CASE REPORT

ACUTE APPENDICITIS

Lecturer:
Dr.dr. BAMBANG ARIANTO, Sp. B

By :
Lely Diah T W

(2008.04.0.0025)

Puspita Retnaning Widawati

(2009.04.0.0117)

Elen Velia C

(2010.04.0.0089)

SURGERY DEPARTMENT HAJI GENERAL HOSPITAL SURABAYA

MEDICAL FACULTY HANG TUAH UNIVERSITY SURABAYA
2015

VALIDATION PAGE

CASE REPORT
ACUTE APPENDICITIS

This Acute Appendicitis case study has been corrected and accepted as a task to
accomplish clinical study in Surgery Departement of Haji Public Hospital
Surabaya Faculty of Medicine Hang Tuah University Surabaya.

Surabaya, January 2016

Lecturer

Dr.dr.BAMBANG ARIANTO Sp.B

TABLE OF CONTENTS
Validation Page....................................................................................................i
Table of Contents................................................................................................ii
Table of Picture...................................................................................................iii
Table of table.......................................................................................................iv
CHAPTER I INTRODUCTION.........................................................................1
1.1 Background..............................................................................................1
CHAPTER II LITERATUR................................................................................2
2.1 Anatomy of Appendix..............................................................................2
2.2 Definition..................................................................................................4
2.3 Epidemiology...........................................................................................4
2.4 Etiology....................................................................................................5
2.5 Stage of Appendicitis................................................................................6
2.6 Patophysiology.........................................................................................7
2.7 Diagnosis..................................................................................................8
2.8 Differential diagnosis...............................................................................17
2.9 Treatment..................................................................................................17
2.10 Complication..........................................................................................19
CHAPTER III CASE REPORT..........................................................................21
CHAPTER IV CONCLUSION...........................................................................26
REFERENCE......................................................................................................27

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TABLE OF PICTURE
Picture 2.1. Anatomy of Appendix................................................................2
Picture 2.2. Location of Appendix.................................................................3
Picture 2.3. Infected Appendix......................................................................4
Picture 2.4. Rovsing sign, Psoas sign, Obturator sign.................................11
Picture 2.5. Rectal examination...................................................................12
Picture 2.6. USG feature of each type of appendicitis.................................14
Picture 2.7. CT-Scan of Acute Appendicitis................................................15

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TABLE OF TABLE
Table 2.1. Bacteria isolated in perforated Appendicitis.................................5
Table 2.2 Imaging and Diagnosis o Acute Appendicitis..............................13
Table 2.3. MANTERLS Score.....................................................................16
Table 2.4. Differential diagnose of Acute Appendicitis...............................17
Table 2.5. Indication for surgical treatment of Appendicitis........................19

iv

CHAPTER I
INTRODUCTION
1.1 Background
Acute appendicitis is the most common abdominal emergency requiring
surgery with an estimated lifetime prevalence of 7%. (Gwynn, 2010). Despite its
high prevalence, the diagnosis of appendicitis remains challenging. The diagnosis
of appendicitis embodies Sir William Oslers spirit when he stated, Medicine is a
science of uncertainty and an art of probability. The clinical presentation is often
atypical and the diagnosis is especially difficult because symptoms often overlap
with other conditions. (Andersson, 2004). The fundamental clinical decision in the
diagnosis of a patient with suspected appendicitis is whether to operate or not.
Ideally, the goal is to expeditiously treat all cases of appendicitis without
unnecessary surgical interventions. A 2001 study reported negative appendectomy
rates between 15% and 34% with approximately 15% being commonly accepted
as appropriate to reduce the incidence of perforation. (Bergeron, 2006).
The meaningful evaluation of acute appendicitis balances early operative
intervention in hopes of preventing perforation against a more restricted approach
with the hope of reducing the risk of unnecessary surgery. Additionally, physicians
must consider the accuracy, delay-to-surgery, and radiation risks of using
computed tomography (CT) imaging, as well as the reliability of laboratory results
and clinical scoring systems. Lastly, physicians actions are often unfortunately
influenced by malpractice litigation as appendicitis is one of the most frequent
medical conditions associated with litigation against emergency department (ED)
physicians with claims paid to patients in up to one third of cases. (Howell, 2010).
The goal of this article is to present the reader with an update on the
diagnostic approach to appendicitis by providing an evidence-based review of
radiological imaging, clinical scoring systems, laboratory testing, and novel
biomarkers for appendicitis. (Flum, 2001).

