CASE PRESENTATION

APPENDICITIS

By :
FINDA SAFITRI
110.2011.106

Councelor:
dr. HERRY SETYA YUDHA UTAMA, Sp.B, MH.Kes, FINACS

CLINICAL CLERKSHIP OF SURGERY DEPARTMENT

FACULTY OF MEDICINE YARSI UNIVERSITY
ARJAWINANGUN DISTRICT GENERAL HOSPITAL
2015
CASE PRESENTATION

I.Identity
Name
Age
Gender
Tribe
Occupation
Address
In hospital since
II.

III.

: Mrs. A
: 30 years old
: Female
: Javenese
: House wife
: Cupang
: August 23th 2015

Anamnesis
- Main Complaint

: Pain in the lower right side of the abdomen

:-

Additional Complaint

History of Disease
A woman came to Arjawinangun hospital because of a pain in the lower right side of abdomen
since 2 days ago. The pain is sudden and continous. No vomiting, but feeling nauseous. No
fever.

IV.

History of Past Disease

-

V.

History of Family Disease

Same kind of disorder (-)

VI.
Physical Examination
General Status
Present Status
1

General Condition
Awareness
Blood Pressure
Pulse
Breathing
Temperature

: Bad
: Compos mentis
: 120/80
: 78 x/minute
: 20 x/minute
: 36,8 C

Head
Form
Hair
Eye

: Normocephale, Symmetrical
: Black, No hair fall
: Anemic Conjungtivas (-/-), Icteric Schleras (-/-), Light Reflexes (+/+), isochore pupil

Ear
Nose
Mouth

right = left
: Normal form, cerumen (-), thympany membrane intact
: Normal form, no septum deviation, epitaxis (-/-)
: Normal

Neck
Enlargement of lymph nodes (-)
Trachea is in the middle
No mass found
Thorax
Lungs - pulmonary
Inspection
: The chest shape is symmetrical both left and right
Palpation
: Fremitus and vocale tactile both symmetrical left and right, crepitation (-),
tenderness (-), rebound tenderness (-)
Percussion
: Resonance sound in both lung fields
Auscultation : Vesicular and bronchial sound in the entire lung field, rhonchi (-/-), wheezing (-/-)

Abdomen
Inspection
Palpation
Percussion
Auscultation
Extremities
Upper

Lower

: Flat, symmetrical, mass (-)

: Tenderness (+), rebound tenderness (+) a/r iliaca dextra,
: Tympanity sound in four quadrants
: Bowel sound (+)
: Muscle Tone
Movement
Mass
Strenght
Oedema
: Muscle Tone

: normal
: active / active
:-/: 5/5
:-/: normal
2

Movement
Mass
Strenght
Oedema
Genitalia

: active / active
: - /: 5/5
:-/-

: No abnormalities

Localized Status
Laboratory Examination

Routine Blood
Test
WBC
RBC
HGB
HCT
MCV
MCH
MCHC
RDW
PLT
Neut
Lymph
Mono
Eos
Baso
Luc

Result
17,4
5,3
12,0
36,4
78,3
24,3
33,3
15,3
302
64,0
26,7
6,5
4,7
0,6
2,7

Test
Ureum
Creatinin

Result
23,9
0,63

Unit
10e3/L
10e6/ L
g/dL
%
fL
Pg
g/dl
%
10e3/ L
%
%
%
%
%
%

Unit

Diagnosis
Appendicitis
Differential Diagnosis
Two main differential diagnosis:
1. Urethrolithiasis
2. Ectopic pregnancy

Management
Operative

: Open Appendectomy

Prognosis
Quo ad vitam

: Ad bonam
3

Quo ad fungsionam
Quo ad sanationam

VII.

