Presentation on theme: "ACUTE APPENDICITIS Roy Phitayakorn, M.D. Christopher Brandt, M.D. Case Western Reserve University School of Medicine."— Presentation transcript:
ACUTE APPENDICITIS Roy Phitayakorn, M.D. Christopher Brandt, M.D. Case Western Reserve University School of Medicine
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.
History What other points of the history do you want to know?
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
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
What is your Differential Diagnosis?
Differential Diagnosis Based on History and Presentation Systemic or infectious conditions Influenza Gastroenteritis Hepatitis Diaphragmatic pleurisy Spinal disease Typhoid Tuberculosis Acute porphyria Diabetic ketoacidosis
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
Physical Examination, Patient ZC Vital Signs: 39 o C, HR=75, RR=15, BP=125/75 Appearance: Patient is lying quietly on bed in fetal position HEENT : No icterus VAGINAL: nontender, no Discharge CV : nl S1S2, no murmurs RECTAL: Guaiac neg, uncomfortable during exam PULM : CTA Bilat. no pain with inspiration Neuromuscular: Minimal hyperesthesia above umbilicus ABD : Moderately tender in RLQ between pubic symphysis and ASIS, involuntary guarding, Neg bowel sounds
Would you like to revise your Differential Diagnosis?
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?
Studies What further studies would you want at this time?
Radiologic Studies to Consider Flat/Upright Abdomen CT Scan: Abd/Pelvis CT Scan: Other ? US Abdomen/Pelvis
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?
Abdominal X-ray Findings Non-specific gas pattern No fecalith No free air
CT Scan Abdomen & Pelvis
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?
Revised Differential Diagnosis
What next? Additional Imaging? Observation? OR? Other?
What next? Discussion of suggested interventions
Discussion Pathophysiology of the disease process, visceral vs. parietal abdominal pain, laparoscopy vs. open, antibiotic management, appropriate utilization of resources, etc.
Discussion Additional teaching points
Alternative scenarios Acute Appendicitis with perforation/ Abscess or tumor IBD Acute Diverticulitis Ovarian Cyst / Torsion/ Perforated Right colon tumor
CT Cecal Tumor
CT Sigmoid Diverticulitis
CT Ovarian Cystic Mass
CT Terminal Ileal Crohn’s
CT Acute Appendicitis
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