1. What is happening to SM?

- Abdominal pain with 2 episodes of vomiting then gradually localize to the right lower quadrant
- Extracted from the history prior to any PE
2. What is your impression
- Acute Appendicitis
o Right LQ pain
o Direct and rebound tenderness
o Muscle guarding
o 2 episodes of vomiting
3. What is your differential diagnosis? If child? Elderly? Male?
*DDx of acute appendicitis is based on four major factors:
a) Anatomic location of the inflamed appendix
b) Stage of the process (complicated or uncomplicated
c) Patient’s age
d) Patient’s gender
- Peritonitis- inflammation of the peritoneum causing pain
- Female
o Ovarian cyst- stretching of the visceral peritoneum
o Torsion and ectopic pregnancy – emergency surgery
o PID – ask for history of sexual contact
o UTI – E. coli most common pathogen
o Mittleschmerz – usually during menses
 Due to rupture of graafian follicle with the fluid seeping into the peritoneum
 Self-limited: 24 hours
- Elderly
o Malignancy (Colon CA)- usually chronic and a slow growing mass, pain is gradual
o Diverticulitis
o Perforating carcinoma of the cecum or a portion of the sigmoid that overlies the right lower abdomen
o Ischemia of the bowels- mesenteric ischemia
o Adhesions from previous surgery
 Interval appendectomy- treat appendicitis first then of the patient improves, proceed to surgery
after 2 weeks
- Male
o Inguinal hernia
o Hydrocele
o Uretherolothiasis
- Children
o Acute mesenteric adenitis
 if URTI has been noted for 1-2wks
 most common
 self-limited
o Small bowel obstruction
o Diverticulum
 Rule of 2s: half of those who are symptomatic are under 2 years old
o Aganglionic colon or hirschprung disease
 o Intusucception
o Parasitism specify: Giardiasis
4. What are the causes of your impression?
- Symptoms extracted from history and PE
- Mainly caused by: fecalith & calculi 40% of cases, also by stricture or tumor
- Obstruction followed by infection
- The lumen of the appendix becomes obstructed by hyperplasia of submucosal lymphoid follicles
5. Show your groupmates a proper abdominal examination
- With patient supine, knees bent to relax abdomen
- Steps: Inspection, Auscultation, Percussion, Palpation (PePa: would depend on the patient’s ability to tolerate
the pain)
- Auscultation is 2nd as to not alter the bowel movements
- Inspection
o Symmetry, masses, stretch marks, previous surgeries
o Inspect groin area for masses
- Auscultate for bowel sounds
o Hyperactive bowels sounds- early manifestation of obstruction (1st 24H) in an attempt to remove the
blockage
o Warm your hands and the stethoscope
- Percussion
o Tympanic vs dull
- Palpitation
o Direct vs indirect
o Area of less pain must be examined first , let patient flex knees
o Organs to be palpated:
 Liver palpation: 6-12cm right midclavicular line; 4-8cm midsternal line
 Spleen palpation: only palpable in 5% of individuals, normally tympanitic, dullnes mean
enlarged spleen
 Kidney: usually not palpable due to retroperitoneal location: palpable in thin and relaxed
abdomen; asses costovertebral angle
6. Review the anatomy of your impression
- Appendix if 6-9cm long in an average adult.
- Blood supply is the appendicular branch of the ileocecal artery
- Sympathetic innervation is T10-L1
- Parasympathetic innervation is vagus nerve
- Medially towards the ileocecal valve
- Typical location: retrocecal-retrocolic, pelvic, subcecal, ileocecal(anterior to ileum) and ileocecal(posterior
to cecum)
- Layers:
- Outer serosa: an extension of the peritoneum
- Muscularis layer: not well defined and may be absent on some locations
- Submucosa
- Mucosa
7. What is the pathophysiology of your impression

8. What are the stages of your impression?

- Focal/catarrhal
o Obstruction of the lumen
o Build up of mucus which produces distention
o Inc appendicial pressure, dec blood flow and oxygen delivery
o Ulcer
o Poorly localized visceral pain
- Suppurative
o Continued mucosal secretion from rapid multiplication of resident bactria
o Venous obstruction and edema and ischemia in the appendix
o Inflammatory process soon involves the serosa and in turn the peritoneum which produces the shift in
pain to the RLQ
- Gangrenous
o Continuation of pathologic process leads to venous thrombosis and impairment of blood supply
o The area of poorest blood supply suffers the most: ellipsoidal infarcts develop in the antimesenteric
border
- Ruptured/Perforated
o Escape of bacteria from the lumen of the appendix and contamination of the peritoneal cavity.
