GIS-K-25

ACUTE APPENDICITIS
Appendiceal Mass / Abscess
Syahbuddin Harahap
Division of Digestive Surgery
Department of Surgery
Faculty of Medicine University of North Sumatera
Adam Malik Hospital
INTRODUCTION

The appendix is :

-Wormlike extension of the cecum (vermiform appendix).

-Length is 8-10 cm (ranging from 2-20 cm).

-Fifth month of gestation

-Several lymphoid follicles.

Etiology:
Obstruction of the lumen appendix followed by infection

Catarrhal appendicitis.
-lymphoid hyperplasia (60% children)
-Gastro enteritis
-Virus
-Acute respiratory infection
-Mononucleosis

Obstructive appendicitis
-fecalith 35% adults.

-foreign body / parasites (4%)

- tumors (1%)
 Pathophysiology
Wangensteen proposed
1. Closed loop obstruction
2. Increase in luminal pressure.
3. Exceeds capillary pressure causes mucosal ischemia
4. Luminal bacterial overgrowth and translocation bacteria across the
appendiceal wall result :
-Inflammation
-Edema
-Necrosis  perforation occur about 48 hours .

If the body successfully walls off the perforation Appendiceal Mass

If the perforation is not successfully walled off  Diffuse peritonitis will
develop.
Problem:

Appendicitis can mimic several abdominal conditions.

Laboratory test
Imaging investigation

Statistics report
1 of 5 cases is misdiagnosed

Normal appendix is found in

15-40% Emergency appendectomy.(Negative Appendectomy)
 Differential diagnosis of acute appendicitis
Surgical Urological
• Acute Intestinal obstruction • Right ureteric colic

• Intussusception • Right pyelonephritis

• Acute cholecystitis • Urinary tract infection

• Perforated peptic ulcer • Right Acute epididymitis

• Mesenteric adenitis Gynaecological

• Acute Meckel's diverticulitis • Ectopic pregnancy

• Acute Pancreatitis • Ruptured ovarian follicle

Medical • Torted ovarian cyst

• Gastroenteritis
• Basal Pneumonia dextra • Salpingitis/pelvic inflammatory disease
• Terminal ileitis
Differential diagnosis of appendicitis appendicitis
can mimic several abdominal conditions.
Lab Studies:

Complete blood cell count

A mild elevation of WBCs (ie, >10,000/µL)

Urinalysis

Mild pyuria relationship of the appendix with the right

ureter.

Severe pyuria in UTI.

For women of childbearing age,

Ectopic pregnancy test urin (beta-hCG)
 On physical examination

•Lying down

•Flexing their hips

•The most common symptom of appendicitis is :

- Acute abdominal pain.
- Epigastric or Periumbilical pain migrating to the
right lower quadrant (RLQ) of the abdomen.
- Vomiting, nausea, and anorexia
- Afebrile or has a low-grade fever , 38 º C

•Higher fevers are associated with a perforated appendix

 Special maneuvers
McBurney sign

McBurney's point
it is only the area
of greatest tenderness

Blumberg sign

Rovsing’s Sign

Dunphy sign Cough Test

Obturator sign

Psoas sign

Markle sign
Location appendix during pregnancy
INDICATIONS

Consider an appendectomy for patients with a

history of :

•Persistent abdominal pain

•Fever
•Clinical signs of localized or diffuse peritonitis
•Especially if leukocytosis is present.
 Imaging Studies
Abdomen plain film:
Fecalith within the appendix
Urolithiasis right middle third
 normal less than 6 mm
Sonography
Advantages of sonography

1. Noninvasiveness,
2. Short acquisition time
3. Lack of radiation exposure
4. Potential for diagnosis of
other causes of abdominal
pain
5. Pediatric patients
6. Women of childbearing age.
7. Pregnant women
 CT scan more than 6 mm

-Oral contrast medium

-Rectal Gastrografin enema

Reserved for patients

-Uncertain diagnosis
-Severe obesity.
 Complications
• Perforation
• General Secondary Peritonitis
• Appendiceal Mass
• Appendiceal Abscess
• Pylephlebitis is suppurative thrombophlebitis of the
portal venous system
• Hepatic absces
• Chills
• High fever
• Jaundice
 TREATMENT
Medical therapy

Resuscitated adequately with fluids .

Preoperative prophylactic antibiotics

-Acute Appendicitis single agent second-generation
cephalosporin.
-Perforated appendix triple antibiotic therapy
Ampicillin , gentamycin , metronidazol

Antibiotic prophylaxis should be administered before every

appendectomy.

Antibiotic treatment may be stopped.

-Becomes afebrile
-WBC count normalizes
Two approaches to appendectomy

1. Open Emergency Appendicectomy ( Appendectomy)

2. Laparoscopic appendectomy

 If normal appendix removed need to look for:

- Meckel's diverticulum
- Acute salpingitis
- Crohn's disease
If the body successfully walls off the localized perforation

Appendiceal Mass
RLQ mass
The pain may actually improve.
Symptoms do not completely resolve.
Still have right lower quadrant pain
Decreased appetite
Change in bowel habits (eg, diarrhea, constipation)
Intermittent low-grade fever.
Treatment of

Appendiceal Mass
Nonoperative management
Becomes walled off by omentum and ajacent viscera.
Initially treated with intravenous broad-spectrum antibiotic

Appendiceal Abscess  USG or CT scan

-Percutaneous aspiration
-Drain placement
Intravenous antibiotics are continued until the patient
- afebrile for 24 hours
- return of normal gastrointestinal function
- normal WBC count with a normal differential.
At this time, patients are switched to oral antibiotics for a total antibiotic
course of 10-14 days.

Traditionally, interval appendectomy is performed 6-8 weeks

later.
Appendicitis Perforation