Approach to a Patient with Abdominal Pain
Patac, Juan Roberto G. Paulino, Alberto Paulino, Patriccia Pe, Marie Gemma T.
Patac, Juan Roberto G.
General Data
Name: DD Sex: Male Age: 22 Date of birth: June 24, 1990 Address: Bintawan Sur. Villaverde Nueva Vizcaya Nationality: Filipino Religion: Roman Catholic Civil status: Single Occupation: Production operator Informant: Patient Reliability: Good
Patac, Juan Roberto G.
Chief Complaint
Abdominal Pain (RLQ)
Patac, Juan Roberto G.
History of Present Illness
3 days PTA
2 days PTA
Few hours PTA
Patient experienced intermittent cramping epigastric pain graded 6/10, which localized to the RLQ after a few hours. Diarrhea was noted. Neither medication nor consult was done. persistent symptoms graded 8/10 with fever (undocumented). He had nausea and vomiting and lost his appetite. Still no medication, no consult were done.
persistence of symptoms graded 8-9/10 with easy fatigability prompted consultation at Charity Division Emergency Room in UST Hospital.
Patac, Juan Roberto G.
Past Medical History
(-) previous hospitalizations (-) previous surgery (-) medications taken (-) allergies
Patac, Juan Roberto G.
Family History
(+) Hypertension: Father (+) Pulmonary TB: Grandmother (-) Diabetes Mellitus (-) Cancer
Patac, Juan Roberto G.
Personal and Social History
Good family relationship No sexual contacts Non-smoker Non-alcoholic drinker Mixed diet, prefers vegetables Denies illicit drug use
Patac, Juan Roberto G.
Review of Systems
SYSTEM General Skin Head, Eyes, Ears, Nose, Throat REMARKS (+) easy fatigability, anorexia (-) fever, weight loss, (-) weakness (-) pallor, rash, pigmentation, pruritus, jaundice () photophobia, redness, blurring of vision, ear pain, discharge, clogged nose, discharge, epistaxis, sore throat (-) stiffness, sensation of lump in throat () cough, colds, dyspnea (+) fatigability, palpitations, edema, hypertension (-)chest pain, orthopnea, syncope (-) constipation
Neck Pulmonary Cardiac
Gastrointestinal
Patac, Juan Roberto G.
Review of Systems
SYSTEM Genitourinary Musculoskeletal Neurologic REMARKS () hematuria, dysuria, frequency, incontinence, nocturia () limitation of movement, joint swelling (-)headache, seizure, speech disturbance, sensory & motor dysfunction () heat and cold intolerance, excessive sweating, polyphagia, polydipsia, polyuria (-) easy bruisability, gum bleeding, pallor, bleeding episodes (-) anxiety, depression, delusions, paranoia
Endocrine
Hematologic Psychiatric
Patac, Juan Roberto G.
Physical Examination
SYSTEM
General
REMARKS
Conscious, coherent, ambulatory, not in distress Vital Signs: BP: 110/70, PR: 88 bpm, RR: 19 cpm, T: 37.3C Warm and dry skin, no pallor, good skin turgor, no jaundice, no petechiae, no active dermatoses, and no rashes Normocephalic, normal hair growth and quantity, no head masses, no lesions, sutures closed, no nits/lice Symmetrical, no deformities, no characteristic fascies No matting of the eyelashes, palpebral conjunctiva, anicteric sclera, clear cornea, iris pigmented pupils measuring 2-3 mm and reactive to both light and accommodation No tragal tenderness, no ear discharge Nasal septum midline, non-hyperemic nasal mucosa, turbinate is not congested
Skin Head Face Eyes
Ears Nose
Patac, Juan Roberto G.