: Dubia ad bonam
: Ad bonam

Literature Review

DEFINITION
Appendicitis is defined as an inflammation of the inner lining of the vermiform appendix that spreads
to its other parts. Despite diagnostic and therapeutic advancement in medicine, appendicitis remains a
clinical emergency and is one of the more common causes of acute abdominal pain.
ANATOMY
The appendix is a wormlike extension of the cecum and, for this reason, has been called the
vermiform appendix. The average length of the appendix is 8-10 cm (ranging from 2-20 cm). The
appendix appears during the fifth month of gestation, and several lymphoid follicles are scattered in
its mucosa. Such follicles increase in number when individuals are aged 8-20 years. A normal
appendix is seen below.

The appendix is contained within the visceral peritoneum that forms the serosa, and its exterior layer
is longitudinal and derived from the taenia coli; the deeper, 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.
Taenia coli converge on the posteromedial area of the cecum, which is the site of the appendiceal
base. The appendix runs into a serosal sheet of the peritoneum called the mesoappendix, within which
4

courses the appendicular artery, which is derived from the ileocolic artery. Sometimes, an accessory
appendicular artery (deriving from the posterior cecal artery) may be found.

EPIDEMIOLOGY
Appendicitis is one of the more common surgical emergencies, and it is one of the most common
causes of abdominal pain.
In Asian and African countries, the incidence of acute appendicitis is probably lower because of the
dietary habits of the inhabitants of these geographic areas. The incidence of appendicitis is lower in
cultures with a higher intake of dietary fiber. Dietary fiber is thought to decrease the viscosity of
feces, decrease bowel transit time, and discourage formation of fecaliths, which predispose
individuals to obstructions of the appendiceal lumen.
There is a slight male preponderance of 3:2 in teenagers and young adults; in adults, the incidence of
appendicitis is approximately 1.4 times greater in men than in women. The incidence of primary
appendectomy is approximately equal in both sexes.
The incidence of appendicitis gradually rises from birth, peaks in the late teen years, and gradually
declines in the geriatric years. The mean age when appendicitis occurs in the pediatric population is 610 years. Lymphoid hyperplasia is observed more often among infants and adults and is responsible
for the increased incidence of appendicitis in these age groups. Younger children have a higher rate of
perforation, with reported rates of 50-85%. The median age at appendectomy is 22 years. Although
rare, neonatal and even prenatal appendicitis have been reported. Clinicians must maintain a high
index of suspicion in all age groups.

ETIOLOGY
Appendicitis is caused by obstruction of the appendiceal lumen. The most common causes of luminal
obstruction include lymphoid hyperplasia secondary to inflammatory bowel disease (IBD) or
infections (more common during childhood and in young adults), fecal stasis and fecaliths (more
common in elderly patients), parasites (especially in Eastern countries), or, more rarely, foreign bodies
and neoplasms.
Fecaliths form when calcium salts and fecal debris become layered around a nidus of inspissated fecal
material located within the appendix. Lymphoid hyperplasia is associated with various inflammatory
and infectious disorders including Crohn disease, gastroenteritis, amebiasis, respiratory infections,
measles, and mononucleosis.
Obstruction of the appendiceal lumen has less commonly been associated with bacteria (Yersinia
species, adenovirus, cytomegalovirus, actinomycosis, Mycobacteria species, Histoplasma species),
parasites (eg, Schistosomes species, pinworms, Strongyloides stercoralis), foreign material (eg,
shotgun pellet, intrauterine device, tongue stud, activated charcoal), tuberculosis, and tumors.

PATHOPHYSIOLOGY
Reportedly, appendicitis is caused by obstruction of the appendiceal lumen from a variety of causes
(see Etiology). Independent of the etiology, obstruction is believed to cause an increase in pressure
within the lumen. Such an increase is related to continuous secretion of fluids and mucus from the
mucosa and the stagnation of this material. At the same time, intestinal bacteria within the appendix
multiply, leading to the recruitment of white blood cells (see the image below) and the formation of
pus and subsequent higher intraluminal pressure.
If appendiceal obstruction persists, intraluminal pressure rises ultimately above that of the
appendiceal veins, leading to venous outflow obstruction. As a consequence, appendiceal wall
ischemia begins, resulting in a loss of epithelial integrity and allowing bacterial invasion of the
appendiceal wall.
Within a few hours, this localized condition may worsen because of thrombosis of the appendicular
artery and veins, leading to perforation and gangrene of the appendix. As this process continues, a
periappendicular abscess or peritonitis may occur.

