Case Report ACUTE APPENDICITIS
Composer: Jessica Stephanie S 07120100019 FK UPH 2010
Preceptor : dr. Setiawan William, Sp.B
CLINICAL CLERKSHIP-SURGERY DEPARTMENT FACULTY OF MEDICINE UPH RUMAH SAKIT MARINIR CILANDAK st
th
PERIOD 1 JUNE 2015 – 8 AUGUST 2014
PATIENT’S IDENTITY
Medical Record
: 34 77 47
Name
: Mrs. I
Gender
: Female
Place, Date of birth
: Jakarta, 21st of December 1952
Age
: 62 years old
Religion
: Muslim
Address
: Pondok Labu, Cilandak
Job
: Housewifes
HISTORY TAKING
Autoanamnesis was performed at Emergency Unit RS Marinir Cilandak on 7th of July 2015, 00.20 AM.
CC
: Right lower abdominal pain 1 day prior to hospital admission.
HPI
: Patient complains pain in her right right lower abdomen 1 day day prior prior to hospital admission. The pain is continously. At first the pain is on the area around the umbilicus, and then the pain was migrating to the right lower part of the abdomen. Fever is also present since 3 days prior to hospital admission. The fever is unstable with periods of high and normal temperature. The patient denies chills accompanying the fever.
Aside from the pain and fever, the patient also complains about loss loss of her appetite. She felt nausea and vomiting. She had vomited twice, containing clear liquid, roughly the total of liquid was half an aqua cup. The patient is not taking anymedication before. She denied allergy towards any medicine or any kind of food.
PI
: The patient denies any history of the same condition in the past. She never had any abdominal pain before. She denies having any medical problems prior
!
to this hospital admission. She denied any history about hypertension, diabetes mellitus, dyslipidemia, or heart disease.
Medication history
: Patient never consume any routine medications before.
Family history
: All members in her family that lived together with her never experienced the same condition as the patient. They denied any familial diseases such as hypertension and diabetes.
Social history
: Patient lives with her son, daughter in law, and her grandchildrens. She never smoke cigarette, or consume alcohol.
PHYSICAL EXAMINATION
Physical examination was performed on 7th of July 2015, 00.20 AM at Emergency Unit RSMC. General cond.
: Moderately ill
Consciousness
: Compos mentis
BP
: 120/80 mmHg (lying down)
Pulse
: 102 x/min regular, strong, equal
Respiration
: 20 x/min regular
Temperature : 37,7°C (axilla)
STATUS GENERALIS Eyes
: RCL +/+, RCTL +/+, isocor 3mm, CA-/-, SI -/-
ENT
: hyperemia phanynx (-), T1/T1
Thorax
: - Heart
: Ictus cordis (N) Regular S1 S2 heart sound Murmur (-) Gallop S3 S4 (-)
- Lungs
: Chest expansion R=L Sonor on percussion Vesicular breath sound ; wheezing -/- ronchi -/-
Exremities : warm, edema -/-, CRT< 2s
#
LOCAL STATUS: Abdomen : Inspection : distended, surgical scars (-) Auscultation : Bowel sound (+) normal Palpation : Muscular defense (-) , tenderness (+) & rebound tenderness (+) on right lower quadrant.
