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A woman, aged 19 years, comes to the ER with complaints of lower right abdominal pain.

History taking:
• Has regullar menstruation
• Pain since one day ago around the pit of the liver, when it is felt over time down to the
lower right abdomen
• The pain gets worse
• Fever (-)
• There is nausea, vomiting (once)
• Previously never experienced anything like this
• When urinating is not painful
• Diarrhea pooping a week ago, just once
• Pain feels continuous, more ill when standing
• Have been treated with ulcer drug but not cured
• Past Medical History: gastritis
Physical examination:
• General situation: weak, painful
• BP: 120/80 mmHg
• Pulse: 88x / min
• RR: 22x.min
• Axilla temperature: 37.2 c
• Eyes: normal
• Thorax: symmetrical, sonor
• Lung: vesicular / ronkhi (-)
• Heart: murmur (-)
• Abdomen: Darm Countour (-) / Darm Steifung (-), bowel noise decreases
• Palpation: mass (-), tenderness at mcburney point, soepel abdominal wall, flats
• Rectal Touche : RT / DRE pain at 10/11 clock, mass (-), slippery mucosa, no
blood, and mucus on the handscoon
• Acral: warm, edema (-)
• ROM: good
• Complete Blood:
• Hb: 14
• Leukocytes: 12,000
• Platelets: 300,000
• Plano test (-)
• Ultrasound: no abnormality

1. A woman, 19 years old.

2. Complaining lower right abdominal pain. The more pain
when standing.
3. In abdominal palapation pain at mcburney point.
4. Bowel noise decreases
5. In the rectal touche feels pain at the direction of 10/11
Learning Objectives

1. Explain DD and Dx
2. Explain the anatomy and physiology of the colon
3. Explain the etiology and risk factors of appendicitis
4. Explain the pathophysiology of appendicitis
5. Explain symptoms and signs of appendicitis
6. Explain the examination for appendicitis
7. Explain the management of appendicitis
8. Explain the complications and prognosis of appendicitis
9. Explain visceral and somatic pain
Differential diagnosis of Acute Appendicitis
Acute Appendicitis PID Ovarian Cysts Urololithiasis
Epidemiolog Found at all ages Often found in young Often occurs in women In a developing
y Incidence in men and women of reproductive age country, especially in
women is generally The incidence is Less than 20 years old children
comparable highest at the age of and over 50 years old In developing
The highest incidence is 15-24 years countries, especially
in the 20-30 year age in adults
group, and at this age
more in men

Clinical Pain at Mc Burney's Fever, malaise, nausea A lump in the abdomen Hematuria
Manifestation point Bloated accompanied by severe Pain disappears
Accompanied by nausea Lower abdominal pain, complaints With nausea or no
and sometimes vomiting local tenderness, loose Leg Edema vomiting
Decreased appetite pain, muscular defans Crowded Pain over the typical
Stomach ache when Urethritis sign Hormonal disorders: Hydronephrosis
walking or coughing Leukorea menstrual disorders
Visceral pain in the

Examinition Fever is usually mild Lower abdominal Percussion: timpani Physical examination:
with a temperature of tenderness because cecum and palpable kidney
37.5-38.5 ° C Vaginoabdominal: pain ascendens colon enlarged by the
Inspection: no specific occurs if the cervix or contains air presence of
description was found uterus is moved Percussion: deaf from hydronephrosis
Palpation: Pain in the Pain when adnexa is ovarian cysts
right iliac region touched
Anal shaft: pain when
the area of infection can
be achieved with the
index finger
Anatomy of Colon

