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Author by:
Dr. dr. Koernia Swa Oetomo, SpB.(K)Trauma. FINACS.,FICS
ILMU BEDAH
SMF BEDAH RSU HAJI SURABAYA
2015
PREFACE
Drafting Praise to the presence of Almighty God upon His mercy and
grace so that the author completed paper entitled " Appendecitis Acute ".
During the preparation of this paper , authors have a lot of no small
assistance from several parties, so in this occasion we thank you profusely to all
those who have provided assistance so that this paper can be resolved properly.
The author, aware that during the preparation of this paper is far from perfect and
many deficiencies in their preparation. Therefore constituent suggestions and
constructive criticism to the perfection of this paper. Constituent hope this paper
can be beneficial for all parties read in general and in particular constituent.
TABLE OF CONTENTS
Foreword .......................................................................................................... i
Table of Contents ............................................................................................. ii
List Tables ........................................................................................................ iii
List Of Figures ................................................................................................. iv
Chapture 1 Introduction .................................................................................. 1
1.1 Background ..................................................................................... 1
Chapture 2 Review of Literature 2 ................................................................... 2
2.1 Anatomi Appendix .......................................................................... 2
2.2 Appendesitis Acute .......................................................................... 5
2.2.1 Definition ............................................................................... 5
2.2.2 Epidemiologi ......................................................................... 5
2.2.3 Etiology dan Patophysiology ................................................. 6
2.2.4 Bacteriology........................................................................... 8
2.2.5 Pathology ............................................................................... 8
2.2.6 Clinical Features .................................................................... 10
2.2.7 Examination ........................................................................... 13
2.2.8 Laboratory ............................................................................. 14
2.2.9 Radiology............................................................................... 14
2.2.10Diagnosis ............................................................................... 16
2.2.11Differential Diagnosis............................................................ 20
2.2.12Complication ......................................................................... 22
2.2.13Management .......................................................................... 23
References............................................................................................... 31
ii
LIST OF TABEL
Tabel 2.1 The bacteria are often found in appendicitis perforata ......................... 8
Tabel 2.2 Relationship between pathological changes and ......................................... 9
Tabel 2.3 Frequency of symptoms appendisitis ......................................................... 12
Tabel 2.4 Imaging modality in the diagnosis of acute appendicitis. ............................ 15
Tabel 2.5 Alvarado Score ..................................................................................... 18
Tabel 2.6 The Ohmann Score ............................................................................... 18
Tabel 2.7 Criteria Ohmann Score.......................................................................... 19
Tabel 2.8 Kriteria Lintula Score............................................................................ 19
Tabel 2.9 Kriteria RIPASA Score ........................................................................ 20
Tabel 2.10 Guideline RIPASA Score.................................................................... 20
iii
LIST OF FIGURES
iv
CHAPTER 1
INTRODUCTION
1.1 Background
CHAPTER II
LITERATURE REVIEW
Three taenia coli in colon ascendens and cecum united on the basis of the
appendix, and join into the longitudinal muscles. Taenia caecal separate anterior
and can usually be traced to appendix, which can be used as a guide to find the
location of the appendix on Clinically practice. Appendix sizes vary in length,
from 2 cm to 20 cm; relatively longer commonly found in children and may
undergo
atrophy
and
retracts
with
increasing
age.(8)
Lumen appendix narrow and open to the cecum through the orifice is located
below and slightly posterior to the ileocaecal orifice. The orifice is sometimes
guarded by semilunaris mucosal folds that form the valve. Lumen may be a patent
on the early lives of children and often lost in the last decade kehidupan.(11)
Vascularization appendix.
The main artery of the appendix, a branch of the lower division ileocolic
artery, runs behind the terminal ileum and entering mesoappendiks with close
3
distance from the base of the appendix and anastomoses with the branches of the
artery caecal posterior.(11,12)
Vena Appendix
Appendix artery flow through one or more veins appendikular heading ileo
colic or caecum posterior vein. Then from these veins leading to the mesenteric
vein superior.(11)
Lymphatics.
