APPENDECITIS ACUTE

Author by:
Dr. dr. Koernia Swa Oetomo, SpB.(K)Trauma. FINACS.,FICS

ILMU BEDAH
SMF BEDAH RSU HAJI SURABAYA
2015

PREFACE

Drafting Praise to the presence of Almighty God upon His mercy and
grace so that the author completed paper entitled " Appendecitis Acute ".
During the preparation of this paper , authors have a lot of no small
assistance from several parties, so in this occasion we thank you profusely to all
those who have provided assistance so that this paper can be resolved properly.
The author, aware that during the preparation of this paper is far from perfect and
many deficiencies in their preparation. Therefore constituent suggestions and
constructive criticism to the perfection of this paper. Constituent hope this paper
can be beneficial for all parties read in general and in particular constituent.

Surabaya, Agust 2015

Dr.dr. Koernia Swa Oetomo, SpB. (K) Trauma. FINACS,FICS

TABLE OF CONTENTS
Foreword .......................................................................................................... i
Table of Contents ............................................................................................. ii
List Tables ........................................................................................................ iii
List Of Figures ................................................................................................. iv
Chapture 1 Introduction .................................................................................. 1
1.1 Background ..................................................................................... 1
Chapture 2 Review of Literature 2 ................................................................... 2
2.1 Anatomi Appendix .......................................................................... 2
2.2 Appendesitis Acute .......................................................................... 5
2.2.1 Definition ............................................................................... 5
2.2.2 Epidemiologi ......................................................................... 5
2.2.3 Etiology dan Patophysiology ................................................. 6
2.2.4 Bacteriology........................................................................... 8
2.2.5 Pathology ............................................................................... 8
2.2.6 Clinical Features .................................................................... 10
2.2.7 Examination ........................................................................... 13
2.2.8 Laboratory ............................................................................. 14
2.2.9 Radiology............................................................................... 14
2.2.10Diagnosis ............................................................................... 16
2.2.11Differential Diagnosis............................................................ 20
2.2.12Complication ......................................................................... 22
2.2.13Management .......................................................................... 23
References............................................................................................... 31
ii

LIST OF TABEL

Tabel 2.1 The bacteria are often found in appendicitis perforata ......................... 8
Tabel 2.2 Relationship between pathological changes and ......................................... 9
Tabel 2.3 Frequency of symptoms appendisitis ......................................................... 12
Tabel 2.4 Imaging modality in the diagnosis of acute appendicitis. ............................ 15
Tabel 2.5 Alvarado Score ..................................................................................... 18
Tabel 2.6 The Ohmann Score ............................................................................... 18
Tabel 2.7 Criteria Ohmann Score.......................................................................... 19
Tabel 2.8 Kriteria Lintula Score............................................................................ 19
Tabel 2.9 Kriteria RIPASA Score ........................................................................ 20
Tabel 2.10 Guideline RIPASA Score.................................................................... 20

iii

LIST OF FIGURES

Figure 2.1 Various Positions Appendix ................................................................ 3

Figure 2.2 Vascularity Appendix ........................................................................... 4
Figure 2.3 A variety of positions in accordance...................................................12
Figure 2.4 Imaging modality in the diagnosis......................................................15
Figure 2.5 The result of the ultrasound shows......................................................17
Figure 2.6 Choice of Incision is up to the surgeon...............................................27
Figure 2.7- 2.16 Surgical Technique....................................................................31

iv

CHAPTER 1
INTRODUCTION

1.1 Background

Acute appendicitis is the main cause abdominal recorded more than

40,000 patients admitted to hospital in the UK each year. Appendiksitis occurs
mostly ages 10 and 20 years, but did not rule out another age. Males have a
greater predisposition numbers than women is 1.4: years.
Appendicitis is the emergency medical service in the field of general
surgery. In the diagnosis of acute appendicitis may not be established with the
gold standard (histopathology) before the operation, we can use a simple test such
as Alvarado scores where there is or absence of symptoms in patients on variable
will determine the condition of the patient. Proper diagnosis and intervention can
reduce the speed of morbidity and mortality year. (4,7)
Appendicitis is an inflammation of the appendix vermicularis and is the
leading cause of acute abdominal disease most commonly in children and adults.
There are about 250,000 cases of appendicitis occur in the US each year and
mainly occurs in children aged 6-10 years. (4,7)
All cases of appendicitis require removal action of the inflamed appendix,
either by laparotomy or by laparoscopy. If no action is taken the treatment, the
mortality rate will be high, mainly due to peritonitis and shock years. (1,4,7)

CHAPTER II
LITERATURE REVIEW

2.1 Anatomy Appendiks

Vermiformis appendix is an organ like a tube with a narrow lumen,
vermian (shaped like a worm) arising from the cecum wall posteromedial section,
2 cm below the ileum end. Can occupy one of the following positions: (11)
1. Retrocaecal
2. Retrocolic (behind the cecum or the bottom of the ascending colon),
3. Pelvic or descending (if dependent on the edge of the pelvis, close to the
uterine tube and right ovary in women). It is the most common position
that is often found in Clinical Practice. Other positions are rare, especially
if there is a long appendix mesenteric appendix which can cause higher
mobility.
4. Subcaecal (under the cecum),
5. Promontoric
6. Preilial (anterior to the terminal ileum)
7. Postileal (behind the terminal ileum).

