Appendicitis

Pembimbing:
dr. Wendell Ken, SpB

Bintari Anindhita
0961050058

Outlines

Introduction
Anatomy and Embryology
Epidemiology
Etiology and Patoghenesis
Clinical Manifestasion

Symptoms
Signs
Laboratory Findings
Imaging Studies

Diagnosis
Management
Outcomes
Special Attention: Appendicitis in Pregnancy

Introduction

Appendicitis is defined as an inflammation of the inner

lining of the vermiform appendix that spreads to its other
parts.

Despite diagnostic and therapeutic advancement in

medicine, appendicitis remains a clinical emergency and
is one of the more common causes of acute abdominal
pain

Anatomy and Embryology

The appendix, ileum and ascending

colon are all derived from the midgut

The appendix first appear at 8th

week of gestation

The length of the appendix 2 to

20 cm average length = 9 cm in
adults.

The base of the appendix is located

at the convergence of the taeniae
along the inferior aspect of the
cecum

Anatomy and Embryology

The variety location of
appendix

Blood supply of appendix

Epidemiology

Acute appendicitis = most common emergency case

in general surgery
About 8% of people in Western countries have
appendicitis at some time during their life
Peak incidence -> 20-40 years (31.3 years old)
Woman = man

Etiology and Patogenesis

Appendiceal
obstruction
Intraluminal
pressure
Necrosis and
perforation

Fecalith
Limphoid hyperplasia
Vegetables and fruit seeds
Parasit
Neoplasms

Stimulates the visceral nerve

ending
Disruption of venous drainage

Disruption of arterial
blood flow

Clinical Manifestasion
Symptoms
Epigastric pain
migrating to right lower
quadrant pain
Usually preceded by
nausea, vomitting,
anorexia
Obstipation / diarrhea

Clinical Manifestasion
Signs

Pelvic position
Elevated temperature
Palpation pain over
McBurney point
Referred pain
Muscular defense local
or diffuse
Rovsing sign
Anatomical variation
psoas sign and obturator
sign

Laboratory Findings

Leucocytosis (1000018000 cell/mm3)

Polymorphonuclear cell
(>75%)

Psoas Sign

Obturator Sign

Imaging Studies

Ultrasonography

Imaging Studies

CT Scan

Diagnosis

Alvarado Score

Diagnosis

Tzanakis Score
Tzanakis Score

Score

Appendicitis appearance on ultrasound

Tenderness over right lower quadrant

Rebound pain

Leucoccyte count > 12000/ul

Diagnostic Algorithm

Management

Preoperative:

Fluid resucitation
Antibiotic

Uncomplicated appendicitis single dose

Appendicitis with perforation / gangren continued
the antibiotic intravenously until the patient is
afebrile / WBC is normal

Acute appendicitis without perforation

emergency appendectomy
Peritonitis emergency laparotomi +
appendectomy
Periappendicular mass conservative for 3
months observation of general condition
Inform Concent elective appendectomy

Open Appendectomy

Uncomplicated cases
Transversal/oblique
(McBurney) incision

Big phlegmon midline

subumbilical incision

Laparoscopic Appendectomy

Offers the advantage of

diagnostic laparoscopy combined
with the potential for shorter
recovery and incisions that are
less conspicuous

Conservative Treatment ???

There has recently been an increase in the use of

antibiotic therapy as primary treatment for acute
appendicitis.

Hows the efficacy compared with open

appendectomy ??

Conservative Treatment

Efficacy was significantly higher for surgery (OR = 6.01, 95% CI = 4.27
8.46).
No differences were found in the numbers of perforated appendices (OR
= 0.73,95% CI = 0.291.84) and patients treated with antibiotics (OR =
0.04, 95% CI = 0.003.27).
Complication rates were significantly higher for surgery (OR = 1.92, 95%
CI = 1.302.85).

Evaluation index comparing antibiotic treatment with

appendicectomy in acute appendicitis.

