CASE REPORT

ACUTE APPENDICITIS

Preceptor :

dr. M. Bob Muharly Rambe, M.Ked (Surg), Sp.B

Created By :

Ahmad Fadlurrahman (20360700)

Chandra pratama (20360228)

Novan Triyansyah AKL (20360000)

Novrizal Muhammad Fadillah (20360000)

KEPANITRAAN KLINIK SENIOR BAGIAN ILMU BEDAH

FAKULTAS KEDOKTERAN UNIVERSITAS MALAHAYATI

RUMAH SAKIT UMUM HAJI MEDAN

1
 2022

Preface

First of all, thanks to Allah SWT because of the help of Allah, writer finished writing this
case report entitled "Appendicitis" right in the calculated time. In arranging this case report, the
writer trully get lots challenges and obstructions but with help of many indiviuals, those
obstructions could passed. writer also realized there are still many mistakes in process of writing
this case report.

Therefore, with this opportunity writer expressed his sincere gratitude to dr. M. Bob
Muharly Rambe, M.Ked (Surg), Sp.B as a preceptor who has provided a lot of knowledge,
guidance, advice and gave us the opportunity to complete this case report.

Because of that, the writer says thank you to all individuals who helps in the process of
writing this case report. Hopefully allah replies all helps and bless you all.the writer realized this
case report still imperfect in arrangment and the content. Then the writer hope the criticism from
the readers can help the writer in perfecting the next case report last but not the least. Hopefully,
this paper can helps the readers to gain more knowledge about samantics major.

Medan, February 2022

The Writer

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 TABLE OF CONTENTS

Cover................................................................................................................................................................................. 1

Preface.............................................................................................................................................................................. 2

TABLE OF CONTENTS.......................................................................................................................................... 3

CHAPTER I..................................................................................................................................................................... 4

INTRODUCTION......................................................................................................................................................... 4

CHAPTER II................................................................................................................................................................... 5

CASE REPORT............................................................................................................................................................. 5

2.1 Patient Information........................................................................................................................................... 5

2.2 Anamnesis........................................................................................................................................................... 5

2.3 VITAL SIGN........................................................................................................................................................... 5

2.4 PHYSICAL EXAMINATION........................................................................................................................... 6

2.5 Localization Status Abdomen............................................................................................................................. 7

2.6 Pemeriksaan Penunjang........................................................................................................................................ 7

2.7 Working Diagnosis.............................................................................................................................................. 10

2.8 Differential Diagnosis......................................................................................................................................... 10

2.9 Therapy.................................................................................................................................................................... 11

REVIEW........................................................................................................................................................................ 12

3.1 ANATOMY........................................................................................................................................................... 12

3.1.1 APPENDIX VERMIFORM.......................................................................................................................... 12

CHAPTER III............................................................................................................................................................... 16

APPENDICITIS.......................................................................................................................................................... 16

4.1 Definition................................................................................................................................................................ 16

4.2 Epidemiology........................................................................................................................................................ 16

4.3 Etiology................................................................................................................................................................... 17

4.4 Pathophysiology................................................................................................................................................... 18

4.5 Sign and Symptom............................................................................................................................................... 19

4.6 Diagnosis................................................................................................................................................................ 19

4.7 Laboratory Test..................................................................................................................................................... 21

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4.8 Differential Diagnosis......................................................................................................................................... 23

Chapter IV..................................................................................................................................................................... 31

Summary........................................................................................................................................................................ 31

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 CHAPTER I
INTRODUCTION

The appendix is a narrow tubular pouch attached to the caecum. When the appendix is
blocked, it becomes inflamed and results in a condition termed appendicitis. If the blockage
continues, the inflamed tissue becomes infected with bacteria and begins to die from a lack of blood
supply, which finally results in the rupture of the appendix (perforated or ruptured appendix).
The American Journal of Epidemiology study found that appendicitis was a common
condition affecting approximately 6.7% to 8.6% of the population. IN the U.S. 250,000 cases of
appendicitis are reported annually. Individuals of any age may be affected, with the highest
incidence occurring in the teens and twenties; however, rare cases of neonatal and prenatal
appendicitis have been reported. Increased vigilance in recognizing and treating potential cases of
appendicitis is critical in the very young and elderly, as this population has a higher rate of
complications. Appendicitis is the most common pediatric condition requiring emergency
abdominal surgery. (1)

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 CHAPTER II
CASE REPORT

2.1 Patient Information

Name : Arief Tri Wanda

Age : 24 years old

Address : Jl. Starban, Gg.Sawah, Medan Polonia

Job : Student

Religion : Islam

Room : Annisa B1

RM : 374791

DOE : 10/02/2022

2.2 Anamnesis
Main Complaint

Abdominal Pain on right lower quadrant

History of illness

A man aged 24 years came to the ER of the Haji Medan General Hospital on February 10,
2022 with complaints of pain in the lower right abdomen since 1 day ago. Initially, the pain is felt
to radiate to all areas of the abdominal and pulsating. Os also feels weak and has no appetite, nausea
and vomiting (+), pale (+), dry cough (+), Fever (-).