SYSTEM Mouth Neck Breast Pulmonary REMARKS () Moist buccal mucosa, non-hyperemic posterior pharyngeal wall, tonsils not enlarged Supple neck, midline trachea, no palpable cervical lymph nodes, thyroid gland midline, not enlarged No breast tenderness, no discharge, no skin changes, no nipple retraction No lesions, no chest wall deformities, symmetrical chest expansion, no retractions, no tenderness, equal tactile fremiti, resonant, equal and clear breath sounds, equal vocal fremiti Adynamic precordium, apex beat at 5th LICS MCL, S1 louder than S2 at the apex, S2 louder than S1 at the base, no murmurs, no heaves, thrills, lifts No CVA tenderness, kidneys are not palpable (-) easy bruisability, gum bleeding, pallor, bleeding episodes no limitation of movement, no deformities (+) direct and rebound tenderness on RLQ, abdominal guarding, psoas sign, flat, symmetrical abdomen, no visible peristalsis or pulsations, no skin lesions, umbilicus midline, inverted, normoactive bowel sounds (10 in 1 minute), no bruit, Tympanitic, liver span 7cm, smooth edge, Traubes space not obliterated, spleen non-palpable, no palpable masses
Cardiovascular Genitourinary Hematologic Musculoskeletal Gastrointestinal
Patac, Juan Roberto G.
Neurologic Examination
Conscious, coherent, oriented to time, person, and place; GCS 15(E4V5M6) Cranial Nerves: I no anosmia II, III pupils 2-3 mm ERTL III, IV, VI full and equal extraocular muscle movements V all sensory branches (V1-V3) intact VII can smile, raise eyebrows, and wrinkle forehead VIII intact gross hearing IX, X uvula midline XI can elevate and shrug shoulders XII tongue midline on protrusion Cerebellum: can do FTNT/APST Motor: good muscle tone and posture, (-) hypotonia, rigidity, spasticity, fasciculations Sensory: (-) sensory deficit DTR: ++ in all extremities Meningeal signs: (-) Babinski, nuchal ridgidity, Kernigs, Brudzinski
Patac, Juan Roberto G.
Plans
Admission and monitor vital signs every hour CBC and Urinalysis Schedule for emergency appendectomy
Patac, Juan Roberto G.
Salient Features
Subjective Positive Migration of pain to right lower quadrant Anorexia Vomiting Nausea Easy fatigability Fever Loss of appetite Negative Skin jaundice Hematuria Dysuria Urinary frequency Urinary incontinence Nocturia Constipation Positive Direct and rebound tenderness on RLQ Abdominal guarding (+) Psoas sign Objective Negative No CVA tenderness No visible peristalsis or pulsations Skin jaundice Anicteric sclera
22 years old
Male
Patac, Juan Roberto G.
Clinical Impression
Acute Appendicitis
Patac, Juan Roberto G.
Differential Diagnosis
Acute Mesenteric Adenitis Gynecologic disorders
Pelvic inflammatory disease Ruptured graafian follicle Twisted ovarian cyst Ruptured ectopic pregnancy
Acute Gastroenteritis Colonic lesions
Schwartzs Principles of Surgery, 9th Edition
Patac, Juan Roberto G.
Clinical Features
Appendicitis is a condition characterized by inflammation of the appendix. It is classified as a medical emergency that requires immediate removal of the appendix. Obstruction of the lumen of appendix
It is the dominant etiologic factor in acute appendicitis. Fecaliths are the most common cause of appendiceal obstruction
Schwartzs Principles of Surgery, 9th Edition
Clinical Features (Symptoms)
Patac, Juan Roberto G.
Abdominal pain is the prime symptom of acute appendicitis
Initially starts at lower epigastrium (umbilical area) Right lower quadrant pain
Anorexia
Nearly always accompanies appendicitis
Vomiting
It is caused by both neural stimulation and the presence of ileus.
Schwartzs Principles of Surgery, 9th Edition
Clinical Features (Signs)
Vital signs
Minimally changed
Patac, Juan Roberto G.
Patients prefer to lie supine
Any motion increases pain
Direct rebound tenderness Abdominal guarding Psoas sign Obsturator sign Laboratory Findings
Mild leukocytosis (10,000 to 18,000 cells/mm3)
Schwartzs Principles of Surgery, 9th Edition
DIAGNOSIS and TREATMENT
The Normal Appendix
Barium Enema
http://www.emedicine.com/radio/topic47.htm
Contrast on CT Scan
The Normal Appendix
http://www.ultrasoundcases.info/Slide-View.aspx?cat=183&case=3708
Ultrasound
The Normal Appendix
MRI
http://eradiology.bidmc.harvard.edu/LearningLab/gastro/Pani.pdf
Diagnosis
Appendicitis
Graded compression sonography High resolution helical CT scan Laparoscopy*
Schwartzs Principles of Surgery, 9th ed.
