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