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ACUTE APPENDICITIS
Lecturer:
Dr.dr. BAMBANG ARIANTO, Sp. B
By :
Lely Diah T W
(2008.04.0.0025)
(2009.04.0.0117)
Elen Velia C
(2010.04.0.0089)
VALIDATION PAGE
CASE REPORT
ACUTE APPENDICITIS
This Acute Appendicitis case study has been corrected and accepted as a task to
accomplish clinical study in Surgery Departement of Haji Public Hospital
Surabaya Faculty of Medicine Hang Tuah University Surabaya.
TABLE OF CONTENTS
Validation Page....................................................................................................i
Table of Contents................................................................................................ii
Table of Picture...................................................................................................iii
Table of table.......................................................................................................iv
CHAPTER I INTRODUCTION.........................................................................1
1.1 Background..............................................................................................1
CHAPTER II LITERATUR................................................................................2
2.1 Anatomy of Appendix..............................................................................2
2.2 Definition..................................................................................................4
2.3 Epidemiology...........................................................................................4
2.4 Etiology....................................................................................................5
2.5 Stage of Appendicitis................................................................................6
2.6 Patophysiology.........................................................................................7
2.7 Diagnosis..................................................................................................8
2.8 Differential diagnosis...............................................................................17
2.9 Treatment..................................................................................................17
2.10 Complication..........................................................................................19
CHAPTER III CASE REPORT..........................................................................21
CHAPTER IV CONCLUSION...........................................................................26
REFERENCE......................................................................................................27
ii
TABLE OF PICTURE
Picture 2.1. Anatomy of Appendix................................................................2
Picture 2.2. Location of Appendix.................................................................3
Picture 2.3. Infected Appendix......................................................................4
Picture 2.4. Rovsing sign, Psoas sign, Obturator sign.................................11
Picture 2.5. Rectal examination...................................................................12
Picture 2.6. USG feature of each type of appendicitis.................................14
Picture 2.7. CT-Scan of Acute Appendicitis................................................15
iii
TABLE OF TABLE
Table 2.1. Bacteria isolated in perforated Appendicitis.................................5
Table 2.2 Imaging and Diagnosis o Acute Appendicitis..............................13
Table 2.3. MANTERLS Score.....................................................................16
Table 2.4. Differential diagnose of Acute Appendicitis...............................17
Table 2.5. Indication for surgical treatment of Appendicitis........................19
iv
CHAPTER I
INTRODUCTION
1.1 Background
Acute appendicitis is the most common abdominal emergency requiring
surgery with an estimated lifetime prevalence of 7%. (Gwynn, 2010). Despite its
high prevalence, the diagnosis of appendicitis remains challenging. The diagnosis
of appendicitis embodies Sir William Oslers spirit when he stated, Medicine is a
science of uncertainty and an art of probability. The clinical presentation is often
atypical and the diagnosis is especially difficult because symptoms often overlap
with other conditions. (Andersson, 2004). The fundamental clinical decision in the
diagnosis of a patient with suspected appendicitis is whether to operate or not.
Ideally, the goal is to expeditiously treat all cases of appendicitis without
unnecessary surgical interventions. A 2001 study reported negative appendectomy
rates between 15% and 34% with approximately 15% being commonly accepted
as appropriate to reduce the incidence of perforation. (Bergeron, 2006).
The meaningful evaluation of acute appendicitis balances early operative
intervention in hopes of preventing perforation against a more restricted approach
with the hope of reducing the risk of unnecessary surgery. Additionally, physicians
must consider the accuracy, delay-to-surgery, and radiation risks of using
computed tomography (CT) imaging, as well as the reliability of laboratory results
and clinical scoring systems. Lastly, physicians actions are often unfortunately
influenced by malpractice litigation as appendicitis is one of the most frequent
medical conditions associated with litigation against emergency department (ED)
physicians with claims paid to patients in up to one third of cases. (Howell, 2010).
The goal of this article is to present the reader with an update on the
diagnostic approach to appendicitis by providing an evidence-based review of
radiological imaging, clinical scoring systems, laboratory testing, and novel
biomarkers for appendicitis. (Flum, 2001).
