Mr. T Case Study
Mr T presented with acute generalised abdominal pain and vomiting over 24 hours. During his treatment for gastroenteritis the appendix perforated, leading him to have laparoscopic appendectomy. Abscesses formed around the abdominal wall causing the patient to become tachycardic and pyrexic. Most patients are discharged 24 to 36 hours after the laparoscopy, however in this case Mr T was kept in for longer to control the infection and abscesses that formed in his abdomen. As well as affecting the health of the patient, this also occupied a hospital bed for longer than necessary. It is essential to diagnose and treat perforated appendicitis when it is suspected as this complication increases the incidence of morbidity and mortality.
Background: …show more content…
One of the most common acute surgical abdominal emergencies is acute appendicitis. Between 2006 to 2007, 34,6000 cases were treated in UK hospitals. DIGITAL SQUARE . As the incidence of appendicitis is high, these cases are seen regularly in the Emergency Department and clinicians are regularly faced with the decision on the diagnosis of acute abdomen. Reducing the misdiagnosis, and therefore the morbidity and mortality of these cases, should be of great interest to clinicians. The rate of perforation varies from 16% to 40%, with a higher frequency in younger age groups and patients over 50 years old. MEDSCAPE Perforation of the appendix leads to more health problems, with the risk of complication rising to 58%. GIRAUDO There is a 3.5 to tenfold increase in mortality rate after perforation. BROKER
Perforation of the appendix increases the risk of wound infection, abscess formation, sepsis, pneumonia, prolonged ileus, heart failure, and renal insufficiency.
This in turn leads to longer hospital stays and delayed complications such as bowel obstruction. In women, there is a five-fold increased risk of infertility, which is a huge complication as a result of a common condition. GRAFF.
Case Presentation:
Following 24 hours of stomach pain and vomiting Mr T came into hospital. He woke up during his sleep with a severe 8/10 pain locating to the lower quadrants of the abdomen. Having been for a buffet dinner the night before he initially blamed this on food poisoning, but he became feverish and dehydrated so seeked further help. He had not recently travelled and no other contacts at the meal were ill.
He had opened his bowels more often than usual in the past 24 hours, but no diarrhoea or blood with the stools. The vomiting had followed a few hours after the lower abdominal pain started and there was no haemoptysis. As he vomited over 15 times, the contents ranged from food to just bile. He felt thirsty and had not eaten since the meal.
Previous to this Mr T, who works night shifts with the police, had been fit and well. He had had no previous hospital admissions and only sees his GP the occasional cough. He lives at home with his parents, and was brought into A&E by his …show more content…
father.
Investigations
On examination Mr T was pyrexic but all other observations were normal. His left lower quadrant was tender and was hot to touch. His white blood cell count (26.6) and lactate (4) levels were raised, CRP and urea and electrolytes were normal.
The initial diagnosis was gastroenteritis; he was given ciprofloxacin, anti-emetics and paracetamol and oramorph for the pain. He had IV fluids and was nil by mouth. chest X-ray RESULTS. Salmonella and campylobacter was ruled out with a stool sample. As all his symptoms and the history of a buffet meal 12 hours before the pain started suggests gastroenteritis, he continued on this treatment overnight in the acute medical unit.
His CRP serum levels increased from 12 to 332 and his venous blood gas showed his lactate at 4mmol/L (0.5-1mmol/L). This is indicative of sepsis, which could have been caused by a UTI, renal stones or gastroenteritis. Blood was found in urinalysis, which suggest more likely a UTI, however, that doesn’t justify the abdominal cramps and vomiting.
On the second day of admission, at 1600 his respiratory rate raised to 30 and his temperature was 38.5. He was hypotensive and tachycardic. The tenderness was now localised to the right iliac fossa and he had dysuria. The medical team now diagnosed appendicitis and he was referred to the surgical team. The surgeon planned surgery the next morning, which would be 72 hours since the pain started.
