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Appendicitis

Appendix
An immunologic organ
Secrete Ig; particularly IgA

An integral component of GALT


system
Vermiform shape

Appendix
Derivate of the midgut
The base is more medial
location (posteromedial
wall of the cecum) toward
and caudal to the ileocecal
valve during both
antenatal and post natal
development, the growth
rate of the cecum exceeds
that of the appendix
(unequal elongation of the
lateral wall of the cecum)

Appendix
The orifice is always
at the confluence of
three caecal taenia
coll converge at the
junction of the
cecum with
appendix
Useful landmark to
identify the
appendix

Appendix
The final location of the appendix is
determined by the location of the
caecum
The normal location of the appendix
is retrocecal but within the peritoneal
cavity (because the most inferior portion
of the caecum is within the peritoneal
cavity), 65%

Appendix
The relationship of the base of the
appendix to the caecum remains constant,
whereas the tip can be found located in a
variety of locations explains the myriad
of symptoms, in the position:
Retrocecal
Pelvic
Subcecal
Preileal
Right pericolic

Incidence
Lymphoid follicles in the submucosa
gradually increased through adolescence,
then decrease over time peak
incidence: late teens & 20s
The amount of lymphoid tissue increase throughout
puberty, remains steady for the next decade, and
then begins a steady decrease with age
After the age of 60 years, virtually no lymphoid
tissue remains within the appendix, and complete
obliteration of the appendiceal lumen is common

Pathophysiology
Obstruction of the lumen is the dominant cause
Fecalith
Hypertrophy/swelling of the mucosal and
submucosal lymphoid tissue at the base
of the appendix
Inspissated barium from previous x-ray studies
Tumors
Vegetable and fruit seeds
Intestina parasites

Pathophysiology
The proximal obstruction of the appendiceal lumen
A closed-loop obstruction

* Bacterial overgrowth
* Continued mucus secretion

* Distention of the lumen


* Increased intraluminal pressure

..

Pathophysiology
..

Stimulates nerve endings of visceral afferent stretch


fibers,
producing visceral pain (vague, dull, diffuse pain) in
the mid abdomen or lower epigastrium
Stimulates peristalsis cramping
Nausea and vomiting

Pathophysiology
..

Pressure in the organ increased

Lymphatic obstruction

Venous pressure is exceeded then obstructed

Capillaries and venules are occluded, arterial inflow


continues

Engorgement and vascular congestion

..

Pathophysiology
..

The inflammatory process soon involves the serosa of


the appendix and in turn parietal peritoneum; producing
the characteristic shift in pain to the right lower quadrant
(i.e. somatic pain)

..

Pathophysiology
..

As distention continue; arteriolar inflow occluded


Increase pressure in the appendiceal wall exceeds capillary
pressure

*Elipsoidal infarcts (mucosal ischemia)


develop in the antimesenteric border,
the area with the poorest blood supply suffers most
*Integrity of mucosa compromised bacterial invasion

Acute inflammatory response ensues bacterial


overgrowth

edema

..

Pathophysiol
ogy
..

The appendix becomes more edematous

ischemic

Necrosis of the appendiceal wall


along with
Translocation of bacteria through the ischemic wall

Perforation occurs
Usually through one of the infarcted areas on the antimesenteric borders
Perforation generally occurs just beyond the point of obstruction rather than at the tip
because of the effect of diameter on intraluminal tension

Gangrenous appendix

Pathophysiology
Gangrenous appendix, without
intervention

Will perforate

Spillage of the appendiceal contents into the


peritoneal cavity

Pathophysiology
If the sequence of events occurs slowly

The appendix is contained by the inflammatory response and


the omentum

Localized peritonitis

The body does not wall of

the process

Appendiceal abscess

Diffuse peritonitis

Clinical Presentation
Appropriate sequence of symptoms:
Pain followed by nausea and
vomiting with fever and exaggerated
local tenderness in the position
occupied by the appendix

(Murphy, 1905)

