CASE PRESENTATION

ACUTE APPENDICITIS

Consulent:

Dr. Herry Setya Yudha Utama, SpB, MHKes, FInaCS

Author:

Annisa Ulkhairiyah

1102014034

Clinical Clerkship of Surgery Departement

Faculty of Medicine YARSI University

Arjawinangun Hospital

July 2019
 CHAPTER I
CASE PRESENTATION

I. IDENTITY
th
Date of hospital entry : July 18 2019
Name : Ny. M
Age : 22 years
Gender : Female
Occupation : Employe
Addres : Tegal Gubuk
Religion : Islam
Marital status : Married

II. ANAMNESIS
Main complaint
Lower right abdominal pain since two days ago.
History of disease
This has been experienced by patients since two days ago and increasingly become
heavy 1 today. Initially heartburn two days ago, like punctured and needles, intermittent
to spread to the lower right abdomen. Nausea encountered. Vomiting is found, the
frequency of 3 times a day, the contents of the food. Decreased appetite encountered.
Body felt limp encountered. Fever is not found. BAK (+) Normal. BAB (+) Normal.
History of past disease
Asthma, Dyspepsia
History of family disease
Ny. M said, there is no family members with the same disease as patient.
III. PHYSICAL EXAMINATION
a. Present Status
Genereal condition : Severe pain
Awareness : Compos mentis
Blood pressure : 120/80 mmHg
Pulse : 90 x/minute
 Breathing : 20 x/minute
Temperature : 36,7 oC

Head
Shape : Normocephale, symmetrical
Hair : Black
Eye : Pupil isokor Ø 3mm / 3mm, light reflex (+ / +), conjunctiva
inferior eyelid pale (- / -), sclera jaundice (- / -)
Ear : Normal shape, cerumen (-), intact thympany membrane

Nose : Normal shape, septum deviation (-), epitaxis(-/-)


Mouth : Within normal limits

Thorax

Lungs – pulmonary


Inspection : The chest is symmetrical both left and right


Palpation : Fremitus vocale and tactile are symmetrical,

crepitation (-), tenderness (-), rebound tenderness (-)

Percussion : Resonance sound in both lung fields


Auscultation : Vesicular and bronchial sound in the entire lung field, ronchi (-
/-), wheezing (-/-)
Extremity : within normal limits
Genitalia :
Rectal Touche

Spincter suffocating, mucosal slick, empty ampulla, tumor mass (-). Tenderness in the
10 o'clock direction.
Handschoen: Feces (-) blood (-) mucus (-)

b. Localized Status
Abdomen
Inspection : Flat, follow the motion of breath, skin color is equal to about.
Darm Contour (-), Darm Steifung (-)
 Auscultation : Peristaltic (+) decreased impression
Palpation : Mass Tumor (-), Pain Press (+) at the point Mc Burney (+),
Rovsing Sign (+), Blumberg Sign (+), psoas sign (+) Obturator
Sign (+)
Hepatic / Lien was not palpable.
Percussion : Timpani, pain at the point of word Mc Burney (+).

c. Laboratory Examination
EXAMINATION RESULTS REFERENCE
Complete blood
hb 12.0 12-16
Ht 41.1 37-47
Leukocytes 7,500 4000-11000
platelets 331 000 150000-450000

Calculate Type leukocytes

eosinophils 2 1.0 to 3.0
basophils - 0-1.0
neutrophils 80 50.0 to 70.0
lymphocytes 15 20.0 to 40.0
monocytes 3 2.0 to 8.0

d. SUPPORTING INVESTIGATION
Ultrasound Examination

GB : The walls are not thickened and regular

Pankrease : Size within normal limits

Spleen : The size and parenchymal echo within normal limits

Mc Burney Area : tubular lesions appear deadlocked, uncompressible

Both kidneys : Size and parenchymal echo within normal limits

VU : Mucosa is regular and does not thicken, nothing seemed to echo

rock and SOL
 IMPRESSIONS: appropriate description of Acute Appendicitis

IV. DIAGNOSIS
Susp Acute Appendicitis

V. DIFFERENTIAL DIAGNOSIS
Ec abdominal colic

Acute Gastritis

PID

VI. TREATMENT
Bed rest
IVFD RL 20 GTT / i macro
Inj. Ketorolac 30mg / 8J
Inj. Ranitidine 50mg / 12J
Consul surgery
appendectomy
VII. PROGNOSIS
Ad vitam : ad bonam
Ad sanationam : ad bonam
Ad fungsionam : ad bonam
 CHAPTER II

LITERATURE REVIEW

2.1 Anatomy, Physiology, AND EMBRYOLOGY APPENDIX

Appendix is a part of the midgut derivatives contained in the ileum and Colon
ascendens. Cecum visible in the 5th week of pregnancy and Appendix seen at 8 weeks of
pregnancy as a bulge in the cecum. Initially Appendix are at the apex of the cecum, but then
more medially rotated and situated close to the plica ileocaecalis. In the process of its
development, the intestinal rotation. Cecum end on the right lower quadrant abdomen.
Appendix always associated with Taenia caecalis. Therefore, the final location is determined
by the location Appendix Caecum.1,2,3

Figure 1. Appendix vermicularis4

Vascularization comes from branching Appendix A. ileocolica. Appendix histologic

picture shows the number of lymphoid follicles in submukosanya. At age 15 found about 200
or more lymphoid nodules. Lumen Appendix usually experience obliteration in adults. 1.3
 Figure 2. Transverse Pieces Appendix 5