- Defecate :-

- Urinate : 1x/days, clear yellow

- Past medical history : -

- History of Drug Use : -

- Family disease history : -

2.3 VITAL SIGN

- General Condition : Moderate
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 - Awareness : Compos Mentis

- Blood Pressure : 120/70 mmHg

- Pulse : 84x bpm

- Temperature : 36,6 °C

- Respiration rate : 20x tpm

- SpO2 : 98%

2.4 PHYSICAL EXAMINATION

Eyes : Anemia Conjungtive (-/-), oedem eyelid (-/-), Icteric Sclera (-/-)

Nose : nosetril breathing (-/-), nasal secretion (-/-), septal deviation (-)

Mouth : Pale (-), Cyanosis (-).

Thorax : Chest Wall symmetrical in static and dynamic condition

Mammae : localization status

Pulmo : Inspection : normal

Palpation : Vocal Fremitus Right and left symmetrical, mass (-),

Crepitation (-)

Percussion : Sonor in both lungs fields

Auscultation : Right : Vesicular

Left : Vesicular

Heart : Inspection : Ictus Cordis Invisible

Palpation : ICS V

Percussion : No signs of enlargement

Auscultation : Heart Sound S1 and S2 normal; Murmur (-); Gallop

(-)

Abdomen : Inspection : there is no visible change in the color of the

abdomen.Abdominal.
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 Palpation : Mc Burney Pain (+), Rebound Pain (+), Rovsing Sign
(+),
Dunphy Sign (+), Obturator Sign (+), Psoas Sign (+),
Defans Muscular (+),
Percussion : Tymphani (+)
Auscultation : Peristaltic (+), Normal.

Extremity : Superior Inferior

Oedem - -

Hipotermia - -

Physiology Reflex + +

Pathologic Reflex + +

2.5 Localization Status Abdomen

Inspection : there is no visible change in the color of the
abdomen.Abdominal.
Palpation : Mc Burney Pain (+), Rebound Pain (+), Rovsing Sign (+),
Dunphy Sign (+), Obturator Sign (+), Psoas Sign (+), Defans
Muscular (+),
Percussion : Tymphani (+)
Auscultation : Peristaltic (+), Normal

2.6 Supporting Investigation

A. Laboratory

Hematologi

No. Test Result Normally Unit

Full Blood

1. Hemoglobin 15.5 11.7-15.5 gr/dl

2. Hematokrit 47.7 37-45 %

3. Leukosit 9.20 4-11 ribu/mm3

4. Trombosit 223 150-440 ribu/mm3

5. Eritrosit 5.24 4.00-5.00 juta/uL

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 6. PDW 16.4 9.0-13.0 fL

7. RDW-CV 11.9 11.5-14.5 %

8. MPV 10.6 7.2-11.1 fL

9. PCT 0.237 0.150-0.400 %

Eritrosit Index

1. MCV 91 80-100 fl

2. MCH 30 26-34 pg

3. MCHC 33 32-36 g/dL

Leucocyte Count

1. Basofil 0 0-1 %

2. Eosinofil 2 1-3 %

3. Neutrofil Segmen 47 50-70 %

4. Limfosit 44 20-45 %

5. Monosit 7 4-8 %

Total number of cells

1. Total Lymphosit 4.06 0.58-4.47 ribu/uL

2. Total Basofil 0.00 0-0.1 ribu/uL

3. Total Monosit 0.63 0.17-1.22 ribu/uL

4. Total Eosinofil 0.20 0-0.61 ribu/uL

5. Total Neutrofil 4.3 1.88-7.82 ribu/uL

HEMOSTASIS

1. Masa pendarahan (BT) 3 1-3 menit

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 2. Masa pembekuan (CT) 5 2-6 menit

IMMUNOSEROLOGY

1. HbsAG negative Negative

2. HIV Non Non Reaktif

Reaktif

3. Klorida Negative Negative

Alvarado Score : 7

1. Migration of Pain 1

2. Anorexia 1

3. Nausea 1

4. Tenderness in right lower quadrant 2

5. Rebound Pain 1

6. Elevated Temperature 1

7. Leucocytocys 0

8. Shift of white blood cell count to the leftn 0

A. Thorax Photo

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 Result :

- Costophrenicus sinus and diaphragma normal

- COR : Normal size

- Pulmo : Normal bronchovascular pattern, No specific active

abnormalities and other pathologies are seen

- Normal cor/pulmo

B. Clinical Photo Post Surgery

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2.7 Working Diagnosis

Appendicitis Acute

2.8 Differential Diagnosis

- Uretric Colic

- Pancreatitis

- Tortion Testis

- Perforation Ulcer

2.9 Therapy
A. Surgical Therapy

Appendectomy Appendix

B. Post Operation Medical Therapy

- IVFD RL 20 gtt/minute

- Inj. Ceftriaxone 1gr/12 hours

- inj. Metronidazole 500mg/8 hours

- inj. Keterolac 30 mg/8 hours

- inj. Ranitidine 50 mg/12 hours

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13
 REVIEW

3.1 ANATOMY

3.1.1 APPENDIX VERMIFORM

Also called as vermix, vermiform appendix is a narrow vermin (worm shaped) tube arising from the
posteromedial aspect of the cecum (a large blind sac forming the commencement of the large
intestine) about 1 inch below the iliocecal valve. Small lumen of appendix opens into the cecum
and the orifice is guarded by a fold of mucous membrane known as ‘valve of Gerlach’. The 3 taenia
coli (taenia libera, taenia mesocoli and taenia omental) of the ascending colon and caecum converge
on the base of the appendix.
Although the appendix serves no digestive function, it is thought to be a vestigial remnant of an
organ that was functional in human ancestors. (2)

