APPENDICITIS


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1 : CASE DISCUSSION Appendicitis Nirajan Subedi Ananya Adhikari
2 : Patient Particulars: Age/Sex: 29/M Date of admission: 2068/06/27 Chief Complaints: Pain in the lower abdomen X 2 days Vomiting X 2 days Fever X 2 days
3 : History of Presenting Illness: He was apparently well 2 days back when he suddenly developed pain in the abdomen (umbilical region). Acute in onset, severe, continuous type & colicky in nature. The pain was relieved on medication. No aggravating factors known. Pain was associated with vomiting, 2 episodes, non-projectile, watery, non-bilious, contained food particles.
4 : The patient also developed fever associated with chills and rigors. The temperature was not recorded. The patient also developed fever associated with chills and rigors. The temperature was not recorded. The patient had no complaints of loss of appetite or disturbance of sleep. There was no h/o burning micturition.
5 : Past History: No h/o surgery in the past. No h/o PTB, HTN, DM. Personal History: Non-vegetarian by diet. Smoker X 10 sticks/day X 3 years. Consumes alcohol occasionaly. Family History: Patient’s mother has PTB at present & is under medications for the past 3 months as per DOTS regimen. No h/o HTN, DM in the family. Drug & Allergy History: NKTD.
6 : On Examination : General Condition : Fair. Pallor, Icterus, Lymphadenopathy, Cyanosis,Oedema, Clubbing, Oedema : Absent. Respiratory Examination: B/L Vesicular Breath Sounds – (+), No added sounds. Cardiovasular Examination: S1, S2, M0. Vitals: BP-120/80 mm Hg, Pulse – 80/min, Temperature- 98.6 F, RR – 22/min.
7 : Per Abdomen: Tenderness (+) at Right Iliac fossa region. Rovsing’s Sign (+) Rigidity (-) Bowel Sounds (+) No organomegaly.
8 : Treatment given in the ER: Inj. Diclofenac x 1 amp X IM X STAT Inj. NS 1 pint X IV X STAT Inj. Ranitidine X 1 amp X IV X STAT Inj. Buscopan X 1 amp X IV X STAT Inj. Metoclopramide X 1 amp X IV X STAT Inj. Metronidazole X 1 amp X IV X STAT
9 : Provisional Diagnosis: Acute Appendicitis Differential Diagnosis: Meckel’s Diverticulitis Urinary Tract Infection Distal Ilietis Enteritis
10 : Investigation Report: Hb – 17.7 Total WBC Count – 13,300 Neutrophils – 81 Lymphocytes – 10 Eosinophils – 09 Platelets – 201000 Urine R/E: Colour – Light Yellow Transparency – Clear Reaction – Acidic Pus Cells – 1-2 Epithelial Cells – 0-1
11 : THE ALVARADO SCORE: Symptoms Score Migratory RIF Pain 1 Anorexia 1 Nausea and Vomiting 1 Signs Tenderness (RIF) 2 Rebound Tenderness 1 Elevated Temperature 1 Laboratory Leucocytosis 2 Shift to left 1 TOTAL 10
12 : USG- Abdomen: Probe compression & Rebound Tenderness (+). A tubular blind ending, aperistaltic, non-compressible structure measuring 7-8 cm in length and 12 mm in diameter was noted. No mass or fluid collection was seen adjacent to the structure.
13 : Tzankie’s Score: Ultrasound suggestive of Appendicitis- 6 Tenderness - 4 Rebound Tenderness- 3 Total Count >12,000 - 2 Total Score - 15
14 : Pre-Operative Management: Admission Nil Per Oral IV Fluids- Normal Saline & 5% Dextrose IV Antibiotics – Ceftriaxone 1g Metronidazole 500 mg Pantoprazole 40mg Diagnosis explained Operative procedure & risks explained Consent taken from the patient party Patient shifted to the OT
15 : EMERGENCY APPENDICECTOMY Operative Findings: Gangrenous Appendix with inflamed base. Caecum – Inflamed. Early lump formation was noted. Pyoperitoneum – Around 200 ml of pus was present.
16 : Operative Procedure: Under all asceptic conditions, the abdomen was opened in layers. The mesoappendix was ligated and divided. The appendix was then ligated and excised. Peritoneal lavage was done. The drain was kept at the pelvis. The wound was closed in layers. The pus was sent for C/S. The appendix was sent for histopathological examination.
