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APPENDICITIS
Moch. Junaidy Heriyanto, dr, SpB, FINACS

Anatomi

Appendix
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The appendix is a small, finger-like tube about 10 cm (4 in) long that is attached to the cecum just below the ileocecal valve. The appendix fills with food and empties regularly into the cecum. Because it empties inefficiently and its lumen is small, the appendix is prone to obstruction and is particularly vulnerable to infection (ie, appendicitis).

FREQUENCY
Incidence appendicitis : USA : 1.1 / 1000 people per year Indonesia : unknown data Predispositions : Appendicolith may made both diet low in fiber or hyperplasia submucosal lymphoid and Peyeri patchs to respons a bacterial or viral infection

Pathophysiology

Pathophysiology
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The appendix becomes inflamed and edematous as a result of either becoming kinked or occluded by a fecalith (ie, hardened mass of stool), tumor, or foreign body. The inflammatory process increases intraluminal pressure, initiating a progressively severe, generalized or upper abdominal pain that becomes localized in the right lower quadrant of the abdomen within a few hours.

PATHOGENESIS
Appendiceal obstruction
Secreting mucosa Atrophic mucosa

Secretion retained Increase pressure

No infection mucocele

infection

ball valve Relief of obstructio n Edema Hyperemi a Exudate

Complication : Gangrene perforation

Peritoniti s Sepsis shock

absces s

Clinical Manifestations

Clinical Manifestations
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Epigastric or periumbilical pain progresses to the right lower quadrant. Low-grade fever, nausea and sometimes vomiting. Loss of appetite. Local tenderness is elicited at McBurneys point when pressure is applied (next 2 slides). Rebound tenderness (ie, production or intensification of pain when pressure is released) may be present. Rovsings sign may be elicited by palpating the left lower quadrant; this causes pain to be felt in the right lower quadrant. If the appendix has ruptured, the pain becomes more diffuse; abdominal distention develops, and the patients condition worsens.

APPENDICITIS

An appendix ruptured can lead to peritonitis and abscess, that is often delayed and misdiagnose of appendicitis acute Moving pain periumbilical area (visceral pain) to Mac Burney pin point (somatic pain)

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Location of McBurney's point (1), located two thirds the distance from the umbilicus (2) to the anterior superior iliac spine (3).

CLINICAL APPENDICITIS
Invasive Bacterial Viral

Lymphoid Follicle Hyperplasia

GALT-MALT, Peyeri patch IMMUNOCOMPROMISE Ischemia APPENDI- Total Rupture (Vascular COLITH Obstructions Compromise) Peritoniti (Vomiting 50%) s

Feces Partial Retensions Obstructions Intralumen (Anorexia, 74-78%, appendix Nausea 61-92%) Colicky Pain 80% (Periumbilic al) N Th X

Abscess
Constan Pain Mac Burney point

Low Residu Diet

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Assessment and Diagnostic Findings

Health history and physical exam. Complete blood cell count demonstrates an elevated white blood cell count (> 10,000 cells/mm3). The neutrophil count may exceed 75%. Abdominal x-ray films, ultrasound studies, and CT scans may reveal a right lower quadrant density or localized distention of the bowel.

USG (ultrasound examination)

Appendic: appendicolith thick wall diameter 15,2 mm (normal < 6mm)

APPENDICOGRAM
APPENDICITIS 5 GRADE: CLOUDS CLASSIFICATIONS I SIMPLE OBSTRUCTION II SUPPURATIVE III GANGREN IV RUPTURE V ABSCES

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Medical Management

Surgical intervention (appendectomy), next slide, as soon as possible after diagnosis to decrease the risk of perforation. Before surgery, correction or prevention of fluid and electrolyte imbalance and dehydration could be through antibiotics and intravenous fluids. Analgesics can be administered after the diagnosis is made.

Surgery technique: open vs laparoscopic

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Everything will be simple after systematized Medical problem Surgical problem:

Anamnesis:
Chief complain History

Elective Emergencies

Physical Examinations Laboratory:

blood, urine etc. X rays plain/contras USG (non invasive) CTscan MRI

Diagnosis Treatment Prognosis

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PERITONITIS
Moch. Junaidy Heriyanto, dr, SpB, FINACS

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Definition and structure

Definition
Peritonitis (pear-ih-tuh-NYE-tis) Infection, or rarely some other type of inflammation, of the peritoneum. Peritoneum is a membrane that covers the surface of both the organs that lie in the abdominal cavity and the inner surface of the abdominal cavity itself.

Structure
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Consists of a closed sac, containing a small amount of serous fluid, within the abdominal cavity. Two layers The parietal layer - lines the abdominal wall Visceral layer covers the organs (viscera) in the abdominal and pelvic cavities

The organs are invaginated into the closed sac from above, below and behind so that they are at least partly covered by the visceral layer Pelvic organs are covered only on their superior surface The stomach and intestines deeply invaginated from behind are almost completely surrounded by peritoneum and have a double fold ( the mesentery).

