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.