STAGES OF APPENDICITIS
6

The stages of appendicitis can be divided into early, suppurative, gangrenous, perforated,
phlegmonous, spontaneous resolving, recurrent, and chronic.
1. Early stage appendicitis
In the early stage of appendicitis, obstruction of the appendiceal lumen leads to mucosal edema,
mucosal ulceration, bacterial diapedesis, appendiceal distention due to accumulated fluid, and
increasing intraluminal pressure. The visceral afferent nerve fibers are stimulated, and the patient
perceives mild visceral periumbilical or epigastric pain, which usually lasts 4-6 hours.
2. Suppurative appendicitis
Increasing intraluminal pressures eventually exceed capillary perfusion pressure, which is associated
with obstructed lymphatic and venous drainage and allows bacterial and inflammatory fluid invasion
of the tense appendiceal wall. 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.
3. Gangrenous appendicitis
Intramural venous and arterial thromboses ensue, resulting in gangrenous appendicitis.
4. Perforated appendicitis
Persisting tissue ischemia results in appendiceal infarction and perforation. Perforation can cause
localized or generalized peritonitis.
5. Phlegmonous appendicitis or abscess
An inflamed or perforated appendix can be walled off by the adjacent greater omentum or smallbowel loops, resulting in phlegmonous appendicitis or focal abscess.
6. Spontaneously resolving appendicitis
If the obstruction of the appendiceal lumen is relieved, acute appendicitis may resolve spontaneously.
This occurs if the cause of the symptoms is lymphoid hyperplasia or when a fecalith is expelled from
the lumen.
7. Recurrent appendicitis
The incidence of recurrent appendicitis is 10%. 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 appendicitis
Chronic appendicitis occurs with an incidence of 1% and is defined by the following: (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.
7

CLINICAL SIGN
No single sign, symptom, or diagnostic test accurately confirms the diagnosis of appendiceal
inflammation in all cases. The clinical presentation of appendicitis is notoriously inconsistent. The
classic history of anorexia and periumbilical pain followed by nausea, right lower quadrant (RLQ)
pain, and vomiting occurs in only 50% of cases. Features include the following:

Abdominal pain: Most common symptom

Nausea: 61-92% of patients

Anorexia: 74-78% of patients

Vomiting: Nearly always follows the onset of pain; vomiting that precedes pain suggests
intestinal obstruction

Diarrhea or constipation: As many as 18% of patients

Features of the abdominal pain are as follows:

Typically begins as periumbilical or epigastric pain, then migrates to the RLQ.

Patients usually lie down, flex their hips, and draw their knees up to reduce movements and to
avoid worsening their pain

The duration of symptoms is less than 48 hours in approximately 80% of adults but tends to
be longer in elderly persons and in those with perforation.

DIAGNOSIS
Physical Examination
The most specific physical findings in appendicitis are rebound tenderness, pain on percussion,
rigidity, and guarding. Tenderness on palpation in the RLQ over the McBurney point is the most
important sign in these patients.
The following accessory signs may be present in a minority of patients:

Rovsing sign (RLQ pain with palpation of the LLQ): Suggests peritoneal irritation

Obturator sign (RLQ pain with internal and external rotation of the flexed right hip): Suggests
the inflamed appendix is located deep in the right hemipelvis

Psoas sign (RLQ pain with extension of the right hip or with flexion of the right hip against
resistance): Suggests that an inflamed appendix is located along the course of the right psoas
muscle
8

Dunphy sign (sharp pain in the RLQ elicited by a voluntary cough): Suggests localized
peritonitis

RLQ pain in response to percussion of a remote quadrant of the abdomen or to firm

percussion of the patient's heel: Suggests peritoneal inflammation

Markle sign (pain elicited in a certain area of the abdomen when the standing patient drops
from standing on toes to the heels with a jarring landing): Has a sensitivity of 74%

Diagnostic Scoring
Several investigators have created diagnostic scoring systems to predict the likelihood of acute
appendicitis.
The best known of these scoring systems is the MANTRELS score, which tabulates migration of pain,
anorexia, nausea and/or vomiting, tenderness in the RLQ, rebound tenderness, elevated temperature,
leukocytosis, and shift to the left.