Appendix lymphatic vessels are numerous: there are many lymphoid tissue
on his wall. Of whole sections of the appendix are 8-15 lymph vessels that pass
through mesoappendiks and is usually accompanied by some of the lymph nodes.
They unite to form approximately 3-4 larger lymph vessels which also goes into
the lymph vessels in the ascending colon. Everything will end in the inferior and
superior node of a series of lymph vessels ileokolik.(10,11)
4
Innervation of Appendix
Parasympathetic
innervation
is derived
from
a branch
n. vagus
Physiology
Appendix produce mucus 1-2 ml / day. This mucus is normally poured
into the lumen and then flows into the cecum. Barriers to the flow of mucus in the
estuary seems to play a role in the pathogenesis of appendisitis. (9)
Secretie immunoglobulin produced by the GALT ( Gut Associated
Limphoid Tissue) located along the gastrointestinal tract, including the appendix,
is IgA. Immunoglobulin was very effective as a protective barrier against
infection. However, removal of the appendix no affects to the body's immune
system, due to the small number of lymph tissue here once, when compared
with its number in the gastrointestinal tract and throughout tubuh.
(9)
surgical
2.2.2 Epidemiology
The incidence of acute appendicitis higher in developed countries is
than in developing countries. However, in the last three-four decades incidence
decreased significantly. This is thought to be caused by the increasing use of
fiber in the daily menu day.(1,4,9)
Appendicitis can be found at all ages, only in children less than one year rarely.
The highest incidence in the age group 20-30 years, after which it decreased. The
5
incidence in men and women are generally comparable except at the age of 20-30
years, while the incidence in men more highest.(6)
closed, but arteriolar flow will continue, causing dilation and congestive vascular.
Inflammatory process soon involves the serosa in the appendix and regional
parietal peritoneum, producing pain typical displacement towards the right
quadrant. (1,3)
Disruption to the lymphatic and venous flow will cause mucosal ischemia.
Appendix mucosa prone to interruption of blood supply, and if the integrity is
compromised, will facilitate the occurrence of bacterial invasion. During the more
progressive distention of the more pressing venous return and then the flow of
arterioles, causing infarction in areas with poor blood supply. With increased
distention, bacterial invasion, disruption of blood flow, and progression infarction,
this combination will lead to a more localized inflammatory process and cause
gangrene and perforation, usually at one of the infarcted area on antimesenteric
limit. Perforation usually occurs after at least 48 hours of onset of the onset of the
symptoms .(1,3,7)
Acute appendicitis is a bacterial infection such as Escherecia coli ,
viridans Streptoccocus,
and
Bacteroides.(6)
Allegedly,
lumen
integrity
2.2.4 Bacteriology
Normal flora in the appendix are similar to those in the colon, with there
are a wide variety of aerobic and facultative anaerobic bacteria. Some kinds
of microbes from perforated appendix is known. Escherichia coli. Streptococcus
viridans, Bacteroides spp., And Pesudomonas spp., The microbe most often
isolated (table 2.1) 4
Table 2.1 The bacteria are often found in appendicitis perforata (4,7)
In patients with non-perforated acute appendicitis, peritoneal fluid culture
than is usually negative and do not provide a real clinical role. However, in
patients with perforated appendicitis, peritoneal fluid culture will usually
positive, and show bacteria in the colon with sensitivity to antibiotics that can
be predicted. Due to the selection of antibiotic administration rarely been
affected by the outcome of this culture, then the culture is rarely doing.
