PRESENTORS:CLAVICILLAS, RAY CHRISTOPHERCONSTANTINO, CLYVE KIRSTEN CANICULA, SHALIMARDELA CRUZ, CLAUDINEMALANA, CHARLENE GAILEMALAYAO, ANALEAHMORALES, NINA SOFIA

(PYRIDOXINE)

A CASE PRESENTATION ON RUPTURED APPENDIXWITH GENERALIZED E.L PERITITONITIS P.L

INTRODUCTION APPENDICITISis 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 toPERITONITIS , 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 appendixKinking of the appendixSwelling of the bowel wall External occlusion of the bowel by adhesion Infection with Yersinia organism has been found un up to 30% of casesNo 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:Dullpainnear the navel or the upper abdomen that becomes sharp as it moves to the lower right abdomen. (First Sign)Loss of appetiteNausea and/orvomitingsoon afterabdominal painbeginsAbdominal swellingFever of 99-102 degrees Fahrenheit (LOW GRADE FEVER)

Inability to pass gasSharp 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 rectumPainful urinationVomiting that precedes the abdominal painSevere crampsConstipation ordiarrheawith gas

DIAGNOSIS

Diagnosing appendicitis can be tricky. Symptoms of appendicitis are frequently vague or extremely similar to other ailments, includinggallbladderproblems,bladder orurinary 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 inflammationUrine test to rule out a urinary tract infectionRectal examBlood test to see if your body is fighting infectionCT scans and/orultrasound

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 abdomenDizziness/feelings of faintnessIncreased pain and redness in your incisionFeverPus 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.Before surgery, the anesthesiologist visits the patient to do a brief physical examination and to obtain a medical history.

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

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

PERITONITISis inflammation of the peritoneal membrane. Peritoneumis 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 FACTORSPeritonitis 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 appendixgallbladder perforated peptic ulcerbowel obstruction

Left untreated, peritonitis can rapidly spread into theblood(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 severeabdominal pain-- it's essential to seek prompt medical evaluation and treatment that can prevent potentially fatal complications

SYMPTOMS OF PERITONITISThe first symptoms of peritonitis are Poor Appetite andNausea, 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 distensionFeverFluid in the abdomenExtreme thirstNot passing any urine, or passing significantly less urine than usualDifficulty passing gas or having a bowel movementVomiting

MEDICATION

Theinitial treatment for peritonitisinvolves injections of antibiotics or antifungal medication. This will usually last for 10 to 14 days.NICE TO KNOWAppendix 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 KNOWAlvarado Score for AcuteAppendicitisThe Alvarado scoreis 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 leftDue to the popularity of this mnemonic, the Alvarado score is sometimes referred to as theMANTRELS score.(http://emergencyradiology.wordpress.com)

REFERENCES:http://www.nlm.nih.gov/medlineplus/appendicitis.htmlhttp://www.mayoclinic.comhttp://www.webmd.com/http://health.nytimes.comhttp://www.nhs.ukshttp://www.abc.net.auhttp://www.scientificamerican.comhttp://emergencyradiology.wordpress.comBrunner and Siddharths( twelfth edition) Black, J., & Hawks, J. (eight edition)

PATIENTS PFROFILE

NAME: C.AAGE: 37 years oldADDRESS: Bagumbayan, Tuguegarao CitySEX: MaleBIRTHDATE: OCTOBER 6,1973HEIGHT: 57WEIGHT: 58 KGS BMI: 20.03 BIRTH PLACE: Tuguegarao CityCIVIL STATUS: MarriedEDUCATIONAL ATTAINMENT: College GraduateOCCUPATION: Civil Engineer

RELIGION: Roman CatholicNATIONALITY: FilipinoDIALECT: Ilokano

ADMISSION:Date: August 26,2013 Time: 6:00 PM ADMITTING VITAL SIGNS: RR: 22cpm PR: 86 bpm TEMP:37.2BP:140/90 mmHg

ATTENDING PHYSICIAN: Dr. R. Marzen (Surgeon)Dr. J. Marzen (Anesthesiologist)Dr.Pagaddu (CHIEF COMPLAINT:RLQ LOWER QUADRANT PAINADMITTING DIAGNOSIS:T/C APPENDICITISFINAL 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.

APPENDICITISis an inflammation of theappendix, a 3 1/2-inch-long tubeof tissue that extends from thelarge 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 promptsurgery 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.

