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Wednesday, 11 April 2012

DIGESTIVE SURGERY SERIE : APPENDICITIS (SIGN, SYMPTOMS, ETIOLOGY, DEFINITION, DIAGNOSIS AND MANAGEMENT)


Appendix Definitions
Appendix appendix is ​​called an organ found in the cecum located in the proximal colon, a hitherto unknown function.

Anatomy
Appendix is ​​a tube-shaped organ with a length of approximately 10 cm (range 3-15 cm) and stem from the cecum. The appendix has a narrow lumen of the proximal section and wide in the distal. At birth, short and wide dipersambungan appendix with the cecum. During the children, growth is usually rotates into the intraperitoneal retrocaecal but still. At 65% of cases, the appendix is ​​intraperitoneal. It is possible to move the position of the appendix and the motion depends on the length of mesoapendiks lynchings. In the remaining cases, the appendix lies peritoneal, which is behind the ascending colon, or the lateral edge of the ascending colon. Clinical symptoms of appendicitis are known by the location of the appendix. In the appendix there are 3 tanea dipersambungan caecum coli are fused and can be useful in indicating where to detect the appendix. The position of the appendix is ​​most Retrocaecal (74%) and then following the Pelvic (21%), Patileal (5%), Paracaecal (2%), subcaecal (1.5%) and preleal (1%).

Appendix diperdarahi by apendicular arteries that branch from the bottom of the arteries ileocolica. Artery appendix includes end arteries. The appendix has more than 6 lymph channels leading to obstruct mesoapendiks ileocaecal lymph nodes.




CLASSIFICATION
Classification of appendicitis is divided into two, namely:
A. Acute appendicitis, are divided into: Acute appendicitis or segmentalis fokalis, that recovery will occur after the local strictures. Appendisitis purulenta diffusion, which may have accumulated pus.
2. Chronic appendicitis, divided into: Chronic appendicitis fokalis or partial, recovery will occur after the local strictures. Chronic appendicitis appendix obliteritiva is tilted, usually found in old age. Chronic appendicitis is a recurrent inflammation of the appendix. Defined as follows: (1) patients had a history of RLQ pain for at least 3 weeks which is not caused by other diseases, (2) after 1-3 months of intermittent pain, (3) by histopathology, these symptoms are caused by a proven active chronic inflammation of the appendix wall or fibrosis of the appendix. On physical examination found symptoms similar to acute appendicitis, whereas in normal leukocytes obtained laboratory-up.

Anatomical location of the appendix


Physiological
Although lacking the appendix has a function, but the appendix may serve as other organs. Appendix 1-2 ml per day to produce mucus. Slime poured into the lumen and then flows into the caecum. If there is resistance there will be the pathogenesis of acute appendicitis. Galt (Gut Tissue Assoiated lymphoid) contained in the appendix to produce Ig-A. however, if the appendix is ​​removed, does not affect the body's immune system because their numbers are few.
   Appendicitis is caused by various factors.
Etiology
Some of the factors that facilitate the occurrence of inflammation of the appendix, including:
A. Factor blockage (obstruction)
Obstruction factor is the most important factor in the occurrence of appendicitis (90%) followed by infection. Approximately 60% of obstruction caused by sub mucosal lymphoid tissue hyperplasia, 35% for faecal stasis, 4% due to foreign objects and other causes 1% of the blockage by parasites and worms.
2. Bacterial factors
Enterogen infection is the primary factor in the pathogenesis of acute appendicitis. Fekalith presence in the lumen of the appendix which had been infected exacerbate and aggravate the infection, because an increase in stagnation of feces in the lumen of the appendix, in most cultures obtained is a combination of Bacteriodes fragililis and E.coli, and Splanchicus, lacto-bacilus, Pseudomonas, Bacteriodes splanicus. While the germs that cause perforation is 96% anaerobic and aerobic <10%.
3. Familiar tendency
It is associated with a hereditary malformation tedapatnya of organ, the appendix is ​​too long, vascularization is not good and it's an easy place appendicitis. It is also linked to food habits in the family, especially with low-fiber diet can ease the fekolith and result in lumen obstruction.
4. Race and dietary factors
Racial factors associated with habits and patterns of daily food. White people who were once low-fiber diet have a higher risk of a country that many fiber diet. However, when present, reverse happened. White people have changed their diet to a diet high in fiber. Developing countries that used to actually have now switched to high-fiber diet low in fiber, have a higher risk of appendicitis.

