Professional Documents
Culture Documents
Appendicitis
Appendicitis
Appendicitis
• 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
…..
Pathophysiology
…..
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
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
Rovsing’s 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 patient’s age
• The patient’s sex
Differential Diagnosis
(based on group of age)
Preschool children
• Intussusception
Colicky-type pain
< 3 y.o.
Mass with no true peritonitis
• Meckel’s 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)