Title: acute appendicitis

Summary

17 years old Malay gentleman presented with sudden colicky abdominal pain lasted about
1 day at right iliac fossa. It is associated with watery stool and slight abdominal masses at
right iliac fossa with palpation.

Introduction
a. Background of the study

Appendicitis is a common and urgent surgical illness with protean manifestation,
generous overlapping with other clinical syndrome. It is a significant morbidity, that
increases with diagnostic delay yet no single sign, symptom or diagnostic test can
accurately confirms the diagnosis of appendiceal inflammation in all cases.

Acute appendicitis remains one of the most common surgical diseases encountered by
physicians. When appendicitis manifests in its classic form, it is easily diagnosed and
treated. Unfortunately, these classic symptoms occur in just over half of patients with
acute appendicitis; therefore, an accurate and timely diagnosis of atypical appendicitis
remains clinically challenging and one of the most commonly missed problems in the
emergency department. Furthermore, the consequence of missing appendicitis, thus
leading to perforation, significantly increases morbidity and prolongs hospitalization

b. Rational and significance of choosing the case

It is a surgeons goal to evaluate a population of patient referred for suspected
appendicitis and to minimize negative appendectomy rate without increasing the rate of
perforation. Therefore, identifying the presentation remains a challenge.

By choosing this case, it may help the researcher to better understand the clinical
presentation of acute appendicitis acute appendicitis as we know remains one of the
most common surgical diseases. It may manifest in its classical form yet it can present
itself in many ways; atypical appendicitis. When the diagnosis is delayed the
consequences may lead to perforation.

In the long run, this case definitely will provide a better understanding on disease of
surgery; no just for acute appendicitis but also the other acute abdomen diseases;
cholecystitis, pancreatitis, intestinal obstruction, renal colic, etc.

History of admission
a. Patient biography

Name initials : MR. NI
Age : 17 y/o
Sex : Male
Religion : Islam
Civil status : Single
Race : Malay
Occupation : secondary school student
Admission : 22/2/2009
Clerking : 22/2/2009

b. Chief complaint
Patient presented with right abdominal pain. The colicky pain was unbearable that he
asked to admit into the hospital

History of presenting illness

Mr. NI complains of having sudden excruciating colicky abdominal pain at the right
abdomen since one day before the admission. He claimed that he experience such pain a
week prior to the admission at the same place right iliac fossa. However, the pain
described during this clerking was not radiating to or from umbilical fossa, the pain is not
migrating and gradually resolving.

The abdominal pain is associated with slight tenderness of the abdomen. But there is no
accompanying fever, no nausea and vomit. Mr. NI can tolerate orally. He claimed his
bowel output was normal with slight watery stool.

When he was asked about the previous episode of the abdominal pain, he claimed that he
vomited for a few times accompanied by diarrhoea he suspected a case of food
poisoning because during that time keropok lekor contamination was an issue at
Kelantan. He also experienced fever and loss of appetite due to the pain.

Review of system
system finding
Cardiovascular
no significant findings such as palpitation, lower limb oedema,
orthopnea, syncope, dizziness, etc.
Endocrine
No significant findings such as moon features, exophthalmos,
tremor, acromegaly, etc.
Gastrointestinal As stated
Genitourinary
No significant findings such as dysuria, oliguria, haematuria,
incontinence, nocturia, etc.
Hematopoietic
No significant findings such as pallor, jaundice or bleeding
tendency, etc.
Musculoskeletal No significant findings such as m my ya al lg gi ia a, , a ar rt th hr ra al lg gi ia a o or r a ar rt th hr ri it ti is s, , e et tc c. .
Neurologic
No significant findings such as recurrent headaches, fits, blurring
of vision or drowsiness, etc.
Respiratory
No finger clubbing, no accessory muscle used during respiration,
no shortness of breath, no noisy breathing, no hemoptysis, no
night sweats.
Skin, hair, nails
No significant findings. The skin colour is normal according to his
race; with hair growth distribution is normal. Nail is normal, no
clubbing, koilonychia, leukonychia, etc.
Head and neck
Normal head size, shape and symmetry; no skull enlargement,
bossing, etc. no significant findings of the neck such as webbing,
goitre, etc.

Comprehensive health history
a. Past medical/ surgical history
This is Mr. NI first hospitalization. Patient has no significant surgical history. He had no
other significant medical history, no hypertension or diabetes mellitus. Plus, he
completed the immunization according to MoH immunization program, and additional
immunization for hepatitis as previous job requirement.

b. Social history
Mr. NI was currently studying in final year of secondary school at Tumpat. He staying
with his mother she was working a food stall at Tumpat. His father was passed away
due to ischemic heart disease. He claimed to not smoke, do not sexually active and do not
drink alcohols.

c. Family history
He is the youngest of 6 siblings. Hi father passed away due to ischemic heart disease after
a long life with hypertension died at age of 54. Other than hypertension, he denies of
other family history of diabetes mellitus, malignancy, etc.

d. Allergy and medication history
Patient claimed had no known allergy to food or medication yet.

