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Appendix

An immunologic organ
Secrete Ig; particularly IgA
An integral component of GALT system
Vermiform shape
Appendix
Derivate of the midgut
The base is more medial
location (posteromedial wall
of the cecum) toward and
caudal to the ileocecal valve
during both antenatal and
post natal development, the
growth rate of the cecum
exceeds that of the appendix
(unequal elongation of the
lateral wall of the cecum)
Appendix
The orifice is always at
the confluence of three
caecal taenia coll
converge at the junction
of the cecum with
appendix
Useful landmark to
identify the appendix
Appendix
The final location of the appendix is
determined by the location of the caecum
The normal location of the appendix is
retrocecal but within the peritoneal cavity
(because the most inferior portion of the caecum is
within the peritoneal cavity), 65%
Appendix
The relationship of the base of the appendix to
the caecum remains constant, whereas the tip
can be found located in a variety of locations
explains the myriad of symptoms, in the position:
Retrocecal
Pelvic
Subcecal
Preileal
Right pericolic
Incidence
Lymphoid follicles in the submucosa gradually
increased through adolescence, then decrease
over time peak incidence: late teens & 20s
The amount of lymphoid tissue increase throughout
puberty, remains steady for the next decade, and then
begins a steady decrease with age
After the age of 60 years, virtually no lymphoid tissue
remains within the appendix, and complete obliteration
of the appendiceal lumen is common
Pathophysiology
Obstruction of the lumen is the dominant cause
Fecalith
Hypertrophy/swelling of the mucosal and
submucosal lymphoid tissue at the base of the
appendix
Inspissated barium from previous x-ray studies
Tumors
Vegetable and fruit seeds
Intestina parasites
Pathophysiology
The proximal obstruction of the appendiceal lumen
A closed-loop obstruction

* Bacterial overgrowth
* Continued mucus secretion

* Distention of the lumen
* Increased intraluminal pressure

..
Pathophysiology
..

Stimulates nerve endings of visceral afferent stretch fibers,
producing visceral pain (vague, dull, diffuse pain) in the mid abdomen
or lower epigastrium
Stimulates peristalsis cramping
Nausea and vomiting
Pathophysiology
..

Pressure in the organ increased

Lymphatic obstruction

Venous pressure is exceeded then obstructed

Capillaries and venules are occluded, arterial inflow continues

Engorgement and vascular congestion

..
Pathophysiology
..

The inflammatory process soon involves the serosa of the appendix
and in turn parietal peritoneum; producing the characteristic shift in
pain to the right lower quadrant (i.e. somatic pain)


..
Pathophysiology
..

As distention continue; arteriolar inflow occluded
Increase pressure in the appendiceal wall exceeds capillary pressure

*Elipsoidal infarcts (mucosal ischemia)
develop in the antimesenteric border,
the area with the poorest blood supply suffers most
*Integrity of mucosa compromised bacterial invasion

Acute inflammatory response ensues bacterial overgrowth
edema

..
Pathophysiology
..

The appendix becomes more edematous
ischemic

Necrosis of the appendiceal wall
along with
Translocation of bacteria through the ischemic wall

Perforation occurs
Usually through one of the infarcted areas on the antimesenteric borders
Perforation generally occurs just beyond the point of obstruction rather than at the tip
because of the effect of diameter on intraluminal tension

Gangrenous appendix
Pathophysiology
Gangrenous appendix, without intervention

Will perforate

Spillage of the appendiceal contents into the peritoneal cavity
Pathophysiology
If the sequence of events occurs slowly

The appendix is contained by the inflammatory response and the omentum

Localized peritonitis The body does not wall of the process

Appendiceal abscess Diffuse peritonitis
Clinical Presentation
Appropriate sequence of symptoms:
Pain followed by nausea and vomiting with
fever and exaggerated local tenderness in the
position occupied by the appendix

(Murphy,
1905)
Clinical Presentation Obstruction of
the appendiceal
lumen

The typical history/The classic pain sequence


Generalized abdominal pain (crampy, dull, colicky, & intermittent) that difficult to localize
followed by anorexia and nausea

