1. Mengapa perut nyeri ketika disentuh?

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 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

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 2. Macam- macam nyeri abdomen
There are three different types of abdominal pain: visceral pain, parietal pain and referred pain. The type of pain varies depending on the organ involved.

Visceral Pain

Visceral pain is directly related to the organ involved. The majority of organs do not have an abundance of nerve fibers, so the patient might experience mild or less severe pain that is poorly localized. Its important to understand this does not mean the patient is experiencing a mild or less severe condition. Characteristics: Less severe pain Poorly localized The pain is usually dull or aching and constant or intermittent

Parietal Pain
Parietal pain occurs when there is an irritation of the peritoneal lining. The peritoneum has a higher number of sensitive nerve fibers, so the pain is generally more severe and easier to localize. The patient will typically present in a guarded position with shallow breathing. This minimizes the stretch of the abdominal muscles and limits the downward movement of the diaphragm, which reduces pressure on the peritoneum and helps ease the pain. Characteristics: More severe pain Easily localized The pain is usually sharp, constant and on one side or the other

Referred Pain
Referred pain is visceral pain that is felt in another area of the body and occurs when organs share a common nerve pathway. For this reason, it is poorly localized but generally constant in nature. An example is a patient with liver problems that experiences referred pain in the neck or just below the scapula. Characteristics: Poorly localized The pain is usually constant

3. Mengapa nyerinya dijalarkan dari umbilicus ke inguinal kanan? 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 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

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

4. Mengapa jalannya bungkuk ke kanan dan kaki kanan melipat ke atas?

Psoas sign

Pain on hyperextension of right thigh (often indicates retroperitoneal retrocecal appendix)

So, if the appendicitis locate on retrocaecal, thats why when patient do flexion of right thigh, it will make the m. psoas being relaxed and not touch the appendix which have an inflammation on it 5. 6. 7. 8. Mengapa disertai muntah mual dan nafsu makan menghilang? Mengapa demam semakin meninggi sejak 6 jam yang lalu? Interpretasi dari pemeriksaan fisik ? Apa DD (etiologic, patofisiologi, factor resiko, komplikasi, pemeriksaan, penatalaksanaan)

What causes appendicitis?

An obstruction, or blockage, of the appendiceal lumen causes appendicitis. Mucus backs up in the appendiceal lumen, causing bacteria that normally live inside the appendix to multiply. As a result, the appendix swells and becomes infected. Sources of blockage include stool, parasites, or growths that clog the appendiceal lumen

enlarged lymph tissue in the wall of the appendix, caused by infection in the GI tract or elsewhere in the body inflammatory bowel disease (IBD), which includes Crohns disease and ulcerative colitis, longlasting disorders that cause irritation and ulcers in the GI tract trauma to the abdomen An inflamed appendix will likely burst if not removed.

PATOFISIOLOGI

PATHOPHYSIOLOGY: APPENDICITIS
tumor foreign body fecal mass stricture infection

fecal movement in the earlier parts of the colon continues movement of new materials down the digestive tract

tension

fecal impaction backflow pressure reaches the appendix irritation aggravation of condition blood flow immune response

imflammation

edema

fever

pain

mass

stretching of lumen

APPENDICITIS

rupture release of fecal materias in the abdominal cavity reaches the peritoneum immune response PERITONITIS inflammation (+) abdominal incision (McBurney)

appendectomy

operative site (cecum)

Immune response (WBC on the site)

pain

fever

risk for infection

How is appendicitis diagnosed?