(7)
2.2.5 Pathology
Pathology appendicitis can begin in the mucosa and then involve all layers
of the wall of the appendix within the first 24-48 hours. Efforts body's defense
sought to limit this inflammatory process by closing the appendix to the
omentum, small intestine, or adnexal mass forming periapendikuler wrongly
known as the appendix or periapendikular infiltrates infiltrates. In it, tissue
necrosis can occur in the form of an abscess that can be perforated. Otherwise
abscesses, appendicitis will recover and periapendikuler mass will be quiet
and will unravel slowly themselves lambat. (9)
Who once inflamed appendix will not recover completely but form scar
tissue that cling to the surrounding tissue. These adhesions can cause complaints
recurring in the lower right abdomen. One time, this organ can acutely
inflamed again and declared as experiencing an acute exacerbation is referred to
as acute in chronic appendicitis. (1,9)
8
Clinical Manifestations
not localized
visceral)
appendix)
Perforasi
Efforts by the omentum and nearby
perforation
If not successful will cause widespread
peritonitis
Table 2.2 Relationship between pathological changes and clinical manifestations (9)
region around the umbilicus. These complaints are often accompanied by nausea
and vomiting sometimes there. Generally, decreased appetite. Within a few hours,
the pain will move to the bottom right to the point of McBurney. Here, the pain
feels sharper and clearer located so sign with local somatic pain. Sometimes there
is no epigastric pain, but there is constipation, so people feel the need for
laxatives. The action was considered dangerous because it could be perforation.
When there is stimulation of the peritoneum, patients usually complain of
abdominal pain when walking or coughing (Dunphy sign) . (6,4) (1,7,9)
When the appendix is located retrocecal retroperitoneal, mark the lower
right abdominal pain is not so clear and there was no sign of peritoneal
stimulation as appendix protected by cecum. Pain more toward the right side of
the abdomen or pain arises when walking due to contraction of the psoas major
muscle straining of dorsal.(2,9)
Inflammation of the appendix is located in the pelvic cavity can cause
symptoms and signs of sigmoid or rectal stimulation that increases peristaltic and
emptying the rectum become faster and repeatedly so as to give the complaints of
diarrhea or tenesmus. If the appendix had been attached to the bladder, can
increase urinary frequency or dysuria caused excitement in the appendix to the
bladder wall.(9,12)
Symptoms of acute appendicitis in children is not specific. At first, the
child is often only show symptoms fussy and would not eat. Children often can
not describe the pain. Several hours later, the child will vomit so that it becomes
weak and lethargic. Because the symptoms are not typical earlier, appendicitis is
often only discovered after the perforation. In infants, 80-90% of new appendicitis
known after the perforasi
(6).
bacterial or viral disease, which can cause enlargement of the follicle appendix
and obstruksi.(12)
In some circumstances, appendicitis is rather difficult to diagnosis thus
not treated in time and complications. For example, in elderly people, the
symptoms are often vague so that more than half of the new cases are diagnosed
after perforasi.(9)
(12)
and vomiting.
are
encouraged to kraniolateral that the complaint was not felt in the lower right
abdomen, but more in the right lumbar region .(9)
At its research Treaves assume caecum is the center of the clock and the appendix
is a needle of hours. Therefore, the position of the appendix can be described as: 2
11
12
2.2.7 Inspection
Fever is usually mild with temperatures around 37.5 38,5 C.
When the temperature is higher, there may be perforation. There can be
differences in axillary and rectal temperature up to 1 C. On inspection the
stomach, was not found specific features. Bloating commonly seen in patients
with complications of perforation. Protrusion of the lower right abdomen can
be seen in the mass or abscess periapendikuler.(1,9)
On palpation, tenderness obtained is limited to the right iliac region, can
be accompanied by pain off (rebound phenomenon). Defans muskuler shows the
stimulation of peritoneal parietale. Lower right abdominal tenderness are mainly
located at McBurney's point is the key to diagnosis. Normal appendix mobile
character, so that the location of inflammation can be found in various places on a
circular area around the base of 360 of the cecum. In the lower left abdominal
pressure, pain will be felt in the lower right abdomen, called the sign Rovsing. At
retrosekal appendicitis or retroileal, required deep palpation to determine the
presence of a sense nyeri.(1,7,9)
Often normal intestinal peristalsis, but also can disappear due to paralytic
ileus in generalized peritonitis caused by appendicitis perforata. (6)
Digital rectal examination cause pain when the area of infection can be
achieved with the index finger on appendicitis pelvika.(6)
At pelvika appendicitis, abdominal signs are often dubius, then the
diagnosis is key pain when performed digital rectal limited. Psoas test
examination and an examination of the obturator test is intended to determine the
location of the appendix. Psoas test conducted by stimulation of the peritoneum
through the right hip joint hyperextension or flexion of the right hip joint active,
then the right thigh detained. When the inflamed appendix attached to the psoas
major muscle, such actions will cause pain. Obturator test is used to see if the
appendix is inflamed in contact with the internal obturator muscle which is a
small pelvic wall. Endorotasi flexion and hip joint in the supine position will
cause pain in appendicitis pelvika.(1,9).
