A CASE PRESENTATION ON RUPTURED APPENDIX WITH GENERALIZED E.L PERITITONITIS P.

L
PRESENTORS: CLAVICILLAS, RAY CHRISTOPHER CONSTANTINO, CLYVE KIRSTEN CANICULA, SHALIMAR DELA CRUZ, CLAUDINE MALANA, CHARLENE GAILE MALAYAO, ANALEAH MORALES, NINA SOFIA (PYRIDOXINE)

INTRODUCTION
APPENDICITIS is an inflammation of the vermiform appendix that develops mostly in adolescents and young adult. It can occur at any age but rare in clients younger than 2 years reaches a peak incidence in client between 20 and 30 years It is not common in older adults; however, when it does occur in such clients, rupture of the appendix is more common.

NOTE: Appendicitis is a medical emergency that requires prompt surgery to remove the appendix. Left untreated, an inflamed appendix will eventually burst, or perforate, spilling infectious materials into the abdominal cavity. This can lead to PERITONITIS , a serious inflammation of the abdominal cavity's lining (the peritoneum) that can be fatal unless it is treated quickly with strong antibiotics.

ETIOLOGY AND RISK FACTORS

Appendicitis can be caused by the following: A fecalith (fecal calculus, or stone) that occludes the lumen of the appendix Kinking of the appendix Swelling of the bowel wall External occlusion of the bowel by adhesion Infection with Yersinia organism has been found un up to 30% of cases No particular risk factors for appendicitis have been identified. Because it is not preventable, early detection of the condition is important

SIGNS AND SYMPTOMS The classic symptoms of appendicitis include: Dull pain near the navel or the upper abdomen that becomes sharp as it moves to the lower right abdomen. (First Sign) Loss of appetite Nausea and/or vomiting soon after abdominal pain begins Abdominal swelling Fever of 99-102 degrees Fahrenheit (LOW GRADE FEVER)

 Inability to pass gas Sharp pain in your lower right abdomen that

occurs when the area is pressed on and then the pressure is quickly released (rebound tenderness). Halitosis(fetid breath) Tenderness at McBurneys point, which lies midway between the right anterior superior iliac crest and the umbilicus

Almost half the time, other symptoms of appendicitis appear, including:

Dull or sharp pain anywhere in the upper or

lower abdomen, back, or rectum Painful urination Vomiting that precedes the abdominal pain Severe cramps Constipation or diarrhea with gas

DIAGNOSIS

Diagnosing appendicitis can be tricky. Symptoms of appendicitis are frequently vague or extremely similar to other ailments, including gallbladder problems, bladder or urinary tract infection, Crohn's disease, gastritis, intestinal infection, and ovary problems.

The following tests are usually used to make the diagnosis.

Abdominal exam to detect inflammation
Urine test to rule out a urinary tract infection Rectal exam

Blood test to see if your body is fighting

infection CT scans and/or ultrasound

TREATMENT

There is NO MEDICAL TREATMENT for appendicitis. Preoperatively, IV fluids and antibiotics are administered. Pain medication is withheld until diagnosis is confirmed. Surgical intervention involves removal of the appendix (APPENDECTOMY) within 24 to 48 hours of onset of manifestation.

 Antibiotics are given before an appendectomy

to fight possible peritonitis. General anaesthesia is usually given, and the appendix is removed through a 4-inch incision or by laparoscopy.

NOTE:
If you have peritonitis, the abdomen is also irrigated

and drained of pus. Within 12 hours of surgery you may get up and move around. You can usually return to normal activities in two to three weeks. If surgery is done with a laparoscope (a thin telescope-like instrument for viewing inside the abdomen), the incision is smaller and recovery is faster.

After an appendectomy, call the doctor if you have:

Increased pain in your abdomen Dizziness/feelings of faintness Increased pain and redness in your incision

Fever
Pus in the wound

PRE- OPERATIVE PROCEDURES

Informed consent form must be signed acknowledging that the patient understands the procedure, the potential risks, and that they will receive certain medications. 2. Before surgery, the anesthesiologist visits the patient to do a brief physical examination and to obtain a medical history.
1.