A health care provider can diagnose most cases of appendicitis by taking a persons medical history and performing a physical exam. If a person does not have the usual symptoms, health care providers may use laboratory and imaging tests to confirm appendicitis. These tests also may help diagnose appendicitis in people who cannot adequately describe their symptoms, such as children or people who are mentally impaired. Medical History The health care provider will ask specific questions about symptoms and health history. Answers to these questions will help rule out other conditions. The health care provider will want to know when the abdominal pain began the exact location and severity of the pain when other symptoms appeared other medical conditions, previous illnesses, and surgical procedures whether the person uses medications, alcohol, or illegal drugs Physical Exam Details about the persons abdominal pain are key to diagnosing appendicitis. The health care provider will assess the pain by touching or applying pressure to specific areas of the abdomen. Responses that may indicate appendicitis include Rovsings sign. A health care provider tests for Rovsings sign by applying hand pressure to the lower left side of the abdomen. Pain felt on the lower right side of the abdomen upon the release of pressure on the left side indicates the presence of Rovsings sign. Psoas sign. The right psoas muscle runs over the pelvis near the appendix. Flexing this muscle will cause abdominal pain if the appendix is inflamed. A health care provider can check for the psoas sign by applying resistance to the right knee as the patient tries to lift the right thigh while lying down. Obturator sign. The right obturator muscle also runs near the appendix. A health care provider tests for the obturator sign by asking the patient to lie down with the right leg bent at the knee. Moving the bent knee left and right requires flexing the obturator muscle and will cause abdominal pain if the appendix is inflamed. Guarding. Guarding occurs when a person subconsciously tenses the abdominal muscles during an exam. Voluntary guarding occurs the moment the health care providers hand touches the abdomen. Involuntary guarding occurs before the health care provider actually makes contact and is a sign the appendix is inflamed. Rebound tenderness. A health care provider tests for rebound tenderness by applying hand pressure to a persons lower right abdomen and then letting go. Pain felt upon the release of the pressure indicates rebound tenderness and is a sign the appendix is inflamed. A person may also experience rebound tenderness as pain when the abdomen is jarredfor example, when a person bumps into something or goes over a bump in a car.

Women of childbearing age may be asked to undergo a pelvic exam to rule out gynecological conditions, which sometimes cause abdominal pain similar to appendicitis. The health care provider also may examine the rectum, which can be tender from appendicitis. Laboratory Tests Laboratory tests can help confirm the diagnosis of appendicitis or find other causes of abdominal pain. Blood tests. A blood test involves drawing a persons blood at a health care providers office or a commercial facility and sending the sample to a laboratory for analysis. Blood tests can show signs of infection, such as a high white blood cell count. Blood tests also may show dehydration or fluid and electrolyte imbalances. Electrolytes are chemicals in the body fluids, including sodium, potassium, magnesium, and chloride. Urinalysis. Urinalysis is testing of a urine sample. The urine sample is collected in a special container in a health care providers office, a commercial facility, or a hospital and can be tested in the same location or sent to a laboratory for analysis. Urinalysis is used to rule out a urinary tract infection or a kidney stone. Pregnancy test. Health care providers also may order a pregnancy test for women, which can be done through a blood or urine test. Imaging Tests Imaging tests can confirm the diagnosis of appendicitis or find other causes of abdominal pain. Abdominal ultrasound. Ultrasound uses a device, called a transducer, that bounces safe, painless sound waves off organs to create an image of their structure. The transducer can be moved to different angles to make it possible to examine different organs. In abdominal ultrasound, the health care provider applies gel to the patients abdomen and moves a hand -held transducer over the skin. The gel allows the transducer to glide easily, and it improves the transmission of the signals. The procedure is performed in a health care providers office, an outpatient center, or a hospital by a specially trained technician, and the images are interpreted by a radiologista doctor who specializes in medical imaging; anesthesia is not needed. Abdominal ultrasound creates images of the appendix and can show signs of inflammation, a burst appendix, a blockage in the appendiceal lumen, and other sources of abdominal pain. Ultrasound is the first imaging test performed for suspected appendicitis in infants, children, young adults, and pregnant women. Magnetic resonance imaging (MRI). MRI machines use radio waves and magnets to produce detailed pictures of the bodys internal organs and soft tissues without using x rays. The procedure is performed in an outpatient center or a hospital by a specially trained technician, and the images are interpreted by a radiologist. Anesthesia is not needed, though children and people with a fear of confined spaces may receive light sedation, taken by mouth. An MRI may include the injection of special dye, called contrast medium. With most MRI machines, the person lies on a table that slides into a tunnel-shaped device that may be open ended or closed at one end; some machines are designed to allow the person to lie in a more open space. An MRI can show signs of inflammation, a burst appendix, a blockage in the appendiceal lumen, and other sources of abdominal pain. An MRI used to diagnose appendicitis and other sources of 2 abdominal pain is a safe, reliable alternative to a computerized tomography (CT) scan. CT scan. CT scans use a combination of x rays and computer technology to create threedimensional (3-D) images. For a CT scan, the person may be given a solution to drink and an injection of contrast medium. CT scans require the person to lie on a table that slides into a tunnel-shaped device where the x rays are taken. The procedure is performed in an outpatient center or a hospital by an x-ray technician, and the images are interpreted by a radiologist;