The pain then becomes most prominent diffusely centered in the lower epigastrium ,
moderately severe and is steady,
Transmural
sometimes with intermittent cramping superimposed inflammation of
the appendix
leads to
inflammation of
Gradually moves toward the umbilicus the peritoneal
lining of the RLQ
abdomen
After a period varying from 1-12 hours
Finally localizing in the right lower quadrant (sharp & constant pain)
Direct tenderness and muscle spasm in the right lower quadrant
Movement & Valsalva maneuver worsen the Pain
(when the inflamed serosa contacts the
(the obstructed lumen of appendix cause parietal peritoneum, the somatic nerves of the
distention leads to the sensation of poorly peritoneum are stimulated and the previous
localized, usually periumbilical, crampy pain nonspecific pain becomes localized to the right
via stimulation of the visceral afferent nerves) lower quadrant)
Clinical Presentation
The process continues
The amount of spasm increases
Muscular resistance to palpation of the abdominal wall roughly
parallels the severity of the inflammatory process
The appearance of rebound tenderness
The temperature is often mildly elevated/
low grade fever (38,30C)
Usually rises to higher levels in the event of perforation

Jadi urutan nyerinya


nyeri tekan defans muskular nyeri lepas
Clinical Presentation
Variation in the anatomic location of the appendix account for
many of the variations in the principal locus of the somatic phase
of the pain
A long appendix with the inflamed tip in the left lower
left lower quadrant pain
A retrocecal appendix right flank or back pain
A pelvic appendix suprapubic pain
A retrocecal appendix testicular pain
(presumably from irritation of the spermatic artery and ureter)
Right upper quadrant pain
Right-sided pelvic tenderness on rectal examination
Clinical Presentation

The surgeon should systematically


examine the entire abdomen, starting
in the left upper quadrant away from
the patients described pain
Clinical Presentation
Accompanied symptoms
Anorexia
Vomiting neural stimulation
the presence of ileus
neither prominent nor prolonged
only twice or once
If nausea and vomiting precede the pain, patients are
likely to have another cause for their abdominal pain, such
as GE
Urinary or bowel frequency appendiceal inflammation
irritating the adjacent bladder or rectum
Clinical Presentation
The sequence of symptom
Anorexia
If the patient is not anorectic, the diagnosis of appendicitis should be questioned


Abdominal pain

Vomiting
If vomiting procedes the onset of pain, the diagnosis of appendicitis should be questioned
Clinical Presentation
RT dikerjakan bila pasien mengeluh nyeri perut tapi
saat kita periksa tidak ada NT Mc Burney
Karena bisa saja letak ujung appendiks di/
menuju rongga pelvis
Sehingga saat RT jari menekan peritoneum kavum
Douglaspasien mengeluh nyeri di suprapubik
rektum
Clinical Presentation
Right lower quadrant tenderness is THE MOST
consistent of all signs of acute appendicitis
Its presence should always raise the specter of
appendicitis, even in the absence of other signs and
symptoms
Clinical Presentation
Laboratory
Leucocytosis (12.000-18.000)
Neutrophils (left shift)
Pyuria the proximity of the ureter to the inflamed appendix
ureteral or baldder iritation as a result of an inflamed appendix
Clinical Presentation
Physical Examination
Physical findings are determined principally by
The anatomic position of the inflamed
appendix
Whether the organ has already ruptured
when the patient is first examined
Physical Examination
Rovsings sign
Elicited when pressure
applied in the left lower
quadrant reflects pain
in the right lower
quadrant
Physical Examination
Psoas sign
Elicited by extension of
the right thigh with the
patient lying on the left
side, stretching of the
iliopsoas muscle
Pain suggests the
presence of an inflamed
appendix overlying the
psoas muscle
Indicates that the
inflamed appendix is
retrocaecal in orientation
Physical Examination
Obturator sign/
Hypogastric pain
Elicited by passive
internal rotation of the
flexed right hip/thigh
with the patient in the
supine position, stretching
of the obturator internus
muscle
Indicates that the
inflamed appendix is
pelvic in orientation
Imaging
Sonographic criteria
Thickening of the appendiceal wall, 6 or 7 mm
Noncompressible appendix of or greater in AP diameter
The presence of an appendicolith
Interruption of the continuity of the echogenic
submucosa
Periappendiceal fluid or mass
Increased echogenicity of the surrounding fat signifying
inflammation
Loculated pericecal fluid
Imaging
False-negative sonogram can occurs if:
The appendicitis is confined to the appendiceal
tip
Retrocecal location
The appendix is markedly enlarged and
mistaken for small bowel
The appendix is perforated and therefore
compressible
Imaging
Plain abdominal radiograph are neither
helpful nor cost effective and are not
recommended for the diagnosis of acute
appendicitis
RLQ fecalith (appendocolith) was not
pathognomonic for acute appendicitis
Differential Diagnosis
Depends upon 4 major factors:
The anatomic location of the inflamed
appendix
The stage of the process (i.e. simple or
ruptured)
The patients age
The patients sex
Differential Diagnosis
(based on group of age)