Appendix long in adults varies between 2-22 cm, with an average length of 6-9 cm.
Although basic Appendix associated with Taenia caealis on the basis of the cecum, appendix
tip has a variety of locations as seen in the image below. Variations in these locations will
affect the location of abdominal pain that occurs when the appendix becomes inflamed. 1.2

Figure 3. Variation Appendix location vermicularis1

 Initially, Appendix considered to have no function. But lately, Appendix regarded as
immunological organ which actively secrete immunoglobulins, especially immunoglobulin A
(IgA). Although Appendix is an integral component of the systemGut Associated Lymphoid
Tissue (GALT), its function is not important and appendectomy will not be a predisposing
sepsis or immunodeficiency diseases lainnya.2

2.2 Incidence

Appendicitis can be found at all ages. But rarely in children less than one year.2

2.3 ETIOLOGY AND PATHOPHYSIOLOGY

Obstruction of the lumen is the primary culprit in Appendicitis acuta. Fecalith is a

common cause obstruction of the appendix, which is about 20% in children with acute
appendicitis and 30-40% in children with perforated appendix. Less common causes
hyperplasia in sub mucosal lymphoid tissue Appendix, barium drying on X-ray examination,
grains, gallstone, especially intestinal worms Oxyuris vermicularis. Lymphatic tissue reaction,
local or generalized, can be caused by infection with Yersinia, Salmonella, and Shigella; or due
to the invasion of parasites such as Entamoeba, Strongyloides, Enterobius vermicularis,
Schistosoma, or Ascaris. Appendicitis can also be caused by infections or systemic enteric
viruses, such as measles, chicken pox, and cytomegalovirus. Appendicitis incidence also
increased in patients with cystic fibrosis. This occurs because of changes in the mucus-secreting
glands. Appendix obstruction can also occur as a result of a carcinoid tumor, especially if the
tumor is located in the proximal third. For more than 200 years, the corpus alienum such as
pins, vegetable seeds and cherry stones involved in the occurrence of appendicitis. Other
factors that influence the occurrence of appendicitis is trauma, psychological stress, and
herediter.6
Obstruction frequency increases with the severity of the inflammatory process. Fecalith
found in 40% of cases of Appendicitis acuta modest, about 65% in the case of gangrenous
appendicitis without perforation, and 90% in the case of acuta gangrenous appendicitis with
perforation. 1,2,6,7

Figure 3.1. Appendicitis (with fecalith) 8

Lumen obstruction due to blockage in the proximal and normal secretion of mucous
Appendix soon led to distention. Appendix lumens at a normal capacity of 0.1 mL. Secretion
of about 0.5 mL in the distal occlusion increased intraluminal pressure of about 60 cmH2O.
Distention stimulate suffix visceral pain afferent nerve fibers, resulting in a vague pain, diffuse
pain in the lower abdomen or epigastric middle. 2

Distention continues not only from the mucous secretion, but also from the rapid growth of
bacteria in the Appendix. In line with the increase in organ pressure exceeds venous pressure,
capillary and venous flow is inhibited causing vascular congestion. But the flow is not
obstructed arterioles. Distention usually cause reflex nausea, vomiting, and pain more real.
Inflammatory process soon involves serous Appendix and the parietal peritoneum in this
region, resulting in a typical shift to RLQ pain. 2,6,7

Gastrointestinal mucosa including the Appendix, are particularly vulnerable to lack of

blood supply. With increasing pressure distension beyond the arterioles, blood supply areas
with the least will suffer the most damage. With distention, bacterial invasion, vascular
disorders, tissue infarction, perforation usually in one of the areas of infarction in
antemesenterik limit. 1,2,6,7

