Appendicitis

1
Appendicitis

• by Chanda McDaniel 1/08

2
Objectives

• To review 3 cases of appendicitis (that presented
  to AUCC at DH)
• To discuss how we could improve the care of these
  patients
• To review the presentation, work-up, and
  differential diagnosis of appendicitis

3
Case 1 HPI

• 37yo female presents to PCP (seen by resident)
  for 6 wk postpartum check up with abdominal pain
  x 5-7 days.
• No N/V. Pain is achy/diffuse. Subjective fever
  yesterday.
• No appetite. Drinking. Nl BMs. No dysuria or
  abnormal vaginal discharge. Stopped bleeding 1 ½
  weeks ago.

4
Case 1 Physical

• 37.5 128 124/81 22
• NAD
• H - RRR w/o M
• A - TTP midline, RLQ, LLQ, NABS, soft,
  non-distended, guarding
• Pelvic - midline tenderness, no adnexal
  tenderness, no foul-smelling discharge

5
Case 1 Labs

• U/A-1.025, pH 5, 1pro, 1Hgb, 1-5 WBCs, 6-10
  RBCs
• UHCG - negative

6
Case 1 PCP Dx, Plan

• Late postpartum endometritis
• Doxycycline 100mg po BID x 14 days
• Vicodin, Colace, Ibuprofen
• RTC 1 week

7
3 days later

• Pt presents to AUCC with worsening abdominal and
  low back pain.
• Dizzy. Decreased appetite. Fever. Pain 5/10.
  Nausea x 1 wk.
• No emesis, diarrhea, dysuria, vaginal discharge
  or URI sxs.

8
AUCC Physical

• 38.3 113 16 113/70 99 RA
• HEENT pale conjunctiva, nl o/p
• H RRR w/o M (90)?
• L CTAB
• A NABS, soft, tender in suprapubic area, less
  in RLQ, no rebound, no obturator or psoas sign
• GU no CMT, min. discharge, uterus TTP

9
AUCC Labs/xray

• UA 1-5 WBC, 1-5 RBC, 1 bacteria
• WBC 12.6, Hb 12.5, Hct 38.9, plts 323
• Chem 7 nl, Calcium nl
• Pelvic US nl
• CT 9.6x7cm mass abuts cecum with surrounding
  fat stranding most likely perforated appendicitis
  with associated abscess

10
AUCC course

• Pt seen by surgery who wanted to admit take pt
  to OR. She refused and left AMA, but said she
  would return in AM.
• Pt returned the next day and said that she
  refused admission due to a religious holiday and
  was admitted to surgery.
• She was discharged on Levo and Flagyl post op.

11
Endometritis

• Most cases develop within the 1st week after
  delivery
• 15 present between 1-6 weeks postpartum
• May present as late postpartum hemorrhage
• Clinical criteria
• Fever and uterine tenderness occurring in a
  postpartum woman
• foul lochia, chills, and lower abdominal pain
• Admit for IV antibiotics (Clinda/Gent)?

12
What could we (at DH) have done differently?

• PCP could have considered appendicitis in the
  differential
• Pt presentation was atypical for endometritis
• Late onset
• No VB or discharge
• Abnormal vitals (HR 128) not addressed
• No labs were drawn (even for baseline)?
• Needed admission/IV Abx (?), if diagnosis of
  endometritis was correct

13
Case 2 HPI

• 21 yo female presents with abd. pain and vaginal
  bleeding x 3 days.
• Not using pad just on TP.
• Recently had IUD removed.
• No N/V.
• PMH Depression
• Meds Prozac
• NKDA

14
Case 2 Physical

• 36.3 119 110/63 18
• NAD
• Chest clear
• H RR
• A soft, marked tenderness in RLQ, tender in
  suprapubic area LLQ, no rebound, NABS
• Pelvic blood in vault, cervix/uterus tender,
  adnexa tender RgtL

15
Case 2 Labs

• UA mod ketones, 1.015, 2pro, tr blood, tr leu,
  11-20 WBC, no RBC, 1crystals
• UHCG negative
• CBC WBC 26.6, hb 14.9, hct 42.9, plt 406, 87
  segs
• Chem 7 normal except Na 133

16
Case 2 Dx Plan

• Abdominal pain with elev. WBCs, some WBCs in
  urine
• R/O PID vs UTI, doubt appy
• Urine cx P
• Gonorrhea/Chlamydia P
• Levofloxacin 500mg BID, Flagyl 500mg BID x 14 days

17
Case 2 AUCC f/u

• Seen 1 day later in AUCC Pt did not want CT
  yesterday. Feels better. Meds upset stomach. Ate
  some breakfast. No nausea now.
• VS 38.4 113/69 124 20
• A - BS, soft, tender in RLQ w/ guarding
• WBC 20.7, Hb 13.7, Hct 40.2, Plts 333
• CT RLQ 11x4cm abscess, adj to cecum

18
Case 2 Hosp. course

• Pt admitted for perforated appendix
  (approximately 7-10 days old) and placed on IV
  Timentin.
• IR placed drain on hosp. day 1 and removed on day
  7 after 2nd CT scan (although I cant find the
  report of 2nd CT).
• Discharged on Augmentin, Colace, Vicodin.

