{

APPENDICITIS
 BY:
GROUP 3

1. FINDIANI APRILIA SARI

2. SAKINA LUMBESSY
3. NOOR ROSVALINA ISTIQAMAH
4. SYAMSUL ARIFIN
5. A.MD.DIAH PADMAYONI
6. TITIN SETYANINGSIH
7. NAILUS SAADAH
8. PITRIA KHAIRUNNISA
9. RENNY FITRIANI
10. ROME SBASTIAN
 Appendicitis is a condition characterized by inflammation of
the appendix. It is classified as a medical emergency and many
cases require removal of the inflamed appendix, either by
laparotomy or laparoscopy. Untreated, mortality is high,
mainly because of the risk of rupture leading to peritonitis and
shock.
 Signs and symptoms
Pain first, vomiting next and fever last has been described as the
classic presentation of acute appendicitis. Since the innervation of the
appendix enters the spinal cord at the level T10, the same level as the
umbilicus (belly button), the pain begins mid-abdomen. Later, as the
appendix becomes more inflamed and irritates the adjoining
abdominal wall, it tends to localize over several hours into the right
lower quadrant, except in children under three years. This pain can be
elicited through various signs and can be severe. Signs include
localized findings in the right iliac fossa. The abdominal wall becomes
very sensitive to gentle pressure (palpation). Also, there is severe pain
on sudden release of deep pressure in the lower abdomen (rebound
tendernes). In case of a retrocecal appendix (appendix localized
behind the cecum), however, even deep pressure in the right lower
quadrant may fail to elicit tenderness (silent appendix), the reason
being that the cecum, distended with gas, protects the inflamed
appendix from the pressure.
 Similarly, if the appendix lies entirely within the pelvis, there is
usually complete absence of abdominal rigidity. In such cases, a
digital rectal examination elicits tenderness in the rectovesical
pouch. Coughing causes point tenderness in this area (McBurney's
point) and this is the least painful way to localize the inflamed
appendix. If the abdomen on palpation is also involuntarily guarded
(rigid), there should be a strong suspicion of peritonitis, requiring
urgent surgical intervention.
Clinical Manifestations

