O.O.Bogomolets National Medical University Department of Faculty Surgery #1 “Approved” at the Methodist Faculty Surgery Department # 1 Council “__”_____2008, protocol #_____ Head of Faculty Surgery Department # 1 Professor _______ M.P.ZakharashStudy Guide for Practical Work for Teachers and Students Topic: “ The differential diagnosis for appendicitis”. Course 4 Foreign Students’ Medical Faculty Duration of the lesson – 45 min. Worked out by Assistant T.Kravchenko Kyiv 2008
I. The theme actualityThe differential diagnosis of appendicitis can include almost all causes of abdominalpain, as described in the classic treatise “Copes Early Diagnosis of the AcuteAbdomen.” A useful rule is never to place appendicitis lower than second in thedifferential diagnosis of acute abdominal pain in a previously healthy person.II. Student must know: - the differential diagnosis of appendicitis - appendicitis in young children - appendicitis in elderly - appendicitis during pregnancy - appendicitis in HIV infectionIII. Student must be able to: - to interpret correctly the present manifestations of disease and investigation results - to differentiate appendicitis - to diagnose and make the chart of treatment - to apply the instrumental methods of examination - to conduct examination of patient - to interpret data of examinationsIV. Education aims of the study - forming the deontology presentations, skills of conduct with the patients - to develop deontology presentations, be able to carry out deontology approach to the patient - to develop the presentations of influence of ecological and socio-economic factors on the state of health
- to develop sence of responsibility for a timeliness and loyalty of professional actions - to lay hands on ability to set psychological contact with a patient and his familyV. The contents of a themeDifferential DiagnosesThe diagnosis of appendicitis is particularly difficult in the very young and in theelderly. It is in these groups that diagnosis is most often delayed and perforationoccurs most frequently. Imaging studies are strongly considered here. Because ofincreasing concerns about radiation-induced cancers among children, ultrasonographyis the preferred initial imaging modality in this group. Ultrasonography was shown tochange the disposition of 59% of children with abdominal pain that had already beenevaluated by the surgical team. For older patients, CT has the advantages of detectionof the broader array of conditions, such as diverticulitis and malignancy, found in thedifferential diagnosis.In infants, nonfocal findings such as lethargy, irritability, and anorexia may be presentin the early stages, with vomiting, fever, and pain apparent as the disease progresses.Ultrasound is useful in the evaluation of appendicitis and other acute abdominalemergencies, such as pyloric stenosis, in infants.In preschool-aged children, the differential diagnosis includes intussusception,Meckels diverticulitis, and acute gastroenteritis. Intussusception may be distinguishedby the colicky nature of the pain, with intervening pain-free periods, and the absenceof peritonitis. Meckels diverticulitis is relatively uncommon, but its presentation issimilar to that of appendicitis with the exception that the pain and tenderness typicallylocalize in the periumbilical region. Gastroenteritis can be difficult to distinguish from
acute appendicitis in any age group. Typically, diarrhea and vomiting occur early andpersistently in gastroenteritis, and focal abdominal tenderness and peritoneal signs areuncommon. However, it is advisable to discuss with parents of a child suspected ofhaving gastroenteritis the importance of re-evaluation within 12 to 24 hours if thechild develops worsening abdominal pain, or other signs of clinical deterioration,because misdiagnosed appendicitis remains high on the list of considerations.In school-aged children, gastroenteritis often presents with abdominal pain anddiarrhea without fever or leukocytosis. The most common mimicker of appendicitis inthis population is mesenteric lymphadenitis, which may be caused by a wide varietyof enteric infections. Ultrasonography may be helpful in identifying enlarged lymphnodes in the region of the ileal mesentery in conjunction with thickening of the ilealwall and a normal appendix, in which case appendectomy may be avoided. It isimportant to bear in mind that enlarged mesenteric lymph nodes may also be the resultof acute appendicitis. Inflammatory bowel disease