Liu ZH, Li C, Zhang XW, Kang L, Wang JP. Meta-analysis of the therapeutic effects of
antibiotic versus appendicectomy for the treatment of acute appendicitis. Experimental and
Therapeutic Medicine. 2014; 7: p. 1181-6.

Outcomes

Mortality rate after appendectomy is less than 1%.

The morbidity of perforated appendicitis is higher than

that of nonperforated cases and is related to:

Surgical site infections

increased rates of wound infection, intra-abdominal abscess

formation, increased hospital stay, and delayed return to full
activity.

5% patients with uncomplicated appendicitis

Small bowel obstruction

Occur in less than 1% of patients for uncomplicated

appendicitis & 3% of patients with perforated appendicitis

Appendicitis in Pregnancy

The most common nonobstetric surgical disease of the

abdomen during pregnancy

The incidence by trimester is 32%, 42%, and 26%.

The main challenge recognize the possibility of

appendicitis in pregnant patients and intervene promptly
because peritonitis significantly increases the rate of fetal
loss

Diagnosis difficult

Nausea, vomiting, anorexia, elevated white blood cell count

common during pregnancy
The location of tenderness varies with gestation
Increased separation of peritoneum decreased perception of
somatic pain and localization

Changes in location and direction of the appendix during pregnancy

Appendicitis in Pregnancy: Treatment

Suspicion immediate surgical intervention

to avoid perforation and resultant severe
complications
Delay generalized peritonitis
Antimicrobial therapy:
2nd cephalosporin, perioperative, unless gangrene, perforation,
phlegmon

Gestational age Complication rate

Uterine contractions 80% over 24w
Preterm labor:
1. 3rd trimester
2. Perforated appendix & peritonitis

References
Maa J, Kirkwood KS. The Appendix. In Sabiston Textbook Of Surgery. 18th ed.: Saunders Elsevier; 2008.
Berger DH, Jaffie BM. The Appendix. In Brunicardi FC, Andersen DK, Billiar TR, Hunter JG, Pollock RE, editors. Scwartz's Manual
Of Surgery. 8th ed.: The McGraw-Hill Company; 2006. p. 784-99.
Riwanto I, Hamami AH, Pieter J, Tjambolang T, Ahmadsyah B. Usus Halus, Apendiks, Kolon dan Anorektum. In.
Chen LE, Buchman TG. Acute Abdominal Pain and Appendicitis. In Klingensmith ME, Chen LE, Glasgow SC, Goers TA, Melby SJ.
Washington Manual of Surgery. 5th ed.: Lippincott Williams and Wilkins; 2008. p. 200-13.
Sigdel G, Lakhey P, Mishra P. Tzanakis Score vs Alvarado Score in Acute Appendicitis. J Nepal Med Assoc. 2010; 49(178): p. 96-9.

Ohle R, O'Reilly F, O'Brien KK, Fahey T, Dimitrov BD. The Alvarado score for predicting acute appendicitis: a systematic review.
BMC Medicine. 2011; 9(139): p. 1-13.
Tzanakis NE, Efstathiou SP, Danulidis K, Rallis GE, Tsioulos DI, Chatzivasiliou A, et al. A New Approach to Accurate Diagnosis of
Acute Appendicitis. World Journal of Surgery. 2005; 29(9): p. 1151-6.
Ansaloni L, Catena F, Coccolini F, Ercolani G, Gazzoti F, Pasqualini E, et al. Surgery versus Conservative Antibiotic Treatment in
Acute Appendicitis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Dig Surg. 2011; 28: p. 210-21.

Liu ZH, Li C, Zhang XW, Kang L, Wang JP. Meta-analysis of the therapeutic effects of antibiotic versus appendicectomy for the
treatment of acute appendicitis. Experimental and Therapeutic Medicine. 2014; 7: p. 1181-6.

ANY QUESTION ??