Picture 1

The length varies from 2 to 20 cm with an average of 9 cm with diameter of about 5mm. It is longer
in children compared to adults. In the fetus it is a direct outpouching of the caecum, but differential
overgrowth of the lateral caecal wall results in its medial displacement.
The appendix is suspended by a small traignular fold of peritoneum, called the mesoappendix

Picture 2
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Location of Appendix:
 Right lower quadrant of abdomen and more specifically right iliac fossa.
 McBurney’s point lying at the junction of lateral one-third and the medial two-thirds of the
line joining the umbilicus to the right anterior superior iliac spine roughly corresponds to the
position of the base of the appendix.
 McBurney’s point is the site of maximum tenderness in appendicits.

Variations in Appendix position:

Although the base of the appendix is fixed, the tip can point in any direction. Hence, the position of
the appendix is extremely variable. The appendix is the only organ in the body which is said to
have no anatomy. When compared to the hour hand of a clock, the positions would be:
1. 12 o clock: Retrocolic or retrocecal (behind the cecum or colon)
2. 2 o clock: Splenic (upwards and to the left – Preileal and Postileal)
3. 3 o clock: Promonteric (horizontally to the left pointing the sacral promontory)
4. 4 o clock: Pelvic (descend into the pelvis)
5. 6 o clock: Subcecal (below the cecum pointing towards inguinal canal)
6. 11 o clcok: Paracolic (upwards and to the right)

Most common position of appendix (75% of cases): Retrocecal

Second most common position of appendix (20% of cases): Subcecal

If the appendix is very long, it may actually extend behind the ascending colon and abut against the
right kidney or the duodenum; in these cases its distal portion lies extraperitoneally.

Picture 3

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Arterial Supply:
1. Appendicular artery: The mesoappendix, containing the appendicular branch of the
ileocolic artery (branch of superior mesenteric artery), descends behind the ileum.
2. Accessory appendicular artery: An accessory appendicular artery can branch from the
posterior cecal artery which is also a branch of ileocolic artery.

Picture 4
Venous drainage:
Appendicular vein –> Ileocolic vein –> Superior mesenteric vein –> Portal vein

Lymphatic drainage:
 There is abundant lymphoid tissue in its walls.
 From the body and apex of the appendix 8-15 vessels ascend in the mesoappendix and are
16ccasionally interrupted by one or more nodes –> unite to form 3 or 4 larger vessels –>
inferior and superior ileocolic nodes
 A few of them pass indirectly through the appendicular nodes situated in the mesoappendix.

Nerve supply:
1. Sympathetic nerves: T9 and T10 spinal segments through the celiac plexus
2. Parasympathetic nerves: Vagus

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Histology: Inside to outside

Picture 5

1. Mucosa:
 No villi
 Epithelium invaginates to form crypts of Liberkuhn but the crypts do not occur as frequently
as in the colon
 Muscularis mucosae is ill defined

2. Submucosa:
 Large accumulations of lymphoid tissue in the lamina propria and submucosa. Hence
appendix is also called abdominal tonsil.
 There is often fatty tissue in the submucosa
.
3. Muscularis externa:
 Thinner than in the remainder of the large intestine
 Comprises 2 layers: Inner circular muscle layer and Outer longitudinal muscle layer
 Outer longitudinal smooth muscle layer does not aggregate into taenia coli
4. Serosa and peritoneum

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 CHAPTER III

APPENDICITIS

4.1 Definition
Appendicitis is defined as an inflammation of the inner lining of the vermiform appendix
that spreads to its other parts. This condition is a common and urgent surgical illness with protean
manifestations, generous overlap with other clinical syndromes, and significant morbidity, which
increases with diagnostic delay. In fact, despite diagnostic and therapeutic advancement in
medicine, appendicitis remains a clinical emergency and is one of the more common causes of
acute abdominal pain. (3)

4.2 Epidemiology
Appendicitis is one of the more common surgical emergencies, and it is one of the most common
causes of abdominal pain. In the United States, 250,000 cases of appendicitis are reported annually,
representing 1 million patient-days of admission. The incidence of acute appendicitis has been
declining steadily since the late 1940s, and the current annual incidence is 10 cases per 100,000
population. Appendicitis occurs in 7% of the US population, with an incidence of 1.1 cases per
1000 people per year. Some familial predisposition exists.
In Asian and African countries, the incidence of acute appendicitis is probably lower because of the
dietary habits of the inhabitants of these geographic areas. The incidence of appendicitis is lower in
cultures with a higher intake of dietary fiber. Dietary fiber is thought to decrease the viscosity of
feces, decrease bowel transit time, and discourage formation of fecaliths, which predispose
individuals to obstructions of the appendiceal lumen.
In the last few years, a decrease in frequency of appendicitis in Western countries has been
reported, which may be related to changes in dietary fiber intake. In fact, the higher incidence of
appendicitis is believed to be related to poor fiber intake in such countries.
There is a slight male preponderance of 3:2 in teenagers and young adults; in adults, the
incidence of appendicitis is approximately 1.4 times greater in men than in women. The incidence
of primary appendectomy is approximately equal in both sexes.
The incidence of appendicitis gradually rises from birth, peaks in the late teen years, and gradually
declines in the geriatric years. The mean age when appendicitis occurs in the pediatric population is
6-10 years. Lymphoid hyperplasia is observed more often among infants and adults and is
responsible for the increased incidence of appendicitis in these age groups. Younger children have a
higher rate of perforation, with reported rates of 50-85%. The median age at appendectomy is 22