CHAPTER II

LITERATUR
2.1 Anatomy of Appendix
Appendix is a tube -shaped organ, length approximately 10 cm (4 inches),
width of 0.3-0.7 cm and 0.1 cc of the contents of the cecum attached just below
the ileocecal valve . At the third meeting taenia namely : taenia anterior, medial,
and posterior. Clinically, the appendix is located in the area Mc. Burney is 1/3 the
center line connecting the anterior superior iliac spine to the center right. The
lumen narrow at the proximal and distal widening. However , in infants, the
appendix is conical, broad at the base and narrows towards the ends.
Parasympathetic innervation in apensiks derived from a branch of the vagus nerve
which follows artery superior mesenteria and appendicular artery, whereas
sympathetic innervation derived from thoracic nerve X. therefore, visceral pain in
appendicitis begins around the umbilicus. (Craig, 2010).

Picture 2.1 Anatomy of Appendix (Craig, 2010)

Appendiceal vasculature
The vasculature of the appendix must be addressed to avoid intraoperative
hemorrhages. The appendicular artery is contained within the mesenteric fold that
arises from a peritoneal extension from the terminal ileum to the medial aspect of

the cecum and appendix; it is a terminal branch of the ileocolic artery and runs
adjacent to the appendicular wall. Venous drainage is via the ileocolic veins and
the right colic vein into the portal vein; lymphatic drainage occurs via the ileocolic
nodes along the course of the superior mesenteric artery to the celiac nodes and
cisterna chyli. (Craig, 2010).

Appendiceal location
The appendix has no fixed position. It originates 1.7-2.5 cm below the
terminal ileum, either in a dorsomedial location (most common) from the cecal
fundus, directly beside the ileal orifice, or as a funnel-shaped opening (2-3% of
patients). The appendix has a retroperitoneal location in 65% of patients and may
descend into the iliac fossa in 31%. In fact, many individuals may have an
appendix located in the retroperitoneal space; in the pelvis; or behind the terminal
ileum, cecum, ascending colon, or liver. Thus, the course of the appendix, the
position of its tip, and the difference in appendiceal position considerably changes
clinical findings, accounting for the nonspecific signs and symptoms of
appendicitis. (Howell, 2010)

Picture 2.2 Location of Appendix (Drake, 2010)

2.2 Definition
Acute appendicitis is inflammation of bacteria that occur suddenly,
appendicitis caused by various factors. Appendicitis is commonly caused by the
blockage of the lumen of the appendix by follicular lymphoid hyperplasia, fekalit,
foreign objects, strictures because of fibrosis due to previous inflammation, or
neoplasm. (Sjamsuhidajat, 2010).

Picture 2.3 Infected Appendix (Drake, 2010)

2.3 Epidemiology
Epidemiology of acute appendicitis incidence is higher in developed
countries than in developing countries. But in three-four years of the last decade
decreased significantly. This incident allegedly caused by the increased use of
fiber in the daily menu. The incidence in men and women are generally
comparable except at the age of 20-30 years the incidence of males is higher.
(Katz, 2011).
The prevalence results of research in the world is appendicitis is a disease
that is often found in people not only in Indonesia but also in the whole world.
Based on the source of emedicine.com stated there were about 86 cases per
100,000 population of the world. (Katz, 2011).
Based on the World Health Organization (2010), the mortality rate due to
appendicitis was 21,000 inhabitants, where the male population more

dibangdingkan women. The mortality rate of appendicitis is about 12,000

inhabitants in men and women around 10,000 inhabitants. (Katz, 2011).
According to Craig (2010), perforated appendicitis often occurs in less
than 18 years of age or over 50 years. The incidence of appendicitis in men 1.4
times greater than women. The ratio of men and women is about 2 : 1. (Katz,
2011).
2.4 Etiology
Appendicitis is caused by obstruction of the appendiceal lumen. The most
common causes of luminal obstruction include lymphoid hyperplasia secondary to
inflammatory bowel disease (IBD) or infections (more common during childhood
and in young adults), fecal stasis and fecaliths (more common in elderly patients),
parasites (especially in Eastern countries), or, more rarely, foreign bodies and
neoplasms. (Brown, 2010).
Fecaliths form when calcium salts and fecal debris become layered around
a nidus of inspissated fecal material located within the appendix. Lymphoid
hyperplasia is associated with various inflammatory and infectious disorders
including Crohn disease, gastroenteritis, amebiasis, respiratory infections,
measles, and mononucleosis. (Brown, 2010).
Obstruction of the appendiceal lumen has less commonly been associated
with bacteria (Yersinia species, adenovirus, cytomegalovirus, actinomycosis,
Mycobacteria species, Histoplasma species), parasites (eg, Schistosomes species,
pinworms, Strongyloides stercoralis), foreign material (eg, shotgun pellet,
intrauterine device, tongue stud, activated charcoal), tuberculosis, and tumors.
Table 2.1 Bacteria Isolated in Perforated Appendicitis (Howell, 2010)