Figure 2.1 Various Positions Appendix (11)

Three taenia coli in colon ascendens and cecum united on the basis of the
appendix, and join into the longitudinal muscles. Taenia caecal separate anterior
and can usually be traced to appendix, which can be used as a guide to find the
location of the appendix on Clinically practice. Appendix sizes vary in length,
from 2 cm to 20 cm; relatively longer commonly found in children and may
undergo

atrophy

and

retracts

with

increasing

age.(8)

Lumen appendix narrow and open to the cecum through the orifice is located
below and slightly posterior to the ileocaecal orifice. The orifice is sometimes
guarded by semilunaris mucosal folds that form the valve. Lumen may be a patent
on the early lives of children and often lost in the last decade kehidupan.(11)

Vascularization appendix.
The main artery of the appendix, a branch of the lower division ileocolic
artery, runs behind the terminal ileum and entering mesoappendiks with close
3

distance from the base of the appendix and anastomoses with the branches of the
artery caecal posterior.(11,12)

Figure 2.2 Vascularity Appendiks.(7,10)

Vena Appendix
Appendix artery flow through one or more veins appendikular heading ileo
colic or caecum posterior vein. Then from these veins leading to the mesenteric
vein superior.(11)

Lymphatics.
Appendix lymphatic vessels are numerous: there are many lymphoid tissue
on his wall. Of whole sections of the appendix are 8-15 lymph vessels that pass
through mesoappendiks and is usually accompanied by some of the lymph nodes.
They unite to form approximately 3-4 larger lymph vessels which also goes into
the lymph vessels in the ascending colon. Everything will end in the inferior and
superior node of a series of lymph vessels ileokolik.(10,11)
4

Innervation of Appendix
Parasympathetic

innervation

is derived

from

a branch

n. vagus

appendix that follows a.mesenterikasuperior and a.apendikularis. Her sympathetic

innervation comes from n.torakalis X. (9)

Physiology
Appendix produce mucus 1-2 ml / day. This mucus is normally poured
into the lumen and then flows into the cecum. Barriers to the flow of mucus in the
estuary seems to play a role in the pathogenesis of appendisitis. (9)
Secretie immunoglobulin produced by the GALT ( Gut Associated
Limphoid Tissue) located along the gastrointestinal tract, including the appendix,
is IgA. Immunoglobulin was very effective as a protective barrier against
infection. However, removal of the appendix no affects to the body's immune
system, due to the small number of lymph tissue here once, when compared
with its number in the gastrointestinal tract and throughout tubuh.

(9)

2.2 Acute appendicitis

2.2.1 Definitions
Appendicitis is an inflammation of the appendix bacterial vermiformis.
Acute appendicitis is the onset of acute appendicitis requiring

surgical

intervention and is usually characterized by pain in the lower right quadrant of

the abdomen with local tenderness and referred pain, muscle spasm that is
above, and skin hiperestesia.(3,6)

2.2.2 Epidemiology
The incidence of acute appendicitis higher in developed countries is
than in developing countries. However, in the last three-four decades incidence
decreased significantly. This is thought to be caused by the increasing use of
fiber in the daily menu day.(1,4,9)
Appendicitis can be found at all ages, only in children less than one year rarely.
The highest incidence in the age group 20-30 years, after which it decreased. The
5

incidence in men and women are generally comparable except at the age of 20-30
years, while the incidence in men more highest.(6)

2.2.3 Etiology and Pathophysiology

Epidemiological studies have shown a role eat foods low in fiber and
constipation effect on the incidence of appendicitis. Constipation will raise
intrasecal pressure, which cause a functional blockage of the appendix and
writed normal colonic flora germ growth. All this will facilitate the emergence of
appendicitis akut.(1,9)
Obstruction of the appendix lumen is a major etiological factor in acute
appendicitis, following a variety of causes of obsruksi (3 ,7)
1. Fecaliths or Appendicolith, is a major cause of obstruction, was found in
40%