In the early hours of day 4 of the pain he was looking increasingly unwell with a temperature of 39, the nurses called the surgeon to see him. His blood results showed that the CRP (332) and WBC (11.6 x10^6 /L) had increased. The tenderness on the abdomen was now all over. The surgeon decided that this was either perforated appendicitis or another source of significant peritonitis. A laparoscopy appendectomy was carried out and the entire appendix was gangrenous and perforated. Pus was found all over the abdomen and cleared by the surgical team.
After the surgery, his was tachycardic at 101, with a temperature of 38.5. His CRP was 267 and white blood cell count 13.8. He had sweats and rigors and felt very systemically unwell.
The following few days his NEWS score came to 0 and his inflammatory markers came down so he was switched to oral ciprofloxacin. He was discharged with 10 day antibiotic course.
Outcome and follow-up
8 days later he presented again with severe pain all over his abdomen, unable to stand straight. He reported this pain to be worse than the initial appendicitis pain. His appetite was poor making him feel weak and was experiencing night sweats. His bowels were opening but the stools were loose with blood. He had guarding in his right iliac fossa and his inflammatory markers were high. The differential diagnoses were post-surgical abscesses or collections. A CT scan showed pockets of collections.
During this second admission it was found that the infection was resistant to the antibiotics he had been given so the microbiology team gave him a new course of antibiotics. He also developed phlebitis where the cannula was administering the antibiotics.
After over 2 weeks of recovering he was discharged again. During this time, he had lost his appetite a lot of weight and muscle mass. Although he was systemically feeling well his recovery would be a lot longer.
DISCUSSION
The early diagnosis of appendicitis is key in reducing the incidence of perforated appendicitis and therefore decreasing the risk of complications.
Of all emergency patients with abdominal pain only 1%-3% will have acute appendicitis, and many of these will present atypically. CRAIG Therefore, doctors are used to ruling out appendicitis rather than including it in the differential diagnoses. Delaying the diagnosis of this can cause major difficulties in the recovery of the patient. A study done with 723 appendicitis cases from 2003 to 2009 looked at the risk of complication compared with the time of surgery after admission. 3% of patients in the delayed appendectomy group (later than 24hours after admission) died. GIRAUDO Having a high mortality rate in such a common diagnosis should be of concern to clinicians. In this case the appendectomy was carried out over 48 hours after admission, but this patient was young and fit which reduced his risk of serious complications. However, in the young population or elderly population this risk would have been much greater.
Only a small number of patients present with a history of abdominal pain migrating from the epigastrium to the right lower quadrant.
The white blood cell count will be elevated in 70%-90% of patients with acute appendicitis. WAGNER Pain in the right lower quadrant, abdominal rigidity and location and migration of pain to the right lower quadrant increases the likelihood of appendicitis. Similarly, the absence of these symptoms lessens the suspicion of appendicitis. The presence of vomiting before the onset of pain makes appendicitis unlikely and suggests intestinal obstruction. Diarrhoea or constipation is a less common with 18% having this symptom. WAGNER. In this case the patient presented with the 3 main symptoms of appendicitis but the diagnosis for the first 24 hours was still gastroenteritis. If appendicitis was ruled out early in the admission the perforation could have been avoided, giving this patient a better recovery time.
Gastroenteritis is a common misdiagnosis with these similar symptoms, however this should not cause significant continuous pain. Moving on from these diagnoses the clinician must decide whether to continue inpatient observation or send the patient for imaging. If a clinician has a high suspicion of appendicitis time should not be wasted on getting a CT scan and a surgeon should be called.
DRAKE
Blood tests are an important investigation into the diagnosis. Women who present with acute abdominal pain, the serum b HCG should be measured to rule out uterine or ectopic pregnancy. 70% to 90% of patients with acute appendicitis have an elevated leukocyte count, however this is also indicative of many other acute abdominal and pelvic diseases. CRP levels >1mg/dL and WBC> 10,500cells/microL is common in appendicitis.