is also considered in children,particularly if there is a history of recurrent episodes of abdominal pain. Constipationand functional pain are common in this age group. Although constipation may beassociated with relatively severe pain, there are no peritoneal signs, fever, orleukocytosis, and the diagnosis is supported by a recent history of hard stools.Functional pain is usually somewhat milder, recurrent, and self-limited.In adults, it is important to consider other regional inflammatory conditions, such aspyelonephritis, colitis, and diverticulitis. The pain and tenderness of pyelonephritis aretypically located in the flank and are accompanied by high fever and white blood cellcount as well as pyuria. Colitis is often accompanied by diarrhea, and the location ofthe pain typically outlines the trajectory of the colon. In Crohns colitis, diarrhea isuncommon, but there is often a pattern of recurrent symptoms. The onset of right-sided diverticulitis is typically insidious, worsening over a period of days, and
involves a larger area of the right lower abdomen than does appendicitis. CT scan ishelpful in identifying the inflamed diverticula and enhancement of cecal wallthickening that accompanies this diagnosis.The differential diagnosis for appendicitis among women in their childbearing years isbroad and accounts for the higher incidence of false-positive diagnoses in this group.Pelvic pathology that may mimic acute appendicitis includes pelvic inflammatorydisease (PID), tubo-ovarian abscess, ruptured ovarian cyst or ovarian torsion, andectopic pregnancy, among others. These conditions are typically distinguished fromacute appendicitis by the absence of gastrointestinal symptoms. Pelvic ultrasound isespecially helpful in these patients because of its high sensitivity and specificity forthe diagnosis of pelvic pathology. If a normal appendix is also seen, appendicitis isunlikely.Appendicitis is the most common nonobstetric surgical disease of the abdomen duringpregnancy. Diagnosis may be difficult because symptoms of nausea, vomiting, andanorexia, as well as elevated white blood cell count, are common during pregnancy.Moreover, the location of tenderness varies with gestation. After the 5th month ofgestation, the appendix is shifted superiorly above the iliac crest, and the appendicealtip is rotated medially into the right upper quadrant by the gravid uterus. Ultrasound ishelpful both in establishing the diagnosis and the location of the inflamed appendix. Incases in which ultrasound has been equivocal, magnetic resonance imaging (MRI) hasbeen used successfully, thereby avoiding ionizing radiation exposure to thedeveloping fetus. The main challenge is to recognize the possibility of appendicitis inpregnant patients and intervene promptly because peritonitis significantly increasesthe rate of fetal loss (2.6%-10.9% in one meta-analysis). Laparoscopic appendectomyhas been performed through the second trimester of pregnancy, although data arelacking comparing the safety of this approach to the open procedure.
Appendicitis in the elderly can be difficult to diagnose because many patients delay inseeking care and present atypically. Fever is uncommon, the white blood cell countmay be normal, and many older patients with appendicitis do not experience rightlower quadrant pain. About one half of older patients are incorrectly diagnosed at thetime of admission, and these patients have a much higher rate of perforation at thetime of surgery because of delays in operative intervention. More than 50% of olderpatients have perforated appendicitis, compared with less than 20% for youngerpatients. Diverticulitis and bowel obstruction are common misdiagnoses in this patientpopulation, and the differential diagnosis also includes malignancies of thegastrointestinal tract and reproductive system, perforated ulcers, and cholecystitis,among others. CT has become an invaluable tool in the evaluation of abdominal painamong older patients, and its use has shortened preoperative hospital delays.Diagnostic AlgorithmPatients in whom the diagnosis of appendicitis is being considered should have asurgical evaluation. Early involvement of the surgical team in the diagnosticevaluation of these patients may improve diagnostic accuracy and help to avoidexpensive and unnecessary diagnostic studies. Experienced clinicians accuratelydiagnose appendicitis based on a combination of history, physical exam, andlaboratory studies about 80% of the time. We stratify patients based on their clinicalfindings starting with the extremes, which are easier to identify. Patients with a highprobability of uncomplicated appendicitis undergo surgery. Patients suspected ofhaving an appendiceal abscess undergo further imaging, typically ultrasonography forchildren or CT for adults. The next step in the evaluation of patients in whom thelikelihood of appendicitis is believed to be low is determined by the probability and