of cases of acute appendicitis is simple, 65% of cases of

appendicitis ganggrenosa without rupture , and approaching 90% of

cases ganggrenosa with ruptured appendicitis.
2. Hypertrophy Lymphoid Network
3. Barium remaining from previous x-ray examination (examination Colon in
the loop)
4. Tumor
5. Seeds of fruits
6. Intestinal Parasites
Obstruction of the appendix lumen accompanied by continuous secretion
of mucous appendix causing distension. Distension of the appendix stimulate the
nerve endings due to stretching visceral afferent nerve fibers, causing tenderness
that diffus in the mid - abdomen or epigastric below. Peristalsis is also stimulated
by sudden onset distention , thus cramping may accompany the visceral pain early
on appendisitis.(3)
Distension continues due to the secretion of mucous continuous and of
multiplication of bacteria in the appendix. This distention causes reflex nausea
and vomiting, and visceral pain will get worse. Along with the increased emphasis
on the organ, also increased pressure on the veins. Capillaries and veins become
6

closed, but arteriolar flow will continue, causing dilation and congestive vascular.
Inflammatory process soon involves the serosa in the appendix and regional
parietal peritoneum, producing pain typical displacement towards the right
quadrant. (1,3)
Disruption to the lymphatic and venous flow will cause mucosal ischemia.
Appendix mucosa prone to interruption of blood supply, and if the integrity is
compromised, will facilitate the occurrence of bacterial invasion. During the more
progressive distention of the more pressing venous return and then the flow of
arterioles, causing infarction in areas with poor blood supply. With increased
distention, bacterial invasion, disruption of blood flow, and progression infarction,
this combination will lead to a more localized inflammatory process and cause
gangrene and perforation, usually at one of the infarcted area on antimesenteric
limit. Perforation usually occurs after at least 48 hours of onset of the onset of the
symptoms .(1,3,7)
Acute appendicitis is a bacterial infection such as Escherecia coli ,
viridans Streptoccocus,

and

Bacteroides.(6)

Allegedly,

lumen

integrity

disturbed due to increased pressure lumen or intramural ischemia can be the

source location of invasion organisme other cause which allegedly can cause
appendicitis is appendiceal mucouse erosion due to parasites E.histolytica. (1,6)

2.2.4 Bacteriology

Normal flora in the appendix are similar to those in the colon, with there
are a wide variety of aerobic and facultative anaerobic bacteria. Some kinds
of microbes from perforated appendix is known. Escherichia coli. Streptococcus
viridans, Bacteroides spp., And Pesudomonas spp., The microbe most often
isolated (table 2.1) 4

Table 2.1 The bacteria are often found in appendicitis perforata (4,7)
In patients with non-perforated acute appendicitis, peritoneal fluid culture
than is usually negative and do not provide a real clinical role. However, in
patients with perforated appendicitis, peritoneal fluid culture will usually
positive, and show bacteria in the colon with sensitivity to antibiotics that can
be predicted. Due to the selection of antibiotic administration rarely been
affected by the outcome of this culture, then the culture is rarely doing.

(7)

2.2.5 Pathology
Pathology appendicitis can begin in the mucosa and then involve all layers
of the wall of the appendix within the first 24-48 hours. Efforts body's defense
sought to limit this inflammatory process by closing the appendix to the
omentum, small intestine, or adnexal mass forming periapendikuler wrongly
known as the appendix or periapendikular infiltrates infiltrates. In it, tissue
necrosis can occur in the form of an abscess that can be perforated. Otherwise
abscesses, appendicitis will recover and periapendikuler mass will be quiet
and will unravel slowly themselves lambat. (9)

Who once inflamed appendix will not recover completely but form scar
tissue that cling to the surrounding tissue. These adhesions can cause complaints
recurring in the lower right abdomen. One time, this organ can acutely
inflamed again and declared as experiencing an acute exacerbation is referred to
as acute in chronic appendicitis. (1,9)
8

Pathological Changes Process

Clinical Manifestations

Inflmasi beginning, often due to

Acute abdominal pain middle and diffus or

obstruction by fekalit (Fecalith)

not localized

Acute inflammatory mucosa

Acute abdominal pain persists then

accompanied by nausea and vomiting (due
to stimulation of the autonomic)

Expansion of inflammatory pass through

Symptoms and signs began to localized

the wall of the appendix

because of the involvement of parietal

peritoneum (somatic innervation)

Inflammatory achieve serous (peritonitis

Classical symptoms: Tenderness, rebound

visceral)

tenderness, and prisoners RIF

Fever, facial flush, and tachycardia

Peritonitis deployment to surrounding

Pain extends to the entire abdomen with

structures (depending on the position of the

increased rigidity and systemic symptoms

appendix)

were more pronounced (increase in fever,

Gangrene in the wall of the appendix

apathy and dehydration)

Perforasi
Efforts by the omentum and nearby

The formation of "mass apenndiks" or that

structures of the appendix to cover

one is known by infiltrates appendix

perforation
If not successful will cause widespread
peritonitis
Table 2.2 Relationship between pathological changes and clinical manifestations (9)

