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    APENDISITIS

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    Iqbal Ali Rabbani
    The document discusses appendicitis and hernia. It provides learning objectives about gaining anatomy and diagnosis skills. It covers the epidemiology, etiology, symptoms, diagnosis process, and complications of appendicitis. Physical exam findings and diagnostic tools like the Alvarado score, ultrasound, CT scan, and x-ray are presented. Differential diagnoses are listed. Appendicitis results from luminal obstruction leading to inflammation and potential perforation. Accurate diagnosis can be difficult due to variable appendix location and mimicking conditions.

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    © All Rights Reserved
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    APENDISITIS

    Uploaded by

    Iqbal Ali Rabbani
    129 views76 pages
    The document discusses appendicitis and hernia. It provides learning objectives about gaining anatomy and diagnosis skills. It covers the epidemiology, etiology, symptoms, diagnosis process, and complications of appendicitis. Physical exam findings and diagnostic tools like the Alvarado score, ultrasound, CT scan, and x-ray are presented. Differential diagnoses are listed. Appendicitis results from luminal obstruction leading to inflammation and potential perforation. Accurate diagnosis can be difficult due to variable appendix location and mimicking conditions.

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    The document discusses appendicitis and hernia. It provides learning objectives about gaining anatomy and diagnosis skills. It covers the epidemiology, etiology, symptoms, diagnosis process, and complications of appendicitis. Physical exam findings and diagnostic tools like the Alvarado score, ultrasound, CT scan, and x-ray are presented. Differential diagnoses are listed. Appendicitis results from luminal obstruction leading to inflammation and potential perforation. Accurate diagnosis can be difficult due to variable appendix location and mimicking conditions.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    129 views76 pages

    APENDISITIS

    Uploaded by

    Iqbal Ali Rabbani
    The document discusses appendicitis and hernia. It provides learning objectives about gaining anatomy and diagnosis skills. It covers the epidemiology, etiology, symptoms, diagnosis process, and complications of appendicitis. Physical exam findings and diagnostic tools like the Alvarado score, ultrasound, CT scan, and x-ray are presented. Differential diagnoses are listed. Appendicitis results from luminal obstruction leading to inflammation and potential perforation. Accurate diagnosis can be difficult due to variable appendix location and mimicking conditions.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 76

    APENDISITIS & HERNIA

    2014
    dr.Gunawan

    Tohir SpB.MM
    F.K.Muhammadiyah Palembang

    LEARNING OBJEKTIF
    1.Mampu

    dan menguasai anatomi

    abdomen
    2.Mampu membuat Diagnosa banding
    3.Mampu menentukan penunjang medis
    4.Mampu menentukan kasus ini perlu
    tindakan segera atau tidak
    5.Mampu mempersiapkan pasien untuk
    tindakan

    APENDISITIS
    1.Epidemiologi
    2Apendiks

    vermiformis :embriologi , topo


    grafi berupa Holotrofi , skeletopi ,sintopi
    Histologi , letak / posisi,
    3.Grade pada anak
    4 Etiologi dan patogenesis
    5.Gejala dan tanda

    6.Komplikasi
    7.Etiologi

    dan patogenesis
    A.Lingkungan : makanan
    B.Peranan Obstruksi
    C.Peranan flora bakterial
    8. Diagnosa
    A.anamnesa
    B.Pemeriksaan fisik
    c.Penunjang

    Skor Alvorado :Apendisitis


    akut
    1.Nyeri berpindah
    : 1
    2.Anoreksia
    : 1
    3.Mual dan muntah : 1
    4.Nyeri fossa Iliaka kanan : 2
    5.Nyeri lepas
    :1
    6.Suhu > 37.5 C
    :1
    7.Leukosit diatas 10.000 : 2
    8.Netrofil > 75 %
    :1

    Hasil penilaian
    Skor < 4

    : Kronis

    Skor 4-7

    : Observasi

    Skor > 7

    : Akut

    Acute
    Appendicitis

    Epidemiology
    The

    incidence of appendectomy appears


    to be declining due to more accurate
    preoperative diagnosis.
    Despite newer imaging techniques,
    acute appendicitis can be very difficult
    to diagnose.

