ACUTE APPENDICITIS

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Slide 1 :

ACUTE APPENDICITIS Roy Phitayakorn, M.D. Christopher Brandt, M.D. Case Western Reserve University School of Medicine

Slide 2 :

Ms. Z. Cope You are called to see a patient in the Emergency Department, who is a 25 year-old female with a 1 day history of right-lower quadrant abdominal pain.

Slide 3 :

History What other points of the history do you want to know?

Slide 4 :

History, Ms. Cope Characterization of symptoms Temporal sequence Alleviating / Exacerbating factors: Pertinent PMH, ROS, MEDS. Relevant family hx. Associated signs and symptoms Consider the Following

Slide 5 :

History, Patient ZC Pain started in the middle of the night and woke the patient from sleep. Felt nauseated and vomited after pain No significant MED.HX. or SURG HX. Negative Family HX Noted some indigestion yesterday Feels urge to have bowel movement, but has been constipated

Slide 6 :

What is your Differential Diagnosis?

Slide 7 :

Differential DiagnosisBased on History and Presentation Systemic or infectious conditions Influenza Gastroenteritis Hepatitis Diaphragmatic pleurisy Spinal disease Typhoid Tuberculosis Acute porphyria Diabetic ketoacidosis

Slide 8 :

Differential Diagnosis(cont.) Intra-abdominal conditions Acute Appendicitis Acute Cholecystitis Diverticulitis (Meckel’s) Inflammatory Bowel Disease (Crohn’s) Duodenal Ulcer Intestinal Obstruction Carcinoma of the Cecum Nonspecific adenitis – Possible Yersinia infection

Slide 9 :

Differential Diagnosis(cont.) Intra-pelvic conditions Salpingitis Pelvic Inflammatory Disease Ectopic Pregnancy Ruptured Corpus Luteum Cyst Ruptured Follicular Cyst (Mittelschmerz) Ruptured Ovarian Cyst Ovarian Torsion Pyelonephritis Ureteral/Renal stone

Slide 10 :

Physical Examination What would you look for?

Slide 11 :

Physical Examination, Patient ZC Vital Signs: 39o C, HR=75, RR=15, BP=125/75 Appearance: Patient is lying quietly on bed in fetal position

Slide 12 :

Would you like to revise your Differential Diagnosis?

Slide 13 :

Would you like to revise your Differential Diagnosis? Acute appendicits Diverticulitis (Meckel’s) Inflammatory Bowel Disease (Crohn’s) Ovarian pathology Acute cholecystitis Intestinal obstruction Nonspecific adenitis – Possible Yersinia infection

Slide 14 :

Laboratory What would you obtain?

Slide 15 :

Labs ordered

Slide 16 :

Lab Results, Ms. Cope CBC: 14,500 LFTs : WNL HCG : WNL Electrolytes : WNL Amylase : WNL U/A: WNL

Slide 17 :

Interventions at this point?

Slide 18 :

Interventions at this point?Consider the following Start IV with Ringers Lactate or similar isotonic crystalloid solution Administer antibiotics Admit to the hospital Go Directly to the OR? Other?

Slide 19 :

Studies What further studies would you want at this time?

Slide 20 :

Radiologic Studies to Consider Flat/Upright Abdomen CT Scan: Abd/Pelvis CT Scan: Other ? US Abdomen/Pelvis

Slide 21 :

Considering your Differential Diagnosis What would you expect to see on a flat/upright abdominal series? What specific abnormalities do you look for on US? What population? Are there specific CT findings in any of your top 3 diagnoses?

Slide 22 :

Abdominal Film

Slide 23 :

Abdominal X-ray Findings Non-specific gas pattern No fecalith No free air

Slide 24 :

CT Scan Abdomen & Pelvis

Slide 25 :

CT Scan – Results Acute Appendicitis Thickened dilated appendix Peri-appendiceal fat stranding Scant free fluid Incidental small left ovarian cyst What is the differential diagnosis at this point?

Slide 26 :

Revised Differential Diagnosis

Slide 27 :

What next? Additional Imaging? Observation? OR? Other?

Slide 28 :

What next? Discussion of suggested interventions

Slide 29 :

Management Surgical Options Pre-operative preparation

Slide 30 :

Laparoscopic Acute Appendicitis

Slide 31 :

Discussion Pathophysiology of the disease process, visceral vs. parietal abdominal pain, laparoscopy vs. open, antibiotic management, appropriate utilization of resources, etc.

Slide 32 :

Discussion Additional teaching points

Slide 33 :

QUESTIONS ??????

Slide 34 :

Summary

Slide 35 :

Alternative scenarios Acute Appendicitis with perforation/ Abscess or tumor IBD Acute Diverticulitis Ovarian Cyst / Torsion/ Perforated Right colon tumor

Slide 36 :

CT Cecal Tumor

Slide 37 :

CT Sigmoid Diverticulitis

Slide 38 :

CT Ovarian Cystic Mass

Slide 39 :

CT Terminal Ileal Crohn’s

Slide 40 :

CT Acute Appendicitis

Slide 41 :

Acknowledgment The preceding educational materials were made available through theASSOCIATION FOR SURGICAL EDUCATION In order to improve our educational materials wewelcome your comments/ suggestions at: feedbackPPTM@surgicaleducation.com

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Acute Appendicitis; Acute Cholecystitis; Diverticulitis (Meckel’s); Inflammatory Bowel Disease (Cro more Acute Appendicitis; Acute Cholecystitis; Diverticulitis (Meckel’s); Inflammatory Bowel Disease (Crohn’s); Duodenal Ulcer; Intestinal Obstruction ... less
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