CASE # 01

A Discussion o f t h e A c u te Abdomen
a n d A c u t e Appendicitis
Objectives
• To present and discuss a case of Acute Abdomen
• Specific Objectives
1. To discuss the approach to a patient presenting with an acute abdomen
a. Discuss the important features of the history and PE for the case, and other similar cases
b. Discuss the primary impression, salient features, and the differential diagnosis to consider
c. Discuss the approach and management of the case, including its surgical management
2. To discuss the basic anatomy, histology, and physiology of the appendix
3. To discuss the following about acute appendicitis
a. Etiology
b. Clinical Manifestation
c. Pathophysiology
d. Classification
e. Diagnosis
f. Management
 P. M. 26 yo female, came in at the
ER, complaining of severe right
lower quadrant pain. She is
SCENARIO: accompanied by her boyfriend with
difficulty walking properly.
 IDENTIFYING DATA
Name PM

Age 26

HISTORY Gender Female

Marital Status

Occupation

Address

Religion
 CHIEF COMPLAINT severe RLQ pain
HISTORY
INFROMANT & PM, (% Reliability)
RELIABILITY
 HISTORY OF PRESENT ILLNESS

Characterize Pain Onset

Location RLQ
Duration
Radiation
Chronology/Pattern
Severity Severe
Pain Scale
Aggravating Factors
HISTORY Alleviating Factors
Associated Symptoms Difficulty in walking
Medication Taken

PAST MEDICAL HISTORY

Previous Hospitalization/Surgery
Chronic Illnesses
Maintenance medication or anyh medications currently taking
Allergy to food and drugs
 GYNECOLOGIC HISTORY

Menarche
Irregular/ Irregular Cycle
Duration
Dysmenorrhea
Use of Contraceptive
Sexual History
HISTORY
PAST MEDICAL HISTORY

Previous Hospitalization/Surgery
Chronic Illnesses
Maintenance medication or any medications currently taking
Allergy to food and drugs
 FAMILY HISTORY
Heredofamilial Hypertension? Diabetes?
disease Cancer?

PERSONAL-SOCIAL HISTORY
HISTORY
Occupation
Activities
Hobbies
Diet
Vices
Recreational Drugs
Review of Systems
General: Fatigue, weakness, recent weight loss, fever

Skin: pruritus, scar, rashes, easy bruising

Heent: Headaches, head trauma, Visual and hearing problems, colds

Respiratory: cough, pain with deep breath

Cardiovascular: high blood pressure, SOB, chest pain, tachycardia

Genitourinary: dysuria, hematuria, frequency, pelvic pain, vaginal discharge, bladder control abnormalities

Neuromuscular: abnormalities in sensation or motor control

Physical Examination
General: level of consciousness, coherence, in respiratory distress,
posture, facial expression
Vital Signs BP HR Height Wight Temperature

Skin Lesion, Diaphoresis, Pallor, Cyanosis, Turgor

HEENT and Neck: Sclera, Conjuntiva, Pupils, Visual Acquity,

Discharges,lip (color, dry or moist), Lymphadenipathy
 Chest and Lungs:

• Inspection: Scars, equal expansion,

retraction
• Palpation: tactile fremitus
• Percussion: Resonance
Physical • Auscultation: breath sounds, adventitious
sounds

Examination Heart

• Inspection: PMI
• Palpation: Heaves, Thrills
• Percussion: CAD
• Auscultation: Rate, Rhythm, Murmurs
 Abdomen: Inspection

CONTOUR
• Distended? Scaphoid? Mass effect?
Physical SCARS
• Previous Surgery?
Examination ERYTHEMA, EDEMA
• Cellulitis?
ECCHYMOSIS
• Necrotizing infections of
fascia/abdominal structures?
 Abdomen: Auscultation

• Bowel Sounds
• Quality and Quantity:
• Hyperactive: Enteritis, early
Physical ischemia

Examination • Quiet: Ileus

• Pitch and Pattern:
High pitch: MBO
Echoing, far-sounding- luminal
distention
• Bruit
 Abdomen: Percussion

• Normal: Tympanitic (Hyperresonant)

• Bowel Obstruction/Ileus: Tympanitic all
throughout except RUQ (liver)

Physical • Localized abdominal mass: dullness to

percussion

Examination • Free intra-abdominal air: liver dullness is

lost, resonant is uniform all throughout
• Degree of ascites: fluid wave, ripple on
percussion, shifting dullness
• Peritonitis: (+) pain when iliac crest, the
flank, or the heel of an extended leg is
firmly tapped
 Abdomen: Palpation