Clinical Presentation

Obstruction of
the
appendiceal
lumen

The typical history/The classic pain sequence


Generalized abdominal pain (crampy, dull, colicky, & intermittent) that
difficult to localize
followed by anorexia and nausea

The pain then becomes most prominent diffusely centered in the


lower
Transmural
inflammation
epigastrium ,
of the
appendix
moderately severe and is steady,
leads to
sometimes with intermittent cramping superimposed
inflammation
of the

peritoneal
lining of the
Gradually moves toward the umbilicus
RLQ abdomen

After a period varying from 1-12 hours


Finally localizing in the right lower quadrant (sharp & constant pain)
Direct tenderness and muscle spasm in the right lower quadrant
Movement & Valsalva maneuver worsen the Pain

Clinical Presentation
The process continues
The amount of spasm increases
Muscular resistance to palpation of the abdominal wall roughly
parallels the severity of the inflammatory process

The appearance of rebound tenderness


The temperature is often mildly elevated/
low grade fever (38,30C)
Usually rises to higher levels in the event of perforation
Jadi urutan nyerinya
nyeri tekan defans muskular
nyeri lepas

Clinical Presentation

Variation in the anatomic location of the appendix account for


many of the variations in the principal locus of the somatic
phase of the pain
A long appendix with the inflamed tip in the left lower
left lower quadrant pain
A retrocecal appendix right flank or back pain
A pelvic appendix suprapubic pain
A retrocecal appendix testicular pain
(presumably from irritation of the spermatic artery and ureter)
Right upper quadrant pain
Right-sided pelvic tenderness on rectal examination

Clinical Presentation
The surgeon should
systematically examine the
entire abdomen, starting in the
left upper quadrant away from
the patients described pain

Clinical Presentation
Accompanied symptoms
Anorexia
Vomiting neural stimulation
the presence of ileus
neither prominent nor prolonged
only twice or once
If nausea and vomiting precede the pain, patients are
likely to have another cause for their abdominal pain,
such as GE
Urinary or bowel frequency appendiceal inflammation
irritating the adjacent bladder or rectum

Clinical Presentation
The sequence of symptom
Anorexia
If the patient is not anorectic, the diagnosis of appendicitis should be
questioned

Abdominal pain

Vomiting
If vomiting procedes the onset of pain, the diagnosis of appendicitis should
be questioned

Clinical Presentation
RT dikerjakan bila pasien mengeluh nyeri
perut tapi saat kita periksa tidak ada NT
Mc Burney
Karena bisa saja letak ujung appendiks di/
menuju rongga pelvis
Sehingga saat RT jari menekan peritoneum
kavum Douglaspasien mengeluh nyeri di
suprapubik
rektum

Clinical Presentation
Right lower quadrant tenderness is THE
MOST consistent of all signs of acute
appendicitis
Its presence should always raise the
specter of appendicitis, even in the
absence of other signs and symptoms

Clinical Presentation
Laboratory
Leucocytosis (12.000-18.000)
Neutrophils (left shift)
Pyuria the proximity of the ureter to the inflamed appendix
ureteral or baldder iritation as a result of an
inflamed appendix

Clinical Presentation

Physical Examination
Physical findings are determined
principally by
The anatomic position of the
inflamed appendix
Whether the organ has already
ruptured when the patient is first
examined

Physical Examination
Rovsings sign
Elicited when
pressure applied in
the left lower
quadrant reflects
pain in the right
lower quadrant

Physical
Examination
Psoas sign
Elicited by extension of
the right thigh with the
patient lying on the left
side, stretching of the
iliopsoas muscle

Pain suggests the


presence of an inflamed
appendix overlying the
psoas muscle
Indicates that the
inflamed appendix is
retrocaecal in
orientation

Physical
Examination
Obturator sign/
Hypogastric pain
Elicited by passive
internal rotation of the
flexed right hip/thigh
with the patient in the
supine position,
stretching of the
obturator internus muscle