    Pathophysiology
    Acute

    appendicitis is thought to begin


    with obstruction of the lumen
    Obstruction can result from food matter,
    adhesions, or lymphoid hyperplasia
    Mucosal secretions continue to increase
    intraluminal pressure

    Pathophysiology
    Eventually

    the pressure exceeds


    capillary perfusion pressure and venous
    and lymphatic drainage are obstructed.
    With vascular compromise, epithelial
    mucosa breaks down and bacterial
    invasion by bowel flora occurs.

    Pathophysiology
    Increased

    pressure also leads to arterial


    stasis and tissue infarction
    End result is perforation and spillage of
    infected appendiceal contents into the
    peritoneum

    Pathophysiology
    Initial

    luminal distention triggers visceral


    afferent pain fibers, which enter at the
    10th thoracic vertebral level.
    This pain is generally vague and poorly
    localized.
    Pain is typically felt in the periumbilical
    or epigastric area.

    Pathophysiology
    As

    inflammation continues, the serosa


    and adjacent structures become
    inflamed
    This triggers somatic pain fibers,
    innervating the peritoneal structures.
    Typically causing pain in the RLQ

    Pathophysiology
    The

    change in stimulation form visceral


    to somatic pain fibers explains the
    classic migration of pain in the
    periumbilical area to the RLQ seen with
    acute appendicitis.

    History
    Migration

    of pain from initial


    periumbilical to RLQ was 64% sensitive
    and 82% specific
    Anorexia is the most common of
    associated symptoms
    Vomiting is more variable, occuring in
    about of patients

    Physical Exam
    Findings

    depend on duration of illness


    prior to exam.
    Early on patients may not have localized
    tenderness
    With progression there is tenderness to
    deep palpation over McBurneys point

    Physical Exam
    McBurneys

    Point: just below the middle


    of a line connecting the umbilicus and
    the ASIS
    Rovsings: pain in RLQ with palpation to
    LLQ
    Rectal exam: pain can be most
    pronounced if the patient has pelvic
    appendix

    Physical Exam
    Additional

    components that may be


    helpful in diagnosis: rebound
    tenderness, voluntary guarding,
    muscular rigidity, tenderness on rectal

    PROFFERED APPENDICEAL
    ACTIVITIES FUNCTIONS:
    lymphatic,
    exocrine,
    endocrine,

    neuromuscular.

    The role of race, ethnicity, health


    insurance, education, access to
    healthcare, and economic status on the
    development and treatment of
    appendicitis are widely debated. Cogent
    arguments have been made on both
    sides for and against the significance of
    each socioeconomic or racial condition.

    Sex:
    The

    male-to-female ratio is
    approximately 2:1.

    RISK OF DEVELOPING
    APPENDICITIS WITH AGE

    Age:
    The

    mean age in the pediatric


    population is 6-10 years.
    Appendicitis is rare in the neonate, and
    the diagnosis in this age group is
    typically made after perforation.
    Younger children have a higher rate of
    perforation, with reported rates of 5085%.

    Perforated appendicitis

    Pathophysiology of
    Abdominal Pain
    Somatic

    pain
    Visceral pain

    Somatic

    pain
    -Parietal peritoneum
    -Somatic n. (T5-L2), except diaphragm (C3-C5 &
    lower 6 intercostal and subcostal nn.)
    -Sensitive to mechanical, thermal or chemical
    stimulation
    -Muscle rigidity/guarding and hyperaesthesia
    -Sharp or knife-cut like in nature; well localized

    Visceral

    pain
    -Visceral peritoneum
    -Mediated through sympathetic branches of
    autonomic nerve system joining presacral and
    splanchnic nn., which eventually join thoracic(T6T12) and lumbar (L1-L2) nn.
    -Insensitive to mechanical, thermal or chemical
    stimulation
    -Sensitive to tension-overdistension or traction on
    mesenteries, visceral m. spasm & ischemia
    -Dull and deep-seated; vaguely to localize

    Pathogenesis
    Inflammation
    Obstruction

    Time Delay in Appendicitis


    Diagnosis and Treatment

    Lee SL, Walsh AJ, Jung SH. Computed Tomography and Ultrasonography Do Not Improve and May
    Delay the Diagnosis and Treatment of Acute Appendicitis. Arch Surg 136:May 2001. p556-562

    PAIN
    The Most Important Symptom

    Characteristics of abdominal pain


    1.
    2.
    3.
    4.
    5.
    6.
    7.
    8.
    9.
    10.

