APENDISITIS

Stase Ilmu Bedah RSIJ Cempaka Putih

Pembimbing: dr. Winoto, Sp.B

PANJANGNYA KIRA-KIRA

ADA KESAMAAN

Anatomi
Berasal dari MID GUT Di fossa iliaka kanan titik Mc. Burney Basis di puncak sekum pertemuan 3 taenia Bentuk tabung, panjang 3 15 cm Pangkal lumen sempit, distal lebar Lokasi : retrosekal (65%), pelvinal, antesekal, medial, preileal,postileal, dll Vaskularisasi A.apendikularis (end arteri)

Definition
Appendicitis is a condition characterized by inflammation of the appendix. It is classified as a medical emergency and many cases require removal of the inflamed appendix, either by Untreated, laparotomy mortality is or high, laparoscopy. mainly because of the risk of rupture leading to

Etiology

Foreign object
Fecalith Neoplasma

Hiperplasia Lymphoid

Obstruksi Lumen

Parasit

Patogenesis

Patogenesis
Obstru ksi
tekanan intra luminer tinggi

edema + ulserasi mukosa gangguan drainase limfe

mukus >>>

APENDISITIS AKUT

Symptoms : - Nyeri visera di epigastrium, sekitar umbilicus - Mungkin Kolik

Patogenesi s Appendisitis

Tekanan Intralumen Tinggi

obstruksi vena

invasi kuman Iskemia edema semakin berat

Trombosis

APENDISITIS AKUT SUPURATIF / PURULENTA

Symptoms - Nyeri sentral berpindah ke perut kanan bawah - Nyeri somatik ( peritonitis lokal) - Mual dan muntah

Gejala Klinis
Nyeri samarsamar dan tumpul Nyeri pada titik Mcburney

Sakit bertambah

Mual dan kadang ada muntah

Konstipasi/diare

Pemeriksaan Fisik
KEADAAN UMUM Demam ringan 0 0 37,5 0 38,5 C (beda 1 C rektal dan aksiler sudah bermakna) Demam tinggi infiltrat, abses, peritonitis Nadi cepat infiltrat, abses, peritonitis Kurang bergerak, paha difleksikan INSPEKSI Tidak tampak kelainan Penonjolan perut kanan bawah INFILTRAT ATAU ABSES Cembung ikut gerak nafas PERFORASI / PERITONITIS PALPASI Nyeri tekan perut kanan bawah (Mc Burney) Massa di perut kanan bawah INFILTRAT ATAU ABSES Defans lokal defans menyeluruh sudah PERITONITIS BLUMBERG SIGN , ROVSING SIGN OBTURATOR SIGN, PSOAS SIGN

McBurneys Point

McBurneys point (1) appears about one-third of the distance along a line starting at the right ASIS (3) and ending at the umbilicus (2).

The psoas sign. Pain on passive extension of the right thigh. Patient lies on left side. Examiner extends patient's right thigh while applying counter resistance to the right hip (asterisk).

Anatomic basis for the psoas sign: inflamed appendix is in a retroperitoneal location in contact with the psoas muscle, which is stretched by this maneuver.

The obturator sign. Pain on passive internal rotation of the flexed thigh. Examiner moves lower leg laterally while applying resistance to the lateral side of the knee (asterisk) resulting in internal rotation of the femur.

Anatomic basis for the obturator sign: inflamed appendix in the pelvis is in contact with the obturator internus muscle, which is stretched by this maneuver.

Pemeriksaan Fisik
PERKUSI Nyeri ketok perut kanan bawah Pekak hepar hilang PERFORASI (sering pekak ada) AUSKULTASI Peristaltik normal Bising usus menghilang PERITONITIS COLOK DUBUR Nyeri pukul 10 11 LETAK PELVINAL Sfingter longgar bila PERITONITIS

Pemeriksaan Penunjang
Laboratorium: Peningkatan jumlah leukosit CRP, Urinalisa Foto polos abdomen

Ultrasonografi

CT-scan

Laparoskopi

Histopatologi

COMPUTED TOMOGRAPHY

In fewer than 5 percent of patients, an opaque fecalith may be apparent in the right lower quadrant. Plain abdominal films generally are not recommended unless other conditions(e.g., perforation, intestinal obstruction, ureteral calculus) are suspected.8 Likewise, as advanced cross-sectional imaging techniques have become available, barium enema is now used infrequently.