anesthesia is not needed. Children may be given a sedative to help them fall asleep for the test. A CT scan of the abdomen can show signs of inflammation, such as an enlarged appendix or an abscessa pus-filled mass that results from the bodys attempt to keep an infection from spreadingand other sources of abdominal pain, such as a burst appendix and a blockage in the appendiceal lumen. Women of childbearing age should have a pregnancy test before undergoing a CT scan. The radiation used in CT scans can be harmful to a developing fetus. 2 Heverhagen J, Pfestroff K, Heverhagen A, Klose K, Kessler K, Sitter H. Diagnostic accuracy of magnetic resonance imaging: a prospective evaluation of patients with suspected appendicitis (diamond). Journal of Magnetic Resonance Imaging. 2012;35:617623.

Common Signs of Acute Appendicitis

SIGN McBurney sign DESCRIPTION Localized right lower quadrant pain or guarding on palpation of the abdomen (the single most important sign) Pain on hyperextension of right thigh (often indicates retroperitoneal retrocecal appendix) Pain on internal rotation of right thigh (pelvic appendix) Pain in the right lower quadrant with palpation of the left lower quadrant Increased pain in the right lower quadrant with coughing Patient maintains hip flexion with knees drawn up for comfort Rebound tenderness, hyperesthesia of the skin in the right lower quadrant

Psoas sign

Obturator sign Rovsing sign Dunphys sign Hip flexion Other peritoneal signs

NOTE:The absence of these signs does not exclude appendicitis. Information from references 8, 9, and 15.

Prevalence of Common Signs and Symptoms of Appendicitis

SIGN OR SYMPTOM Abdominal pain Right lower quadrant pain or tenderness Anorexia FREQUENCY (%) 99 to 100 96 24 to 99

SIGN OR SYMPTOM Nausea Low-grade fever Vomiting Pain migration from periumbilical area to the right lower quadrant Rebound tenderness Right lower quadrant guarding

FREQUENCY (%) 62 to 90 67 to 69 32 to 75 50 26 21

Information from references 6 and 11.

How is appendicitis treated?

Appendicitis is typically treated with surgery to remove the appendix. The surgery is performed in a hospital; general anesthesia is needed. If appendicitis is suspected, especially in patients who have persistent abdominal pain and fever, or signs of a burst appendix and infection, a health care provider will often suggest surgery without conducting diagnostic testing. Prompt surgery decreases the chance that the appendix will burst. Surgery to remove the appendix is called an appendectomy. A surgeon performs the surgery using one of the following methods: Laparotomy. Laparotomy removes the appendix through a single incision in the lower right area of the abdomen. Laparoscopic surgery. Laparoscopic surgery uses several smaller incisions and special surgical tools fed through the incisions to remove the appendix. Laparoscopic surgery leads to fewer complications, such as hospital-related infections, and has a shorter recovery time. With adequate care, most people recover from appendicitis and do not need to make changes to diet, exercise, or lifestyle. Surgeons recommend limiting physical activity for the first 10 to 14 days after a laparotomy and for the first 3 to 5 days after laparoscopic surgery. [Top]

The treatment of appendicitis:The treatment can be summed up in one word - Appendicectomy. Appendicectomy:In early cases the operation is straightforward. An incision is made over McBurney's point. McBurney's point is centred along a line joining the

umbilicus with the anterior superior iliac spine. It is situated at a point 2/3 of the way along this line - rather closer to the iliac spine than to the umbilicus.

An oblique incision is made centred over this point, and slopes downwards and inwards, not quite parallel with the more horizontal skin creases. The incision is taken down to the aponeurosis of the external oblique muscle.

The external oblique muscle is then split in the line of its fibres for about ten centimetres. This can be made easier if the fascia over it is lightly incised

with a scalpel before the splitting is completed with straight dissecting scissors. The internal oblique muscle is then likewise split in the line of its fibres, again for about ten centimetres. It may be found to lie at a different angle from the external oblique, and again lightly incising the fascia over the muscle before it is split will help in showing where the split will be made.