9. What is the most important sign of your impression’?
- Tenderness on palpation in the right iliac fossa over the McBurney’s point in the most important sign.
- Localized right lower quadrant pain or guarding on palpation of the abdomen
10. When do you suspect your impression is of surgical importance
- Consider an appendectomy for pt. with history of persistent abdominal pain, fever & clinical signs of
localized or diffused peritonitis, especially if leukocytosis is present with cbc result.
11. What other signs point to your impression
- Muscle guarding – muscular resistance of the right iliac fossa
- Episodes of vomiting
 - Indirect tenderness (Rovsing’s sign) and indirect rebound tenderness – pain in the right lower quadrant when
the left lower quadrant is palpated
- Rebound tenderness - When examiners hand is quickly relieved, the patient feels a sudden pain
- Psoas sign – pain with extension of the right leg indicates a focus of irritation in the proximity of the right psoas
muscles
- Obturator sign- stretching of the obturator internus through internal rotation of a flexed thigh suggest
inflammation near the muscle
- Psoas and Obturator both points to the tip of the appendix
- The Dunphy sign (sharp pain in the RLQ elicited by a voluntary cough) may be helpful in making the clinical
diagnosis of localized peritonitis.
- The Markle sign, pain elicited in a certain area of the abdomen when the standing patient drops from standing
on toes to the heels with a jarring landing, was studied in 190 patients undergoing appendectomy and found to
have a sensitivity of 74%.
12. Do you have to elicit all these signs
- Good guide but not necessary
- The most specific physical findings in appendicitis are rebound tenderness, pain on percussion, rigidity, and
guarding however, their absence should never be used to rule out appendiceal inflammation.
13. What is McBurney’s point
- Point of maximum pain or tenderness
- Reference for incision
- the junction of the outer 1/3 and inner 2/3 of a line joining the anterosuperior iliac spine and the umbilicus.
- READ: maingot and skandalakis surgical anatomy
14. Do you have to do a rectal exam on this patient
- Locates the appendix which could be in the rectal wall – pararectal tenderness right-sided rectal tenderness
- There is no evidence in the medical literature that the digital rectal examination (DRE) provides useful
information in the evaluation of patients with suspected appendicitis; however, failure to perform a rectal
examination is frequently cited in successful malpractice claims
- Contraindications of DRE
o No finger
o No anus
o Painful hemorrhoids
15. What is Alvarado scoring? Mantrell scoring
- Alvarado:
FINDINGS POINTS
Migratory right iliac fossa pain 1
Anorexia 1
Nausea or vomiting 1
Tenderness: right iliac fossa 2
Rebound tenderness right iliac fossa 1
Fever >36.3 C 1
Leukocytosis >10 x 10^9 cells/L 2
Shift to the eft of neutrophils 1
Score: <3: low likelihood of appendicitis
4-6: consider further imaging
>7: high likelihood of appendicitis
 - Mantrell:
CHARACTERISTICS POINTS
Migration of pain to right lower quadrant 1
Anorexia 1
Nausea and Vomiting 1
Tenderness in right lower quadrant 2
Rebound pain 1
Elevated temperature 1
Leukocytosis 2
Shift of white blood cell count to left 1
10
Score: <5: Appendicitis unlikely
5 or 6: Appendicitis possible
7 or 8: Appendicitis likely
9 or 10: Appendicitis highly likely
16. Make your admitting orders for this patient
- Please admit patient at surgical ward under the service of Dr. ____
- Secure consent to care
- TOR q 4; i/o q shift
- Diet: NPO temporarily
- IV: PNSS 1 liter at 20 gtts/min
- Medications:
o Cefoxitin IVTT ANST on call to OR
o Ranitidine 50mg IVTT on call to OR
o Metoclopramide 10mg IVTT on call to OR
- For ‘E’ appendectomy
- To secure 1 unit of PRBC, roperly screened and crossmatched
- Inform OR team
- Inform anesthesiologist on duty
- For abdominal prep
- Secure specimen for biopsy
- Thank you!
- Additional order: should be before medication
- Labs:
- Cbc
- BT
- Pt apt (bleeding panel
- Serum creatinine, BUN
- HbSAg
- Pregnancy test for females on reproductive age
17. Why request a CBC? Urinalysis
- In CBC, an elevated WBC count is expected, with more than 75% neutrophils in most patients. A high WBC count
(>20,000/ml) suggests complicated appendicitis with gangrene or perforation. The white blood cell (WBC) count
is elevated (greater than 10,000 per mm3 [100 × 109 per L]) in 80 percent of all cases of acute appendicitis.