19
What could we have done differently?

• If appendicitis was in the differential and it
  was not visualized on US ? consider CT or surgery
  consult.
• If patient refused CT, we could have improved our
  documentation on her initial visit.

20
Case 3 HPI

• 51 yo male with epigastric pain since this am.
  N/V x 3. No diarrhea. No fever.
• PMH No hospitalizations.
• Meds Tylenol flu
• All none
• SHx no exposures, ETOH yesterday

21
Case 3 Physical

• 36.7 142/85 66 20 (not orthostatic)?
• General - Alert, NAD
• HEENT NCAT, anicteric, o/p -, neck supple w/o
  LAD
• H RRR w/o m
• L CTAB
• A NABS, soft, mild epigastric tenderness to
  palpation, more TTP in RLQ, rebound, - heel
  tap, - obturator, psoas, nl rectal

22
Case 3 Labs

• WBC 16.4, Hb 16.1, Hct 47.8, Plts 221, 91 Segs
• Chem 7 normal
• LFTs normal
• Amylase 27
• U/A 1.038, 2pro, 1Hb, 2glc, - WBC, - RBC
• Guaiac - negative

23
Case 3 CT

• Verbal report Equivocal for appendicitis
• Written report There is considerable fecal
  material within the cecum, but the terminal ileum
  is not dilated and the appendix is normal.
  Moderate thickening of sigmoid colon, which may
  indicate a prior inflammatory process. No
  evidence of acute diverticulitis.

24
Case 3 Surgery Consult

• 51 yo w/ epigastric pain better now. N/V x 1.
• A NTTP
• CT poorly visualized appendix
• A/P resolved Abd pain, with elevated WBC. Would
  like to admit for obs, but pt would like to go
  home. Return to AUCC in am for recheck, CBC.

25
Case 3 AUCC f/u

• 51 yo w/ abd pain seen yesterday. N/V x2 this am.
  Constant pain. No appetite.
• 37.3 64 20 128/74
• A RLQ tenderness
• WBC 20.3, Hb 15.7, Hct 46, plts 225, 87S
• Admitted to surgery. Laproscopic eval gt
  partially necrotic appendix (ruptured per path) ?
  open appendectomy. Discharged on Levo/Flagyl.

26
What could we have done differently?

• Talked pt into staying the night in the hospital?
  This may have prevented rupture?

27
Appendicitis Epidemiology

• 250,000 cases/yr in US
• most common in 2nd/3rd decades of life
• highest incidence in 10-19 yo age group
• no age is exempt
• males gt females
• rate of negative appendectomies (15-20) has not
  declined in the last 15 years despite the
  increasing use of US and CT
• DH 1-2 carcinoids, 2-3 parasitic infections, TB,
  TOA/several hundred surgeries (lt1)?
• Mortality lt1 (nonperf)?, gt5 (perf)?

28
Pathophysiology

• 1) Obstruction of lumen
• young lymphoid follicular hyperplasia (due to
  viral or bacterial infection and dehydration)?
• older fibrosis, fecalith, neoplasm
• 2) Fills with mucus?distends?increases
  intraluminal pressure?thrombosis?
  ischemia?necrosis (lt24hrs) and perforation
  (gt48hrs)?

29
Organisms

• E. coli
• Peptostreptococcus
• Bacteriodes Fragilis
• Pseudomonas

30
Appendix Anatomy

• normal lies in RLQ
• retrocecal (65)?
• pelvic (30)?
• intestinal malrotation LUQ
• pregnant RUQ

31
Symptoms

• Initial
• indigestion
• flatulence
• bowel irregularity
• Epigastric or periumbilical pain
• visceral - constant, not very severe in
  intensity, poorly localizable
• Then, N/V (not usually 1st symptoms)?
• Fever (higher suggests perf)?
• Sxs may subside (temporarily) after rupture

32
Abdominal Pain

• Visceral
• Parietal
• Referred

33
Visceral pain

• Stretching, distention, torsion, or contraction
  of abdominal organs
• Carried on slow-conducting fibers
• Dull ache
• Location correspond to dermatomes that match the
  innervation of the injured organ
• Epigastrium? organs proximal to ligament of
  treitz (hepatobiliary, spleen)?
• Periumbilical?ligament of treitz to hepatic
  flexure of colon
• Midline lower abd?organs distal to hepatic
  flexure

34
Parietal Pain

• Well-localized
• Results from direct irritation of the peritoneal
  lining
• A delta fibers?rapid conduction
• Sharp pain sensation

35
Referred pain

• Occurs when visceral afferents carrying stimuli
  from a diseased organ enter the spinal cord at
  the same level as somatic afferents from a remote
  anatomic location.
• Typically well-localized
• Gall bladder inflammation to R shoulder
• Diaphragmatic rupture to shoulder
• Heart attack to L arm