Laboratory tests
The white blood cell count (WBC) and CRP are of diagnostic value. The WBC usually exceeds
10,000/mm3. In severe cases associated with diffuse peritonitis, however, the WBC may be decreased
rather than increased, so care must be taken. Although the CRP rises in appendicitis, the increase is
not necessarily associated with the severity of inflammation
CBC

WBC >10,500 cells/L: 80-85% of adults with appendicitis

Neutrophilia >75-78% of patients

Less than 4% of patients with appendicitis have a WBC count less than 10,500 cells/L and
neutrophilia less than 75%
9

In infants and elderly patients, a WBC count is especially unreliable because these patients may not
mount a normal response to infection. In pregnant women, the physiologic leukocytosis renders the
CBC count useless for the diagnosis of appendicitis.
C-reactive protein

CRP levels >1 mg/dL are common in patients with appendicitis

Very high levels of CRP in patients with appendicitis indicate gangrenous evolution of the
disease, especially if it is associated with leukocytosis and neutrophilia

In adults who have had symptoms for longer than 24 hours, a normal CRP level has a
negative predictive value of 97-100% for appendicitis

Urinary 5-HIAA
HIAA levels increase significantly in acute appendicitis and decrease when the inflammation shifts to
necrosis of the appendix. Therefore, such decrease could be an early warning sign of perforation of
the appendix.
Imaging diagnosis
Plain abdominal radiographs show no particular evidence of appendicitis. Ultrasonography and CT
scanning are of diagnostic value, and provide useful information for determining whether or not
appendectomy is necessary.
1) Abdominal ultrasonography
Because this minimally invasive examination is easy to perform and can be repeated, it is essential for
diagnosing acute appendicitis. A normal appendix is usually not imaged by ultrasonography. When it
is involved by inflamma- tion and enlarges, however, it can be visualized
The features of appendicitis include hyper hypertrophy of the appendiceal wall, disturbance of
the normal layered structure, destruction of the wall, and purulent fluid or fecaliths within the
appendiceal lumen. Thus, ultrasonography is superior to CT for assessing the severity of appendicitis
depending on the mural changes.
2) Abdominal CT
CT is superior to ultrasonography in some respects, because its findings are more objective and it is
not affected by the presence of intestinal gas. The diagnosis of appendicitis by CT depends on
hypertrophy of the appendiceal wall, enlargement of the appendix, periappendiceal abscess formation,
the presence of a fecalith, increased density of periappendiceal adipose tissue, and/or the presence of
ascites in the pouch of Douglas. CT can depict an enlarged appendix, but cannot visualize the
structure of the wall unlike ultrasonography.

10

TREATMENT
Emergency department care is as follows:

Establish IV access and administer aggressive crystalloid therapy to patients with clinical
signs of dehydration or septicemia

Keep patients with suspected appendicitis NPO

Administer parenteral analgesic and antiemetic as needed for patient comfort; no study has
shown that analgesics adversely affect the accuracy of physical examination.