a. Main symptom of appendicitis is abdominal pain caused by

obstruction of the appendix, because it is of the same nature as in
intestinal obstruction. At first the pain is felt faint with discomfort in
the epigastric area or areas preumbilikal. After four hours the
intensity increased to colic and localized in the right lower quadrant.
If the patient flatus and bowel pain lessened. If the appendix
ruptures will occur peritonitis accompanied by localized pain in the
right lower quadrant at the point of Mc. Burney (the mid point
between the umbilicus and the anterior superior iliac spine) indicates
irritation peritoneum. Abdominal pain turned into a sharp and
continuous. Any movement that causes it to move or stretch the area
will cause pain. If there is perforation pain disappeared for a while,
but then came up with intense pain throughout the abdomen due to
generalized peritonitis.
 b. Annoreksia almost always there, and vomiting are typical.
Vomiting occurred after the pain, initially intermittent in reflektoris.
c. Constipation is common in children, in patients with a normal
appendix near the rectum diarrhea.
d. A fever is not too high, but a case of perforation hiperpireksi.
e. Rectus muscle stiffness
f. Leukocytosis (kebih of 12.000/mm3) with an increased number of
neutrophils to 75%.
 7. Management
a. Antibiotics and parenteral fluid administration, to overcome or
prevent fluid and electrolyte imbalance.
b. Analgesic given after the diagnosis of appendicitis is made, is not
given before the enforcement of diagnosis because it can mask the
signs and symptoms for differential diagnosis.
c. Not given an enema because it can cause irritation to stimulate
peristalsis in the area of inflammation that can increase the
perforation.
d. Appendiktomi, a surgical removal of the inflamed appendix. This
is done to prevent perforation. Appendix removed through an
incision in the right lower quadrant abdominal beginning with
general or spinal anesthesia.
 8. Complication
a. Perforation of the appendix (most common) which developed into
peritonitis
b. Paralytic ileus
c. Portal vein thrombosis
d. Septicemia
 Causes
On the basis of experimental evidence, acute appendicitis seems to
be the end result of a primary obstruction of the appendix lumen (the
inside space of a tubular structure). Once this obstruction occurs, the
appendix subsequently becomes filled with mucus and swells,
increasing pressures within the lumen and the walls of the appendix,
resulting in thrombosis and occlusion of the small vessels, and stasis
of lymphatic flow. Rarely, spontaneous recovery can occur at this
point. As the former progresses, the appendix becomes ischemic and
then necrotic. As bacteria begin to leak out through the dying walls,
pus forms within and around the appendix (suppuration). The end
result of this cascade is appendiceal rupture (a 'burst appendix')
causing peritonitis, which may lead to septicemia and eventually
death.
 The causative agents include foreign bodies, trauma, intestia, worms,
lymphadenitis, and, most commonly, calcified fecal deposits known as
appendicoliths or fecaliths The occurrence of obstructing fecaliths has
attracted attention since their presence in patients with appendicitis is
significantly higher in developed than in developing countries, and an
appendiceal fecalith is commonly associated with complicated appendicitis.
Also, fecal stasis and arrest may play a role, as demonstrated by a
significantly lower number of bowel movements per week in patients with
acute appendicitis compared with healthy controls. The occurrence of a
fecalith in the appendix seems to be attributed to a right-sided fecal
retention reservoir in the colon and a prolonged transit time. From
epidemiological data, it has been stated that diverticular disease and
adenomatous polyps were unknown and colon cancer exceedingly rare in
communities exempt from appendicitis. Also, acute appendicitis has been
shown to occur antecedent to cancer in the colon and rectum. Several
studies offer evidence that a low fiber intake is involved in the pathogenesis
of appendicitis. This is in accordance with the occurrence of a right-sided
fecal reservoir and the fact that dietary fiber reduces transit time.
 Diagnosis
Diagnosis is based on patient history (symptoms) and physical examination
backed by an elevation of neutrophilic white blood cells. Histories fall into
two categories, typical and atypical. Typical appendicitis usually includes
abdominal pain beginning in the region of the umbilicus for several hours,
associated with anorexia, nausea or vomiting. The pain then "settles" into the
right lower quadrant (or the left lower quadrant in patients with situs inversus
totalis), where tenderness develops. A commonly used acronym for diagnosis
is PALF: pain, anorexia, leukocytosis, and fever. Atypical histories lack this
typical progression and may include pain in the right lower quadrant as an
initial symptom. Atypical histories often require imaging with ultrasound
and/or CT scanning. A pregnancy test is vital in all women of child bearing
age, as ectopic pregnancies and appendicitis present similar symptoms. The
consequences of missing an ectopic pregnancy are serious, and potentially
life threatening. Furthermore the general principles of approaching
abdominal pain in women (in so much that it is different from the approach
in men) should be appreciated.
 Differential diagnosis
In children Gastroenteritis, mesenteric adenitis, Meckel's diverticulitis,
intussusception, Henoch-Schnlein purpura, lobar pneumonia, urinary
tract infection (abdominal pain in the absence of other symptoms can
occur in children with UTI), new-onset Crohn's disease or ulcerative
colitis, pancreatitis, and abdominal trauma from child abuse; distal
intestinal obstruction syndrome in children with cystic fibrosis; typhlitis
in children with leukemia; In women menarche, dysmenorrhea, severe
menstrual cramps, Mittelschmerz, pelvic inflammatory disease, ectopic
pregnancy. The most common mimic of appendicitis is the ruptured
ovarian cyst in young women. In adults regional enteritis, renal colic,
perforated peptic ulcer, pancreatitis, rectus sheath hematoma; in men:
testicular torsion, new-onset Crohn's disease or ulcerative colitis; in
women: pelvic inflammatory disease, ectopic pregnancy, endometriosis,
torsion/rupture of ovarian cyst, Mittelschmerz (the passing of an egg in
the ovaries approximately two weeks before an expected menstruation
cycle) In elderly diverticulitis, intestinal obstruction, colonic carcinoma,
mesenteric ischemia, leaking aortic aneurysm.
 Pathology

