Appendicitis

The appendix is a small, finger-like tube about 10 cm (4 in) long that is attached to the cecum just below the ileocecal valve. The appendix fills with food and empties regularly into the cecum. Because it empties inefficiently and its lumen is small, the appendix is prone to obstruction and is particularly vulnerable to infection (ie, appendicitis).

Appendix

Introduction
Viscous perforation Local Peritonitis General Peritonitis Sepsis Intraabdominal SIRS Sepsis Organ Dysfunction The most common & serious Infection When delay in diagnosis, admission, & therapy... it will followed by highly morbidity & mortality

Introduction
The Outcome Early Detection & Surgical Intervention Mortality 3% when it still as the Initial Infection 60% in advanced infection Doubling or more...when the MODS occured Need comprehensive analysis start from anamnesis physical exam, laboratory & imaging

Acute Appendicitis

Pathophysiology
The appendix becomes inflamed and edematous as a result of either becoming kinked or occluded by a fecalith (ie, hardened mass of stool), tumor, or foreign body. The inflammatory process increases intraluminal pressure, initiating a progressively severe, generalized or upper abdominal pain that becomes localized in the right lower quadrant of the abdomen within a few hours.

Pathophysiology
Initial phase of Appendicitis - The most common of ethiology is obstruction of the basis of appendix due to many causes - The pain impulse is visceral pain vague and dullness Referred pain the patient will feel pain on the epigastric and periumbilical region - There are a lot of possibilities of causes and varies in severity of painful & also a lot of conclusion

Caution..

The use of Analgesic & Spasmolytic could masked the real pathology & recent progress ...

Pathophysiology
Second Phase of Acute Appendicitis - Bacteria & endotoxin tranlocation to the systemic stream - Mild SIRS will occure slight fever, anorexia, nausea and discomfort - Be aware for the other systemic disease systematic anamnesis adjunct to physical exam - Make sure...it might not the acute appendicitis

Caution...

The Analgesic could be administered when final diagnosis excisted & the therapy in plan

Pathophysiology
The third phase of the Acute Appendicitis - Micro-perforation of appendiceal content to extraluminal - Local peritonitis occured with its inflammatory reaction rubor, kalor, tumor, dolor & paralytic pain on the right lower quadrant - Anorexia, nausea, vomite & fever will strongly occured - Hypovolemic state with body compensation

Caution...

Diagnosis much more easier Do not ever...ever missed it !

Pathophysiology
The fourth phase of Acute Appendicitis - The latest phase and complicated phase - The patients will be in worse general condition - Local and slight extended peritonitis - Need rapid fluid rescucitation, broad spectrum antibiotic, NGT decompression & monitor - Rapid consultation to the surgeon - Being criminal...if you stay in manage this patient

Caution...

As a doctor... Always do the right thing and do the thing right...

Problems Identification
Sepsis Intraabdominal patients will suffer from: Anorexia Syndrome of Inflammatory Fever SIRS and or vasoconstriction Abdominal distension Segmental Paralytic Dystress Respiration Severe peritonitis Hypoxia Unconscious Hipovolemia + Hypoksia Cell & Tissue perfusion decreased Organ Disfunction Organ failure Dead

Problems Identification
Multidymension phenomenon need Multimodality treatment Early Diagnosis Meticolous Anamnesis Spend your time Physical Diagnostic Laboratory examination Imaging if available Rapid Pra - operative preparation Emergent Operation Decompression, debridement and may only do the damage control

Pre-Operatively
Be aware of Pathophysiology Diagnosis Recognize the occuring problems: Initial phase symptoms & signs The signs of Dehydration The signs of Dystres respiration The signs of Hypoxia Multiorgan Dysfunction Multiorgan Failured

Appendicitis

Clinical Manifestations
Epigastric or periumbilical pain progresses to the right lower quadrant. Low-grade fever, nausea and sometimes vomiting. Loss of appetite. Local tenderness is elicited at McBurneys point when pressure is applied (next 2 slides). Rebound tenderness (ie, production or intensification of pain when pressure is released) may be present. Rovsings sign may be elicited by palpating the left lower quadrant; this causes pain to be felt in the right lower quadrant. If the appendix has ruptured, the pain becomes more diffuse; abdominal distention develops, and the patients condition worsens.

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Titik McBurneys

Location of McBurney's point (1), located two thirds the distance from the umbilicus (2) to the anterior superior iliac spine (3).
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Rovsing sign

Psoas sign

Obturator sign

Assessment and Diagnostic Findings

Health history and physical exam. Complete blood cell count demonstrates an elevated white blood cell count (> 10,000 cells/mm3). The neutrophil count may exceed 75%. Abdominal x-ray films, ultrasound studies, and CT scans may reveal a right lower quadrant density or localized distention of the bowel.

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USG appendik

Appendicitis akut

non compressible blind ending tubular structure > 6 mm

Medical Management
Surgical intervention (appendectomy), next slide, as soon as possible after diagnosis to decrease the risk of perforation. Before surgery, correction or prevention of fluid and electrolyte imbalance and dehydration could be through antibiotics and intravenous fluids. Analgesics can be administered after the diagnosis is made.

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Nursing Management
Prepare the patient for surgery, which includes an intravenous infusion to replace fluid loss and promote adequate renal function and antibiotic therapy to prevent infection. Post-operatively, Place the patient in a semi-Fowler position to reduce the tension on the incision and, thus, reduce pain. Administer pain killers (usually morphine sulfate), as prescribed. Start oral fluids when tolerated and intravenous fluids as indicated. Food is provided as desired and tolerated on the day of surgery.

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Nursing Management (Continued..)

Instruct the patient to make an appointment to have the surgeon remove the sutures between the fifth and seventh days after surgery. Teach incision care (dressing) and activity guidelines; normal activity can usually be resumed within 2 to 4 weeks.

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