CHAPTER II
LITERATUR
2.1 Anatomy of Appendix
Appendix is a tube -shaped organ, length approximately 10 cm (4 inches),
width of 0.3-0.7 cm and 0.1 cc of the contents of the cecum attached just below
the ileocecal valve . At the third meeting taenia namely : taenia anterior, medial,
and posterior. Clinically, the appendix is located in the area Mc. Burney is 1/3 the
center line connecting the anterior superior iliac spine to the center right. The
lumen narrow at the proximal and distal widening. However , in infants, the
appendix is conical, broad at the base and narrows towards the ends.
Parasympathetic innervation in apensiks derived from a branch of the vagus nerve
which follows artery superior mesenteria and appendicular artery, whereas
sympathetic innervation derived from thoracic nerve X. therefore, visceral pain in
appendicitis begins around the umbilicus. (Craig, 2010).
the cecum and appendix; it is a terminal branch of the ileocolic artery and runs
adjacent to the appendicular wall. Venous drainage is via the ileocolic veins and
the right colic vein into the portal vein; lymphatic drainage occurs via the ileocolic
nodes along the course of the superior mesenteric artery to the celiac nodes and
cisterna chyli. (Craig, 2010).
Appendiceal location
The appendix has no fixed position. It originates 1.7-2.5 cm below the
terminal ileum, either in a dorsomedial location (most common) from the cecal
fundus, directly beside the ileal orifice, or as a funnel-shaped opening (2-3% of
patients). The appendix has a retroperitoneal location in 65% of patients and may
descend into the iliac fossa in 31%. In fact, many individuals may have an
appendix located in the retroperitoneal space; in the pelvis; or behind the terminal
ileum, cecum, ascending colon, or liver. Thus, the course of the appendix, the
position of its tip, and the difference in appendiceal position considerably changes
clinical findings, accounting for the nonspecific signs and symptoms of
appendicitis. (Howell, 2010)
2.2 Definition
Acute appendicitis is inflammation of bacteria that occur suddenly,
appendicitis caused by various factors. Appendicitis is commonly caused by the
blockage of the lumen of the appendix by follicular lymphoid hyperplasia, fekalit,
foreign objects, strictures because of fibrosis due to previous inflammation, or
neoplasm. (Sjamsuhidajat, 2010).
2.7 Diagnosis
Variations in the position of the appendix, age of the patient, and degree of
inflammation make the clinical presentation of appendicitis notoriously
inconsistent. Statistics report that 1 of 5 cases of appendicitis is misdiagnosed;
however, a normal appendix is found in 15-40% of patients who have an
emergency appendectomy.
Niwa et al reported an interesting case of a young woman with recurrent
pain in who was referred for appendicitis, treated with antibiotics, and was found
to have an appendiceal diverticulitis associated with a rare pelvic pseudocyst at
laparotomy after 12 months. Her condition was probably due to diverticular
perforation of the pseudocyst. (Gwynn, 2001).
1. Clinical manifestations
Abdominal pain, fever, and anorexia are classical symptoms. Pain occurs
in the upper abdomen at first. It then moves slowly and localizes to the right lower
quadrant. In many cases, a fever of around 38C is present.
The classic history of anorexia and periumbilical pain followed by nausea,
right lower quadrant (RLQ) pain, and vomiting occurs in only 50% of cases.
Nausea is present in 61-92% of patients; anorexia is present in 74-78% of patients.
Neither finding is statistically different from findings in patients who present to
the emergency department with other etiologies of abdominal pain. In addition,
when vomiting occurs, it nearly always follows the onset of pain. Vomiting that
precedes pain is suggestive of intestinal obstruction, and the diagnosis of
appendicitis should be reconsidered. Diarrhea or constipation is noted in as many
as 18% of patients and should not be used to discard the possibility of
appendicitis. (Andersson, 2004).
The most common symptom of appendicitis is abdominal pain. Typically,
symptoms begin as periumbilical or epigastric pain migrating to the right lower
quadrant (RLQ) of the abdomen. This pain migration is the most discriminating
feature of the patient's history, with a sensitivity and specificity of approximately
80%, a positive likelihood ratio of 3.18, and a negative likelihood ratio of 0.5. [3]
Patients usually lie down, flex their hips, and draw their knees up to reduce
movements and to avoid worsening their pain. Later, a worsening progressive pain
along with vomiting, nausea, and anorexia are described by the patient. Usually, a
fever is not present at this stage.