Provides the most information

Reveals severity and exact location of
abdominal pain, (+) peritonitis, (+)
Physical organomegaly or mass lesion

Examination Begin gently and far away from the

reported area of pain
Voluntary guarding to pain on palpation
limits information obtained
Involuntary guarding (muscle spasm) –
peritonitis
 Abdomen: Palpation

Peritonitis: Obturator, Psoas, Rovsing

Physical
signs
Intraabdominal Disease: Carnett Sign

Examination Abdominal wall disease

(hematomas): Fothergill Sign
Appendicitis: Obturator (retrocecal),
psoas (pelvic), Rovsing sign,
Cutaneous hyperesthesia, etc.
Physical Examination

Presence of masses
DRE Pelvic pain
Intraluminal blood

Evaluates pain below the umbilicus

Pelvic Exam Speculum and Bimanual Exam
Gynecologic and Adnexal Processes

Peripheral pulses
Extremities Clubbing
 ACUTE APPENDICITIS
PRIMARY Severe RLQ pain causing difficulty in ambulation

IMPRESSION Possible presenting features, history features:

Migratory abdominal pain, Intermittent cramping,
Vomiting, Fever, Anorexia, Abdominal rigidity
Differential Diagnosis
Rule In Rule Out
Ovarian Torsion Unilateral abdominal pain that worsens over (-) UTZ: Ovarian enlargement (>5cm)
hours
Nausea and vomiting after pain
Occurs in 20s (median 28)
Ruptured Ectopic RLQ to pelvic pain (-) Pregnancy test, ↓ Hematocrit
Pregnancy Abdominal guarding (-) Hx of abnormal menses, Vaginal bleeding
reproductive age (-) Signs of hemorrhagic shock

Pelvic Inflammatory (+) RLQ pain (-) vaginal discharge

Disease Fever (-) dyspareunia
N/V (-) dysuria
(-) chandelier sign (CMT)

Nephrolithiasis RLQ Pain (-) Dysuria

Nausea and Vomiting (-) CVA tenderness
(-) Kidney punch sign
 Acute AppendicitisDiagnosis: Lab Work-Up

Mild leukocytosis w/ left shift (10,000 cells/mm3), Neutrophilia

CBC
Higher WBC count with gangrenous or perforated appendicitis (~17,000)

↑ (>10-20mg/L)
CRP
May have a 12h delay
To exclude UTI (pyelonephritis), renal colic (d/t obstruction)
Urinalysis Mild pyuria and/or hematuria may be present if inflamed appendix has involved
the right ureter

β-HCG Test Always performed in all women of childbearing age age to R/O pregnancy
Urine/Serum
(ectopic)
 Acute Appendicitis Diagnosis: Scoring Systems

Alvarado Score (MANTRELS)

- Most widespread
- Not very reliable in the
extremes of age
 Acute Appendicitis Diagnosis: Imaging

Sensitivity Specificity Features that suggest appendicitis

Enlarged lumen
Double wall thickness >6mm
Wall thickening >2mm
Contrast CT 96% 96% (+) Periappendiceal fat stranding
(+) Appendiceal wall thickening
(+) Appendicolith
Diameter >6mm
Pain w/ compression
- extremely painful for those w/ peritonitis
UTZ 85% 90% (+) Appendicolith
↑ Echogenicity of the fat
(+) Periappendicial fluid

Recommended for whom risk of ionizing radiation outweighs ease

MRI 95% 92% in CT
Acute Appendicitis Diagnosis: Imaging
Acute Appendicitis Diagnosis: Imaging
 Acute Appendicitis Preoperative Management

• Preoperative Management
• Place px on NPO
• Rehydrate if dehydrated
• Cefoxitin (2nd Gen Cephalosporin) – continue 24h postop
• 2g IV or 40mg/kg IV
• If w/ strong suspicion for perforation:
• Ceftriaxone (3rd Gen Cephalosporin) 2g/IV q24h + Metronidazole 1.5g IV q24h
• Obtain Surgery consent (Open or Lap)
.
 Acute Appendicitis Operative Management
Open Appendectomy ● Incision is made on McBurney’s point
● McBurney’s incision (oblique incision) OR
Rocky-Davis incision (transverse incision)
● Bed position: Trendelenburg’s position with left
side down
● To identify appendix, trace the taenia Liberia of
the cecum distally
● Mesentery is ligated for better exposure

