Appendicitis

Dwi yuliannisa amri
20100310133

Laporan Kasus

Identitas pasien

Anamnesis
Keluhan

Serumen (-)
Pendarahan (-)

Normocephale (+), mesocephale (+)
Konjunctiva anemis (-/-), Sklera Ikterik (-/-),
Sekret (-), Epiktasis (-)
Pembesaran tonsil (-), faring hiperemis (-), gusi berdarah (Pembesaran limfonodi (-)
Retraksi dada (-)
Suara Dasar Paru vesikuler (+/+)
Suara Ronkhi (-/-)
Suara Wheezing (-/-)
Supel (+)
Asites (-)
Nyeri tekan (+)
Suara peristaltik usus (+)
Pembesaran hepar (-), pembesaran lien (-)
Akral hangat (+)
Perfusi baik (+), Capillary Refill Time RT < 2 detik

Vital Sign
 T = 37,1 °C
 N = 88x/ menit
 RR = 22x/menit
 TD = 120/70 mmHg

Akral Hangat (+)
Perfusi Baik (+)
Nadi teraba kuat (+)

roving sign (+). Psoas sign (-). • Palpasi : Nyeri tekan dalam pada mc burney (+) . Obturator sign (+) . Blumberg sign (+). ▫ tidak ada pembengkakan pada perut.Pemeriksaan lokalis • Inspeksi : ▫ Setiap regio abdomen simetris. • Perkusi : Timpani • Auskultasi : peristaltik (+) .

Pemeriksaan penunjang Darah Rutin .

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USG .

TINJAUAN PUSTAKA .

Anatomi .

colon ASIS Caecum Here! Sigmoid colon . colon Terminal Ileum Desc.Relevant Anatomy The Appendix is… McBurney’s Point Transverse colon Asc.

Relevant Anatomy … and during pregnancy .

appendix) T10 umbilicus ASIS Hindgut Lower urinary tract Sexual organs T12 Pubic symphisis .Paired organs Relevant Anatomy unpaired Innervation of appendix & other organs l a t cos T6 ma rgin Foregut (inc. duodenum) Midgut (inc.

Relevant Anatomy Structures near the appendix R abdominal pain • • • • • • • • • Caecum Ileum Ureter Ovary Bladder Asc Colon Psoas Inguinal canal Iliac vessels Pelvic/lower abdo pain .

ialah IgA. Lendir itu normalnya dicurahkan ke dalam lumen dan selanjutnya mengalir ke caecum. Immunoglobulin itu sangat efektif sebagai pelindung terhadap infeksi. Namun demikian. pengangkatan apendiks tidak mempengaruhi sistem imun tubuh .  Immunoglobulin sekretoar yang dihasilkan oleh GALT (gut associated lymphoid tissue) yang terdapat di sepanjang saluran cerna termasuk apendiks.Fisiologi  Apendiks menghasilkan lender 1-2ml per hari. Hambatan aliran lender di muara apendiks tampaknya berperan pada pathogenesis appendicitis.

ETIOLOGI Obstruksi .

Pathofisiologi .

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Risk Factors for Perforation of The Appendix Diabetes Immunosuppression Extremes Faecolith Pelvic Previous appendix Mellitus abdominal obstruction of age surgery Source: Bailey & Loves Short Practice of Surgery 25th ed .

Clinical Manifestations Symptoms Source: Bailey & Loves Short Practice of Surgery 25th .

Penegakan diagnosis .

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abdominal USG or contrast-enhanced CT scan is used to further Source: Bailey & Loves Short Practice of reduce the rate of negative appendicectomy th .The Alvarado (MANTRELS) Score Score Symptoms • Migratory RIF pain • Anorexia • Nausea and vomiting 1 1 1 Signs • Tenderness (RIF) • Rebound tenderness • Elevated temperature 2 1 1 Laboratory • Leucocytosis • Shift to the left (segmented neutrophils) 2 1 TOTAL 10 • < 5 is strongly against a diagnosis of appendicitis • 7 or more is strongly predictive of acute appendicitis • In patients with an equivocal score of 5 or 6.