- Unfortunately, the WBC is elevated in up to 70 percent of patients with other causes of right lower quadrant
pain. Thus, an elevated WBC has a low predictive value. Serial WBC measurements (over 4 to 8 hours) in
 suspected cases may increase the specificity, as the WBC count often increases in acute appendicitis (except in
cases of perforation, in which it may initially fall).
- In general, however, the WBC count and differential are only moderately helpful in confirming the diagnosis of
appendicitis because of their low specificities.
o Neutrophil- bacterial
o Eosinophil- parasitic
o Hgb and Hct- anemia
- U/A- can be helpful in ruling out pyelonephritis or nephrolithiasis. Microscopic hematuria is common in
appendicitis due to inflammation adjacent to the ureter while gross hematuria is uncommon and may indicate
the presence of kidney stones.
- Inflammation of appendicitis can spread to the urinary tract. It may lead to abnormal urinalysis.
- Normal urinalysis in appendicitis suggests that inflammation seems to be limited to the appendix, and no spread
to the urinary tract.
- In women of reproductive age, a urine β-hcG is obtained to exclude the possibility of ectopic pregnancy or alert
the surgeon for intrauterine pregnancy
o Cloudy urine with increased WBC maybe due to appendix on top of urinary bladder
18. Can the diagnosis be based on history and PE only
- Have labs and imaging to confirm diagnosis
- Patient safety and tolerance due to severity of inflammation
- Early diagnosis remains the most important clinical goal in patients with suspected appendicitis and can be
made primarily on the basis of history and physical exam in most cases. The classic pattern of migratory pain is
the most reliable symptom of acute appendicitis.
19. What other diagnostic modalities can you request
- Plain Film Radiograph :
o Not cost effective
o Not specific
o Can be misleading
o Kidney stones
o Obstructions- dilated bowels and leveling of fluids (step ladder appearance)
o Pneumoperitoneum- air t the right side of bowel- emergency case
o Not recommended unless other pathology is suspected: eg. perforation, intestinal obstruction, ureteral
calculus
- Ultrasound
Advantages:
o Safe and Non-invasive: No ionizing radiation
o Cost-effective: cheap and can efficiently rule out other abnormalities
o Very sensitive with a skilled technician: (71 to 97% accuracy)
Disadvantages:
o Sensitivity very dependent on operator skill
o Greater potential for false positives
o Normal appendix must be visualized to rule out appendicitis: Diagnosis limited by position of appendix
- CT scan
Advantages:
o More Precise than US: less hospital to hospital variation
o More accurately identifies pathology
o Reveals normal appendix better than US
Disadvantages:
o Radiation and/or contrast exposure: increased risk for peds and pregnant women
o Cost: relatively expensive
 o Patient discomfort: children often unable to tolerate without sedation
- Barium enema
o Less done
o Ruptured appendix causes leaking of barium to abdominal cavity
20. What are the chances for perforation in this patient? If very young? Old?
- Children <5 years old: negative appendectomy rate of 25% and appendiceal perforation rate of 45%
- 5-12 years old: negative perforation rate of <10% and a perforated appendix rate of 20%
- General population rate: 20-30%
- Elderly: 50-70%
21. How will you prepare the patient for surgery?
- Acquire informed consent from patient
- IV line: Plain NSS 1 liter 20 gtts/min
- FBC: monitor urine output: if red orange you have to push more fluid, if clear patient is hydrated
- NPO = 6-8 hours
- Bleeding time = quantitative platelet count
- Prothrombin time = extrinsic pathway
- Antibiotic for prophylaxis: Cefoxitin 2 g IV single dose (Adults); 40 mg/kg IV single dose (Children)
22. If you are the anesthesiologist and patient had a meal 3 hours ago, what will you do? Why?
- Anesthetic medications can suspend the body’s normal reflexes, which could cause food to become inhaled
into the lungs. It can take up to 6 hours for a person to completely digest food.
