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Pathophysiology Of Acute Appendicitis : Appendicitis Mimicking Appendicular

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Pathophysiology Of Acute Appendicitis : Appendicitis Mimicking Appendicular

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Pathophysiology Of Acute Appendicitis : Appendicitis Mimicking Appendicular

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Question:
Describe about the Pathophysiology of Acute Appendicitis for Appendicitis Mimicking Appendicular.
 
Answer:
1: As discussed by Guest (2015), Appendix is a small, tube shaped organ that is located in the junction of the small and the large intestine. Although its function is unknown, certain theories suggest that this organ is a storehouse for several essential bacteria which ultimately help in the digestion process. Acute appendicitis is referred to as a condition with acute inflammation and infection of the appendix. The most common cause of abdominal pain is the enlargement of the appendix (Didier et al., 2015).
The pathophysiology of acute appendicitis is that it is an inflammation which occurs in the inner lining of the vermiform appendix which later spreads on the other parts of the organ. As stated by Kollár et al., (2015), an obstruction of the appendiceal lumen can lead to this condition. Such an obstruction can elevate the pressure within the appendiceal lumen. In turn this results in incessant secretion of mucus and fluids from the mucosa. Once the intestinal bacteria within this organ multiply, the white blood cells are being used up leading to the formation of pus. As discussed by Jaschinski et al. (2015), the increase in the intraluminal pressure will lead to the obstruction in the venous outflow. Such a condition causes Ischemia of the appendiceal wall which results in the loss of integrity of the epithelium and invasion of bacteria. The appendicular veins and artery undergoes thrombosis that causes rapid perforation and ultimately gangrene of the appendix. With the continuation of the process, a development of a peri-appendicular abscess occurs. If walled off by the omentum, this may be localized (Chandanwale et al., 2015).
Within the last twenty years the treatment of appendicitis has completely turned surgical. The current surgical treatment for appendicitis is appendectomy. According to Jaschinski et al. (2015), “Appendectomy” involves the abdominal incision about two to four inches. Laparoscopic surgery is only applicable if the infection has not spread beyond the organ. But once the infection has spread all over the appendix or an individual have an abscess an open appendectomy is required. An open appendectomy allows the physician to clean the abdominal cavity properly(Guest, 2015). Many theorize that perforated and nonperforated appendicitis could have dissimilar patterns and pathological processes. According to Gerard (2011), patients with severe condition have higher white cell count compared to patient under antibiotic treatment. One of the studies reveal the fact that, although perforation was directly connected to the period of symptoms before surgery, the risk are linked more with pre-hospital delay than with in-hospital delay (“Pediatric Appendicitis Treatment & Management: Approach Considerations, Fluid Resuscitation, Antibiotic Therapy”, 2016). Thus, in this case study, Ajay who was suffering from tremendous pain due to rupturing of the appendix wall and spreading of the infection should be suggested for open appendectomy. Since such a surgery could aid in cleaning of the whole abdominal cavity (Bullock & Hales, 2012).
2: According to the case study, Ajay Mahajan is a student of 18 years old whose medical history reveals asthma. He was addicted to alcohol, cigarette and certain party drugs. One day during work he complained of abdominal pain and feeling of nausea. He experienced vomiting and therefore was immediately taken to the hospital. Later the physicians diagnosed him with an acute stage of appendicitis. Although initially a laparoscopy was suggested and procedure was applied, the rupturing of the appendix made the change in the surgical treatment. Appendectomy with peritoneal lavage took place (Cools et al., 2015).  
In the “Post Anaesthetic Recovery room” Ajay was drowsy and was sleeping in the supine position. When he roused from sleep he felt chills and his mouth was dry. Three conditions related to his body condition can be indicated. The three conditions are ventilation, circulation and consciousness (Guest, 2015). Firstly ventilation of Ajay was affected due to anesthesia which was followed by surgery. His signs and symptoms reflected that his respiration is 10 and oxygen saturation is 94%. Due to his stomach pain he was administered with Morphine and later IV analgesia, IV anti-emetics, IV antibiotics and nicotine patch was also prescribed (O’reilly, 2014).   
As stated by Gerard (2011), most of the agents that are used as a general anesthetic in order to relieve the pain drastically change the control of breathing. They impact on the chemical control of an individual’s breathing or ventilation. According to O’reilly (2014), anesthesia, opioids and surgery exerts many affects in the clinical condition of the patient. Anesthesia causes chills and shivers and researchers have suggested that this may happen due to the cooling of the body. In this case, it has been observed that Ajay after regaining his senses suffered from chills due to the affect of the anesthesia. Certain studies reveal the fact that in regards to opioid as an anesthetic, it affects the chemical control of respiration (Lee & Goldman, 2012). The normal respiratory rate has been calculated as 12. Less than twelve and more than 25 is considered to be an abnormal medical condition. In terms of Ajay the consumption of Morphine which is an opioid lowered his respiration rate per minute to 10. The consumption of Morphine in order to relief his pain acted as a suppressor of painthrough the course of respiratory depression (White et al., 2014).
 
