General Surgery · Year 3 · from General Surgery
Case 1: Acute Appendicitis with Perforation
Patient Demographics
- Age: 28 years
- Sex: Male
- Occupation: Software engineer
Chief Complaint
"I have severe pain in my lower right abdomen that started around my belly button yesterday."
History of Present Illness
The patient presents to the emergency department with a 24-hour history of abdominal pain. The pain initially began as vague periumbilical discomfort yesterday morning, associated with nausea and one episode of vomiting. Over the past 12 hours, the pain has migrated to the right lower quadrant and has become sharp and constant. He reports anorexia and low-grade fever. The pain worsens with movement, and he has been lying still on the stretcher with his right hip flexed. He denies urinary symptoms, diarrhea, or recent travel.
Past Medical History
- No significant medical history
- No prior surgeries
Medications
- None
Allergies
- No known drug allergies
Social History
- Non-smoker
- Occasional alcohol use
- Lives with girlfriend
Physical Examination
- Vitals: BP 128/78 mmHg, HR 102 bpm, RR 18/min, Temp 38.4°C, SpO2 99% on room air
- General: Young male in moderate distress, lying still, reluctant to move
- Abdomen:
- Inspection: No distension, no surgical scars
- Auscultation: Hypoactive bowel sounds
- Palpation: Maximal tenderness at McBurney's point, guarding present, rebound tenderness positive
- Rovsing's sign: Positive (pain in RLQ with palpation of LLQ)
- Psoas sign: Positive (pain with right hip extension)
- Obturator sign: Negative
- Rectal exam: Tenderness on the right side of the rectum
Laboratory Results
- WBC: 16,800/μL (92% neutrophils, 2% bands)
- Hemoglobin: 14.2 g/dL
- Platelets: 284,000/μL
- Creatinine: 0.9 mg/dL
- Glucose: 112 mg/dL
- Lactate: 1.4 mmol/L
- Urinalysis: Normal, no pyuria or hematuria
- CRP: 145 mg/L
Imaging
CT Abdomen/Pelvis with IV contrast:
- Dilated appendix measuring 12 mm in diameter
- Appendiceal wall thickening with enhancement
- Periappendiceal fat stranding
- Small amount of free fluid in the pelvis
- No appendicolith visualized
- No evidence of abscess formation
Clinical Assessment
Alvarado Score: 9/10
- Migration of pain: +1
- Anorexia: +1
- Nausea/vomiting: +1
- RLQ tenderness: +2
- Rebound tenderness: +1
- Elevated temperature: +1
- Leukocytosis: +2
Differential Diagnosis
- Acute appendicitis (most likely)
- Mesenteric lymphadenitis
- Right-sided colonic diverticulitis (less likely given age)
- Meckel's diverticulitis
- Crohn's disease
Management
- NPO status
- IV fluid resuscitation
- IV antibiotics (ceftriaxone and metronidazole)
- Surgical consultation for appendectomy
- Consent for laparoscopic appendectomy
Operative Course
Laparoscopic appendectomy performed. Intraoperatively, the appendix was found to be gangrenous with microperforation at the tip. Purulent fluid present in the pelvis. Appendix removed with stapled base. Peritoneal lavage performed. No drain placed.
Postoperative Course
- Antibiotics continued for 5 days (transitioned to oral amoxicillin-clavulanate)
- Diet advanced on POD 1
- Discharged POD 2 in good condition
- Pathology confirmed acute gangrenous appendicitis with perforation
Teaching Points
- Classic migration of pain from periumbilical to RLQ occurs in only 50-60% of cases
- CT scan is the gold standard for diagnosis with sensitivity >95%
- Early surgical intervention reduces perforation risk
- Laparoscopic approach preferred when expertise available
- Perforated appendicitis requires extended antibiotic course
Clinical Image
Image Description: Contrast-enhanced CT scan of the abdomen demonstrating an enlarged, inflamed appendix with periappendiceal fat stranding characteristic of acute appendicitis. The appendix diameter exceeds 6 mm with wall thickening and enhancement.
Attribution: Image from Wikimedia Commons, Category:CT images of appendicitis. Source: https://commons.wikimedia.org/wiki/Category:CT_images_of_appendicitis