2.2.6 Clinical Features

Acute appendicitis is often performed with typical symptoms based on the
occurrence of a sudden inflammation of the appendix that gives local sign, either
accompanied or not accompanied by local peritoneal irritation. Classic symptoms
of appendicitis are vague pain and blunt that is visceral pain in the epigastric
9

region around the umbilicus. These complaints are often accompanied by nausea
and vomiting sometimes there. Generally, decreased appetite. Within a few hours,
the pain will move to the bottom right to the point of McBurney. Here, the pain
feels sharper and clearer located so sign with local somatic pain. Sometimes there
is no epigastric pain, but there is constipation, so people feel the need for
laxatives. The action was considered dangerous because it could be perforation.
When there is stimulation of the peritoneum, patients usually complain of
abdominal pain when walking or coughing (Dunphy sign) . (6,4) (1,7,9)
When the appendix is located retrocecal retroperitoneal, mark the lower
right abdominal pain is not so clear and there was no sign of peritoneal
stimulation as appendix protected by cecum. Pain more toward the right side of
the abdomen or pain arises when walking due to contraction of the psoas major
muscle straining of dorsal.(2,9)
Inflammation of the appendix is located in the pelvic cavity can cause
symptoms and signs of sigmoid or rectal stimulation that increases peristaltic and
emptying the rectum become faster and repeatedly so as to give the complaints of
diarrhea or tenesmus. If the appendix had been attached to the bladder, can
increase urinary frequency or dysuria caused excitement in the appendix to the
bladder wall.(9,12)
Symptoms of acute appendicitis in children is not specific. At first, the
child is often only show symptoms fussy and would not eat. Children often can
not describe the pain. Several hours later, the child will vomit so that it becomes
weak and lethargic. Because the symptoms are not typical earlier, appendicitis is
often only discovered after the perforation. In infants, 80-90% of new appendicitis
known after the perforasi

(6).

In older children there can be just a history of

bacterial or viral disease, which can cause enlargement of the follicle appendix
and obstruksi.(12)
In some circumstances, appendicitis is rather difficult to diagnosis thus
not treated in time and complications. For example, in elderly people, the
symptoms are often vague so that more than half of the new cases are diagnosed
after perforasi.(9)

symptoms in older people usually malaise, atypical pain,

10

constipation,or even a change of status mental.

(12)

In pregnancy , the main

complaint of appendicitis is abdominal pain, nausea, and vomiting. This needs

to be examined carefully because in the first trimester of pregnancy often also
occur nausea

and vomiting.

In later pregnancy, cecum and appendix

are

encouraged to kraniolateral that the complaint was not felt in the lower right
abdomen, but more in the right lumbar region .(9)
At its research Treaves assume caecum is the center of the clock and the appendix
is a needle of hours. Therefore, the position of the appendix can be described as: 2

Position at 11 or the colic / the caecum. Appendix pointing up and sits on

the right of the cecum. In this position, the appendix is also located at the
front instead of the right kidney. In the long appendix, can irritate the
ureter, resulting in leukocytes detected in urinalysis / resemble the
symptoms rather than pyelonephritis.

Position at 12 or retrocaecal. Appendices are behind the caecum or

ascending colon and can intra peritoneal or retro-peritoneal.

Position at 2 or splenik position. Appendix leading to the spleen or to the

upper left quadrant, and can be located in front of the terminal ileum
(preileal) or in behind the terminal ileum (ileal post).

Position at 3 or promonterik position. Appendix leads transversely toward

the sacral promontory.

Position at 4 or pelvic. Appendix leading toward the pelvic cavity.

Position at 6 or mid inguinal. Appendix leading to the midpoint of the

inguinal ligament. Another name for this position is the position of the sub
caecum.

11

Figure 2.3 A variety of positions in accordance with the manifestation appendix

klinisnya(10)

Table 2.3 Frequency of symptoms appendisitis(2)