Physical Examination and assessment

a. General
Patient appearance matches his description of age and race; 17 years old Malay
gentleman with light brown skin. His mental status was normal whereas he was alert.
Conscious time and place oriented, and comfortable. He was breathing normally and
able to communicate with the examiner. He was well nourished and fit; height 167 cm
and weight of 59 kg. His body mass index is 21.15kg/m
2
ideal. His posture was normal
and no abnormal gait pattern can be seen.

Inspection of the hand revealed no clubbing, peripheral cyanosis or nicotine stain. No
swelling or tenderness of the wrist. No wasting of muscle or flapping tremor. The hand
was warm and dry. The radial pulse were palpable, beats per minute, it is regular rhythm
and good volume. There was no radio-radial delay or radio-femoral delay and there was
also no collapsing pulse.

Examination of the eye shows no sign of ptosis, constricted pupil and loss of sweating.
No jaundice noted on the sclera and the conjunctiva was not pale. The tongue was moist
and no central cyanosis seen. Oral hygiene was good.
Hi vital signs were as recorded;
Blood pressure : 122/76 mmHg
Heart rate : 86 beat per minute
Respiratory rate : 26 breaths per minute
Temperature : 37C

Impression: no remarkable findings, patient was stable

b. Cardiovascular assessment

Inspection JVP demonstrated; no elevation, no chest deformities, no
visible pulsation except at the fifth left intercostals space
at mid clavicular line apex pulsation, no dilated vein
noted.
Palpation Apex beat palpable at fifth left intercostals space at or
medial to mid clavicular line. No loss cardiac dullness,
palpable thrills or parasternal heaves.
No pulsation at aortic and pulmonic areas, no pulsation at
tricuspid area. Full pulsation at apical area. Pulsation at
epigastric area.
Percussion
Dullness along the cardiac border
Auscultation Full and rapid pulsation. 86 bpm BP: 122/76 mmHg
The sounds on aortic and pulmonic areas; lub sound on
apex and dub sounds on tricuspid area.
1
st
and 2
nd
heart sounds were audible without presence of
murmur. All peripheral pulses were present.

Impression: no remarkable findings


c. Respiratory assessment

Inspection Anterior; breathing normally. N No o c ch he es st t d de ef fo or rm mi it ti ie es s. . T Th he er re e
w wa as s a al ls so o n no o d di il la at te ed d v ve ei in n. . T Th he e c ch he es st t w wa as s slightly deviated to
the right from the chest symmetry during respiration not
asymmetrical. No accessory muscle used while breathing.
Posterior; spine is vertically aligned, the shape and
symmetry of chest are normal.
Palpation Anterior; the skin is intact, equal warmth on both side. No
masses noted. No tracheal deviation
Posterior; no masses or tenderness; equal warmth on each
side. Chest expanded symmetrically
Percussion No significant finding noted. Cardiac dullness and liver
dullness at fifth intercostals space.
Auscultation Anterior; no significant finding noted. No crepitation or
ronchi, the breathing sound was normal

Impression: no remarkable findings.


d. Abdominal assessment
Inspection No distension noted, move symmetry with respiration.
Umbilical centrally located and inverted. No previous scar,
localized swelling, distended vein, or pulsation noted.
Palpation Soft, non tender. No organomegaly; liver, spleen are
normal. Kidneys are not ballotable renal punch was
negative. Mild guarding of the right iliac fossa. Rovsigs
sign demonstrated; it is positive.
Upon deep palpation, mass can be felt at right iliac fossa
appendicular mass noted. No other masses noted.
Percussion Upper border of the liver was at right fifth intercostals
space, with liver span of 12cm. spleen percussion was not
demonstrated. No shifting dullness or fluid thrills.
Auscultation Bowel sound present and normal

Impression: there is a mild guarding reflex of the abdomen during palpation.
Appendicular mass was palpable at right iliac fossa. Acute appendicitis that resolved by
conservative management usually presented with abdominal mass later.
[]


e. Musculoskeletal examination
Generally, muscle size and side comparison appears normal. Muscle tone and strength
also appears normal. Joints can be moved well and no pain noticed.

