1050325 高雄地區第415次小兒科聯合病例討論會

Appendicitis & epididymoorchitis in a 10 Y/O Boy 高雄市立聯合醫院小兒科 黃士銘 李偉揚 莊上林 李冠賢 楊炎穎 許文馨

General Data Age & Sex : 10 y/o , boy BW: 34 Kg Date of admission : 104.12.12

Chief Complaint Frequent watery diarrhea upto 10+ time

for 2 days Intermittent Abdominal pain for 2 days Fever 38.8 0C for 2 days

Present Illness 104.12.11

Night

afternoon

Periumbilical Frequent watery diarrhea upto 6+ pain since times/day afternoon No vomiting Fever 38.5 C

104.12.12 night

Admission

PER

Watery diarrhea upto 5+ time/day Intermittent abd. pain Fever 38.8 c Poor intake & activity Nausea & Vomiting x 1 No cough , mild rhinorrhea

Associated History Past history: Influenza A , bronchopneumonia on 102.12.19~12.23

No hernia , no hydrocele , No UTI

Family History & Travel : NP

Physical Examination Vital signs: T/P/R=38.8/130/18 (min) BP=112/61 mmHg General appearance: acute ill-looking, weakness HEENT: injected throat, mild, dry oral mucosa Chest: mild rhonchi BS , symmetric , no retraction Heart: RHB , no murmur ABD: hyperactive bs , soft , guarding (-), tenderness (+) over periumbilical & RLQ (+) , rebounding pain (+/-), Psoas & obturator sign (-), palpable mass (-) EXT: no edema , no rash, dry skin turgor

Impression Infectous gastroentertitis with

Dehydration R/O Acute appendicitis

Plan to Do Diagnosis plan: CBC/DC , CRP, B/C Na,K, Sugar, BUN/CR, GPT S/R, S/C, Rota/Adeno stool Ag KUB Treatment plan: IV Fluid supplement NPO

12.12

Lab data CBC/DC WBC x 103/ ul RBC(X106)/ ul Hb g/dl Hct % MCV fl PLT x 103/ ul Seg %

12.12 20.03 5.46 15.2 43.2 79.1 28.5 86.9

lymph% mono% CRP(mg/dl)

5.7 7.3 30.84

Lab Data 12.12 Na (mmol/L)

133

K (mmol/L)

4.4

Sugar (mg/dL)

108

GPT (U/L)

17

BUN/CR (mg/dL) S/R

Rota/Adeno Ag (stool) S/C

27/1.2 Fluid/brown, RBC (-), OB(-) WBC (-),Pus(-),Mucus (-) Neg. No growth

U/R

12.12

Color

Brown

Specific gravity

1.025

pH

5.0

Sugar

-

Protein

-

Ketone body

-

O.B.

1+

Urobilinogen

-

Bilirubin

1+

NIT/LEU

-/-

RBC

/HP

1-2

WBC

/HP

1-2

Epithelial cell /HP Bac

1-2 -

U/C

No growth

Hospital course 1 Fever 37~38 C

Diffuse tenderness

Abdominal pain

Rebounding pain (+)

Watery diarrhea x 3

Tenderness over RLQ

12.13

Abdominal Echo

Perforated Appendicitis with abscess

Ascites (-)

Hospital course 1 Fever 37~38 C

Diffuse tenderness

Abdominal pain

Rebounding pain (+)

Watery diarrhea x 3

Tenderness over RLQ

12.13 Abdominal Echo : perforated appendicitis with abscess Consult PEDS : suggest conservative treatment Antibiotic : Cefazolin + GM + Metronidazole

Hospital course 2 Fever 37~38 C

Fever 37~37.5

Abdominal pain

Abdominal pain

Watery diarrhea x 3

Diarrhea x 2

Diffuse tenderness

Activity & appetite: increased

Rebounding pain (+) Tenderness over RLQ

12.13 Abdominal Echo

Rebounding pain Tenderness over RLQ

12.14 Activity & appetite

Consult PEDS Antibiotic : Cefazolin + GM + Metronidazole

Hospital course 3 Fever (-)

Fever 38~39

Abdominal & rebounding pain

R’t Scrotum pain

Prepuce swelling afternoon

& swelling

12.15 BCG ointment

12.16 Urologist : Scrotal Echo CBC/DC, CRP, B/C

Cefazolin + GM + Metronidazole

U/R,U/C Mump Ig M,G : negative

CBC/DC WBC x 103/ ul RBC(X106)/ ul Hb g/dl

12.12 20.03 5.46 15.2

12.16 23.11 4.36 12.2

Hct

%

43.2

34.6

PLT

x 103/ ul

28.5

30.6

Seg % lymph% mono% CRP(mg/dl)