2.5 Stage of Appendicitis

The stages of appendicitis can be divided into early, suppurative,
gangrenous, perforated, phlegmonous, spontaneous resolving, recurrent, and
chronic. (Ishikawa, 2003).
Early stage appendicitis
In the early stage of appendicitis, obstruction of the appendiceal lumen
leads to mucosal edema, mucosal ulceration, bacterial diapedesis, appendiceal
distention due to accumulated fluid, and increasing intraluminal pressure. The
visceral afferent nerve fibers are stimulated, and the patient perceives mild
visceral periumbilical or epigastric pain, which usually lasts 4-6 hours. (Ishikawa,
2003).
Suppurative appendicitis
Increasing intraluminal pressures eventually exceed capillary perfusion
pressure, which is associated with obstructed lymphatic and venous drainage and
allows bacterial and inflammatory fluid invasion of the tense appendiceal wall.
Transmural spread of bacteria causes acute suppurative appendicitis. When the
inflamed serosa of the appendix comes in contact with the parietal peritoneum,
patients typically experience the classic shift of pain from the periumbilicus to the
right lower abdominal quadrant (RLQ), which is continuous and more severe than
the early visceral pain. (Ishikawa, 2003).
Gangrenous appendicitis
Intramural venous and arterial thromboses ensue, resulting in gangrenous
appendicitis. (Ishikawa, 2003).
Perforated appendicitis
Persisting tissue ischemia results in appendiceal infarction and perforation.
Perforation can cause localized or generalized peritonitis. (Ishikawa, 2003).
Phlegmonous appendicitis or abscess
An inflamed or perforated appendix can be walled off by the adjacent
greater omentum or small-bowel loops, resulting in phlegmonous appendicitis or
focal abscess. (Ishikawa, 2003).

Spontaneously resolving appendicitis

If the obstruction of the appendiceal lumen is relieved, acute appendicitis
may resolve spontaneously. This occurs if the cause of the symptoms is lymphoid
hyperplasia or when a fecalith is expelled from the lumen. (Ishikawa, 2003).
Recurrent appendicitis
The incidence of recurrent appendicitis is 10%. The diagnosis is accepted
as such if the patient underwent similar occurrences of RLQ pain at different
times that, after appendectomy, were histopathologically proven to be the result of
an inflamed appendix. (Ishikawa, 2003).
Chronic appendicitis
Chronic appendicitis occurs with an incidence of 1% and is defined by the
following: (1) the patient has a history of RLQ pain of at least 3 weeks duration
without an alternative diagnosis; (2) after appendectomy, the patient experiences
complete relief of symptoms; (3) histopathologically, the symptoms were proven
to be the result of chronic active inflammation of the appendiceal wall or fibrosis
of the appendix. (Ishikawa, 2003).
2.6 Pathophysiology
Appendicitis is caused by obstruction of the appendiceal lumen from a
variety of causes. Independent of the etiology, obstruction is believed to cause an
increase in pressure within the lumen. Such an increase is related to continuous
secretion of fluids and mucus from the mucosa and the stagnation of this material.
At the same time, intestinal bacteria within the appendix multiply, leading to the
recruitment of white blood cells and the formation of pus and subsequent higher
intraluminal pressure. If appendiceal obstruction persists, intraluminal pressure
rises ultimately above that of the appendiceal veins, leading to venous outflow
obstruction. As a consequence, appendiceal wall ischemia begins, resulting in a
loss of epithelial integrity and allowing bacterial invasion of the appendiceal wall.
Within a few hours, this localized condition may worsen because of
thrombosis of the appendicular artery and veins, leading to perforation and
gangrene of the appendix. As this process continues, a periappendicular abscess or
peritonitis may occur. (Bergeron, 2006).
7

2.7 Diagnosis
Variations in the position of the appendix, age of the patient, and degree of
inflammation make the clinical presentation of appendicitis notoriously
inconsistent. Statistics report that 1 of 5 cases of appendicitis is misdiagnosed;
however, a normal appendix is found in 15-40% of patients who have an
emergency appendectomy.
Niwa et al reported an interesting case of a young woman with recurrent
pain in who was referred for appendicitis, treated with antibiotics, and was found
to have an appendiceal diverticulitis associated with a rare pelvic pseudocyst at
laparotomy after 12 months. Her condition was probably due to diverticular
perforation of the pseudocyst. (Gwynn, 2001).
1. Clinical manifestations
Abdominal pain, fever, and anorexia are classical symptoms. Pain occurs
in the upper abdomen at first. It then moves slowly and localizes to the right lower
quadrant. In many cases, a fever of around 38C is present.
The classic history of anorexia and periumbilical pain followed by nausea,
right lower quadrant (RLQ) pain, and vomiting occurs in only 50% of cases.
Nausea is present in 61-92% of patients; anorexia is present in 74-78% of patients.
Neither finding is statistically different from findings in patients who present to
the emergency department with other etiologies of abdominal pain. In addition,
when vomiting occurs, it nearly always follows the onset of pain. Vomiting that
precedes pain is suggestive of intestinal obstruction, and the diagnosis of
appendicitis should be reconsidered. Diarrhea or constipation is noted in as many
as 18% of patients and should not be used to discard the possibility of
appendicitis. (Andersson, 2004).
The most common symptom of appendicitis is abdominal pain. Typically,
symptoms begin as periumbilical or epigastric pain migrating to the right lower
quadrant (RLQ) of the abdomen. This pain migration is the most discriminating
feature of the patient's history, with a sensitivity and specificity of approximately
80%, a positive likelihood ratio of 3.18, and a negative likelihood ratio of 0.5. [3]
Patients usually lie down, flex their hips, and draw their knees up to reduce