13
2.2.8 Laboratory
Examination of the number of leukocytes help with the diagnosis of acute
appendicitis. In most cases there is leukocytosis, especially in cases with high
complication.
(3)
2.2.9. Radiology
Plain abdominal rarely useful for diagnosing acute appendicitis. Plain
abdominal instrumental in getting rid of pathological states of barium enema
(1,4)
Failure to meet the appendix lumen associated with appendicitis, but this finding
is less sensitive and 20% specific for normal appendix is not filled with barium
enema.(4,7)
In patients with abdominal pain, ultrasonography had a sensitivity of 85%
and a specificity of more than 90% in diagnosing appendicitis acute.4 This was
confirmed by research conducted Memisoglu et al which states that only 34% of
patients with acute appendicitis who had a negative ultrasound results.
(5)
sonographic findings consistent with acute appendicitis, among others, the size of
the appendix 7 mm or more in the anteroposterior diameter, thick wall, which was
14
not depressed lumen structure can be seen in cross section, known as the target
lesion, or seems appendicolith.(3,4)
CT scans are often used to evaluate adult patients with suspected acute
appendicitis. CT scans have a sensitivity of approximately 90% and a specificity
of 80% -90% in diagnosing acute appendicitis in patients with abdominal pain
akut.(9) From research Willms et al in 2011 concluded that in addition to
anamnesis, physical examination, and laboratory tests, radiological examination
(especially CT Scan) is required for patients with suspected appendicitis.
15
Figure 2.4 4
A CT scan of the abdomen / pelvis in patients with acute appendicitis showed
appendicalith (white arrows)
B. CT scan showed the distended appendix terdistensi (white arrow) with
thickening of the wall and fluid than periapendikular. (white triangles) This
picture is referred to as a target sign.
C = caecum
16
2.2.10 Diagnosis
Although the test is done carefully and accurately, the clinical diagnosis of
acute appendicitis is still probably one of the approximately 15-20% of cases.
Fault diagnosis is more common in women than men. This can be realized given
to women, especially the young ones, often arise disorders resembling acute
appendicitis. The complaint comes from internal genitalia because ovulation,
menstruation, inflammation in the pelvis, or gynecologic disease another.(1,3,4,9)
Appendicitis should be considered as a differential diagnosis in any patient
with acute abdominal pain. Early diagnosis is the most important clinical goal for
patients with suspected appendicitis and in most cases can be enforced through a
careful history and physical examination. The initial symptoms usually starts with
pain periumbilikal (due to the activation of the visceral afferent neuron) and then
followed by anorexia and nausea.(4)
Pain then localized to the right lower quadrant as a progressive
inflammatory process involving the parietal peritoneum above the appendix.
17
18
19
2.2.11 Diagnosis
In certain circumstances, some diseases need Differential Diagnosis (1,4,9)
1) Gastroenteritis.
At gastroenteritis, nausea, vomiting, and diarrhea precedes the pain.
Abdominal pain is more mild and not demarcated. Often found their
hiperperistalsis. Heat and leukocytosis less pronounced than with acute
appendicitis.