He or she will want to know about any other medical conditions;

if the patient is taking any medication (prescription

or over-the-counter); if any dietary supplements or herbal products are being used; if there has been recent illicit drug use; if the patient smokes cigarettes or drinks alcohol; if the patient has a history of allergies, especially to medications; or a family history of problems with anesthesia.

3. Patients are required to refrain from eating or drinking after midnight on the day before surgery; however, because an appendectomy is an emergency procedure, this may not be possible. 4. As soon as the decision is made to operate, the patient must take nothing by mouth, including oral medications

5. Prior to surgery, an intravenous (IV) is started to administer fluid and medications that have been ordered, including antibiotics and pain medication. 6. A sedative may be given to help the patient relax. 7. Anesthesia is administered in the operating room.

POST OPERATIVE TEACHINGS

A nasogastric tube is passed through the nose

and into the stomach to relieve the distension. When bowel function returns to normal (evident by passing gas or having a bowel movement), the tube is removed. Antibiotics are started to rule out infection

PERITONITIS is inflammation of the peritoneal membrane. Peritoneum is a semipermeable two layered sac filled with about 1500 ml of fluid. this sac covers all the organs in the abdominal cavity. Because it is well supplied with somatic nerves, stimulation of the parietal peritoneum that lines the abdominal and pelvic cavities causes sharp well localized pain. The visceral peritoneum is relatively insensitive

ETILOGY AND RISK FACTORS

Peritonitis is a localized or generalized inflammation process that may be acute or chronic. Acute Peritonitis is caused by decrease in the motor activity of the bowel, causing the intestinal lumen to become distended with gas and fluid.

 Inability of the intestine to reabsorb fluid

causes an accumulation in the peritoneal cavity. Normal flora of the intestine becomes a source of infection when they enter the sterile peritoneal cavity. usually caused by infection from bacteria or fungi (E coli, staphylococci, and pneumococci).

NOTE:

There are no primary risk factors for peritonitis because the condition is a result of another problem. Causes include: ruptured appendix gallbladder perforated peptic ulcer bowel obstruction

Left untreated, peritonitis can rapidly spread into the blood (sepsis) and to other organs, resulting in multiple organ failure and death. If a person develops any of the symptoms of peritonitis -- the most common of which is severe abdominal pain -- it's essential to seek prompt medical evaluation and treatment that can prevent potentially fatal complications

SYMPTOMS OF PERITONITIS The first symptoms of peritonitis are Poor Appetite and Nausea, and a Dull Abdominal Ache that quickly turns into persistent, severe abdominal pain, which is worsened by any movement. Other signs and symptoms related to peritonitis may include: Abdominal tenderness or distension Fever Fluid in the abdomen Extreme thirst Not passing any urine, or passing significantly less urine than usual Difficulty passing gas or having a bowel movement Vomiting

MEDICATION
The initial treatment for peritonitis involves injections of antibiotics or antifungal medication. This will usually last for 10 to 14 days. NICE TO KNOW Appendix acts as a safe house for good bacteria, which can be used to effectively reboot the gut following a bout of dysentery or cholera. (http://www.abc.net.au)

Appendix serves an important role in the fetus and in young adults. Endocrine cells appear in the appendix of the human fetus at around the 11th week of development. These endocrine cells of the fetal appendix have been shown to produce various biogenic amines and peptide hormones, compounds that assist with various biological control (homeostatic) mechanisms. There had been little prior evidence of this or any other role of the appendix in animal research, because the appendix does not exist in domestic mammals.(http://www.scientificamerican.com)

MUST KNOW Alvarado Score for Acute Appendicitis The Alvarado score is a clinical scoring system used in the diagnosis of appendicitis. The score has 6 clinical items and 2 laboratory measurements with a total 10 points. A score of 5 or 6 is compatible with the diagnosis of acute appendicitis. A score of 7 or 8 indicates a probable appendicitis, and A score of 9 or 10 indicates a very probable acute appendicitis. A popular mnemonic used to remember the Alvarado score factors is