Pathophysiology
Pathology of appendicitis begins in mucosal tissues and then spread to all layers of the wall of the appendix. Mucosal tissue in the appendix produces mucus (phlegm) every day. Causing obstruction of the drainage of mucus from the lumen of the appendix into the cecum becomes blocked. The longer the growing body of mucus and then forming a dam mucous in the lumen. However, due to the limited elasticity of the wall of the appendix, so that it causes an increase in intraluminal pressure. Increased pressure will cause delays in the flow of lymph, thus resulting in the emergence of edema, diapedesis of bacteria, and mucosal ulceration. At this moment there are focal acute appendicitis is characterized by pain in the epigastric area around the umbilicus.

If the mucus secretion persists, intraluminal pressure will continue to increase. This will cause the occurrence of venous obstruction, edema increased, and the bacteria will penetrate the wall of the appendix. Inflammation that arise are more widespread and the local peritoneum, causing pain in the lower right abdomen. This is called the acute suppurative appendicitis. If then the arterial flow is compromised, then the myocardial wall of the appendix will be followed by the occurrence of gangrene. This condition is called appendicitis gangrenosa. If the wall has undergone a gangrenous appendix is ​​ruptured, it means being in a state of perforated appendicitis.
Actually, the body also make an effort to limit the defense of this inflammatory process. The trick is to close the appendix with the omentum, and small intestine, thus forming a mass that is wrong periapendikuler known as infiltrates the appendix. In it can occur in the form of abscess tissue necrosis that can be perforated. However, if not formed an abscess, appendicitis would recover and periapendikuler mass will become calm and will unravel itself slowly. Gangrenous appendix wall caused by the occlusion of blood vessel walls due to distention of the appendix lumen of the appendix. If the pressure continues to increase intra-luminal perforation occurs, accompanied by increased body temperature rise and high living.
In children, the shorter the omentum, the appendix is ​​longer, and the thinner walls of the appendix, and endurance are still lacking, facilitate the occurrence of perforation. Whereas in the elderly, perforation easily occurs due to an interruption of blood vessels.
Inflamed appendix will not ever heal completely, but will form scar tissue. This network causes adhesions to the surrounding tissue. Adhesions can cause complaints back to the lower right abdomen. At one time these organs can become inflamed again and found to have exacerbations.


Clinical Overview
Image. location of pain

The initial symptoms are the classic symptoms of appendicitis is a vague pain (dull pain) in the area around the umbilicus or epigastrium periumbilikus. These complaints are usually accompanied by nausea and sometimes vomiting, and decreased appetite in general. Then in a few hours, the pain will turn to the right lower quadrant, to the point Mc Burney. On this point the pain was sharper and clearer the location, so it is a local somatic pain. But sometimes, do not feel any pain in the epigastric region, but there is constipation, so people feel the need for laxatives. This action is considered dangerous because it could facilitate the occurrence of perforation. Sometimes appendicitis is also accompanied by a low-grade fever of about 37.5 -38.5 degrees Celsius.
In addition to the classic symptoms, there are some other symptoms that may arise as a result of appendicitis.
      Onset of symptoms is dependent on the location when the inflamed appendix. The following are symptoms that arise.
A. When retrosekal retroperitoneal location of the appendix, which is behind the cecum (protected by the cecum), signs of right lower abdominal pain is not so clear and no signs of peritoneal stimulation. Abdominal pain is more towards the right or the pain occur at the time of movement such as walking, breathing deeply, coughing, and straining. This pain occurs due to contraction of major m.psoas straining of the dorsal.
2. If the appendix is ​​located in the pelvic cavity
• If the appendix is ​​located near or attached to the rectum, will be symptoms or rectum and sigmoid stimulation, thus increasing peristalsis, emptying the rectum would be faster and repetitive (diarrhea).
• If the appendix is ​​located near or attached to the bladder, may be an increase in urinary frequency, because the excitement walls.
Symptoms of appendicitis is often not clear and distinctive, making diagnosis difficult, and as a result of appendicitis is not treated in time, so it is usually only discovered after the perforation. Here are some circumstances in which the symptoms of appendicitis is unclear and not typical.