17 : Post-operative medications: Inj. 5% Dextrose III pints X IV X over 24 hrs Inj. Metronidazole 500 mg X IV X TDS Inj. Pantoprazole 40 mg X IV X BD Inj. Pethidine 50 mg X IM X SOS Inj. Ceftriaxone 1g X IV X BD Inj. Clavulinic Acid 1.2g X IV X TDS Tab. Tramadol 50 mg X PO X TDS The patient is currently on liquid to soft diet.
18 : THE VERMIFORM APPENDIX
19 : Anatomy: The appendix averages 11 cm in length but can range from 2 to 20 cm. The diameter of the appendix is usually between 4-5 mm. The appendix is located in the right iliac fossa. During childhood growth, the caecum rotates appendix into a retrocaecal position. When rotation does not occur it results in a pelvic, subcaecal or paracaecal position.
20 : Positions of the Appendix:
21 : Blood & Lymphatic Supply: The appendicular artery, branch of the ileocolic artery enters the mesoappendix coming to lie in its free border. Mostly it is an end artery, thrombosis of which leads to necrosis or gangrenous appendix. 4 – 6 or more lymphatic channels traverse the mesoappendix to empty into the ileocaecal lymph nodes.
22 : Aetiology of Acute Appendicitis: No unifying hypothesis. Decreased dietary fibre and increased consumption of refined carbohydrates. Incidence is lowest in societies with high dietary fibre intake. Mixed growth of aerobic and anaerobic organisms. Luminal obstruction by faecolith or stricture.
23 : Symptoms: Periumbilical Colic Pain shifts to Right Iliac Fossa Anorexia Nausea and Vomiting Signs: Pyrexia (Low Grade) Abdominal Tenderness localised in the Right Iliac Fossa Muscle Guarding Rebound Tenderness
24 : Specific Abdominal Signs: Rovsing's sign: Deep palpation in the left iliac fossa causes pain in the right iliac fossa, by pushing bowel contents towards the ileocaecal valve and thus increasing pressure around the appendix. Psoas sign: Right lower-quadrant pain that is produced with extension of the right hip while supine. Pain is due to inflammation of the peritoneum or the psoas muscles, positive in retrocaecal position of appendix.
25 : Obturator sign: If an inflamed appendix is in contact with the obturator internus, spasm of the muscle can be demonstrated by flexing and internal rotation of the hip. This indicates the pelvic position of appendix. Pointing Sign : Patient is asked to point to where the pain began and where it moved. Cough sign : Patient is asked to cough and there is pain in the right iliac fossa.
26 : Investigations: Blood: Leucocytosis Neutrophilia Shift to left Elevated CRP Urinalysis : Abnormal if there is irritation of the urinary tract. In females to rule out Ectopic Pregnancy.
27 : Radiological: Plain abdominal X-Ray – may demonstrate faecolith, to rule out SAIO/IO. Abdominal Ultrasonography – Detects Appendicitis with 90% diagnostic accuracy and gynaecological pathology. Computed Tomography Scan – Useful when there is diagnostic uncertainty.95% accuracy.
28 : The Alvarado Score: Symptoms Score Migratory RIF Pain 1 Anorexia 1 Nausea and Vomiting 1 Signs Tenderness (RIF) 2 Rebound Tenderness 1 Elevated Temperature 1 Laboratory Leucocytosis 2 Shift to left 1 TOTAL 10
29 : Tzankie’s Score: Ultrasound suggestive of Appendicitis- 6 Tenderness - 4 Rebound Tenderness- 3 Total Count >12,000 - 2 Total Score - 15
30 : Pre-Operative Management: Admission Nil Per Oral IV Fluids IV Antibiotics Analgesics
31 : Emergency Appendicectomy: Position : Supine Skin Incision : Gridiron , Lanz. Two layers of superficial fascia are cut. External Oblique aponeurosis is opened in the line of incision. Internal oblique and Transverse muscles are split . Peritoneum is opened in the line of incision. Caecum is identified by the confluence of the 3 taenia coli. Appendix is held by Babcok’s forceps. Mesoappendix with appendicular artery is ligated. Base is cut with artery forceps and transfixed using vicryl. Appendix is cut distal to the suture ligature and removed. Stump is cleaned with antiseptics. Purse string suture is tightened to bury the stump. Abdomen is closed in layers. .
32 : Complications of Appendicitis:
33 : THANK YOU

 

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