The duration of symptoms is less than 48 hours in approximately 80% of
adults but tends to be longer in elderly persons and in those with perforation.
Approximately 2% of patients report duration of pain in excess of 2 weeks. A
history of similar pain is reported in as many as 23% of cases, but this history of
similar pain, in and of itself, should not be used to rule out the possibility of
appendicitis. (Andersson, 2004).
In addition to recording the history of the abdominal pain, obtain a
complete summary of the recent personal history surrounding gastroenterologic,
genitourinary, and pneumologic conditions, as well as consider gynecologic
history in female patients. An inflamed appendix near the urinary bladder or ureter
can cause irritative voiding symptoms and hematuria or pyuria. Cystitis in male
patients is rare in the absence of instrumentation. Consider the possibility of an
inflamed pelvic appendix in male patients with apparent cystitis. Also consider the
possibility of appendicitis in pediatric or adult patients who present with acute
urinary retention. (Flum, 2001).
2. Findings on physical examination
It is important to remember that the position of the appendix is variable. Of
100 patients undergoing 3-dimensional (3-D) multidetector computed tomography
(MDCT) scanning, the base of the appendix was located at the McBurney point in
only 4% of patients; in 36%, the base was within 3 cm of the point; in 28%, it was
3-5 cm from that point; and, in 36% of patients, the base of the appendix was
more than 5 cm from the McBurney point. (Humes, 2006).
The most specific physical findings in appendicitis are rebound tenderness,
pain on percussion, rigidity, and guarding. Although RLQ tenderness is present in
96% of patients, this is a nonspecific finding. Rarely, left lower quadrant (LLQ)
tenderness has been the major manifestation in patients with situs inversus or in
patients with a lengthy appendix that extends into the LLQ. Tenderness on
palpation in the RLQ over the McBurney point is the most important sign in these
patients.
A careful physical examination, not limited to the abdomen, must be
performed in any patient with suspected appendicitis. Gastrointestinal (GI),
genitourinary, and pulmonary systems must be studied. Male infants and children
occasionally present with an inflamed hemiscrotum due to migration of an
inflamed appendix or pus through a patent processus vaginalis. This is often
initially misdiagnosed as acute testicular torsion. In addition, perform a rectal
examination in any patient with an unclear clinical picture, and perform a pelvic
examination in all women with abdominal pain. (Ishikawa, 2003).
According to the American College of Emergency Physicians (ACEP)
2010 clinical policy update, clinical signs and symptoms should be used to stratify
patient risk and to choose next steps for testing and management. (Ishikawa,
2003).
Accessory signs
In a minority of patients with acute appendicitis, some other signs may be
noted. However, their absence never should be used to rule out appendiceal
inflammation. The Rovsing sign (RLQ pain with palpation of the LLQ) suggests
peritoneal irritation in the RLQ precipitated by palpation at a remote location. The
obturator sign (RLQ pain with internal and external rotation of the flexed right
hip) suggests that the inflamed appendix is located deep in the right hemipelvis.
The psoas sign (RLQ pain with extension of the right hip or with flexion of the
right hip against resistance) suggests that an inflamed appendix is located along
the course of the right psoas muscle. (Mishara, 2008).
The Dunphy sign (sharp pain in the RLQ elicited by a voluntary cough)
may be helpful in making the clinical diagnosis of localized peritonitis. Similarly,
RLQ pain in response to percussion of a remote quadrant of the abdomen, or to
firm percussion of the patient's heel, suggests peritoneal inflammation. (Mishara,
2008).
The Markle sign, pain elicited in a certain area of the abdomen when the
standing patient drops from standing on toes to the heels with a jarring landing,
10
Picture 2.4 Rovsing sign, Psoas Sign, Obturator sign (1) pain and nausea in
epigastrium, (2) pain or Defans muscular in Mc Burney point, (3) Rovsing dan
Blumberg sign (Andersson, 2004).