PERITONEUMis a smooth, glistening, serous Membrane that lines the abdominal wall as theparietal peritoneum and is reflected from the body wall to various organs, where, as visceral peritoneum, it formsan 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 betweenminimizes 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

PERITONITISis 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 ExaminationsURINALYSISAugust 26, 2013 10:40 PM

Physical Examination

TESTSRESULTSNORMAL VALUESANALYSISCOLORDark YellowLight Yellow to AmberNormalTRANSPARENCYClearTransparent to clearNormal

Chemical ExaminationMicroscopic Examination

TESTSRESULTSNORMAL VALUESANALYSISReaction (pH)5.04.5 8.0NormalSpecific Gravity1.0301.005 1/ 035NormalSugarNegativeNegativeNormalProteinNegativeNegativeNormal

TESTSRESULTSNORMAL VALUESANALYSISWhite Blood Cells0-20-2NormalRed Blood Cells0-20-2NormalSquamous Epithelial CellsOccassionalNone to OccasionalNormal

HEMATOLOGY REPORTDate Released: August 26, 2013Time: 04:15 pm

TESTSRESULTSNORMAL VALUESANALYSISWhite Blood Cells15.85-10 x 10 g/LIncreaseHemoglobin16.213.0 18. 0 g/dLNormalHematocrit5239.0 54.0 %NormalDifferential CountSegmenters0.850.60 0.70IncreaseLymphocytes0.130.20 0.30DecreaseEosinophils0.020.01 0.08NormalPlatelet Count310150 450Normal

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

EXAMINATION PROFILE BDate Released August 27, 2013

TESTSRESULTSNORMAL VALUESANALYSISSodium136.1135 155 mmol/LNormalPotassium3.833.6 5.5Normal

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

TESTSRESULTSNORMAL VALUESANALYSISWhite Blood Cells13.575-10 x 10 g/LIncreaseHemoglobin12.413.0 18. 0 g/dLDecreaseHematocrit3839.0 54.0 %DecreaseDifferential CountSegmenters0.870.60 0.70IncreaseLymphocytes0.050.20 0.30DecreaseMonocytes0.080.02 0.06IncreasePlatelet Count310150 450Normal

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 BDate Released: August 29, 2013

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

TESTSRESULTSNORMAL VALUESANALYSISSodium138.1135 155 mmol/LNormalPotassium3.083.6 5.5Decrease

EXAMINATION PROFILE BDate Requested: August 30, 2013

TESTSRESULTSNORMAL VALUESANALYSISFasting Blood Sugar4.473.89 5.80 mmol/LNormalCreatinine9665 -120 umol/LNormalTotal Cholesterol2.795.87 6.71 mmol/LDecreaseTriglycerides1.480.08 1.88 mmol/LNormalHigh Density Lipoprotein0.52>1.4 mmol/LDecreaseLow Density Lipoprotein1.60

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

Intravenous Fluid Chart

BOTTLE NO.IV SOLUTIONIV SITETYPE OF CANNULARATE FLOW1D5LRSLEFT METACARPAL VEING 2042 gtts2D5LRSLEFT METACARPAL VEING 2042 gttsOR 1PLRSLEFT METACARPAL VEING 2056 gttsFast Drip 200 cc56 gttsFast Drip 100 cc56 gttsOR 2D5LRSLEFT METACARPAL VEING 2056 gttsOR3D5NRLEFT METACARPAL VEING 2056 gttsD5NRLEFT METACARPAL VEING 20Fast Drip 200 ccD5NRLEFT METACARPAL VEING 20Fast Drip 200 cc

BOTTLE NO.IV SOLUTIONSIV SITETYPE OF CANNULARATE OF FLOW3PLRSLeft Metacarpal VeinG20Fast Drip4PLRSLeft Metacarpal VeinG20100 gtts5PLRSLeft Metacarpal VeinG1880 gtts6D5LRSLeft Metacarpal VeinG1842 gtts7PLRSLeft Metacarpal VeinG1840 gtts8D5 LRSLeft Metacarpal VeinG1840 gtts9D5 LRSLeft Metacarpal VeinG1842 gtts10D5 LRSLeft Metacarpal VeinG1842 gtts11PLRSLeft Metacarpal VeinG1842 gtts12PNSS 1L + 40 mcg KCLLeft Metacarpal VeinG1842 gtts13PNSS 1L + 40 mcg KCLLeft Metacarpal VeinG1842 gtts14D5 NMLeft Metacarpal VeinG1842 gtts15D5 LRSLeft Metacarpal VeinG1842 gttsSD90 CC PNSS + 1 amp NicardipineLeft Metacarpal VeinG1825

INTAKE AND OUTPUT MONITORINGAugust 26, 2013August 27, 2013

TIMEORALPARENTERALTOTALURINEDRAINAGETOTAL7-11NPO650650350------------350TOTAL650650350350

TIMEORALPARENTERALTOTALURINEDRAINAGETOTAL7 3----------1001009------------93 11----------2300230059------------5911 7 ----------180018001050------------1050TOTAL420042003501118

August 28, 2013August 29, 2013

TIMEORALPARENTERALTOTALURINEDRAINAGETOTAL7 3NPO14001400580400 NGT9003 11NPO140014003801000138011 7 NPO10001000550100650TOTAL38003800151015002930

TIMEORALPARENTERALTOTALURINEDRAINAGETOTAL7 3NPO850850405300 NGT 100 VOMIT8053 11NPO10001000280150 NGT43011 7 NPO850850380150530TOTAL2700270010657001765

August 30, 2013

TIMEORALPARENTERALTOTALURINEDRAINAGETOTAL7 3NPO800800800--------------8003 11NPO105010501800850 NGT265011 7 NPO125012501100550 NGT1650TOTAL31003100370014005100