Laporan KasusACUTE APPENDICITIS

Narasumber: dr Faizon Sp B (k) OnkDisusun oleh:Joandrew J.H. GultomRSUD Dr MurjaniSampit2015

INTRODUCTION

The appendix is :

Wormlike extension of the cecum (vermiform appendix). -Length is 8-10 cm (ranging from 2-20 cm). -Fifth month of gestation-Several lymphoid follicles.

Etiology: Obstruction of the lumen appendix followed by infection

Obstructive appendicitis -fecalith 35% adults.-foreign body / parasites (4%)

- tumors (1%)

Problem:

Appendicitis can mimic several abdominal conditions.

Laboratory testImaging investigation

Statistics report 1 of 5 cases is misdiagnosed

Normal appendix is found in 15-40% Emergency appendectomy.(Negative Appendectomy)

Differential diagnosis of acute appendicitis Surgical Acute Intestinal obstruction Intussusception Acute cholecystitis Perforated peptic ulcer Mesenteric adenitis Acute Meckel's diverticulitis Acute Pancreatitis Medical GastroenteritisBasal Pneumonia dextraTerminal ileitis

Urological Right ureteric colic Right pyelonephritis Urinary tract infection

Right Acute epididymitis

Gynaecological

Ectopic pregnancy Ruptured ovarian follicle Torted ovarian cyst Salpingitis/pelvic inflammatory disease

Differential diagnosis of appendicitis appendicitis can mimic several abdominal conditions.

Lab Studies: Complete blood cell countA mild elevation of WBCs (ie, >10,000/L)

Urinalysis

Mild pyuria relationship of the appendix with the right ureter.

Severe pyuria in UTI.

For women of childbearing age, Ectopic pregnancy test urin (beta-hCG)

On physical examination

Lying down

Flexing their hips

The most common symptom of appendicitis is :- Acute abdominal pain.- Epigastric or Periumbilical pain migrating to the right lower quadrant (RLQ) of the abdomen. - Vomiting, nausea, and anorexia- Afebrile or has a low-grade fever , 38 C

Higher fevers are associated with a perforated appendix

Special maneuvers

McBurney sign

McBurney's point it is only the area of greatest tenderness

Blumberg sign

Rovsings Sign

Dunphy sign Cough Test

Obturator sign

Psoas sign

Markle sign

Location appendix during pregnancy

INDICATIONS

Consider an appendectomy for patients with a history of :

Persistent abdominal painFeverClinical signs of localized or diffuse peritonitisEspecially if leukocytosis is present.

Sonography

Advantages of sonography

Noninvasiveness,Short acquisition timeLack of radiation exposurePotential for diagnosis of other causes of abdominal painPediatric patientsWomen of childbearing age. Pregnant womennormal less than 6 mm

CT scan

-Oral contrast medium -Rectal Gastrografin enema

Reserved for patients -Uncertain diagnosis -Severe obesity.more than 6 mm

If the clinical picture is unclear

Short period (4-6 h) of watchful waiting

USG / CT scan -May improve diagnostic accuracy Without a definite diagnosis - return for continued or recurrent symptoms - follow-up examination in 24 hours.

ComplicationsPerforationGeneral Secondary PeritonitisAppendiceal MassAppendiceal Abscess Pylephlebitis is suppurative thrombophlebitis of the portal venous systemHepatic abscesChillsHigh fever Jaundice

TREATMENTMedical therapy

Resuscitated adequately with fluids .

Preoperative prophylactic antibiotics-Acute Appendicitis single agent second-generation cephalosporin. -Perforated appendix triple antibiotic therapy Ampicillin , gentamycin , metronidazol

Antibiotic prophylaxis should be administered before every appendectomy.

Antibiotic treatment may be stopped. -Becomes afebrile -WBC count normalizes

Two approaches to appendectomy

Open Emergency Appendicectomy ( Appendectomy)

Laparoscopic appendectomy

If normal appendix removed need to look for: - Meckel's diverticulum

- Acute salpingitis

- Crohn's disease

Treatment of

Appendiceal Mass Nonoperative management Becomes walled off by omentum and ajacent viscera.Initially treated with intravenous broad-spectrum antibiotic

Appendiceal Abscess USG or CT scan-Percutaneous aspiration-Drain placementIntravenous antibiotics are continued until the patient - afebrile for 24 hours- return of normal gastrointestinal function- normal WBC count with a normal differential. At this time, patients are switched to oral antibiotics for a total antibiotic course of 10-14 days.

Traditionally, interval appendectomy is performed 6-8 weeks later.

Acute AppendicitisAppendicitis Perforation

Anamnesis:Anamnesis dan pemeriksaan fisik dilakukan pada hari selasa 13 januari 2015 pukul 15.00 WIB di ruang IGD RSUD Dr. Murjani SampitIdentitas:Nama Penderita : Tn. AJenis Kelamin : laki-lakiUmur : 37 tahunPekerjaan : Petani sawitPendidikan: SMA

Agama : Kristen ProtestanAlamat : PelantaranStatus Pernikahan : MenikahMasuk RS : 13 Januari 2015No MR: 163073Riwayat Penyakit:Keluhan Utama: Nyeri perut kanan bawahKeluhan tambahan: BAB sejak 1 hari SMRS. Flatus (-), Mual (-), Muntah (+) 4x SMRS, demam (-).BAB (-), BAK (+) NRiwayat penyakit terdahulu: Pasien belum pernah mengalami keluhan ini sebelumnya.