Percussion : Timpanic (+) on all abdominal regions - McBurney ’s sign (+) - Rovsing’s sign (+) - Psoas sign (+) - Obturator sign (-) - Dunphy sign (+)
WORKUP
-
Laboratory examination was performed on 7th of July 2015, 00.30 AM at RSMC, with results as following: TEST
RESULT
UNIT
NORMAL
Hemoglobin
12,7
g/dL
12 – 16
Hematokrit
36
%
37 – 54
Leukosit
9500
/!L
5.000 – 10.000
Trombosit
75.000
/!L
150.000 – 400.000
CT
4
menit
2–6
BT
2
menit
1–3
Glukosa Sewaktu
130
mg/Dl
<200
SGOT
19
u/l
<35
SGPT
19
u/l
<35
Ureum
21
Mg/dl
20-50
Creatinin
0,75
Mg/dl
0,8-1,1
$
Hasil
Nilai Normal
Warna
Kuning
Kuning
Kekeruhan
Jernih
Jernih
pH
6,5
6-8
Protein
-
-
Reduksi
-
-
Berat jenis
1,005
1,015-1,025
Bilirubin
-
-
Urobilin
+
+
Keton/ Blood
-/-
-/-
Nitrit
-
-
leukosit
2-3
<5 / LPB
Eritrosit
1-2
<3 / LPB
EPITEL
+
<1 / LPK
Silinder
-
-
K. Ca Oxalat
-
-
K. As. Urat
-
-
K. Tripel Phosphat
-
-
Amorf
-
-
SEDIMEN
-
Electrocardiogram :
%
SUMMARY
A 62 year-old woman came to Emergency Unit RS Marinir Cilandak on 7th of July 2015, 00.20 AM, with complaint of right lower abdominal pain 1 days prior to hospital admission. The patient was also have fever for 3 days prior to hospital admission, chills (-). Loss of appetite, nausea and vomiting was present. She had vomited twice, half an cup of clear liquid. The patient is not taking any medication before. Allergy (-), hypertension(-), DM (-), heart disease (-), or another chronic disease. On physical examination, the patient seems moderately ill, temperature of 37,7°C. Abdominal examination reveals distended surface and no surgical scars on inspection, normal bowel sound on auscultation. On palpation, muscular defense (-),but tenderness and rebound tenderness on right lower quadrant are found. On percussion, all abdominal regions are timpanic. Special tests performed revealed all positive results, they are McBurney’s, Rovsing’s, Dunphy’s and psoas sign. Laboratory examination performed on 00.30 AM on the same day reveals there is thrombocytopenia but no leukocytosis. And for the result of urinalysis and ECG were normal.
DIAGNOSIS
Based on history taking, physical examination and laboratory examination, the working diagnosis of the patient can be established. Working diagnosis: •
Thrombocytopenia e.c. susp. Dengue fever
•
Acute appendicitis
MANAGEMENT
Instructions from dr.Sinarta , Sp.PD: -
IVFD RL 20 gtt/min
-
Consult general surgeon (dr. Setiawan W., Sp.B)
-
Consult anesthesiologist (dr.Eka, Sp.An)
-
Stop per oral for 8 hours pre-operative.
! scheduling
for surgery
MEDICATIONS -
Inj. Ondancentron 3 x 4 mg IV
&
-
Inj. Ceftriaxone 2 x 1 gr IV / drip in NaCl 0,9% 100cc.
-
Ulsafat syrup 3 x C1 PO
-
Paracetamol 3 x 500 mg tab PO
! skin
test
SURGICAL INTERVENTION Appendictomy was performed on 8th of July 2015, 08.00 AM at OK 1 RSMC with team as following: Operator
: dr. Setiawan, Sp.B
Instrument
: Nunung
Surgical assistant
: Coass
Onloop
: Lela
Anesthesiologist
: dr. Eka, Sp.An
Operation Report : Spinal anesthesia was performed by dr. Eka, Sp.An
After septic-antiseptic procedure using povidone iodine has been done, incision was made on Mc.Burney point. +/10cm.
'
Visualization of the peritoneum
Exploration of the peritoneal content to find the appendix.
The apendix was found.
The rest of mesoappendix was ligated and cut.
(
Using
polypropylene
thread,
the
surrounding of the cut appendix was sutured.
And
then
we
did
appendectomy.
Appearance of the resected appendix.
We used pivodine iodine to the tip of appendix where we cut it.
And also used cauterization to the tip of appendix.
)
The remaining part of the cut appendix were inserted into the caecum while the surrounding sutured were pulled to from
the
“Tabaczac”
or
“tobacco
pouch”-like suture.
Bleeding treated. Intestines were put back to place and then closing the abdomnal layers.
The
deep
abdominal
layers
were
completely closed.
Skin sutures made using subcuticular technique.
*+
The suture was done.