ULTRASONOGRAPHY

Ultrasonogram showing longitudinal section (arrows) of inflamed appendix.

COMPUTED TOMOGRAPHY

Computed tomographic scan showing crosssection of inflamed appendix (A) with appendicolith (a).

Computed tomographic scan showing enlarged and inflamed appendix (A) extending from the cecum (C).

Alvarado Scale for the Diagnosis of Appendicitis

Manifestations Symptoms Migration of pain Anorexia Nausea and/or vomiting Signs Right lower quadrant tenderness (Nyeri fossa iliaca kanan) Rebound (Nyeri lepas) Value 1 1 1 2 1

Elevated temperature (> 37,30C )

Laboratory values Leukocytosis (> 10103/L Left shift in leukocyte count (neutrofil > 75% ) )

1
2 1 Total points 10

>7 : Appendiksitis akut

Modified Alvarado score (Kalan et al) tanpa observasi of

Hematogram

Skor 1 4 : dipertimbangkan appendicitis akut : Observasi Skor 5 6 : possible appendicitis tidak perlu operasi : Antibiotik Skor 7 9 : appendicitis akut perlu pembedahan : Operasi dini

DIANGNOSIS BANDING
Gastroenteritis Demam Dengue Limfadenitis Mesenterika Kelainan Ovulasi Infeksi Panggul Kehamilan di Luar Kandungan Kista Ovarium Terpuntir Endometriosis Eksterna Urolitiasis Pielum/Ureter Kanan Penyakit Saluran Cerna Lainnya

Penatalaksanaan
Apendectomy Drainage Conservative

Appendectomy
An appendectomy (sometimes called appendisectomy or appendicectomy (British English)) is the surgical removal of the vermiform appendix

An appendectomy may be laparoscopic or traditional. Laparoscopic surgery uses a few small incisions.

The various layers of the abdominal wall are then opened, On entering the peritoneum, the appendix is identified, mobilized and then ligated and divided at its base

Drainage
Drainage involves placing a needle through the skin in the abscess, usually under xray guidance. The drain is then left in place for days or weeks until the abscess goes away. PAD is performed using standard aseptic technique and local lidocaine anesthesia. Begin with a diagnostic aspiration, followed by catheter placement if fluid is purulent

Conservative
Pada Infiltrat Appendikularis
Prosedur Oshner-Shener 1. Istirahat total 2. Posisi fowler 3. Antibiotika 4. Monitoring suhu , ukuran tumor, Laju endap darah (led) & leukosit Appendectomy elektif setelah 12 minggu

Posisi duduk atau setengah duduk, bagian kepala tempat tidur lebih tinggi atau dinaikkan. Fowler (45o-90o) dan semi fowler (15o-45o). Dilakukan untuk mempertahankan kenyamanan, memfasilitasi fungsi pernapasan, dan pasien pasca bedah.

REFERENSI
1. 2. 3. De Jong, W. & Sjamsuhidajat, R.,2004. Buku Ajar Ilmu Bedah Edisi 2. EGC. Jakarta. Reksoprodjo, S., dkk. 1995. Kumpulan Kuliah Ilmu Bedah. Bagian Bedah Staf Pengajar Fakultas Kedokteran Universitas Indonesia. Bina Rupa Aksara. Jakarta. Mansjoer, A., dkk. 2000. Kapita Selekta Kedokteran Edisi Ketiga Jilid Kedua. Penerbit Media Aesculapius Fakultas Kedokteran Universitas Indonesia. Jakarta. Bagian Ilmu bedah Fakultas Kedokteran Universitas Sumatra Utara. http://library.usu.ac.id/ download/fk/bedah-emir%20jehan.pdf Mubin, Halim. Buku Panduan Praktis : Ilmu Penyakit Dalam Diagnosis dan Terapi Edisi 2. Jakarta : Penerbit Buku Kedokteran EGC. 2007. Price, Sylvia A. Patofisiologi : Konsep Klinis Proses-Proses Penyakit, Edisi 4. Jakarta: Penerbit Buku Kedokteran EGC. 1995. Schwartz, Spencer, S., Fisher, D.G., 1999. Principles of Surgery Sevent Edition. Mc-Graw Hill a Division of The McGraw-Hill Companies. Enigma an Enigma Electronic Publication.

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