The case study of Ajay suggest that before his discharge from the “Post anaesthetic recovery room (PARU),” his signs and symptoms reflected certain abnormalities in the circulation process of the patient. His blood pressure observed was 90 / 50, temperature was 35 degree centigrade and pulse rate was 80. The observations indicate that his blood pressure was low, pulse rate was more and body temperature is less than normal. According to Hawn et al. (2013), anesthesia is a kind of drug that is used to num either a specific area or the whole body during a surgery. In some cases it has been seen that such drugs can lead to the significant drop in the blood pressure. Attenuation of normal homeostatic thermoregulation takes place during the course of anesthesia and surgery that might impose large thermal stress (Seol et al., 2012).
As stated by Song et al. (2015), any opioid used to relief pain due to surgery might lead fluctuations in his heart. The various observations indicates that the lowering of Ajay’s blood pressure which accounted to 90 / 50. The consumption of an opioid like Morphine may develop postural hypotension or severe down fall of pressure while lying on the bed in the PARU (Lee & Goldman, 2012). Moreover, hypothermia is a state where an individual’s body temperature gets lower than the normal body temperature that is 37 degree centigrade. This has been observed in case of Ajay where his body temperature measured was less than the normal body temperature which is 35 degree centigrade. This condition is termed as hypothermia (Ching & Brown, 2014).
As discussed by (Lee & Goldman, 2012), after surgery other than ventilation and circulation, consciousness is also affected. When Ajay was carried to the PARU he was drowsy as well as in a supine position. He was under sound sleep and was snoring. During his unconsciousness he could not realize the abdominal pain. But as he regained his consciousness, it was observed that he was under tremendous pain. Literature review suggests that consciousness is lost due to the use of anesthetics which produce functional disconnection in the posterior complex since it interrupts the cortical communication and cause a loss of integration (Ching & Brown, 2014). Such drugs cause unconsciousness when they cause blockage in the brain which lead to the brain’s inability to integrate information. In this case study, Ajay was unconsciousness after the surgery due to the application of anesthetics during the surgery. Moreover, the use of opioid such as Morphine helped to reduce his pain and by affecting his senses. In addition to this, general anesthesia can cause some mild effects such as dry mouth(Cools et al., 2015).
3: Ajay has undergone appendectomy surgery due to chronic appendicitis. Post surgery he was transferred to the post-anesthetic recovery room. At that time Ajay was sleepy and difficult to arouse. His medical condition reflected lowering of blood pressure, hypothermia, abnormal pulse rate and dryness of mouth. He had acute abdominal pain then. He was worried about her examination and his addictions. His discharge was planned after five days once he was reviewed (Ching & Brown, 2014). He as prescribed with Metronidazole and Tramadol. The discharge instructions for Ajay are as follows:
It is necessary to put the dry dressing on his abdomen twice a day. This is necessary because there might be drainage from wounds and if the drainage is not reducing, the patient must consult the surgeon. Meanwhile, the patient is prohibited from applying any cream or ointments on the incision till six weeks (Cools et al., 2015).
The patient should be careful about the stitches and it should be removed only by the medical practitioner after three weeks of the discharge.
He should be assisted by a family after his discharge, even he can mobilize alone. This will minimize the risk of falling and allow the abdomen to dry and recover fast.
It is also important for Ajay to take prescribed medicines on time and take it in proper amount. The prescribed with Metronidazole and Tramadol should be taken on the recommended time in order to recover fast Gerard (2011).
While taking shower Ajay must be careful to pat dry the incision and do soak it in bath tub till six weeks. However, it is advised that the patient avoids bathing for 4-5 days after discharge (Cools et al., 2015).
Ajay is advised to attend rehabilitation session post surgery so that he can manage his ADLs and live independently at home without his parents. It would involve giving physical therapy to Ajay to prevent contractures, improve knowledge about management post surgery and strengthen muscles around the hips through controlled exercised.
The result of the low blood pressure, high pulse rate and other weaknesses were the result of the drugs used and surgery. Later the pain reliever that was given was due to his abdominal pain. Such medicines should be avoided and only taken with doctor’s recommendation Song et al. (2015).
 