Rectal examination
11
12
3. Laboratory tests
The white blood cell count (WBC) and CRP are of diagnostic value. The
WBC usually exceeds 10,000/mm3. In severe cases associated with diffuse
peritonitis, however, the WBC may be decreased rather than increased, so care
must be taken. Although the CRP rises in appendicitis, the increase is not
necessarily associated with the severity of inflammation. (Ishikawa, 2003).
4. Imaging diagnosis
Plain abdominal radiographs show no particular evidence of appendicitis.
If an air-fluid level is seen in the lower abdomen, however, localized peritonitis
should be suspected. Ultrasonography and CT scanning are of diagnostic value,
and provide useful information for determining whether or not appendectomy is
necessary. (Ishikawa, 2003).
Table 2.2 Imaging and diagnosis of acute appendicitis (Ishikawa, 2003).
13
lumen.1) In catarrhal appendicitis, the wall of the appendix shows three layers,
while this layered structure becomes unclear in phlegmonous appendicitis. No
layered structur is depicted in the more advanced gangrenous appendicitis (Fig.
2). The periappendiceal accumulation of fluid suggests abscess formation
secondary to perforation. A high periappendiceal echo suggests the aggregation of
the omentum and other tissues that have been affected by inflammation. If some
of these findings are recognized, an operation is indicated. Kojima et al. divided
appendicitis into three types depending on the ultrasonographic findings. 2) The
classification depended on the features of the high echo bands representing the
submucosal layer, as described by Yuasa et al., as well as the presence or absence
of a visualized appendix and the length of the shorter diameter of the appendix.
The ultrasonographic pattern was type I in 76% of patients with catarrhal
appendicitis, while it was type II in 82% of patients with phlegmonous
appendicitis and type III in 94% of patients with ganagrenous appendicitis. They
concluded that, the severity of appendicitis could be assessed by preoperative
ultrasonography, so that unnecessary appendectomy could be avoided. As
described above, ultrasonography is an indispensable modality because it can be
used to both diagnose appendicitis and assess its severity. (Brown, 2010).
14
(2) Abdominal CT
CT is superior to ultrasonography in some respects, because its findings
are more objective and it is not affected by the presence of intestinal gas. The
diagnosis of appendicitis by CT depends on hypertrophy of the appendiceal wall,
enlargement of the appendix, periappendiceal abscess formation, the presence of a
fecalith, increased density of periappendiceal adipose tissue, and/or the presence
of ascites in the pouch of Douglas.1) CT can depict an enlarged appendix, but
cannot visualize the structure of the wall unlike ultrasonography. Thus,
ultrasonography is superior to CT for assessing the severity of appendicitis
depending on the mural changes. (Brown, 2010).
Score
A = Anorexia
T = Tenderness in RLQ
R = Rebound pain
E = Elevated temperature
L = Leukocytosis
2
S = Shift of WBCs to the left
1
Total
10
Source: Alvarado.[19]
RLQ = right lower quadrant; WBCs = white blood cells
Clinical scoring systems are attractive because of their simplicity;
however, none has been shown prospectively to improve on the clinician's
judgment in the subset of patients evaluated in the emergency department (ED)
for abdominal pain suggestive of appendicitis. The MANTRELS score, in fact,
was based on a population of patients hospitalized for suspected appendicitis,
which differs markedly from the population seen in the ED. (Howell, 2010).
In reviewing the records of 150 ED patients who underwent
abdominopelvic computed tomography (CT) scanning to rule out appendicitis,
McKay and Shepherd suggested that patients with an MANTRELS score of 0-3
could be discharged without imaging, that those with scores of 7 or above receive
surgical consultation, and those with scores of 4-6 undergo CT evaluation. [20] The
investigators found that patients with a MANTRELS score of 3 or lower had a
3.6% incidence of appendicitis, patients with scores of 4-6 had a 32% incidence of
appendicitis, and patients with scores of 7-10 had a 78% incidence of appendicitis.
In another study, Schneider et al concluded that the MANTRELS score
was not sufficiently accurate to be used as the sole method for determining the
need for appendectomy in the pediatric population.[21] These investigators, studied
16
588 patients aged 3-21 years and found that a MANTRELS score of 7 or greater
had a positive predictive value of 65% and a negative predictive value of 85%.