Preschool children
Intussusception
Colicky-type pain
< 3 y.o.
Mass with no true peritonitis
Meckels diverticulitis
Pain localize to the periumbilical area
Acute gastroenteritis
Diarrhea
Nausea
Vomit
Leukocytes in the stool
No peritoneal signs
Differential Diagnosis
(based on group of age)

School-age children
Gastroenteritis
Functional pain
Constipation
Omental infarction
Palpable mass
The pain does not migrate
Differential Diagnosis
(based on group of age)

Adolescent boys and young adult men


Chrons disease
Ulcerative colitis
Epididimytis
Differential Diagnosis
(based on group of age)

Adolescent Girls and young adult women


PID
Onset in the lower abdomen
The pain is usually bilateral
Exacerbated on pelvic examination
Ovarian cyst ruptured
torsion
No migration or changing symptoms
UTI
Differential Diagnosis
(based on group of age)

Eldery age group


Malignancies GIT
reproductive system
Diverticulitis
Perforated ulcer
Cholecystitis
Differential Diagnosis
Differential Diagnosis
Acute mesenteric adenitis
Acute gastroenteritis viral
Salmonella
leucocyte count normal or
Nausea and vomiting precede the abdominal pain
Diarrhea is a prominent symptoms
Meckels diverticulitis
Diseases of the male urogenital system
Torsion of the testis
Acute epididymitis
Seminal vesiculitis
Differential Diagnosis
Intussusception
Children younger than age 2 years
A well-nourished infant
Suddenly doubled up by apparent colicky pain, between attacks
of pain the infant appears well, after several hours passes a
bloody mucoid stool
A sausage-shaped mass palpable in the right lower quadrant
Crohns enteritis
Acutely inflamed distal ileum with no cecal involvement and a
normal appendix
Subacute course include fever
weight loss
pain
Differential Diagnosis
Colonic lesions
Should be considered in older patients
Diverticulitis
Quicker progression to localized tenderness
Prodorme of an alteration in bowel habits
Perforating carcinoma of
The cecum
That portion of the sigmoid that lies on the right side
Appendicitis caused by a mass obstructing the appendiceal orifice
Guaiac-positive stools
Anemia
History of weight loss
Differential Diagnosis
Perforated peptic or duodenal ulcer, with fluid
tracking into the right paracolic gutter
Yersiniosis
Epiploic appedagitisinfarction of the colonic
appedage(s)torsion
Differential Diagnosis
Urinary tract infection; acute pyelonephritis (on the right side)
Chills
Right CVA tenderness
Pyuria
Bacteriuria
Ureteral stone; if the calculus is lodged near the appendix
Pain referred to the labia
scrotum
penis
Hematuria
Absence of fever
leukocytosis
Differential Diagnosis
Primary peritonitis nephrotic syndrome
cirrhosis
endogenous/exogenous
immunosupression
Henoch-Schnlein purpura
Beside abdominal pain, joints pain
purpura
nephritis
Differential Diagnosis
Foreign-body perforation of the bowel
Closed-loop intestinal obstruction
Mesenteric vascular occlusion
Plueritis of the right lower chest
Acute cholecystitis
Acute pancreatitis
Hematoma of the abdominal wall
Differential Diagnosis
(Gynecologic Disorders)