Appendix at the beginning of the inflammatory process, the patient will experience mild
gastrointestinal symptoms such as diminished appetite, change in bowel habits, and digestion
error. Anorexia plays an important role in the diagnosis of appendicitis, especially in children
anak.6
Appendix distention caused visceral stimulation of nerve fibers that are perceived as
pain in the periumbilical area. The initial pain is dull pain in dermatome Th 10. The growing
distension cause nausea and vomiting within a few hours after the onset of abdominal pain. If
nausea and vomiting arise precede abdominal pain, can be considered a diagnosis another.6
Appendix obstructed a good place for breeding bacteria. Along with increased
intraluminal pressure, disruption of lymphatic flow, causing more severe edema. Those things
are getting increasing intraluminal pressure Appendix. Eventually, this causes increased
pressure flow disturbance that caused the system vascularization Appendix Appendix iskhemia
intraluminal tissue, infarction, and gangrene. After that, the bacteria invade the walls of the
Appendix; followed by fever, tachycardia, and leukocytosis due to the release of inflammatory
mediators because iskhemia network. When the inflammatory exudate emanating from the wall
associated with peritoneal Appendix parietale, somatic nerve fibers are activated and the pain
will be felt locally at the location of the Appendix, in particular in Mc Burney's point. Rare
somatic pain in the right lower quadrant without any prior visceral pain before. In the Appendix
located in retrocaecal or in the pelvis, somatic pain is usually delayed because the inflammatory
exudate not perforate the peritoneum parietale before the Appendix and the spread of infection.
Pain in the Appendix located in retrocaecal may arise in the back or waist. Appendix located in
the pelvis, which is located near the ureter or testicular blood vessels can lead to increased
frequency of urinating, pain in the testicles, or both. Inflammation of the ureter or urinary vesica
result of the spread of infection Appendicitis can cause pain during urination, or pain such as
retention of urine. In the Appendix located in retrocaecal or in the pelvis, somatic pain is usually
delayed because the inflammatory exudate not perforate the peritoneum parietale before the
Appendix and the spread of infection. Pain in the Appendix located in retrocaecal may arise in
the back or waist. Appendix located in the pelvis, which is located near the ureter or testicular
blood vessels can lead to increased frequency of urinating, pain in the testicles, or both.
Inflammation of the ureter or urinary vesica result of the spread of infection Appendicitis can
cause pain during urination, or pain such as retention of urine. In the Appendix located in
retrocaecal or in the pelvis, somatic pain is usually delayed because the inflammatory exudate
not perforate the peritoneum parietale before the Appendix and the spread of infection. Pain in
the Appendix located in retrocaecal may arise in the back or waist. Appendix located in the
pelvis, which is located near the ureter or testicular blood vessels can lead to increased
frequency of urinating, pain in the testicles, or both. Inflammation of the ureter or urinary vesica
result of the spread of infection Appendicitis can cause pain during urination, or pain such as
retention of urine. Pain in the Appendix located in retrocaecal may arise in the back or waist.
Appendix located in the pelvis, which is located near the ureter or testicular blood vessels can
lead to increased frequency of urinating, pain in the testicles, or both. Inflammation of the
ureter or urinary vesica result of the spread of infection Appendicitis can cause pain during
urination, or pain such as retention of urine. Pain in the Appendix located in retrocaecal may
arise in the back or waist. Appendix located in the pelvis, which is located near the ureter or
testicular blood vessels can lead to increased frequency of urinating, pain in the testicles, or
both. Inflammation of the ureter or urinary vesica result of the spread of infection Appendicitis
can cause pain during urination, or pain such as retention of urine.
Appendix perforation will cause local abscess or diffuse peritonitis. This process
depends on the speed of progression in the direction of the perforation and the ability of the
body of the patients responded to perforation. Appendix perforation mark includes an increase
in the temperature exceeds 38.6oC, leukocytosis> 14,000, and the symptoms of peritonitis on
physical examination. Patients may be asymptomatic before the perforation, and the symptoms
can persist up to> 48 hours without perforation. Diffuse peritonitis is more common in infants
because babies do not have the omentum fat tissue, so there is no network to localize the spread
of infection due to perforation. Perforations occur in older children or teenagers, are more likely
to occur abscess.
Constipation is rare. Ad tenesmus ani often encountered. Diarrhea is common in
children, occurring in the short term, due to irritation of the terminal ileum or cecum. The
presence of diarrhea may indicate an abscess pelvis.6

2.4 CLINICAL

2.4.1 Clinical Symptoms

Appendicitis acuta symptoms generally arise less than 36 hours, starting with
abdominal pain preceded Appendicitis acuta anoreksia.12,13 main symptom is abdominal pain.
Initially, the pain is felt in the epigastric diffuse centralized and settled, sometimes
accompanied by cramping intermittent. The duration of pain ranged between 1-12 hours, with
an average of 4-6 hours. Persistent pain is generally localized to the RLQ. Variations of
Appendix anatomical location affect the location of pain, for example; Appendix long with
inflammation in LLQ end that causes pain in the area, the appendix in the pelvis causing pain
suprapubic, retroileal appendix can cause testicular pain. 1,2,3,7,8

Generally, patients have a fever during an appendix inflammation, usually the

temperature rises to 38oC. But in circumstances perforation, the body temperature rises to>
39oC. Anorexia is almost always accompanies appendicitis. In 75% of patients found vomiting
that generally only happens once or twice only. Vomiting caused by nerve stimulation and
ileus. Generally, the order of appearance of symptoms of appendicitis are anorexia, abdominal
pain and vomiting followed. If vomiting precedes the abdominal pain, the diagnosis of
appendicitis in doubt. Vomiting arising prior abdominal pain led to the diagnosis of
gastroenteritis. 2

Most patients experience abdominal pain obstipasi at the beginning and many patients
feel less pain after defecation. Diarrhea occurs in some patients, especially children. Diarrhea
can occur after perforation Appendix. 2.3

Alvarado score

All patients with suspected appendicitis acuta made the Alvarado score and classified into
2 groups, namely; score <6 and a score> 6. The next determined whether it will be done
appendectomy. After the appendectomy, examination of the tissue PA PA Appendix and the
results are classified into two groups: acute inflammation and not the acute inflammation.5

Table 2. Alvarado scale to help enforce diagnosis.2

Clinical symptoms Value

symptom Their migration pain 1

anorexia 1

Nauseous vomit 1

Sign RLQ pain 2

rebound 1
 febrile 1

Lab leukocytosis 2

Shift to the left 1

total points 10

When the score of 5-6 is recommended for observation at the hospital, when a score> 6 then
surgery should do it. 2

On physical examination, change of bowel sounds associated with the level of

inflammation in the Appendix. Almost all patients feel pain in local pain at Mc Burney's point.
But patients with Appendix retrocaecal local symptoms are minimal. Their psoas sign,
obturator sign, and Rovsing's sign is a confirmation than diagnostic. Toucher rectal
examination are also compared the diagnostic confirmation, especially in patients with pelvic
abscess due to rupture Appendix.6

Appendicitis Diagnosis is difficult in patients who are too young or too old. In both groups,
the diagnosis is usually often delayed so Appendicitisnya has been perforated. In the early
course of the disease in infants, only encountered symptoms of lethargy, irritability, and
anorexia. Furthermore, symptoms of vomiting, fever, and nyeri.7

2.4.2 Clinical Signs

Children with Appendicitis usually quieter when lying down with minimal movement.
Child writhing and screaming, in the end is rarely diagnosed as appendicitis, except in children
with appendicitis retrocaecal layout. On Appendicitis retrocaecal layout, excitation occurs
ureter so that the pain arising resemble renal colic pain.6