Although this patient was 30 years old and fit and well, many diagnostic problems occur with the young population and patients older than 50 years. The pain is atypically not in the right iliac fossa which opens the diagnosis up to many more possibilities. Infants may present with watery diarrhoea and vomiting, and young children may only show anorexia and vague pain. Elderly patients may present with confusion without pain, they may also present with shock and progression can be fast. LOWTH M
Background: …show more content…
One of the most common acute surgical abdominal emergencies is acute appendicitis. Between 2006 to 2007, 34,6000 cases were treated in UK hospitals. DIGITAL SQUARE . As the incidence of appendicitis is high, these cases are seen regularly in the Emergency Department and clinicians are regularly faced with the decision on the diagnosis of acute abdomen. Reducing the misdiagnosis, and therefore the morbidity and mortality of these cases, should be of great interest to clinicians. The rate of perforation varies from 16% to 40%, with a higher frequency in younger age groups and patients over 50 years old. MEDSCAPE Perforation of the appendix leads to more health problems, with the risk of complication rising to 58%. GIRAUDO There is a 3.5 to tenfold increase in mortality rate after perforation. BROKER
Perforation of the appendix increases the risk of wound infection, abscess formation, sepsis, pneumonia, prolonged ileus, heart failure, and renal insufficiency.
This in turn leads to longer hospital stays and delayed complications such as bowel obstruction. In women, there is a five-fold increased risk of infertility, which is a huge complication as a result of a common condition. GRAFF.
Case Presentation:
Following 24 hours of stomach pain and vomiting Mr T came into hospital. He woke up during his sleep with a severe 8/10 pain locating to the lower quadrants of the abdomen. Having been for a buffet dinner the night before he initially blamed this on food poisoning, but he became feverish and dehydrated so seeked further help. He had not recently travelled and no other contacts at the meal were ill.
He had opened his bowels more often than usual in the past 24 hours, but no diarrhoea or blood with the stools. The vomiting had followed a few hours after the lower abdominal pain started and there was no haemoptysis. As he vomited over 15 times, the contents ranged from food to just bile. He felt thirsty and had not eaten since the meal.
Previous to this Mr T, who works night shifts with the police, had been fit and well. He had had no previous hospital admissions and only sees his GP the occasional cough. He lives at home with his parents, and was brought into A&E by his …show more content…
father.
Investigations
On examination Mr T was pyrexic but all other observations were normal. His left lower quadrant was tender and was hot to touch. His white blood cell count (26.6) and lactate (4) levels were raised, CRP and urea and electrolytes were normal.
The initial diagnosis was gastroenteritis; he was given ciprofloxacin, anti-emetics and paracetamol and oramorph for the pain. He had IV fluids and was nil by mouth. chest X-ray RESULTS. Salmonella and campylobacter was ruled out with a stool sample. As all his symptoms and the history of a buffet meal 12 hours before the pain started suggests gastroenteritis, he continued on this treatment overnight in the acute medical unit.
His CRP serum levels increased from 12 to 332 and his venous blood gas showed his lactate at 4mmol/L (0.5-1mmol/L). This is indicative of sepsis, which could have been caused by a UTI, renal stones or gastroenteritis. Blood was found in urinalysis, which suggest more likely a UTI, however, that doesn’t justify the abdominal cramps and vomiting.
On the second day of admission, at 1600 his respiratory rate raised to 30 and his temperature was 38.5. He was hypotensive and tachycardic. The tenderness was now localised to the right iliac fossa and he had dysuria. The medical team now diagnosed appendicitis and he was referred to the surgical team. The surgeon planned surgery the next morning, which would be 72 hours since the pain started.
In the early hours of day 4 of the pain he was looking increasingly unwell with a temperature of 39, the nurses called the surgeon to see him. His blood results showed that the CRP (332) and WBC (11.6 x10^6 /L) had increased. The tenderness on the abdomen was now all over. The surgeon decided that this was either perforated appendicitis or another source of significant peritonitis. A laparoscopy appendectomy was carried out and the entire appendix was gangrenous and perforated. Pus was found all over the abdomen and cleared by the surgical team.
