REPORT

APPENDICITIS





DISUSUN OLEH :

Anggi Wibisono NIM P07120112043
Annisa Rahmatiah NIM P071201120
Clara Tyas Eviningrum NIM P071201120
Eka Yuliana Fatimah NIM P071201120
Febrita Laysa Susana NIM P07120112060
Khoirul Mustofa NIM P07120112063
Normalasari Dwinugraheni NIM P07120112067
Utita Agustina NIM P071201120


KEMENTRIAN KESEHATAN REPUBLIK INDONESIA
POLITEKNIK KESEHATAN YOGYAKARTA
JURUSAN KEPERAWATAN
2014
A. Definition
Appendicitis (also called epityphlitis) is inflammation of the appendix and is a
surgical emergency. Many cases of appendicitis require removal of the inflamed
appendix by laparotomy or laparoscopy due to the high mortality associated with
rupture of the appendix, which may lead to severe complications such as peritonitis
and sepsis. Appendicitis was first described by Reginald Fitz in 1886, and is today
recognized as one of the most common and significant causes of severe acute
abdominal pain worldwide.
Appendicitis is a medical emergency that requires prompt surgery to remove the
appendix. Left untreated, an inflamed appendix will eventually burst, or perforate,
spilling infectious materials into the abdominal cavity. This can lead to peritonitis, a
serious inflammation of the abdominal cavity's lining (the peritoneum) that can be
fatal unless it is treated quickly with strong antibiotics.
Sometimes a pus-filled abscess (infection that is walled off from the rest of the
body) forms outside the inflamed appendix. Scar tissue then "walls off" the appendix
from the rest of the abdomen, preventing infection from spreading. An abscessed
appendix is a less urgent situation, but unfortunately, it can't be identified without
surgery. For this reason, all cases of appendicitis are treated as emergencies, requiring
surgery.
In the U.S., one in 15 people will get appendicitis. Although it can strike at any
age, appendicitis is rare under age 2 and most common between ages 10 and 30.

B. Etiology
On the basis of experimental evidence, acute appendicitis seems to be the end
result of a primary obstruction of the appendix lumen (the inside space of a tubular
structure). Once this obstruction occurs, the appendix subsequently becomes filled
with mucus and swells, increasing pressures within the lumen and the walls of the
appendix, resulting in thrombosis and occlusion of the small vessels, and stasis of
lymphatic flow. Rarely, spontaneous recovery can occur at this point. As the former
progresses, the appendix becomes ischemic and then necrotic. As bacteria begin to
leak out through the dying walls, pus forms within and around the appendix
(suppuration). The end result of this cascade is appendiceal rupture (a 'burst
appendix') causing peritonitis, which may lead to septicemia and eventually death.
The causative agents include foreign bodies, trauma, intestinal worms,
lymphadenitis, and, most commonly, calcified fecal deposits known as appendicoliths
or fecaliths. The occurrence of obstructing fecaliths has attracted attention since their
presence in patients with appendicitis is significantly higher in developed than in
developing countries, and an appendiceal fecalith is commonly associated with
complicated appendicitis. Also, fecal stasis and arrest may play a role, as
demonstrated by a significantly lower number of bowel movements per week in
patients with acute appendicitis compared with healthy controls. The occurrence of a
fecalith in the appendix was thought to be attributed to a right-sided fecal retention
reservoir in the colon and a prolonged transit time, although a prolonged transit time
was not observed in subsequent studies. From epidemiological data, it has been stated
that diverticular disease and adenomatous polyps were unknown and colon cancer
exceedingly rare in communities exempt from appendicitis. Also, acute appendicitis
has been shown to occur antecedent to cancer in the colon and rectum. Several
studies offer evidence that a low fiber intake is involved in the pathogenesis of
appendicitis. This is in accordance with the occurrence of a right-sided fecal reservoir
and the fact that dietary fiber reduces transit time.