movements and to avoid worsening their pain. Later, a worsening progressive pain
along with vomiting, nausea, and anorexia are described by the patient. Usually, a
fever is not present at this stage.
The duration of symptoms is less than 48 hours in approximately 80% of
adults but tends to be longer in elderly persons and in those with perforation.
Approximately 2% of patients report duration of pain in excess of 2 weeks. A
history of similar pain is reported in as many as 23% of cases, but this history of
similar pain, in and of itself, should not be used to rule out the possibility of
appendicitis. (Andersson, 2004).
In addition to recording the history of the abdominal pain, obtain a
complete summary of the recent personal history surrounding gastroenterologic,
genitourinary, and pneumologic conditions, as well as consider gynecologic
history in female patients. An inflamed appendix near the urinary bladder or ureter
can cause irritative voiding symptoms and hematuria or pyuria. Cystitis in male
patients is rare in the absence of instrumentation. Consider the possibility of an
inflamed pelvic appendix in male patients with apparent cystitis. Also consider the
possibility of appendicitis in pediatric or adult patients who present with acute
urinary retention. (Flum, 2001).
2. Findings on physical examination
It is important to remember that the position of the appendix is variable. Of
100 patients undergoing 3-dimensional (3-D) multidetector computed tomography
(MDCT) scanning, the base of the appendix was located at the McBurney point in
only 4% of patients; in 36%, the base was within 3 cm of the point; in 28%, it was
3-5 cm from that point; and, in 36% of patients, the base of the appendix was
more than 5 cm from the McBurney point. (Humes, 2006).
The most specific physical findings in appendicitis are rebound tenderness,
pain on percussion, rigidity, and guarding. Although RLQ tenderness is present in
96% of patients, this is a nonspecific finding. Rarely, left lower quadrant (LLQ)
tenderness has been the major manifestation in patients with situs inversus or in
patients with a lengthy appendix that extends into the LLQ. Tenderness on

palpation in the RLQ over the McBurney point is the most important sign in these
patients.
A careful physical examination, not limited to the abdomen, must be
performed in any patient with suspected appendicitis. Gastrointestinal (GI),
genitourinary, and pulmonary systems must be studied. Male infants and children
occasionally present with an inflamed hemiscrotum due to migration of an
inflamed appendix or pus through a patent processus vaginalis. This is often
initially misdiagnosed as acute testicular torsion. In addition, perform a rectal
examination in any patient with an unclear clinical picture, and perform a pelvic
examination in all women with abdominal pain. (Ishikawa, 2003).
According to the American College of Emergency Physicians (ACEP)
2010 clinical policy update, clinical signs and symptoms should be used to stratify
patient risk and to choose next steps for testing and management. (Ishikawa,
2003).
Accessory signs
In a minority of patients with acute appendicitis, some other signs may be
noted. However, their absence never should be used to rule out appendiceal
inflammation. The Rovsing sign (RLQ pain with palpation of the LLQ) suggests
peritoneal irritation in the RLQ precipitated by palpation at a remote location. The
obturator sign (RLQ pain with internal and external rotation of the flexed right
hip) suggests that the inflamed appendix is located deep in the right hemipelvis.
The psoas sign (RLQ pain with extension of the right hip or with flexion of the
right hip against resistance) suggests that an inflamed appendix is located along
the course of the right psoas muscle. (Mishara, 2008).
The Dunphy sign (sharp pain in the RLQ elicited by a voluntary cough)
may be helpful in making the clinical diagnosis of localized peritonitis. Similarly,
RLQ pain in response to percussion of a remote quadrant of the abdomen, or to
firm percussion of the patient's heel, suggests peritoneal inflammation. (Mishara,
2008).
The Markle sign, pain elicited in a certain area of the abdomen when the
standing patient drops from standing on toes to the heels with a jarring landing,

10

was studied in 190 patients undergoing appendectomy and found to have a

sensitivity of 74%. (Ishikawa, 2003).