Deepen the split with the points of the scissors, but by spreading the points rather than by cutting in the usual way. By this means you are less likely to do deep damage. You may find that you have already split the transversus abdominis muscle together with the internal oblique, but if you have not, repeat the process with this final muscular layer to expose the peritoneum.

When you have exposed the peritoneum, sweep it away from the overlying muscles with your fingers before opening it. This will make it easier to close it when the time comes. Otherwise it is stuck to the overlying muscles. Opening the peritoneum is done between two artery forceps in the usual way. Have a sucker to hand in case there is any free fluid, and if you have bacteriology, keep some for culture and sensitivity. Now it will be your job to find the appendix. This may be done by trying to identify the caecum which is probably lateral to your incision.

If you find small bowel, tuck it back into the abdomen, but if you find bowel that you think may be caecum, check that it has the typical taeniae or longitudinal muscular bands that are characteristic of large bowel. Once you have identified a taeniae, that is the time to trace it down to where it meets the other two taeniae on the caecum. At the point where the three taeniae meet you will find the base of the appendix. You may, if you are lucky, be able to "hook up" the appendix with your finger if it is lying medially or hanging down over the brim of the pelvis. Even if it is normal, you would probably be wise to remove it, because any future surgeon looking at your incision will probably conclude that there is no appendix now, and if you had left it in, he could be making a fatal mistake! If the appendix that you find is swollen, covered with fibrinous or purulent tags, discoloured, gangrenous or perforated you should certainly remove it!

The appendix can be taken out retrograde or in the normal fashion. The normal fashion is to clamp the meso-appendix and divide it between clamps or between ligatures, and then to apply two clamps to the base of the appendix. The one nearest the caecum is removed, and a No. 1 chromic catgut ligature is tied round where the clamp had been.

The stump of the appendix is then cut through between that tie and the other clamp, and then is buried in a purse string suture. This step is necessary, whatever you may have been taught, to prevent the rare but unfortunate development of a faecal fistula if the tie cuts through the base of the appendix. "Retrograde removal" of the appendix can be done if the base of the appendix is visible but the rest of the organ is hidden and lying retrocaecally. To do this, you divide the base of the appendix and

invaginate the stump in a purse string as before, and then, holding the appendix in the other clamp, the appendix is located by burrowing with your finger along it, so that the meso-appendix can be identified, ligated and divided bit by bit until the whole of the appendix has been removed.

What do you do when the appendix is lying retrocaecally and you cannot reach it at all? It can be particularly difficult when you are in an isolated hospital where relaxant anaesthesia is unavailable and when the usual grid- iron incision was used (as described above). The answer is not found in many standard textbooks. It is a muscle-cutting incision. Instead of splitting the muscles, layer by layer, in the line of their fibres, a longer McBurney incision is made, and the muscles are cut (using a scalpel, not scissors) in the line of the skin incision all the way down to the peritoneum. This incision can be extended laterally very far if necessary (indeed it can be used for nephrectomy). It can also be extended medially as far as the edge of the rectus abdominis muscle. If further medial extension is needed, the rectus muscle can be cut, but that is a bit untidy, and it is usually sufficient to curve the incision down parallel to the edge of the rectus, and to displace the rectus medially with a retractor. Once you have this extended incision, you will be able to see a great deal more than with the grid-iron incision. If the appendix is lying retrocaecally, you can incise the peritoneal reflection on the lateral side of the caecum, and then lift the caecum, displacing it medially until you can see the whole of its underside, and with blunt finger dissection, strip the appendix away from it until you have sufficient exposure to complete the appendicectomy.

Drainage is only necessary if you have opened an abscess cavity, in which case a corrugated rubber drain at least three cm. wide should be used, and should be brought out through a separate skin incision away from the original incision. This separate incision should easily admit two fingers side by side, and if it is too tight, should be enlarged by cutting with a scalpel. Otherwise it will contract around the drain preventing rather than encouraging the drainage of pus. Closure is easy if you have done a grid-iron incision. You just need one suture for the peritoneum, and a few catgut sutures to approximate the muscle layers. Nylon will do for the skin. If however you have done a muscle-cutting incision, or enlarged a grid-iron incision into the muscle cutting one, it is probably better to close the incision with interrupted wire (or nylon) sutures that go through the peritoneum and all the muscle layers in one, rather than suture each layer separately.
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The Appendix Mass - a special case The only situation when it may prove wiser to delay appendicectomy for a bit is the rare case when there is an appendix mass that seems to be settling. Nearly always the history will support the diagnosis, and it will be clear that the patient has clearly had appendicitis, and that the condition is settling (often without antibiotics). The pain is settling, the patient will tell you, and examination reveals a fit patient with no pyrexia (and therefore no abscess!), no signs of peritonitis, and no mass felt per rectum. This is an unusual situation, and clearly the inflammatory process has walled itself off and no pus has accumulated. How should such a patient be treated?