86.9 5.7 7.3 30.84

86.1 6.4 7.1 8.13

U/R

12.12

12.16

Color

Brown

Yellow

Specific gravity

1.025

1.015

5.0

5.0

Sugar

-

-

Protein

-

-

Ketone body

-

-

1+

2+

-

-

Bilirubin

1+

-

NIT/LEU

-/-

-

RBC

/HP

1-2

0

WBC

/HP

1-2

1-2

1-2

0

-

-

No growth

No growth

pH

O.B. Urobilinogen

Epithelial cell /HP Bac U/C

Epididymo-orchitis with reactive hydrocele

Testis torsion (-) Processus vaginalis (-)

Hospital course 3 Fever (-)

Fever 38~39

Abdominal & rebounding pain

R’t Scrotum pain

Prepuce swelling at night

& swelling

12.15 BCG ointment

12.16 Urologist : Scrotal Echo CBC/DE, CRP, B/C

Cefazolin + GM + Metronidazole

U/R,U/C , Mump Ig M,G (-) Abdominal CT NSAID (Ibuprofen)

Perforated appendicitis with abscess (4x7 cm) Ascites (-), appendicolith (+)

Well-localized abscess

Spermatic cord swelling Processus vaginalis (-)

Hospital course 4 Fever 37~38 C Rt scrotum pain & swelling Abdominal pain

12.17

Fever 36.5-37 C R’t Scrotum pain & swelling, still Abdominal pain

12.18~19

NSAID (Ibuprofen) Cefazolin + GM + Metronidazole

Hospital course 5 Fever 37~38 C

Fever 36.5-37 C

Fever 38.5

Rt scrotum pain & swelling

R’t Scrotum pain

R’t Scrotum pain &

Abdominal pain

Abdominal pain

swelling

12.17

12.18~19

12.20 CBC/DC, CRP, B/C

NSAID (Ibuprofen)

Urologist : Scrotal Exploration

Cefazolin + GM + Metronidazole

Pus culture

CBC/DC WBC x 103/ ul

12.12

12.16

12.20

20.03

23.11

21.03

RBC(X106)/ ul

5.46

4.36

4.21

Hb

g/dl

15.2

12.2

11.6

Hct

%

43.2

34.6

34

PLT

x 103/ ul

28.5

30.6

476

Seg % lymph% mono% CRP(mg/dl)

86.9 5.7 7.3 30.84

86.1 6.4 7.1 8.13

79 12.6 6.6 2.82

Orchiectomy

Processus vaginalis (-)

Pus or fluid (-)

Pathology Testis and epididymis, right, orchiectomy --Suppurative inflammation No evidence of malignancy in the sections examined

Hospital course 6 Fever 37~38 C

Fever 36.5~37 C

Abdominal pain

Scrotal Wound pain

Scrotal Wound pain

Abdominal pain RLQ tenderness

12.21 CD wound & Wet dressing

12.24 CBC/DC, CRP Pus culture : E. coli

Cefazolin + GM + Metronidazole

Cefmetazole

CBC/DC WBC x 103/ ul

12.12 20.03

12.16 23.11

12.20 21.03

12.24 10.59

RBC(X106)/ ul Hb g/dl Hct %

5.46 15.2 43.2

4.36 12.2 34.6

4.21 11.6 34

4.08 11.2 33.5

x 103/ ul

28.5

30.6

476

518

Seg % lymph% mono% CRP(mg/dl) B/C

86.9 5.7 7.3 30.84

86.1 6.4 7.1 8.13

79.4 12.6 6.6 2.82

61.3 28.5 6.7 1.15

PLT

No growth

No growth

No growth

Scrotal abscess culture

Hospital course 7 Fever 37~38 C

Fever 36.5~37 C

Abdominal pain

Scrotum Wound pain

Scrotum Wound pain

Discharge OPD FU

Abdominal pain RLQ tenderness

12.21

12.24

12.25

12.26

CD wound & Wet dressing CBC/DC, CRP Pus/C : E. coli Cefazolin + GM + Metronidazole

Wound closure Abdominal Echo: Abscess

Cefmatazole

Oral antibiotic

Diagnosis Perforated appendicitis with

intraabdominal abscess Rt epididymo-orchitis with abscess s/p orchiectomy

From : UpToDate

APPROACH Early appendicitis: appendix intact Advanced appendicitis: perforation +

peritonitis Appendiceal abscess ill-appearing Well-appearing

Early appendicitis Appendectomy: safe for children , less morbidity Single prophylactic antibiotic dose before op wound infections ,intraabdominal abscesses Pos-op : unnecessary

Laparoscopic > open approach hospital stay, wound infection, post-op pain

earlier return to normal activities

Nonoperatively Evidence insufficient 10~20 % fails

Advanced appendicitis Urgent appendectomy prevent progression to sepsis and septic shock

Preoperative antibiotics Laparoscopic or open approach well trained

Postop IV antibiotics

tolerating a regular diet , resolution of pain, return of bowel function, normalization of WBC, fever (-)

Appendiceal abscess Ill-appearing — early appendectomy Well-appearing well-localized abscess, tender mass in RLQ without

signs of generalized peritonitis treated nonoperatively

Nonoperative VS early appendectomy ?

