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    1. 1. CASE PRESENTATION Presented by: Fatma Al-Ghaithi
    2. 2. Objectives <ul><li>Case presentation </li></ul><ul><li>Differential diagnosis </li></ul><ul><li>Discussion </li></ul><ul><li>Home massage </li></ul>
    3. 3. <ul><li>Fraught with potential pitfalls, because of absence of a pathognomonic sign or symptom. </li></ul><ul><li>7% of people will develop it sometime during there lifetime. </li></ul><ul><li>Is the 6 th most common missed diagnosis. </li></ul>
    4. 4. case <ul><li>60 yr old female with rt. Lower abdominal pain for 2 days. </li></ul>
    5. 5. <ul><li>Concious, in pain. </li></ul><ul><li>Breathing spontaneously </li></ul><ul><li>Sat-100% R.A </li></ul><ul><li>RR-18 </li></ul><ul><li>BP- 120/75 mmHg </li></ul><ul><li>HR-76/min </li></ul><ul><li>T-36.8 </li></ul>
    6. 6. <ul><li>Known case of HTN. menopaused. </li></ul><ul><li>RLQ pain for 2 days, started at periumbilical. </li></ul><ul><li>Intermittent, colicky. </li></ul><ul><li>Dysurea. </li></ul><ul><li>- No vomiting </li></ul><ul><li>- No diarrhoea or constipation. </li></ul><ul><li>- No fever </li></ul><ul><li>- No no vaginal discharge or bleeding. </li></ul><ul><li>- No hematurea. </li></ul>
    7. 7. Physical examination <ul><li>In pain </li></ul><ul><li>Sat-100% R.A </li></ul><ul><li>RR-18 </li></ul><ul><li>BP- 120/75 mmHg </li></ul><ul><li>HR-76/min </li></ul><ul><li>T-36.8 </li></ul><ul><li>Chest: clear </li></ul><ul><li>CVS: S1, S2 normal, no murmurs. </li></ul><ul><li>Abdomen: </li></ul><ul><li>- no distension, LSCS scar. </li></ul><ul><li>- RLQ tenderness, ? rebound tenderness, - Cough reflex absent </li></ul><ul><li>-No masses felt. </li></ul><ul><li>-BS+, </li></ul>
    8. 8. <ul><li>CBC </li></ul><ul><li>WBC= 11.7 </li></ul><ul><li>NEU= 8.9 </li></ul><ul><li>LYM=1.54 </li></ul><ul><li>EOS=0.01 </li></ul><ul><li>RBC=4.5 </li></ul><ul><li>HGB=12.5 </li></ul><ul><li>HCT=38% </li></ul><ul><li>MCV=84 </li></ul><ul><li>MCH=27.8 </li></ul><ul><li>MCHC-33 </li></ul><ul><li>PLT=246 </li></ul><ul><li>Urea & electrolyte </li></ul><ul><li>Urea= 4.0 </li></ul><ul><li>Creatinine= 86.0 </li></ul><ul><li>Na=141 </li></ul><ul><li>K+= 3.9 </li></ul><ul><li>Cl=103 </li></ul>ESR=40 <ul><li>Urine routine </li></ul><ul><li>Suger= NIL </li></ul><ul><li>Albumin=trace </li></ul><ul><li>WBC=20 per cm2 </li></ul><ul><li>RBC< 2 per cm2 </li></ul><ul><li>Epith. Cells= 8 per cm2 </li></ul><ul><li>CAST=NIL </li></ul><ul><li>CRYSTALS=NIL </li></ul><ul><li>PH=6.0 (7.35- 7.45) </li></ul>β HCG-1.22 AMYLASE=39.4
    9. 9. us <ul><li>liver, spleen, pancreas, gallbladder and both kidneys are normal in size and echogenicity with no evidence of focal lesions. Mild intrahepatic dilatation with borderline diameter of CBD but no obvious stone seen. Well distended unremarkable urinary bladder. </li></ul><ul><li>Impression: mild intrahepatic dilatation and CBD size further evaluation by CT is recommended. </li></ul>
    10. 10. Deferential diagnosis <ul><li>appendicitis </li></ul><ul><li>AAA </li></ul><ul><li>Diverticulitis </li></ul><ul><li>Mesenteric ischemia </li></ul><ul><li>UTI </li></ul><ul><li>Biliary tract disease </li></ul><ul><li>Diabetic ketoacidosis </li></ul><ul><li>Ovarian cyst </li></ul><ul><li>Ovarian torsion </li></ul><ul><li>Pelvic inflammatory disease </li></ul><ul><li>Obstructive bowel disease </li></ul><ul><li>Pancratitis </li></ul><ul><li>Malignancy </li></ul><ul><li>Renal colic </li></ul><ul><li>Gastritis, peptic ulcer disease </li></ul><ul><li>pneumonia </li></ul><ul><li>Constipation </li></ul><ul><li>Herpes zoster </li></ul>