C. Pathophysiology
The main thrust of events leading to the development of acute appendicitis lies in
the appendix developing a compromised blood supply due to obstruction of its lumen
and becoming very vulnerable to invasion by bacteria found in the gut normally.
Obstruction of the appendix lumen by faecolith, enlarged lymph node, worms,
tumour, or indeed foreign objects, brings about a raised intra luminal pressure,
which causes the wall of the appendix to become distended.
Normal mucus secretions continue within the lumen of the appendix, thus
causing further build up of intra-luminal pressures. This in turn leads to the occlusion
of the lymphatic channels, then the venous return, and finally the arterial supply
becomes undermined.
Reduced blood supply to the wall of the appendix means that the appendix gets
little or no nutrition and oxygen. It also means a little or no supply of white blood
cells and other natural fighters of infection found in the blood being made available to
the appendix.
The wall of the appendix will thus start to break up and rot. Normal bacteria
found in the gut gets all the inducement needed to multiply and attack the decaying
appendix within 36 hours from the point of luminal obstruction, worsening the
process of appendicitis. This leads to necrosis and perforation of the appendix. Pus
formation occurs when nearby white blood cells are recruited to fight the bacterial
invasion.
A combination of dead white blood cells, bacteria, and dead tissue makes up pus.
The content of the appendix (faecolith, pus and mucus secretions) are then released
into the general abdominal cavity, bringing causing peritonitis. So, in acute
appendicitis, bacterial colonisation follows only when the process have commenced.

D. Sign and Symptoms
The following signs and symptoms may accompany appendicitis :
1. Pain, starting around the navel, then moving down and to the right side of the
abdomen. The pain gets worse when moving, taking deep breaths, coughing,
sneezing, or being touched in this area.
2. Loss of appetite
3. Nausea
4. Vomiting
5. Change in bowel movements, including diarrhea or not being able to have a bowel
movement or pass gas
6. Low fever that starts after other symptoms
7. Urinating often, or difficult or painful urination

E. Diagnostic Examination
1. Blood and urine test
While there is no laboratory test specific for appendicitis, a complete blood
count (CBC) is done to check for signs of infection. Although 70-90 percent of
people with appendicitis may have an elevated white blood cell count, there are
also many other abdominal and pelvic conditions that can cause the white cell
count to elevate.

A urinalysis generally does not show infection but it is important for
determining the pregnancy status, especially the possibility of an ectopic
pregnancy in childbearing females, and for ruling out urinary tract infection.
However, there is a possibility of a microscopic pyuria, the condition of urine
containing pus, or hematuria, urine containing red blood cells, caused by the
proximity of the appendix to the ureter and bladder in acute appendicitis. The
presence of more than 20 WBC per high-power field in the urine is more
suggestive of a urinary tract disorder.

2. Imaging
Appendicitis in children is common enough to merit special attention.
Because of the health risks of exposing children to radiation, many medical
societies recommend that in confirming a diagnosis with children the ultrasound
is a preferred first choice with x-rays being a legitimate follow-up when
warranted. CT scan is more accurate than ultrasound for the diagnosis of
appendicitis in adults and adolescents. CT scan has a sensitivity of 94%,
specificity of 95%. Ultrasonography had an overall sensitivity of 86%, a
specificity of 81%.
3. XRay
In general, plain abdominal radiography (PAR) is not useful in making the
diagnosis of appendicitis. Plain abdominal films may be useful for the detection
of ureteral calculi, small bowel obstruction, or perforated ulcer, but these
conditions are rarely confused with appendicitis. An opaque fecalith can be
identified in the right lower quadrant in less than 5% of patients. A barium enema
has proven to be a poor diagnostic tool because, while failure of the appendix to
fill during a barium enema has been associated with appendicitis, this finding
lacks both sensitivity and specificity because up to 20% of normal appendices
also do not fill.

