CPC

RIF Pain
History
25 year old female
P.C. - Pain RIF x 36 hours
Pain was initially periumbilical and then
moved to RIF
Nausea
Vomited x 1
PMH - Nil of note
S/R - Nil of note
LMP - 10/7 ago

Examination
Pyrexia
HR 90/min
R/R Normal
BP 120/75

CVS, RS, CNS - NAD
Abdomen
Rebound tenderness RIF
Guarding RIF
No rigidity [when relaxed so this is nothing to do
with musculature]
Bowel sounds present
PR NAD
What is guarding?
What is rigidity?
Differential Dx of Pain RIF
Differential Diagnosis
Acute appendicitis [most probable]
Urinary tract infection/pyelonephritis
Renal colic
Ectopic pregnancy commonest site fallopian tube, others
abdominal cavity
Salpingitis - inflamed fallopian tubes
Ovarian mass
Terminal Ileitis
Meckels Diverticulum may give rise to peptic ulcer
Perforated DU [duodenal ulcer] usually epigastric/left hypogastrium.
Hence, less likely.
What laboratory tests are indicated?
FBC - especially WCC and differential
MSU - C/S [culture-sensitivity] and microscopy
Pregnancy Test to rule out ectopic pregnancy [ esp if no baby seen in
womb despite positive toolkit test]
+ [with or without]Plain Abdomen X-ray when there is a rupture, gas
under diaphragm / rupture of inflamed appendix, surgical emergency and
highly infective; usually isolation ward
+ Ultrasound abdomen when?
FBC
Hb - 12.5g(Norm)
MCV 90fL(Norm)
MCHC 29pg (Norm)
WCC 14,500 *usually 4 to 11 thousand, >12 to 40
thousand inflammation; >40 leukamoid ]
95% polymorphs [neutrophil] this is acute inflmmation
What is the significance of polymorphs compared to
lymphocytes? Lymphocytes raised in viral, eosinophil rise in
allergies.
Conclusion person having acute inflammation
Urine
Microscopy - < 5 pus cells [neutrophils]
Culture - mixed growth E-coli and
Staphylococcus
Colony count - < 100,000 organisms/ml

What is the significance of these urine
findings?
Why isnt it a UTI? Pus count is fine and
composition of mo is normal.
Pregnancy test - Negative

DIAGNOSIS?
Dx Acute appendicitis
Normal
Appendicits
The point of maximal tenderness may be
illicited at the McBurneys point.
Gross pathology
Normal
Appendicits
mucosa
outer
What is the predominant
inflammatory cell in acute
appendicitis?
Normal appendix

Lymphoid follicle
Appendicitis
Mucosa glands
RBC
Neutrophils
What is the role of the polymorph in
the inflammatory process?
Phagocytosis
Killing
superoxide radicals
hydrogen peroxide

What other cells in the
body are macrophages?
T phagocytic
What is the outcome of acute
inflammation?
Outcome of acute inflammation
COMPLETE RESOLUTION
rare in acute appendicitis

CHRONIC INFLAMMATION

FIBROSIS
How should this patient be
managed?
Treatment of this patient
Appendicectomy by open surgery or
laparoscopy

Role of prophylactic antibiotics
What are the causes of
acute appendicitis?
98% due to inflammation of the wall of the
appendix by organisms native to bowel.

What precipitates the infection?
Obstruction to the lumen by a faecolith causes
Stasis
Bacterial proliferation
Inflammation
Oedema
Reduced blood supply and sometimes gangrene

Sometimes obstruction may be due to stenosis of
the appendix lumen due to other causes
examples...
faecolith
Other causes of acute appendicitis:
Crohns disease
Yersinia
TB
Measles

Granuloma giant cell
Granuloma - epitheloid

What are the complications of
acute appendicitis?

Complications of acute appendicitis:


Gangrenous appendicitis
Perforation
Appendix abscess
Septicaemia
What is an abscess?
Abscess
Localised collection of pus
Dead and degenerate leucocytes
Dead and degenerate host tissue cells
Oedema fluid
Dead microorganisms
What does perforation of
the appendix mean?
Perforation
Inflammation extending from the lumen of
the appendix to the peritoneum.

What is the clinical significance of
perforation?
Appendicitis can cause a localised or a
generalised peritonitis.
What are the clinical signs of an
abdominal perforation?

Guarding and rigidity
Absent bowel sounds


What do you see on an X-ray??
X-ray diagnosis of perforation
Air under the diaphragm on an erect x-ray film
of the abdomen
perforated viscus
e.g. perforated duodenal ulcer
post laparoscopy , post surgery ,
peritonitis with gas forming organisms
air Air with level mark
What are the systemic effects of
inflammation?
Systemic effects of inflammation
Acute phase response
Inflammatory mediators produced in response to
infection / injury
Pyrexia
Acute phase proteins (eg CRP, ESR)
Leucocytosis
Increased BP and pulse, sweating and rigors,
sleep, anorexia, malaise
Severe sepsis DIC, hypotension and shock
Treatment of perforated appendicitis.
Surgery
IV antibiotics
Why does the pain of acute appendicitis
classically migrate from the peri-
umbilical area to the RIF?
1. Visceral pain umbilicus and appendix innervated
by same segment autonomic nervous system

2. Somatic pain serosal and parietal peritoneum
irritated, pain localises to RIF

In the case of retro-caecal or pelvic appendix,
presentation may not be typical


Chronic inflammation
What type of cells are found in chronic
inflammation?

Chronic inflammation
Inflammation of a prolonged duration
Progress from acute inflammation
Ab initio
Autoimmune diseases
Mononuclear cells
Macrophages
Lymphocytes
Plasma cells
Granulation tissue
Vs
Granuloma??
Define Granulation tissue
Granulation tissue
Specialised type of tissue that is characteristic
of healing
Characterised by proliferation of fibroblasts
and new thin-walled capillaries in a loose
extracellular matrix
Progressively accumulates connective tissue
matrix, eventually resulting in dense fibrosis
Define a Granuloma
epitheloid
lymphocyte
Giant cell
What are the causes of
granulomatous inflammation?
Granulomatous inflammation
Infection (specific types)
Foreign body (eg. splinter, suture, keratin, hair)
Response to tumours
Metal/dust
Berylliosis
Silicosis
Unknown aetiology
Sarcoidosis
Crohns disease
Infectious causes of granulomatous
inflammation
Bacteria
TB, Leprosy, Cat scratch disease
Fungi
Histoplasmosis, Blastomycosis
Parasites
Schistosomiasis, Toxoplasmosis, Leishmaniasis
Spirochetes
Syphilis
What did we cover?
Acute inflammation
Clinical effects (local and systemic)
Acute appendicitis presentation and
management
Chronic inflammation
When it occurs
Cells present
Granulation tissue Vs Granulomatous
inflammation