18
years. Although rare, neonatal and even prenatal appendicitis have been reported. Clinicians must
maintain a high index of suspicion in all age groups.

4.3 Etiology
Appendicitis is caused by obstruction of the appendiceal lumen. The most common causes
of luminal obstruction include lymphoid hyperplasia secondary to inflammatory bowel disease
(IBD) or infections (more common during childhood and in young adults), fecal stasis and fecaliths
(more common in elderly patients), parasites (especially in Eastern countries), or, more rarely,
foreign bodies and neoplasms.
Fecaliths form when calcium salts and fecal debris become layered around a nidus of
inspissated fecal material located within the appendix. Lymphoid hyperplasia is associated with
various inflammatory and infectious disorders including Crohn disease, gastroenteritis, amebiasis,
respiratory infections, measles, and mononucleosis.
Obstruction of the appendiceal lumen has less commonly been associated with bacteria
(Yersinia species, adenovirus, cytomegalovirus, actinomycosis, Mycobacteria species, Histoplasma
species), parasites (eg, Schistosomes species, pinworms, Strongyloides stercoralis), foreign material
(eg, shotgun pellet, intrauterine device, tongue stud, activated charcoal), tuberculosis, and tumors. (3)
(5)(7)

Type of Appendicitis
1. Acute
Acute appendicitis is considered to be the most common cause of abdominal pain and
distress in children and teenagers worldwide. Acute appendicitis develops very fast and is
much simpler to detect, in most cases it requires immediate surgery.
Acute appendicitis refers to complete obstruction of the vermiform appendix. Bacterial
infections are also a cause of acute appendicitis. The appendix is a tubular extension of the
large intestine and its function is thought to be related with the process of digestion. When
the appendix is blocked by calculus and faeces or it is squeezed by the lymph nodes (due to
bacterial infection, the lymph nodes usually become swollen and press against the
appendix), it swells and usually doesn't receive enough blood. Bacteria grow inside the
appendix, eventually causing its death. In acute appendicitis, the inflammation of the
appendix is serious and can lead to complications (perforation, gangrene, sepsis). Acute
appendicitis is a surgical emergency and most patients with this form of illness already have
complications before entering the operation room.
2. Chronic
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 Chronic appendicitis usually refers to a milder form of the illness and almost unperceivable
symptoms this may include inflammation of the vermiform appendix with recurring attacks
of right-sided abdominal pain over an extended period of time.
Chronic appendicitis is quite rare, develops slower, has less pronounced symptoms and it is
much more difficult to diagnose. Some people with chronic appendicitis may only
experience a generalized state of fatigue and illness.Treatment doesn't necessarily involve
surgery, as in the case of acute appendicitis. If it is discovered in time, chronic appendicitis
can often be cured with antibiotics. However, chronic appendicitis has a recidivating
character and therefore ongoing treatment is required.
Symptoms of chronic appendicitis may vary on an individual basis for each patient. Only
your doctor can provide adequate diagnosis of symptoms and whether they are indeed
symptoms of Chronic appendicitis. (4)

4.4 Pathophysiology
Reportedly, appendicitis is caused by obstruction of the appendiceal lumen from a variety of
causes. Independent of the etiology, obstruction is believed to cause an increase in pressure within
the lumen. Such an increase is related to continuous secretion of fluids and mucus from the mucosa
and the stagnation of this material. At the same time, intestinal bacteria within the appendix
multiply, leading to the recruitment of white blood cells and the formation of pus and subsequent
higher intraluminal pressure.
If appendiceal obstruction persists, intraluminal pressure rises ultimately above that of the
appendiceal veins, leading to venous outflow obstruction. As a consequence, appendiceal wall
ischemia begins, resulting in a loss of epithelial integrity and allowing bacterial invasion of the
appendiceal wall.
Within a few hours, this localized condition may worsen because of thrombosis of the appendicular
artery and veins, leading to perforation and gangrene of the appendix. As this process continues, a
periappendicular abscess or peritonitis may occur. (3)(5)