    11. 11. <ul><li>Gyn. Review (ward) </li></ul><ul><li>-normal vaginal examination. </li></ul><ul><li>- TVS: endometrial thickness of 13.3 with cystic spaces, rt. Ovary bulky with follicles. </li></ul><ul><li>Lt. ovary: cyst 1.7x1.8 cm with echogenic mass inside. </li></ul><ul><li>Minimal free fluid + </li></ul>
    12. 12. CT abdomen and pelvis <ul><li>Pelvis shows diffuse fat stranding and pockets of fluid associated with thickened ileal loops & mesentery. </li></ul><ul><li>Picture is suggestive of ruptured appendix or ovarian pathology. </li></ul><ul><li>Liver: few scattered tiny hypodense lesions in the liver suggestive of small cysts, for US correlation. </li></ul><ul><li>spleen, Gb, pancreas and both kidneys are normal. </li></ul>
    13. 13. Appendicitis in geriatric patient <ul><li>Dx of appendicitis in elderly is challenging. </li></ul><ul><li>Is rare in elderly. </li></ul><ul><li>More likely to present atypically. </li></ul><ul><li>Is accounts for 7% of abdominal pain in the elderly. </li></ul><ul><li>Higher perforation rate- 72%. </li></ul><ul><li>Mortality approaches 15% if perforated in elderly. </li></ul>
    14. 14. Appendicitis <ul><li>Incidence peaked in 2ed and 3ed decades of life. </li></ul><ul><li>The overall mortality rate < 1%, if ruptured it is 3% and approaches 15% in elderly. </li></ul><ul><li>In pregnancy: </li></ul><ul><li>-unruptured appendectomy, fetal loss 3%-5%. </li></ul><ul><li>-ruptured appendectomy, fetal loss 20-25% </li></ul><ul><li>Maternal mortality-4%. </li></ul><ul><li>Emerg. Med Clin N Am 28 (2010) 103-118) </li></ul>
    15. 15. Appendicitis <ul><li>Pathophysiology: </li></ul><ul><li>Luminal obstruction. </li></ul><ul><li>Varies with age: </li></ul><ul><li>- children: lymphoid hyperplasia due to infection or dehydration </li></ul><ul><li>-adults:fecaliths </li></ul><ul><li>- elderly: neoplasm </li></ul>
    16. 16. <ul><li>Time required for appendix perforation usually occur within 24- 36 hrs from onset of symptomes . </li></ul><ul><li>Marx: Rosen's Emergency Medicine, 7th ed . </li></ul>
    17. 17. Appendicitis <ul><li>Why pain of appendicitis referred to periumbilical area? </li></ul><ul><li>- afferent fibers that conduct visceral pain from the appendix accompany the sympathetic nerves and enter the spinal cord at the level of the 10 TH thoracic segment. </li></ul>
    18. 18. Clinical signs <ul><li>Rebound tenderness: </li></ul><ul><li>-sensitivity:63 to 82%, specificity: 69 to 90%, respectively. (1 ) </li></ul><ul><li>A positive cough sign has been found to be </li></ul><ul><li>80 to 95% sensitive in diagnosing acute peritonitis. </li></ul>
    19. 19. LRs for specific symptoms in appendicitis LR of 5–10, presence moderately increases probability of disease. LR of 2–5, may increase probability of the disease. LR of <2, not likely to change the probability of the disease. Negative LR Increase in posttest probability Positive LR Historical symptom 0-0.28 Moderate probability 7.31-8.46 RLQ pain 0.50 Small increase 3.18 Migration - Small increase 2.76 Pain before vomiting 0.323 Not helpful 1.50 No past similar pain 0.64 Not helpful 1.27 anorexia 0.70-0.84 Not helpful 0.69-1.20 nausea 1.12 Not helpful 0.92 vomiting
    20. 20. LRs for specific signs in appendicitis LR of 5–10, presence moderately increases probability of disease. LR of 2–5, may increase probability of the disease. LR of <2, not likely to change the probability of the disease Negative LR Increase in posttest probability Positive LR Physical sign 0.82 Small increase 3.76 Rigidity 0.0-0.1 Small increase 2.30 Tender RLQ 0.90 Small increase 2.38 Psoas sign 0.43 Small increase 3.70 Rebound tenderness 0.58 Not helpful 1.94 Fever 0.27 Not helpful 1.65-1.78 Guarding 0.76 Not helpful 0.83-5.34 Rectal tenderness
