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Afrisya Bimo Siwendro

Marisha Yadian Putri

Preceptor: dr.Liza Nursanty, SpB. FINACS


 The appendix first becomes visible in the 8 week
of embryologic development as a protuberance
off the terminal portion of the cecum. During
both antenatal and postnatal development, the
growth rate of the cecum exceeds that of the
appendix, displacing the appendix medially
toward the ileocecal valve. The relationship of
the base of the appendix to the cecum remains
constant, whereas the tip can be found in a
retrocecal, pelvic, subcecal, preileal, or right
pericolic position. 3 taenia coli converge at the
junction of the cecum with the appendix and can
be a useful landmark to identify the appendix
 Appendix is an immunologic organ that
actively participates in the secretion of
immunoglobulin A (IgA).
 Appendix is an integral component of the
gut-associated lymphoid tissue (GALT)
system.
 After the age of 60 years, virtually no
lymphoid tissue remains within the appendix,
and complete obliteration of the appendiceal
lumen is common.
 Inflammationof the vermiform appendix
with acute onset
 Appendicitis is most frequently seen in
patients in their second through fourth
decades of life, with a mean age of 31.3
years and a median age of 22 years. There is
a slight male to female predominance (M:F
1.2 to 1.3:1).
 Obstruction of the lumen is the dominant causal
factor in acute appendicitis.
 Fecaliths are the usual cause of appendiceal
obstruction.
 Less-common causes are hypertrophy of
lymphoid tissue, inspissated barium from
previous x-ray studies, tumors, vegetable and
fruit seeds, and intestinal parasites.
 Fecaliths are found in 40% of cases of simple
acute appendicitis, 65% of cases of gangrenous
appendicitis without rupture, and nearly 90% of
cases of gangrenous appendicitis with rupture.
 Symptom
- Migrating abdominal pain. (May vary, depend on
variant location of appendix)
- Anorexia, although vomiting occurs in nearly 75% of
patients, it is neither prominent nor prolonged and
most patients vomit only once or twice. Vomiting is
caused both by neural stimulation and the presence
of ileus.
- Obstipation, but it some patient, particularly
children may cause diarrhea.
 Sign
- Vital signs are minimally changed. Temperature
elevation is rarely more than 1°C (1.8°F) and the
pulse rate is normal or slightly elevated.
- Patients with appendicitis usually prefer to lie
supine, with the right thigh drawn up. If asked to
move, they do so slowly and with caution.
- McBurney tenderness, Rovsing sign (+), Right sided
Hyperesthesia T 10, 11, 12
- Psoas and obturator sign (+) indicate muscle and
pelvic irritation.
 Rovsing’s sign
 Obturator sign
 Psoas sign
 When the inflamed
appendix hangs into the
pelvis, abdominal findings
may be entirely absent,
and the diagnosis may be
missed unless the rectum is
examined. As the
examining finger exerts
pressure on the peritoneum
of the cul-de-sac of
Douglas, pain is felt in the
suprapubic area, as well as
locally within the rectum.
 Mild leukocytosis, ranging from 10,000 to
18,000/mm3, is usually present in patients
with acute, uncomplicated appendicitis and
is often accompanied by a moderate
polymorphonuclear predominance.
 Acute Mesenteric Adenitis  Acute gastroenteritis
 Most often confused with  Common in childhood but can
acute appendicitis in usually be easily
children. differentiated from
 The pain is usually appendicitis.
diffuse, and tenderness is  Viral gastroenteritis, an acute
not as sharply localized as self-limited infection of
in appendicitis. diverse causes, is
 Voluntary guarding is characterized by profuse
sometimes present, but watery diarrhea, nausea, and
true rigidity is rare. vomiting.
 Generalized  Hyperperistaltic abdominal
lymphadenopathy may be cramps precede the watery
noted. Laboratory stools. The abdomen is
procedures : relative relaxed between cramps, and
lymphocytosis, when there are no localizing signs.
present, suggests  Laboratory values are normal.
mesenteric adenitis.
 Meckel's diverticulitis causes a clinical picture
similar to that of acute appendicitis. The Meckel's
diverticulum is located within the distal 2 feet of the
ileum.
 Intussusception
 Differentiate intussusception from acute
appendicitis as the treatment is different.
 Appendicitis is very uncommon in children younger
than age 2 years, whereas nearly all idiopathic
intussusceptions occur in children younger than
age 2 years.
 Intussusception occurs typically in a well-
nourished infant who is suddenly doubled up by
apparent colicky pain. Between attacks of pain,
the infant appears well. After several hours, the
patient usually passes a bloody mucoid stool.
 A sausage-shaped mass may be palpable in the
right lower quadrant. As the intussusception
progresses distally, the right lower quadrant feels
abnormally empty.
 Crohn’s enteritis
The manifestations of acute regional enteritis—fever,
right lower quadrant pain and tenderness, and
leukocytosis—often simulate acute appendicitis.
Diarrhea and the infrequency of anorexia, nausea, and
vomiting favor a diagnosis of enteritis but are not
sufficient to exclude acute appendicitis.