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 Picture 6

4.5 Sign and Symptom

Symptoms include pain in the abdomen, loss of appetite, nausea, vomiting, constipation or
diarrhea, inability to pass gas, low-grade fever, and abdominal swelling. Not everyone has all of
these symptoms, and it can be especially hard to diagnose the condition in very young children. (5)
A more detailed list of symptoms follows:
 Pain in the abdomen. It often starts first around the belly button, then moving to the lower
right area.
 loss of appetite
 nausea
 vomiting
 constipation or diarrhea
 inability to pass gas
 low-grade fever and chills
 abdominal swelling
 elevated white blood cell count
The pain in the abdomen may be vague and mild at first, but it usually gets worse over time.
The pain can also get worse with moving, taking deep breaths, coughing, or sneezing. People may
have a sensation called "downward urge," also known as "tenesmus," or the feeling that a bowel
movement will relieve their discomfort. It is extremely important that people with these symptoms
21
do not take laxatives, enemas to relieve constipation, or highly potent pain medications in this
situation, as these can mask other symptoms that the doctor should know about and even cause the
appendix to rupture. Anyone with these symptoms needs to see a qualified physician immediately.
In cases of untreated appendicitis, the appendix can rupture, spilling pus and infective
material into the abdomen and causing a serious condition called peritonitis. Peritonitis is an
inflammation of the peritoneum which is a thin membrane that lines the abdominal wall and covers
most of the organs of the body. Peritonitis resulting from a ruptured appendix may occur 36-72
hours after the onset of appendicitis. Symptoms of peritonitis include fever, severe abdominal pain,
and tenderness that is worsened by movement and pressure on the abdomen. The abdomen may also
become stiff and board-like. Other symptoms can include weakness, pale skin, and shock. The
death rate from peritonitis is approximately 20%.

4.6 Diagnosis
Appendicitis remains a clinical diagnosis. The three signs and symptoms
t h a t a r e m o s t predictive of acute appendicitis are pain in the right lower quadrant, abdominal
rigidity, and migration of pain from the periumbilical region to the right lower quadrant. A reliable
historical feature is the characteristic sequence of symptoms, which is periumbilical abdominal pain
followed by anorexia, nausea, fever, and right lower quadrant pain. The diagnosis of appendicitis should be
reconsidered inpatients in whom nausea and emesis are the first signs of illness. (5)(7)

The most valuable physical examination finding is localized tenderness.

1. McBurney's point islocated two inches from the anterior superior iliac spine on a line drawn from this
process through the umbilicus. However, the site of maximal tenderness may be some distance
away from McBurney'spoint. Rebound tenderness, which suggests peritoneal inflammation, is also
referred to the right lower quadrant. Local hyperesthesia of the skin and muscular rigidity may be present.
Several signs of muscle inflammation may also be present.

Picture 7
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 2. The psoas sign is elicited by asking the patient to raise a straightened right leg against
resistance by the examiner; alternatively, the patient lies on the left side and the examiner
gently hyperextends the straightened right leg to stretch the psoas major muscle.

Picture 8

3. The obturator sign is sought by passive internal rotation of the right leg with the patient
supine and the right hip and knee flexed.

Picture 9

4. Pain in the right lower quadrant with palpation in the left lower quadrant (Rovsing's sign) is
associated with a pelvic appendix and also indicates the site of peritoneal irritation.

4.7 Laboratory Test

Elevated white blood cell counts are common in acute appendicitis, with the average leukocyte count
ranging from 10,000 to 18,000 cells/mm3. Significant peripheral lymphocytopenia is
23
also common. Although leukocytosis is common, 30% of patients with acute appendicitis have a
normal white blood cell count. Small numbers of erythrocytes and leukocytes are found in the urine
in about half of patients with appendicitis. However, urinary erythrocyte counts exceeding 30 cells
per high-power field or leukocyte counts exceeding 20 cells per high-power field suggest
a urinary tract disorder. Pelvic cultures may be useful in sexually active, menstruating women. Pregnancy
test to exclude pregnancy.

Imaging Test

Diagnostic imaging should be performed in patients suspected of having appendicitis in

whom the diagnosis is unclear.

1. CT scan
The best radiologic test is a computed tomography (CT) scan. An abdominal CT scan for acute
appendicitis has a sensitivity of 95% and a specificity of 90%. Air in the appendix or a contrast-filled
lumen in a normal-appearing appendix virtually excludes the diagnosis. However,
anonvisualized appendix does not rule out appendicitis. A benefit of a complete abdominal
CT scan is that it permits visualization of the entire abdomen, and an alternative diagnosis is
found in up to 15%of patients. Alternative diagnoses include, but are not limited to,
colitis, diverticulitis, small-bowel obstruction, inflammatory bowel disease, adnexal cysts, acute
cholecystitis, and acute pancreatitis.A limitation of abdominal CT scanning is that it takes up to two hours
to perform the test after apatient receives the standard oral preparation. In addition, a normal
appendix is visualized in only75% of patients. An appendiceal CT scan can be performed
with rectal contrast alone and thin cutsthrough the right iliac fossa. Because oral contrast is
not given, the scan can be performed within 15minutes, and exposes the patient to only one-third
the radiation of standard abdominal CT. Results of an appendiceal CT scan are 93% to 98% accurate in
confirming or ruling out appendicitis. The routineuse of appendiceal CT in emergency
department patients improves patient care both by avertingunnecessary
appendectomies and by expediting delivery of the necessary medical or
surgicaltreatment. Computed tomography scans may be less accurate in diagnosing
appendicitis in younger children compared with adults. A relative lack of body fat makes it difficult to
identify fat streaking andvisually separate an inflamed appendix from surrounding tissue or bowel.
2. Plain Radiograph
Abdominal radiography has a low sensitivity and specificity for the
d i a g n o s i s o f a c u t e appendicitis. Plain radiographs are abnormal in about 55% of
patients with early acute appendicitis and are usually not helpful for establishing the