The definitive diagnosis is based on pathology. The histologic

findings of appendicits are neutrophils in the muscularis propria.
Periappendicits, inflammation of tissues around the appendix, is
often found in conjunction with other abdominal pathology.
 Pain
Pain from appendicitis can be severe. Strong (i.e., narcotic) pain medications are
recommended for pain management prior to surgery. Morphine is generally the standard
of care in adults and children in the treatment of pain from appendicitis prior to surgery.
In the past (and in some medical textbooks that are still published today), it was
commonly accepted among the majority of academic sources that pain medication not. be
given until the surgeon has the chance to evaluate the patient, so as to not "corrupt" the
findings of the physical examination. This line of practice, combined with the fact that
surgeons may sometimes take hours to come to evaluate the patient, especially if he or she
is in the middle of surgery or has to drive in from home, often leads to a situation that is
ethically questionable at best. More recently, due to better understanding of the
importance of pain control in patients, it has been shown that the physical examination is
actually not dramatically disturbed when pain medication is given prior to medical
evaluation. Individual hospitals and clinics have adapted to this new approach of pain
management of appendicitis by developing a compromise of allowing the surgeon a
maximum time to arrive for evaluation, such as 20 to 30 minutes, before active pain
management is initiated. Many surgeons also advocate this new approach of providing
pain management immediately rather than only after surgical evaluation.
 Antibiotics
While antibiotics are effective for treating uncomplicated appendicitis 20%
of people had a recurrence within a year and required eventual
appendectomy.
Surgery
See also: Appendectomy
Inflamed appendix removal by open surgery
Laparoscopic appendectomy.
The surgical procedure for the removal of the appendix is called an
appendicectomy (also known as an appendectomy). Often now the operation
can be performed via a laparoscopic approach, or via three small incisions
with a camera to visualize the area of interest in the abdomen. If the findings
reveal suppurative appendicitis with complications such as rupture, abscess,
adhesions, etc., conversion to open laparotomy may be necessary. An open
laparotomy incision if required most often centers on the area of maximum
tenderness, McBurney's point in the right lower quadrant. A transverse or a
gridiron diagonal incision is used most commonly.
 Laparotomy
Laparotomy is the traditional type of surgery used for treating
appendicitis. This procedure consists in the removal of the infected
appendix through a single larger incision in the lower right area of
the abdomen. The incision in a laparotomy is usually 2-3 inches
long. This type of surgery is used also for visualizing and
examining structures inside the abdominal cavity and it is called
exploratory laparotomy.
 Laparoscopic surgery
The newer method to treat appendicitis is the laparoscopic surgery.
This surgical procedure consists of making three to four incisions
in the abdomen, each 0.25 to 0.5 inches (6.3 to 13 mm) long. This
type of appendectomy is made by inserting a special surgical tool
called laparoscope into one of the incisions. The laparoscope is
connected to a monitor outside the patient's body and it is
designed to help the surgeon to inspect the infected area in the
abdomen. The other two incisions are made for the specific
removal of the appendix by using surgical instruments.
Laparoscopic surgery also requires general anesthesia and it can
last up to two hours. The latest methods are NOTES
appendectomy pioneered in Coimbatore, India where there is no
incision on the external skin] and SILS (Single incision
laparoscopic Surgery) where a single 2.5 cm incision is made to
perform the surgery.
Preventiv to appendicitis
How to treat disease prevention appendix is to consume a health
drink jellygamat luxor is excellent for preventing and treating
diseases of the appendix.
Eating vegetables and fruits that contain lots of fiber, avoiding spicy
foods, seeds, are like guava, peppers, etc, because the seeds of
food can not be digested well by the body. consume high fiber
foods, because foods that contain lots of fiber to facilitate the
circulation of blood in the body and keeping the immune system.
PREVENTION TIPS to avoid the disease of the appendix
Not too many foods that contain seeds that can settle the
appendix.
When eating food should drink plenty of seed, so the seed flow to
the intestines and does not precipitate removal of the appendix.
Expand the foods that contain fiber.
exercise more.