12

2.2.7 Inspection
Fever is usually mild with temperatures around 37.5 38,5 C.
When the temperature is higher, there may be perforation. There can be
differences in axillary and rectal temperature up to 1 C. On inspection the
stomach, was not found specific features. Bloating commonly seen in patients
with complications of perforation. Protrusion of the lower right abdomen can
be seen in the mass or abscess periapendikuler.(1,9)
On palpation, tenderness obtained is limited to the right iliac region, can
be accompanied by pain off (rebound phenomenon). Defans muskuler shows the
stimulation of peritoneal parietale. Lower right abdominal tenderness are mainly
located at McBurney's point is the key to diagnosis. Normal appendix mobile
character, so that the location of inflammation can be found in various places on a
circular area around the base of 360 of the cecum. In the lower left abdominal
pressure, pain will be felt in the lower right abdomen, called the sign Rovsing. At
retrosekal appendicitis or retroileal, required deep palpation to determine the
presence of a sense nyeri.(1,7,9)
Often normal intestinal peristalsis, but also can disappear due to paralytic
ileus in generalized peritonitis caused by appendicitis perforata. (6)
Digital rectal examination cause pain when the area of infection can be
achieved with the index finger on appendicitis pelvika.(6)
At pelvika appendicitis, abdominal signs are often dubius, then the
diagnosis is key pain when performed digital rectal limited. Psoas test
examination and an examination of the obturator test is intended to determine the
location of the appendix. Psoas test conducted by stimulation of the peritoneum
through the right hip joint hyperextension or flexion of the right hip joint active,
then the right thigh detained. When the inflamed appendix attached to the psoas
major muscle, such actions will cause pain. Obturator test is used to see if the
appendix is inflamed in contact with the internal obturator muscle which is a
small pelvic wall. Endorotasi flexion and hip joint in the supine position will
cause pain in appendicitis pelvika.(1,9).
13

If the appendix perforation, abdominal pain will be felt intense and

thorough, increased spasm rather than abdominal muscles (muscular defans),
heart rate will increase with the elevation of temperature over 39C. Patients
looked very ill and in need of resuscitation fluids and antibiotics before operasi.
(4,7)

2.2.8 Laboratory
Examination of the number of leukocytes help with the diagnosis of acute
appendicitis. In most cases there is leukocytosis, especially in cases with high
complication.

(3)

leukocytes (> 20,000 / mL) may indicate the presence of

complications of appendicitis, could be gangrene or perforation. Urinalysis can be

useful to rule out pyelonephritis or nephrolithiasis. In the female patients should
also be examined Beta-HCG to rule out the possibility gravidity.(4,7,12)
From research conducted by Memisoglu et al. 2010 in patients with postappendectomy performed a retrospective study, it was found that the number of
acute appendicitis with high leukocytes are found as much as 83%, and in patients
with high leukocyte his appendix apparently normal, as much as 61%. Memisoglu
et. al conclude that to diagnose appendicitis are not enough of laboratory results
and radiologi.(1,4,10)

2.2.9. Radiology
Plain abdominal rarely useful for diagnosing acute appendicitis. Plain
abdominal instrumental in getting rid of pathological states of barium enema

(1,4)

Failure to meet the appendix lumen associated with appendicitis, but this finding
is less sensitive and 20% specific for normal appendix is not filled with barium
enema.(4,7)
In patients with abdominal pain, ultrasonography had a sensitivity of 85%
and a specificity of more than 90% in diagnosing appendicitis acute.4 This was
confirmed by research conducted Memisoglu et al which states that only 34% of
patients with acute appendicitis who had a negative ultrasound results.

(5)

sonographic findings consistent with acute appendicitis, among others, the size of
the appendix 7 mm or more in the anteroposterior diameter, thick wall, which was
14

not depressed lumen structure can be seen in cross section, known as the target
lesion, or seems appendicolith.(3,4)
CT scans are often used to evaluate adult patients with suspected acute
appendicitis. CT scans have a sensitivity of approximately 90% and a specificity
of 80% -90% in diagnosing acute appendicitis in patients with abdominal pain
akut.(9) From research Willms et al in 2011 concluded that in addition to
anamnesis, physical examination, and laboratory tests, radiological examination
(especially CT Scan) is required for patients with suspected appendicitis.

Table 2.4 Imaging modality in the diagnosis of acute appendicitis. (5)

15

Figure 2.4 4
A CT scan of the abdomen / pelvis in patients with acute appendicitis showed
appendicalith (white arrows)
B. CT scan showed the distended appendix terdistensi (white arrow) with
thickening of the wall and fluid than periapendikular. (white triangles) This
picture is referred to as a target sign.
C = caecum

16

Figure 2.5 The result of the ultrasound shows: (7)

- Normal Appendix: coronal slice (top left), longitudinal section (top right)
- Appendicitis: there is distention and wall thickening (bottom right): 'Target Sign'
- In appendicitis was also an increase of blood flow (bottom left), so called 'Ring
of Fire appearance'

2.2.10 Diagnosis

Although the test is done carefully and accurately, the clinical diagnosis of
acute appendicitis is still probably one of the approximately 15-20% of cases.
Fault diagnosis is more common in women than men. This can be realized given
to women, especially the young ones, often arise disorders resembling acute
appendicitis. The complaint comes from internal genitalia because ovulation,
menstruation, inflammation in the pelvis, or gynecologic disease another.(1,3,4,9)
Appendicitis should be considered as a differential diagnosis in any patient
with acute abdominal pain. Early diagnosis is the most important clinical goal for
patients with suspected appendicitis and in most cases can be enforced through a
careful history and physical examination. The initial symptoms usually starts with
pain periumbilikal (due to the activation of the visceral afferent neuron) and then
followed by anorexia and nausea.(4)
Pain then localized to the right lower quadrant as a progressive
inflammatory process involving the parietal peritoneum above the appendix.
17