Impression: no remarkable findings

f. Nervous examination
Patient was alert and conscious. No slurred speech or abnormal behaviour. He is well
oriented to time, place and person. No cerebellar signs present nystagmus, past-pointing.
Gait was stable

Impression: unremarkable findings


Summary

17 years old Malay gentleman presented with abdominal pain lasted about 1 day at right
iliac fossa. It is associated with watery stool and slight abdominal masses at right iliac
fossa with palpation.


Provisional diagnosis

Acute appendicitis

Patient presented with symptom of acute colicky abdominal pain at right iliac fossa. From
the history taking, patient also claimed experiencing similar pain a week prior to the
second episode; the first episode were associated with right iliac fossa pain, fever, loss of
appetite, nausea and vomiting classical symptoms for acute appendicitis.

Physical examination and assessment revealed that the patient had mild guarding of the
abdomen and have an appendicular mass palpable at the right iliac fossa. Patient was
positive for Rovsigs sign. There is no tenderness or any other reflex suggestive for other
diseases.

Differential diagnosis

Diagnosis Positive relevant Negative relevant
Cholecystitis
Nausea vomiting, fever,
abdominal pain may
radiated, spontaneous
resolves, etc.
Relieved by move around
appendicitis patient usually
bed-rest, precipitate with
fatty meal, positive
murphys sign
Constipation Colicky abdominal pain,
reduced bowel movement,
loss of appetite, nausea
vomiting,
No fever, constipation
associated with painful
bowel movement, duration
of symptom lasted longer.
Renal calculi
Fever, colicky pain
depending on area affected,
No Nausea vomiting, bowel
movement remains, no loss
of appetite


Investigation

Investigation Reason to support
Full blood count
The total white cell count is raised above normal in 85% of
patients and three quarters have an abnormal differential
white cell count, having more than 75% neutrophils.
Only 4% of patients with appendicitis have both a normal
white cell count and a normal Neutrophil count.
The white cell count, however, is raised in many other
conditions, so although highly sensitive, it has poor
specificity for appendicitis.
Urinalysis
To exclude severe urinary tract infections, but an increase
in the numbers of leucocytes and bacteria is often seen in
acute appendicitis.
Serum amylase
To rule out pancreatitis specific test to diagnose
pancreatitis by serum amylase level elevation more than
10u/dL



Full blood count

Blood
Count
Result Interpretation Normal range
WCC 17.9 High 4.5-13.5 x 10
9
/L
RBC 5.1 Normal 4.0-5.4 x 10
12
/L
Hb 13.1 Normal 11.5-14.5 g/dL
HCT 38.8 Normal 37.0-45.0 Ratio
MCV 77.5 Normal 76.0-92.0 fL
MCH 25.5 Normal 24.0-30.0 Pg
MCHC 30.8 Normal 28.0-33.0 g/dL
Platelet 240 Normal 150-400 10
9
/L
Neutrophil 76.3
13.7
High 40.0-75.0
2.9-7.9
%
10
9
/L
Lymphocyte 21.0
3.8
Normal 20.0-45.0
1.8-4.0
%
10
9
/L
Monocyte 2.1
0.38
Normal 2.0-10.0
0.2-0.8
%
10
9
/L
Eosinophil 0.3
0.05
Normal 0.0-5.0
0.04-0.44
%
10
9
/L
Basophil 0.2
0.04
Normal 0.0-2.0
0.0-0.2
%
10
9
/L

Impression: white blood cell and neutrophil are elevated. The elevation might be due to
the inflammatory reaction of the body. As mentioned, 85% of patient with appendicitis
presented with an increased in white blood count, neutrophil.
[]

Serum amylase
Patient result was 6.9 u/dL
Impression: no significant findings. It is not pancreatitis
Urinalysis

Blood
Count
Result Interpretation Normal range
Specific
gravity
1.030 normal 1.003-1.030 g/mL
Osmolality 850 Normal >800 mOsm/kg
Urobilinogen 0.8 Normal 0.2-1.0 Mg/dL
Erythrocytes 1 Normal <2-3
Per high
field
power
RBC cast Nil Normal Nil
Leukocytes Nil Normal Nil
pH 7 Normal 5-7
Protein 0 Normal Trace
Glucose Nil normal Nil
Ketones Nil Normal Nil
Bilirubin Nil Normal Nil
Blood Nil Normal Nil
Nitrite Nil Normal Nil
Na 180 normal 150-300 mmol/H
K 50 Normal 40-90 mmol/H
Ca 3.4 Normal 2.5-8.0 mmol/H
P 19 Normal <38 mmol/H
Creatinine 7.3 Normal 4.8-19 mmol/H

Impression: no significant findings



Final diagnosis

Acute appendicitis

1) Based on history, Mr. NI presented with sudden colicky abdominal pain at right iliac
fossa for a day before it resolved gradually. The pain was associated with watery
stool. From the history as well, he claimed to have the same abdominal pain a week
before with association of fever, nausea vomiting, loss of appetite, and abdominal
tenderness

2) Based on assessment, patient presented mild guarding at the right iliac fossa. Upon
deep palpation, it revealed that there was an appendicular mass noted at right iliac
fossa region approximately at area of ileocaecal junction. Rovsigs sign
demonstrated and it was positive.