MANTRELS Migration to the right iliac fossa Anorexia, Nausea/Vomiting Tenderness in the right iliac fossa Rebound pain Elevated temperature (fever) Leukocytosis Shift of leukocytes to the left Due to the popularity of this mnemonic, the Alvarado score is sometimes referred to as the MANTRELS score.(http://emergencyradiology.wordpress.com)

 REFERENCES: http://www.nlm.nih.gov/medlineplus/appendiciti

s.html http://www.mayoclinic.com http://www.webmd.com/ http://health.nytimes.com http://www.nhs.uks http://www.abc.net.au http://www.scientificamerican.com http://emergencyradiology.wordpress.com Brunner and Siddharths( twelfth edition) Black, J., & Hawks, J. (eight edition)

PATIENTS PFROFILE
NAME: C.A AGE: 37 years old ADDRESS: Bagumbayan, Tuguegarao City SEX: Male BIRTHDATE: OCTOBER 6,1973 HEIGHT: 57 WEIGHT: 58 KGS RELIGION: Roman Catholic

NATIONALITY: Filipino
DIALECT: Ilokano

BMI: 20.03
BIRTH PLACE: Tuguegarao City CIVIL STATUS: Married EDUCATIONAL ATTAINMENT: College Graduate OCCUPATION: Civil Engineer

ADMISSION: Date: August 26,2013 Time: 6:00 PM ADMITTING VITAL SIGNS: RR: 22cpm PR: 86 bpm TEMP:37.2 BP:140/90 mmHg ATTENDING PHYSICIAN: Dr. R. Marzen (Surgeon) Dr. J. Marzen (Anesthesiologist) Dr.Pagaddu ( RLQ LOWER QUADRANT PAIN T/C APPENDICITIS

CHIEF COMPLAINT: ADMITTING DIAGNOSIS:

FINAL DIAGNOSIS: Ruptured Appendicitis with Generalized Peritonitis Exploratory Laparotomy AppendectomyPeritoneal Lavage
SOURCE OF INFORMATION: S.O, Patient CV, and Chart

ANATOMY and PHYSIOLOGY

APPENDIX -sits at the junction of the small intestine and large intestine. -Its a thin tube about four inches long and sits in the lower right abdomen. -Function is unknown THEORY: the appendix acts as a storehouse for good bacteria, rebooting the digestive system after diarrheal illnesses. Other experts believe the appendix is just a useless remnant from our evolutionary past. Surgical removal of the appendix causes no observable health problems.

APPENDICITIS is an inflammation of the appendix, a 3 1/2-inch-long tube of tissue that extends from the large intestine. No one is absolutely certain what the function of the appendix is. One thing people do know: We can live without it, without apparent consequences. Appendicitis is a medical emergency that requires prompt surgery to remove the appendix (Appendectomy). Left untreated, an inflamed appendix will eventually burst, or perforate, spilling infectious materials into the abdominal cavity. This can lead to PERITONITIS, a serious inflammation of the abdominal cavity's lining (the peritoneum) that can be fatal unless it is treated quickly with strong antibiotics.

PERITONEUM is a smooth, glistening, serous Membrane that lines the abdominal wall as the parietal peritoneum and is reflected from the body wall to various organs, where, as visceral peritoneum, it forms an integral part as the outermost, or serosal, layer. The pericardium pleura, and peritoneum have a similar arrangement in the parietal and visceral layers, with a cavity between minimizes friction, resists infection, and stores fat. It allows free movement of the abdominal viscera In response to injury or infection (peritonitis), it exudes fluid and cells and tends to wall off or localize infection

PERITONITIS is an inflammation of the peritoneum, the thin membrane that lines the abdominal wall and covers the organs inside. It is caused by a bacterial or fungal infection. There are two types:

Primary Peritonitis happens when an infection spreads from the blood and lymph nodes to the peritoneum. Secondary Peritonitis is the more common type of peritonitis; happens when the infection comes into the peritoneum through a perforation in the abdominal wall.