Vomiting can be obtained. Accompanying fever, followed by development of

leukocytosis. Clinical symptoms can vary. For example, not all patients be
anoreksia.4 To reduce the number of fault diagnosis of acute appendicitis, when
the diagnosis is in doubt, the patient should be observed in the hospital with a
frequency of every 1-2 jam.(6)
Photos barium less trustworthy. Ultrasound can improve the accuracy of
diagnosis. Similarly laparoscopy in cases (4,9)
To minimize misdiagnosis of appendicitis, there is a scoring system called
Alvarado Score. Patients with a score of 9 or 10 is almost certainly suffering from
appendicitis, patients with a score of 7 or 8 are most likely suffering from
appendicitis, a score of 5 or 6 have symptoms similar to appendicitis, but not
diagnosed appendisitis.(1)

Tabel 2.5 : Alvarado Score1 (3)

Based on research conducted by Tamanna et. al. (2012) found that

Alvarado score has a sensitivity value of 59.57%, and a specificity of 85.13%.
While its positive predictive value of 71.79% and a negative predictive value of
76.82%. Average accuracy of the Alvarado score ranges from 75.2%. Therefore,
although the Alvarado score is based mostly on clinical evaluation, this scoring

18

system is easy, simple and inexpensive to support the diagnosis of acute

appendicitis his upright.

Table 2.6: Criteria Ohmann Score (6)

Table 2.8: Criteria lintula score (14)

19

Table 2.9: Criteria RIPASA score (14)

Table 2.10: Guideline RIPASA score (14)

2.2.11 Diagnosis
In certain circumstances, some diseases need Differential Diagnosis (1,4,9)
1) Gastroenteritis.
At gastroenteritis, nausea, vomiting, and diarrhea precedes the pain.
Abdominal pain is more mild and not demarcated. Often found their
hiperperistalsis. Heat and leukocytosis less pronounced than with acute
appendicitis.
20

2) Dengue Fever
Can be started with abdominal pain similar to peritonitis. In this disease,
obtained positive test results for Rumpel Leede, thrombocytopenia, and
increased hematocrit.
3) Mesenteric Lymphadenitis.
Inesenterika

lymphadenitis

commonly

preceded

by

enteritis

or

gastroenteritis, is characterized by abdominal pain, especially right

stomach, and nausea and abdominal tenderness that are vague, especially
right stomach.
4) Abnormalities of Ovulation
Ruptured ovarian follicles at ovulation can cause pain in the lower right
abdomen in the middle of the menstrual cycle. In the anamnesis, the same
pain ever arise first. No sign of inflammation, and pain disappeared usual
within 24 hours, but it may interfere for two days.
5) Pelvic Infection.
Acute salpingitis right di often confuse with acute appendicitis.
Temperatures are usually higher than appendicitis and lower abdominal
pain is more diffuse stomach. Pelvic infection in women is usually
accompanied by vaginal discharge and urine infection. In the vaginal plug,
there will be severe pain in the pelvis if the uterus is taken. In the girls to
do a digital rectal if necessary for diagnosis.
6) Ectopic Pregnancy.
There is almost always a history of delayed menstruation with complaints
is errotic. If there is ruptured tubal pregnancy or abortion outside the
uterus with bleeding, there will be a sudden diffuse pain in the pelvis and
hypovolemic shock may occur. On examination of the vagina, pain and
protrusion obtained Douglas cavity and the blood obtained kuldosentesis.
7) Ovarian Cysts twisted.
Sudden pain arising with high intensity and palpable mass in the pelvic
cavity on abdominal examination, vaginal plug, or rectal plug. There is no
fever. Ultrasound examination can determine diagnosis

21

8) Endometriosis Externa
Endometrium outside the uterus will cause pain in the endometriosis is
located, and menstrual blood collected in that place because there is no
way out.
9) Urolithiasis Pyelum / ureter Right
A history of colic from the waist to the abdomen radiating to the right
groin is a typical illustration. Eritrosituria often found. Abdominal plain
radiography or

intravenous

urography

can

ensure

the

disease.

Pyelonephritis is often accompanied by high fever, chills, pain

costovertebral on the right, and pyuria.
10) Other Gastrointestinal Tract Disease.
Other diseases that should be considered is an inflammation of the
stomach, such as Meckel diverticulitis, perforated duodenal or gastric
ulcer, acute cholecystitis, pancreatitis, colonic diverticulitis, bowel
obstruction early, colon perforation, abdominal typhoid fever, carcinoid,
and mukokel appendix.