Differential Diagnosis Children Source: Bailey & Loves Short Practice of th .

Klasifikasi Appendicitis • Appendicitis Akut ▫ Appendicitis Akut Sederhana (Cataral Appendicitis) ▫ Appendicitis Akut Purulenta (Supurative Appendicitis) ▫ Appendicitis Akut Gangrenosa • Appendicitis Perforasi • Appendicitis Kronis .

• Appendicitis infiltrat .

• Appendicitis Abses .

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. atau bagi mereka yang memilki resiko tinggi untuk dilakukan operasi. rujuk ke dokter spesialis bedah.PENATALAKSANAAN • Perawatan appendicitis tanpa operasi Penelitian menunjukkan pemberian antibiotika intravena dapat berguna untuk Appendicitis acuta bagi mereka yang sulit mendapat intervensi operasi (misalnya untuk pekerja di laut lepas).

. seperti Cefotaxime dan Clindamycin.Antibiotika preoperative  Pemberian antibiotika preoperative efektif untuk menurunkan terjadinya infeksi post opersi. atau Cefepime dan Metronidazole. Biasanya digunakan antibiotik kombinasi. Kombinasi ini dipilih karena frekuensi bakteri yang terlibat. termasuk Escherichia coli. Enterococcus. Pseudomonas aeruginosa. Klebsiella.  Antibiotik profilaksis harus diberikan sebelum operasi dimulai. dan Bacteroides.  Diberikan antibiotika broadspectrum dan juga untuk gram negative dan anaerob  Antibiotika preoperative diberikan dengan order dari ahli bedah. Streptococcus viridans.

Pararectal/ Paramedian  Mc Burney/ Wechselschnitt/ muscle splitting • B. Dilakukan tindakan aseptik dan antiseptik. ▫ 2. Dibuat sayatan otot. Dibuat sayatan kulit: Horizontal Oblique ▫ 3. Laparoscopic Appendectomy . Open Appendectomy ▫ 1.Teknik operasi Appendectomy 2 • A. ada dua cara:  a.

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80-90% appendicitis baru diketahui setelah terjadi perforasi. Pada bayi.  Riwayat perjalanan penyakit pasien dan pemeriksaan fisik merupakan hal yang paling penting dalam mendiagnosis appendicitis .  Appendicitis akut merupakan kasus bedah emergensi yang paling sering ditemukan pada anak-anak dan remaja  Gejala appendicitis akut pada anak tidak spesifik. dan merupakan penyebab abdomen akut yang paling sering pada anak-anak maupun dewasa. sehingga anak dtg dengan keadaan app perforasi.BAB III KESIMPULAN  Appendicitis adalah peradangan yang terjadi pada Appendix vermicularis.

crampy central abdo pain • Malaise/vomiting/anorexia/low grade fevers • Pain worsens & localises to RIF with cough/movement tenderness • Systemic symptoms .“Typical” Presentation • Dull.

Early Appendicitis obstruction • Pain: Location: Periumbilical (T10) Character: Dull Over time: Colicky Associated symptoms:  Vomiting  Anorexia distention mucus ▫ ▫ ▫ ▫ .

psoas.Later Appendicitis • Pain: ▫ ▫ ▫ ▫ Distention causing ischaemia Location: R Iliac Fossa Localised peritoneal Character: Localised inflammation Over time: Constant Aggravating: going over bumps. walking ▫ Relieving: hip flexion. coughing. staying still • Exam findings: ▫ “peritonism”  Guarding  rebound tenderness  percussion tenderness ▫ Rovsing. other signs .

tachycardia. palpation. coughing. hypotension ▫ Abdominal – severe. rebound ▫ Associated: Fever • Exam findings: ▫ Systemic features. severe Over time: constant Aggravating: movement.Late Appendicitis • Pain: Gangrene ▫ ▫ ▫ ▫ Location: lower abdominal/generalised Character: diffuse. generalised “peritonism” ▫ RIF mass (sometimes) .fever.

Time Course Appendiceal .

bent over • Pain on coughing/unable to cough .Special Clinical signs • Abdominal examination • Psoas Sign – pain on hip extension • Rovsing Sign – RIF pain on palpating LIF • “The walk” – walk with R hip flexed.