(Howell, 2010).
2.8 Differential Diagnosis
The clinical diagnosis of acute appendicitis relies upon a detailed history and
thorough physical examination. The differential diagnosis is that of the acute
abdomen as it can mimic the presentation of most abdominal emergencies
(Humes, 2006).
Table 2.1 Differential diagnose of acute appendicitis (Humes, 2006)
2.9 Treatment
1. Medical therapy
Appendicitis is diagnosed by physical examination, blood tests,
ultrasonography, and CT, or is characterized by tenderness without peritoneal
irritation. On ultrasonography, the appendix cannot be visualized or is not
enlarged if it is detected. Patients with catarrhal appendicitis should generally be
17
hospitalized for treatment with antibiotics, bed rest, intravenous fluids, and nil
orally. For outpatient management, antibiotics are administered and the course is
followed closely (Ishikawa, 2003).
2. Surgical therapy
Ultrasonographic findings are the most important factor for deciding
whether surgery is necessary. The presence of ascites or an abscess indicates the
necessity for surgery. Among the abdominal findings on physical examination, the
presence of peritoneal irritation is critical. If this is positive, an operation is
indicated. In the field of surgery for acute appendicitis, laparoscopic
appendectomy is attracting much attention. For the patient, the advantages of
laparoscopic appendectomy are reported to include decreased postoperative pain,
faster recovery of muscle tone, earlier return to normal activities, minimal
scarring, a low risk of wound infection, no ventral hernia, and a reduced risk of
postoperative adhesions (Ishikawa, 2003).
On the other hand, conventional open appendectomy seldom causes
problematic postoperative pain, scarring, or ventral hernia. In other words, the
laparoscopic and open procedures may only be different in their degree of
difficulty. From the standpoint of the surgeon, laparoscopy is useful to rule out
appendicitis in patients with confusing symptoms. Also, if a diagnosis of
appendicitis is established, wideranging examination of the peritoneal cavity
becomes possible. Furthermore, intraperitoneal cleansing of the site can be done
under vision on the monitor. It has even been reported that a drain could be
inserted and placed appropriately under laparoscopic vision (Ishikawa, 2003).
The greatest merit of laparoscopic appendectomy is being minimally
invasive. Because conventional open appendectomy is already relatively simple
and not so invasive, however, this merit itself is not highly attractive. In particular
cases, such as obese patients, young female patients seeking a better cosmetic
outcome, and patients with suspected appendicitis who may have other conditions,
it would seem that laparoscopic appendectomy may be useful (Ishikawa, 2003).
Table 2.5 Indication for the surgical treatment of appendicitis.
18
2.10 Complication
The most serious complication of appendicitis is rupture. The appendix
bursts or tears if appendicitis is not diagnosed quickly and goes untreated. Infants,
young children, and older adults are at highest risk. A ruptured appendix can lead
to peritonitis and abscess. Peritonitis is a dangerous infection that happens when
bacteria and other contents of the torn appendix leak into the abdomen. In people
with appendicitis, an abscess usually takes the form of a swollen mass filled with
fluid and bacteria. In a few patients, complications of appendicitis can lead to
organ failure and death (Humes, 2006).
Despite this, complications can occur after removal of a normal
appendix, and the surgical community continues to strive to reduce the numbers of
negative procedures. According to a large historical cohort study, a perforated
appendix during childhood does not seem to have a long term detrimental effect
on subsequent female fertility (Humes, 2006).
Wound infection
The rate of postoperative wound infection is determined by the
intraoperative wound contamination. Rates of infection vary from < 5% in
simple appendicitis to 20% in cases with perforation and gangrene. The
use of perioperative antibiotics has been shown to decrease the rates of
postoperative wound infections (Humes, 2006).
Intra-abdominal abscess
19
CHAPTER III
20
CASE REPORT
I.
II.