3) Full blood count revealed a slight elevation of white blood count and neutrophil
inflammatory markers. The urinalysis shows no unremarkable findings this serve to
rule out any genitourinary factors.

Principal management

1) Admission into surgical ward
2) Continuous observation
3) To nil by mouth
4) IV drip
5) To keep in view for appendectomy
6) To keep in view for interval appendectomy
7) To look out for
a. Increase in pain
b. Peritonitis
c. Increase mass
d. Worsening condition
8) Prophylaxis antibiotic
9) Pain killers

Clinical course and progression

On admission, patient was came in presented with abdominal pain and had to bed
rested. Patient was assessed through Alvarado score, with result of 6/10 therefore, he
was put under observation for 24 hours. The patient was unable to eat by mouth and had
to be given liquid food. He was then prescribed with antibiotic; ampicillin 1-2g IV Q4-
6H and flagyl IV 500mg Q 8H. He was given pain killer to ease the abdominal pain,
to help him rest. He is then evaluated by surgeon whether it is necessary to undergo
appendectomy by Alvarado score patient was to be observed for further changes.

On the second day, patient claimed the pain has subsided. Palpation of abdomen
revealed that there was appendicular mass noted at the right iliac fossa. The patient is
now comfortable and able to tolerate solid food properly doctor starts to encourage solid
fluid slowly. Doctor plans to continue conservative management and to observe for
further changes.

The third day, the patient was comfortable, and is now well ambulated. He can
tolerate solid food very well and there was no abdominal pain killer prescription has
been stop. Mr. NI was scheduled for discharge on the evening doctor plans is for patient
to come to the hospital as soon as possible if the pain reoccur, to come again for interval
appendectomy, to continue antibiotics prescription for 1 week.

Discussion

Acute appendicitis remains as one of the most common surgical diseases encountered by
physicians. The diagnosis of acute appendicitis is predominantly a clinical. Classical
presentation of acute appendicitis includes, epigastric or periumbilical pain followed by
brief nausea, vomiting, and anorexia; after a few hours, the pain shifts to the right lower
quadrant. Association with low grade fever is very common.

The etiology of appendicitis is likely that luminal obstruction by external (lymphoid
hyperplasia) or internal (inspissated fecal material, appendicoliths) compression that
leads to increased mucus production, bacterial overgrowth, and stasis, which increase
appendiceal wall tension. Consequently, blood and lymph flow is diminished, and
necrosis and perforation follow.

In this case, patient presented with abdominal pain lasted more than 24 hour before
admitted into the ward. It is not radiating to or from umbilical fossa, the pain is not
migrating and gradually resolving. The pain accompanied with fever and abdomen
tenderness. This is in fact classical presentations of acute appendicitis. However, as
mentioned in study by Humes et al
1
suggested that patient with a delayed presentation
may present itself with palpable mass can be confirmed on ultrasonography or computer
tomography scan.

A study done by Blomqvist et al
3
in Sweden shows that in most cases the mass will
decrease in size over the subsequent days as the inflammation resolves, although patients
need careful observation to detect early signs of progress of the inflammatory process. As
appendicitis can recur, management after resolution of the mass is usually an interval
appendicectomy; a conservative approach with outpatient follow-up has been suggested,
but no definitive evidence exists to support this.

Conclusion
Appendicitis is inflammation of vermiform appendix whereas patient presented with
abdominal pain migrating from periumbilical or epigastric to right iliac fossa, associated
with fever, nausea vomiting, anorexia, and abdominal tenderness . The gold-standard
treatment for appendicitis is appendicectomy or conservative treatment depending on
the presentation of the patient.
References

1. Humes D.J, Simpson J. Clinical Review: acute appendicitis. BMJ 2006;333:5304
2. Campbell MR, Johnston SL III, Marshburn T, et al. Nonoperative treatment of
suspected appendicitis in remote medical care environments: implications for future
spaceflight medical care. J Am Coll Surg. 2004;198:822 830.
3. Blomqvist PG, Andersson RE, Granath F, Lambe MP, Ekbom AR. Mortality after
appendectomy in Sweden, 1987-1996. Ann Surg 2001;233:455- 60.