Picture 2.4 Rovsing sign, Psoas Sign, Obturator sign (1) pain and nausea in
epigastrium, (2) pain or Defans muscular in Mc Burney point, (3) Rovsing dan
Blumberg sign (Andersson, 2004).
Rectal examination

11

There is no evidence in the medical literature that the digital rectal

examination (DRE) provides useful information in the evaluation of patients with
suspected appendicitis; however, failure to perform a rectal examination is
frequently cited in successful malpractice claims. In 2008, Sedlak et al studied
577 patients who underwent DRE as part of an evaluation for suspected
appendicitis and found no value as a means of distinguishing patients with and
without appendicitis.
Physical examination is the most useful method for diagnosing
appendicitis and for determining whether an operation is necessary. Tenderness
can be elicited at various points in the right lower quadrant of the abdomen,
including McBurneys, Lanzs, and Munros points (Fig. 1). Among the
indications for surgical treatment, the presence of peritoneal irritation is critical.
Operation is indicated when Blumbergs sign is positive (the pain elicited by
steadily increasing pressure at the site of tenderness increases on abrupt release of
the pressure), and when Rosensteins sign is elicited (tenderness in the right lower
quadrant increases when the patient moves from the supine position to a
recumbent posture on the left side). As a matter of course, the detection of
abdominal muscular guarding and tenderness on rectal examination are among the
surgical indications. (Flum, 2001).

Picture 2.5 Rectal examination. (1)rongga peritoneum, (2)peritoneum

parietale, (3) sekum, (4) Apendiks (apendisitis akut). (Humes, 2006).

12

3. Laboratory tests
The white blood cell count (WBC) and CRP are of diagnostic value. The
WBC usually exceeds 10,000/mm3. In severe cases associated with diffuse
peritonitis, however, the WBC may be decreased rather than increased, so care
must be taken. Although the CRP rises in appendicitis, the increase is not
necessarily associated with the severity of inflammation. (Ishikawa, 2003).
4. Imaging diagnosis
Plain abdominal radiographs show no particular evidence of appendicitis.
If an air-fluid level is seen in the lower abdomen, however, localized peritonitis
should be suspected. Ultrasonography and CT scanning are of diagnostic value,
and provide useful information for determining whether or not appendectomy is
necessary. (Ishikawa, 2003).
Table 2.2 Imaging and diagnosis of acute appendicitis (Ishikawa, 2003).

(1) Abdominal ultrasonography

Because this minimally invasive examination is easy to perform and can
be repeated, it is essential for diagnosing acute appendicitis. A normal appendix is
usually not imaged by ultrasonography. When it is involved by inflammation and
enlarges, however, it can be visualized. The features of appendicitis include
hypertrophy of the appendiceal wall, disturbance of the normal layered structure,
destruction of the wall, and purulent fluid or fecaliths within the appendiceal

13

lumen.1) In catarrhal appendicitis, the wall of the appendix shows three layers,
while this layered structure becomes unclear in phlegmonous appendicitis. No
layered structur is depicted in the more advanced gangrenous appendicitis (Fig.
2). The periappendiceal accumulation of fluid suggests abscess formation
secondary to perforation. A high periappendiceal echo suggests the aggregation of
the omentum and other tissues that have been affected by inflammation. If some
of these findings are recognized, an operation is indicated. Kojima et al. divided
appendicitis into three types depending on the ultrasonographic findings. 2) The
classification depended on the features of the high echo bands representing the
submucosal layer, as described by Yuasa et al., as well as the presence or absence
of a visualized appendix and the length of the shorter diameter of the appendix.
The ultrasonographic pattern was type I in 76% of patients with catarrhal
appendicitis, while it was type II in 82% of patients with phlegmonous
appendicitis and type III in 94% of patients with ganagrenous appendicitis. They
concluded that, the severity of appendicitis could be assessed by preoperative
ultrasonography, so that unnecessary appendectomy could be avoided. As
described above, ultrasonography is an indispensable modality because it can be
used to both diagnose appendicitis and assess its severity. (Brown, 2010).

Gamabar 2.6 USG feature of each type of appendicitis

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(2) Abdominal CT
CT is superior to ultrasonography in some respects, because its findings
are more objective and it is not affected by the presence of intestinal gas. The
diagnosis of appendicitis by CT depends on hypertrophy of the appendiceal wall,
enlargement of the appendix, periappendiceal abscess formation, the presence of a
fecalith, increased density of periappendiceal adipose tissue, and/or the presence
of ascites in the pouch of Douglas.1) CT can depict an enlarged appendix, but
cannot visualize the structure of the wall unlike ultrasonography. Thus,
ultrasonography is superior to CT for assessing the severity of appendicitis
depending on the mural changes. (Brown, 2010).

Picture 2. CT-scan of Acute appendicitis (Brown, 2010).

