Question

Ms. D.S., 48 years old, has been admitted to the hospital with severe abdominal pain. Earlier that day she had generalized abdominal pain followed by a severe pain in the lower right quadrant of her abdomen accompanied by nausea and vomiting. That evening she was feeling slightly improved and the pain seemed to subside somewhat. Later that night, severe steady abdominal pain developed with vomiting. A friend took her to the hospital where examination demonstrated lower right quadrant tenderness and mild abdominal rigidity. Fever and leukocytosis indicated infection. A diagnosis of acute appendicitis, with possible perforation was indicated with immediate surgery.

1. Why is the sequence of pain (location and type of pain) significant in the diagnosis of acute appendicitis? Describe the rational for each type of pain. Does this sequence confirm the diagnosis?

Answer 1

1) ans)

The patient’s sequence of pain is within the signs and symptoms of many abdominal disorders. Appendicitis is known to manifest without acute symptoms initially, her vague abdominal pain with nausea and vomiting could be less than anything of importance. Pain in the lower right quadrant is related to the inflamed stretched tissues of the appendix. Abdominal pain is a common presenting complaint for patients seeking care at emergency departments, with the number of cases in the United States estimated at approximately 3.4 million per year. Appendicitis is a common etiology of abdominal pain, caused by acute inflammation of the appendix, and occurs in approximately 8-10% of the population over a lifetime . Untreated appendicitis can lead to perforation of the appendix, which typically occurs within 24 to 36 hours of the onset of symptoms

Diagnosis of right lower quadrant pain/ suspected acute appendicitis:

Guidelines suggest that when a diagnosis of acute appendicitis can be made on clinical grounds surgical consultation should be sought without delay for additional diagnostic testing. Several clinical signs and symptoms have been described as suggestive of appendicitis, including central abdominal pain migrating to the right iliac fossa, fever and nausea/vomiting, signs of peritoneal irritation (rebound tenderness, guarding, rigidity), and classic signs elicited by clinical examination (e.g., the McBurney, Rovsing, psoas, or obturator signs).The performance of clinical signs and symptoms for identifying acute appendicitis seems to be variable across studies, and few clinical findings appear to have adequate sensitivity and specificity when used in isolation.

For patients with right lower quadrant (RLQ) pain, when the diagnosis cannot be made on clinical grounds alone, laboratory or imaging tests are often used to attempt to establish a diagnosis and guide treatment. Laboratory evaluations potentially useful for the diagnosis of appendicitis include white blood cell count, granulocyte count, the proportion of polymorphonuclear blood cells, and C-reactive protein concentration.

Imaging tests, such as ultrasound (US), computed tomography (CT) with and without contrast, and magnetic resonance imaging (MRI), are also used extensively for the diagnosis of appendicitis. Imaging tests can be used alone or in combination. Different factors may affect the performance of alternative tests and their impact on clinical outcomes. CT scanning can be performed with or without the use of contrast agents, and contrast can be administered orally, rectally, intravenously, or via combinations of the these routes.It has been suggested that low body mass index (BMI), a marker for lack of sufficient mesenteric fat (which helps visualize periappendiceal fat stranding, a radiological sign of appendicitis), may affect the relative test performance of CT performed with or without contrast .Contrast being more useful in individuals with low BMI

Clinical signs and symptoms, along with the results of laboratory or imaging tests, can be combined into clinical prediction tools, i.e. algorithms that synthesize the findings of different investigations to determine the most likely diagnosis. In adults, the most commonly used clinical prediction rule for appendicitis is the Alvarado score,which separates patients into 3 groups of increasing probability of appendicitis (the score is based on 8 items: pain migration, anorexia, nausea, tenderness in RLQ, rebound pain, elevated temperature, leukocytosis, and shift of white blood cell count to the left).

        The Alvarado score is also used in pediatric populations. It is based on 9 items (migration of pain, anorexia, nausea/vomiting, fever, cough/percussion tenderness, hopping tenderness, RLQ tenderness, leukocytosis, polymorphonuclear neutrophilia) and classifies children into two groups (high vs. low probability of appendicitis)

Finally, diagnostic laparoscopy is also used for the evaluation of patients with RLQ pain/ suspected acute appendicitis. Although diagnostic laparoscopy is generally considered safe, studies have reported variable rates of morbidity and mortality from the procedure.

In general the diagnostic tests discussed in this section are widely available in the USA. Clinical signs and symptoms can be evaluated relatively easily and inexpensively. Evidence from the National Hospital Ambulatory Medical Care Survey suggests that CT and complete blood counts are obtained in the majority of patients presenting to the emergency department with abdominal pain.
As with all diagnostic tests, the modalities used in the diagnostic investigation of patients with RLQ pain/suspected appendicitis affect clinical outcomes indirectly, through their impact on clinicians’ diagnostic thinking and therapeutic decisionmaking. More accurate and timely diagnosis of appendicitis can minimize the time to the indicated intervention (surgery), thus reducing pain and improving clinical outcomes e.g., reducing bowel perforation and associated infectious complications.

A pain subsiding and recurring acute appendicitis :

Acute appendicitis is an infection of the appendix which is the pouch of tissues attached to the large intestine and the lower right side of the abdomen by this infection ,inflammation occurs can cause the pain subsiding and then recurring the infected material can spread into the abdominal cavity that can cause a severe pain .
the appendicitis starts with abdominal pain II II acute appendicitis can lead to brust appendix within 24 to 72 hours. pain in the upper abdomen are near to the naval, starting the light and optimal sharper as it moves to the lower right side and the pain start with subsiding and other parts of the abdomen the movement was the pain the exact position of the appendix between the abdomen before slightly from person to person so far the reason is too hard to diagnose acute appendicitis for the both patient and doctor is happen because of blockage of the appendix which increases the pressure inside the appendix and can cut off blood flow.

Leukocytosis and fever:

Inside the blocked appendix the bacteria will be multiply and first accumulates, which causes pain and fever and infection Leukocytosis is the Condition in which the high level of white blood cells are present in the blood the lumen digital to the extraction staff to fill with mucosa and closed loop obstruction that will lead to increase the pressure is the pressure of human causes inflammation of appendix bacterial leak out through the walls and pus forms within and around the appendix is the causes of Leukocytosis and fever

abdominal rigidity:

abdominal rigidity is a stiffness of the stomach muscles that wasn't when you touch a someone as touches the abdomen, abdominal rigidity that occurs with an inability to pass gas from the rectum the abdominal rigidity occurs because the abdominal tenderness, nausea, pain vomiting stomach swelling and constipation in the acute appendicitis

The complication that might arise from the rupture of the appendix :

the Rupture spreads the infection throughout the abdomen this condition may be life threatening, because this condition requires immediate surgery to remove the appendix and clean the abdominal cavity .
Appendix ruptured that will develop a pocket of infection, so for removing the infection tube need to place and can remove the infection are clear the infection by the antibiotics. in some cases some other infection after is drained, and the appendix is removed immediately if the bacteria from here after appendix can get into blood stream, it will causes serious condition known as a sepsis this is the inflammation that occurs throughout the body .so sepsis is one another complication that is caused by the method of the appendix .ruptured appendix also can causes the intestinal obstruction. it causes and kinking of the intestine. this will lead to blockage of the floor of the food through the intestinal tract .intestinal obstruction can cause the appendicitis severe. peritonitis is the infection of bacteria when the appendix ruptured . so these are the complications which arises from the ruptured of the appendix