Laparoscopic ● Supine position with the left arm tucked for ● Incisional surgical site
Appendectomy better access infection: half as likely to
● Access to peritoneum via: occur
○ Hasson technique (periumbilical
● Less pain
fashion)
○ Verees or optical trocar in the LUQ 3 cm ● Earlier return to normal
below the costal margin in MCL activity, work, and sporting
● Bed position: Tredelenburg position with left activities
side down to sweep the bowel away ● Increased risk of
intraabdominal abscess
 Acute Appendicitis Post-operative Management

• To Recovery/PACU room, then to ward

when stable
• NPO until bowel movement (+)
• O2 Inhalation at 3L/min via nasal cannula
• Monitor VS q15 until stable, q1hr for 2hrs then q4hrs
• IVF
• I&O • Medication
• Record time of Flatus, Bowel movement • Tramadol 50mg IV q6h x 4doses
• Then PRN
• Post-op antibiotics are usually
unnecessary
ACUTE ABDOMEN
Acute Abdomen
Refers to signs and symptoms of abdominal pain and
tenderness that often require prompt diagnosis and
emergency therapy (Surgical abdomen if needing surgical
Tx)
Acute Pain
• Visceral Pain
- Vague and poorly localized to the epigastric, periumbilical or hypogastric region
- Perceived to be in the MIDLINE as organs transmit signals to BOTH sides of the spinal cord
- Nausea, vomiting, pallor, and sweating are commonly associated

• Somatic/Parietal Pain
- Sharper, better localized (can be pointed out by finger)
- Nausea, vomiting, pallor, and sweating are seldom associated

• Referred Pain
Abdominal Pain
• Referred Pain
Right subscapular
Cholecystitis
Epigastric
Periumbilical
Appendicitis
[Rare] Testicular
Diaphragmatic irritation
Shoulder pain
Spleen, perforated ulcer, abcess
Pancreatitis/CA Back pain
Rectal disease Pain in the small of the back
Flank pain
Nephrolithiasis
Testicular pain
Rectal pain Midline small of the back pain
Small bowel Periumbilical
Uterine Midline small of the back pain
Acute Abdomen
May be caused by Non-surgical or Surgical Causes
The Appendix
• Narrow, muscular tube containing large amounts of
lymphoid tissue
• Base attached to the posteromedial surface of the
cecum
• About 1 in (2.5cm) below the ileocecal junction
• Average length: 6-9cm
• Lumen diameter: 1-3mm
• Outer diameter: 3-8mm
The Appendix
• Lies in the right iliac fossa
• McBurney’s point
• Situated 1/3 of the way up
the line joining the right
anterior superior iliac spine
to the umbilicus
The Appendix

• Mesoappendix
• Adipose tissue + appendiceal vessels
and
• occasionally small lymph nodes
• Anchors the appendix
The Appendix
• Positions:
• Intraperitoneal and retrocecal
• Pelvic or descending (30%)
• Retroperitoneal (7%)
• Subcecal
• Pre-ileal/Post-ileal
The Appendix
The three taeniae coli on the ascending
colon and caecum converge on the base
of the appendix, and merge into its
longitudinal muscle.
Arterial Supply of the Appendix ABDOMINAL
AORTA

SUPERIOR
MESENTERIC
ARTERY

ILEOCOLIC ARTERY

INFERIOR BRANCH
OF ILEOCOLIC
ARTERY

APPENDICULAR
ARTERY
Venous Drainage of the Appendix
Porta Vein

Superior
Mesenteric Vein

Ileocolic Vein

Inferior
Tributaries

Appendicular
Artery
Lymphatic Drainage of the Appendix

• Drain into one or two nodes lying in

the mesoappendix and then into the
superior mesenteric nodes
Nerve Supply of the Appendix
• Superior Mesenteric Plexus (T10 – L1)
• Parasympathetic and Sympathetic
(Vagus) nerves
 Histology of the Appendix

● 3 layers:
○ Outer serosa: extension of peritoneum
○ Muscularis layer: not well defined, may be
absent in some locations
○ Submucosa and mucosa: contains lymphoid tissue
● Arrangement in its wall is similar to that of the
large intestine
● Muscularis externa forms a continuous layer
● Goblet cells produce mucus
Acute Appendicitis
One of the most common surgical emergencies

• Epidemiology
• Male (8.6%) > Female (6.7%)
• 2nd to 3rd decade of life
• Lifetime risk: ∼ 8%
• Yearly incidence rate: 100/100,000
ACUTE APPENDICITIS
Etiology
• Most common causes in
• Children and young adults: Lymphoid tissue hyperplasia (60% of cases)
• Adult: Fecalith and fecal stasis (35%)