The wound then closed by kassa verban
POST-OP INSTRUCTIONS -
IVFD RL : Dextrose 5% = 1:3 (28 gtt/min)
-
Inj. Ceftriaxone 2 x 1 gr (IV)
-
Inj. Tramadol 2 x 100 mg (IV)
-
Dulcolac supp. 1x1
-
Fasting until Bowel sound (+), and flatus (+)
! 2
days
! 2
days
FOLLOW UP
Tanggal
Follow Up
7/7/15
S : nausea (+), vomiting (-), loss of appetite. Fever (+), pain in right lower quadrant of abdomen was persistent. It
**
become worst when she move her right leg to flexed position. O: General condtion : moderately ill Conciousness : CM BP: 120/80 ; P : 90bpm ; RR: 20 x/m; T: 36,5 STATUS GENERALIS Eyes : RCL +/+, RCTL +/+, isocor 3mm, CA -/-, SI -/ENT : hyperemia phanynx (-), T1/T1 Neck : lymphadenopathy (-) Thorax : - Heart : S1S2 regular, M (-), G (-) - Lungs : Vesicular breath sound, Wh -/-, Rh -/Exremities : warm, edema -/STATUS LOKALIS Abdomen : -distended surface, bowel sound (+), tenderness (+) RLQ Lab
Result
Hb
12,7
Ht
36
Leu
7.800
Trom
85.000
A : DHF grade I Acute Appendicitis ! pro-op P: -
IVFD RL 20 gtt/min
-
Inj. Ondancentron 3 x 4 mg IV
-
Inj. Ceftriaxone 2 x 1 gr IV / drip in NaCl 0,9% 100cc.
-
Ulsafat syrup 3 x C1 PO
*!
8/7/15
-
Paracetamol 3 x 500 mg tab PO
-
Operation : appendectomy on 8/7/15.
! stop
oral start at 00.00.
S : nausea (-), vomiting (-). Headache (-). Fever (+). O: General condtion : moderately ill Conciousness : CM BP: 120/70 ; P : 86 bpm ; RR: 20 x/m; T: 37,4 STATUS GENERALIS Eyes : RCL +/+, RCTL +/+, isocor 3mm, CA -/-, SI -/ENT : hyperemia phanynx (-), T1/T1 Neck : lymphadenopathy (-) Thorax : - Heart : S1S2 regular, M (-), G (-) - Lungs : Vesicular breath sound, Wh -/-, Rh -/Exremities : warm, edema -/STATUS LOKALIS Abdomen : -distended surface, bowel sound (+), tenderness (+) RLQ Lab
Result
Hb
12,4
Ht
35
Leu
8.900
Trom
91.000
A : DHF grade I Acute Appendicitis ! pro-op P: -
IVFD RL 20 gtt/min
-
Inj. Ondancentron 3 x 4 mg IV
*#
9/7/15
-
Inj. Ceftriaxone 2 x 1 gr IV / drip in NaCl 0,9% 100cc.
-
Ulsafat syrup 3 x C1 PO
-
Paracetamol 3 x 500 mg tab PO
-
Appendictomy at 08.00 AM
S : nausea (+), vomiting (-), headache (-). Pain on surgical wound. Flaatus (+). O: General condtion : moderately ill Conciousness : CM BP: 120/80 ; P : 90bpm ; RR: 18 x/m; T: 36,3 STATUS GENERALIS Eyes : RCL +/+, RCTL +/+, isocor 3mm, CA -/-, SI -/ENT : hyperemia phanynx (-), T1/T1 Neck : lymphadenopathy (-) Thorax : - Heart : S1S2 regular, M (-), G (-) - Lungs : Vesicular breath sound, Wh -/-, Rh -/Exremities : warm, edema -/STATUS LOKALIS Abdomen : - Surgical wound closed by kassa verban. Leakage (-), Bowel sound (+) minimal. Tenderness (+). A : DHF grade I
! improvement.
Post Appendictomy – Day 1. P: ! 28
-
IVFD RL: D5% = 1: 3
gtt/min
-
Inj. Ceftriaxone 2 x 1 gr IV / drip in NaCl 0,9% 100cc.
-
Inj. Tramadol 2 x 100 mg IV
-
Diet : drink gradually. And for afternoon : porridge.
