluids ,an hour before or after meals It may change color ,consistency and odor of stool .This is harmless. Inform doctor if this bothers you . Advise to patient: Drink plenty of water ( atleast 2.5L/day) Have soft meals that is easy to be digested Include vitamin C containing fruits as these helps in wound healing and fight infections Have proper hygiene and sanitation .

37. MONITORING PARAMETERS 37 DRUG PARAMETER INJ.METROGYL CBC T.CIPLOX TZ CBC,

38. REFERENCES 38 Heverhagen J, Pfestroff K, Heverhagen A, Klose K, Kessler K, Sitter H. Diagnostic accuracy of magnetic resonance imaging: a prospective evaluation of patients with suspected appendicitis (diamond). Journal of Magnetic Resonance Imaging. 2012;35:617–623. Spirt MJ. Complicated intra-abdominal infections: a focus on appendicitis and diverticulitis. Postgraduate Medicine. 2010;122(1):39–51. www.1mg.com www.ncbi.nlm.nih.gov www.drugbank.com www.drugs.com www.mayoclinic.com www.medplusmart.com www.medscape.org

39. 39 THANKYOU