36
(No Transcript)
37
Physical Exam Appendicitis

• Pain is subjective
• Tenderness is objective local tenderness in RLQ
• McBurneys point (1/3 of distance of line from
  anterior iliac spine to umbilicus)
• May have tenderness in RLQ during rectal and
  pelvic

38

• Common Signs of Appendicitis
• Right lower quadrant pain on palpation (the
  single most important sign)?
• Low-grade fever (38C or 100.4F)--absence of
  fever or high fever can occur
• Peritoneal signs
• Localized tenderness to percussion
• Guarding
• Other confirmatory peritoneal signs (absence of
  these signs does not exclude appendicitis)?
• Psoas sign--pain on extension of right thigh
  (retroperitoneal retrocecal appendix)?
• Obturator sign--pain on internal rotation of
  right thigh (pelvic appendix)?
• Rovsing's sign--pain in right lower quadrant
  with palpation of left lower quadrant
• Dunphy's sign--increased pain with coughing
• Flank tenderness in right lower quadrant
  (retroperitoneal retrocecal appendix)?
• Patient maintains hip flexion with knees drawn
  up for comfort

39
3 PE findings with highest predictive value of
appendicitis

• 1) RLQ pain
• 2) Abdominal rigidity
• 3) Migration of a pain from periumbilical region
  to the RLQ
• Occur in about 50 of patients

40
Retrocecal appendix

• Appendix doesn't touch parietal peritoneum
• Sxs
• not localized
• dull ache
• psoas sign
• flank pain

41
Psoas sign

• Inflamed appx is in retroperitoneal location in
  contact with psoas

42
Pelvic Appendix

• May have no abdominal signs
• Urinary frequency
• Dysuria
• Tenesmus
• Diarrhea
• Tenderness with rectal exam
• Positive obturator sign

43
Obturator sign

• Inflamed appx is in pelvis, in contact with
  obturator muscle

44
Labs

• UA
• r/o UTI (micro hematuria/pyuria in 30 appys)?
• gt30 RBC or gt20 WBC -? urinary
• UHCG
• r/o ectopic
• Pelvic cultures
• CBC
• leukocytosis
• 30 have normal WBC (95 have left shift)?

45
Radiology (CT or US)?

• Obtain if diagnosis is unclear.
• A population based study suggested that the rates
  of negative appendectomies have not changed
  between 1980 and 1999.

46
CT Appy

• Sensitivity 94
• Specifity 95
• Air or contrast in appendix excludes dx
• Diameter 6 mm or less - normal
• Non-visualized appx
• does not rule out appendicitis
• If pt with sxs for a short duration, only min.
  inflammation may be present
• IV contrast (?)? - may improve wall
  appearance/inflammation

47
Normal Appendix on CT
48
Appendicitis on CT

• Dm gt6mm
• Appendicolith
• Cecal thickening
• Arrowhead sign
• abscess formation
• cecal thickening

49
Arrowhead sign
An axial CT image in the upper pelvis shows edema
of the cecal wall which, along with barium in the
cecum (C), contributes to the "arrowhead sign" of
appendicitis. A dilated fluid filled appendix
(large arrow) is seen with adjacent stranding of
retroperitoneal fat (arrowheads). The appendix
follows a retrocecal course (small arrows).
50
CT radiation

• There is direct evidence from epidemiologic
  studies that the organ doses corresponding to a
  common CT study (2-3 scans, dose 30-90 mSv)
  result in an increased risk of cancer.
• 10,000 adults, 35 yrs old, US instead of CT
• Appendicitis would be missed in 480 cases
• 2 patients could be prevented from developing
  cancer in the future

51
Differential Diagnosis

• Cecal diverticulitis
• Meckel's diverticulitis
• Ilietis (bacterial infection)?
• Yersinia
• Campylobacter
• Salmonella
• Crohn's
• PID
• Ob/Gyn
• UTI/Nephrolithiasis

52
Treatment

• NPO
• IVF
• Antibiotics
• nonperforated preop Cefazolin, Flagyl,
  (Timentin or Cefotetan at DH)?
• perforated Levo Flagyl (x 7-10 days)

53
Bibliography

• 1) Brenner, D. Computed Tomography An
  Increasing Source of Radiation Exposure. NEJM.
  Nov. 2oo72277-84.
• 2) Doria, A. US or CT for diagnosis of
  appendicitis in Children and adults? A
  meta-analysis. Radiology. Aug. 200624183-94.
• 3) Flaser, M. Acute Abdominal Pain. Medical
  Clinics of North America. May 2006903.
• 4) Goldberg, J. Appendicitis in adults. Uptodate.
  August 2007.
• 5) Hardin, M. Acute appendicitis Review and
  Update. American Family Physician
  1999602027-2034.
• 6) Humes, D. Acute appendicitis. BMJ. Sept
  2006333530-534.
• 7) Morino, M. Acute Nonspecific Abdominal Pain.
  Ann Surg. Dec. 2006244(6)881-888.
• 8) Old, J. Imaging for Suspected Appendicitis.
  American Family Physician. Jan. 200571(1).
• 9) Paulson, E. Suspected appendicitis. NEJM. Jan
  2003348236-242.