*$
PROGNOSIS
Ad vitam
: ad bonam
Ad sanationam
: ad bonam
Ad fungsionam
: ad bonam
CASE DISCUSSION
Based on clinical findings and physical examination found on the patient, the diagnosis made is acute appendicitis. The diagnosis of acute appendicitis was confirmed using MANTRELS/ALVARADO score:
Faetures
Point
Patient
Migrating of pain to the RLQ
1
+
Anorexia
1
+
Nausea
1
+
Tenderness in RLQ
2
+
Rebound tenderness
1
+
Elevated temperature
1
+
Leukocytosis
2
-
Shifting of WBC to the left
1
-
Total
7/10
So even though there is no leukocytosis in this patient the MANTRELS Score still show that the patient can be diagnosed with acute appendictis, because the score that indicates to acute appendicitis is >=7/10 for MANTRELS Score.
But the patient was operated on the second day of hospitalizaton. The reason is because her thrombocytopenia. She diagnose with DHF grade I, and it means when we push for appendictomy to be done in the first day, t may increase the risk of heavy bleeding. So we took the safest way, dr.Setiawan did the appendictomy in the second day, the laboratorium result of the platelets count of patient has increased, which was orignally 75.000/ul into 91.000/ul.
*%
However there is some literature that says that the normal limit of platelets for surgery procedure is 70.000/ul. and the minimum limit for surgery procedures is 50.000/ul with an increased risk for complcation intraoperative or post-operative. If platelets count below 50.000/ul we must not to do surgery, because it would create a risk and requires some pre-operative preparations.
LITERATURE REVIEW 1. Introduction
All physicians should have a thorough knowledge of appendicitis. Although most patients with acute appendicitis can be easily diagnosed, there are many in whom the signs and symptoms are quite variable, and a firm clinical diagnosis may be difficult to establish. It is for this reason that the diagnosis is made rather liberally , with the full expectation that some patients will be operated on and found to have a normal appendix. It is preferable to maintain broad indications, as this tends to include the group of patients with indefinite signs and symptoms who actually have the disease but do not fulfill the classic criteria for the diagnosis. Following this course, patients who might proceed to perforation of the appendix, with a host of possible secondary complications, are spared that fate. Therefore, it is generally agreed that 10% to 15% of patients having a diagnosis of acute appendicitis by acceptable standards in most hospitals will actually be found at operation to have a normal appendix.
2. Anatomy
The vermiform appendix is located in the right lower quadrant, arises from the cecum, and is generally 6 to 10 cm in length. It has a separate mesoappendix with an appendicular artery and vein that are branches of the ileocolic vessels. The appendix is lined with colonic epithelium characterized by many lymph follicles numbering approximately 200, with the highest number occurring in the 10- to 20-year-old age group. After the age of 30, the number of lymph follicles is reduced to a trace, with total absence of lymphoid tissue occurring after the age of 60. The appendix may lie in a number of locations, essentially at any position on a clock wise rotation from the base of the cecum. It is important to emphasize that the anatomic position of the appendix
*&
determines the symptoms and the site of the muscular spasm and tenderness when the appendix becomes inflamed.
3. Pathophysiology
It is widely accepted that the inciting event in most instances of appendicitis is obstruction of the appendiceal lumen. This may be due to lymphoid hyperplasia, inspissated stool (a fecalith), or some other foreign body. Given the correlation with the incidence of appendicitis by age and the size and distribution of the lymphoid tissue, it is likely that lymphoid obstruction or partial obstruction of the lumen is a common cause. Obstruction of the lumen leads to bacterial overgrowth as well as continued mucous secretion. This causes distention of the lumen, and the intraluminal pressure increases. This may lead to lymphatic and then venous obstruction. With bacterial overgrowth and edema, an acute inflammatory response ensues. The appendix then becomes more edematous and ischemic. Necrosis of the appendiceal wall subsequently occurs along with translocation of bacteria through the ischemic wall. This is gangrenous appendicitis. Without intervention, the gangrenous appendix will perforate with spillage of the appendiceal contents into the peritoneal cavity. If this sequence of events occurs slowly, the appendix is contained by the inflammatory response and the omentum, leading to localized peritonitis and everntually an appendiceal abscess. If the body does not wall off the process, the patient may develop diffuse peritonitis.
