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.

2. Using the pathophysiology describe the reason for: a. the pain subsiding, then recurring b. leukocytosis and fever c. abdominal rigidity

Answer 1

a) Appendicitis is generally caused by a blockage of the appendix, which increases the pressure inside the appendix and can cut off blood flow. Inside the blocked appendix, bacteria multiply and pus accumulates, which further damages the wall of the appendix and causes pain and irritation.

Recurrent appendicitis is defined when patients with recurring similar right iliac fossa pain had acute appendicitis confirmed at the time of operation and the pain completely subsided after surgery. We conducted a retrospective study on our patients with appendicitis. There were 290 patients with appendicitis over a two-year period and 33 patients (11%) had reported recurring pain prior to the presentation. Majority had one prior episode but 15% had multiple episodes of right iliac fossa pain. Fifty-eight percent of the episode occur within six months of the presentation. We conclude that recurrent appendicitis should be considered as a differential diagnosis in patients with recurrent right iliac fossa pain.

b)   Fever and leukocytosis are included in both scoring systems, and several reports have indicated that the presence of fever is indicative of acute appendicitis.

  Leukocytosis and white cell left shifts are on the other hand more common in patients with appendicitis. More studies should follow to investigate their role in diagnosis of appendicitis in patients in emergency department.

c) Abdominal rigidity is usually a medical emergency. Severe symptoms that could indicate a life-threatening situation include:

vomiting blood, or hematemesis

rectal bleeding

black, tarry stools, or melena

fainting

inability to eat or drink anything

Other signs of an emergency could include:

severe vomiting

increased abdominal girth, or distended abdomen

shock, which results from very low blood pressure

Other symptoms to look for include:

tenderness

nausea

yellowing of the skin, or jaundice

loss of appetite

feeling of fullness after eating small amounts of food, or early satiety

Abdominal rigidity that occurs with an inability to:

pass gas from the rectum

pale skin

diarrhea

constipation.