A study done in 1999 concluded that "plain abdominal radiographs in
patients with suspected appendicitis are neither sensitive nor specific, are
frequently misleading, are costly per specific and correct diagnosis, and should
not be routinely obtained on patients with suspected appendicitis. Another study
came to the same conclusion, but said they may be useful in a small number of
people with suspected small bowel obstruction or urinary symptoms.
4. Ultrasound
Ultrasonography and Doppler sonography provide useful means to detect
appendicitis, especially in children, and shows free fluid collection in the right
iliac fossa, along with a visible appendix without blood flow in color Doppler. In
some cases (15% approximately), however, ultrasonography of the iliac fossa
does not reveal any abnormalities despite the presence of appendicitis. This is
especially true of early appendicitis before the appendix has become significantly
distended and in adults where larger amounts of fat and bowel gas make actually
seeing the appendix technically difficult. Despite these limitations, sonographic
imaging in experienced hands can often distinguish between appendicitis and
other diseases with very similar symptoms, such as inflammation of lymph nodes
near the appendix or pain originating from other pelvic organs such as the ovaries
or fallopian tubes.
5. CT/CAT/Computed tomography Scan
Where it is readily available, CT scan has become frequently used,
especially in adults whose diagnosis is not obvious on history and physical
examination. Concerns about radiation, however, tend to limit use of CT in
pregnant women and children. A properly performed CT scan with modern
equipment has a detection rate (sensitivity) of over 95%, and a similar specificity.
Signs of appendicitis on CT scan include lack of oral contrast (oral dye) in the
appendix, direct visualization of appendiceal enlargement (greater than 6 mm in
cross-sectional diameter), and appendiceal wall enhancement with IV contrast
(IV dye). The inflammation caused by appendicitis in the surrounding peritoneal
fat (so called "fat stranding") can also be observed on CT, providing a
mechanism to detect early appendicitis and a clue that appendicitis may be
present even when the appendix is not well seen. Thus, diagnosis of appendicitis
by CT is made more difficult in very thin patients and in children, both of whom
tend to lack significant fat within the abdomen. The utility of CT scanning is
made clear, however, by the impact it has had on negative appendectomy rates.
For example, use of CT for diagnosis of appendicitis in Boston, MA has
decreased the chance of finding a normal appendix at surgery from 20% in the
pre-CT era to only 3% according to data from the Massachusetts General
Hospital.

F. Risk Factors
1. Age <20 years, white cell count >10103/mm
In the study to evaluate the impact of timing of appendectomy and other
potential risk factors on progression of acute appendicitis, by searching the
relevant databases of a tertiary medical center identified 1,604 patients with
verified acute appendicitis who underwent appendectomy in 2004-2007with
demographic and clinical data and time from symptom onset to emergency room
admission (patient interval) and from emergency room admission to surgery
(hospital interval) and their combination were analyzed by pathological grade,
indicated that on multivariate analyses, independent risk factors for appendiceal
perforation were age <20 years (OR=1.58, 95 % CI 1.07-2.35) or >50 years
(OR=2.84, 95 % CI 1.82-4.45) (relative to 20-50 years), white cell count
>10103/mm(3) (OR=4.45, 95 % CI 2.05-9.67), body temperature >37.8 C
(OR=2.23, 95 % CI 1.45-3.41), hospital interval >24 h (OR=2.84, 95 % CI
1.49-5.4), patient interval >48 h (OR=3.84, 95 % CI 2.35-6.29), and combined
interval >48 h (OR=4.29, 95 % CI 2.2-8.36).
2. Gender different, among young
According to study appendicitis is common among young, healthy
populations; appendectomy is one of the most common surgical procedures
performed in the United States. Among active and reserve component members,
there were 31,610 cases of appendicitis and 30,183 appendectomies during 2002
to 2011. The overall incidence rate of appendicitis in the active component was
18.4 per 10,000 person-years (p-yrs). Active component males reported greater
rates of perforated appendicitis (2.6 per 10,000 p-yrs). Active component
females had higher rates of incidental appendectomies (2.6 per 10,000 p-yrs).
3. Race, increased over time and is higher in the summer months
Appendicitis is most common in whites and Hispanics and less common in
African Americans and Asians and incidence has increased over time and is
higher in the summer months, according to the study by the University of
California San Diego.
4. Prior antibiotic administration
Prior treatment with antibiotics was an independent risk factor for
therapeutic delay in pediatric AA, according to the study by the National Center
for Child Health and Development, Tokyo