Indicates that the


inflamed appendix is
pelvic in orientation

Imaging
Sonographic criteria
Thickening of the appendiceal wall, 6 or 7 mm
Noncompressible appendix of or greater in AP
diameter
The presence of an appendicolith
Interruption of the continuity of the echogenic
submucosa
Periappendiceal fluid or mass
Increased echogenicity of the surrounding fat
signifying inflammation
Loculated pericecal fluid

Imaging
False-negative sonogram can occurs if:
The appendicitis is confined to the
appendiceal tip
Retrocecal location
The appendix is markedly enlarged
and mistaken for small bowel
The appendix is perforated and
therefore compressible

Imaging
Plain abdominal radiograph are
neither helpful nor cost effective and
are not recommended for the
diagnosis of acute appendicitis
RLQ fecalith (appendocolith) was not
pathognomonic for acute
appendicitis

Differential Diagnosis
Depends upon 4 major factors:
The anatomic location of the
inflamed appendix
The stage of the process (i.e. simple
or ruptured)
The patients age
The patients sex

Differential Diagnosis
(based on group of age)
Preschool children
Intussusception
Colicky-type pain
< 3 y.o.
Mass with no true peritonitis

Meckels diverticulitis
Pain localize to the periumbilical area

Acute gastroenteritis

Diarrhea
Nausea
Vomit
Leukocytes in the stool
No peritoneal signs

Differential Diagnosis
(based on group of age)

School-age children
Gastroenteritis
Functional pain
Constipation
Omental infarction
Palpable mass
The pain does not migrate

Differential Diagnosis
(based on group of age)

Adolescent boys and young adult men


Chrons disease
Ulcerative colitis
Epididimytis

Differential Diagnosis
(based on group of age)

Adolescent Girls and young adult women


PID
Onset in the lower abdomen
The pain is usually bilateral
Exacerbated on pelvic examination

Ovarian cyst ruptured


torsion
No migration or changing symptoms

UTI

Differential Diagnosis
(based on group of age)

Eldery age group


Malignancies GIT
reproductive system
Diverticulitis
Perforated ulcer
Cholecystitis

Differential Diagnosis

Differential Diagnosis
Acute mesenteric adenitis
Acute gastroenteritis viral
Salmonella
leucocyte count normal or
Nausea and vomiting precede the abdominal pain
Diarrhea is a prominent symptoms

Meckels diverticulitis
Diseases of the male urogenital system
Torsion of the testis
Acute epididymitis
Seminal vesiculitis

Differential Diagnosis
Intussusception
Children younger than age 2 years
A well-nourished infant
Suddenly doubled up by apparent colicky pain, between
attacks of pain the infant appears well, after several hours
passes a bloody mucoid stool
A sausage-shaped mass palpable in the right lower quadrant

Crohns enteritis
Acutely inflamed distal ileum with no cecal involvement and
a normal appendix
Subacute course include fever
weight loss
pain

Differential Diagnosis
Colonic lesions
Should be considered in older patients
Diverticulitis
Quicker progression to localized tenderness
Prodorme of an alteration in bowel habits
Perforating carcinoma of
The cecum
That portion of the sigmoid that lies on the right side
Appendicitis caused by a mass obstructing the appendiceal
orifice
Guaiac-positive stools
Anemia
History of weight loss

Differential Diagnosis
Perforated peptic or duodenal ulcer,
with fluid tracking into the right
paracolic gutter
Yersiniosis
Epiploic appedagitisinfarction of the
colonic appedage(s)torsion

Differential Diagnosis
Urinary tract infection; acute pyelonephritis (on the right
side)

Chills
Right CVA tenderness
Pyuria
Bacteriuria

Ureteral stone; if the calculus is lodged near the appendix


Pain referred to the labia
scrotum
penis
Hematuria
Absence of fever
leukocytosis

Differential Diagnosis
Primary peritonitis nephrotic syndrome
cirrhosis
endogenous/exogenous
immunosupression
Henoch-Schnlein purpura
Beside abdominal pain, joints pain
purpura
nephritis