Alvarado Score
Several investigators have created diagnostic scoring systems to predict
the likelihood of acute appendicitis. In these systems, a finite number of clinical
variables is elicited from the patient and each is given a numeric value; then, the
sum of these values is used.
The best known of these scoring systems is the MANTRELS score, which
tabulates migration of pain, anorexia, nausea and/or vomiting, tenderness in the
RLQ, rebound tenderness, elevated temperature, leukocytosis, and shift to the left.
(Ishikawa, 2003).
15

Table 2.3 MANTRELS Score (Ishikawa, 2003).

Characteristic

Score

M = Migration of pain to the RLQ

A = Anorexia

N = Nausea and vomiting

T = Tenderness in RLQ

R = Rebound pain

E = Elevated temperature

L = Leukocytosis
2
S = Shift of WBCs to the left
1
Total
10
Source: Alvarado.[19]
RLQ = right lower quadrant; WBCs = white blood cells
Clinical scoring systems are attractive because of their simplicity;
however, none has been shown prospectively to improve on the clinician's
judgment in the subset of patients evaluated in the emergency department (ED)
for abdominal pain suggestive of appendicitis. The MANTRELS score, in fact,
was based on a population of patients hospitalized for suspected appendicitis,
which differs markedly from the population seen in the ED. (Howell, 2010).
In reviewing the records of 150 ED patients who underwent
abdominopelvic computed tomography (CT) scanning to rule out appendicitis,
McKay and Shepherd suggested that patients with an MANTRELS score of 0-3
could be discharged without imaging, that those with scores of 7 or above receive
surgical consultation, and those with scores of 4-6 undergo CT evaluation. [20] The
investigators found that patients with a MANTRELS score of 3 or lower had a
3.6% incidence of appendicitis, patients with scores of 4-6 had a 32% incidence of
appendicitis, and patients with scores of 7-10 had a 78% incidence of appendicitis.
In another study, Schneider et al concluded that the MANTRELS score
was not sufficiently accurate to be used as the sole method for determining the
need for appendectomy in the pediatric population.[21] These investigators, studied

16

588 patients aged 3-21 years and found that a MANTRELS score of 7 or greater
had a positive predictive value of 65% and a negative predictive value of 85%.
(Howell, 2010).
2.8 Differential Diagnosis
The clinical diagnosis of acute appendicitis relies upon a detailed history and
thorough physical examination. The differential diagnosis is that of the acute
abdomen as it can mimic the presentation of most abdominal emergencies
(Humes, 2006).
Table 2.1 Differential diagnose of acute appendicitis (Humes, 2006)

2.9 Treatment
1. Medical therapy
Appendicitis is diagnosed by physical examination, blood tests,
ultrasonography, and CT, or is characterized by tenderness without peritoneal
irritation. On ultrasonography, the appendix cannot be visualized or is not
enlarged if it is detected. Patients with catarrhal appendicitis should generally be

17

hospitalized for treatment with antibiotics, bed rest, intravenous fluids, and nil
orally. For outpatient management, antibiotics are administered and the course is
followed closely (Ishikawa, 2003).
2. Surgical therapy
Ultrasonographic findings are the most important factor for deciding
whether surgery is necessary. The presence of ascites or an abscess indicates the
necessity for surgery. Among the abdominal findings on physical examination, the
presence of peritoneal irritation is critical. If this is positive, an operation is
indicated. In the field of surgery for acute appendicitis, laparoscopic
appendectomy is attracting much attention. For the patient, the advantages of
laparoscopic appendectomy are reported to include decreased postoperative pain,
faster recovery of muscle tone, earlier return to normal activities, minimal
scarring, a low risk of wound infection, no ventral hernia, and a reduced risk of
postoperative adhesions (Ishikawa, 2003).
On the other hand, conventional open appendectomy seldom causes
problematic postoperative pain, scarring, or ventral hernia. In other words, the
laparoscopic and open procedures may only be different in their degree of
difficulty. From the standpoint of the surgeon, laparoscopy is useful to rule out
appendicitis in patients with confusing symptoms. Also, if a diagnosis of
appendicitis is established, wideranging examination of the peritoneal cavity
becomes possible. Furthermore, intraperitoneal cleansing of the site can be done
under vision on the monitor. It has even been reported that a drain could be
inserted and placed appropriately under laparoscopic vision (Ishikawa, 2003).
The greatest merit of laparoscopic appendectomy is being minimally
invasive. Because conventional open appendectomy is already relatively simple
and not so invasive, however, this merit itself is not highly attractive. In particular
cases, such as obese patients, young female patients seeking a better cosmetic
outcome, and patients with suspected appendicitis who may have other conditions,
it would seem that laparoscopic appendectomy may be useful (Ishikawa, 2003).
Table 2.5 Indication for the surgical treatment of appendicitis.