Patient Identity
Name
: Ms. F.I
Age
: 17 y.o
Sex
: female
Religious
: Islam
Address
Date of Inspection
: 30 November 2015
Anamnesa
a) Chief complaiment
Theres pain in the lower right abdominal
b) Keluhan Tambahan
Nausea and common cold.
c) History of illness
Patients coming to the emergency department RSU Haji Surabaya with
complaints there is pain in the lower right abdomen since 1 months ago
and became more severe in the last week. The pain is intermittent . Firstly
the pain started around the umbilicus and eventually the pain is felt in the
lower right abdomen .Patients said that often nausea without vomiting and
two days before she came to emergency she could not sleep because of
abdominal pain. Theres no complain of difficult defecation. She told that
shes rarely eat vegetables and fruits.
d) Past medical history
: HT(-), DM (-)
21
Status Generalis
1. General situation
: Moderate illness
Awareness
: Compos mentis
Nutrition status
: TB : 155 cm
BB : 48 kg
BMI: 20
Vital Sign
: TD
: 120/80 mmHg
Nadi : 90 x/menit
Suhu : 37,5oC (axiller)
RR
A/I/C/ D
: 20 x/menit
: ///
2. Head
- Conjunctival anemis ()
- Sclera jaundice ()
3. Neck
-
Lymphadenopathy (-)
Thyroid enlargement (-)
4. Thoraks : normochest
- Pulmo : I : Normochest, breath symmetrical motion
P : Motion breath symmetrical, symmetrical touch fremitus
P : Sonor entire lung field
A : vesikuler breath sound, ronkhi /, wheezing /
- Cor
22
Status localist
Regio Abdominal
ALVARADO SCORE :
- abdominal pain : 1
- nausea
:1
- rebound pain
:1
IV.
- fever
:1
- leukositosis
:2
Resume
Female 17 years old with right abdominal pain since one month ago
and became more severe in the last week. The pain is intermittent and
started around the centre and eventually the pain is felt in the lower right
abdomen. Nausea (+) vomit (-) fever (+) and could not sleep because of
abdominal pain..
V.
Diagnosa
Acute Appendicitis
VI.
Diagnosa Banding
Gastroenteritis akut
Ectopic gestational
Adenitis Mesenterium
Perforated Peptic Ulcer
Colonic Lesions
Pielonefritis
23
Kidney stones
VII. Penatalaksanaan
i.
Planning Diagnosa
DL, UL, BOF, USG
ii.
Planing Terapi
Non Medikametosa
Bed rest
fasting
Medikamentosa
Tidak ada
Tindakan
Operatif : Appendictomy
CBC
- Hb : 14,1
- Leukosit : 22.600
- Hematocrit : 41,1
- Trombosit : 350.000
Chemical Clinic
GDA Stick : 92
BUN
: 7, Creatin serum :
iv.
Planning Monitoring
Patient compliment
Vital sign
BAB
Planning Edukasi
Hindari mengejan saat BAB dan jangan terlalu lama saat BAB
VIII. Prognosa
Dubia ad bonam
CHAPTER IV
25
CONCLUSION
Acute appendicitis is the most common abdominal emergency requiring
surgery with an estimated lifetime prevalence of 7%. Despite its high prevalence,
the diagnosis of appendicitis remains challenging.
Acute appendicitis is inflammation of bacteria that occur suddenly,
appendicitis caused by various factors. Appendicitis is commonly caused by the
blockage of the lumen of the appendix by follicular lymphoid hyperplasia, fekalit,
foreign objects, strictures because of fibrosis due to previous inflammation, or
neoplasm.
The diagnosis and management of acute appendicitis have been described
with a focus on some current issues. For diagnosis, findings on ultrasonography
and CT are important. For management, laparoscopic appendectomy should be
considered as a possible choice if there are indications for this procedure.
The most serious complication of appendicitis is rupture. The appendix
bursts or tears if appendicitis is not diagnosed quickly and goes untreated. Infants,
young children, and older adults are at highest risk. A ruptured appendix can lead
to peritonitis and abscess. Peritonitis is a dangerous infection that happens when
bacteria and other contents of the torn appendix leak into the abdomen. In people
with appendicitis, an abscess usually takes the form of a swollen mass filled with
fluid and bacteria. In a few patients, complications of appendicitis can lead to
organ failure and death
REFERENCE
26
Gastrointestinal
Michael,
Tucker
Jeffry.
Appendicitis.
Diakses
dari
URL
27