Professional Documents
Culture Documents
Dr.Oko Chukwuemeka otutodilchukwu 4th year , Group 42 Lugansk state medical university, ukraine 15-05-2013
Objectives
To
review the pathophysiology and clinical presentation of acute appendicitis and the lesions/cancer. To understand which patient groups are at high risk of misdiagnosis To discuss the use of laboratory and imaging studies in the diagnosis of acute appendicitis
% lifetime incidence 69 % are ages 10 to 30 Up to 30 % misdiagnosed initially 20 to 30 % ruptured at surgery Mortality : 0.1 to 0.2 % unruptured, 3 to 5 % ruptured Significant morbidity
Anatomic Aspects
Blind pouch off of cecum Contains lymphoid tissue which peaks in
adolescence, atrophies with age Function still unclear Appendix can be anywhere within peritoneal cavity One study showed 65 % retrocecal, 31 % pelvic Review of 70,000 cases showed 4 % in RUQ, 0.06 % LUQ, 0.04 % LLQ
Pathophysiology of Appendicitis
Lymphoid hyperplasia leads to luminal
obstruction Often follows viral illness Epithelial cells secrete mucus Appendix distends, bacteria multiply Visceral pain begins an average of 17 hours after obstruction Increased pressure compromises blood supply Somatic pain develops Average time to perforation = 34 hrs.
Classic Presentation
Seen
in 60 %
Anorexia Periumbilical pain, nausea, vomiting RLQ pain developing over 24 hrs.
Anorexia
and pain are most frequent Usually nausea, sometimes vomiting Diarrhea, esp. with pelvic location Usually tender to palpation Rebound is a later finding
Physical Exam
Tenderness
at McBurney's point Cutaneous hyperesthesia in T 10 to 12 dermatomes Rovsing's sign Psoas sign Obturator sign
MANTRELS Score
Established
in 1986
Migration of pain Anorexia Nausea / vomiting Tenderness RLQ Rebound Elevated temp. Leukocytosis Shift to left
tenderness and leukocytosis = 2 points each ; all others 1 point Score of 5 to 6 = possible appendicitis Score of 7 to 8 = probable appendicitis Score of 9 to 10 = very probable appendicitis
women
Most common surgical disorder in kids Accounts for 5 % of abd. pain visits Up to 50 % initially misdiagnosed
< 2 yrs. : perforation rate approaches 100 % 3 to 5 yrs. = 71 % 6 to 10 yrs. = 40 %
Most common misdiagnosis is AGE Sequence of pain and vomiting may be helpful Localized tenderness not a feature of AGE
Appendix Mass
An appendix mass is an inflamed appendix with an adherent covering of omentum and small bowel. The history is similar to that of appendicitis with a longer duration since onset. Examination reveals a mass in the right iliac fossa.
If a mass in the appendix is encountered incidentally during the course of abdominal surgery, an appendectomy is performed with frozen-section analysis of the mass. Most masses prove to be benign mucoceles or very small carcinoids. When carcinoid tumors of the appendix are small (<1 cm in diameter), they may be treated adequately by standard appendectomy. If they are greater than 2 cm in size, the patient should have a right hemicolectomy.
Differential Diagnosis
Gastroenteritis TOA
Mesenteric
Ectopic
UTI
pregnancy
Pyelonepritis Other
" No single evaluation can substitute for the diagnostic accuracy of the experienced physician."
Laboratory Studies
CBC
panel
Imaging Studies
Plain
films
Low sensitivity and specificity Appendicolith specific, but seen in only 2 % May see local air-fluid levels, psoas
obliteration, soft tissue mass, gas in appendix : all nonspecific
75 to 90 % sensitive, 86 to 100 % specific Noninvasive, low cost, but operatordependent Good for diagnosing GYN disorders 3 criteria for diagnosis Tender, noncompressible appendix No peristalsis of appendix Overall diameter > 6 mm
(US)
from Austria
Analgesia
Sir
Zachary Cope's 1921 textbook of surgery and Dr.Emeka Oko said no way! Prospective studies (both EM and Surgery literature) now show appropriate use of IV narcotics does not decrease diagnostic accuracy, and may improve exam
Analgesia, cont'd.
Journal
2003
Prospective, randomized, double blind study Adults with abd. pain got up to 15 mg morphine
vs. placebo Increased pain relief, with no change in diagnostic accuracy
Not
all surgeons read their own literature, so give them a chance to come in a reasonable time frame or give the meds
Risk Management
Misdiagnosis
of appendicitis = 5th leading cause of successful litigation against EPs 7 features of misdiagnosed cases : No nausea / vomiting Lack of distress No rebound No guarding No rectal exam (controversial) Narcotic pain meds given Diagnosis of acute gastroenteritis
discharging, stress unclear diagnosis, what to watch for Follow up in 12 hours (PMD or E.D.) Can always observe if unsure
Summary
Appendicitis
is a common surgical emergency with a varied clinical presentation Several patient groups are at high risk of misdiagnosis Lab and imaging studies are helpful, but no single study is a substitute for good clinical judgement