Acute appendicitis

PATIENT’S PROFILE

Patient name: Nguyen. Huu. A PID: 814023394

DOB: 1955 Age: 70 years old
Sex: Male
Admission day:

Chief complaint: Right lower quadrant abdominal pain

WHAT ADDITIONAL INFORMATION WOULD YOU LIKE
TO KNOW ABOUT?
HISTORY OF PRESENTING ILLNESS

•A 70-year-old male patient presented to the hospital due to abdominal pain localized at
right lower quadrant at 7th hour of disease. The pain was characterized as dull, constant and
has been progressively increasing in severity since onset of symptom with no radiation. The
patient rated the pain severity at 5 out of 10, which was not exacerbated upon changes in
position or alleviated by any specific factor. This was the first time he experienced this type of
symptom.

•Associated symptoms include anorexia. Besides, he denied other GI symptoms

(hematemesis, vomiting), constitutional symptoms (fever, weight loss, night sweats), or any
changes of bowel habit (diarrhea, constipation, hematochezia, melena) and urination (urinary
urgency). The patient did not receive any treatment before admission.
PAST MEDICAL HISTORY/ SURGICAL

Past Medical History: Medications:

 Well-controlled diabetes type II, diagnosed 20  Metformin for diabetes, good compliance
years ago. to treatment.
 No history of other chronic GI and other  Multivitamin.
diseases
 No other significant medical history.

Allergies:
Past Surgical History:  Seafood allergy. No history of allergies to
 No known surgical history. drugs, or other allergens.
FAMILY/ SOCIAL HISTORY

Family History:
 No family history of dyslipidemia, diabetes, hypertension, cancer, or coagulopathy diseases.
 No family history of GI related conditions
 No other significant family history.

Social History:
 The patient previously worked as a security guard, but he has retired.
 Regular meal with high-fat diet (prefer fat meat and fried food).
 No regular exercise due to patient’s old age.
 The patient denies using illicit drugs or smoke.
 He used to drink beer 5 times a week with average 1 liter of beer for 10 years, but now he has stopped.

Epidemiological history:
• Patient had not travelled outside of living area 1 month around the day of onset
• There is no family members have similar symptoms or GI conditions
WHAT WILL YOU LOOK FOR ON PHYSICAL
EXAMINATION?
PHYSICAL EXAMINATION

Vital signs:
o Pulse: 71 bpm
o Respiratory rate: 18
o Blood pressure: 150/80 mmHg
o Temperature: 36.8oC
o SpO2: 99% RA
o BMI:
General: Conscious and alert but currently in mild-moderate abdominal pain. No signs of
respiratory distress. There are no signs of respiratory distress, cyanosis, jaundice, or rash. No
dizziness or diaphoresis. No signs of dehydration.
Head-Eyes-Ear-Nose-Throat: No abnormality finding
Neck: No jugular vein distension. No thyroid enlargement. No peripheral lymphadenopathy.
PHYSICAL EXAMINATION
PulmonaryClear to auscultation bilaterally, normal work of breathing without wheezing or stridor.
Cardiovascular: Regular rate and rhythm. Peripheral pulses are equal and symmetrical. PMI in
the left 5th intercostal space at the mid-clavicular line. S1, S2 are heard. No S3/ S4. No murmurs,
rubs, or gallops.
Abdominal:
o No previous surgery scars, vascular changes, fistula or protrusions. No distention.
o Bowel sound is symmetrical bilaterally, neither increasing nor decreasing.
o No hyperresonance or dullness in percussion.
o McBurney’s sign positive (+), guarding (+), rebound tenderness (-), Rovsing sign (-).
Blumberg sign (-). Psoas sign (-), Obturator sign (-). Left iliac fossa is non-tender. No signs of
palpable mass. No detected hepatosplenomegaly.
Genitourinary: Ballot kidney (-). No bladder distention. No CVA tenderness. No ureteral
tenderness.
Musculoskeletal: No clubbing or cyanosis of digits. No edema.
Neurology:
o Cranial nerves are intact. Focal deficits (-).
o Meningism symptoms (-).
Psych: Appropriate memory, judgment, and insight.
WHAT LAB TESTS WILL YOU ORDER?
LABS
IMAGING – ABDOMINAL US

Can you point out some of main finding features of this patient?
ABDOMINAL US - RESULT
Appendiceal Diameter: measurement of Wall Thickening: The wall of the
0.81cm (8.1 mm). What is the upper limit appendix appears thickened (2,2mm) the
of normal diameter in adults? (hoi ntru) hypoechoic ring surrounding the central,
 the diameter in this case is significantly more echogenic lumen appears wider
dilated and appendix appears to be than what we would typically see in a
concentrically layered and blind ending normal appendix, supporting a presence
in appearance, indicating inflammation or of an inflammatory process. (blue arrow)
obstruction.
IMAGING
• Loss of Compressibility: a loss of • Surrounding Tissue: there is slight hyperechoic and
compressibility of the appendix with heterogenous appearance surrounding the appendix,
gentle pressure from the ultrasound which possibly indicates periappendiceal fat
probe is a key feature of acute inflammation.(Orange arrow)
appendicitis. Loss of compressibility
was recorded positive in the • Other organs:
ultrasound result. • Liver cyst/fatty liver grade I. Other structures are
normal including biliary structures, pancreas,
• Internal Echogenicity: The lumen spleen, urinary system (kidney, ureters, bladder),
appears slightly echogenic. This prostate gland.
could indicate the presence of fluid,
pus, which are signs of an inflamed or
obstructed appendix. In this case,
appendicolith was not seen due to
absence of hyperechoic area inside the
lumen or clear posterior acoustic
shadowing. (Green arrrow)
OTHER IMAGINGS?
SUMMARY