AGE GENERAL OR MAC ANESTHESIA
Newborn >6 months Clear fluid: 2 hours
Breast milk: 4 hrs
Infant formula: 5 hrs
6 mos – 36 months Clear fluid: 2 hrs
Breastmilk: 4 hrs
Infant formula: 6 hrs
Solid: 6 hrs
Older than 36 months Clear fluid: 2 hrs
Non-human milk: 6 hrs
Light meal: 6 hrs
Heavy meal: 8 hrs

- Delay surgery for at least 6 hours on NPO from last meal to prevent aspiration
- Induction of anesthesia causes muscle relaxation and loss of reflex which may lead to regurgitation and
resulting to aspiration
23. What microorganism are you dealing with

-
- Appendicitis may occur in clusters, suggesting an infectious genesis. However, an association with various
contagious bacteria and viruses has only been found in a small proportion of appendicitis patients. The flora
of the inflamed appendix differs from that of normal appendix.
- About 60% of aspirates of inflamed appendices have anaerobes compared to 25% of aspirates from normal
appendices. Tissue specimens for the inflamed appendix wall (not luminal aspirates) virtually all grow E. coli
and bacteroides spp on culture. Fusobacterium nucleate/necrophorum, which is not present in the normal
cecal flora has been identified in 62% of inflamed appendices.
- Patients with gangrene or perorated appendicitis appear to have more tissue invasion by Bacteroides.
24. What antibiotic will you give preoperatively and why? Dose? Route? Time? Do you know the costs?
- Antibiotic prophylaxis is effective in the prevention of surgical site infection for patients who undergo
appendectomy and should be considered for routine use.
- The following antibiotics are recommended for prophylaxis in uncomplicated appendicitis:
o Cefoxitin 2 g IV single dose (Adults); 40 mg/kg IV single dose (Children) PRICE: 834PHP/VIAL MARKETED
AS MONOWEL

o
o Alternative agents: ampicillin sulbactam 1.5-3 g IV single dose (adults) 75 mg/kg IV single dose
(children) amoxicillin-clavulanate 1.2-2.4 g IV single dose(adults 45 mg/kg single dose (children)
o For patients with allergy to beta-lactam antibiotics: gentamycin 80-120 mg IV single dose plus
clindamycin 600 mg IV single dose (adults) gentamicin 2.5 mg/kg IV single dose plus clindamycin 7.5-10
mg/kg single dose (children)
 - Recommended antibiotics for complicated appendicitis:
o Ertapenem 1g IV every 24 hours PRICE: 3,016PHP/VIAL MARKETED AS INVANZ

o
o Tazobactam-piperacillin 3.375 g IV every 6 hours or 4.5 g IV every 8 hrs
o For adults with beta-lactam allergy: ciprofloxacin 400mg IV every 12 hrs plus metronidazole 500 mg IV
every 6 hrs
o The recommended antibiotic for therapy of complicated appendicitis in pediatric patient is ticarcillin-
clavulanic acid 75 mg/kg evry 6 hrs. alternative agents for pediatric patients include imipenem-cilastatin
12-25 mg/kg IV evry 6 hrs. for children with allergy to beta-lactam: gentamycin 5 mg/kg IV every 24 hrs
plus clindamycin 7.5-10 mg/kg IV every 6 hrs
25. What incision will you make? What is McBurney incision
- Mcburney incision or muscle-splitting incision its most widely use in uncomplicated appendicitis . A small
oblique incision made through 1/3 of the way along a line from anterior superior spine of ileum to umbilicus
(Mcburney’s point) .the incision made oblique .8-10 cm in length
26. What is gridiron incision? Rockey davis incision
- Gridiron incision is another name of Mcburney incision or muscle-plitting incision its most widely use in
uncomplicated appendicitis .the skin incision made through 1/3 of the way along a line from anterior
superior spine of ileum to umbilicus .the incision made oblique .8-10 cm in lenth
- Rocky Davis incision or transverse incision the incision made transverse direction 1-3 cm below umbilicus
and center on midclavicular line abdominal wall split in direction of their fiber. Like a McBurney’s incision
except transverse (straight across)
27. What are the layers of abdominal wall you will traverse
- The needle or knife will pass through the following structures in succession:
- Skin
- Superficial fascia (Camper and Scarpa)
- External oblique muscle
- Internal oblique muscle
- Transverse abdominis muscle
- Transversalis fascia
- Extraperitoneal fat
- Parietal peritoneum
28. If you open up, what anatomic structure should you grasp because it will guide towards your impression
- The cecum should be located. Tracing the taenia libera (anterior taenia). The most visible of the three
taniea coli. Distally, the base of the appendix can be identified.
