1. Case presentation
Speaker: PGY 林亭妤

2. Basic Data Name: 謝O芸 Chart number: 097809XX Gender: female Age: 15 y/o
Admission date: 2016/10/21
Body weight/height: 167.6cm/47.8kg

3. Chief Complaint
Right lower abdominal pain with fever for 2 days

4. Present Illness Right lower abdominal pain  fever for 2 days
Had visited 吉泰 chinese medical clinic, with oral medication prescribed but in vain
Nausea with vomiting 3 times for 1 day
No diarrhea, dysuria, or other URI symptoms
No trauma history
No vaginal discharge or bleeding
Denied sexual exposure history
 Visited our ER for further evaluation

5. Past History
Birth history: G2P2, full term baby with smooth birth history
Growth and Development: BH: 167.6cm, BW: 47.8kg, Developmental milestones: WNL
Vaccination: as scheduled
TOCC: denied
GYN history: LMP: 2016/10/7, I/D: 1-2 month, irregular/7
Past History: 1. Denied other major disease
**2. Hospitalization history: 2016/06/ /06/13
Acute appendicitis with rupture and abscess formation s/p
CT-guided drainage and antibiotics

6. Last hospital course(2016/06/08-2016/06/13
Acute appendicitis with rupture and fecalith leading to
- Peritonitis with enhanced peritonum and dirty mesentery
- Loculated RLQ abscess, up to 4.1cm
- Inflamed adjacent segmental small bowel
CT-guided drainage
Ceftriaxone 1g Q12H + Metronidazole
500 mg Q6H IVD *7 days
Amoxicillin/ Clavulanic acid
(875/125mg) 1# BIDPC PO *7 days

7. Physical Examination
Vital Signs: TPR: 37.0/129/24, BP: 108/56mmHg Consciousness: clear General appearance: ill-looking HEENT: Head: intact, conjunctiva: not pale, sclera: anicteric Neck: supple, no JVE, no LAP, no discharge Chest: symmetric expansion, bilateral clear breath sounds Heart: regular heart beat, no murmur *Abdomen: diffuse abdominal pain with whole abdominal
rebound tenderness(+), most tenderness over
RLQ/McBurney's point and periumbilical region,
peritoneal sign(+), hypoactive bowel sounds Extremities: warm, no pitting edema Skin: no rash, petechiae or ecchymosis

8. Lab data at admission
Alvarado score: sum 0–4 = not likely appendicitis,
5–6 = equivocal,
7–8 = probably appendicitis,
9–10 = highly likely appendicitis
Pediatric appendicitis score (PAS):
≥6 = appendicitis,
≤5 = observe

9. > Normal configuration of the spine.
> Segmental dilated small bowel loops in left abdomen, favoring reflex ileus.
> No abnormal calcification is noted.

10. pelvic mass 7.9*7.8cm echo: huge pelvic mass, up to 8 cm in diameter
pelvic sonar: Em: 0.5cm, pelivc mass 7.9*7.8cm echocomplex

12. Consistent with previous Hx of appendicitis with rupture showing - Residual fecalith at RLQ - Secondary tubo-ovarian abscess (TOA) at right adenexa - Peritonitis with dirty ascites
1. Still one fecalith at RLQ related to previous appendicitis rupture. 2. Enhanced cystic nodular mass mixed with clustered tubular structure at right sided adexena, up to 6.8cm in length. 3. Dirty ascites mixed with enhanced/thick peritoneum and mesenteric/omental infiltrates consistent with peritonitis. 4. The visible liver, gallbladder, spleen, and pancreas are unremarkable. 5. Both kidneys and urinary bladder show normal. 6. No evidence of retroperitoneal para-aortic, pelvic, and inguinal lymphadenopathy is noted. IMP: Consistent with previous Hx of appendicitis with rupture showing - Residual fecalith at RLQ - Secondary tubo-ovarian abscess (TOA) at right adenexa - Peritonitis with dirty ascites

13. Tentative diagnosis
Right abdominal abscess, suspected appendix rupture with abscess formation
Peritonitis
Right ovarian tumor, suspected secondary tubo-ovarian abscess

14. Plan
Consult GYN and GS doctor for surgical evaluation or emergency surgical indication
Aggressive antibiotic treatment with Ceftriaxone and Metronidazole
NPO and IV fluid hydration
Record I/O and closely monitoring sepsis signs
Pain control

15. Operation on 2016/10/22
Pre-OP diagnosis: Ruptured appendictis with intra-abdominal abscess
Post-OP diagnosis: 1.Ruptured appendictis with intra-abdominal abscess s/p drainage 2.R't ovarian tumor susp. abscess formation with pyosalpinx s/p right oophocystectomy+R't salpingostomy
OP Method: Appendectomy + right oophocystectomy + right salpingostomy