    21. 21. Laboratory tests <ul><li>WBCcount: </li></ul><ul><li>- it is not a reliable independent predictor of appendicitis. </li></ul><ul><li>-positive LR ( 1.59- 2.7) and a negative ratio ( 0.25- 0.50). </li></ul><ul><li>-Repeating WBC counts is not beneficial . </li></ul>
    22. 22. urinalysis <ul><li>is obtained to rule out possible UTI. </li></ul><ul><li>urinalysis can represent a potential pitfall, because the proximate location of the appendix to the ureter and bladder can cause microscopic pyuria or hematuria in up to a third of patients with appendicitis </li></ul>
    23. 23. CRP <ul><li>poor specificity; however, when combined with a WBC count, it may be more useful. </li></ul><ul><li>( LR - 4.24) but when combined with an elevated WBC count, the positive LR of the combination was a significant 23.32. </li></ul><ul><li>Have high negative predictive value when the combination of the WBC count, C-reactive protein, and the neutrophil count were normal. </li></ul>
    24. 24. Diagnostic scores <ul><li>scoring systems yield inconsistent results when prospectively evaluated and appear to be particularly inaccurate when applied to female patients. </li></ul>
    25. 25. Scoring systems <ul><li>The most common is the Alvarado score, also known as the MANTRELS : </li></ul><ul><li>Migration of pain </li></ul><ul><li>Anorexia </li></ul><ul><li>Nausea/vomiting </li></ul><ul><li>Tenderness in the RLQ </li></ul><ul><li>Rebound tenderness </li></ul><ul><li>Elevated T </li></ul><ul><li>Leukocytosis </li></ul><ul><li>Shift to the left). </li></ul>
    26. 26. Imaging <ul><li>US can be helpful in possible appendicitis, particularly in children, pregnant women, and women of childbearing age. </li></ul><ul><li>CT has a greater accuracy than US. </li></ul><ul><li>specificity was similar between CT and ultrasound (94% and 93%, respectively), the sensitivity was better for CT (94% vs 83%). </li></ul>
    27. 27. CT <ul><li>findings suggestive of appendicitis include : </li></ul><ul><li>an appendix greater than 6 mm </li></ul><ul><li>wall thickening </li></ul><ul><li>RLQ inflammatory changes, such as fat stranding </li></ul><ul><li>the presence of appendicoliths </li></ul>
    28. 28. CT <ul><li>A systematic review of 23 studies of CT in suspected appendicitis found a weighted sensitivity and specificity of 93% and 98%, respectively, for noncontrast CT compared with CT with IV and oral contras </li></ul><ul><li>Am J Surg  190. 474-478.2005 </li></ul>In a prospective randomized study compared 3 different techniques, CT with oral and IV contrast, CT with rectal contrast, and CT without contrast showed: - CT with oral and IV contrast was more sensitive than CT with rectal contrast and not significantly different from noncontrast CT. Dis Colon Rectum  50. 1223-1229.2007
    29. 29. US <ul><li>Findings suggestive of appendicitis include: </li></ul><ul><li>thickened wall </li></ul><ul><li>noncompressible lumen </li></ul><ul><li>diameter greater than 6 mm </li></ul><ul><li>absence of gas in the lumen </li></ul><ul><li>appendicoliths </li></ul>
    30. 31. Home massage <ul><li>Not all patients require imaging to diagnose appendicitis. </li></ul><ul><li>Patients with a low risk for appendicitis may be sent home with close follow-up and education about progressive symptoms. </li></ul><ul><li>Patients with equivocal findings should undergo advanced diagnostic imaging or in-hospital serial examinations. </li></ul><ul><li>Pain medication should be offered to all patients with suspected appendicitis. </li></ul>
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