Appendicitis Patients generally prefer to squat stance in the right thigh, because of the
attitude of the cecum depressed so the contents of the cecum is reduced. This will reduce the
pressure towards the Appendix that abdominal pain is reduced. 6
 Figure 4. The position taken to reduce pain perut7

Appendix generally located around McBurney. But keep in mind that the anatomical
location of the appendix actually be at all points, 360osurrounds the base of the cecum.
Appendicitis can retrocaecal known location of pain in between costa 12 and spina iliaca
posterior superior. Appendicitis is the location of the pelvis can cause pain rectal.6

In theory, Appendix acute inflammation may be suspected in the presence of pain in the
rectal examination (rectal toucher). However, these tests are not specific for appendicitis. If
other signs of appendicitis has been positive, toucher rectal examination is not required lagi.6

Clinically, known several diagnostic maneuvers:

 Rovsing's sign
If LLQ pressed, feels pain in the RLQ. This illustrates peritoneal irritation. Appendicitis is
often positive but not specific.

 psoas sign
Patients lie on the left side, the right hand the examiner holds the patient's knee and left
hand to stabilize the pelvis. Then the patient's right leg is moved in the anteroposterior
direction. Pain in this maneuver describe musculus psoas right stiffness due to reflex or
direct irritation that comes from inflammation of the appendix. This maneuver is not useful
when it has happened abdominal rigidity.
 Figure 5. The anatomical basis the psoas sign 7

 obturator sign
Patient supine, the examiner's right hand holding on the right foot on the patient's left hand
in his knee joint. Then the examiner positioning the patient's knee joint in flexion and
articulatio coxae in a position endorotasi then eksorotasi. This test is positive if the patient
feels pain in hipogastrium when eksorotasi. The pain of this maneuver shows the Appendix
perforation, abscess local irritation of the obturator by M. Appendicitis retrocaecal layout,
or the obturator hernia.

Figure 6. How do Obturator sign7

 Figure 7. The anatomical basis Obturator sign7

 Blumberg's sign (pain off contralateral)

The examiner presses in LLQ then release it. This maneuver is said to be positive if at the
time of release, the patient felt pain in the RLQ.

 Wahl's sign
This maneuver is said to be positive when the patient felt pain at the time of percussion in
RLQ, and there is a decrease in the triangle peristaltic Scherren on auscultation.

 Baldwin's test
This maneuver is said to be positive when the patient felt pain in his right leg bent flank
moment.

 Defense musculare
Defense musculare Appendix locally appropriate location.

 Pain in the area of Douglas cavity

Pain in the area of Douglas cavity occurs when there is an abscess in the cavity of Douglas
or the location of the pelvic appendicitis.

 Pain in toucher rectal examination at the time of the emphasis on the lateral side
 Dunphy's sign (pain when coughing)
2.5 Investigations

2.5.1 Laboratory2,3,6,7

Mild leukocytosis ranged between 10000-18000 / mm3, Usually found in a state of acute,
uncomplicated appendicitis and is often accompanied by a predominance of
polymorphonuclear being. If the white blood cell count normally not found the shift to the left
shift to the left, the diagnosis of appendicitis acuta should be considered. Rarely white blood
cell count of more than 18,000 / mm3 in uncomplicated appendicitis. White blood cell count
above this amount increases the likelihood of perforation of the appendix with or without
abscess.

CRP (C-Reactive Protein) is an acute phase reactant synthesized by the liver in response to
bacterial infection. Total serum began to increase between 6-12 hours of tissue inflammation.

The combination of three tests, namely an increase in CRP ≥ 8 mcg / mL, ≥ 11000 white
cell count and neutrophil percentage ≥ 75% had a sensitivity of 86% and specificity of 90.7%.

Urine examination is useful to exclude the diagnosis of urinary tract infection. Although it
boasts some leukocytes or erythrocytes from irritation urethra or the urinary vesica such as
those caused by inflammation of the Appendix, in Appendicitis acuta in a urine samplecatheter
will not be found bacteriuria.

2.5.2.Ultrasonografi1,2,6,7

Ultrasonography is quite helpful in the diagnosis of appendicitis. Appendix identified /

known as a suffix vague, nonperistaltik sections of intestine from the cecum. With maximum
emphasis, Appendix measured in the anterior-posterior diameter. Ratings said positive when
the uncompressed size of the anterior-posterior Appendix 6 mm or more.
discoveryappendicolithwill support the diagnosis. Appendix ultrasound picture of normal,
which with light pressure is a tubular structure that blurred suffix size of 5 mm or less, will get
rid of the diagnosis of appendicitis acuta. Ratings said negative if the Appendix is not visible
and does not look any liquid or pericaecal mass. When the diagnosis of appendicitis acuta
eliminated by ultrasound, a brief observation of other organs in the abdominal cavity should be
done to look for another diagnosis. In women of reproductive age, pelvic organs should be seen
well by transabdominal or endovagina examination in order to get rid of gynecological diseases
that may cause acute abdominal pain. Diagnosis of Appendicitis acuta with ultrasound has been
reported sensitivity of 78% -96% and specificity of 85% -98%.

Ultrasound has certain limitations and the result depends on the user. Rate false positives
can occur with the discovery of inflammation surrounding periappendicitis, dilated fallopian
tubes, foreign objects (inspissated stool) Which can resemble appendicolith and Appendix
obese patients may not be depressed because of an acute inflammatory process Appendix but
because too much fat. Ultrasound false negatives can occur if appendicitis is limited to the end
of the Appendix, where the retrocaecal, Appendix rated enlarged and confused by the small
intestine, or if the appendix is perforated because of the pressure.