Pelvic inflammatory disease


Lower pain and tenderness
Pain of motion of the cervix
Purulent vaginal discharge
Acute salpingitis
Tubo-ovarian abscess
Endometriosis
Differential Diagnosis
(Gynecologic Disorders)

In women of childbearing years


Recent menstrual history
Pelvic examination
Differential Diagnosis
(Gynecologic Disorders)

Ruptured graafian follicle


Ovulation commonly results in the spillage of
sufficient amounts of blood and folicular fluid to
produce brief, mild, lower abdominal pain
Pain and tenderness are rather diffuse
Leukocytosis and fever are minimal or absent
Occurs at the midpoint of the menstrual cycle
(Mittel-Schmerz)
Differential Diagnosis
(Gynecologic Disorders)

Twisted ovarian cyst or tumor


rupture
torsion
Right lower quadrant pain, tenderness, rebound
Fever and leukocytosis
Palpable mass on vaginal exam
Differential Diagnosis
(Gynecologic Disorders)

Ruptured ectopic pregnancy


Abnormal menses
missing one or two periods
noting only slight vaginal bleeding
Pelvic mass
Elevated level of chorionic gonadotropin
Leukocyte counts rises slightly
Hematocrit level falls the intra-abdominal hemorrhage
Cervical motion and adnexal tenderness on vaginal
examination
The presence of blood and decidual tissue on culdocentesis
Patients with a history, physical examination,
and laboratory studies classic for appendicitis
should undergo urgent appendectomy
In those with an evaluation suggestive but not
convincing for appendicitis, further imaging is
indicated
Pelvic US in women of childbearing age to
evaluate ovarian pathology
Abdominopelvic CT to diagnosing other
intrabadominal pathology
Appendiceal Ruptures
Susceptible population:
Children younger than age 5 years
Patients older than age 65 years
Cannot express their symptoms
Delayed in presentation/present late in the course of their
disease
Non operative treatment exposes the patient to the
increased morbidity and mortality associated with a
ruptured appendix
Occurs most frequently distal to the point of luminal
obstruction along the antimesenteric border of the
appendix
Appendiceal Ruptures
Diminished inflammatory response:
Less impressive symptoms
physical signs
Longer duration of symptoms
Decreased leukocytosis
Appendiceal Ruptures
Should be suspected in the presence of:
2 or more days of abdominal pain
The pain may be so severe that patients do not remember the
antecedent colicky pain
Localized RLQ rebound tenderness if the perforation has been
walled off by surrounding intra-abdominal structures including
the omentum
Generalized peritonitis if the walling-off process is ineffective in
containing the rupture
High fever > 390C
Rigors
WBC > 18.000/mm3
Poor oral intake
Dehydration
Periappendiceal Mass
An ill-defined mass will be detected on
physical examination, this could represent a
phlegmon, consists of matted loops of bowel
adherent to the adjacent inflamed appendix,
or a periappendiceal abscess
Have a longer duration of symptoms, usually
at least 5-7 days
When performing appendectomy,
if the appendicitis is not found
or normal appendix,
a methodical search for an alternative
diagnosis must be performed
The cecum and mesentery should first be inspected
Next, the small bowel is examined in a retrograde
fashion beginning at the ileocecal valve and extending
at least 2 feet
Terminal ileum; terminal ileitis infectious causes
-Yersinia
-TB
Crohns disease
Inflamed or perforated Meckels diverticulum
When performing appendectomy,
if the appendicitis is not found
or normal appendix,
a methodical search for an alternative
diagnosis must be performed
In women, special attention should be paid to the
pelvic organs ovaries
fallopian tubes
uterus
An attempts is also made to examine the upper
abdominal contents
If purulent fluid is encountered, it is imperative
that the source be identified

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