• Neoplasm (uncommon): > 50 years of age

• Appendiceal tumors
• Parasitic infestation (uncommon)
• Enterobius vermicularis, Ascaris lumbricoides, and species of the Taenia and Schistosoma
genera
 Pathophysiology
Closed-loop Vascular thrombosis &
obstruction
ischemic necrosis
↑ continuing normal
secretion of appendiceal
mucosa Leak goes to omentum
and surrounding tissues
Distention Visceral nerve pain Vague, dull, diffuse pain in the
fibers periumbilical region
abscess
Bacterial multiplication

Lymphatics, venules, May develop infective suppurative

capillaries occluded thrombosis of the portal vein

Vascular engorgement & Reflex nausea and

congestion vomiting Intrahepatic abscess

Inflammation of the serosa (+) somatic nerve RLQ pain

Absorption of necrotic Fever,

tissue & bacterial toxins
inflammation Leukocytosis
Stages
Catarrhal Characterized by distension of the appendix and vascular congestion

Appendiceal edema and vascular congestion become pronounced with the

formation of multiple abscesses in the wall and purulent fluid on the serosal
Phlegmonous surface

Suppurative if w/o wall abscess

Local circulatory dysfunction → infarction opposite the junction between the

Gangrenous mesoappendix and appendix, where the blood supply is inadequate.
Appendix becomes congested dark red with black necrotic areas

Perforated When perforation of the necrotic wall occurs → perforative peritonitis.

Stages
Catarrhal
• Superficial lesions; slightly
thickened walls
• Hyperemic serous
• Small amount of serous
Phlegmonous
exudate in the abdominal
cavity

Gangrenous

Perforated
Stages
Catarrhal
• Spread to all layers
• Purulent exudate,
Phlegmonous empyema, cloudy
• Peritoneum of right iliac
fossa is cloudy and turbid

Gangrenous

Perforated
Stages
Catarrhal

Phlegmonous

• Necrosis in some areas or

entire whole
Gangrenous • Layered structure lost
• (d/t) thrombosis of
appendiceal mesentery
Perforated vessels
Stages
Catarrhal

Phlegmonous
• Rupture of the appendix
• Early presentation:
• localized/generalized peritonitis and decreased bowel sounds
• Generalized peritonitis indicates a free rupture of the appendix into the
Gangrenous peritoneal cavity.
• Localized peritonitis suggests a concealed perforation
• Delayed presentation:
Perforated • appendiceal mass or appendiceal abscess
Clinical Manifestations
Symptoms
• Nonspecific complaint occur first
• Change in bowel habits
• Malaise
• Vague, intermittent crampy abdominal pain in the epigastric and
periumbilical region
• Pain migrates to the RLQ
• Sharper
• Localilized
Others: nausea, vomiting, fever, weakness, anorexia
Clinical Manifestations
Signs
• Typically appear ill
• Frequently lie still
• Fever
• Abdomen:
• Tenderness with a maximum at or near McBurney’s point
• Aaron sign if early, Kocher sign when migrating
• Muscular guarding in the right iliac fossa
• Bloomberg Sign: Rebound tenderness
• Rovsing Sign: Indirect tenderness
• Hyperesthesia w/in Sherren Triangle
• Lanz point tenderness
• Pain in Pouch of Douglas
Clinical Manifestations
Retrocecal Appendix
• Abdominal findings are less striking, and tenderness may be most marked in the flank
• Psoas sign: RLQ pain on flexion of the right hip against resistance
• RLQ pain may be elicited on passive extension
of the right hip
• d/t iliopsoas irritation s/t retrocecal appendicitis
• Dunphy's sign: Pain w/ coughing
• Baldwin sign: pain in the flank when flexing the right hip
Clinical Manifestations
Pelvic Appendix
• Abdominal findings may be entirely absent, and the diagnosis may be missed
• Obturator sign:
• RLQ pain on passive internal rotation of the
right hip with the hip and knee flexed
Laboratory Findings
Mild Leukocytosis
3 3
10,000cells/mm ; rarely >18,000cells/mm 3
CBC Higher w/ gangrenous and perforated appendicitis (~17,000cells/mm )

Normal WBC does not R/O Appendicitis

CRP ↑ (>10-20 mg/L)
Creatinine ↑; also important for contrast imaging
Electrolytes Abnormalities may be present in patients with severe vomiting and diarrhea
Typically normal in appendicitis;

Mild pyuria and/or hematuria

d/t the inflamed appendix lies in close proximity to the right ureter → ureteric irritation and/or
U/A
inflammation