Figure 3.7.Ultrasonogram in longitudinal section Appendicitis 6

2.5.3. radiological examination1,2,6,7

Abdominal X-ray diagnosis of appendicitis acuta rarely helps, but it can be very helpful to
get rid of diagnosis. In patients Appendicitis acuta, sometimes visible picture of abnormal
bowel gas, this is a finding that is not specific. Fecalith their rarely seen on plain radiography,
but if found strongly support the diagnosis. Thorax sometimes advised to get rid of the pain
rather than the right lower lobe pneumonia.

Additional radiographic techniques include CT scan, barium enema, and radioisotope

leukocytes. Although CT scans have been reported equally or more accurate than ultrasound,
but much more expensive. For reasons of cost and effects of radiation, a CT scan is checked,
especially when suspected appendix to perform percutaneous abscess drainage appropriately.

Diagnosis is based on barium enema examination depends on the specific inventions that
result from extrinsic period in the cecum and appendix are empty and connected with a
precision that ranges between 50-48%. Radiographs of patients with suspected appendicitis
patient must be prepared for the diagnosis doubtful and may not be suspended or replaced,
requiring immediate surgery when clinically indicated.

Figure 3.8. Abdominal CT scan picture: perforated appendicitis

with abscess and fluid collection in pelvis

Figure 3.9. Abdominal CT scan picture: Thickening Appendix

(Arrows) with appendicolith

 Table 3. Comparison of Ultrasound and CT Scan Appendix to Appendicitis5

ultrasound CT Scan Appendix

sensitivity 85% 90-100%

specificity 92% 95-97%

Use Evaluation of the patient Evaluation of the patient

on the patient Appendicitis on the patient Appendicitis

profit Secure More accurate

relatively cheap Appendix better in

identifying normal,
Can get rid of pelvic
phlegmon and abscess
disease in women

Better in children

Loss depending operator Expensive

Technically inadequate in ionizing radiation

assessing gas
Contrast
painful

2.6 DIAGNOSIS

The differential diagnosis of appendicitis acuta is essentially a diagnosis of acute abdomen.

This is because the clinical manifestations are not specific to a specific disease but to a
physiological disorder or malfunction. So basically identical clinical picture can be obtained
from a variety of acute processes inside or around the peritoneal cavity resulting in the same
change as Appendicitis acuta. 2.6

There are some circumstances that are contraindicated surgery, but in general the processes
of disease diagnosis is often confounded by Appendicitis mostly also a matter of surgery or not
will become worse with surgery. The differential diagnosis of appendicitis depends on three
main factors: the anatomical location of the appendix inflammation, levels of process from the
simple to the perforation, as well as the age and sex of the patient. 2.6

1. Acute gastroenteritis

The disease is very common in children but are usually easily distinguished with
Appendicitis. Gastroenteritis because the virus is one of the acute infectionself-
limitedvarious reasons, which is characterized by diarrhea, nausea, and vomiting.
Hiperperistaltik abdominal pain precedes the occurrence of diarrhea. Results of laboratory
tests are usually normal.

2. Diverticulitis Meckel

These diseases pose a very similar clinical picture Appendicitis acuta. Preoperative
difference and not only theoretically important for Diverticulitis Meckel same is associated
with complications such as appendicitis and require the same treatment, namely surgery
immediately.

3. Intususseption

Diverticulitis Meckel very opposite, it is important to distinguish Intususseptionof

Appendicitis acuta because the treatment is very different. Age of the patient is very
important, appendicitis is rare under the age of 2 years, while Intususseption idiopathic
almost everything happens under the age of 2 years. Patients usually issued bloody stools
and slimy. Sausage-shaped mass can be palpated in RLQ. Therapy was chosen on
intususseption when no signs of peritonitis is a barium enema, barium enema while giving
therapy in patients Appendicitis acuta very dangerous.

4. ureter infection
 Acuta pyelonephritis, especially those located on the right side can mimic appendicitis
acuta retroileal layout. The cold, painful vertebral costo right, and especially the urine test
is usually sufficient to distinguish the two.

2.7 COMPLICATIONS

2.7.1. Perforation

2.7.2. peritonitis

2.7.3. Appendicular infiltrates

Appendicular is Appendicular infiltrates infiltrates are infiltrates / mass formed by micro or

macro perforation of the inflamed appendix which is then covered by omentum, small intestine
or large intestine. Appendix mass generally formed on the 4th day since the inflammation
begins if there is no generalized peritonitis. Appendix mass is more common in patients aged
five years or more because the immune system has been developed and omental have quite
long and thick to wrap radang.6

2.7.3.1. pathophysiology
When all the pathophysiological process Appendicitis is running slow, omentum and
adjacent bowel will move towards the Appendix to arise a local mob called Appendicularis
infiltrates. Inflammation of the appendix may be an abscess or menghilang.17
AppendicularisAppendicitis infiltrates the pathological stage which starts dimukosa and
involve all layers of the wall of the Appendix within the first 24-48 hours, this is the body's
defense effort by limiting the inflammatory process by closing the Appendix to the omentum,
small intestine, or adnexa forming periappendikular mass. Therein tissue necrosis can occur in
the form of an abscess that can be perforated. If not formed an abscess, appendicitis will recover
and periappendikular mass will be quiet for the next will unravel themselves slowly. 7
 In children, because omentum Appendix shorter and longer, thinner walls Appendix. The
condition, coupled with the immune system is still lacking ease of perforation. While parents
perforation easily happen because there darah.7 vessel disorder
The speed of the event depends on the virulence of microorganisms, endurance, fibrosis in
Appendix wall, omentum, bowel another, parietale peritoneum and other organs such as the
bladder, uterus tuba, trying to limit and localize this inflammatory process. When localizing
process is not finished and already perforation peritonitis will arise. Although the process of
localizing already finished but still not strong enough to hold prisoners or tension in the
abdominal cavity, therefore patients should really break (bedrest) .8
Who once inflamed appendix will not recover completely, but will form scar tissue that
causes adhesions with the surrounding tissue. These adhesions can cause recurrent stomach
complaint bottom right. At one time these organs can become inflamed again and expressed
acute experiencing an acute exacerbation. 8