20
2) Dengue Fever
Can be started with abdominal pain similar to peritonitis. In this disease,
obtained positive test results for Rumpel Leede, thrombocytopenia, and
increased hematocrit.
3) Mesenteric Lymphadenitis.
Inesenterika
lymphadenitis
commonly
preceded
by
enteritis
or
21
8) Endometriosis Externa
Endometrium outside the uterus will cause pain in the endometriosis is
located, and menstrual blood collected in that place because there is no
way out.
9) Urolithiasis Pyelum / ureter Right
A history of colic from the waist to the abdomen radiating to the right
groin is a typical illustration. Eritrosituria often found. Abdominal plain
radiography or
intravenous
urography
can
ensure
the
disease.
2.2.12 Complications
The most dangerous complication is perforation either free perforation or
perforation of the appendix that have experienced fencing so that a mass
consisting of a collection of the appendix, cecum, and the curve of the intestine
fine.(9)
1).Periapendikular
Appendix Mass or gangrenous appendicitis occurs when mikroperforasi
covered or wrapped by omentum and / or the curve of the small intestine. At
periapendikuler mass with the formation of rudimentary wall, can occur
throughout the deployment pussy peritoneal cavity if perforation is followed by
generalized purulent peritonitis. In the event of perforation, abscess will form
appendix. It is characterized by the increase in temperature and pulse rate,
increasing pain, and swelling palpable masses, as well as increasing numbers
leukosit.(6)
22
Classic history of acute appendicitis, which was followed by the painful mass
in the right iliac region and accompanied by fever, directs the diagnosis to the
mass or abscess periapendikuler.(4,6,9)
2) Perforated appendicitis
Fecalith presence in the lumen, age (elderly or small children), and late
diagnosis, a factor that plays a role in the occurrence of perforation of the
appendix. The incidence of perforation in patients over the age of 60 years
were reported around 60% .(9)
Factors influencing the high incidence of perforation in the elderly is vague
symptoms, delay treatment, the change in the anatomy of the appendix in the
form of a narrowing of the lumen, and arteriosclerosis. High incidence in
children is caused by the appendix wall is still thin, the child is less
communicative thereby extending the time of diagnosis, and the process of
fencing less than perfect due to perforation that goes fast and omentum child
has not developed.(9)
Perforated appendix will result in purulent peritonitis that is characterized by
high fever, more severe pain, tenderness and defans muscular, intestinal
peristaltic can be decreased to disappear due to paralytic ileus. Peritoneal
cavity abscess occurs when pus can spread localized somewhere, most often
in the pelvic cavity and subdiafragma. The existence of intra-abdominal mass
that pain with fever should be suspected as an abscess. Ultrasound can help
detect the presence of pockets nanah.(4,6,9)
3). Acute Exacerbation on Appendicitis Chronic
Diagnosis of acute exacerbation of chronic appendicitis only can be
considered if there is a history of repeated attacks of pain in the lower right
abdomen that encourage appendectomy, and the pathology results showed
acute inflammation. This disorder occurs when attack acute appendicitis first
healing spontaneously. However, the appendix was never returned to its
original shape due to fibrosis and scarring. The risk of recurrent attacks was
approximately 50%. The incidence of acute exacerbation of chronic
23
2.2.13 Management
If the clinical diagnosis is clear, the most appropriate measures and is the
only good option is appendectomy. In the uncomplicated appendicitis, usually do
not need to be given antibiotics, unless the gangrenous appendicitis or perforated
appendicitis. Delays while providing follow-surgical antibiotics can lead to an
abscess or perforasi.(1,9)
Appendectomy can be done openly or by laparoscopy. When the open
appendectomy, McBurney incision most preferred by surgeons. In patients whose
diagnosis is unclear, observations should be done first. Laboratorium examination
and ultrasound can be done if the observations, there are still doubts. When
available laparoscope, a diagnostic laparoscopy in case of doubt can be done
immediately determine the operation or not.(6)
Appendisectomi or appendectomy is an act of surgically removing the
appendix. As for the indications appendectomy: (13)
24
1) Acute Appendicitis.