5. Decreased bowel sounds, rebound tenderness, and presence of psoas, obturator,
or Rovsings signs
Factors associated with an increased likelihood of appendicitis included
decreased bowel sounds; rebound tenderness; and presence of psoas, obturator,
or Rovsings signs.
6. In patients with end-stage renal disease
The independent risk factors were atrial fibrillation (hazard ratio [HR],
2.08), severe liver disease (HR, 1.74), diabetes mellitus (HR, 1.58), and
hemodialysis (HR, 1.74), according to the study by the Taipei Medical
University.
7. Severity of inflammation
CRP concentration may be a potent objective predictor of pathological
severity in appendicitis. Combination with the other diagnostic modalities may
improve the diagnostic accuracy in predicting the severity of appendicitis.
8. Other risk factors
The principal factors contributing to perforation of appendix are: age of
children, delays of surgical intervention, family anamnesis, social group and late
recognition of symptoms of appendicitis.
9. Appendicolith
Presence of an appendicolith was associated with a 72% rate of recurrent
appendicitis compared with a recurrence rate of 26% in those with no
appendicolith (chi2 test, P < .004).

G. Complications
1. Peritonitis
If the appendix ruptures and releases the infection into the abdomen the patient
may develop peritonitis. The peritoneum will become inflamed. The peritoneum
is the membrane that lines the abdominal cavity and covers most of the
abdominal organs. Peritonitis causes the bowels to shut down - bowel
movements will stop and the bowel will become blocked. The patient will
develop a fever and could go into shock. Peritonitis requires urgent treatment.
2. Abscess
If the infection seeps out of the appendix and mixes with intestinal contents, it
may form an abscess. If the abscess is not treated it can cause peritonitis.
Sometimes abscesses are treated with antibiotics. Often they are surgically
drained with the aid of a tube which is placed into the abdomen.