After the surgery, his was tachycardic at 101, with a temperature of 38.5. His CRP was 267 and white blood cell count 13.8. He had sweats and rigors and felt very systemically unwell.
The following few days his NEWS score came to 0 and his inflammatory markers came down so he was switched to oral ciprofloxacin. He was discharged with 10 day antibiotic course.
Outcome and follow-up
8 days later he presented again with severe pain all over his abdomen, unable to stand straight. He reported this pain to be worse than the initial appendicitis pain. His appetite was poor making him feel weak and was experiencing night sweats. His bowels were opening but the stools were loose with blood. He had guarding in his right iliac fossa and his inflammatory markers were high. The differential diagnoses were post-surgical abscesses or collections. A CT scan showed pockets of collections.
During this second admission it was found that the infection was resistant to the antibiotics he had been given so the microbiology team gave him a new course of antibiotics. He also developed phlebitis where the cannula was administering the antibiotics.
After over 2 weeks of recovering he was discharged again. During this time, he had lost his appetite a lot of weight and muscle mass. Although he was systemically feeling well his recovery would be a lot longer.
DISCUSSION
The early diagnosis of appendicitis is key in reducing the incidence of perforated appendicitis and therefore decreasing the risk of complications.
Of all emergency patients with abdominal pain only 1%-3% will have acute appendicitis, and many of these will present atypically. CRAIG Therefore, doctors are used to ruling out appendicitis rather than including it in the differential diagnoses. Delaying the diagnosis of this can cause major difficulties in the recovery of the patient. A study done with 723 appendicitis cases from 2003 to 2009 looked at the risk of complication compared with the time of surgery after admission. 3% of patients in the delayed appendectomy group (later than 24hours after admission) died. GIRAUDO Having a high mortality rate in such a common diagnosis should be of concern to clinicians. In this case the appendectomy was carried out over 48 hours after admission, but this patient was young and fit which reduced his risk of serious complications. However, in the young population or elderly population this risk would have been much greater.
Only a small number of patients present with a history of abdominal pain migrating from the epigastrium to the right lower quadrant.
The white blood cell count will be elevated in 70%-90% of patients with acute appendicitis. WAGNER Pain in the right lower quadrant, abdominal rigidity and location and migration of pain to the right lower quadrant increases the likelihood of appendicitis. Similarly, the absence of these symptoms lessens the suspicion of appendicitis. The presence of vomiting before the onset of pain makes appendicitis unlikely and suggests intestinal obstruction. Diarrhoea or constipation is a less common with 18% having this symptom. WAGNER. In this case the patient presented with the 3 main symptoms of appendicitis but the diagnosis for the first 24 hours was still gastroenteritis. If appendicitis was ruled out early in the admission the perforation could have been avoided, giving this patient a better recovery time.
Gastroenteritis is a common misdiagnosis with these similar symptoms, however this should not cause significant continuous pain. Moving on from these diagnoses the clinician must decide whether to continue inpatient observation or send the patient for imaging. If a clinician has a high suspicion of appendicitis time should not be wasted on getting a CT scan and a surgeon should be called.
DRAKE
Blood tests are an important investigation into the diagnosis. Women who present with acute abdominal pain, the serum b HCG should be measured to rule out uterine or ectopic pregnancy. 70% to 90% of patients with acute appendicitis have an elevated leukocyte count, however this is also indicative of many other acute abdominal and pelvic diseases. CRP levels >1mg/dL and WBC> 10,500cells/microL is common in appendicitis.
Although this patient was 30 years old and fit and well, many diagnostic problems occur with the young population and patients older than 50 years. The pain is atypically not in the right iliac fossa which opens the diagnosis up to many more possibilities. Infants may present with watery diarrhoea and vomiting, and young children may only show anorexia and vague pain. Elderly patients may present with confusion without pain, they may also present with shock and progression can be fast. LOWTH M