Part of Colon. (1) caecum. (2) appendix

vermiformis. (3) ascending colon. (4)
transverse colon. (5) descending colon. (6)
sigmoid colon. (7) rektum. (8) anal canal.
The anatomy of Appendix
• Appendix vermiformis or often called the appendix is a narrow, tubular organ that has muscles
and contains many lymphoid tissue. Appendix length varies from 3-4 inches (8-13 cm). Basically
attached to the surface of the cecum.
• In 65% of cases, the appendix is located in the intraperitoneal, attached to the lower layer of
mesenterial intestinum tenue through its own short mesenterium called mesoapendiks
(mesoapendiks containing arteries, veins and nerves (Snell, 2006)), and in the latter case the
appendix is located at retroperitoneal, behind the cecum, behind the ascending colon, or on the
lateral edge of the ascending colon (Sjamsuhidajat & Jong, 2005)
• The parasympathetic innervation is derived from the branches of the vagus nerve following the
superior mesenteric artery and apendicular artery, whereas the sympathetic innervation comes
from the thoracic nerve X. Therefore, visceral pain in appendicitis begins around the umbilicus.
• Appendix bleeding originates from appendicular artery, which is an artery without collateral. If
this artery is blocked, for example in thrombosis, the appendix will have gangrene (Sjamsuhidajat
& de Jong, 2005).
• The main function of the colon is the absorption • Immunoglobulins of a creator produced by
of water and electrolytes from the kimus to GALT (gut associated lymphoid tissue) found
form dense feces and accumulation of fecal along the gastrointestinal tract including the
material until it can be removed (Guyton, 2008), appendix, are IgA. Immunoglobulin is very
the colon alters the 1000-2000mL isotonic clima effective as a protector against infection.
which enters daily from ileum into semisolid However, appendix removal does not affect the
stools with a volume of about 200-250mL body's immune system because the amount of
(Ganong, 2008). lymph tissue here is very small compared to its
• Appendix produces 1-2 ml of slime per day. The amount in the gastrointestinal tract and
mucus is normally poured into the lumen and throughout the body (Sjamsuhidajat, De Jong,
then flows into the caecum. The mucus flow 2005).
resistance at the apendix estuary appears to play
a role in the pathogenesis of appendicitis
The classic symptoms of appendicitis include:
• Dull pain near the navel or the upper abdomen that
becomes sharp as it moves to the lower right abdomen.
This is usually the first sign.
• Loss of appetite
• Nausea and/or vomiting soon after abdominal pain begins
• Fever mild with a temperature of about 37.5-38.5OC
• Inability to pass gas
• Painful urination and difficulty passing urine
• Examination of appendicitis is purely clinical examination and
supporting examination can not eliminate clinical examination.
• On examination of vital signs, mild fever 37.5 ° -38.5 ° celcius.
When higher temperatures may have occurred perforation. In
palpation of the abdominal region, there is limited pain in the right
iliac region, which can result in pain relief. The presence of
muscular defans suggests stimulation of peritoneum parietale.
• On the left abdominal emphasis, the pain will be felt on the right
abdomen is called Rovsing sign, which is due to air in the intestinal
cavity will return to the ascendent colon when descendent colon is
• On rectal examination (lithotomy position) there is pain in
the direction of 9-11 hours. Examination of psoas test by
hyperextension the right hip joint or active flexion of the
right hip joint then the right thigh is retained. When the
inflamed appendix attaches to the psoas major muscle,
this psoas test will cause pain.
• The oburator test is used to check whether the inflamed
appendix is in contact with the internal obturator wall
which is a small pelvic wall. Investigations that are often
used are leukocytosis and usg. If on a normal ultrasound
picture in the patient, then this does not exclude the
clinical diagnosis of appendicitis
Management of Appendicitis
When the clinical diagnosis is clear, the best
course of action and good choice is the
Delays in surgery while administering
antibiotics may result in abscesses or
Appendectomy can be done openly (incision
on McBurney) or with laparoscopy
8. The Complications and Prognosis Of Appendicitis

The Prognosis
• The complications:
• In appendicitis with no complication, the mortality less
 Perforation than 0.1%. In appendicitis with complications now the
mortality rate drops to 2-5%, but remains high (10-15%)
 Appendix abscess in small children and the elderly. Reduced mortality can
be achieved by early surgery
 Purulent peritonitis
 Peritoneal cavity
 Subdiafragma
 Liver abscess