4. Clinical diagnosis
The diagnosis of acute appendicitis is made primarily on the basis of the history and the physical findings, with additional assistance from laboratory examinations. The typical history is one of onset of generalized abdominal pain followed by anorexia and nausea. The pain then becomes most prominent in the epigastrium and gradually moves toward the umbilicus, finally localizing in the right lower quadrant. Vomiting may occur during this time. Examination of the abdomen usually shows diminished bowel sounds, with direct tenderness and spasm in the right lower quadrant. As the process continues, the amount of spasm increases, with the appearance of rebound tenderness. The temperature is usually mildly elevated (approximately 38° C.) and usually rises to higher levels in the event of perforation. Direct tenderness is usually present in the right lower quadrant
*'
and may involve other parts of the abdomen, particularly if perforation has occurred. The appendix is usually situated at or around McBurney's point (a point one third of the way on a line drawn from the anterior superior spine to the umbilicus). However, it must be emphasized that the exact anatomic location of the appendix can be at any point on a 360-degree circle surrounding the base of the cecum, as shown in (Figure 1) This is the site where the pain and tenderness are usually maximal, and the exact site may vary from patient to patient. Rovsing's sign, elicited when pressure applied in the left lower quadrant reflects pain to the right lower quadrant, is often present. The psoas sign may be positive and is elicited by extension of the right thigh with the patient lying on the left side. As the examiner extends the right thigh with stretching of the muscle, pain suggests the presence of an inflamed appendix overlying the psoas muscle. The obturator sign can be elicited with the patient in the supine position with passive rotation of the flexed right thigh. Pain with this maneuver indicates a positive sign. Rectal examination generally elicits tenderness at the site of the inflamed appen-dix in the right lower quadrant. If the appendix ruptures, abdominal pain becomes intense and more diffuse, the muscular spasm increases, and there is a simultaneous increase in the heart rate above 100, with a rise in temperature to 39° or 40° C. At this time, the patient appears toxic, and it becomes obvious that the clinical situation has deteriorated. Olivier Monneuse and colleague, in France from 2002-2005 review of 326 patients, this study was designed to quantify the proportion of patients with a preoperative diagnosis of acute appendicitis that had isolated right lower quadrant pain without biological inflammatory sign's and then to determine which imaging examination led to the determination of the diagnosis. The diagnosis acute appendicitis can not be excluded when an adult patient present with isolated rebound tenderness in the right lower quadrant evwen without fever and biological inflammatory signs.
5. Laboratory finding
The clinical history and physical examination are most important in establishing a diagnosis of acute appendicitis, but laboratory findings may be helpful. The majority of patients with acute appendicitis have an elevated leukocyte count of 10,000 to 20,000. For those in whom the level is normal, there is generally a shift to the left in the
*(
differential leukocyte count, indicating acute inflammation. However, it should be emphasized that a number of patients have a normal leukocyte count, especially the elderly. Urinary analysis may show a few red cells, indicating some inflammatory contact with the ureter or urinary bladder; a significant number of erythrocytes in the urine indicates a primary disorder of the urinary tract. 6. Treatment
For the vast majority of patients with a diagnosis of acute appendicitis, the appropriate management is appendectomy. For patients with simple acute appendicitis, intravenous fluids should be initiated as well as an antibiotic agent effective against both aerobic and anaerobic organisms. All patients are begun on antibiotics preoperatively and maintained post-operatively as needed. If the appendix is unruptured and not gangrenous, antibiotics can be discontinued after 24 hours. Although many agents are effective, cefoxitin is often the agent of choice on the basis of a multicenter randomized trial of 1735 patients. Half received 2 gm. of cefoxitin preoperatively. Three groups were evaluated: patients with a normal appendix, those with an acutely inflamed appendix, and those with a gangrenous appendix. The incidence of wound infection was significantly lower in all three groups. However, the formation of intra-abdominal abscess was not influenced by preoperative antibiotics. In a recent double-blind controlled study, prophylactic cefotetan was compared with prophylactic cefoxitin in the development of postoperative wound infections in patients with acute nonperforated ap-pendicitis. The results showed that single-dose cefotetan and multiple-dose cefoxitin are equally effective. However, because of the greater convenience and decreased cost, single-dose cefotetan was considered the prophylaxis of choice in appendectomy for nonperforated appendicitis. Clindamycin with an aminoglycoside is indicated when Bacteroides fragilis is present; metronidazole can also be used for this organism. This meta-analysis suggest that although antibiotic may be used as primary treatment for selected patients with suspected uncomplicated at present. Selection bias and crossover to surgery in the RCTs suggest that appendectomy is still the gold standard therapy for acute appendicitis.
