Introduction

Acute appendicitis is one of the most common surgical emergencies, affecting approximately 7% of the population during their lifetime. Prompt diagnosis and management are crucial to prevent complications such as perforation, abscess formation, and peritonitis, which can significantly increase morbidity and mortality. This case study discusses the clinical presentation, diagnosis, and management of a patient with acute appendicitis, highlighting the importance of timely intervention and comprehensive care.

Case Presentation

Patient Profile

• Age: 24 years
• Gender: Male
• Chief Complaint: Right lower abdominal pain for 24 hours

History of Present Illness

The patient presented with a 24-hour history of progressively worsening right lower abdominal pain. The pain initially started around the umbilicus and later localized to the right lower quadrant. He reported associated nausea and anorexia but denied vomiting, diarrhea, or fever before the onset of pain. There was no significant past medical or surgical history and no known allergies.

Physical Examination

• Vital Signs: Temperature: 38.2°C, Heart Rate: 90 bpm, Blood Pressure: 120/80 mmHg
• Abdominal Examination:
  • Tenderness in the right lower quadrant
  • Positive McBurney’s point tenderness
  • Rebound tenderness
  • Guarding and rigidity

The patient also exhibited a positive Rovsing’s sign (pain in the right lower quadrant upon palpation of the left lower quadrant) and a positive psoas sign (pain on passive extension of the right hip).

Laboratory and Imaging Studies

• Complete Blood Count (CBC): Elevated white blood cell count (WBC) of 14,000/mm³ with a left shift, indicating an inflammatory response
• Urinalysis: Normal, ruling out urinary tract infection or renal colic
• C-Reactive Protein (CRP): Elevated, supporting the diagnosis of acute inflammation
• Ultrasound of the Abdomen: Non-compressible, dilated appendix with a diameter of 8 mm, periappendiceal fluid, and increased echogenicity of the surrounding fat

Given the clinical presentation and supportive imaging findings, a diagnosis of acute appendicitis was made.

Management

Preoperative Care

• Intravenous Fluids: The patient was started on IV fluids to maintain hydration and electrolyte balance.
• Antibiotics: Broad-spectrum antibiotics (e.g., ceftriaxone and metronidazole) were administered to cover common pathogens and reduce the risk of postoperative infections.

Surgical Intervention

The patient underwent an emergency laparoscopic appendectomy. During the surgery, the appendix was found to be inflamed but not perforated. The procedure involved:

• Three small incisions to insert the laparoscope and surgical instruments
• Visualization and identification of the inflamed appendix
• Isolation and removal of the appendix using a stapler or ligature
• Inspection of the abdominal cavity for any signs of complications

The surgery was completed without complications, and the appendix was sent for histopathological examination to confirm the diagnosis and rule out any other pathology.

Postoperative Care

• Pain Management: The patient received analgesics, including acetaminophen and opioids as needed for pain control.
• Antibiotics: Continued for 24 hours postoperatively to prevent infection.
• Diet: The patient was started on a clear liquid diet and gradually advanced to a regular diet as tolerated.
• Monitoring: Vital signs and the surgical wound site were closely monitored for signs of infection or other complications.

Follow-Up

The patient was discharged on the third postoperative day with instructions on wound care and a follow-up appointment scheduled for one week later. He was advised to avoid strenuous activities for a few weeks and to report any signs of infection, such as fever, increased pain, or discharge from the wound site.

Outcome

The patient recovered well postoperatively with no complications. He returned to normal activities within a few weeks and had no recurrent symptoms during follow-up visits.

Discussion

Acute appendicitis is primarily a clinical diagnosis, supported by laboratory and imaging studies. The classical presentation includes initial periumbilical pain that migrates to the right lower quadrant, accompanied by tenderness, nausea, and anorexia. However, variations in presentation can occur, especially in children, the elderly, and pregnant women, making diagnosis more challenging in these populations.

Key Points

1. Clinical Presentation: Typically starts with periumbilical pain that later localizes to the right lower quadrant, often associated with nausea and anorexia.
2. Diagnosis: Based on clinical signs, elevated WBC, and imaging studies like ultrasound or CT scan. In cases where diagnosis is uncertain, a CT scan can provide more detailed information.
3. Treatment: Surgical removal of the appendix (appendectomy) is the standard treatment. Laparoscopic appendectomy is preferred due to its minimally invasive nature, faster recovery, and lower complication rates.
4. Postoperative Care: Includes pain management, antibiotics, and gradual dietary advancement. Early mobilization and patient education on wound care are essential for a smooth recovery.

References

1. Mayo Clinic on Appendicitis
2. American College of Surgeons: Appendectomy
3. UpToDate: Clinical manifestations and diagnosis of acute appendicitis in adults

By following this approach, MBBS students and medical professionals can gain insights into the diagnosis and management of acute appendicitis. For more detailed information and case studies, visit MSMBBs.