Atypical presentations Location of appendix Signs/symptoms McBurney’s point “typical” presentation. crampy pain Pelvic Suprapubic pain. urinary frequency. Rovsig sign Retro/paracaecal Psoas sign/flank pain/absence of peritonism Retro/paraileal Diarrhoea. pyuria .

Supportive and symptomatic management Antibiotics/fluids/etc 2.Management 1. Treatment of underlying cause Appendicectomy .

What to do in ED/awaiting surgery • Resuscitation! ▫ A: ensure airway patent ▫ B: ensure adequate oxygenation ▫ C: correct hypotension/tachycardia/instability .

usual appropriate local responses make no sense when systemic ▫ Generalised vasodilation (flushing). capillary leakfluid leaves central circulation ▫ Hypotension.organs not perfused properly ▫ Either fever or hypothermia ▫ Other complications like coagulopathy/DIC/multiorgan failure ▫ ARDS in severe sepsis.Septic shock • Systemic inflammatory response. tachycardia.hypoxia .

enterococcus (ampicillin/vancomycin).find source • Correct other organ dysfunction • If necessary ICU and advanced life support . sepsis • Antibiotics. anaerobes (metronidazole) • Drain pus. remove infected material • Replace fluid that is lost peripherally – IV cannula. other tests.Treatment of infection. fluid resuscitation • Blood tests.in appendicitis cover gram negs (gentamicin/ceftriaxone). imaging.

Procedures • Appendicectomy ▫ Laparoscopic ▫ Open • Diagnostic laparoscopy • Laparotomy .

Appendicectomy . quicker recovery • Sometimes difficulty in mobilisation requiring open procedure .Laparoscopic • “Keyhole” surgery • Lower complication rate.

good exposure. technically easier • Longer recovery. can’t see pelvic structures as well .Appendicectomy .Open • Incision over McBurney’s point or point of maximal tenderness • Straightforward. risk of hernia & adhesions.

Source: Bailey & Loves Short Practice of th .

Source: Bailey & Loves Short Practice of th .

Laparoscopic appendicectomy • The placement of operating ports may vary according to operator preference and previous abdominal scars. • The operator stands to the patient’s left and faces a video monitor placed at the patient’s right foot. and the small skin incisions may be closed with subcuticular sutures. • It is not usual to invert the stump of the appendix • A single absorbable suture is used to close the linea alba at the umbilicus. • By elevating the appendix. can be ligated at its base with an absorbable loop ligature. • A moderate Trendelenburg tilt of the operating table • The appendix is identify & controlled using a laparoscopic tissueholding forceps. the mesoappendix is displayed • A dissecting forceps is used to create a window in the mesoappendix to allow the appendicular vessels to be coagulated or ligated using a clip applicator. • The appendix. & removed through one of the operating ports. free of its mesentery. Source: Bailey & Loves Short Practice of th .divided. • Patients who undergo laparoscopic appendicectomy are likely to have less postoperative pain & to be discharged from hospital and return to activities of daily living sooner than those who have undergone open appendicectomy.

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Source: Bailey & Loves Short Practice of th .

 · Dunphy sign: nyeri ketika batuk.  Blumberg’s sign: nyeri lepas kontralateral (tekan di LLQ kemudian lepas dan nyeri di RLQ)  · Wahl’s sign: nyeri perkusi di RLQ di segitiga Scherren menurun.  · Defence musculare: bersifat lokal.  · Baldwin test: nyeri di flank bila tungkai kanan ditekuk. kemudian gerakan endorotasi tungkai kanan dari lateral ke medial.Pemeriksaan fisik  Rovsing’s sign:  Psoas sign:  Obturator sign: dilakukan dengan posisi pasien terlentang. lokasi bervariasi sesuai letak Appendix. .

Infeksi Panggul Kehamilan ektopik terganggu.DIAGNOSIS BANDING • • • • • • • Gastroenteritis Limfadenitis Mesenterika Demam dengue. Divertikulosis Meckel Ulkus peptikum perforasi .