severity of alternate diagnoses under consideration. Many of these patients will bedischarged with a planned follow-up visit or phone call the next day. Most olderpatients with abdominal pain undergo CT before discharge because of the highprevalence of surgical pathology in this patient population. The remaining patients arebelieved to have an intermediate probability of having appendicitis. Children andpregnant women in this category typically undergo abdominal ultrasonography.Women in their childbearing years may undergo pelvic ultrasonography or CT scandepending on the index of suspicion of pelvic pathology. Among patients that wouldotherwise be admitted to the hospital for observation, CT may reduce hospital costs byreducing length of stay. Following the completion of imaging studies, the patient is re-examined to determine whether pain and tenderness have localized to the right lowerquadrant. If the diagnosis remains uncertain at this point, patients either undergodiagnostic laparoscopy, especially in fertile women, are admitted for observation andre-examination, or are discharged with follow-up the next day.VI. Lesson topic control questions.Key points:- Acute appendicitis in young children: diagnosis is more difficult and more rapid progression to peritonitis and rupture- Acute appendicitis in elderly: more rapid progression to perforation, comorbid diseases, high index of suspicion should be maintained- Acute appendicitis during pregnancy: more frequent during first two trimesters, rebound and guardian signs are less frequent, when diagnosis is in doubt, ultrasound may be beneficial- Acute appendicitis in HIV infection: increased risk of appendeceal rupture (delay in clinical presentation), possible cause of RLQ pain may be the opportunistis infections (CMV, Kaposhi sarcoma, TB, lymphoma, mucosal ischemia)
- Appendectomy remains the only curative treatment for appendicitisCasesA 42-year-old white male presents to the ER at 10:00 p.m. with complaints ofabdominal pain, nausea, vomiting. He states the pain is 8/10 in intensity and beganearly in the morning. The pain is located in the left upper quadrant (LUQ) withoutradiation and is described as being achy and dull. There are no exacerbating oralleviating factors. He also complains of a low-grade fever and having no bowelmovements in the last two days. There is no other significant medical history. Labworks reveals WBC 16,000 with left shift, UA is negative. Physical examinationreveals tenderness in the lower border of LUQ, with some guarding, but no rebound orrigidity. A CT of abdomen revealed malrotation with appendicitis. What is the mostappropriate surgical option? 1. A Rocky-Davis incision with appendectomy 2. A midline mini-laparotomy incision with appendectomy 3. Laparoscopic appendectomy 4. Mini-laparotomy incision with appendectomy and excision of Ladd’s bandsAnswer is 4This is a rare presentation of appendicitis within this age group. Malrotation is mostcommonly found within the pediatric population secondary to obstruction. The smallbowel lacks appropriate fixation to the posterior wall and therefore the cecum fails tomigrate to the RLQ as well as the colon not attaching to the lateral abdominal wall.The may lead to right upper quadrant (RUQ) position of the cecum which may extendbands (Ladd’s bands) across the duodenum which may lead to obstruction. Thesurgical correction is to perform an appendectomy as well as a Ladd’s procedure. Thisis extremely difficult throught a Rocky-Davis incision and therefore best performedthrough a midline incision.
VII. Supporting materials required for teaching1. Participation in clinical duties on admission2. Working in libraryVIII. Literature1. Townsend CM, Harris JW. Sabiston’s Textbook of Surgery, 16th ed. Philadelphia, PA: W.B. Saunders Co, 2001, vol.442. Schwartz SI, Schires GT, Spencer FC, Daly JM, Fischer JE, Galloway AC. Principles of Surgery, 7th ed. New York: McGraw-Hill, 1999, vol.273. Bruce E. Jarrell, R.Antthony Carabasi. Surgery, 3rd ed. Williams & Wilkins, 1998