Laboratory Examinations
URINALYSIS August 26, 2013 10:40 PM

Physical Examination
TESTS COLOR TRANSPAR ENCY RESULTS Dark Yellow Clear NORMAL VALUES Light Yellow to Amber Transparent to clear ANALYSIS Normal Normal

Chemical Examination
TESTS Reaction (pH) Specific Gravity Sugar Protein RESULTS 5.0 1.030 Negative Negative NORMAL VALUES 4.5 8.0 1.005 1/ 035 Negative Negative ANALYSIS Normal Normal Normal Normal

Microscopic Examination TESTS White Blood Cells Red Blood Cells Squamous Epithelial Cells RESULTS 0-2 0-2 Occassional NORMAL VALUES 0-2 0-2 None to Occasional ANALYSIS Normal Normal Normal

HEMATOLOGY REPORT Date Released: August 26, 2013 Time: 04:15 pm

TESTS
White Blood Cells Hemoglobin Hematocrit Differential Count Segmenters Lymphocytes Eosinophils Platelet Count

RESULTS
15.8 16.2 52

NORMAL VALUES
5-10 x 10 g/L 13.0 18. 0 g/dL 39.0 54.0 %

ANALYSIS
Increase Normal Normal

0.85 0.13 0.02 310

0.60 0.70 0.20 0.30 0.01 0.08 150 450

Increase Decrease Normal Normal

Interpretation: Increase white blood cells indicates presence of infection due to ruptured appendix, spilling infectious materials in the abdominal cavity Increase segmenters indicates bacterial infection while increase lymphocytes suggests viral infection. Therefore, Bacterial Infection: Increase Segmenters; Decrease Lymphocytes Viral Infection: Increase Lymphocytes; Decrease Segmenters

EXAMINATION PROFILE B Date Released August 27, 2013

TESTS Sodium Potassium

RESULTS 136.1 3.83

NORMAL VALUES 135 155 mmol/L 3.6 5.5

ANALYSIS Normal Normal

HEMATOLOGY REPORT Examination Requested: CBC Date Released: August 29, 2013 Time Released: 04:14 PM

TESTS
White Blood Cells Hemoglobin Hematocrit Differential Count Segmenters Lymphocytes Monocytes Platelet Count

RESULTS
13.57 12.4 38

NORMAL VALUES
5-10 x 10 g/L 13.0 18. 0 g/dL 39.0 54.0 %

ANALYSIS
Increase Decrease Decrease

0.87 0.05 0.08 310

0.60 0.70 0.20 0.30 0.02 0.06 150 450

Increase Decrease Increase Normal

Interpretation: Increase white blood cells indicates presence of infection due to ruptured appendix, spilling infectious materials in the abdominal cavity Increase segmenters indicates bacterial infection while increase lymphocytes suggests viral infection. Therefore, Bacterial Infection: Increase Segmenters; Decrease Lymphocytes Viral Infection: Increase Lymphocytes; Decrease Segmenters Decrease hemoglobin & hematocrit due to insufficient nutrients in the body. Increase monocytes indicate destruction of bacteria.

EXAMINATION PROFILE B Date Released: August 29, 2013 TESTS Sodium Potassium RESULTS 138.1 3.08 NORMAL VALUES 135 155 mmol/L 3.6 5.5 ANALYSIS Normal Decrease

Interpretation: Decrease Potassium due to vomiting and diarrhea as side effects of antibiotics taken.