*)
7. Surgical
There are two approaches to removal of the non perforated appendix: through an open incision, usually a transverse right lower quadrant skin incision (Davis-Rockey) or an oblique version (McArthur-McBurney) with separation of the muscles in the direction of their fibers, or a paramedian incision, but this is not routinely done. The incision is centered on the midclavicular line. Occasionally, where the diagnosis is uncertain, a periumbilical midline incision can be used. Once the peritoneum is entered, the appendix is delivered into the field. This can usually be accomplished with careful digital manipulation of the appendix and cecum. It is important to avoid too extensive of a blind dissection. In difficult cases, extending the incision 1 to 2 cm can greatly simplify the procedure. Once the appendix is delivered into the wound, the mesoappendix is sacrificed between clamps and ties. There are several ways to handle the actual removal of the appendix. Some surgeons simply suture ligate the base of the appendix and excise it. Others place a purse string or Z- stitch in the cecum, excise the appendix, and invert the stump into the cecum. We have used both approaches. Once the appendix is removed, the cecum is returned to the abdomen, and the peritoneum is closed. The wound is closed primarily in most patients with non perforated appendicitis because the risk of infection is less than 5%.
Acute appendicitis is one of the commonest of surgical emergencies and appendectomy has become established as the gold standard of therapy. However as the diagnosis of appendicitis in most centers is mainly a clinical one , based on history and examinations diagnostic uncertainly in patients with suspected appendicitis may lead to delay in treatment or negative surgical exploration, adding to the morbidity associated with the condition.
!+
REFERENCES
1. Beauchamp RD, Evers BM, Mattox KL, Sabiston Textbook of Surgery, 16th ed. Philadelphia, W.B.Saunders Company. 2001. P. 919. 2. Sabiston DC, Lyerly HK, Sabiston Textbook of Surgery, 15th ed. Philadelphia, W.B.Saunders Company. 1997. P. 964. 3. Brunicardi FC, Anderson DK, Billiar TR, Dunn DL, Hunter JG, Pollock RE. Schwartz's Principles of Surgery. 8th ed , New York , McGraw Hill, 2010. P. 1080. 4. Salari AA. Peritonitis and Intraabdominal abscess. Yazd, Tebgostar, Shahid Sadoghi University of Medical sciences. Yazd, Iran. 2003. P. 93-110. 5. Sabiston DC, Lyerly HK, Sabiston Textbook of Surgery, 15th ed. Philadelphia, W.B.Saunders Company. 2001. P. 961-969. 6. Schwartz SI, Shires GT, Spencer FC. Principles of Surgery. 8th ed , New York , McGraw Hill, 1994. P.1304-1318. 7. Ronald F. Anderson. Routine ultrasound and limited computed tomography for the diagnosis of acute appendicitis : A surgeon perspective. World Journal of Surgery. 2011; 35: 295-296. 8. Sjamsuhidajat R, Karnadihardja W, Prasetyono TO, Rudiman R. Apendiks Vermiformis. Dalam: Buku Ajar Ilmu Bedah. Edisi 3. Jakarta; 2007.h.755-62. 9. Doherty GM. Appendix. Dalam: Current Diagnosis and Treatment: Surgery. Thirteenth Ed. New York, NY: McGraw-Hill Companies; 2010. h,615-8.
!*
