INTRODUCTION

Appendicitis
is the inflammation of the appendix and it can either be chronic or acute.
Appendix is a finger-shaped pouch about 5-10cm that projects or protrudes from
the colon on the lower right side of the abdomen. It existence does not have
any specific purpose actually.in article reviewed by Nancy Carteron stated that
in the United States, appendicitis is the most common cause of abdominal pain
which cause to surgery. Also stated that about 2 percent of Americans will
experience appendicitis at some point of their lives. Appendicitis can happen
at any time, and most occur often during the age of 10 and 30. Males are
commonly to get appendicitis.

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Appendicitis
exact cause is not known, but it may be because of food or faeces (poo) that
get ledged in the appendix. Naturally, faeces will go through a process which is
mixed in the distensable well of the cecum before being pushed on. Some of the
stool may pass into the appendix, but peristalsis of appendiceal may push it
back into the colon. The appendix also make antibodies and mucous which are
also pushed into the cecum by peristalsis. The likely cause of appendicitis to
occur is due to blockage in the lining of the appendix that results in
infection. The bacteria rapidly multiply, which is causing the appendix to
become inflamed, swollen and filled with pus.

As we
discussing about appendicitis usually it refer to acute appendicitis, which is
marked by a sharp abdominal pain as it quickly spreads and worsens just a
matter of hours. But in some cases, some people may develop chronic
appendicitis which causes mild, recurrent abdominal pain that often subsides on
its own. These patients usually do not realize that they have appendicitis
until an acute episode strikes.

The
hallmark of appendicitis is the abdominal pain as it described as cramping ,or
aching pain, dull throughout the abdomen that starts gradually. It often occur
at belly button. Appendicitis often mistaken with other illnesses because of
its closeness to other internal organs, it is sometimes difficult to sure if it
is appendicitis. To confirm this condition, the doctor will conduct a physical
examination and ask about the health history.

Johns
Hopkin Medicine states that an inflamed appendix can rupture within 48 hours to
72 hours as soon as the symptoms have started. That’s why it is very important
to consult physician immediately as soon as exhibit the symptoms that
indicating the appendicitis.

 

 

 

 

2.0 HISTORY TAKING

2.1 Chief Complaint

A 13 year old boy presents with
abdominal pain, anorexia, nausea and low grade fever.

2.2 History of
Presenting Illness

He claimed that he did not
have any appetite and did not feel like eating. The pain was getting gradually
worse in the last few hours. He had not taken any food in the last 8 hours. He
denied any difficulty in passing urine and there were no symptoms of frequency
or dysuria. The pain was more towards his right side of abdomen and pointed the
right iliac fossa where he feels the maximum pain.

2.3 Past Medical History

Patient never experienced
any similar episode in the past and has been very healthy and active. He had
all his childhood immunization.

2.4 Family History

No history of similar
experienced

2.5 Social History

The patient is a form 1
student lives with his parents and go to elementary school in Ampang. He did
not smoke or take any alcohol.

2.6 Physical Examination

Physical examination
reveals a low grade fever (38?C ; 100.5?F), pain on palpation at right lower quadrant that it was
essentially soft and scaphoid. There was appreciable direct tenderness over the
right iliac fossa and in particular over the McBurney’s point. The liver and
spleen were not palapable and no mass was felt in the abdomen. His temperature was 100.2? F with a pulse rate of 88/mt and BP
of 110/70 mmHg. Cardiovascular system and respiratory system were entirely
within normal limits.

 

 

 

 

3.0 INVESTIGATIONS

1.     
Physical exam to assess the pain.

Additional
testing for rebound tenderness, Rovsing’s sign, Psoa’s sign and obturator sign.

2.     
Blood test

To
check for signs of infection

The
white blood cell count was 14500 with 89 polymorphous and 11 lymphocytes

3.     
Urine test

To
make sure causing the pain is not from urinary tract infection or kidney stone.

The
urinalysis was essentially normal except for presence of ketones

4.     
Imaging test

Abdominal
X-ray, an abdominal ultrasound or a computerized tomography (CT) scan to
confirm appendicitis

 

4.0 DIFFERENTIAL
DIAGNOSIS

•        
Crohn’s disease,

•        
ulcerative colitis,

•        
gallbladder problems,

•        
urinary tract infections (UTI),

•        
pelvic inflammatory disease,

•        
gastritis

•        
intestinal obstruction

5.0 DEFINITIVE DIAGNOSIS

Acute appendicitis

6.0 MANAGEMENT

IV fluids

emergency surgical care,
transverse incision appendectomy

 

 

 

 

7.0 DISCUSSION

7.1 LOCATION

Appendicitis usually occur
at the appendix which is the finger-shaped pouch that attached to the junction
of the small intestine and large intestine. Normally it sits in the lower right
abdomen.

7.2 PREVALENCE

In the United States,
appendicitis is the most common cause of abdominal pain which cause to surgery.
About 2 percent of Americans will experience appendicitis at some point of
their lives. Appendicitis can happen at any time, and most occur often during
the age of 10 and 30. It tends to affect males, those in lower income groups
and, for unknown reasons, people living in rural areas. In 2013 it resulted in
72,000 deaths globally down from 88,000 in 1990. The annual mortality rate per 100,000 people from
appendicitis in Malaysia has decreased by 31.0% since 1990, an average of 1.3%
a year.

