Tetanus by Neurolog

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
Consider the Following
• Characterization of • Pertinent PMH, ROS,

symptoms MEDS.
• Temporal sequence • Relevant family hx.
• Alleviating / • Associated signs and
Exacerbating factors: symptoms
History, Patient ZC
• Pain started in the middle of • Noted some indigestion
the night and woke the yesterday
patient from sleep.
• Felt nauseated and vomited • Feels urge to have bowel

after pain movement, but has been
constipated
• No significant MED.HX. or
SURG HX.
• Negative Family HX
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
(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
(cont.)
• Intra-pelvic conditions
• Salpingitis
• Pelvic Inflammatory Disease
• Ectopic Pregnancy
• Ruptured Corpus Luteum Cyst
• Ruptured Follicular Cyst (Mittelschmerz)
• Ruptured Ovarian Cyst
• Ovarian Torsion
• Pyelonephritis
• Ureteral/Renal stone
Physical Examination
What would you look for?

Physical Examination, Patient ZC
• Vital Signs: 39o C, HR=75, RR=15, BP=125/75
• Appearance: Patient is lying quietly on bed in fetal position
VAGINAL: nontender, no
HEENT : No icterus Discharge
CV : nl S1S2, no murmurs RECTAL: Guaiac neg,
uncomfortable during exam
PULM : CTA Bilat. no pain with Neuromuscular: Minimal
inspiration 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?
Would you like to revise your
Differential Diagnosis?
• Acute appendicits
• Diverticulitis (Meckel’s)
• Inflammatory Bowel Disease (Crohn’s)
• Ovarian pathology
• Acute cholecystitis
• Intestinal obstruction
• Nonspecific adenitis – Possible Yersinia infection
Laboratory
What would you obtain?

Labs ordered
CBC Electrolytes
LFT’s Amylase /Lipase
B-HCG Urinalysis
Lab Results, Ms. Cope
CBC: 14,500
LFTs : WNL
HCG : WNL
Electrolytes : WNL
Amylase : WNL
U/A: WNL
Interventions at this point?
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 Film
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

Management
• Surgical Options
• Pre-operative preparation
Laparoscopic Acute Appendicitis
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
QUESTIONS ??????
Summary
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
Acknowledgment
The preceding educational materials were made available through the
ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we

welcome your comments/ suggestions at:
feedbackPPTM@surgicaleducation.com

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ACUTE APPENDICITIS

Roy Phitayakorn, M.D.

• You are called to see a patient in the

What other points of the history do you

• Characterization of • Pertinent PMH, ROS,

• Felt nauseated and vomited • Feels urge to have bowel

• Systemic or infectious conditions

What would you look for?

What would you obtain?

LFT’s Amylase /Lipase

• Start IV with Ringers Lactate or similar

What further studies would

• What would you expect to see on a flat/upright

• Non-specific gas pattern

What is the differential diagnosis at this point?

Discussion of suggested interventions

Pathophysiology of the disease process, visceral vs.

• Acute Appendicitis with perforation/ Abscess or

ASSOCIATION FOR SURGICAL EDUCATION

In order to improve our educational materials we

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