29. Upon opening, you encounter turbid fluid, what will you do
 - In case of free peritoneal fluid, a sample is aspirated and sent for microbiology. A lavage with saline is not
necessary. The decision to start post-op antibiotic and to leave abdominal drain are left at the discretion of
the surgeon
- Suction fluids – whitish to yellowish green
- Maybe due to ruptured appendix
- Foul smelling (dead frog / rat)

30. If you encounter an abscess around your impression, what will you do
- If an abscess is identified on CT scan, an attempt should be made to drain abscess percutanously under CT or US
guidance. If unsuccessful, the abscess should be drained surgically (shakleford’s)
- Pus in the abdomen should be aspirated, but irrigation in complicated appendicitis is not recommended
(Schwartz)
31. Will you leave a drain and why
- Drains are not routinely placed unless a discrete abscess cavity is present. If an abscess cavity is present, a
single closed suction Jackson-Pratt drain is placed within its base and left for several days.
32. If on opening your impression is normal, what will you do
- Incidental appendectomy
- Extend incision and explore
- If appendix appears normal at operation, we routinely remove it and explore other causes of pain
33. After surgery, will you close the abdomen? Why?
- Increase chance of hernia if not closed
- The wound is primarily closed in most patients with nonperforated appendicitis because the risk of infection is
less than 5%. It can also be done in perforated appendicitis
- Yes, if non-perforated we use subcuticular absorbable suture or staples coz it reduce scar formation but if rupture
we use staples or interrupted nonabsorbable placed 2-3 cm apart alternating with gauze packing. If heavy fecal
contamination is present, the skin is often left open to close secondarily.
34. How will you give post op care ? if condition is ruptures
- Not ruptured
o Monitor closely V/S
o flatus passed
o no signs and symptoms of SSI
o antibiotic usually 1 dose only
- Ruptured
o drainage maintained but may not be placed if area was washed thoroughly
o antibiotics taken for 5-7 days
o In case of rupture the patient should be given brod-spectrum antibiotics 4-7 days
o -not recommend in uncomplicated patient
o - in case of small abscess treat with antibiotics
o - In case of lage abscess Percutaneous drainage with CT or US guide should be done
35. What are the complications of your impression? Most lethal complication?
- - Peritonitis is the most lethal, because the bacteria can spread to the other parts of body lead to sepsis and
death.
- - Female infertility due to impaired tubal function
- NOTE others complication if possible
- - Surgical site infection
1. -Celluitis
- - Post OP intra abdominal abscess
 1. -Fever, leukocytosis, abdominal pain
2. -ileus, bowel obstruction, diarrhea, tenesmus
- - Stump appendicitis
1. -incomplete remove appendic
2. -Recurrent symptoms within 9 years after surgery
36. When will you feed your patient? If ruptured?
- All bowel must be in function prior to any feeding
- Anything that irritates the bowel lengthens the return of function or delays return of function of bowels
- Patient can start diet the same day or the following day especially if patient has already passed flatus
- In case of ileus, diet should be started based on daily clinical evaluation
37. If you are dealing with a child with unclear history, what should you do?
- In children, the physical examination findings of maximal tenderness in the right lower quadrant, the
inability to walk or walking with a limp, and pain with percussion, coughing, and hopping were found to
have the highest sensitivity for appendicitis.
- Do imaging and labs
- Extract history from care giver
- Prenatal history
o Malrotation syndrome which is common if mom became infected in the 1st tri or took medications
38. How do you make progress notes on this patient (SAMPLE ONLY)
- S – RLQ pain that is continuous, characterized as sharp, aggravated by activities that increase
intraabdominal pressure, minimally relieved by rest. 2 episodes of vomiting of previously ingested food, non
projectile, nonbloody
- O – awake, in pain, oriented, irritable, not in respiratory distress, afebrile
- Skin – warm, good turgor and mobility
- HEENT – anicteric sclera, pink palpebral conjunctiva (-) nasoaural discharge
- C/L – equal chest expansion, clear breath sounds
- CVS – regular rate and rhythm
- Abd – flat, (+) muscle guarding, (+) direct rebound tenderness on the right lower quadrant, no
masses
- GUT – (-) KPS
- Ext. – (-) edema, CRT <2 secs
- A – Acute Appendicitis
- P – Diet: NPO
- IVF: PNSS 1L @ 20 gtts/min
- Labs: CBC, U/A, abdl utz
- V/s q 4
- i/o q shift
- Medication: Cefoxitin and Ranitidine for preop