internship presentation

1. Case Presentation
Pramod Bhandari
Intern
Department of General Surgery
Gandaki Medical College

2. Patient Profile
• Name : Anjan Gharti
• Age/Sex: 12 y/ male
• Address: Damauli
• Date of Admission: 2074-11-30

3. Chief Complain
• Pain in lower right quadrant of abdomen for 1 day
• Vomiting for 1 day
• Fever for 1 day

4. History of present illness
• According to patient’s statement he was apparently
asymptomatic 1 day back, then he suddenly developed pain in
periumbilical region. It was cloicky in nature, migrating to
right iliac fossa , associated with fever and vomiting. Fever
was continuous, unrecorded, not associated with chills and
rigors. Vomiting was single episode, non projectile, containing
of food particles, non blood stained and non bilious.
• He has no complains of loose stools and burning micturation.

5. Past History
• No histrory of similar illness in the past
• No history of trauma and surgery
• No history of Tuberculosis, pneumonia.
Allergy History
• Not allergic to known food and drugs.

6. Family History
• No history of similar illness in the family

7. Personal History
• Mixed diet
• Non-alcoholic, non smoker

8. On Examination
• General condition
– Ill looking, well oriented to time, place and person
• No evidence pallor, icterus, lymphadenopathy, clubbing,
cyanosis, oedema and dehydration.
• Vitals: Temperature 101.2 F
Other within normal limits

9. Systemic Examination
• Per abdominal:
Tenderness present over right iliac fossa
Rebound tenderness present
Gaurding and rigidity present
Psoas sign positive
Hernial sites intact

10. • Respiratory system: Bilaterally clear
• Cardiovascular system: first and second heart sound heard, no
murmur

11. Investigations
• Blood examination
• WBC-17*10^9 / L
• Neutrophil -83%
• Ultarasonography
• Appendix measures 8.5 cm in diameter
• Probe tenderness present in Right iliac fossa

12. Diagnosis
• Acute appendicitis

13. Management
• Appendicectomy under general anaesthesia
OT Findings
• Retrocaecal appendix
• Base healthy
• Reactive fluid present

14. Post Operative Course
• NPO till next order
• IVF Isolyte P 90ml per Hour
• Injection Ceftriaxone 1 gm IV BD
• Injection Ornidazole 500 mg IV BD
• Injection Ketorolac 15 mg IV TDS
• Injection Pantoprazole 40 mg IV OD

15. Appendicitis

16. Anatomy of Vermiform Appendix:
• Located at the terminal end of the caecum where three taeniae
join, about 2 cm below the ileocaceal orifice.
• Blind muscular tube with mucosal, submucosal, muscular and
serosal layers.
• Average length 7.5-10 cm , Outer Diameter: 3-8 mm , lumen
diameter: 1-3 mm
• Mesentry of appendix (Mesoappendix) arises from the lower
surface of the mesentry and contains appendicular artery.

17. Anatomical positions of Appendix:
• Retrocaecal- 74%
• Pelvic- 21%
• Paracaecal- 2%
• Subcaecal-1.5%
• Preileal- 1%
• Postileal- 0.5 %

18. Acute Appendicitis
• Inflammation of the inner lining of the vermiform appendix
that spreads to its other parts.
• Etiology
– Common in childhood and early adulthood
– Decreased dietary fibre and increased consumption of
refined carbohydrates increases risk.
– Bacterial infection : E. coli , enterococci, streptococci,
bacteroids
– Obstruction of the lumen due to ; faecoliths, stricture,
foreign body, round worm etc.