EXAMINATION PROFILE B Date Requested: August 30, 2013 TESTS Fasting Blood Sugar Creatinine Total Cholesterol RESULTS 4.47 96 2.79 NORMAL VALUES 3.89 5.80 mmol/L 65 -120 umol/L 5.87 6.71 mmol/L 0.08 1.88 mmol/L ANALYSIS Normal Normal Decrease Normal

Triglycerides 1.48 High Density 0.52 Lipoprotein Low Density Lipoprotein 1.60

>1.4 mmol/L Decrease <3.50 mmol/L Normal

SGPT/ALT

13

Up to 40 u/L Normal

Interpretation: Decrease total cholesterol due to insufficient nutrients in the body as manifested by Nothing Per Orem Decrease High Density Lipoprotein related to smoking and eating fatty foods.

Intravenous Fluid Chart

BOTTL E NO. IV SOLUTION IV SITE TYPE OF CANN ULA RATE FLOW

1
2 OR 1

D5LRS
D5LRS PLRS

LEFT METACARPAL VEIN

LEFT METACARPAL VEIN LEFT METACARPAL VEIN

G 20

42 gtts
42 gtts 56 gtts Fast Drip 200 cc 56 gtts Fast Drip 100 cc 56 gtts

G 20 G 20

OR 2 OR3

D5LRS D5NR D5NR D5NR

LEFT METACARPAL VEIN LEFT METACARPAL VEIN LEFT METACARPAL VEIN LEFT METACARPAL VEIN

G 20 G 20 G 20 G 20

56 gtts 56 gtts Fast Drip 200 cc Fast Drip 200 cc

BOTTLE NO. 3 4 5 6 7 8 9 10 11 12 13 14 15 SD

IV SOLUTIONS

IV SITE

TYPE OF CANNULA G20 G20 G18 G18 G18 G18 G18 G18 G18 G18 G18 G18 G18 G18

RATE OF FLOW Fast Drip 100 gtts 80 gtts 42 gtts 40 gtts 40 gtts 42 gtts 42 gtts 42 gtts 42 gtts 42 gtts 42 gtts 42 gtts 25

PLRS PLRS PLRS D5LRS PLRS D5 LRS D5 LRS D5 LRS PLRS PNSS 1L + 40 mcg KCL PNSS 1L + 40 mcg KCL D5 NM D5 LRS 90 CC PNSS + 1 amp Nicardipine

Left Metacarpal Vein Left Metacarpal Vein Left Metacarpal Vein Left Metacarpal Vein Left Metacarpal Vein Left Metacarpal Vein Left Metacarpal Vein Left Metacarpal Vein Left Metacarpal Vein Left Metacarpal Vein Left Metacarpal Vein Left Metacarpal Vein Left Metacarpal Vein Left Metacarpal Vein

INTAKE AND OUTPUT MONITORING

August 26, 2013

TIME
7-11 TOTAL

ORAL
NPO

PARENT TOTAL ERAL

650 650 650 650

URINE
350 350

DRAINA TOTAL GE
------------ 350 350

August 27, 2013 TIME 73 ORAL ---------PARENT TOTAL ERAL 100 100 URINE 9 DRAINA TOTAL GE ------------ 9

3 11
11 7 TOTAL

-------------------

2300
1800 4200

2300
1800 4200

59
1050 350

------------ 59
------------ 1050 1118

August 28, 2013

TIME 73 3 11 11 7 TOTAL August 29, 2013 TIME 73 3 11 ORAL NPO NPO PARENT TOTAL ERAL 850 1000 850 1000 URINE 405 280 DRAINAG TOTAL E 300 NGT 805 100 VOMIT 150 NGT 430 ORAL NPO NPO NPO PARENT TOTAL ERAL 1400 1400 1000 3800 1400 1400 1000 3800 URINE 580 380 550 1510 DRAINA TOTAL GE 400 NGT 1000 100 1500 900 1380 650 2930

11 7
TOTAL

NPO

850
2700

850
2700

380
1065

150
700

530
1765

August 30, 2013

TIME 73 3 11 11 7 TOTAL ORAL NPO NPO NPO PARENT TOTAL ERAL 800 1050 1250 3100 800 1050 1250 3100 URINE 800 1800 1100 3700 DRAINAG TOTAL E -------------- 800 850 NGT 550 NGT 1400 2650 1650 5100