1. Case Western Reserve University
ACUTE APPENDICITIS
Roy Phitayakorn, M.D.
Christopher Brandt, M.D.
Case Western Reserve University
School of Medicine

2. 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.

3. History
What other points of the history do you want to know?

4. Consider the Following
History, Ms. Cope
Consider the Following
Characterization of symptoms
Temporal sequence
Alleviating / Exacerbating factors:
Pertinent PMH, ROS, MEDS.
Relevant family hx.
Associated signs and symptoms

5. 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

6. What is your Differential Diagnosis?

7. Differential Diagnosis Based on History and Presentation
Systemic or infectious conditions
Influenza
Gastroenteritis
Hepatitis
Diaphragmatic pleurisy
Spinal disease
Typhoid
Tuberculosis
Acute porphyria
Diabetic ketoacidosis

8. 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

9. Differential Diagnosis (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

10. Physical Examination
What would you look for?

11. 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
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

12. Would you like to revise your Differential Diagnosis?

13. 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

14. Laboratory
What would you obtain?

15. Labs ordered
CBC
Electrolytes
LFT’s
Amylase /Lipase
B-HCG
Urinalysis

16. Lab Results, Ms. Cope CBC: 14,500 LFTs : WNL HCG : WNL
Electrolytes : WNL
Amylase : WNL
U/A: WNL

17. Interventions at this point?

18. 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?

19. What further studies would
you want at this time?

20. Radiologic Studies to Consider
Flat/Upright Abdomen
CT Scan: Abd/Pelvis
CT Scan: Other ?
US Abdomen/Pelvis

21. 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?

22. Abdominal Film

23. Abdominal X-ray Findings
Non-specific gas pattern
No fecalith
No free air

24. CT Scan Abdomen & Pelvis

25. 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?

26. Revised Differential Diagnosis

27. What next?
Additional Imaging?
Observation?
OR?
Other?

28. Discussion of suggested interventions
What next?
Discussion of suggested interventions
Value of 1 intervention over another?
Interject EBM where appropriate

29. Management
Surgical Options
Pre-operative preparation

30. Laparoscopic Acute Appendicitis

31. Discussion
Pathophysiology of the disease process, visceral vs. parietal abdominal pain, laparoscopy vs. open, antibiotic management, appropriate utilization of resources, etc.

32. Discussion
Additional teaching points

33. QUESTIONS ??????

34. Summary

35. Alternative scenarios
Acute Appendicitis with perforation/ Abscess or tumor
IBD
Acute Diverticulitis
Ovarian Cyst / Torsion/
Perforated Right colon tumor

36. CT Cecal Tumor

37. CT Sigmoid Diverticulitis

38. CT Ovarian Cystic Mass

39. CT Terminal Ileal Crohn’s

40. CT Acute Appendicitis

41. Acknowledgment
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