Surgical
Appendectomy remains the only curative treatment of appendicitis, but management of patients with
an appendiceal mass can usually be divided into the following 3 treatment categories:

Phlegmon or a small abscess: After IV antibiotic therapy, an interval appendectomy can be

performed 4-6 weeks later

Larger well-defined abscess: After percutaneous drainage with IV antibiotics is performed,

the patient can be discharged with the catheter in place; interval appendectomy can be
performed after the fistula is closed

Multicompartmental abscess: These patients require early surgical drainage

Types of appendectomy:
-

Laparoscopic Appendectomy
The appendix is removed with instruments placed into small abdominal incisions. The surgeon
makes 1 to 3 small incisions in the abdomen. A port (nozzle) is inserted into one of the slits, and
carbon dioxide gas inflates the abdomen to make it easier to see the appendix. A laparoscope is
inserted through another port. Surgical instruments are placed in the other small openings and
used to remove the appendix.

11

Open appendectomy
The appendix is removed through an incision in the lower right abdomen. The surgeon makes an
incision about 2 to 4 inches long in the lower right side of the abdomen. The appendix is removed
from the intestine.

Based on emergency:

Appendectomy cito (acute appendicitis, abcess, dan perforation)

Appendectomy elective (chronic appendicitis) usually in 2-3 months.
Conservative then elective operation (infiltrate appendicitis)
Acute appendicitis operation is called A. Chaud
Chronic appendicitis operation is called A. Froid

Medication
The goals of therapy are to eradicate the infection and to prevent complications. Thus, antibiotics have
an important role in the treatment of appendicitis, and all such. Agents under consideration must offer
full aerobic and anaerobic coverage. The duration of the administration is closely related to the stage
of appendicitis at the time of the diagnosis.
Antibiotic agents are effective in decreasing the rate of postoperative wound infection and in
improving outcome in patients with appendiceal abscess or septicemia. The Surgical Infection Society
recommends starting prophylactic antibiotics before surgery, using appropriate spectrum agents for
less than 24 hours for nonperforated appendicitis and for less than 5 days for perforated appendicitis.
Broad-spectrum gram-negative and anaerobic coverage is indicated . Cefotetan and cefoxitin seem to
be the best choices of antibiotics. In penicillin-allergic patients, carbapenems are a good option.
Antibiotic treatment may be stopped when the patient becomes afebrile and the WBC count
normalizes
COMPLICATION
a. Peritonitis
Perforation of the appendix can lead to a peri-appendiceal abscess (a collection of infected pus) or
diffuse peritonitis (infection of the entire lining of the abdomen and the pelvis). The risk of
perforation 36 hours after the onset of symptoms is at least 15%. Therefore, once appendicitis is
diagnosed, surgery should be done without unnecessary delay.
b. Obstruction
A less common complication of appendicitis is blockage or obstruction of the intestine. Blockage
occurs when the inflammation surrounding the appendix causes the intestinal muscle to stop working,
and this prevents the intestinal contents from passing. If the intestine above the blockage begins to fill
with liquid and gas, the abdomen distends and nausea and vomiting may occur.

PROGNOSIS

12

Acute appendicitis is the most common reason for emergency abdominal surgery. Appendectomy
carries a complication rate of 4-15%, as well as associated costs and the discomfort of hospitalization
and surgery. Therefore, the goal of the surgeon is to make an accurate diagnosis as early as possible.
Delayed diagnosis and treatment account for much of the mortality and morbidity associated with
appendicitis.
The overall mortality rate of 0.2-0.8% is attributable to complications of the disease rather than to
surgical intervention. The mortality rate in children ranges from 0.1% to 1%; in patients older than 70
years, the rate rises above 20%, primarily because of diagnostic and therapeutic delay.

BIBLIOGRAPHY
F Charles Brunicardi, et al. Schwartz Principles of Surgery Ed.10. Mc.Graw-Hill Education.
Sjamsuhidajat, De Jong. 2010. Buku Ajar Ilmu Bedah ed.3. EGC: Jakarta.
Price SA, Wilson LM. 2003. Patofisiologi: Konsep Kllinis dan Proses-Proses Penyakit Ed.6. EGC:
Jakarta.
13

http://emedicine.medscape.com/article/773895-overview
https://www.med.upenn.edu/gastro/documents/BMJappendicitis.pdf

14