Diagnosis
Graded Compression Sonography
Normal appendix: compressible, less than 5mm Appendicitis: noncompressible, greater than 6mm
Appendocolith Appendiceal wall thickening Periappendiceal fluid
Inconclusive: appendix not visualized; no pericecal fluid
Schwartzs Principles of Surgery, 9th ed.
Diagnosis
Graded Compression Sonography
http://www.minnisjournals.com.au/ajum/article/Appendicitis-21
Diagnosis
Graded Compression Sonography
Limitations
False Positive Periappendicitis Inspissated Stool Appendocolith Dilated fallopian tube Inflamed Ap Obesity (Ap not compressible) False Negative Confined to appendiceal tip Retrocecal Markedly enlarged Perforated (compressible)
Schwartzs Principles of Surgery, 9th ed.
Diagnosis
High Resolution Helical CT
Appendicitis
Dilated >5 cm Thickened wall Inflammation with dirty fat Phlegmon Arrowhead sign
Schwartzs Principles of Surgery, 9th ed.
Diagnosis
High Resolution Helical CT
http://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/appendicitis1.htm
Diagnosis
High Resolution Helical CT
Arrowhead sign Phlegmon
http://radiology.rsna.org/content/227/1/44/F1.expansion.html http://radiology.rsna.org/content/227/1/46/F3.expansion.html
Ultrasound vs. CT scan
Ultrasound Inexpensive Expensive CT Scan
Rapid No contrast medium
Applicable to pregnant
Radiation Requires contrast
Not applicable to pregnant
Schwartzs Principles of Surgery, 9th ed.
Ultrasound vs. CT scan
Ultrasound Sensitivity 80 CT scan 97
Specificity Accuracy
PPV NPV Positive impact on management *Negative appendectomy rate
93 89
91 88 19 17
94 95
92 98 73 2
Schwartzs Principles of Surgery, 9th ed.
Ultrasound vs. CT scan
Ultrasound: high intra-observer variability CT scan: selective use!
Alvarado scale to improve diagnosis
Schwartzs Principles of Surgery, 9th ed.
Alvarado scale
Score Interpretation
0-4
5-6 7-8 9-10
Schwartzs Principles of Surgery, 9th ed.
Extremely unlikely, but not impossible
Compatible with, but not diagnostic of *appropriate for CT scan High likelihood Almost certain appendectomy
Treatment
Open appendectomy Laparoscopic appendectomy Natural Orifice Transluminal Endoscopic Surgery (NOTES) Antibiotics Interval appendectomy
Schwartzs Principles of Surgery, 9th ed.
Treatment
Open Appendectomy
McBurney (oblique) or Rocky-Davis (transverse) RLQ muscle splitting incision
Point of maximal tenderness/palpable mass Abscess: lateral incision
Retroperitoneal drainage, avoid gen. contamination
Diagnosis in doubt: lower midline incision
Older patients malignancy, diverticulosis
Schwartzs Principles of Surgery, 9th ed.
Treatment
Open Appendectomy
If (-) appendicitis
1st: cecum and mesentery 2nd: small bowel In females: pelvic organs
Peritoneal fluid grams stain and culture Fowler-weir incision: further eval. of lower abdomen
Schwartzs Principles of Surgery, 9th ed.
Treatment
Open Appendectomy
http://www.surgicalcore.org/chapter/182301
Treatment
Laparoscopic Appendectomy
3 or 4 ports
4th mobilize retrocecal appendix
Trocars:
Umbilicus (10mm) Suprapubic/LLQ (10-12mm) LLQ/Epigastrium/RUQ (5mm)
As diagnostic tool
Decrease negative appendectomy
Schwartzs Principles of Surgery, 9th ed.
Treatment
Laparoscopic Appendectomy
Advantages and Disadvantages over Open Appendectomy
Advantages
Less wound infection Decreased post-op pain Shorter hospital stay
Disadvantages
More expensiv 3x intraabdominal abscess
Schwartzs Principles of Surgery, 9th ed.
http://health.allrefer.com/health/appendectomy-appendectomy-series-3.html
Treatment
NOTES
Natural Orifice Transluminal Endoscopic Surgery
Access through organs
Advantages
Reduce post-op wound pain Shorter convalescence Avoidance wound infection Abdominal wall hernias Absence of scars
Schwartzs Principles of Surgery, 9th ed.