Pemeriksaan Fisik:Kesadaran: Compos MentisKeadaan: Tampak sakit sedangTekanan darah: 150/100 mmHgNadi: 80 x/menit, regulerRespirasi: 24 x/menitSuhu: 37,5 CStatus Generalisata: Mata: Konjungiva pucat-/-, Sklera ikterik -/-,Telinga: Bentuk normal, simetris, serumen (-/-)Tenggorok: Bibir kering, sianosis (-), tonsil T1-T1Faring tidak hiperemis

Leher: Tidak teraba pembesaranThoraks: Inspeksi: bentuk simetris, retraksi sela iga (-), retraksi suprasternal (-)Paru:

ANTERIORPOSTERIORKIRIKANANKIRIKANANInspeksiPergerakan napas simetrisPergerakan napas simetrisPergerakan napas simetrisPergerakan napas simetrisPalpasiFremitusvokal = simetrisFremitusvokal= simetriFremitusvokal= simetrisFremitusvokal= simetrisPerkusiSonorSonorSonorSonorAuskultasiBunyi napas vesikuler, Rhonki (-/-) danWheezing (-/-)

Jantung: Inspeksi: Iktus cordis tidak terlihatPalpasi: Iktus kordis teraba di sela iga IV garis midklavikula kiriPerkusi: Batas jantung normalAuskultasi: Bunyi jantung I-II reguler, murmur(-), gallop (-), Abdomen:Inspeksi: Datar, simetrisAuskultasi: Peristaltik usus meningkatPalpasi: Supel, nyerti tekan titik Mc burney(+), psoas sign (+), rovsing sign (+), obturator sign (+), hepar dan limfa tidak teraba membesar.Perkusi: Timpani, nyeri tekan (+) perut kanan bawah

Ekstremitas:Superior: Oedem (-/-), sianosis (-/-)Inferior: Oedem (-/-), sianosis (-/-)Pemeriksaan penunjang:

Jenis pemeriksaanHasilSatuanNilai normalH2TLHemoglobin14,6g/dLLk: 14 17,5 Leukosit12,0ribu/uL5-10Hematokrit38,6%41,5 5-,4 / dLTrombosit83Ribu/uL150-400Kimia KlinikUK (Ureum, Kreatinin)Ureum darah30mg/dL15-50Kreatinin darah0,80mg/dL< 1,4Gula darah sewaktu105mg/dL

Lanjutan:

Jumlah Lekosit 12,04,4 11 x 103 / uLHitung Jenis LekositEosinofil10 3 %Basofil00 1%Neutrofil8450 -70 %Limfosit1320- 40 %Monosit22 8 %Jumlah Eritrosit4,184,5 5 x 106 / uLIndex EritrositMCV9280 96 fLMCH35,027,5 33,2 pgMCHC37,933,4 35,5 g/ dL

Diagnosis Kerja: Susp Appendisitis AkutPenatalaksanaan:Pro: Rawat inapIVFD: RL 20 tpm (makro)Inj. Ceftriaxon 1gr/12 jamInj. Ranitidin 50 mg/12 jamInj. Ketorolac 70 mgCek darah lengkap, LFT, RFT, GDS, USG Abdomen

Follow Up

14 Januari 201515 Januari 2015S: Nyeri perut kanan bawah, BAB (-), BAK (+) N, mual (-), muntah (-), demam (-).O: kes : komposmentisTD 130/90 mmHgHR 76x/menitRR 20x/menitSuhu 38,2 CKepala: CA -/- , SI -/-.Thoraks: Ins: Gerakan dinding dada simetris, iktus kordis terlihat.Pal: Vokal Fremitus simetris.Per: Sonor simetris.Aus: BND Vesikuler, Rh -/-, Wh -/-.BJ 1-2 normal , murmur (-), gallop (-).Abdomen : Ins: Tampak datar.Pal: Supel, Nyeri tekan perut kanan bawah.Aus: BU (+).Per: Timpani.Ekstremitas : Akral hangat, CRT < 2.A: Susp Appendisitis AkutP: Pro Rawat Inap, Operasi laparotomiDiet : PuasaIVFD : RL 20 tpm (makro)Mm/: Inj Ceftriaxon 1 gr / 12 jam.Inj. Ranitidin 50 mg / 12 jam.Inj. Metronidazol 500 mg/8 jam.S: Tidak ada keluhan, BAB (+) N, BAK (+) N, mual (-), muntah (-), demam (-)O: kes : komposmentisTD 120/90 mmHgHR 80 x/menitRR 20 x/menitSuhu 37 CKepala: CA -/-, SI -/-.Thoraks: Ins: Gerakan dinding dada simetris, iktus kordis terlihat.Pal: Vokal Fremitus simetris.Per: Sonor simetris.Aus: BND Vesikuler, Rh -/-, Wh -/-.BJ 1-2 normal , murmur (-), gallop (-).Abdomen : Ins: Tampak datar.Pal: Nyeri post operasi appendektomiAus: BU (+)Per: Timpani.Ekstremitas : Akral hangat, CRT < 2.A: Post Operasi Appendektomi ec Appendisitis PerforasiP: Pro Rawat InapDiet : TKTP IVFD : RL 20 tpm (makro)Mm/: Inj Ceftriaxon 1 gr / 12 jam.Inj. Ranitidin 50 mg / 12 jamInj Metronidazol 500 mg/8 jam.

TERIMA KASIH

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