Acute
Appendicitis
Clinical Case
Opening Prayer
01
PATIENT’S CASE
PATIENT PROFILE
Patient J.Y.
25/M
CC: abdominal pain
HISTORY OF PRESENT ILLNESS
1 day prior to admission, patient experienced generalized abdominal pain,
non radiating, with a pain scale of 8/10, associated with bloatedness, nausea
and constant feeling to defecate. No associated urinary symptoms. Patient
was given Omeprazole and Dulcolax, which provided slight relief.
7 hours prior to admission, patient experienced right lower quadrant
abdominal pain, described as sharp, contracting pain with a pain scale of
10/10. Associated with fever with a Tmax of 38.1. Patient was given
Paracetamol 500mg 1 tab which afforded lysis of fever.
HISTORY OF PRESENT ILLNESS
3 hours prior to admission, still with the right lower quadrant abdominal pain.
Patient was given HNBB which did not afford relief. Due to persistence of
symptoms, patient sought ER consult.
Last meal: 1 day PTC
Last intake: Water and HNBB at 3 hours prior to consult
PAST MEDICAL HISTORY
● No known comorbidities
● No previous hospitalizations
● No known allergies to food and medications
● No previous COVID-19 infection
● COVID 19 vaccine: Sinovac x2 primary series, no booster
FAMILY HISTORY AND PERSONAL-
SOCIAL HISTORY
● Bronchial asthma
● Non smoker
● Non alcoholic beverage drinker
PHYSICAL EXAMINATION
GENERAL Awake, conversant, in distress
VITAL SIGNS BP: 120/70 mmHg, HR 91 bpm, RR
20 cpm, Temp 37.5C O2sat 98%RA
SKIN No jaundice, no pallor, no
dermatoses, good skin turgor
HEENT Pink palpebral conjunctivae,
anicteric sclerae, septum at midline,
no cervical lymphadenopathy
CHEST/LUNGS Clear breath sounds
PHYSICAL EXAMINATION
HEART Normal rate, regular rhythm
ABDOMEN No evidence of lesions or
hematoma, normoactive, soft,
tender, distended, with direct
tenderness pain on RLQ, (+)
rebound tenderness, (+) Rovsing’s
sign, (+) Dunphy’s sign, (+)
Obturator sign, (+) Psoas sign,
GUT No CVA tenderness
EXTREMITIES Full equal pulses, no edema
02
DIFFERENTIAL
DIAGNOSIS
DIFFERENTIAL DIAGNOSES
Patient’s Profile Acute Appendicitis Acid-Related Disease Nephrolithiasis
25/M Migratory pain Abdominal pain Abdominal pain
Periumbilical abdominal pain Anorexia Nausea Hematuria
described as sharp and crampy, Nausea Bloatedness Dysuria
migrated to the RLQ graded 10/10 Tenderness in the RLQ Dyspepsia Nausea
(-) anorexia Rebound pain Vomiting
(+) bloatedness Elevated temperature Heartburn (-) CVA tenderness
(+) nausea Leukocytosis (pending)
(+) fever Shift of WBC to the left Diffuse abdominal
(-) vomiting (pending) tenderness
(-) urinary symptoms Alvarado: 6
BP: 110/80, HR 70, RR 18, T37.8, (+) Rovsing’s sign
O2sat 98%@RA (+) Dunphy’s sign
(+) tenderness RLQ (+) Obturator sign
(+) rebound tenderness (+) Iliopsoas sign
(+) Rovsing’s sign
(+) Dunphy’s sign
(+) Obturator sign
(+) Iliopsoas sign
Laboratory Results at the ER
CBC PT 11.7
Hgb 15.7 Activity 91.7
Hct 46 INR 1.02
WBC 18.48
Seg 89 Na 138
Lym 4 K 3.70
Plt 221 BUN 3.80
Crea 69.10
PRIMARY IMPRESSION: ACUTE
APPENDICITIS
ALVARADO SCORE
Migratory pain 1
Anorexia 0
Nausea 1
Tenderness in the RLQ 2
Rebound pain 1
Elevated temperature 1
Leukocytosis 2
Shift of WBC to the left 1
TOTAL = 9 PTS
S/P LAPAROSCOPIC APPENDECTOMY
SUPPURATIVE
Schwartz Club Appendicitis
01
ANATOMY
AND
PATHOPHYSIOLOGY
ETIOLOGY
ANATOMY OF THE APPENDIX
● Blind intestinal TRUE diverticulum
(6–10 cm in length)
● Arises from the posteromedial
aspect of the cecum
● Usually intraperitoneal and
retrocecal in location
● Develops from the midgut and
appears at 8 weeks gestations
Reference: Schwartz’s Principles of Surgery, 11th Ed.
ANATOMY OF THE APPENDIX
● Various positions of the appendix
○ Intraperitoneal and retrocecal (65%)
○ Pelvic (30%)
○ Retroperitoneal (7%)
● Blood supply and drainage:
○ Appendicular branch of the ileocolic branch of the
superior mesenteric artery
○ Drained by appendicular vein → ileocolic vein
● Nerve supply:
○ Autonomic parasympathetic and sympathetic fibers
from superior mesenteric plexus T10-L1 of the spinal
cord
Reference: Schwartz’s Principles of Surgery, 11th Ed.
ETIOLOGY
Acute Appendicitis
● Pediatric: lymphoid hyperplasia
● Adults: fecaliths, fibrosis, foreign bodies (food, parasites, calculi), or
neoplasia.
Reference: Schwartz’s Principles of Surgery, 11th Ed.