18

2.10 Complication
The most serious complication of appendicitis is rupture. The appendix
bursts or tears if appendicitis is not diagnosed quickly and goes untreated. Infants,
young children, and older adults are at highest risk. A ruptured appendix can lead
to peritonitis and abscess. Peritonitis is a dangerous infection that happens when
bacteria and other contents of the torn appendix leak into the abdomen. In people
with appendicitis, an abscess usually takes the form of a swollen mass filled with
fluid and bacteria. In a few patients, complications of appendicitis can lead to
organ failure and death (Humes, 2006).
Despite this, complications can occur after removal of a normal
appendix, and the surgical community continues to strive to reduce the numbers of
negative procedures. According to a large historical cohort study, a perforated
appendix during childhood does not seem to have a long term detrimental effect
on subsequent female fertility (Humes, 2006).
Wound infection
The rate of postoperative wound infection is determined by the
intraoperative wound contamination. Rates of infection vary from < 5% in
simple appendicitis to 20% in cases with perforation and gangrene. The
use of perioperative antibiotics has been shown to decrease the rates of
postoperative wound infections (Humes, 2006).
Intra-abdominal abscess

19

Intra-abdominal or pelvic abscesses may form in the postoperative

period after gross contamination of the peritoneal cavity. The patient
presents with a swinging pyrexia, and the diagnosis can be confirmed by
ultrasonography or computed tomography scanning. Abscesses can be
treated radiologically with a pigtail drain, although open or per rectal
drainage may be needed for a pelvic abscess. The use of perioperative
antibiotics has been shown to decrease the incidence of abscesses (Humes,
2006).

CHAPTER III

20

CASE REPORT
I.

II.

Patient Identity
Name

: Ms. F.I

Age

: 17 y.o

Sex

: female

Religious

: Islam

Address

: Jl. Ngagel Jaya No.2 Surabaya

Date of Inspection

: 30 November 2015

Anamnesa
a) Chief complaiment
Theres pain in the lower right abdominal
b) Keluhan Tambahan
Nausea and common cold.
c) History of illness
Patients coming to the emergency department RSU Haji Surabaya with
complaints there is pain in the lower right abdomen since 1 months ago
and became more severe in the last week. The pain is intermittent . Firstly
the pain started around the umbilicus and eventually the pain is felt in the
lower right abdomen .Patients said that often nausea without vomiting and
two days before she came to emergency she could not sleep because of
abdominal pain. Theres no complain of difficult defecation. She told that
shes rarely eat vegetables and fruits.
d) Past medical history

: HT(-), DM (-)

e) History Family Disease : HT(-), DM (-)

Anamnesa Food and drink
1. Sources of food and drinks derived from rice, fish / meat, vegetable, fruit
and water
2. Rarely eat fruit and vegetables
III. Physical Examination

21

Status Generalis
1. General situation

: Moderate illness

Awareness

: Compos mentis

Nutrition status

: TB : 155 cm

BB : 48 kg

BMI: 20
Vital Sign

: TD

: 120/80 mmHg

Nadi : 90 x/menit
Suhu : 37,5oC (axiller)
RR
A/I/C/ D

: 20 x/menit

: ///

2. Head
- Conjunctival anemis ()
- Sclera jaundice ()
3. Neck
-

Lymphadenopathy (-)
Thyroid enlargement (-)

4. Thoraks : normochest
- Pulmo : I : Normochest, breath symmetrical motion
P : Motion breath symmetrical, symmetrical touch fremitus
P : Sonor entire lung field
A : vesikuler breath sound, ronkhi /, wheezing /
- Cor

: I : Ictus cordis invisible

P : Ictus cordis not palpable
P : A normal heart Limits
A : S1 S2 tunggal, murmur (), gallop ()

Abdomen: I: Convex symmetrical, mass (-), injury (-)

P: Soepel, H / L / R is not palpable, tenderness (-)
P: Thympani
A: Bising usus (+) normal, metallic sound ()
5. Extrimitas
- Akral hangat :
Edema

22

Status localist
Regio Abdominal

Inspection : flat, symmetric

Palpation : tenderness in Mc Burney area, psoas sign (+), obturator sign

(+), rebound sign (+), rovsing sign (-)

RT : pain at the 10-11

ALVARADO SCORE :
- abdominal pain : 1
- nausea

:1

- rebound pain

:1

- pain at Mc Burney area : 2

IV.

- fever

:1

- leukositosis

:2

Resume
Female 17 years old with right abdominal pain since one month ago
and became more severe in the last week. The pain is intermittent and
started around the centre and eventually the pain is felt in the lower right
abdomen. Nausea (+) vomit (-) fever (+) and could not sleep because of
abdominal pain..

V.

Diagnosa

Acute Appendicitis
VI.

Diagnosa Banding

Gastroenteritis akut
Ectopic gestational
Adenitis Mesenterium
Perforated Peptic Ulcer
Colonic Lesions
Pielonefritis

23

Kidney stones

VII. Penatalaksanaan
i.

Planning Diagnosa
DL, UL, BOF, USG

ii.