    Site
    Onset time and mode
    Severity
    Nature colicky, spasm, gripping, dull, vague, sharp, knifecut, throbbing, etc.
    Progression or change of pain persistent, gradually improve
    or worsen, fluctuate, etc.
    Duration
    Radiation
    Movement of pain
    Aggravating or relieving factors
    Associated symptoms bowel or urinary, etc.

    Onset of Pain
    Sudden

    onset pain which wakes the patient


    from sleep
    eg. perforation or strangulation of bowel
    Slow insidious Onset
    a. Inflammation of visceral peritoneum.
    b. Contained process such as evolving
    abscess.
    Crampy or colicky pain
    Biliary colic, Ureteric colic or Intestinal
    colic

    Mortality/Morbidity
    At

    the time of diagnosis, the rate of


    perforation varies from 17-40%, with a
    higher frequency occurring in younger
    age groups.
    The mortality rate for children with
    appendicitis ranges from 0.1-1%.
    Perforation increases the complication
    rate.

    Obstacles to Diagnosis
    Position

    of the appendix:

    Size varies from 2-20cm


    Tip can lie in retrocaecal, pelvic, subcaecal, preileal
    and post-ileal positions

    Closely

    mimicked by other common


    conditions: ureteral calculi, gynecological pathology
    such as acute salpingitis, ectopic pregnancy, etc.

    Age,

    gender and comorbidities:

    eg.
    Up to 45% of females of reproductive age are
    misdiagnosed

    POSITIONS OF APPENDIX

    Differential Diagnosis for Acute


    Appendicitis
    Gastrointestinal

    Abdominal pain, cause


    unknown
    Cholecystitis
    Crohn's disease
    Diverticulitis
    Duodenal ulcer
    Gastroenteritis
    Intestinal obstruction
    Intussusception
    Meckel's diverticulitis
    Mesenteric
    lymphadenitis
    Necrotizing enterocolitis
    Neoplasm (carcinoid,
    carcinoma, lymphoma)
    Omental torsion
    Pancreatitis
    Perforated viscus
    Volvulus

    Gynecologic

    Ectopic pregnancy
    Endometriosis
    Ovarian torsion
    Pelvic inflammatory disease
    Ruptured ovarian cyst
    (follicular, corpus luteum)
    Tubo-ovarian abscess

    Systemic

    Diabetic ketoacidosis
    Porphyria
    Sickle cell disease
    Henoch-Schnlein purpura

    Pulmonary

    Pleuritis
    Pneumonia (basilar)
    Pulmonary infarction

    Genitourinary

    Kidney stone
    Prostatitis
    Pyelonephritis
    Testicular torsion
    Urinary tract infection
    Wilms' tumor

    Other

    Parasitic infection
    Psoas abscess
    Rectus sheath hematoma

    Causes of right iliac


    fossa mass
    Appendix

    mass
    Crohn's disease
    Caecal carcinoma
    Mucocele of the gallbladder
    Psoas abscess
    Pelvic kidney
    Ovarian cyst

    Causes of right iliac fossa


    pain
    Appendicitis
    Urinary

    tract infection
    Non-specific abdominal pain
    Pelvic inflammatory disease
    Renal colic
    Ectopic pregnancy
    Constipation

    Physical Signs Associated with


    Appendicitis (what the books say)
    Sign

    Description

    McBurney sign

    Localized right lower quadrant pain or guarding on


    palpation of the abdomen (the single most important
    sign)

    Psoas sign

    Pain on hyperextension of right thigh (often indicates


    retroperitoneal retrocecal appendix)

    Obturator sign

    Pain on internal rotation of right thigh (pelvic appendix)

    Rovsing sign

    Pain in the right lower quadrant with palpation of the left


    lower quadrant

    Dunphys sign

    Increased pain in the right lower quadrant with coughing

    Hip flexion

    Patient maintains hip flexion with knees drawn up for


    comfort

    Other peritoneal
    signs

    Rebound tenderness, hyperesthesia of the skin in the


    right lower quadrant

    History and Physical

    Most common
    Signs/Sx
    Right lower
    quadrant pain
    Anorexia

    Sensitivity

    Specificity

    81%

    53%

    68%

    36%

    Nausea

    58%

    37%

    Fever

    67%

    79%

    Pain Migration

    64%

    82%

    Psoas
    sign

    Obturator
    sign

    rectal examination

    Plain
    Film Radiography
    cost effective

    Not
    Not

    specific

    Can

    be misleading

    Not

    recommended
    unless other pathology is
    suspected: eg. perforation,
    intestinal obstruction,
    ureteral calculus