Treatment
Antibiotics
Prophylaxis effective in preventing post-op wound infection and intra-abdominal abscess
24-48 hours: nonperforated 7-10 days: perforated
Schwartzs Principles of Surgery, 9th ed.
Treatment
Interval Appendectomy
Palpable or radiographically documented mass
Abscess or phlegmon
6-10 weeks later DA: Greater expense, longer hospital stay IV antibiotics, bowel rest Interval Appendectomy
Schwartzs Principles of Surgery, 9th ed.
CRITICAL APPRAISAL
Paulino, Patriccia Anne Mae P.
Research Question
Will laparascopic appendectomy yield less postoperative complications than open appendectomy in patients with uncomplicated appendicitis?
Paulino, Patriccia Anne Mae P.
P: patients with preop diagnosis of uncomplicated appendicitis I: Laparoscopic appendectomy, open appendectomy O: Rate of postoperative complications M: Prospective RCT
Paulino, Patriccia Anne Mae P.
The Article
Comparison of open and laparoscopic appendectomy in uncomplicated appendicitis:a prospective randomized trial
Kocatas, A. et.al. (2013). Turkish Journal of Trauma & Emergency Surgery pp. 200-204
Paulino, Patriccia Anne Mae P.
Relevance
Is the objective of the article comparing therapeutic interventions similar to your clinical dilemma?
o YES. The objective of the study was to compare the outcome of laparoscopic appendectomy and open appendectomy with regards to postoperative complications.
Paulino, Patriccia Anne Mae P.
Validity
Was the assignment of the patients to treatment randomized?
YES.
Paulino, Patriccia Anne Mae P.
Validity
Were all the patients who entered the trial properly accounted for and attributed at the conclusion? Was follow-up complete?
YES. All the subjects included in the study were included in the data at the conclusion. They were all monitored for 30 days. And follow up was done after 30 days.
Paulino, Patriccia Anne Mae P.
Validity
Were patient analyzed in the groups to which they were randomized?
YES. All patients included in both groups remained in their assigned group from beginning till the end of the study.
Paulino, Patriccia Anne Mae P.
Validity
Were patients, their clinicians, and study personnel blind to the treatment?
NO. Blinding is not possible in surgery trials.
Paulino, Patriccia Anne Mae P.
Validity
Were the group similar at the start of the trial?
YES.
Paulino, Patriccia Anne Mae P.
Validity
Aside from the experimental intervention, were groups treated equally?
YES. No treatment other than the said interventions were given to subjects of both groups.
Paulino, Patriccia Anne Mae P.
Validity
OVERALL, IS THE STUDY VALID?
YES. It has met almost all of the validity guidelines used to measure if the article is valid.
PO,RAINER WANDREW Y.
Results
PO,RAINER WANDREW Y.
Results
PO,RAINER WANDREW Y.
Results
PO,RAINER WANDREW Y.
Results
Population in Group Intra-op complication Conv Lap cLAP Conversion 52 52 25 27 8 15 10 5 Post op complications 21 10 1 9
Results
Intraoperative LAP 15 8
PO,RAINER WANDREW Y. Postoperative 10 21
How large was the treatment effect?
CONV
Rt
Rc RR ARR RRR NNT
0.2884
0.1538 1.875 - 0.1346 - 0.875 - 7.407
0.1923
0.4038 0.4762 0.2115 0.5238 4.7281
PO,RAINER WANDREW Y.
Results
How precise was the estimate of treatment effect?
No confidence interval cited p-value less than 0.1
PO,RAINER WANDREW Y.
Can the results help me in caring for my patients?
Can the results be applied to my patient care?
Yes, the article is mainly oriented towards discussing treatment for post surgical SBO due to adhesion
PO,RAINER WANDREW Y.
Can the results help me in caring for my patients?
Were all clinically important outcomes considered?
Yes. The study assessed intraoperative complications, postoperative complications, days confined, and recovery of bowel movement
PO,RAINER WANDREW Y.
Can the results help me in caring for my patients?
Are likely treatment benefits worth the potential harm and costs?
Yes. Although laporoscopic adhesiolysis shows increase risk of intraoperative complications, there is decrease risk in developing post-op complications and hospital stays.