2.7.3.2. Clinical manifestations

Appendicitis infiltrates preceded by complaints of acute appendicitis who later
accompanied periapendikular mass. The classic symptoms of acute Appendicitis usually begins
with pain in the umbilicus or periumbilikus associated with vomiting. In the 2-12 hour shift to
the right upper quadrant pain, which will be settled and is aggravated when walking or
coughing. There are also complaints of anorexia, malaise, and fever is not too high. Usually
there is also constipation, but sometimes diarrhea, nausea and vomiting. At the onset of the
disease has been no abdominal complaints are settled. But within a few hours the lower right
abdominal pain will be more progresif.7

2.7.3.3. Physical examination

Fever is usually mild, with temperatures around 37,5-38,5 C. When the temperature is
higher, it may be perforation. There can be differences axillar and rectal temperature until 1 C.
In the belly inspection found no specific description. Bloating is often seen in patients with
complications of perforation. Appendicitis infiltrates or their Appendicular abscess seen with
the protrusion on the right abdomen bawah.8
Pain on palpation obtained is limited to the right iliac region, can be accompanied by pain
off. Defense muscular stimulation peritoneum showed parietale. Lower right abdominal
tenderness is the key to diagnosis. In the lower left abdomen emphasis will feel pain in the
lower right abdomen called Rovsing sign. On Appendicitis retrosekal or retroileal required
deep palpation to determine their pain. 8
If you already formed an abscess that is, if there is omentum or other intestinal areas which
quickly stem the Appendix then in addition there is pain in the right iliac fossa for 3-4 days (the
time required for the formation of abscess) also on palpation will be palpable masses fixed with
tenderness and the top edge of a palpable mass. If Appendix intrapelvinal then the mass can be
palpated in RT (Rectal toucher) as mass hangat.7
Often normal intestinal peristalsis, peristaltic can be lost due to the paralytic ileus
generalized peritonitis due to perforated appendicitis. Digital rectal examination infections
cause pain when the area can be reached with the index finger, for example on pelvika
Appendicitis. 8
On Appendicitis pelvika stomach often dubious mark, then the key to diagnosis is limited
pain when performed a digital rectal. Digital rectal in children is not recommended. Test
examination psoas and obturator test is an examination is intended to determine the location of
Appendix.8

2.7.3.4. diagnosis
Acute Appendicitis classical history, which was followed by the painful mass in the right
iliac region and accompanied by fever, leading to mass or abscess diagnosis Appendikuler.
Diagnosis is supported by physical examination or investigation. This situation sometimes
difficult to distinguish from carcinoma of the cecum, Crohn's disease, amuboma and intra-
abdominal malignant lymphoma. It should also ruled out the possibility of intestinal
actinomycosis, enteritis, tuberculosis, and gynecological disorders such as ectopic pregnancy
Impaired (KET), Adnexitis and twisted ovarian cyst. Key to diagnosis is usually located at the
anamnesis khas.7
Tumors cecum, usually occurs in older people with a bad general state sign, anemia and
weight loss. It needs to be ensured by a colon in the loop and benzidine test. In children, the
cecum tumor that often is a sarcoma of the glands of the mesentery. On Appendicitis
tuberculosis, clinical among other complaints of pain were not so great at the right side of the
abdomen, with or without vomiting and timing of the attack may arise fever, leukocytosis
medium, usually tenderness and rigidity in the quadrant lateral bottom right, sometimes
palpable mass. 7
Appendix mass with active inflammatory process characterized by:
1. the general state of the patient is very sick, the body temperature is still high;
2. Local examination on the right lower quadrant abdominal still clearly there are signs of
peritonitis;
3. there is still a lekositosis laboratory and on counts there is a shift to the left.
Appendix mass with inflammation process which has eased with characterized by:
1. general state has improved by not look sick, the body temperature is not high anymore;
2. Local examination of the abdomen is quiet, there are no signs of peritonitis and only
palpable masses with clear boundaries with mild tenderness
3. laboratory leukocyte count and differential count normal.6