H. Treatments
1. Laparatomy
Laparotomy is the traditional type of surgery used for treating
appendicitis. This procedure consists in the removal of the infected appendix
through a single larger incision in the lower right area of the abdomen. The
incision in a laparotomy is usually 2 to 3 inches (51 to 76 mm) long. This type
of surgery is used also for visualizing and examining structures inside the
abdominal cavity and it is called exploratory laparotomy.
During a traditional appendectomy procedure, the patient is placed under
general anesthesia to keep the muscles completely relaxed and to keep the
patient unconscious. The incision is two to three inches (76 mm) long and it is
made in the right lower abdomen, several inches above the hip bone. Once the
incision opens the abdomen cavity and the appendix is identified, the surgeon
removes the infected tissue and cuts the appendix from the surrounding tissue.
After careful and close inspection of the infected area, and ensuring there are no
signs that surrounding tissues are damaged or infected, the surgeon will start
closing the incision. This means sewing the muscles and using surgical staples
or stitches to close the skin up. In order to prevent infections the incision is
covered with a sterile bandage.
The entire procedure does not last longer than an hour if complications
do not occur.
2. Laparoscopic surgery
The newer method to treat appendicitis is the laparoscopic surgery. This
surgical procedure consists of making three to four incisions in the abdomen,
each 0.25 to 0.5 inches (6.4 to 12.7 mm) long. This type of appendectomy is
made by inserting a special surgical tool called laparoscope into one of the
incisions. The laparoscope is connected to a monitor outside the patient's body
and it is designed to help the surgeon to inspect the infected area in the
abdomen. The other two incisions are made for the specific removal of the
appendix by using surgical instruments. Laparoscopic surgery also requires
general anesthesia and it can last up to two hours. The latest methods are
NOTES appendectomy pioneered in Coimbatore, India where there is no
incision on the external skin
[38]
and SILS (Single incision laparoscopic Surgery)
where a single 2.5 cm incision is made to perform the surgery.
3. Drug Therapies
Your health care provider may prescribe the following medications :
a. Antibiotics
b. Medications taken to ease nausea
4. Pre surgery
The treatment begins by keeping the patient away from eating or drinking
in preparation for surgery. An intravenous drip is used to hydrate the patient.
Antibiotics given intravenously such as cefuroxime and metronidazole may be
administered early to help kill bacteria and thus reduce the spread of infection in
the abdomen and postoperative complications in the abdomen or wound.
Equivocal cases may become more difficult to assess with antibiotic treatment
and benefit from serial examinations. If the stomach is empty (no food in the
past six hours) general anaesthesia is usually used. Otherwise, spinal anaesthesia
may be used.
Once the decision to perform an appendectomy has been made, the
preparation procedure takes approximately one to two hours. Meanwhile, the
surgeon will explain the surgery procedure and will present the risks that must
be considered when performing an appendectomy. With all surgeries there are
certain risks that must be evaluated before performing the procedures. However,
the risks are different depending on the state of the appendix. If the appendix has
not ruptured, the complication rate is only about 3% but if the appendix has
ruptured, the complication rate rises to almost 59%.
[39]
The most usual
complications that can occur are pneumonia, hernia of the incision,
thrombophlebitis, bleeding or adhesions. Recent evidence indicates that a delay
in obtaining surgery after admission results in no measurable difference in
patient outcomes.

The surgeon will also explain how long the recovery process should take.
Abdomen hair is usually removed in order to avoid complications that may
appear regarding the incision. In most of the cases patients experience nausea or
vomiting which requires specific medication before surgery. Antibiotics along
with pain medication may also be administrated prior to appendectomies.
5. After surgery
Hospital lengths of stay typically range from a few hours to a few days,
but can be a few weeks if complications occur. The recovery process may vary
depending on the severity of the condition, if the appendix had ruptured or not
before surgery. Appendix surgery recovery is generally a lot faster if the
appendix did not rupture.
[41]
It is important that patients respect their doctor's
advice and limit their physical activity so the tissues can heal faster. Recovery
after an appendectomy may not require diet changes or a lifestyle change.
After surgery occurs, the patient will be transferred to a postanesthesia
care unit so his or her vital signs can be closely monitored to detect anesthesia-
and/or surgery-related complications. Pain medication may also be administered
if necessary. After patients are completely awake, they are moved into a hospital
room to recover. Most individuals will be offered clear liquids the day after the
surgery, then progress to a regular diet when the intestines start to function
properly. Patients are recommended to sit up on the edge of the bed and walk
short distances for several times a day. Moving is mandatory and pain
medication may be given if necessary. Full recovery from appendectomies takes
about four to six weeks, but can be prolonged to up to eight weeks if the
appendix had ruptured.















REFERENCE

http://medicaladvisorjournals.blogspot.com/2013/08/appendicitis-causes-ans-
risk-factors_7.html

Raahave D, Christensen E, Moeller H, Kirkeby LT, Loud FB, Knudsen LL
(2007). "Origin of acute appendicitis: fecal retention in colonic reservoirs: a case
control study". Surg Infect (Larchmt)

Wan, M. J.; Krahn, M.; Ungar, W. J.; Caku, E.; Sung, L.; Medina, L. S.; Doria,
A. S. (2009). "Acute Appendicitis in Young Children: Cost-effectiveness of US
versus CT in Diagnosis--A Markov Decision Analytic Model". Radiology 250
(2): 378386.

Ellis, H (March 2012). "Acute appendicitis.". British journal of hospital medicine
(London, England : 2005) 73 (3): C468.