    Radiology
    Abdominal X ray film
    -

    Air-Fluid Levels
    Stones
    Ascites
    Eggshell calcification in AAA
    Air in Biliary tree.
    Obliteration of Psoas Shadow in retroperitoneal disease
    Right lower quadrant sentinel loops in acute
    appendicitis

    Ultrasonography

    Transverse abdominal US demonstrates a


    noncompressible mixed echotexture mass in the RLQ
    consistent with appendiceal abscess/phlegmon.

    1.thickened

    appendix
    2.Caecum
    3.Small amount
    of
    pericaecal fluid
    4.perippendicular
    hyperemia

    Helical CT scan:
    Enlarged appendix,
    No filling with contrast material,
    Periappendiceal inflammatory changes
    Nonpregnant patients 98% sensitivity
    Pregnant - useful, noninvasive & accurate
    (Am J Obstet Gynecol 2001
    Apr;184(5):954-7
    Radiation ?

    The Big
    Picture:
    Is US or CT
    better?

    Predictive Probablility of US vs CT

    Terasawa T, Blackmore CC, Bent S, Kohlwes RJ. Systematic review: computed


    tomography and ultrasonography to detect acute appendicitis in adults and adolescents.
    Ann Intern Med. 2004 Oct 5;141(7):537-46

    LAPAROSCOPIC
    APPENDECTOMY

    LAPAROSCOPIC
    APPENDECTOMY 2

    Appendectomy

    Adhesive Small Bowel Obstruction After


    Appendectomy in Children: Comparison
    Between the Laparoscopic and Open
    Approach
    Jan 98-June 05: 1105 Appendectomies-447 Open, 628 Lap.

    AAP 2006
    J Pediatr Surg 42:939-942, 2007

    laparoscopy:
    Adv:

    Disadv:

    Less post-op
    complication

    Co2 pneumoperitoneum:
    Dec. uterine blood flow
    Fetal acidosis
    Premature labor

    Safe

    especially in 1st half of pregnancy (size of


    gravid uterus)
    Similar perinatal outcomes compared to
    laparotomies (Reedy and colleagues,1997)

    Perforated appendicitis:

    Incidence:

    4 -19% nonpregnant patients


    57%
    pregnant women (Tracey &
    Fletcher,2000)

    Gestational age
    Perforations
    Peritonitis

    White appendix:
    Nonpregnant

    20%
    Pregnant 20-50% ( higher in advanced
    pregnancy)

    How Do We Define
    Perforation?

    Hole in appendix

    Stool in abdomen

    Classic history for


    appendicitis
    Patients

    with a classic history for appendicitis


    require prompt surgical consultation but may not
    require emergency surgery. In fact, emergency
    appendectomy (operation within 6 h) in children
    has no advantages over urgent appendectomy
    (operation with 12 h) with respect to gangrene and
    perforation rates, readmissions, postoperative
    complications, hospital stay, or hospital charges.
    This does not mean the emergency physician who
    has made the diagnosis of appendicitis will not
    contact the surgeon right away, but the hospital
    admission and course must be discussed with the
    surgeon, patient, and family

    Examples of protocols and Risk


    Stratification for Equivocal Patients
    Surgical Protocol

    Risk Stratification
    Suspected Appendicitis

    Suspected
    Appendicitis

    Perform US
    -+
    +
    Appendectomy
    CT

    Polys <67%

    Polys >67%

    Bands <5%

    WBC >10,000

    No Guarding

    Guarding

    Abdominal Pain <


    13hrs

    Abdominal Pain
    >13hrs

    Low Risk
    --

    Observe/discharge Home

    US
    +Surgery
    - Observe

    High Risk
    CT

    + Surgery
    - Observe

    Conclusion
    There

    is currently no standardized
    protocol for diagnosis of acute
    appendicitis

    Diagnosis

    include:

    Accurate

    of Acute Appendicitis should

    H&P, lab studies, urinalysis


    Consideration of risk when exposing patients
    to unnecessary radiation
    Selective use of US and CT

    The end

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