Differential Diagnosis
Foreign-body perforation of the
bowel
Closed-loop intestinal obstruction
Mesenteric vascular occlusion
Plueritis of the right lower chest
Acute cholecystitis
Acute pancreatitis
Hematoma of the abdominal wall

Differential Diagnosis
(Gynecologic Disorders)

Pelvic inflammatory disease


Lower pain and tenderness
Pain of motion of the cervix
Purulent vaginal discharge

Acute salpingitis
Tubo-ovarian abscess
Endometriosis

Differential Diagnosis
(Gynecologic Disorders)

In women of childbearing
years
Recent menstrual history
Pelvic examination

Differential Diagnosis
(Gynecologic Disorders)

Ruptured graafian follicle


Ovulation commonly results in the
spillage of sufficient amounts of blood
and folicular fluid to produce brief, mild,
lower abdominal pain
Pain and tenderness are rather diffuse
Leukocytosis and fever are minimal or
absent
Occurs at the midpoint of the menstrual
cycle (Mittel-Schmerz)

Differential Diagnosis
(Gynecologic Disorders)

Twisted ovarian cyst or tumor


rupture
torsion
Right lower quadrant pain, tenderness,
rebound
Fever and leukocytosis
Palpable mass on vaginal exam

Differential Diagnosis
(Gynecologic Disorders)

Ruptured ectopic pregnancy


Abnormal menses
missing one or two periods
noting only slight vaginal bleeding
Pelvic mass
Elevated level of chorionic gonadotropin
Leukocyte counts rises slightly
Hematocrit level falls the intra-abdominal hemorrhage
Cervical motion and adnexal tenderness on vaginal
examination
The presence of blood and decidual tissue on
culdocentesis

Patients with a history, physical


examination, and laboratory studies
classic for appendicitis should
undergo urgent appendectomy
In those with an evaluation suggestive
but not convincing for appendicitis,
further imaging is indicated
Pelvic US in women of childbearing age to
evaluate ovarian pathology
Abdominopelvic CT to diagnosing other
intrabadominal pathology

Appendiceal Ruptures
Susceptible population:
Children younger than age 5 years
Patients older than age 65 years
Cannot express their symptoms
Delayed in presentation/present late in the course of
their disease

Non operative treatment exposes the patient to the


increased morbidity and mortality associated with a
ruptured appendix
Occurs most frequently distal to the point of
luminal obstruction along the antimesenteric
border of the appendix

Appendiceal Ruptures
Diminished inflammatory response:
Less impressive symptoms
physical signs
Longer duration of symptoms
Decreased leukocytosis

Appendiceal Ruptures
Should be suspected in the presence of:
2 or more days of abdominal pain
The pain may be so severe that patients do not remember the
antecedent colicky pain
Localized RLQ rebound tenderness if the perforation has been
walled off by surrounding intra-abdominal structures including
the omentum
Generalized peritonitis if the walling-off process is ineffective in
containing the rupture
High fever > 390C
Rigors
WBC > 18.000/mm3
Poor oral intake
Dehydration

Periappendiceal Mass
An ill-defined mass will be detected
on physical examination, this could
represent a phlegmon, consists of
matted loops of bowel adherent to
the adjacent inflamed appendix, or a
periappendiceal abscess
Have a longer duration of symptoms,
usually at least 5-7 days

When performing appendectomy,


if the appendicitis is not found
or normal appendix,
a methodical search for an
alternative diagnosis must be
performed
The cecum and mesentery should first be inspected
Next, the small bowel is examined in a retrograde
fashion beginning at the ileocecal valve and
extending at least 2 feet
Terminal ileum; terminal ileitis
infectious causes
-Yersinia
-TB

Crohns disease
Inflamed or perforated Meckels diverticulum

When performing appendectomy,


if the appendicitis is not found
or normal appendix,
a methodical search for an
alternative diagnosis must be
performed
In women, special attention should be paid to
the pelvic organs ovaries
fallopian tubes
uterus
An attempts is also made to examine the
upper abdominal contents
If purulent fluid is encountered, it is
imperative that the source be identified