2) Subacute Appendicitis.
3) Appendicitis infiltrates (appendikular mass) which is already in the quiet stage
(afroid).
4) Perforated Appendicitis
5) Chronic Appendicitis
25
Figure 2.6
Step 2. Incise the aponeurosis of the external oblique along the lines of its fibers
(Fig. 2.7)
Step 3. Use a curved Kelly clamp o make an opening on both the internal oblique
and the transversus abdominis muscles. Enlarge the opening with the Kelly
clamp and insert two Richa Richardsons retractors.
Step 4. If the transversalis fascia was divided together with the flat muscles,
occasionally there will be a thick stroma of preperitoneal fat which can be
pushed laterally, or sometimes medially, revealing the peritoneum.
Figure 2.7
Step 5. Elevate the peritoneum and, if applicable, the transversalis fascia. Make a
small opening in the peritoneum with a knife or scissors, then enlarge it
with both index fingers and insert the retractors of your choice (Fig. 2.8)
26
Figure 2.8
Step 6. Take cultures of the free peritoneal fluid and, using moist gauze, pull the
cecum out of the wound. In most cases, the appendix is delivered with the
cecum or my be seen.
Step 7. Grasp and study the mesentry of the appendix and reinsert the cecum into
the peritoneal cavity, Divide the mesoappendix between clamps (Fig. 2.9).
Figure 2.9
Step 8. Ligate the mesoappendix with 2-0 silk (Fig. 2.10)
27
Figure 2.10
Step 9. With hemostasis completed, lift teh appendix straight up and attach two
clamps to its base. Remove the clamp close to the cecum and ligate the
appendiceal base doubly with 0 chromic catgut. Stump inversion is done
only when the base of the appendix is necrotic. When inverting, use a 3-0
silk purse string (Fig. 2.11 and Fig. 2.12).
Figure 2.11
28
Figure 2.12
Step 10. Divide appendix between the clamp and the catgut ligatures using a knife
with phenol and alcohol or electrocautery (Fig. 2.13).
(Alternatively, the appendix can be divided with a GIA stappler.)
Figure 2.13
29
Figure 2.14
Figure 2.15
30
Figure 2.16
4) Complications Appendisektomi: 10
1) Durante operations:
a) Intra-peritoneal hemorrhage that of artery appendicularis or of the
omentum.
b) Bleeding in the abdominal wall (of the muscles).
c) There is a tear of the cecum or other bowel.
2) Early Post-Surgery:
a) hemorrhage.
b) Infection of the abdominal wall.
c) Hematoom abdominal wall.
d) Paralytic ileus.
e) Peritonitis.
f) Intestinal fistula.
g) Abscess in the peritoneal cavity.
3) Further postoperative complications:
a) Streng ileus.
b) Hernia.
31
Post-Surgical Nursing: 10
On the day of the surgery patients were given infusions according to the
daily needs (maintenance) of approximately 2 to 3 liters of fluid Ringer
lactat and Dextrosa.
Giving oral food starts with giving sip (50 cc) per hour when it occurs
intestinal activity, namely the existence of flatus, and bowel sounds.
Where the provision of free drinking the patient did not bloating oral
feeding begins. Normally on the first or second day after surgery the
patient may be fed.
Procedures PAI
Adult patients with mass periapendikuler clamped with a perfect fencing
should be treated beforehand and given a combination of antibiotics that are active
against aerobic and anaerobic bacteria, while monitoring the body temperature,
the size of the mass, as well as the extent of peritonitis. If there is no fever,
periappendikuler mass is lost, and the patient may return to normal leukocytes and
elective appendectomy can be done 2-3 months later in order to bleeding due to
adhesions can be suppressed as small as possible. In young children, pregnant
women, and elderly patients, if conservative not improve / develop into an
abscess, surgery is recommended secepatnya.(6)
33
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