2.7.3.5. Management
The journey begins at the moment of pathological diseases Appendix be covered by
omentum and small intestine rolls nearby. At first, the mass formed composed of a mixture of
these buildings and the granulation tissue and usually can be immediately perceived clinically.
If inflammation of the appendix can not overcome the obstacles so that the patient continues to
experience a general peritonitis, the masses had become filled with pus, initially in small
amounts, but it soon became obvious abscess batasnya.7
The pathological sequence is a problem for the surgeon. This issue was whether patients
met through about 48 hours, the surgeon will operate to throw Appendix which may gangrene,
of the mass of the attachment of lightweight loose and very dangerous, and because this mass
has become more fixed, thus making a dangerous operation then have to wait for the
establishment of abscess that can easily didrainase.7
Massa Appendix Appendicitis occurs when a gangrenous or mikroperforasi covered or
wrapped in omentum and small intestine or curves. In mass periappendikular that
pendindingannya not perfect, can occur throughout the peritoneal cavity of pus deployment if
perforation followed generalized purulent peritonitis. In children, prepared for operation within
2-3 days. Adult patients with masses periappendikular clamped with perfect fencing,
recommended for treatment in advance and were given antibiotics while supervised body
temperature, the size of the mass, as well as the extent of peritonitis. If there is no fever,
periapendikular mass is lost, and normal leukocytes, the patient can go home and elective
appendectomy can be done 2-3 months later in order to bleeding, adhesions can be minimized.
When the perforation, Appendix abscess is formed. It is characterized by the increase in
temperature and pulse frequency, increased pain and swelling palpable mass, and increased
numbers of leukocytes. 7
 Management Appendicular infiltrates in children is still controversial. From the results of
the case study infiltrates Appendicular therapy in children, most of whom are conservative ie
with strict observation and antibiotics, intravenous fluids, and NGT installation when needed.
Conservative lasted for ± 6 days in the hospital, and then planned to do an elective
appendectomy after 4-6 weeks later to prevent possible recurrence risk and wider perforation.
From the research result of complications after surgery with conservative treatment in advance
much less when compared with surgical treatment as soon as an injury to the ileum (ileal
injury), intrabdominal abscesses, infections due to injuries during the operation. So that the
non-operative therapy in appendicular infiltrates followed by elective appendectomy is a safe
and effective method. The therapy is similar to that in adults is conservatively first, followed
by elective appendectomy. This is because to prevent postoperative complications and the risk
of major surgical procedures (extensive) .2

In children, if conservatively does not improve or develop into an abscess, recommended

for immediate surgery. In adult patients, appendectomy planned at Appendicular infiltrates
without any pus that has been pacified. Previous patient is given antibiotics active against a
combination of aerobic and anaerobic bacteria. Only after the state of calm, which is about 6-
8 weeks later do Appendectomy.2

Lately there is Management of the latest therapy with PLD (Primary Laparoscopic
Drainage) which can be followed by LA (Laparoscopic appendectomy). The PLD average
surgery takes about 80-100 minutes, oral food can be given 2-3 days after the PLD, a decrease
in the patient's body heat becomes afebrile in 4-7 days after the PLD, intravenous antibiotics
can be removed 4-5 days after, treatment at the hospital between 7-15 days. PLD is not proven
there are complications during intra and post operation, whereas when followed by LA, the
complications that can occur is the adhesion obstruction usus.2

When it happens abscess, recommended for drainage alone and appendectomy is done after 6-
8 weeks later. If it does not find any complaints or symptoms, and physical and laboratory
examination showed no signs of inflammation or abscess, can be considered canceling the
action bedah.2
2.8 MANAGEMENT

The management of patients Appendicitis acuta ie 1,2,3,6,7

1.Pemasangan crystalloid infusion and administration to patients with clinical symptoms

of dehydration or septicemia.

2. Puasakan patient, do not give anything by mouth

3. Provision of drugs and analgesics should be in consultation with the surgeon.

4. Antibiotics iv in patients undergoing laparotomy.

5. Consider the possibility of an ectopic pregnancy in women of childbearing age and beta-
hCG obtained qualitatively positive.

When the surgery, surgical therapy include; Prophylactic antibiotics should be

administered before surgery begins in acute cases, usedsingle dose selected antibiotics that can
fight anaerobic bacteria.

Appendectomy surgery techniques 1,2,6,:

a. open appendectomy

1. Aseptic and antiseptic action.

2. Skin incision is made:
horizontal
 Oblique

3. Muscle incision is made, there are two ways:

a. Pararectal / paramedian
The incision / incisions on vaginae tendineae M. rectus abdominis muscle then set
aside to medial. Fascia clamped until the closing of the vagina M. rectus abdominis
as fascianya No 2 in order to not fall behind at the time of sewing. When sewn only
one layer of fascia course, can happen cicatricalis hernia.

b. Mc Burney / Wechselschnitt / muscle-splitting

The incision varies according to the muscle fibers.

1) Apponeurosis incision M. obliquus externus abdominis from lateral to medial

down.
 Caption:

One neat skin incisions made with a blade belly. The second incision of the
subcutaneous tissue to the fascia M. obliquus externus abdominis.

2) Splitting M. obliquus internus abdominis from medial to lateral the top down.

Caption:

From the edge of the rectus sheath, thin fascia M. obliquus internus diincisi
direction of the fiber laterally.

3) Splitting M. transversus abdominis horizontal direction.

Caption:
 At the time of draw M. obliquus internus let cautious so there are no tissue
trauma. It may be added that the vessels N. memperdarahinya iliohipogastricus
and located laterally between M. obliquus externus and internus. Pull too hard
will rip endangering vessels and nerves.

4. The peritoneum is opened.

Caption:

Laparotomy gauze fitted on all exposed subcutaneous tissue. The peritoneum often
appears inflamed, describes the process that lay beneath. Peritoneum piece lifting with
tweezers. Visible here is the De Bakey tissue forceps. Now also raised the same way
on the side next to the surgeon. The surgeon releases tweezers, put up again until he is
convinced that only the peritoneum is lifted.

5. Sought cecum is then removed and then taenia libera traced to seek Appendix. After
Appendix discovered, Appendix clamped with a clamp Babcock direction is always up
(to prevent contamination to the surrounding tissue).
Appendix released from mesoappendix by:

Mesoappenddix penetrated with sonde Kocher and on both sides, clamped, then cut in
between two ties.
 Caption:

Appendix carefully lifted in order mesenteriumnya stretched. Babcock clamp and a

clamp encircling appenddix inserted through the mesentery as shown. Another way is
to clamp the free end of the mesentery under appenddix end. Appendix too much should
not be touched and held so as not to spread the contamination.