Immediate appendicectomy is a good treatment for such a patient, but it must be admitted that the operation will be a difficult one, although not impossible for an experienced surgeon. But the inflammation is settling down, and the improvement is not due to antibiotics because the patient is not on antibiotics. (If the patient is on antibiotics, then decision making is quite difficult, because the antibiotics may well be masking the signs of serious complications). However, if the condition is undergoing resolution, why not let it resolve and then take the appendix out? What to do:- Admit the patient. Forbid antibiotics if the patient is not already on them, so that if complications do develop they will not be masked. If the patient is already on them, you may have to continue them. Forbid aperients, which might cause perforation, and likewise forbid enemas at this stage. With a ball-point pen or something similar, draw the outline of the mass on the skin so that you can trace the progress from day to day. You will have to examine the patient at least once daily, and check that the mass is getting smaller. Success will be marked by the pain disappearing, the temperature remaining normal, the appetite coming back, and the abdomen becoming soft and normal again. If this occurs, then book the patient for interval appendicectomy in exactly six weeks. Six weeks is just right for adhesions to have disappeared, and it is unlikely that appendicitis will recur before then. If you leave it longer, that chance increases, and the eventual operation may become tricky.
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What are the complications and treatment of a burst appendix?

A burst appendix spreads infection throughout the abdomena potentially dangerous condition called peritonitis. A person with peritonitis may be extremely ill and have nausea, vomiting, fever, and severe abdominal tenderness. This condition requires immediate surgery through laparotomy to clean the abdominal cavity and remove the appendix. Without prompt treatment, peritonitis can cause death. Sometimes an abscess forms around a burst appendixcalled an appendiceal abscess. A surgeon may drain the pus from the abscess during surgery or, more commonly, before surgery. To drain an abscess, a tube is placed in the abscess through the abdominal wall. The drainage tube is left in place for about 2 weeks while antibiotics are given to treat infection. Six to 8 weeks later, when infection and inflammation are under control, surgeons operate to remove what remains of the burst appendix.

Hasil Pemeriksaan Fisik dan Penunjang Sederhana (Objective) Pemeriksaan Fisik Inspeksi Penderita berjalan membungkuk sambil memegangi perutnya yang sakit, kembung (+) bila terjadi perforasi, penonjolan perut kanan bawah terlihat pada appendikuler abses. Palpasi 1. Terdapat nyeri tekan Mc.Burney 2. Adanya rebound tenderness (nyeri lepas tekan) 3. Adanya defens muscular. 4. Rovsing sign positif 5. Psoas sign positif 6. Obturator Sign positif

Perkusi Nyeri ketok (+) Auskultasi Peristaltik normal, peristaltik(-) pada illeus paralitik karena peritonitis generalisata akibat appendisitis perforata. Auskultasi tidak banyak membantu dalam menegakkan diagnosis apendisitis, tetapi kalau sudah terjadi peritonitis maka tidak terdengar bunyi peristaltik usus. Rectal Toucher / Colok dubur Nyeri tekan pada jam 9-12 Tanda Peritonitis umum (perforasi) : 1. Nyeri seluruh abdomen 2. Pekak hati hilang 3. Bising usus hilang Apendiks yang mengalami gangren atau perforasi lebih sering terjadi dengan gejala-gejala sebagai berikut: a. Gejala progresif dengan durasi lebih dari 36 jam b. Demam tinggi lebih dari 38,50C c. Lekositosis (AL lebih dari 14.000) d. Dehidrasi dan asidosis e. Distensi f. Menghilangnya bising usus g. Nyeri tekan kuadran kanan bawah h. Rebound tenderness sign i. Rovsing sign j. Nyeri tekan seluruh lapangan abdominal