Planing Terapi
Non Medikametosa
Bed rest
fasting
Medikamentosa
Tidak ada
Tindakan
Operatif : Appendictomy

CBC
- Hb : 14,1
- Leukosit : 22.600
- Hematocrit : 41,1
- Trombosit : 350.000
Chemical Clinic
GDA Stick : 92
BUN

: 7, Creatin serum :

SGOT : 18, SGPT : 14

24

K/ Na/ Cl : 4,8 ; 136 ; 98

Urine :
Bj : 1,005
pH : 7,1
protein : negative
glukosa : normal
keton : negative
urobilin : normal
bilirubin : negative
sedimen : Ery : 1-2, Leuko : 0-1, Cylynd : negative, Epithel : 0-1, Backterial :
negative, Cyst : negatif
iii.

iv.

Planning Monitoring

Patient compliment

Vital sign

BAB

Planning Edukasi

Kurangi makan makanan yang pedas

Perbanyak makan makanan berserat

Perbanyak minum air putih

Hindari mengejan saat BAB dan jangan terlalu lama saat BAB

Hindari duduk terlalu lama

VIII. Prognosa
Dubia ad bonam

CHAPTER IV

25

CONCLUSION
Acute appendicitis is the most common abdominal emergency requiring
surgery with an estimated lifetime prevalence of 7%. Despite its high prevalence,
the diagnosis of appendicitis remains challenging.
Acute appendicitis is inflammation of bacteria that occur suddenly,
appendicitis caused by various factors. Appendicitis is commonly caused by the
blockage of the lumen of the appendix by follicular lymphoid hyperplasia, fekalit,
foreign objects, strictures because of fibrosis due to previous inflammation, or
neoplasm.
The diagnosis and management of acute appendicitis have been described
with a focus on some current issues. For diagnosis, findings on ultrasonography
and CT are important. For management, laparoscopic appendectomy should be
considered as a possible choice if there are indications for this procedure.
The most serious complication of appendicitis is rupture. The appendix
bursts or tears if appendicitis is not diagnosed quickly and goes untreated. Infants,
young children, and older adults are at highest risk. A ruptured appendix can lead
to peritonitis and abscess. Peritonitis is a dangerous infection that happens when
bacteria and other contents of the torn appendix leak into the abdomen. In people
with appendicitis, an abscess usually takes the form of a swollen mass filled with
fluid and bacteria. In a few patients, complications of appendicitis can lead to
organ failure and death

REFERENCE

26

Andersson RE. Meta-analysis of the clinical and laboratory diagnosis of

appendicitis. Br J Surg. 2004;91(1):2837.
Bergeron E. Clinical judgment remains of great value in the diagnosis of acute
appendicitis. Can J Surg. 2006;49(2):96100.
Brown TW, McCarthy ML, Kelen GD, et al. An epidemiologic study of closed
emergency department malpractice claims in a national database of
physician malpractice insurers. Acad Emerg Med. 2010;17(5):553560.
Craig Sandy, 2010. Appendicitis, Acute. Diakses dari URL : www.emedicine.com,
tanggal 25 Desember 2015.
Drake, Richard, Wayne Vogl, Mitchell Adam WM 2010. Grays Anatomy for
Students 2nd edition. Philadephia: Churchill Livingstone. p. 899.
Flum DR, Morris A, Koepsell T, et al. Has misdiagnosis of appendicitis decreased
over time? A population-based analysis. JAMA. 2001;286(14):17481753.
Gwynn LK. The diagnosis of acute appendicitis: clinical assessment versus
computed tomography evaluation. J Emerg Med. 2001;21(2):119123.
Howell JM, Eddy OL, Lukens TW, et al. Clinical policy: critical issues in the
evaluation and management of emergency department patients with
suspected appendicitis. Ann Emerg Med. 2010;55(1):71116.
Humes DJ, Simpson J. 2006. Acute appendicitis. Division of

Gastrointestinal

Surgery, Section of Surgery, University Hospital, Queens Medical Centre,

Nottingham. BMJ 333;530-534.
Ishikawa H. 2003. Diagnosis and Treatment of Acute Appendicitis. JMAJ 46(5):
217221.
Katz

Michael,

Tucker

Jeffry.

Appendicitis.

Diakses

dari

URL

www.emedicine.com, tanggal 25 Desember 2015.

Mishra RK, Hanna GB, Cuschieri A. 2008. Laparoscopic versus open
appendectomy for the treatment of acute appendicitis. Worl journal of
laparoscopy surgery: 1(1);19-28.
Sjamsuhidajat, R., De Jong, W., 2004. Buku-Ajar Ilmu Bedah. Edisi 2. Jakarta:
EGC, 639-645.

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