ETTY HERLIN I

15710367
 Untuk mengetahui patofisiologi dan pemeriksaan
fisik appendisitis akut
 Untuk mengetahui pasien yang mempunyai resiko
tinggi kesahalahan diagnosis
 Untuk mengetahui hasil laboratorium dan
pemeriksaan radiologi dalam menegakkan diagnosis
appendisitis akut
 6% indisidensi
 69% antara umur 10 sampai 30
 30% misdiagnosis
 20%-30% terjadi rupture saat pembedahan
 Kematian : 0.1 sampai 0.2% tidak rupture, 3-5%
rupture
 morbiditas
Anatomic Aspects
Blind pouch off of cecum
Contains lymphoid tissue which peaks in
adolescence, atrophies with age
Function still unclear
Appendix can be anywhere within
peritoneal cavity
One study showed 65 % retrocecal, 31 %
pelvic
Review of 70,000 cases showed 4 % in
RUQ, 0.06 % LUQ, 0.04 % LLQ
 Pathophysiology of Appendicitis

Lymphoid hyperplasia leads to luminal

obstruction
Often follows viral illness
Epithelial cells secrete mucus
Appendix distends, bacteria multiply
Visceral pain begins an average of 17 hours after
obstruction
Increased pressure compromises blood supply
Somatic pain develops
Average time to perforation = 34 hrs.
Classic Presentation

Seen in 60 %
Anorexia
Periumbilical pain, nausea, vomiting
RLQ pain developing over 24 hrs.
Anorexia and pain are most frequent
Usually nausea, sometimes vomiting
Diarrhea, esp. with pelvic location
Usually tender to palpation
Rebound is a later finding
Physical Exam

Tenderness at McBurney's point

Rovsing's sign
Psoas sign
Obturator sign

Rectal
exam: pain can be most
pronounced if the patient has pelvic
appendix
MANTRELS Score (Alvarado
score)
Established in 1986
Migration of pain
Anorexia
Nausea / vomiting
Tenderness RLQ
Rebound
Elevated temp.
Leukocytosis
Shift to left
MANTRELS Score, cont'd.

RLQ tenderness and leukocytosis = 2

points each ; all others 1 point
Score of 5 to 6 = possible appendicitis
Score of 7 to 8 = probable appendicitis
Score of 9 to 10 = very probable
appendicitis
High Risk Patients

Ovulating women
PID, TOA, ovarian cyst rupture can mimic
appendicitis
Look for cervical motion tenderness,
adnexal tenderness, history of STD’s
Can have CMT with pelvic appendix
High Risk Patients, cont'd.

Pregnancy
Most common surgical emergency in
pregnancy
Mortality rate if missed = 2 % for mother,
up to 35 % for fetus
WBC elevated in pregnancy
Appendix changes location
 High Risk Patients, cont'd.

Pediatrics
Most common surgical disorder in kids
Accounts for 5 % of abd. pain visits
Up to 50 % initially misdiagnosed
ƒ < 2 yrs. : perforation rate approaches 100 %
ƒ 3 to 5 yrs. = 71 %

ƒ 6 to 10 yrs. = 40 %

Most common misdiagnosis is AGE

Sequence of pain and vomiting may be helpful
Localized tenderness not a feature of AGE
High Risk Patients, cont'd.

Elderly
Vital signs and exam may not reflect
severity
> age 60 : only 5 to 10 % diagnosed
without delay
Perforation rate = 46 to 83 %
RLQ tenderness absent in 23 %
N/V, anorexia less common
Leukocytosis less pronounced
Only 20 % classic presentation
High Risk Patients, cont'd.

Immunocompromised
HIV, chronic steroids, sickle cell,
chemotherapy, DM, dialysis
Increased risk of complications and
misdiagnosis
Inflammatory response decreased
Differential Diagnosis

Gastroenteritis TOA
Mesenteric Ectopic pregnancy
lymphadenitis UTI
PID Pyelonepritis
Crohn's disease Otherprocesses
Diverticulitis involving appendix
Endometriosis
Laboratory Studies

CBC
75 to 85 % have elevated WBC, but it is
nonspecific
WBC normal in 80 % in the first 24 hrs.
Can see elevated ANC in up to 89 %
WBC usually 12 to 18,000 in appendicitis
Chemistry panel
May help with diagnosis of dehydration
Laboratory Studies, cont'd.

Urinalysis
Specific gravity, ketones
Can see WBC’s, RBC’s, bacteria if
inflamed appendix close to ureter
> 30 WBC’s = probable UTI
CRP
Acute phase reactant
 Imaging Studies

Plain films
Low sensitivity and specificity
Appendicolith specific, but seen in only 2 %
May see local air-fluid levels, psoas
obliteration, soft tissue mass, gas in
appendix : all nonspecific
Imaging Studies, cont'd.

Ultrasound
75 to 90 % sensitive, 86 to 100 % specific
Noninvasive, low cost, but operator-
dependent
Good for diagnosing GYN disorders
3 criteria for diagnosis
ƒ Tender, non compressible appendix

ƒ No peristalsis of appendix

ƒ Overall diameter > 6 mm

Imaging Studies, cont'd.

Ultrasound (US)
Appendix may not be seen, due to obesity,
guarding, bowel gas, perforation,
retrocecal location
2.4 to 56 % of normal appendixes seen
One study of 736 pediatric patients
showed 36.6 % without preop US had
negative appendectomy vs. 9.8 % who had
US
Imaging Studies, cont'd.

Ultrasound
Study from Australia showed total WBC
and neutrophil count were more accurate
than US. They recommended with
unequivocal presentation go to OR. If
equivocal, obtain CBC. If WBC > 15,000,
go to OR. If < 11,000, obtain CT (US only
in pregnancy).
Imaging Studies, cont'd.

CT
Early studies showed low yield, but helical
CT much more accurate
Sensitivity 97 to 100 %, specificity 95 %
(similar no matter what type or whether
contrast is used)
Often shows alternative diagnosis
More expensive, radiation exposure
Imaging Studies, cont'd.

CT
Criteria for appendicitis :
ƒ Diameter > 6 mm
ƒ Failure to completely fill with contrast or
air
ƒ Appendicolith

ƒ Wall thickening or enhancement

Other contributory signs include fat

stranding, fluid, inflammatory mass,
adenopathy
Imaging Studies, cont'd.

CT
One study showed negative laparotomy
rates of 4 % in men, 8 % in ovulating
women with CT (typical is 20 % and 45 %
respectively), but no change in perforation
rate
Another study showed increase in CT use
led to earlier diagnosis, less severe
pathologic findings, and decreased length
of stay
Imaging Studies, cont'd.

CT
Study from Dept. of Surgery, Stamford,
Connecticut : use of CT markedly
increased from 1994 to 2000, without
change in rate of negative appendectomy.
They concluded use of CT by
nonsurgeons leads to increased E.D. LOS
without improving accuracy. They
recommend mandatory surgical consult if
CT considered.
Risk Management
Misdiagnosis of appendicitis = 5th
leading cause of successful litigation
against EPs
7 features of misdiagnosed cases :
No nausea / vomiting
Lack of distress
No rebound
No guarding
No rectal exam (controversial)
Narcotic pain meds given
Diagnosis of acute gastroenteritis
Summary

Appendicitis is a common surgical

emergency with a varied clinical
presentation
Several patient groups are at high risk of
misdiagnosis
Lab and imaging studies are helpful, but
no single study is a substitute for good
clinical judgement