AppendicitisRizky Fauzi030.09.212

Lecturer : dr. Aplin Ismunanto Sp.B

Introduction

•appendicitis is inflammation of the vermiform appendix due to an obstruction

•it’s most common between puberty and age 30

•In the United States, 250,000 cases of appendicitis are reported annually, representing 1 million patient-days of admission.

•Man : Woman = 3:2

Definition• Appendicitis is an

inflammation of the appendix, which is the small, finger-shaped pouch attached to the beginning of the large intestine on the lower-right side of the abdomen. Appendicitis is a medical emergency, and if left untreated, the appendix may rupture and cause a potentially fatal infection.

EtiologyAppendicitis is caused by obstruction of the appendiceal lumen

Lymphoid Hyperplasia

Fecolith

Obstruction :•Corpus Alienum•Stricture

Infection :•E.Coli•Streptococcus

Epidemiology

Anatomy• The appendix is a

wormlike extension of the cecum and. The average length of the appendix is 8-10 cm (ranging from 2-20 cm)

• The appendix runs into a serosal sheet of the peritoneum called the mesoappendix, within which courses the appendicular artery, which is derived from the ileocolic artery

Anatomy

•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

Histology• Interior muscle layer

is circular. • Beneath these layers

lies the submucosal layer, which contains lymphoepithelial tissue. The mucosa consists of columnar epithelium with few glandular elements and neuroendocrine argentaffin cells.

Symptoms

•Periumbilical Pain/Epigastric pain (Visceral Pain) →Right Lower Quadrant (RLQ) Pain

•Anorexia•Nausea Vomitting•Diarrhea•Constipation

Physical Examination

•General : Pain, Fever, Flexi of articulatio Coxae Dextra

•Auscultation : Bowel Sounds Increased or Decreased

•Palpation : Rebound Tenderness, Rovsing sign, Rigidity, Guarding

•Percussion : Pain

McBurney’s Sign

Rovsing Sign

Psoas Sign Obturator Sign

Workup

•White Blood Cell (WBC) Count (>10,500)•Ultrasonography•Appendicogram•CT Scan

Ultrasonography

Appendicogram

Non Filling

CT Scan

Stages

No Stage Explanation

1. Early Stage obstruction of the appendiceal lumen leads to mucosal edema, mucosal ulceration, bacterial diapedesis, appendiceal distention due to

accumulated fluid, and increasing intraluminal pressure. The patient

perceives mild visceral periumbilical or epigastric pain, which usually lasts

4-6 hours

2. Suppurative 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.

No Stage Explanation

3. Gangrenous Intramural venous and arterial thromboses ensue

4. Perforated Persisting tissue ischemia results in appendiceal infarction and perforation. Perforation can cause

localized or generalized peritonitis.

5 Phlegmonous/Abcess An inflamed or perforated appendix can be walled off by the adjacent greater omentum or small-bowel

loops

6 Spontaneusly Resolving If the obstruction of the appendiceal lumen is relieved, acute appendicitis may resolve

spontaneously

7 Recurrent 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.

8 Chronic (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.

Diagnosis

TreatmentConservative :•Bed rest : Fowler Position•Antibiotics (Broad Spectrum)Penicillins (Ampicillin/Sulbactam)Cephalosporins (Ceftriaxone, Cefipime)Aminoglycosides (Gentamicin)Carbapenem (Meropenem)Fluoroquinolones (Ciprofloxacin,

Levofloxacin)Anti-Infective Agents (Metronidazole)• Analgesics

Indications Of Surgery

•Consider an appendectomy for patients with a history of persistent abdominal pain, fever, and clinical signs of localized or diffuse peritonitis, especially if leukocytosis is present.

•If the clinical picture is unclear, a short period (4-6 h) of watchful waiting and a computed tomography (CT) scan may improve diagnostic accuracy and help to hasten the diagnosis

Open Appendectomy

Conclusion• Appendicitis means inflammation of the appendix. It is

thought that appendicitis begins when the opening from the appendix into the cecum becomes blocked. Historically, the diagnosis of appendicitis has been made based on clinical findings. Diagnostic imaging has been used primarily to evaluate patients who have an atypical clinical presentation. Over the past several years, improvements in imaging technology have contributed to an increase in diagnostic accuracy in these patients. Early and accurate diagnosis of appendicitis can decrease patient morbidity and hospital costs by reducing the delay in diagnosis of appendicitis and its associated complications, as well as by avoiding inpatient observation prior to surgery in patients who present with atypical symptoms.

References• Craig S. Appendicitis Treatment & Management. Avilable at :

http://emedicine.medscape.com/article/773895 . Accessed 1 October 2013.

• Stengel JW, Webb EM, Poder L, et al. Acute appendicitis: clinical outcome in patients with an initial false-positive CT diagnosis. Radiology 2010; 256:119.

• Mangram AJ, Horan TC, Pearson ML, et al. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999; 20:250.

• Spirt MJ. Complicated intra-abdominal infections: a focus on appendicitis and diverticulitis. Postgrad Med 2010; 122:39.

• Eriksson S, Tisell A, Granström L. Ultrasonographic findings after conservative treatment of acute appendicitis and open appendicectomy. Acta Radiol 1995; 36:173.

• Guller U, Hervey S, Purves H, et al. Laparoscopic versus open appendectomy: outcomes comparison based on a large administrative database. Ann Surg 2004; 239:43.