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Appendicitis
Appendicitis
Appendix
An immunologic organ
Secrete Ig; particularly IgA
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
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Pathophysiology
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Pathophysiology
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Lymphatic obstruction
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Pathophysiology
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Pathophysiology
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edema
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Pathophysiol
ogy
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ischemic
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
Pathophysiology
If the sequence of events occurs slowly
Localized peritonitis
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
peritoneal
lining of the
Gradually moves toward the umbilicus
RLQ abdomen
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
Clinical Presentation
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
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
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)
Differential Diagnosis
(based on group of age)
UTI
Differential Diagnosis
(based on group of age)
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
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)
Acute salpingitis
Tubo-ovarian abscess
Endometriosis
Differential Diagnosis
(Gynecologic Disorders)
In women of childbearing
years
Recent menstrual history
Pelvic examination
Differential Diagnosis
(Gynecologic Disorders)
Differential Diagnosis
(Gynecologic Disorders)
Differential Diagnosis
(Gynecologic Disorders)
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
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
Crohns disease
Inflamed or perforated Meckels diverticulum