PATHOPHYSIOLOGY
Acute Appendicitis
(1) Obstruction
(2) Increased intraluminal pressure
(3) Decreased blood flow
(venous>arterial)
(4) Congestion of appendix
(5) Ischemia and bacterial translocation
(6) Irritation of the parietal peritoneum
(suppuration)
(7) Prolonged ischemia and inflammation
(8) Gangrene and perforation
(9) Rupture
02
DIAGNOSIS
HISTORY
● Migratory pain
○ Classic sign of appendicitis
● Anorexia, nausea, vomiting, fever
○ Inflammatory signs
● Regional inflammation
○ Ileus, diarrhea, small bowel obstruction, hematuria
● Obtain pertinent negatives
Reference: Schwartz’s Principles of Surgery, 11th Ed.
PHYSICAL EXAMINATION
● Low-grade fever (38.0)
● Focal tenderness with guarding
● McBurney’s point
○ Point of maximal tenderness (anatomically normal
appendix)
○ ⅓ of the distance between ASIS and umbilicus
● Signs and eponyms
○ Obturator sign = pelvic appendix location
○ Iliopsoas sign = retrocecal appendix location
○ Rovsing sign = normal position appendix
○ Dunphy's = retrocecal
Reference: Schwartz’s Principles of Surgery, 11th Ed.
LABORATORY FINDINGS
● Leukocytosis
○ 10,000 cells/mm3
○ Higher value = gangrenous and perforated appendicitis (~17,000)
● C-reactive protein, Bilirubin, IL-6, Procalcitonin
○ Predictive of perforated appendicitis
● Urinalysis
○ Rule out nephrolithiasis or pyelonephritis
Reference: Schwartz’s Principles of Surgery, 11th Ed.
ALVARADO SCORING
Reference: Feldman, M., Friedman, L. S., & Brandt, L. J. (2015). Sleisenger and Fordtran’s Gastrointestinal and Liver Disease E-
Book: Pathophysiology, Diagnosis, Management. Elsevier Health Sciences..
IMAGING
● Ultrasound of the abdomen
○ High sensitivity and specificity
○ Easily compressible appendix <5mm = r/o appendicitis
○ Features
■ >6mm diameter
■ (+) pain with compression
■ Presence of appendicolith
■ Increased echogenicity of fat
■ Periappendiceal fluid
○ Cheaper and readily available
○ Limited use in obese patients
Reference: Schwartz’s Principles of Surgery, 11th Ed.
IMAGING
● CT scan of the abdomen with contrast
○ High sensitivity and specificity > Ultrasound
○ Features
■ Enlarged lumen and double wall thickness
>6mm
■ Wall thickening >2mm
■ Periappendiceal fat stranding
■ Visualization of an appendicolith
● MRI of the abdomen
○ High sensitivity and specificity
■ Higher than ultrasound but lesser than CT
scan
○ Expensive
○ Not readily available
○ Recommended for special patients (pregnant,
pediatric)
Reference: Schwartz’s Principles of Surgery, 11th Ed.
03
MANAGEMENT
UNCOMPLICATED APPENDICITIS
● Non-perforated
○ No clinical or radiographic signs of perforation
○ 80% of appendicitis are not perforated at presentation
● Can be managed medically
○ Patient to be admitted for at least 1-3 days in the hospital then discharged
with oral antibiotics
● If with identified appendicolith:
○ Medical management almost
always fail to resolve symptoms
○ Requires appendectomy instead
● Sample medical regimen
Reference: Schwartz’s Principles of Surgery, 11th Ed.
COMPLICATED APPENDICITIS
● Perforated and gangrenous appendicitis with abscess or phlegmon
● Usually presents after 24 hours of onset
○ Acutely ill, dehydrated, requires resuscitation
● Can be managed operatively or non-operatively
○ Check stability of the patient → septic → immediate appendectomy
○ If stable → IV antibiotics, resuscitation with or without percutaneous
image-guided drainage
■ Interval appendectomy (6-8 weeks after non-operative
management)
● 8% appendicitis recurrence rate
Reference: Schwartz’s Principles of Surgery, 11th Ed.
OPEN APPENDECTOMY
Typically performed under GA
- Uncomplicated appendicitis
- Right lower quadrant incision at McBurney
(oblique) or Rocky Davis (transverse)
- Complicated appendicitis
- Lower midline laparotomy can be considered
Slight trendelenburg position with bed rotation to
patient’s left
Reference: Schwartz’s Principles of Surgery, 11th Ed.
LAPAROSCOPIC APPENDECTOMY
Performed under general anesthesia
Standard laparoscopic appendectomy uses 3 ports
- 10- or 12-mm port is placed at the umbilicus
- Two 5-mm ports placed at the supra pubic and left
lower quadrant
Trendelenburg position and to the left
Appendix should be grasped, secured and elevated to
the 10 o’clock position.
Appendiceal critical view should be appreciated
Taenia liberia at 3 o’clock position
Terminal ileum 6 o’clock
Retracted appendix 10 o’clock position
Reference: Schwartz’s Principles of Surgery, 11th Ed.
OPEN VS LAPAROSCOPIC
APPENDECTOMY
OPEN APPENDECTOMY LAPAROSCOPIC APPENDECTOMY
- Decreased operative duration - Fewer surgical site complications
- Lesser cost - Increased risk of intra-abdominal
- Longer hospital stay abscess
- Effective in ruptured appendix and - Shorter hospital stay
severe inflammation - Faster recovery
THANK
YOU!