16. Operative Findings
Retrocecal supprative appendix -size: 6x 1 x 0.9 cm -ascites: mild ; Ometum shift(+) -fecalith(+); fecal pus(+) -cecum base: mild inflammation
Right ovarian tumor --> table consult GYN -size: 4x 5 cm with pus formation -right pyosalpinx(+) --> right salpingostomy
Retrocecal supprative appendix -size: 6x 1 x 0.9 cm -ascites: mild ; Ometum shift(+) -fecalith(+); fecal pus(+) -cecum base: mild inflammation
Right ovarian tumor --> table consult GYN -size: 4x 5 cm with pus formation -right pyosalpinx(+) --> right salpingostomy

18. Treatment of acute appendicitis
Discussion
Treatment of acute appendicitis

20. Topics Diagnostic efficiency of clinical scoring systems
Role of Imaging
Non-operative treatment for uncomplicated appendicitis
Timing of appendectomy and in-hospital delay
Surgical treatment
Scoring systems for intra-operative grading of appendicitis and their clinical usefulness
Non-surgical treatment for complicated appendicitis: abscess or phlegmon
Pre-operative and post-operative antibiotics

21. Non-operative treatment for uncomplicated appendicitis
Can appendicitis resolve without treatment?
How common is it?
Antibiotic therapy can be successful in selected patients with uncomplicated appendicitis who wish to avoid surgery and accept the risk up to 38 % recurrence. (1A)
Current evidence supports initial intravenous antibiotics with subsequent conversion to oral antibiotics. (2B)

22. Timing of appendectomy and in-hospital delay
Does in-hospital delay increase the rate of complication or perforation?
Is it safe to delay appendectomy?
Timing of appendectomy
In the absence of level 1 evidence, the question of whether in-hospital delay is safe and not associated with more perforations cannot be answered with certainty

23. Timing of appendectomy and in-hospital delay
Most cases of uncomplicated appendicitis emergency operation is not necessary
Short, in-hospital surgical delay up to 12/24 h is safe in uncomplicated acute appendicitis and does not increase complications and/or perforation rate. (2B)
However, delays should be minimised wherever possible to relieve pain, to enable quicker recovery and decrease costs

24. Non-surgical treatment for complicated appendicitis: abscess or phlegmon
Role of percutaneous drainage and Interval Appendectomy or immediate surgery
Percutaneous drainage of a periappendicular abscess, if accessible, is an appropriate treatment in addition to antibiotics for complicated appendicitis. (2B)
Non-operative management is a reasonable first line treatment for appendicitis with phlegmon or abscess. (1A)
Operative management of acute appendicitis with phlegmon or abscess is a safe alternative to non-operative management in experienced hands. (2B)

25. Non-surgical treatment for complicated appendicitis: abscess or phlegmone
Role of percutaneous drainage and Interval Appendectomy or immediate surgery
Interval appendectomy is not routinely recommended both in adults and children. (1A)
Interval appendectomy is recommended for those patients with recurrent symptoms. (2B)
Overall, the complications reported included wound infection, prolonged postoperative ileus, hematoma formation, and small bowel obstruction, but the incidence of any individual complication was not determined [147].
Because of its consistent morbidity, after successful conservative management, the routine indication to interval appendectomy is justified only in case of persistent or recurrent symptoms, and should be avoided in asymptomatic patients

26. Preoperative and postoperative antibiotics
Should Preoperative antibiotics prophylaxis be given?
When should postoperative antibiotics be given? What antibiotics? Duration?
In patients with acute appendicitis preoperative broad-spectrum antibiotics are always recommended. (1A)
For patients with uncomplicated appendicitis, post- operative antibiotics are not recommended .(2B)
Overall, the complications reported included wound infection, prolonged postoperative ileus, hematoma formation, and small bowel obstruction, but the incidence of any individual complication was not determined [147].
Because of its consistent morbidity, after successful conservative management, the routine indication to interval appendectomy is justified only in case of persistent or recurrent symptoms, and should be avoided in asymptomatic patients

27. Preoperative and postoperative antibiotics
When should postoperative antibiotics be given? What antibiotics? Duration?
In patients with complicated acute appendicitis, postoperative, broad-spectrum antibiotics are always recommended. (2B)
Although discontinuation of antimicrobial treatment should be based on clinical and laboratory criteria such as fever and leucocytosis, a period of 3–5 days for adult patients is generally recommended. (2B)
Overall, the complications reported included wound infection, prolonged postoperative ileus, hematoma formation, and small bowel obstruction, but the incidence of any individual complication was not determined [147].
Because of its consistent morbidity, after successful conservative management, the routine indication to interval appendectomy is justified only in case of persistent or recurrent symptoms, and should be avoided in asymptomatic patients

28. Thanks for your attention !!