Appendicitis

Consultant : dr. Syaiful Mukhtar, Sp.B KBD

Epidemiology
One of the more common surgical emergencies , and it is one of the most common causes of abdominal pain

United States

250,000 cases of appendicitis are reported annually, current annual incidence is 10 cases per 100,000 population

countries, the incidence of acute appendicitis is probably lower because Asian and of the dietary habits of the inhabitants of these geographic areas.
African

The incidence of appendicitis gradually rises from birth, peaks in the late teen years, and gradually declines in the geriatric years

Anatomy

Vascularization

Pathophysiology
Acute appendicitis is thought to begin with obstruction of the lumen

Obstruction can result from food matter, fechalit, or lymphoid hyperplasia

Mucosal secretions continue to increase intraluminal pressure

Increasing of intraluminal pressure

Initial luminal distention triggers visceral afferent pain fibers, which enter at the 10th thoracic vertebral level.

Also triggers n.vagus

This pain is generally vague and poorly localized.

Nausea & vomiting

Pain is typically felt in the periumbilical or epigastric area.

Pathophysiology
Eventually the pressure exceeds capillary perfusion pressure and venous and lymphatic drainage are obstructed That condition makes an increasing of intramucosa pressure Lead to an ischemic

With vascular compromise, epithelial mucosa breaks down

Increased pressure also leads to arterial stasis and tissue infarction

Infiltration of microorganism to the wall of appendix supuratif inflamation to the wall of appendix

Pathophysiology
As inflammation continues, the serosa and adjacent structures become inflamed This triggers somatic pain fibers, innervating the peritoneal structures. Typically causing pain in the RLQ

Pathophysiology
The change in stimulation form visceral to somatic pain fibers explains the classic migration of pain in the periumbilical area to the RLQ seen with acute appendicitis.

Pathophysiology
Infiltration of microorganism to the wall of appendix supurative inflammation to the wall of appendix

Infiltration
the omentum wrap up the inflamed appendix in an attempt to prevent infection from spreading by isolating the inflamed organ

Strong

Weak

INFILTRATION

conservative treatment

Complete perforation

Poor defances mechanism of the omentum

Week infiltrat

Complete perforation

Abcess

Drainage

Operative surgery in 2-3 months later

Appendicular Mass
Is a defense mechanism of the body due to inflammation with limiting the inflammation by covered the appendix with omentum, intestine, or adnexa appendicular mass

History
Primary symptom: abdominal pain Pain beginning in epigastrium or periumbilical area that is vague and hard to localize Mild fever Nausea Vomiting

History
Retroperitoneal may present :
Flank area pain Pain when theres a contraction of the great psoas muscle.

History

Physical Exam
Findings depend on duration of illness prior to exam. Early on patients may not have localized tenderness With progression there is tenderness to deep palpation over McBurneys point

Physical Exam
McBurneys point Nyeri lepas Rovsing sign Blumberg sign

Physical Exam
Psoas sign: place patient in L lateral decubitus and extend R leg at the hip. If there is pain with this movement, then the sign is positive. Obturator sign: passively flex the R hip and knee and internally rotate the hip. If there is increased pain then the sign is positive

Physical Exam

Physical Exam
Fever: another late finding. At the onset of pain fever is usually not found. Temperatures >39 C are uncommon in first 24 h, but not uncommon after rupture

Diagnosis
Acute appendicitis should be suspected in anyone with epigastric, periumbilical, right flank, or right sided abd pain who has not had an appendectomy

Diagnosis
Women of child bearing age need a pelvic exam and a pregnancy test. Additional diagnostic modalities: CBC, UA, imaging studies

Diagnosis
the WBC is of limited value. Sensitivity of an elevated WBC is 70-90%, but specificity is very low. But, (+) predictive value of high WBC is 92% and ()predictive value is 50% Increasing of LED : appendicular mass

 Urinalysis

Specific gravity, ketones Can see WBCs, RBCs, bacteria if inflamed appendix close to
ureter

> 30 WBCs = probable UTI HCG Essential in women of child-bearing age CRP Acute phase reactant

Diagnosis

Ultrasound

75 to 90 % sensitive, 86 to 100 % specific Noninvasive, low cost, but operator-

dependent 3 criteria for diagnosis Tender, noncompressible appendix No peristalsis of appendix Overall diameter > 6 mm Appendix may not be seen, due to obesity, guarding, bowel gas, perforation, retrocecal location

Management
Pre-operative treatment Operation post operative treatment Treatment of complications

Pre-operative treatment
Pain Antibiotics Fluids Preparation Consent

OperativeTreatment
Open Appendectomy
A transverse Rocky-Davis or the classical McBurney skin incision is made in the RLQ over the area of maximal tenderness. If purulent or cloudy peritoneal fluid is encountered, it should be sent for culture and sensitivity. The appendix is identified at the confluence of the taeniea coli, and the mesoappendix is clamped and divided. A silk purse string suture is placed at the base of the

appendix,then clamped,ligated with catgut, and divided sharply.

OperativeTreatment[cont]
The appendiceal stump can be cauterizedeither chemically or electrically (dealers choice), and dunked into the cecum. The fascia is closed, and the skin also except in cases of

perforated appendicitis.

OperativeTreatment
If the appendix is perforated, historical management has been either delayed primary closure or primary closure with drainage. When a normal appendix is encountered, a limited exploration is warranted to rule out nearby pathology. In all cases except for IBD, the appendix should be removed to eliminate the possibility of confusion in future cases of RLQ pain. If an appendix is removed in the presence of active IBD, a fecal fistula may ensue. LOOK FOR MECKLES DIVERTICULUM/OTHRERS

OperativeTreatment
Laparoscopic Appendectomy

If normal appendix removed -need to look for:

Meckel's diverticulum Acute salpingitis Crohn's disease

Antibiotics
Metronidazole Sefalosphorin

COMPLICATIONS
Perforation Abscess and mass formation Liver abscess Gen.peritonitis Septicaemia

Appendiceal Mass and Abscess

A palpable conglomeration of inflamed tissues, including the appendixand adjacent viscera. CT scan of the abdomen and appendix can delineate a phlegmon versus an abscess, the treatment of which are distinct. A difference of opinion revolves around the necessity of an operative approach conservative regimen. A conservative approach with antibiotics, the so-called Ochsner method,

Appendicular abscess may be treated with

; Percutaneous Drainage and concomitant IV antibiotics. As it resolves, an interval appendectomy can be entertained, usually at least 3 months after the attack. It has been shown that of the patients treated nonoperatively for abscess as well as phlegmon

5% will fail this approach,and up to 40% will return within a year with recurrent acute appendicitis requiring appendectomy.4

Open drainage