24
 diagnosis. Multiple nonspecific abnormalities may beseen, including a right lower quadrant
appendicolith, localized right lower quadrant ileus, loss of the psoas shadow, deformity of
the cecal outline, and right lower quadrant soft tissue densities. Plainradiographs are not useful
for establishing the diagnosis of acute appendicitis and have no role in the diagnostic workup, unless
an alternative diagnosis is being considered that might show up on plain film.
3. Ultrasonography
Ultrasonography is used to diagnose acute appendicitis, especially in children and pregnant
women. It can be very useful for defining pelvic pathology in women. Limitations of
ultrasonographyare that it is operator-dependent and may be non diagnostic in those with a
large body habitus or a large amount of bowel gas. Although appendicitis may be ruled out if the
appearance of the appendixis normal on ultrasonography, a normal appendix is seen in less than
5% of patients. Failure to seethe appendix, whether it is diseased or normal, limits the
usefulness of this imaging modality for the diagnosis of acute appendicitis. The overall
sensitivity of ultrasonography varies between 75% and90%; specificity ranges from 86% to
100%.
4. Laparoscopy
Laparoscopy is the only diagnostic procedure other than formal laparotomy that allows
direct visualization of the appendix. The entire appendix must be seen before the operator can conclude it
is n o r m a l ( f r e e o f d i s e a s e ) . F e a s i b i l i t y o f l a p a r o s c o p y i n o b e s e p a t i e n t s
a n d t h o s e w i t h p r e v i o u s abdominal operations depends greatly on the surgeon's
experience with the procedure. Diagnostic laparoscopy is most useful for female patients, since a
gynecologic cause of symptoms is identified in approximately 10% to 20% of women with
suspicion of appendicitis. However, laparoscopy is an invasive procedure with
approximately a 5% complication rate, usually associated with the use of general anesthesia.

4.8 Differential Diagnosis (6)

Surgical Urological Gynecological Medical

Intestinal Obstruction Right ureteric colic Ectopic pregnancy Gastroenteritis
Intussusception Right pyelonephritis Ruptured ovarian Diabetic ketoacidosis
follicle
Acute Cholecystitis Urinary tract infection Torted ovarian cyst Terminal ileitis
Perforated Peptic Salpingitis/pelvic Preherpetic pain on the
Ulcer inflammatory disease right 10th and 11th
dorsal nerves

25
Mesentric Adenitis
Meckel’s Diverticulitis
Pancreatitis

4.9 Treatment (5)(6)

Appendectomy is the only acceptable treatment for acute appendicitis. Although
appendicitis occasionally resolves without surgery, a policy of nonoperative treatment is hazardous
because delay risks perforation. Patients who present within 24 to 72 hours after symptom onset can
usually be treated with immediate appendectomy.
In contrast, patients who present with a longer duration of symptoms and have findings
localized to the right lower quadrant are presumed to have appendiceal abscesses and should be
treated initially with antibiotics, intravenous fluids, and bowel rest. Immediate surgery in these
patients is associated with increased morbidity, often requires extensive dissection, and has the
additional risks of spreading a localized infection throughout the peritoneal cavity and injuring
adjacent structures. Percutaneous CT-guided drainage of the abscess, with appropriate antibiotic
coverage, allows the majority of abscesses to resolve. Most patients have a follow-up CT scan when
their drain output is minimal and no longer purulent. Antibiotics are continued for 14 days or for
one week after documented resolution of the abscess. Elective appendectomy is performed six to
ten weeks later to prevent recurrent appendicitis, which occurs in up to 20% of patients. Older
patients should also have a colonoscopy or barium enema to rule out cecal pathology.
Appendectomy can be performed through a traditional open procedure or laparoscopically.
The operative approach depends on the confidence in the diagnosis, history of prior surgery, and the
patient's age, gender, and body habitus. For example, a conventional appendectomy is
recommended for a thin, adolescent man with a classic presentation for acute appendicitis. On the
other hand, for an obese, premenopausal female with equivocal symptoms, a laparoscopic approach
is recommended. Laparoscopy is preferred when the diagnosis of appendicitis is in doubt,
especially in premenopausal females and in the obese. A number of published studies have
compared open versus laparoscopic surgery for appendicitis. The weight of the evidence suggests
that in adults, although operative costs are higher with laparoscopy, overall costs to society are
lower because pain is reduced and patients can return to work sooner.
The procedure begins with a diagnostic laparoscopy and continues with appendectomy if
appropriate. The success rates are high, and complications are infrequent. Compared with open
appendectomy, laparoscopic appendectomy requires less postoperative analgesia, a shorter hospital
stay, and a shorter period of disability. Surgical wound infections are also less frequent.
Laparoscopy may offer an advantage to patients in whom the diagnosis is uncertain since it permits
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inspection of other abdominal organs. This benefit is greater for women, who have higher negative
appendectomy rates, and in whom laparoscopy often reveals other pathology.
Evidence supports the use of systemic antibiotics to prevent wound infection in appendicitis.
In patients with acute nonperforated appendicitis, antibiotic coverage for surgical wound
prophylaxis is adequate and postoperative antibiotics are unnecessary. In those with perforated
appendicitis, the antibiotic regimen should cover enteric gram-negative rods and anaerobes. A
second- or third-generation cephalosporin or a fluoroquinolone plus metronidazole is adequate for
most patients. Antibiotics should be continued for seven to ten days.