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The fold of peritoneum attaches them to the posterior abdominal wall The pancreas, spleen, kidneys and adrenal glands are invaginated from behind - only their anterior surfaces are covered by the peritoneum therefore retroperitoneal Liver completely covered attached to the diaphragm

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The main blood vessels and nerves pass close to the posterior abdominal wall and send branches to the organs between the two folds of peritoneum

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Parietal peritoneum lines the anterior abdominal wall The two layers are actually in contact - friction prevented by the presence of serous fluid secreted by the peritoneal cells Peritoneal cavity is only a potential cavity In women there is communication of the peritoneal cavity to the external atmosphere through the openings of the fallopian tubes (at fimbrial ends) In males the peritoneal cavity is completely closed.

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Pathophysiology

Pathophysiology
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Peritonitis is caused by leakage of contents from abdominal organs into the abdominal cavity due to inflammation, infection, ischemia, trauma, or tumor perforation. Edema of the tissues results, and exudation of fluid develops in a short time. Fluid in the peritoneal cavity becomes turbid with increasing amounts of protein, white blood cells, cellular debris, and blood. The immediate response of the intestinal tract is hypermotility, followed by paralytic ileus with an

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Pathophysiology (secara singkat):

inflammation , exudation ascites, paralytic ileus, distension of abdomen dehydration respiratory embarassment due to the distension septicemia death

Pathogenesis
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Intra-abdominal infections result in 2 major clinical manifestations:

1. Early or diffuse infection results in localized or generalized peritonitis. 2. Late and localized infections produces an intra-abdominal abscess.

Pathogenesis
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2 Major Types: 1. Primary: Caused by the spread of an infection from the blood & lymph nodes to the peritoneum. Very rare < 1% Usually occurs in people who have an accumulation of fluid in their abdomens (ascites). The fluid that accumulates creates a good environment for the growth of bacteria.

Pathogenesis
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2. Secondary: Caused by the entry of bacteria or enzymes into the peritoneum from the gastrointestinal or biliary tract. This can be caused due to an ulcer eating its way through stomach wall or intestine when there is a rupture of the appendix or a ruptured diverticulum. Also, it can occur due to an intestine to burst or injury to an internal organ which bleeds into the internal cavity.

Aetiology
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Bacterial infection commonest organisms are Escherichia coli, aerobic and anaerobic streptococci, and the bacterioides.klebsiella pneumoniae. Mycobacterium tuberculosis Bile irritation biliary peritonitis Biliary peritonitis following peptic ulcer perforation. Trauma, open surgery, drains Inflammatory bowel disease, appendicitis, ischaemic bowel Pelivic inflammatory disease Haematogenous spread , e.g., septicaemia Pancreatitis inflammation of the peritoneum by the irritant secretions from the pancreas.

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Clinical features

Localised peritonitis
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Abdominal pain which goes on increasing Fever Vomiting Tenderness, rebound tenderness, Rowsings sign. Localised guarding, or rigidity.

Diffuse (generalized) peritonitis

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Severe abdominal pain Pain increases on moving and or breathing Patient lies still Tenderness and rigidity of the abdominal wall Pulse rises progressively The temperature may become subnormal Circulatory failure ensues

Late features:- if resolution or localisation of generalized peritonitis does not occur the abdomen remains silent and increasingly distends. Cold and clammy extremities Sunken eyesDry tongue Thready (irregular) pulse, Drawn and anxious face (Hippocratic

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Exam & Evaluation

Exam & Evaluation

Feel & press the abdomen to detect any swelling & tenderness in the area as well as signs of fluid has collected in the area.

Listen to the bowel sounds & check for difficulty breathing, low blood pressure & signs of dehydration.

Evaluation cont:

The usual sounds made by the active intestine and heard during examination with a stethoscope will be absent, because the intestine usually stops functioning. The abdom may be rigid and boardlike Accumulations of fluid will be notable in primary due to ascites.

Exams cont:

Blood Test

Chest X-rays, X-Ray abdomen Peritoneal diagnostic aspiration called peritoneal tapping Serum amylase USG CT Scan

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Treatment

Treatment Approach

Hospitalization is common. Surgery is often necessary to remove the source of infection. Antibiotics are prescribed to control the infection Intravenous therapy (IV) is used to restore hydration Volume replacement Electrolyte imbalance correction Gastrointestinal decompression

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Complications

Systemic & Abdominal complications

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Systemic

Abdominal

Bacteraemic or endotoxic shock Bronchopneumonia/ respiratory failure Renal failure Bone marrow suppression Multisystem failure

Adhesional small bowel obstruction Paralytic ileus Residual or recurrent abscess Portal pyaemia/liver abscess Paralytic ileus

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Prognosis

Untreated peritonitis is poor, usually resulting in death. With Tx, prognosis is variable, dependent on the underlying causes.

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Jejunal diverticulitis with peritonitis

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TERIMAKASIH