A 70-year-old male patient with well-controlled type II diabetes presented to the hospital due to progressive
right lower quadrant abdominal pain at 7th hour of disease, which is dull, constant. Associated symptoms
include anorexia. Through history taking, examination, other findings:

• Inflammatory syndrome (+): elevated WBC (12.91), NEUT 80.4%,

• Anemia syndrome (-): pink and moist conjunctiva, RBC 5.17, Hgb 149

• Accute appendicitis: McBurney sign (+), guarding, Ultrasound shows image of concentrically layered and
non-compressible appendix, dilated (8.1mm) with wall-thickening(2.2mm), and periappendiceal fat
inflammation.
ACUTE APPENDICITIS

• Acute inflammation of the vermiform appendix

• Uncomplicated appendicitis: appendicitis with no evidence of an appendiceal fecalith, an
appendiceal tumor, or complications, such as perforation, gangrene, abscess, or mass.
• Complicated appendicitis: appendicitis associated with perforation, gangrene, abscess, an
inflammatory mass, an appendiceal fecalith, or an appendiceal tumor.
• Clinical features:
• Migrating abdominal pain (most common): constant and rapidly worsens, within 48 hours onset
• Initial diffuse periumbilical pain  Localizes to the RLQ within ∼ 12–24 hours
• Association: Anorexia (80%), Nausea, Low-grade fever,
• McBurney point tenderness (RLQ tenderness), guarding and/or rigidity, Rovsing sign

Salminen P, Paajanen H, Rautio T, et al. Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial.. JAMA. 2015; 313(23): p.2340-8. doi:
10.1001/jama.2015.6154
 ULTRASOUND IN ACUTE APPENDICITIS

• Distended appendix (diameter > 6 mm)

• Noncompressible, aperistaltic, distended
appendix
• Target sign: concentric rings of hypo-
and hyperechogenicity in the
axial/transverse section of the appendix.
Alternating layers of hyper- and
hypoechogenicity of the appendiceal wall
• Possible appendiceal fecalith: focal
hyperechogenicity with posterior acoustic
shadowing

Di Saverio S, Podda M, De Simone B, et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World Journal of Emergency Surgery. 2020; 15(1). doi: 10.1186/s13017-
020-00306-3

American College of Radiology ACR Appropriateness Criteria® Right Lower Quadrant Pain-Suspected Appendicitis. https://acsearch.acr.org/docs/69357/Narrative/
PROBLEM LIST

What are your differential diagnoses?

DIFFERENTIAL DIAGNOSIS

1. Diverticulitis
- Risk factors: old age
- Pain in lower quadrant abdomen associated with tenderness and local pain upon palpation
can also explained by inflammation of cecal diverticulum
- Ultrasound should show diverticula with surrounding inflammation (hyperechoic), fluid
accumulation and bowel wall thickening. However, US is no sensitivity in diverculitis.
2. Ileocolitis
- Abdominal pain at right iliac fossa region and anorexia. However, more commonly presents
with changes in bowel habits
3. Colon cancer
- Constitutional symptoms
4. Nephrolithiasis
- Pain and tenderness in lower quadrant region. Labs might be similar.
- Commonly presents as colicky flank pain or sharp and intense pain with urinary symptoms
(hematuria, dysuria, frequency, and urgency)
PLAN AND MANAGEMENT
• Supportive care as needed.
• Bowel rest by NPO
• Pain management.
• IV fluids
• Empiric antibiotic therapy (Administer as prophylaxis against surgical site infection, should cover gram-
negative and anaerobic organisms): Third-generation cephalosporin (e.g., ceftriaxone, cefdinir) + metronidazole.
• Laparoscopic appendectomy:
• This patient has early detected uncomplicated appendicitis with negative imaging-identified
appendicolith, which supposedly makes him a candidate for nonoperative treatment (antibiotics only with
the aim of avoiding surgery). However, the choice of nonoperative treatment also depends on patient’
preference, and appendectomy is still the cornerstone for definitive treatment and prophylaxis of
perforation. Therefore, appendectomy is the most appropriate treatment in this case.
• For acute nonperforated appendicitis in a stable patient, appendectomy should be performed within 24
hours of presentation to reduce surgical site infections and other complications.
• Monitor incision, vital signs, blood pressure for delayed complications (e.g., surgical site infection)
TAKE HOME MESSAGES

• Approach to a patient with acute appendicitis suspected

• Findings of US in patients with Acute appendicitis
REFERENCES

• American College of Radiology ACR Appropriateness Criteria® Right Lower Quadrant Pain-
Suspected Appendicitis. https://acsearch.acr.org/docs/69357/Narrative/
• Di Saverio S, Podda M, De Simone B, et al. Diagnosis and treatment of acute appendicitis: 2020
update of the WSES Jerusalem guidelines. World Journal of Emergency Surgery. 2020; 15(1).
doi: 10.1186/s13017-020-00306-3
• Salminen P, Paajanen H, Rautio T, et al. Antibiotic Therapy vs Appendectomy for Treatment of
Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial.. JAMA. 2015;
313(23): p.2340-8. doi: 10.1001/jama.2015.6154
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