4.10 INTRAOPERATIVE SEQUENCE (5)

APPENDECTOMY
 The excision of the appendix usually performed to remove an acutely inflamed organ.
 Many surgeons perform an appendectomy as a prophylactic procedure when operating in the
abdomen for other reasons. This procedure is then referred to as an incidental
appendectomy.
Position
 Supine, with arms extended on armboards
Incision Site
 McBurney (muscle splitting) incision.
Packs/ Drapes
 Laparotomy pack
 Four folded towels
Instrumentation
 Major Lap tray or minor tray
 Internal stapling device
Supplies/ Equipment

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 Basin set
 Blades
 Needle counter
 Penrose drain
 Culture tubes
 Solutions
 Sutures
 Internal stapling instruments
 Medication

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4.11 Procedure

1. An incision is made in the right lower abdomen, either transversely oblique (McBurney) or
vertically (for a primary appendectomy).
2. The surgeon’s assistant retracts the wound edges with a Richardson or similar retractor.
3. The appendix is identifies and its vascular supply ligated.
4. The surgeon grasps the appendix with a Babcock clamp, and delivers it into the wound site.
5. The tip of the appendix may then be grasped with a Kelly clamp to hold it up, and a moist
Lap sponge is placed around the base of the appendix (stump) to prevent contamination of
bowel contents, in case any spill out occurs during the procedure.
6. The surgeon isolates the appendix from its attachments to the bowel (mesoappendix) using a
Metzenbaum scissors.
7. Taking small bits of tissue along the appendix, the mesoappendix is double-clamped, and
ligated with free ties.
8. The base of the appendix is grasped with a straight Kelly clamp, and the appendix is
removed.
9. The stump may be inverted into the cecum, using a purse-string suture on a fine needle,
cauterize with chemicals, or simply left alone after ligation.
10. Another technique is to devascularize the appendix and invert the entire appendix into the
cecum.
11. The appendix, knife, needle holder, and any clamps or scissors that have come in contact
with the appendix are delivered in a basin in the circulating nurse.
12. The wound is irrigated with warm saline, and is closed in layers, except when an abscess has
occurred, as with acute appendicitis.
13. A drain may be placed into the abscess cavity, exiting through the incision or a stab wound.
14. An alternative technique may be use the internal stapling device, by placing the stapling
instrument around the tissue at the appendiocecum junction.
15. By using the technique, the possibility of contamination from spillage is greatly reduced.

4.12 Complication
Complications of appendicitis include wound infection, perforation, peritonitis, abscess
formation, urinary tract disorders, and pylephlebitis. The overall perforation frequency is 10% to
30%. Perforation within 12 hours of pain onset is unusual, but the risk of this complication rises
significantly after 48 hours. Sixty-five percent of patients with perforated appendicitis have been

29
symptomatic longer than 48 hours. Perforation rates are highest in children and the elderly, due to
delays in presentation and diagnosis. Perforation occurs in 90% of children younger than two years
of age and in 35% of all children. In the elderly, a combination of delayed and atypical
presentations, confounding medical conditions, and a decreased index of suspicion contribute to
higher rates of perforation. Between 40% and 75% of patients older than 60 years of age have a
perforated appendix by the time of the operation.

Perforation is recognized preoperatively in 70% of patients. Suggestive clinical features

include symptom duration of more than 36 hours, fever higher than 38.58 C, toxic appearance,
diffuse abdominal tenderness, abdominal mass, and marked leukocytosis. Appendiceal perforation
leads to multiple complications, including peritonitis, abscess formation, wound infection, urinary
retention, and small bowel obstruction. Other intra-abdominal abscesses may develop after
perforation, most commonly in the pelvis.
Pylephlebitis is septic thrombophlebitis of the portal venous system. This rare complication
of appendiceal perforation is characterized by high fever, rigors, jaundice, and abnormal liver
function tests. (5)(6)

Wound infection

The rate of postoperative wound infection is determined by the intraoperative wound

contamination. Rates of infection vary from <5% in simple appendicitis to 20% in cases with
perforationand gangrene. The use perioperative antibiotics has been shown to decrease the rates of
postoperative wound infections.

Intra-abdominal abscess

Intra-abdominal or pelvic abscess may form in the postoperative period after gross contamination of
the peritoneal cavity. The patients present with a swinging pyrexia, and the diagnosis can be
confirmed by ultrasonography or CT scan. Abscesses can be treated radiogically with a pigtail
drain, although open or per rectal drainage may be needed for pelvic abscess. The use of
perioperative antibiotics has been shown to decrease the incidence of abscess.

SPECIAL CONCIDERATION

Pregnancy

The most common non-obstetric emergency needing surgery in pregnancy is appendicitis with an
incident of 0.15 to 2.10 per 1000 pregnancies. A reduction in the incidence of appendicitis during
pregnancy particularly during third semester.

