appendicitis- dr. sigit
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APPENDICITIS
Dr.sigid djuniawan, spB
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Anatomy and physiology of appendix
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The appendix is a slender, worm-shaped pouch, averaging 510cm in length, that protrudes from the top of the colon in the lower right abdomen
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Location
McBurneys point:one-third of the way from the anterior,superior iliac spine to the umbilicus.Pelvis and right ilac fossa appendixAnterior or posterior ileum appendixRetrocaceal appendix Right lateral caceal appendix -
Retrocaceal appendix
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Supply & nerve
Appendix artery: a final artery ,from ileocolic arteryAppendix vein : portal veinsympathetic nerve :celiac plexus and lesser splanchnic nerve T10,T11 -
Acute appendicitisAppendicitis is a common cause of abdominal pain
life-threatening condition because of systemic sepsis (systemic inflammatory response syndrome/SIRS leading to multiple organ failure) following rupture and abscess formation
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Etiology
Obstruction:anatomy :wormed-shaped
narrow
plenty of lymph glands
mechanical reason:
food residue, ascarid,
tumor,etc.
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Etiology
Gastrointestial diseaseBacteria invasion:all kinds of G- bacilus
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Pathology
Four type:
Acute simple appendicitisAcute purulent appendicitisPerforation and gangrenousAppendiceal abscess -
Acute simple appendicitis
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Acute purulent appendicitis -
Perforation and gangrenous
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Gangrenous
Perforation
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Appendiceal abscess
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Results
Inflammation disappearInflammation localizationInflammation diffusion -
Clinical manifestation
symptoms :
abdominal pain :Periumbilical or epigastric pain that migrates to right lower quadrant
Pain becomes persistent and well localized. It worsens with moving, breathing deeply, coughing, sneezing, walking, or being touched
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Symptoms :
Gastrointestinal symptoms:Anorexia, nausea, and vomiting occur after the onset of pain
Constipation
Diarrhea
bladder and rectum stimulus symptoms
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Symptoms
General symptoms :tired ,headach
fever
Rapid pulse
SIRS (systemic inflammatory response syndrome) -
Signs
Tenderness in the right lower abdomen, usually about a third of the distance from the navel to the top of the hip boneperitoneal irritation sign : muscular rigidity
Blumberg sign
bowel sounds disappear
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Others
Rovsings sign:pain in the right lower quadrant upon palpation of the left lower quadrant.Psoas sign :pain on active elevation of the legsThe obturator sign: pain on internal and external rotation of the hipRectal exam & vaginal exam -
Lab test
Mild to moderately elevated WBC with left shift is typical but rarely may be normal, range of 11000-17000/mm3over 20000/ mm3 perforation
UA may show ketonuria or a few RBCs or WBCspregnancy test (women only) -
Lab test
B-usX-rayDiagnostic abdominal puncture -
Diagnosis
Periumbilical or epigastric pain that migrates to right lower quadrantTenderness in the right lower abdomen, usually about a third of the distance from the navel to the top of the hip bone -
Differential diagnosis
Two type :
A: required surgery
B: not required surgery
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Differential diagnosis
Required surgery:
Perforation of gastointestinal tractulcer,tumor, diverticulitis
obstetrics and gynecologic disease:ectopic pregancy,ovarion torsion
Meckel diverticulitisTumor -
Differential diagnosis
Not required surgery
Pelvic inflammationMesenteric adenitis:at exploration a normal appendix and enlarged lymph nodes in the mesenteryViral & bacterial gastroenteritisPneumonia, pleurisy -
Treatment
Early operation:surgical removal(appendectomy)
Acute simple appendicitis: appendectomy Acute purulent and gangrenous appendicitis:appendectomy and/or drainage
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Treatment
Appendiceal abscess:
if local in right low quadrantantibiotic therapy and general treatment
if infection diffusionincision and drainage
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Treatment
Operation
Incision :incision over the point of maximal tenderness,generally at McBurny point
true McBurneys incision
tansvers skin incision
36cm long
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Incision
McBurneysincision
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Incision
tansvers skin incision -
Treatment
Operation
Process:The taenia of the colon are followed to the base of the appendix
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Treatment
Operation
Process:Mesoappendix is divided between clamps and ligated
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Treatment
Operation
Process:The base of appendix is divided and ligated 0.5cm from caceum and inverted using a purse-string
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a
b
c
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Treatment
Suspected case: not definite.Admit the patient to hospital for further observation 12-24hrs
Operation
exploration incision
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Treatment
Antibiotic thearpy:
Acute simple appendicitisContraindication of operationAppendiceal abscess -
Treatment
Antibiotic thearpy
antibiotics: broadspectrum antibiotics
ampicillin-sulbactam
gentamycin triad drugs
metronidazol
3rd generation cefotides
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Treatment
New method :laparoscopy appendectomy
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Complication
Acute appendicitis:
Abdomen abscessInter or extra fistulaPhylephlebitis -
Complication
Operation :
Incision infectionPeritonitis and abdomen abscessBleedingStool fistula Stump infectionAdhesive intestinal obstruction -
Appendicitis in neonate
SeldomNon-specific clinical manifestationAnorexia, nausea, and vomiting diarrhea
dehydration
Difficult in early diagnosisHigh rate of perforationHigh mortality -
Appendicitis in neonate
Diagnosis &Treatment
Carefully physical examEarly operation -
Appendicitis in child
Quick onset and severehigh fever and vomiting present early
Non-typical tenderness at right low quadrantHigh rate of perforationHigh mortalityMore complication -
Appendicitis in child
Treatment:
Early operationTransfusion and correct dehydrationBroadspectrum antibiotics -
Appendicitis in pregnancy
Uterus enlargement
elevation of abdominal wall
Tenderness site upper shift
appendix displaced
superiorly
Inconspicuous of
tenderness
rebound tenderness
muscular rigidity
Without adherent blanket of omentum
Peritonitis diffusion
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Appendicitis in pregnancy
Treatment :
Operation :appendectomyTo late pregancy :early operationSuperior Incision No drainageBroadspectrum antibioticsParturient with perforation :cesarean section and appendectomy
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Appendictis in the elderly
Less well-defined symptoms and signsSevere pathologic typeError diagnosis easilyHigh rate of perforationPay attention to tumor -
Chronic appendicitis
Etiology and pathologyClinic feature and diagnosisright low quadrant pain
local tenderness
x-ray
Treatappendectomy
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