Which better: current evidence insufficient Initially nonoperatively : 14 % complications Early appendectomy : 36 % morbidity (post-op infection, intestinal fistula, small bowel obstruction, recurrence)

Interval appendectomy 8 ~ 12 weeks following appendiceal abscess Avoid morbidity of immediate appendectomy Children with an appendicolith recurrent appendicitis : non-op > interval Interval appendectomy or Nonoperatively ?

Evidence is limited Weigh the risk of morbidity & recurrence

Causes of scrotal pain Testicular torsion Torsion of appendix testis or epididymis Epididymitis Other causes Trauma Incarcerated inguinal hernia Henoch-Schรถnlein purpura Orchitis Referred pain

Processus vaginalis

Patent processus vaginalis (PPV): 15–37% beyond neonatal period

Singapore Med J 2002 Vol 43(7) : 365-366

Case presentation 25 y/o man , no past medical history Appendectomy for perforated appendicitis.

Small amount of peritoneal soilage Five days later Right hemiscrotum swollen Red and tender

BT 37.4 C ,WBC = 15,000

Ultrasound of the right scrotum showing echogenic fluid (arrows) in the scrotal sac.

Ultrasound of the right inguinal region showing the patent processus vaginalis

CT scan of the pelvis showing fluid tracking down the right patent processus vaginalis (arrow).

Management Laparotomy : fair turbid fluid in pelvis, appendix stump intact.

Exploration of Rt scrotum : pus, patent processus vaginalis communicating with abdominal cavity.

Drainage of abdominal and Rt scrotal Cultures (pelvis and scrotum) : Pseudomonas aeruginosus and Proteus mirabilis

Cases Journal 2008, 1:165

Case 1 A 10-year-old male Abdominal pain, Anorexia for 3 days, Admitted with acute appendicitis Tenderness and rebound tenderness

over RLQ 37.9째C ,WBC =16,000, left shift.

Surgery Acute perforated appendicitis removed Appendix drainage abscess cavity and difficulty in removing

Peritoneal fluid culture Broad-spectrum antibiotic

Post-operative day 5 Left scrotal swelling ,redness, pain Doppler US: normal testis & blood flow,

suspected scratal abscess.

Groin exploration: abscess in a patent prcessus vaginalis (PPV), ligated PPV ,drained abscess

Scrotal fluid culture : no growth Peritoneal fluid : gram negative E-coli.

Removed when the drainage stopped Patient made a good recovery

Case 2 4-year-old male, Tetralogy of Fallot, surgical

correction two weeks earlier Lower abdominal pain, fever Left scrotal swelling for two days Swollen left scrotal sac , tenderness in the scrotum, groin & lower abdomen 39.2째C, WBC = 14,200

Scrotal exploration Purulent scrotal fluid Come from abdomen Pressing lower abdomen, fluid coming more Testis and epidydimis : normal The scrotum was drained.

Abdomen exploration Acute perforated appendicitis Appendectomy and drainage of the

pelvis

Scrotum & peritoneum Cultures : Enterobacter.

The drains removed in one week.

Antibiotic coverage for two weeks Uneventful recovery.

Six weeks later : groin exploration revealed PPV and ligated.

Conclusion Scrotal abscess following acute perforated appendicitis is very rare This may precede the diagnosis of acute appendicitis or as a postoperative complication of suppurative or perforated appendicitis.

Ultrasound or CT scan : scrotal abscess communicating with patent processus vaginalis.

Conclusion 2 Early diagnosis : scrotal abscess and

subsequent testicular loss Drainage of both scrotal and abdominal abscesses + antibiotics.

The appropriate time and approach to both abscess and PPV is still individualized.

The Journal of Medical Investigation 58 : 252-254, August, 2011

63 Y/O Japanese man RLQ pain for a night.

PHX: poliomyelitis in infancy.

PE: severe tenderness at McBurny point, and a swollen scrotum with testicular pain.

BT:38.3 C. WBC = 15,600/mm3, CRP=11.05 mg/dl U/R: WBC 10-19/HPF

acute appendicitis and acute epididymitis

Appendectomy Ascites : serous, but not clear.

No surgical drain was used.

Pus was observed in the lumen of the appendix (Fig. 2, arrow).

Pathological analysis infiltrating leukocytes localized in the mucosal layer and exfoliation of the mucosa, so catarrhal appendicitis was diagnosed (Fig. 3a, b).

