Case Report

Case ReportJessica LoGeneral Surgery Clerkship Lenox Hill HospitalMarch 2014Patient GG42 y/o FHPI: 5 day Hx of RLQ pain getting progressively worse. Pain described as sharp, 8/10 at worst, non-radiatingSubjective fever x4 daysFew episodes of diarrhea x3 daysDark, brown urine x1 dayDecreased appetite but no n/v

Patient GGPMHx: nonePSHx: lap cholecystectomy (2011), removal/drainage of spinal cystSocial Hx: denies smoking or drugs; occasional use of alcohol (socially)Home medications: none

Patient GGPhysical examGeneral: AAOx3, mildly distressed due to painHeart: RRR, normal S1/S2Lungs: CTABAbdomen: soft, non-distended; bowel sounds present; tender to deep palpation mostly in RLQ; no rebound or guarding; +Rovsing sign, - psoas sign, - obturator signPatient GGEDWBC: 10.4UA: RBC > 10 CT abdomen/pelvis: acute gangrenous appendicitis with probable adjacent 1.9 cm abscess; no free air or ascitesPatient GGPatient straight to OR for laparascopic appendectomy and abdominal wash-out, with Blake drain placementFindings: non-gangrenous; abscess noted and drainedTreated with 3 days of ZosynPatient had repeated episodes of nausea/vomiting post-operatively - was given scopolamine patch, Zofran (ondansetron), and Vistaril (hydroxyzine)Discharged on HD 2. Blake drain removed prior to d/c, patient home on PO pain meds and low fat dietAppendicitisPathophysiologyObstruction by fecalith, calculi, lymphoid hyperplasia, infectious process, or tumorYoung: lymphoid hyperplasiaOld: fibrosis, fecalith, tumorObstruction leads to increased intraluminal pressure and lumen dilation, which causes thrombosis of blood vessels in appendix wall and lymphatic stasisWall becomes ischemic/necrotic visceral nerves going to T8-10 are stimulated, causing vague periumbilical painBacteria grow and invade wallNeutrophilic recruitment creates fibropurulent reaction on outer surface irritation of parietal peritoneum with sharp well-localized (somatic) painAppendicitisSigns and SymptomsRLQ pain or McBurneys point tendernessMay not be present if appendix is retrocecal. Pain may be elicited on rectal and/or pelvic examRovsings sign right side peritoneal irritationPsoas sign retrocecal appendixObturator sign pelvic appendixAnorexiaNausea/vomitingFever: low-grade (early) or high-grade (late)Indigestion, flatulence, bowel irregularity, diarrhea, generalized malaiseAppendicitis

AppendicitisAlvarado scoreMigratory right ilia fossa pain (1)Anorexia (1)Nausea/vomiting (1)Tenderness in right iliac fossa (1)Rebound tenderness in right iliac fosse (1)Fever >37.5CLeukocytosis (2)AppendicitisLabsMildly elevated WBC & left shiftCan be normal if earlyAcute < Gangrenous < PerforatedMildly elevated bilirubin if perforatedImagingCT enlarged appendix (>6mm), wall thickening (>2mm), wall enhancement, periappendiceal fat stranding, occluded lumen MRI if pregnantUltrasound & plain film not frequently usedAppendicitisCT with contrast

AppendicitisDDxCecal or right-sided diverticulitisMeckels diverticulitisAcute ileitisCrohns diseaseOb/Gyn diseasesTubo-ovarian abscessPIDOvarian cystMittelschmerzOvarian torsionEndometriosisOvarian hyperstimulation syndromeEctopic pregnancyGU diseaseRenal colicTesticular torsionEpididymitisAppendicitisDisease severityInflamedGangrenousPerforated with localized free fluidPerforated with regional abscessPerforated with diffuse peritonitis

AppendicitisManagementMedical vs. SurgicalMedical management in uncomplicated appendicitis in a trial of 243 patients (123 antibiotic group, 120 appendectomy group)Amoxicillin/clavulanic acid for 8-15 daysHigher rate of post-intervention peritonitis in ABX group vs. appendectomy (8% vs. 2%)14 patients (12%) underwent appendectomy within 30 days of treatmentAdditional 30 patients underwent appendectomy within 1 year; 26 of these had acute appendicitisOther studies show high rate of recurrence or development of complicated appendicitisNon-surgical management can be considered for higher risk populations

AppendicitisSurgical managementLaparotomy vs. LaparoscopyLaparoscopyBetter outcomes: decreased rate of wound infection, less post-op pain, shorter hospital stay, sooner return of bowel functionWorse outcomes: higher rate of intra-abdominal abscess, longer operative time, higher rate of intraoperative complications, higher costsPreferred in: uncertain diagnosis, obese patients, elderlyAppendicitisSurgical managementPre-opHydrationCorrection of electrolytesPerioperative antibioticsAcute, non-perforated single pre-op dose for wound prophylaxis. No post-op antibiotics neededPerforated empiric broad-spectrum ABX, pending culture/sensitivity results, for 5-7 daysPost-opNPO clear liquids before discharge. Regular diet as toleratedNo ABX if non-perforatedAppendicitisPerforated appendicitisComplicationsDehydration & electrolyte abnormalitiesGeneralize peritonitisRetroperitoneal or liver abscessIntraperitoneal abscessEnterocutaneous fistulaSBOAppendicitisPerforated appendicitisManagementFree perforation Ex lap to irrigate/drain Contained perforation (abscess or phlegmon) non-surgical (ABX, IVF, bowel rest) and/or drainage of abscess (percutaneous or transrectal)Pts with long duration of symptoms may have difficult dissections due to adhesions & inflammationAppendectomy if bowel obstruction, sepsis, or persistent fever, pain, or leukocytosisInterval appendectomy 6-8 weeks later to prevent recurrence and exclude neoplasm