Case Blog - International Journal of Clinical & Medical Images (2016) Volume 3, Issue 3
Author(s): Guillermo Padr�n Arredondo, Mar�a Dolores Barraza Garc�a and Carlos Contreras Me
Introduction: Acute appendicitis is the most common abdominal emergency in general surgery and diagnostic still remains strictly clinic.
Case presentation: A 9 years old girl is presented in the emergency department because of abdominal pain of 48 hours of evolution, with dysuria, anorexia and a history of a month ago showed clinical urinary tract infection and gastroenteritis probably infectious. Physical examination showed only the right lower quadrant pain and fever which was treated surgically with a preoperative diagnosis of appendicitis was confirmed during surgery.
Discussion: It has always been said that the diagnosis of appendicitis is mainly clinical, and there are studies that reinforce this concept and although it is the most common surgical emergency, diagnosis still remains some difficulty mainly at the start of the pathology. Particularly when the patient presents with clinical isolates with pain in the right lower quadrant with no evidence of clinical inflammation. Few studies report similar cases and some authors exclude the diagnosis of acute appendicitis in the context of a similar clinical picture. The case drew attention because the patient only much localized pain presented high fever accompanied by emphasizing the purely clinical diagnosis is often sufficient for diagnosis and treatment.
Introduction Acute appendicitis is the most common abdominal emergency in general surgery and diagnostic still remains strictly clinic1. Its handling is prior appendectomy start with antibiotics and analgesics postoperatively continued according to the needs and circumstances of the patient. Primrose A. 2 in your article emphasized: let us take for analysis the very common series of phenomena in acute appendicitis where we have localized rigidity of the muscles of the abdominal wall and an area of the superimposed skin hypersensitive. In another hand, Cope VZ 3 establishes que la superficial hyperesthesia in often present in acute abdominal disease and is occasionally of considerable value in diagnosis. In young people the right iliac triangle is confirmatory of appendicitis and the narrow band of hyperesthesia above and parallel to Poupart´s ligament is commonly present in subacute and subsiding appendicitis. Gillespie WF 4 refers to acute appendicitis is recognized by appearance of the following, in the order described by John B. Murphy: 1) abdominal pain; 2) nausea and emesis; 3) iliac tenderness; 4) fever, and 5) leukocytosis.
Case Presentation A 9 years old girl is presented in the emergency department of our hospital because of abdominal pain 48 hours after onset with fever, dysuria and anorexia, with a history that a month ago he presented clinical symptoms of infection pathways urinary and gastroenteritis. And a clinical picture of classic dengue also allergic to cefixime. Physical examination presented with moderately dehydrated oral mucosa, amygdalin hypertrophy without hyperemic pharynx, soft abdomen and palpable abdominal tenderness in the right lower quadrant (point Mac Burney positive) limiting ambulation, with dubious talopercusion normal peristalsis without peritoneal irritation and other negative maneuvers, right Giordano (+) and no evidence of peritoneal irritation; without cardiopulmonary pathological data, other physical examination within normal parameters. Vital signs on admission: HF: 100 × min, BF: 22 × min, BP: 90/60, Temperature: 39ËC. laboratory study is requested with the following results: Normal red blood count formula, white formula with 8200, total 57% neutrophils, 57% segmented neutrophils normal rest; Normal blood chemistry, urinalysis with 7-9 leukocytes field x normal rest; normal serum electrolytes. Plain abdominal radiographs in two positions of normal appearance, and lower abdominal ultrasound to be reported as within normal limits. With the above information and despite support diagnoses were negative for clinical concluded that the case was acute appendicitis, impregnation with antibiotics and analgesics starts and undergoes surgery. Davis Rockie-type incision is made and appendix obtained with necrotic inflammatory process and fibrin in the middle and upper third with healthy initial classifying as acute gangrenous appendicitis Grade III, the patient progressed satisfactorily.
Discussion Since always it said that the diagnosis of appendicitis is mainly clinical, and there are jobs like Monneuse O et al.  which reinforce this concept and although it is the most common abdominal surgical emergency, diagnosis still remains true degree of difficulty mainly the onset of pathology [2,3]. Particularly when the patient presents with clinical signs isolated pain in the right lower quadrant without data from clinical inflammatory process. Few studies report similar cases and some authors exclude the diagnosis of acute appendicitis in the context of a similar clinical picture [4,5]. Furthermore, Melanie DW et al.  Refer to the paucity of symptoms and signs in the right lower quadrant two not exclude appendicitis. And gastroenteritis colic and constipation are the greaters masqueraders of pediatric appendicitis. The pathophysiological basis of obstructive appendicitis is appendiceal lumen process followed by an infection and in 60% of patients the obstruction is caused by hyperplasia of submucosal follicles. This form of obstruction is common to observe in children, as was the case, and is known as catarrhal appendicitis, because of this, some authors suggest that treatment of this condition and in these cases it may be only with antibiotics but often there process recurrency [7,8]. However, due to technological advances in medicine, ultrasound, CT and laparoscopy are offered as highly accurate studies for the diagnosis of this disease. Authors such as Horton MD et al. [9,10] propose that in rare cases the use of ultrasound and positron, which has 100% specificity and 97% sensitivity at 90% specificity and 76% sensitivity for ultrasound have the disadvantage that ultrasound is very operator dependent, but does not radiate the patient and the TAC is very expensive and radiates the subject in question.
However, other authors [11,12] emphasize that when ultrasound is not consistent, the traditional clinical examination provide accurate diagnosis especially in children. Kharbanda AB et al. [13,14] report that a score of 6 items: nausea (2 points), located history of pain in the right lower quadrant (2 points), migration of pain (1 point), difficulty walking (1 point) positive rebound/pain on percussion (2 points), and absolute neutrophilia>6.75 x 103/µL (6 points). With the application of the rules of low risk could be reduced by up to 20% using the TC. Similarly, state that the abdominal pain when walking, jumping or coughing and the presence of any tenderness on physical examination are appropriate for your inclusion in prediction rules for children with possible appendicitis .