7.3 AETIOLOGY AND FACTOR
CONTRIBUTE

Experts believe that having
either partial or complete obstruction in the appendiceal lumen is the primary
cause of appendicitis. Appendiceal lumen blockage occur either because of the
accumulation of fecal matter or other materials such as :

·        
Intestinal parasite like pinworm (Enterobius
vermicularis)

·        
Appendicoliths or fecaliths (calcified fecal deposits)
also known as “appendix stone”

·        
Enlarged lymph tissue on the appendix wall, which
usually arises because of GI tract infections

·        
Ulcers and other GI tract irritation caused by chronic
digestive ailments like ulcerative colitis and diverticulus

·        
Foreign objects like bullets, stones, pins and air gun
pallets that have been accidentally ingested

·        
Tumors

Infection whether viral,
bacterial or fungal in nature, may spread to appendix causing an obstruction.
Some of the common infections that may lead to appendicitis include

·        
Adenovirus

·        
Bacteroides bacteria

·        
Salmonella

·        
Measles

·        
Shigella bacteria

·        
Mucormycosis and histoplasmosis

People who get appendicitis
usually have genetics as an underlying risk factor. One study found that people
who have a family history of appendicitis may have a nearly three times higher
risk of getting this ailment.

7.4 CLINICAL FEATURES
AND SIGNS AND SYMPTOMS

Signs and symptoms of
appendicitis include

·        
Abdominal bloating

·        
Loss appetite

·        
Low grade fever that may worsen as the illness
progress

·        
Constipation or diarrhea

·        
Nausea and vomiting

·        
Pain that worsen if you cough, walk or make other
jarring movements

·        
Sudden pain that begins around your navel and often
shifts to your lower right abdomen

·        
Inability to pass gass

7.5 INVESTIGATION

The aim of
investigation is to help diagnose appendicitis, your doctor will likely take a
history of your signs and symptoms and do physical examination specifically the
abdomen. Physical exam is done to access the pain. The doctor may apply gentle
pressure on the painful area. When the pressure is suddenly released, the
appaendicitis pain will often feel worse, signaling that the adjacent
peritoneum is inflamed. Doctor also may look for abdominal rigidity and a
tendency for you to stiffen your abdominal muscles in response to pressure over
the inflamed appendix.

Another
investigation is blood test which is to allow your doctor to check for a high
white blood cell count that may indicate an infection. During early
appendicitis, before infection occur, white blood cell count can be normal, but
most often there is at least a mild elevation even early in the process.
Unfortunately, appendicitis is not the only condition that causes elevated
white blood cell counts. Almost any infection or inflammation can cause the
count to be abnormally high. Therefore, an elevated white blood cell count
alone cannot be used to confirm a diagnosis of appendicitis.

Urine test
or urinalysis is done to make sure that a urinary tract infection or a kidney
stone is not causing the pain. It is a microscopic examination of the urine
that detects red blood cells, white blood cells and bacteria in the urine. It
is usually abnormal when there is inflammation or stones in the kidneys or
bladder. It also can be abnormal with appendicitis because the appendix lies
near the ureter and bladder. It can spread the inflammation to the ureter and
bladder if the inflammation is great enough. Most patients with appendicitis
however have a normal urinalysis and that conclude that normal urinalysis
suggests appendicitis and not urinary tract infection.

            Doctor will recommend the imaging test such as abdominal
X ray, an abdominal ultrasound or a computerized tomography (CT) scan to help
the confirmation. The abdominal X-ray may detect the fecalith which is the
hardened and calcified, pea sized piece of stool that blocks the appendiceal
opening. An ultrasound is painless procedures that uses sound waves to provide
images to identify organs within the body. Ultrasound can identify enlarged
appendix or an abscess. In
patients who are not pregnant, a CT scan at the area of the appendix is very useful
in diagnosing appendicitis excluding other diseases inside the abdomen and
pelvis that can mimic appendicitis.

7.6 MANAGEMENT OF
PATIENT

            Appendectomy remains the only
curative treatment of appendicitis, but management for patients with an
appendiceal mass can usually be divided into the following 3 treatment
categories:

1.     
Patients with a phlegmon or a small abscess: After
intravenous (IV) antibiotic therapy, an interval appendectomy can be performed
4-6 weeks later.

2.     
Patients with a larger well-defined abscess: After
percutaneous drainage with IV antibiotics is performed, the patient can be
discharged with the catheter in place. Interval appendectomy can be performed
after the fistula is closed.

3.     
Patients with a multicompartmental abscess: These
patients require early surgical drainage.

7.7 TREATMENT

There are
two main types of appendectomy which are both carried out under a general
anesthetic. The doctor will determine which of the two appendectomy to be
recommend.

Laparoscopy- known also as “keyhole surgery” and
it is the most preferred procedure as its quicker recovery time. But it is in
the case of the appendix is not yet ruptured and for obese or elderly patients.
Three or four small incisions are made on the abdomen, and the special
instruments and few small surgical tools are inserted and used to remove the
appendix

Open
surgery – this is
for if the appendix has already ruptured. This is also recommended for someone
has done open abdominal surgery or the surgeon never done the keyhole surgery.

There is
non-surgical treatment which is useful when appendectomy is not accessible or
when it is temporarily a high-risk procedure. Anecdotal reporst describe the
success of IV antibiotics in treating the acute appendicitis without access to
surgical intervention.

 

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