References:
Bullock, S., & Hales, M. (2012). Principles of Pathophysiology. Pearson Higher Education AU.
Chandanwale, S. S., Dey, I., Kaur, S., Nair, R., & Patil, A. A. (2015). Xanthogranulomatous appendicitis mimicking appendicular lump: An uncommon entity. Clinical Cancer Investigation Journal, 4(6), 769.
Ching, S., & Brown, E. N. (2014). Modeling the dynamical effects of anesthesia on brain circuits. Current opinion in neurobiology, 25, 116-122.
Cools, F., Offringa, M., & Askie, L. M. (2015). Elective high frequency oscillatory ventilation versus conventional ventilation for acute pulmonary dysfunction in preterm infants. The Cochrane Library.
Didier, R. A., Vajtai, P. L., & Hopkins, K. L. (2015). Iterative reconstruction technique with reduced volume CT dose index: diagnostic accuracy in pediatric acute appendicitis. Pediatric radiology, 45(2), 181-187.
Gerard J. Fitzmaurice, E. (2011). Antibiotics versus appendectomy in the management of acute appendicitis: a review of the current evidence. Canadian Journal Of Surgery, 54(5), 307. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3195652/
Guest, W. (2015). Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. Internal Medicine.
Hawn, M. T., Graham, L. A., Richman, J. S., Itani, K. M., Henderson, W. G., & Maddox, T. M. (2013). Risk of major adverse cardiac events following noncardiac surgery in patients with coronary stents. JAMA, 310(14), 1462-1472.
Jaschinski, T., Mosch, C., Eikermann, M., & Neugebauer, E. A. (2015). Laparoscopic versus open appendectomy in patients with suspected appendicitis: a systematic review of meta-analyses of randomised controlled trials. BMC gastroenterology, 15(1), 1.
Kollár, D., McCartan, D. P., Bourke, M., Cross, K. S., & Dowdall, J. (2015). Predicting acute appendicitis? A comparison of the Alvarado score, the appendicitis inflammatory response score and clinical assessment. World journal of surgery, 39(1), 104-109.
Lee, T. H., & Goldman, L. (2012). Letter by Lee and Goldman regarding article,”Development and validation of a risk calculator for prediction of cardiac risk after surgery”. Circulation, 125(7), e385-e385.
O’reilly, M. (2014). U.S. Patent No. 8,670,811. Washington, DC: U.S. Patent and Trademark Office.
Pediatric Appendicitis Treatment & Management: Approach Considerations, Fluid Resuscitation, Antibiotic Therapy. (2016). Emedicine.medscape.com. Retrieved 29 August 2016, from https://emedicine.medscape.com/article/926795-treatment
Seol, T. K., Han, M. K., Lee, H. J., Cheong, M., & Jun, J. H. (2012). Bispectral index and their relation with consciousness of the patients who receive desflurane or sevoflurane anesthesia during wake-up test for spinal surgery for correction. Korean journal of anesthesiology, 62(1), 13-18.
Song, Y., Sui, J., & Wang, J. (2015). Acupuncture with function of improving the level of consciousness for 24 cases of coma patients after cardiac surgery. Zhongguo zhen jiu= Chinese acupuncture & moxibustion, 35(1), 36.
White, K. L., Scopton, A. P., Rives, M. L., Bikbulatov, R. V., Polepally, P. R., Brown, P. J., … & Roth, B. L. (2014). Identification of novel functionally selective κ-opioid receptor scaffolds. Molecular pharmacology, 85(1), 83-90.

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