Urinalysis is also useful for ruling out renal colic and UTI, which may manifest similarly to
appendicitis.
Scoring System
Acute Appendicitis: Imaging
Sensitivity Specificity Features that suggest appendicitis
Enlarged lumen
Double wall thickness >6mm
Wall thickening >2mm
Contrast CT 96% 96% (+) Periappendiceal fat stranding
(+) Appendiceal wall thickening
(+) Appendicolith
Diameter >6mm
Pain w/ compression
- extremely painful for those w/ peritonitis
UTZ 85% 90% (+) Appendicolith
↑ Echogenicity of the fat
(+) Periappendicial fluid

Recommended for whom risk of ionizing radiation outweighs ease

MRI 95% 92% in CT
Acute Appendicitis: Management
Operative vs. Nonoperative Management of Uncomplicated Appendicitis
Antibiotics alone can be effective, but has:
• 9% short-term (<30d) failure rate
• 13% recurrence
• 18% development of complicated appendicitis

Operative management of presumed uncomplicated appendicitis remains to be the standard

Reserve nonoperative therapy for acute uncomplicated appendicitis for those in whom operative risk
is prohibitive
Acute Appendicitis: Management
• Preoperative Management
• Majority of Px can be taken to the OR w/in a short interval
• If dehydrated, resuscitate first
• IV 4cc/kg NS bolus then D5 0.5 NS +20mEq/L KCL
• Place px on NPO
• Preoperative antibiotics 30-60mins prior to skin incision (continued for 24h)

Uncomplicated Appendicitis Px w/ β-lactam allergies Perforated Appendicitis

Cefoxitin Gentamicin 80-120mg IV Piperacillin/Tazobactam
2g IV single dose + Clindamycin 600mg IV Ceftriaxone + Metronidazole
40mg/kg IV single dose (children) single dose 2000mg IV q24h + 1500mg IV q24h
Ampicillin/Sulbactam
Cefazoline + Metronidazole
Acute Appendicitis: Management
• Operative Management
1. Px on Trendelenburg's position w/ left side down
Open - For early nonperforated appendicitis 2. Incision at McBurney's point via
Appendectomy • McBurney's Incision - oblique
• Rocky-Davis Incision - Transverse
- Advantage of 1. Px supine w/ left arm tucked for better access
• Fewer surgical site infections 2. Trendelenburg position, left side down
Laparoscopic • Less pain 3. Peritoneal access via
• Shorter hospital stay • Hasson technique (periumbilical)
Appendectomy - ↑risk of intraabdominal abscess • Verees (optical trochar in LUQ 3cm below
- Beneficial in obese patients costal margin in MCL)
Acute Appendicitis: Management
• Operative Management
Post-operative Care
● Uncomplicated appendectomy:
○ Complication rates are low
○ Can quickly be started on diet
○ Discharged the same day or the following day
● Complicated appendectomy:
○ Increased rate of complications compared to uncomplicated
○ Broad spectrum antibiotics should be continued for 4-7 days
○ Look out for any signs of postoperative ileus before starting diet
○ Increased risk for surgical site infection
○ Look for development of:
■ Fever, leukocytosis, pain, and delayed return of bowel function: postoperative
abscess
Post-operative Complications
● Surgical Site infections
○ Obtain culture: typically bowel flora
○ Cellulitis: antibiotics
● Postoperative intra-abdominal abscess
○ Fever, leukocytosis, abdominal pain,
○ Small abscess: antibiotics
○ Larger abscess: percutaneous drainage with CT or US guidance
■ If not amenable: laparoscopic abscess drainage
● Stump Appendicitis
○ Failure of removing the entire appendix on initial procedure
○ Recurrent symptoms
■ Remaining stump should be <0.5cm
Prognosis
• Mortality 0.2 per 100,000
• Death – uncontrolled sepsis – peritonitis, intraabdominal abscess, gram negative septicemia,
pulmonary embolism
Reference
• Schwartz’ Principles of Surgery 11th edition
• Sabiston Textbook of Surgery 21st edition
• Sleisenger and Fordtran's Gastrointestinal and Liver Disease 11th edition
• Snell’s Clinical Anatomy 9th ed
• Bate’s Guide to Physical Examination and History Taking 12th edition
• Amoli HA, Golozar A, Keshavarzi S, Tavakoli, H, Yaghoobi A. Morphine
analgesia in patients with acute appendicitis: a randomised double-blind
clinical trial. Emerg Med J. 2008;25:586-589
• Vaos G, Dimopoulou A, Gkioka E, Zavras N. Immediate surgery or
conservative treatment for complicated acute appendicitis in children? A
meta-analysis. J Pediatr Surg. 2019 Jul;54(7):1365-1371