Acute Appendicitis

Victor Federico B. Acepcion
Medical Officer III
UP-PGH Department of Surgery

CASE PRESENTATION

	General Data:	M.C., 25 year old, Male

	Chief Complaint:	Right lower quadrant pain

	History of Present Illness:

1 day prior to admission, patient experienced dull epigastric pain later with radiation to the right lower quadrant. This was associated with anorexia and vomiting.
		Persistence of symptoms prompted present consult.

		(-) fever	(-) bowel disturbance
		(-) dysuria

		Past Medical History: unremarkable
		Family Medical History: unremarkable
		Personal Social history: single, non-promiscuous, (-) vices

	Physical Examination:

		afebrile,	HR=80	
		ECE, CBS, no rales/wheezes
	abdomen :	flat, soft, NABS, (+)direct/rebound tenderness at RUQ, (+) Rovsing’s, (+) cough sign, (+) Psoas/Obturators test
	rectal exam:	tight sphincters, intact vault, (+) right pararectal tenderness, (-) blood per examining finger

CASE DISCUSSION

          Clinical Diagnosis

	This is a case of a 25 year old, male who presents with a one day
           history of dull epigastric pain with radiation to the R lower quadrant. This
associated with anorexia and vomiting. On PE, there was direct and rebound tenderness at the R lower quadrant, (+) Rovsing’s sign, (+) cough sign, (+) Psoas/obturator’s test, and R pararectal tenderness.

Primary Clinical Diagnosis:	Acute Appendicitis

	Secondary Clinical Diagnosis:	Acute Gastroenteritis

Based on prevalence, appendicitis is the most common acute surgical condition of the abdomen	. It is usually most frequent during the second and the third decade and is more common in males than females, between ages 15 and 25.
The appearance of dull epigastric pain in patients with acute appendicitis is a symptomatic closed loop obstruction of the appendix and the continued mucosal secretion into the 0.1 ml capacity lumen. Distention of the appendix stimulates visceral afferent pain fibers, producing vague, dull, diffuse pain in the abdomen. This is simultaneous with vascular congestion causing reflex nausea. Radiation of pain to the R lower quadrant is initiated by serosal engorgement causing inflammation of the parietal peritoneum.
The closest consideration in our present case is that of acute gastroenteritis. The observed vomiting and anorexia could be explained by gastric mucosal irritation secondary to an inflammatory process. The patient has no history of dysuria, and denies recent sexual contact.

	PARACLINICAL DIAGNOSTIC PROCEDURE

Our present primary impression is acute appendicitis. In our present case, the patient presents with a classical history of acute appendicitis. The patient’s general data as well as the physical examination strengthens our present consideration.
I don’t think there will be a need for further paraclinical diagnostic procedures in this case. The persistent R lower quadrant pain with some signs of peritonitis as confirmed on physical examination warrants an immediate appendectomy.

						Certainty	Treatment Modality
	Primary Diagnosis			    90%	Appendectomy
	Secondary Diagnosis		    10%	Fluid replacement

TREATMENT

	Pre-treatment diagnosis
		Primary:	Acute Appendicitis
		Secondary:	Acute Gastroenteritis

Goal of treatment for Acute Appendicitis

1.	Prevent rupture of appendix
2.	Prevent further spillage if patient has rupture on time of presentation (usually in 15 to 25% of patients)
3.	Prevent morbidity secondary to septic complications due to rupture

Treatment Modality

			Benefit	Risk		Cost		Availability
Nonoperative		none		-		-		
Operative		100%		0.1% mortality
(immediate 				(unruptured)
appendectomy)			3% mortality
					(ruptured)
					morbidity increased
					with rupture
Treatment Procedures

1.	Appendectomy (McBurney incision for best exposure; Rocky-Davis incision with muscle splitting for decreased incidence of wound dehiscence;right paramedian or lower midline incision for general exploration)
2.	Appendectomy via laparoscopic approach

PREVENTION AND HEALTH PROMOTION

	FINAL DIAGNOSIS:		Acute Appendicitis

	Patient education should be emphasized to prevent complications of late diagnosis. Rupture of appendix is related to increased risk of septic complications and even mortalities. It should be emphasized that progression of disease is fast in the young and that rupture is frequent at diagnosis. Likewise, there is 67 to 90% incidence of rupture in the elderly with deceptive clinical course due to presence of other illnesses.

REFERENCE

	Principles of Surgery, 7th edition, Seymour Schartz, M.D. (ed)