6. Appendix in the clamp on the base (so that the groove is formed so that the bond grew
even stronger because the mucosal disconnected while throwing fecalith toward the
cecum). Clamps moved slightly distally, and the former first clamp fastened with thread
absorbed (that can be separated so that no cavity is formed and when formed pus will
get into the cecum).

7. Appendix cut between ties and clamps, butts by betadine.

 8. Appendix butts treatment can be done by:
a. Tabak stitching sacks made in the cecum, appendix stump into the cecum inverted.
Tabak sacks can be coupled with stitching Z.
b. A stump sewn with thread that is not absorbed. The risk of contamination and
adhesion.
c. When the procedure a + b can not be implemented, for example, when butts fragile,
do sewing two layers such as bowel perforation.

9. When no.7 can not be done, then the Appendix is cut first, then released and
mesenteriolumnya (retrograde).
10. The abdominal wall sutured layer by layer.

b. laparoscopic appendectomy

laparoscopycan be used as a means of diagnosis and therapeutic for patients with acute
abdominal pain and suspected appendicitis acuta. Laparoscopy is very useful for examining
women with lower abdominal complaints. By using a laparoscope will easily distinguish acute
gynecological diseases of Appendicitis acuta.1
 Figure 3.10. Laparoscopic appendectomy operation Position 1

2.9 COMPLICATIONS OF OPERATIONS POST 1

1.Fistel berfaeces gangrenous appendicitis, or fistulas do not berfaeces; due to foreign

objects, tuberculosis, Actinomycosis.

2.Hernia cicatricalis.

3.Ileus

4.Perdarahan of the digestive tract: mostly occurs 24-27 hours after appendectomy,
sometimes after 10-14 days. The source is echymosis and small erosion in the stomach
and jejunum, probably due to the retrograde embolism of portal system into a vein in
the stomach / duodenum.

2. 10 PROGNOSIS

Mortality of Appendicitis in the USA declined steadily from 9.9% per 100,000 in 1939 to
0.2% per 100,000 in 1986. The factors that lead to decrease significantly the incidence of
appendicitis is a means of diagnosis and therapy, antibiotics, IV fluids, which the better, the
availability of blood and plasma, as well as the increase in the percentage of patients who
received appropriate treatment before perforation.
 CHAPTER III
CONCLUSION

Appendicitis is an inflammation of the appendix vermicularis. Appendix is a derivative part

of the midgut, the anatomical location may be different for each individual. Appendicitis is an
acute abdominal surgery cases are most commonly found. Factors to be etiologic and
predisposing factors include obstruction Appendicitis, bacteriology, and diet. Obstruction of
the lumen is the primary culprit in Appendicitis acuta.
Clinical symptoms of Appendicitis include abdominal pain, anorexia, nausea, vomiting,
pain shifts, and classic sequelae of pain periumbilikal then anorexia / nausea / vomiting and
then the pain shifts to RLQ then fever is not too high. Clinical signs that can be found and
maneuver diagnostics in case of appendicitis is Rovsing's sign, psoas sign, Obturator sign,
Blumberg's sign, Wahl's sign, Baldwin test, Dunphy's sign, Defense musculare, pain in the area
of the cavity Douglas when there is an abscess in the abdominal cavity or Appendix layout
pelvic pain toucher rectal examination.

Investigations in the diagnosis of appendicitis is a laboratory examination, Scores

Alvarado, ultrasound and radiology. The differential diagnosis of appendicitis, among others;
Adenitis Mesenterica Acuta, Acute gastroenteritis, Urogenital diseases in men, Diverticulitis
Meckel, Intususseption, Crohn's enteritis, perforated peptic ulcer, Epiploic appendagitis,
urinary tract infections, stones urethra, peritonitis primary, Henoch-Schonlein, Yersiniosis, as
well as abnormalities gynecology.

Complications that can be caused by appendicitis is perforation, peritonitis, Appendicular

infiltrates, Appendicular abscess, septic shock, mesenterial pyemia with hepatic abscess, and
bleeding GIT. Appendicitis acuta patient management include; crystalloid administration to
patients with clinical symptoms of dehydration or septicemia, puasakan patients, analgesics
should be in consultation with the surgeon, iv antibiotic therapy in patients undergoing
laparotomy.

Appendicular infiltrates a complication of appendicitis acuta. Appendicular infiltrates are

inflammatory processes Appendix the distribution may be restricted by the omentum and
intestines and peritoneum around it to form a mass (appendiceal mass) were more common in
patients aged 5 years or more because the immune system has been developed and omental
been quite long and thick to wrap up the process of inflammation.
 The etiology and pathophysiology Appendicular infiltrates preceded by their Appendicitis
acuta. Starting from focal acute appendicitis acute suppurative appendicitis gangrenous
appendicitis (the first stage of appendicitis with complications) can occur three possibilities:
o Perforated Appendicitis, a spread of contamination in space or peritoneal cavity will
cause a generalized peritonitis.
o Appendicular occurs when the immune infiltrates good (mass will gradually shrink and
disappear)
o Chronic appendicitis, an appendicitis attack that has healed over.
Appendicular infiltrates can be diagnosed based on the history of Appendicitis acuta
anamnesis, physical examination form palpable mass in the RLQ tenderness. Diagnosis
Appendicular infiltrates tumors can be diagnosed compared with the cecum, intra-abdominal
malignant lymphoma, tuberculosis Appendicitis, amoeboma, Crohn's disease, as well as
gynecological disorders such as KET, adneksitis or torsion of ovarian cysts.
Appendicular therapy is best infiltrates non-operative therapy (conservative) followed by
elective appendectomy (6-8 weeks later), but if the fixed mass and abdominal pain means the
patient increases have occurred abscess and mass should be opened and drained.
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