Appendicitis

Rizky Fauzi 030.09.212

Lecturer : dr. Aplin Ismunanto Sp.B

Introduction
appendicitis is inflammation of the vermiform appendix due to an obstruction its most common between puberty and age 30 In the United States, 250,000 cases of appendicitis are reported annually, representing 1 million patient-days of admission. Man : Woman = 3:2

Definition
Appendicitis is an inflammation of the appendix, which is the small, finger-shaped pouch attached to the beginning of the large intestine on the lowerright side of the abdomen. Appendicitis is a medical emergency, and if left untreated, the appendix may rupture and cause a potentially fatal infection.

Etiology

Appendicitis is caused by obstruction of the appendiceal lumen

Obstruction : Corpus Alienum Stricture

Lymphoid Hyperplasia

Fecolith

Infection : E.Coli Streptococcus

Epidemiology

 The appendix is a wormlike extension of the cecum and. The average length of the appendix is 8-10 cm (ranging from 2-20 cm) The appendix runs into a serosal sheet of the peritoneum called the mesoappendix, within which courses the appendicular artery, which is derived from the ileocolic artery

Anatomy

Anatomy
The appendix has a retroperitoneal location in 65% of patients and may descend into the iliac fossa in 31%. In fact, many individuals may have an appendix located in the retroperitoneal space; in the pelvis; or behind the terminal ileum, cecum, ascending colon, or liver

Histology
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.

Symptoms
Periumbilical Pain/Epigastric pain (Visceral Pain) Right Lower Quadrant (RLQ) Pain Anorexia Nausea Vomitting Diarrhea Constipation

Physical Examination
General : Pain, Fever, Flexi of articulatio Coxae Dextra Auscultation : Bowel Sounds Increased or Decreased Palpation : Rebound Tenderness, Rovsing sign, Rigidity, Guarding Percussion : Pain

McBurneys Sign

Rovsing Sign

Psoas Sign

Obturator Sign

Workup
White Blood Cell (WBC) Count (>10,500) Ultrasonography Appendicogram CT Scan

Ultrasonography

Appendicogram

Non Filling

CT Scan

Stages
No 1. Stage Early Stage Explanation obstruction of the appendiceal lumen leads to mucosal edema, mucosal ulceration, bacterial diapedesis, appendiceal distention due to accumulated fluid, and increasing intraluminal pressure. The patient perceives mild visceral periumbilical or epigastric pain, which usually lasts 4-6 hours 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.

2.

Suppurative

No 3. 4.

Stage Gangrenous Perforated

Explanation Intramural venous and arterial thromboses ensue Persisting tissue ischemia results in appendiceal infarction and perforation. Perforation can cause localized or generalized peritonitis.

Phlegmonous/Abcess

An inflamed or perforated appendix can be walled off by the adjacent greater omentum or small-bowel loops
If the obstruction of the appendiceal lumen is relieved, acute appendicitis may resolve spontaneously 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. (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.

Spontaneusly Resolving

Recurrent

Chronic

Diagnosis

Treatment
Conservative : Bed rest : Fowler Position Antibiotics (Broad Spectrum) Penicillins (Ampicillin/Sulbactam) Cephalosporins (Ceftriaxone, Cefipime) Aminoglycosides (Gentamicin) Carbapenem (Meropenem) Fluoroquinolones (Ciprofloxacin, Levofloxacin) Anti-Infective Agents (Metronidazole) Analgesics

Indications Of Surgery
Consider an appendectomy for patients with a history of persistent abdominal pain, fever, and clinical signs of localized or diffuse peritonitis, especially if leukocytosis is present. If the clinical picture is unclear, a short period (4-6 h) of watchful waiting and a computed tomography (CT) scan may improve diagnostic accuracy and help to hasten the diagnosis

Open Appendectomy

Conclusion
Appendicitis means inflammation of the appendix. It is thought that appendicitis begins when the opening from the appendix into the cecum becomes blocked. Historically, the diagnosis of appendicitis has been made based on clinical findings. Diagnostic imaging has been used primarily to evaluate patients who have an atypical clinical presentation. Over the past several years, improvements in imaging technology have contributed to an increase in diagnostic accuracy in these patients. Early and accurate diagnosis of appendicitis can decrease patient morbidity and hospital costs by reducing the delay in diagnosis of appendicitis and its associated complications, as well as by avoiding inpatient observation prior to surgery in patients who present with atypical symptoms.

References
Craig S. Appendicitis Treatment & Management. Avilable at : http://emedicine.medscape.com/article/773895 . Accessed 1 October 2013. Stengel JW, Webb EM, Poder L, et al. Acute appendicitis: clinical outcome in patients with an initial false-positive CT diagnosis. Radiology 2010; 256:119. Mangram AJ, Horan TC, Pearson ML, et al. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999; 20:250. Spirt MJ. Complicated intra-abdominal infections: a focus on appendicitis and diverticulitis. Postgrad Med 2010; 122:39. Eriksson S, Tisell A, Granstrm L. Ultrasonographic findings after conservative treatment of acute appendicitis and open appendicectomy. Acta Radiol 1995; 36:173. Guller U, Hervey S, Purves H, et al. Laparoscopic versus open appendectomy: outcomes comparison based on a large administrative database. Ann Surg 2004; 239:43.