19. • Types:
1. Acute obstructive appendicitis
2. Acute non-obstructive appendicitis
3. Recurrent appendicitis
4. Sub-acute appendicitis

20. Pathogenesis
• Obstruction of the lumen mucus and inflammatory
exudation collects inside the lumen increase in intrluminal
pressure blockage of lymphatics and venous drainage
edema and mucosal ulceration bacterial translocation to
submucosa and muscularis propia Acute obstructive
Appendicitis further, thrombosis of appendicular artery
ischaemic necrosis of wall of appendix Gangrene
Perforation Peritonitis

21. Clinical Diagnosis
Symptoms
• Pain: First around umbilicus, later colicky pain around
right iliac fossa
• Anorexia
• Nausea and vomiting

22. Signs
• Tender Right iliac fossa
• Rebound tenderness
• Pyrexia
• muscle rigidity and gaurding

23. Signs to elicit in appendicitis
• Pointing sign : Patient is asked to point to where the pain
began and where it moved.
• Rovsing’s sign: Deep palpation of the left iliac fossa may
cause pain in right iliac fossa.
• Psoas sign : Hyperextension of right leg with extension of hip
and knee joint in left lateral position elicits pain.
• Obturator sign: internal rotation of the hip joint with patient in
supine position and slightly flexed right thigh, elicits pain.

24. Special features, according to position of the appendix
• Retrocaecal
– Rigidity and tenderness absent
– Deep tenderness in the loin
– Rigitdity of quadratus lumborum
– Cope’s psoas test positive
• Pelvic
– Diarrhea: inflammed appendix in contact with rectum
– Rigidity and tenderness absent over the abdomen
– Deep tenderness over pubic symphysis
– Increased frequency of micturation
– On digital rectal examination- Tenderness in Pouch of Douglas

25. • Pre-ileal and Post ileal
– Nausea and vomitting
– Diarrhea

26. Differential Diagnosis
Children Adult Adult Female Elderly
Gastroenteritis Regional enteritis Mittelschmerz Diverticulitis
Mesentric adenitis Uereteric colic PID Intestinal
obstruction
Meckel’s
diverticulitis
Perforated peptic
ulcer
Pyelonephritis Colonic
carcinoma
Intussusception Torsion of testis Ectopic
pregnancy
Torsion appendix
epiploicae

27. Investigations
• Blood examination
– Polymorphous leucocytosis
• USG abdomen
– Non compressible appendix of size > 6 mm AP diameter, Hyperechoic
thickened appendix wall > 2 mm- “Target Sign”
– Appendicolith
– Interruption of submucosal continuity
– Periappendicular fluid

28. • Contrast CT scan
– Useful when diagnosis is difficult
– Dilated appendix, dilated lumen , thickened wall
– Non filling of the lumen by contrast or air
– Periappendicular fluid collection

29. Alvarado Scoring System
Score
Symptoms Migratory RIF pain 1
Anorexia 1
Nausea and Vomitting 1
Signs Tenderness (RIF) 2
Rebound tenderness 1
Elevated temperature 1
Laboratory Leucocytosis 2
Shift to left 1
Total 10
Score less than 5: Not sure
Score between 5-6: Compatible
Score between 6-9: Probable
Score more than 9: confirmed

30. Treatment
Surgery: Appendicectomy
• Approaches
1. Laproscopic
2. Gridiron incision
3. Rutherford Morison’s muscle
4. Lanz crease incision
5. Right lower paramedian/lower midline incision
6. Fowler-Weir approach

31. Sequelae of appendicitis
• Resorption
• Relapse and recurrent appendicitis
• Appendicular lump
• Appendicular abscess
• Perforation
• Peritonitis, septicemia
• Intestinal obstruction

32. Complications after Appendicetomy
• Paralytic ileus
• Reactionary hemorrhage
• Residual abscess
• Adhesions and intestinal obstruction
• Right inguinal hernia
• Fecal fistula

33. Refrences
• Hamilton Bailey and McNeill Love.(2012) Bailey and Love’s
SHORT PRACTICE of SURGERY. 26th Edition. New York:
CRC Press
• Sriram Bhat M. (2013) SRB’s MANUAL OF SURGERY. 4th
Edition. New Delhi: Jaypee Brothers Medical Publishers

34. THANK YOU