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Displacement of the appendix by the gravid uterus means that presentation is often atypical or may
be mistaken for the onset of labour. Nausea and vomiting are often present with associated
tenderness located anywhere on the right side of the abdomen.

Appendix Mass

In patients with a delayed presentation, a tender mass with overlying muscle rigidity may be felt in
the right iliac fossa. The presence of a mass may be confirmed on USG or CT scan, underlying
neoplasia must be excluded, especially in an elderly people. The initial treatment in a patient who is
otherwise with initiation of appropriate resuscitation and intravenous broad spectrum antibiotics. In
most cases the mass will decrease in size over in subsequent days as the inflammation resolves.
Although patients need observation to detect early sign of progress of inflammatory process.

Appendix Abscess

Patients with an appendix abscess have a tender mass with a swinging pyrexia, tachocardia and
leukocytosis. The abscess is most often located in the lateral aspect of the right iliac fossa but may
be pelvic; a rectal examination is useful to identify a pelvic collection. Abscess can be showed by
USG and CT scan and a percutaneous radiological drainage may be done.

Chronic (recurrent) Appendicitis

Recently, with the advent of neurogastroenterology, the concept of neuroimmune appendicitis has
evolved. After a previous minor bout of intestinal inflammation, subtle alterations in enteric
neurotransmitters are seen, which may result in altered visceral perception from the gut; this
process has been implicated in a wide range of gastrointestinal conditions. Further work is needed
to determine if the clinical entity of “neuro- immune appendicitis” truly exists, but it remains an
interesting area.
Inflammatory bowel disease

A histor y of appendicectomy is associated with delayed onset of disease and a less severe disease
phenotype in patients with ulcerative colitis. The influence of appendicectomy in Crohn’s disease is
not as clear; some evidence suggests a delayed onset of disease in patients after
appendicectomy,although contradictory evidence also exists to suggest an increased risk of
developing the condition depending on the patient’s age, sex, and diagnosis at the time of operation.

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4.14 Prognosis
Acute appendicitis is the most common reason for emergency abdominal surgery.
Appendectomy carries a complication rate of 4-15%, as well as associated costs and the discomfort
of hospitalization and surgery. Therefore, the goal of the surgeon is to make an accurate diagnosis
as early as possible. Delayed diagnosis and treatment account for much of the mortality and
morbidity associated with appendicitis.
The overall mortality rate of 0.2-0.8% is attributable to complications of the disease rather than to
surgical intervention. The mortality rate in children ranges from 0.1% to 1%; in patients older than
70 years, the rate rises above 20%, primarily because of diagnostic and therapeutic delay.

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 CHAPTER IV

SUMMARY
Appendicitis is an inflammation of the appendix that occurs most often in people between
the ages of 10 and 30. It is considered a medical emergency, and treatment often involves surgery to
remove the appendix. If treatment is delayed, the appendix can burst, causing infection and even
death. Possible symptoms of an inflamed appendix include abdominal pain, fever, and constipation.
When there is a blockage inside the appendix, a person may develop appendicitis. Causes of the
appendix blockage can include feces, bacterial or viral infection in the digestive tract, traumatic
injury, or genetics. If the blockage is not treated quickly, the appendix could rupture. Common
appendicitis signs and symptoms include pain in the lower-right abdomen, loss of appetite, and
vomiting. However, people who have appendicitis may not have all of the usual symptoms. In
addition, symptoms may be different or hard to diagnose in children, the elderly, and pregnant
women. Those who experience possible symptoms should see their doctor for proper diagnosis and
treatment. A physical exam, a medical history, and appendicitis tests, such as x-rays or a CT scan
are all part of the process when making an appendicitis diagnosis. In some cases, a laparoscopy may
be necessary to confirm the condition. This procedure avoids radiation, but requires general
anesthesia. Once a diagnosis of appendicitis is confirmed, the necessary treatment is usually
surgery. In some cases, if the diagnosis is uncertain, the doctor may prescribe antibiotics as
treatment if he or she is unsure whether the symptoms are being caused by appendicitis or
something else, such as an infection. Many people want to know how to prevent appendicitis.
Although there is no way to prevent appendicitis, people who are able to recognize appendicitis
symptoms may be able to prevent more serious appendicitis symptoms from occurring.

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http://www.emedicinehealth.com/appendicitis/article_em.htm. Accessed on: September 23,
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2. Shresta, Sulav. Anatomy of Appendix and Appendicitis. Updated July 9, 2011. Available at:
http://medchrome.com/basic-science/anatomy/anatomy-appendix-appendicitis/. Accessed on:
September 23, 2012.

3. Craig, Sandy. Appendicitis. Updated June 27, 2012. Available at:

http://emedicine.medscape.com/article/773895-overview#a0104. Accessed on: October 10,
2012.

4. Disabled World. What is Appendicitis? Updated 2012. Available at: http://www.disabled-

world.com/artman/publish/whatisappendicitis.shtml#ixzz29TDxbwhC. Accessed on: September
25, 2012.

5. Journal Watch Emergency Medicine. Appendicitis. Updated January 19, 2007.

6. Humes DJ, Simpson J. Acute Appendicitis. BMJ 2006: 330;530-4. Updated July 16, 2007.
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