2.2.12 Complications
The most dangerous complication is perforation either free perforation or
perforation of the appendix that have experienced fencing so that a mass
consisting of a collection of the appendix, cecum, and the curve of the intestine
fine.(9)
1).Periapendikular
Appendix Mass or gangrenous appendicitis occurs when mikroperforasi
covered or wrapped by omentum and / or the curve of the small intestine. At
periapendikuler mass with the formation of rudimentary wall, can occur
throughout the deployment pussy peritoneal cavity if perforation is followed by
generalized purulent peritonitis. In the event of perforation, abscess will form
appendix. It is characterized by the increase in temperature and pulse rate,
increasing pain, and swelling palpable masses, as well as increasing numbers
leukosit.(6)
22

Classic history of acute appendicitis, which was followed by the painful mass
in the right iliac region and accompanied by fever, directs the diagnosis to the
mass or abscess periapendikuler.(4,6,9)
2) Perforated appendicitis
Fecalith presence in the lumen, age (elderly or small children), and late
diagnosis, a factor that plays a role in the occurrence of perforation of the
appendix. The incidence of perforation in patients over the age of 60 years
were reported around 60% .(9)
Factors influencing the high incidence of perforation in the elderly is vague
symptoms, delay treatment, the change in the anatomy of the appendix in the
form of a narrowing of the lumen, and arteriosclerosis. High incidence in
children is caused by the appendix wall is still thin, the child is less
communicative thereby extending the time of diagnosis, and the process of
fencing less than perfect due to perforation that goes fast and omentum child
has not developed.(9)
Perforated appendix will result in purulent peritonitis that is characterized by
high fever, more severe pain, tenderness and defans muscular, intestinal
peristaltic can be decreased to disappear due to paralytic ileus. Peritoneal
cavity abscess occurs when pus can spread localized somewhere, most often
in the pelvic cavity and subdiafragma. The existence of intra-abdominal mass
that pain with fever should be suspected as an abscess. Ultrasound can help
detect the presence of pockets nanah.(4,6,9)
3). Acute Exacerbation on Appendicitis Chronic
Diagnosis of acute exacerbation of chronic appendicitis only can be
considered if there is a history of repeated attacks of pain in the lower right
abdomen that encourage appendectomy, and the pathology results showed
acute inflammation. This disorder occurs when attack acute appendicitis first
healing spontaneously. However, the appendix was never returned to its
original shape due to fibrosis and scarring. The risk of recurrent attacks was
approximately 50%. The incidence of acute exacerbation of chronic
23

appendicitis is appendectomy 10% of the specimens were examined

pathological. In the acute exacerbation of chronic appendicitis, usually done
apendektomi because people come in attack akut. (4,6,9)
4). Chronic Appendicitis
Chronic appendicitis diagnosis can only be enforced if all the following
conditions are met: a history of right lower abdominal pain more than two
weeks, shown to occur with chronic inflammation of the appendix both
macroscopically and microscopically, and the complaints disappear post
appendektomy.(1,4,6)
Chronic appendicitis microscopic criteria include the presence of a thorough
fibrosis in the wall of the appendix, a partial or total blockage of the lumen of
the appendix, the old scar tissue and ulcers in the mucosa, and chronic
inflammatory cell infiltration. The incidence of chronic appendicitis is about
1-5% .(6)

2.2.13 Management

If the clinical diagnosis is clear, the most appropriate measures and is the
only good option is appendectomy. In the uncomplicated appendicitis, usually do
not need to be given antibiotics, unless the gangrenous appendicitis or perforated
appendicitis. Delays while providing follow-surgical antibiotics can lead to an
abscess or perforasi.(1,9)
Appendectomy can be done openly or by laparoscopy. When the open
appendectomy, McBurney incision most preferred by surgeons. In patients whose
diagnosis is unclear, observations should be done first. Laboratorium examination
and ultrasound can be done if the observations, there are still doubts. When
available laparoscope, a diagnostic laparoscopy in case of doubt can be done
immediately determine the operation or not.(6)
Appendisectomi or appendectomy is an act of surgically removing the
appendix. As for the indications appendectomy: (13)
24

1) Acute Appendicitis.
2) Subacute Appendicitis.
3) Appendicitis infiltrates (appendikular mass) which is already in the quiet stage
(afroid).
4) Perforated Appendicitis
5) Chronic Appendicitis

Preparation for surgery: (13)

1) Informed consent
2) Patients should be fasted for at least 4 to 6 hours before surgery.
3) Antibiotics (broad spectrum). Whenever there is a general need to improve the
situation peritonitis public by giving infusions and iv line.
4) The provision of anesthesia premedication.
5) Prepare the surgical field by cleaning (washing) and shaved if necessary.
Patients put to sleep with the supine position and expert Surgery standing on
the right side of the patient.
a. Disinfection
Surgical field is disinfected with 10% Povidone Iodine materials or Alcohol
70%.
b. Then the surgical field is narrowed with the Linen sterile.
c. Surgical Technique
Step 1. Choice of Incision is up to the surgeon. We Prefer McBurney (Fig. 2,6)

25

Figure 2.6
Step 2. Incise the aponeurosis of the external oblique along the lines of its fibers
(Fig. 2.7)
Step 3. Use a curved Kelly clamp o make an opening on both the internal oblique
and the transversus abdominis muscles. Enlarge the opening with the Kelly
clamp and insert two Richa Richardsons retractors.
Step 4. If the transversalis fascia was divided together with the flat muscles,
occasionally there will be a thick stroma of preperitoneal fat which can be
pushed laterally, or sometimes medially, revealing the peritoneum.

