1. 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. 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

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: 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

12. Would you like to revise your Differential Diagnosis?

13. 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 CBCElectrolytes LFT’sAmylase /Lipase B-HCGUrinalysis

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. Studies 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. What next? Discussion of suggested interventions

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 ASSOCIATION FOR SURGICAL EDUCATION 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