U/C : Enterobacter aerogenes Ascites culrue : no growth Cefmetazole (CMZ) administered for 5 days.

Postoperatively, RLQ pain continued for about 4 days and testicular pain gradually disappeared

DISCUSSION We present the first report of concomitant acute appendicitis and epididymitis. could not confirm whether there was a relationship between acute appendicitis and epididymitis.

In conclusion, we encountered a case of acute abdomen with sever RLQ pain due to acute appendicitis and spermatitis followed by epididymitis.

Non-contrast abdominal CT scan.

Scanning range: Liver to symphysis, 5-mm contiguous scan.

Contrast medium administered: Nil. It should be acknowledged that the accuracy of the CT in detecting abdominal pathology was markedly decreased without contrast injection.

Previous study compared: no Findings:

Presence of fatty stranding and low density lesions over RLQ and pelvic cavity, with several enlarged lymph nodes and small high density lesions nearby, DDx: ruptured appendicitis with appendicolith and abscess formation, or other disease entity.

R/O fatty stranding around right scrotum.

Presence of high density lesion in liver considered.

Unremarkable lower lungs.

Imp: As above descriptions. 鄧惠中-放診專字第858號

Present Illness 10 y/o well develop boy Intermittent periumbilical pain since yesterday

afternoon Frequent watery diarrhea upto 10+ times/day happened

since last night with vomiting Fever upto 38.5 C since last night No cough , mild rhinorrhea Poor intake & decreased activity

Hospital course 4 Fever 36.5~37 C Fever 37~38 C

Wound pain

Discharge

Abdominal pain better

OPD FU

Abdominal pain

RLQ tenderness improved 12.21

12.24

12.25

12.26

Open wound with Wet dressing Cefazolin + GM + Metronidazole

U/C : E. coli

Wound closure

Cefmatazole

Abdominal Echo : abscess decreased

APPROACH early appendicitis: appendix intact appendectomy : Laparoscopic nonoperatively : evidence insufficient (10~20% fails )

advanced appendicitis: perforation+ peritonitis Appendectomy :Laparoscopic or open approach

appendiceal abscess ill-appearing: appendectomy Well-appearing: nonoperatively or interval

appendectomy (appendicolith, 8 ~ 12 weeks)

Early appendicitis recent onset : abdominal pain 1~2 days migrated from periumbilical to RLQ followed by low-grade fever, vomiting, and anorexia RLQ tenderness Elevated WBC count, absolute neutrophil count, and/or CRP diagnostic imaging confirms

Advanced appendicitis clinical findings of early appendicitis + peritonitis (eg, fever, rebound, guarding, or rigid abdomen) evidence of perforation on diagnostic imaging (eg, ultrasound, computed tomography [CT], or magnetic resonance imaging [MRI])

Processus vaginalis

Discussion Early diagnosis : scrotal abscess and subsequent testicular loss Ultrasound or CT scan : scrotal abscess communicating with patent processus vaginalis.

Drainage of both scrotal and abdominal abscesses + antibiotics.

Discussion Patent processus vaginalis (PPV): remain patent in 15– 37% beyond neonatal period.

Scrotum as an extension of the peritoneal cavity is very rarely considered as a site of abscess formation following appendicitis.

nonoperatively or interval appendectomy frequency of morbidity (postop infection, intestinal fistula, small bowel obstruction) not substantially different between nonop & interval appendectomy ( 11 vs 7 %) rate of recurrent appendicitis in children with an appendicolith significantly higher than in those without an appendicolith (76 versus 26 percent, respectively)

Absence of history of inguinal hernia or hydrocele was common Abscess : 1~10 day following appendectomy.

All cases :scrotal swelling and redness One case of testicular damage : mechanism of which is obscured

Conclusion 2 Acute appendicitis with scrotal involvement in children may present with scrotal abscess or with appearance of acute scrotum mimicking acute testicular torsion or incarcerated inguinal hernia.

This may precede the diagnosis of acute appendicitis or as a postoperative complication of suppurative or perforated appendicitis.

Hospital course 5 Fever 37~38 C Rt scrotum pain & swelling Abdominal pain

12.17

Fever 36.5-37 C R’t Scrotum pain Abdominal pain

12.18~19

Fever 38.5 R’t Scrotum errosion & pus

12.20 Pus culture

NSAID (Ibuprofen) Cefazolin + GM + Metronidazole

Urologist : Scrotal Exploration CBC/DC, CRP, B/C

Feasibility of a nonoperative management strategy for uncomplicated acute appendicitis in children. J Am Coll Surg 2014; 219:272.

Nonoperative treatment with antibiotics versus surgery for acute nonperforated appendicitis in children: a pilot randomized controlled trial. Ann Surg 2015; 261:67.