 Pelvic Inflammatory Disease


The infection is usually bilateral, but if confined to the
right tube, may mimic acute appendicitis. Nausea and
vomiting often are present in patients with
appendicitis, but only in approximately 50% of those
with pelvic inflammatory disease. The greatest value of
these symptoms for establishing a diagnosis of pelvic
inflammatory disease is their absence. Pain and
tenderness are usually lower, and motion of the cervix
is exquisitely painful. Intracellular diplococci may be
demonstrable on smear of the purulent vaginal
discharge
 Ruptured Ectopic  Ureteral Stone
Pregnancy  Pain referred to the
 Rupture of right tubal labia, scrotum, or
or ovarian penis; hematuria;
pregnancies can and/or absence of
mimic appendicitis. fever or leukocytosis
 Patients usually give a
suggest the presence
history of abnormal of a ureteral stone.
menses; either  Pyelography and CT
missing one or two scanning without oral
periods or noting only contrast usually
slight vaginal confirm the diagnosis.
bleeding.
 The development of
right lower quadrant
or pelvic pain may be
the first symptom.
 Diagnosis of acute appendicitis in young children is more difficult
than in the adult. The more rapid progression to rupture and the
inability of the underdeveloped greater omentum to contain a
rupture lead to significant morbidity rates in children.

 Antibiotic coverage is limited to 24 to 48 hours in cases of


nonperforated appendicitis. For perforated appendicitis, 7 to 10
days of antibiotics is recommended. Intravenous antibiotics are
usually given until the white blood cell count is normal and the
patient is afebrile for 24 hours.

 Laparoscopic appendectomy has been shown to be safe and


effective for the treatment of appendicitis in children.
 Although the incidence of appendicitis in the
elderly is lower than in younger patients, the
morbidity and mortality are significantly
increased in this patient population.
 Delays in diagnosis, a more rapid progression
to perforation, and comorbid disease are all
contributing factors.
 In patients older than age 80 years,
perforation rates of 49% and mortality rates
of 21%
 The incidence is approximately 1 in 2000 pregnancies. Acute
appendicitis can occur at any time during pregnancy, but is more
frequent during the first two trimesters.
 As fetal gestation progresses, the diagnosis of appendicitis
becomes more difficult as the appendix is displaced laterally and
superiorly (Fig. 29-7). Nausea and vomiting after the first
trimester or new-onset nausea and vomiting should raise the
consideration of appendicitis.
 Abdominal pain and tenderness will be present, although rebound
and guarding are less frequent because of laxity of the abdominal
wall. Elevation of the white blood cell count above the normal
pregnancy levels of 15,000 to 20,000/L, with a predominance of
polymorphonuclear cells, is usually present.
 When the diagnosis is in doubt, abdominal ultrasound may be
beneficial. Laparoscopy may be indicated in equivocal cases,
especially early in pregnancy. The performance of any operation
during pregnancy carries a risk of premature labor of 10 to 15%,
and the risk is similar for both negative laparotomy and
appendectomy for simple appendicitis.
 The incidence of acute appendicitis in HIV-
infected patients is reported to be 0.5%. 67 This
is higher than the 0.1 to 0.2% incidence reported
for the general population. 68
 The presentation of acute appendicitis in HIV-
infected patients is similar to that of
noninfected patients. The majority of HIV-
infected patients with appendicitis will have
fever, periumbilical pain radiating to the right
lower quadrant (91%), right lower quadrant
tenderness (91%), and rebound tenderness (74%).
HIV-infected patients will not manifest an
absolute leukocytosis.
 Open appendectomy
 Death is usually attributable to uncontrolled
sepsis—peritonitis, intra-abdominal
abscesses, or gram-negative septicemia.
 Pulmonary embolism continues to account
for some deaths. Aspiration is a significant
cause of death in the older patient group.
 Principalfactors in mortality are whether
rupture occurs before surgical treatment and
the age of the patient. The overall mortality
rate for a general anesthetic is 0.06%. The
overall mortality rate in ruptured acute
appendicitis is about 3%—a 50-fold increase.
The mortality rate of ruptured appendicitis
in the elderly is approximately 15%—a
fivefold increase from the overall rate.
 Characteristically, the pain lasts longer and is less intense than that of
acute appendicitis, but is in the same location. There is a much lower
incidence of vomiting, but anorexia and occasionally nausea, pain with
motion, and malaise are characteristic. Leukocyte counts are predictably
normal and CT scans are generally nondiagnostic.

 At operation, surgeons can establish the diagnosis with 94% specificity


and 78% sensitivity. There is an excellent correlation between clinical
symptomatology, intraoperative findings, and histologic abnormalities.
Laparoscopy can be effectively used in the management of this clinical
entity. Appendectomy is curative. Symptoms resolve postoperatively in 82
to 93% of patients. Many of those whose symptoms are not cured or recur
are ultimately diagnosed with Crohn's disease.
 A number of intestinal parasites cause appendicitis. While
Ascaris lumbricoides is the most common, a wide spectrum
of helminths have been implicated, including Enterobius
vermicularis, Strongyloides stercoralis, and Echinococcus
granulosis. The live parasites occlude the appendiceal
lumen, causing obstruction.
 The presence of parasites in the appendix at operation
makes ligation and stapling of the appendix technically
difficult. Once appendectomy has been performed and the
patient recovered, therapy with helminthicide is necessary
to clear the remainder of the gastrointestinal tract.
 Amebiasis can also cause appendicitis. Invasion of the
mucosa by trophozoites of Entamoeba histolytica incites a
marked inflammatory process. Appendiceal involvement is
a component of more generalized intestinal amebiasis.
Appendectomy must be followed by appropriate antibiotic
therapy (metronidazole).