Figure 2.7
Step 5. Elevate the peritoneum and, if applicable, the transversalis fascia. Make a
small opening in the peritoneum with a knife or scissors, then enlarge it
with both index fingers and insert the retractors of your choice (Fig. 2.8)
26

Figure 2.8
Step 6. Take cultures of the free peritoneal fluid and, using moist gauze, pull the
cecum out of the wound. In most cases, the appendix is delivered with the
cecum or my be seen.
Step 7. Grasp and study the mesentry of the appendix and reinsert the cecum into
the peritoneal cavity, Divide the mesoappendix between clamps (Fig. 2.9).

Figure 2.9
Step 8. Ligate the mesoappendix with 2-0 silk (Fig. 2.10)

27

Figure 2.10
Step 9. With hemostasis completed, lift teh appendix straight up and attach two
clamps to its base. Remove the clamp close to the cecum and ligate the
appendiceal base doubly with 0 chromic catgut. Stump inversion is done
only when the base of the appendix is necrotic. When inverting, use a 3-0
silk purse string (Fig. 2.11 and Fig. 2.12).

Figure 2.11

28

Figure 2.12
Step 10. Divide appendix between the clamp and the catgut ligatures using a knife
with phenol and alcohol or electrocautery (Fig. 2.13).
(Alternatively, the appendix can be divided with a GIA stappler.)

Figure 2.13

Step 11.Irrigate. Close in layers using catgut or absorbable synthetic suture. If

peritonitis is present, close the muscle, but not the skin. The authors use
iodoform gauze to pack the wound (Fig. 2.14-Fig. 2.16).

29

Figure 2.14

Figure 2.15

30

Figure 2.16

4) Complications Appendisektomi: 10
1) Durante operations:
a) Intra-peritoneal hemorrhage that of artery appendicularis or of the
omentum.
b) Bleeding in the abdominal wall (of the muscles).
c) There is a tear of the cecum or other bowel.
2) Early Post-Surgery:
a) hemorrhage.
b) Infection of the abdominal wall.
c) Hematoom abdominal wall.
d) Paralytic ileus.
e) Peritonitis.
f) Intestinal fistula.
g) Abscess in the peritoneal cavity.
3) Further postoperative complications:
a) Streng ileus.
b) Hernia.

31

Post-Surgical Nursing: 10

On the day of the surgery patients were given infusions according to the
daily needs (maintenance) of approximately 2 to 3 liters of fluid Ringer
lactat and Dextrosa.

Mobilization as soon as possible after the patient unconscious by moving

the legs (flexi and extension), tilted to the left and right turns and sit
down. Patients may be the road on the first day after surgery.

Giving oral food starts with giving sip (50 cc) per hour when it occurs
intestinal activity, namely the existence of flatus, and bowel sounds.
Where the provision of free drinking the patient did not bloating oral
feeding begins. Normally on the first or second day after surgery the
patient may be fed.

Procedures PAI
Adult patients with mass periapendikuler clamped with a perfect fencing
should be treated beforehand and given a combination of antibiotics that are active
against aerobic and anaerobic bacteria, while monitoring the body temperature,
the size of the mass, as well as the extent of peritonitis. If there is no fever,
periappendikuler mass is lost, and the patient may return to normal leukocytes and
elective appendectomy can be done 2-3 months later in order to bleeding due to
adhesions can be suppressed as small as possible. In young children, pregnant
women, and elderly patients, if conservative not improve / develop into an
abscess, surgery is recommended secepatnya.(6)

Management of perforated appendicitis

Improvement of the general state of the infusion, antibiotics for Gram
negative and positive bacteria and anaerobes, and the installation of a nasogastric
tube needs to be done before surgery.
Need laparotomy with a long incision, so that can be done washing the
peritoneal cavity of pus and fibrin adequate spending easily and cleaning pus
32

pockets. Lately, ranging widely reported in the laparoscopic management of

perforated appendicitis appendectomy.
In this procedure, the abdominal cavity can be rinsed off easily. the results
reported are not much different than the open laparotomy, but the advantage is
shorter length of hospital and cosmetically more baik.(6)

33

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