McBurney's point

EXAMINATION
A. Physical examination
• Inspection: no visible change, if the appendix is ​​large enough mass, it may be visible lump in the right lower abdomen.
• Palpation: on the lower right abdomen will be sore when pressed. And when the pressure is released too will feel the pain. Right lower abdominal tenderness is the key to the diagnosis of appendicitis. Emphasis on the lower left abdominal pain will be felt in the lower right abdomen. This is called mark Rovsing (Rovsing Sign).

Image. Rovsing Sign

And when the pressure is released in the lower left abdomen will also feel pain in the lower right abdomen. This is called mark Blumberg (Blumberg Sign).
• digital rectal examination: the examination is conducted on appendicitis, to determine the location of the appendix, if the location is difficult to know. If the time of this inspection and feels pain, then the possibility of an inflamed appendix lies pelvic area. This examination is the key to the diagnosis of appendicitis pelvika.
• Inspection and test trials obturator psoas: inspection is also conducted to determine the location of the inflamed appendix. Test performed with psoas psoas muscle stimulation through the right hip joint hiperektensi active flexion of the hip joint or right, then hold right thigh. When the inflamed appendix attached to the m. psoas major, then such action would cause pain.



Image. psoas sign

While the obturator test done and endorotasi flexion movement of the hip joint in supine position. When the inflamed appendix m.obturator contact with the internal wall of the pelvis which is small, then this action will cause pain. These checks are performed on pelvika appendicitis.

2. examination Support
• Laboratory: On the complete blood count was found between 10.000-20.000/ml leukocyte count (leukocytosis), and neutrophils above 75%.
• Radiology: consisting of ultrasound and CT-scan. On ultrasound examination found that the length of the place of inflammation in the appendix. While on a CT-scan found a cross section with apendikalit and expansion of the inflamed appendix and the dilation of the cecum.
-Based on the clinical situation, should be disclosed on a regular basis are:
A. Analysis of urine. This test aims to abolish the ureter stones and to evaluate the possibility of urinary tract infections as a result of lower abdominal pain.
2. Measurement of liver enzymes and amylase levels helps diagnose inflammation of the liver, gallbladder and pancreas if the pain is depicted on the middle abdomen kuadrant even the top right.
3. Serum B-HCG to examine the possibility of pregnancy.
Alvarado scoring system
Alvarado score is a simple scoring system that can be done easily, Sepat, and less invasive. Alfredo Alvarado scoring system in 1986 made ​​based on three symptoms, three signs, and laboratory findings 2. This classification is based on pre-operative findings and to assess the severity of appendicitis. In the Alvarado scoring system uses risk factors include the transfer of pain, anorexia, nausea or vomiting and, tenderness in the right lower quadrant abdominal pain off press, temperature> 37.2 ° C, leukocytosis, and neutrophils> 75%. Right lower quadrant tenderness abdomen and leukocytosis have value 2 and the remaining six each have a value of 1, so that eight of these factors give the score of 10.

Alvarado score for diagnosis of acute appendicitis

Complication
Some of the complications of appendicitis:
• Mass periappendikulae
• perforated appendicitis
Differential Diagnosis
* Limfedenitis mesenteric
   Usually preceded by enteritis or gastroenteritis characterized by abdominal pain, especially right along with feelings of nausea, tenderness, especially right abdominal vague.
* Gastroenteritis
On happen nausea, vomiting, diarrhea precedes the pain. More mild abdominal pain and limited firm. Hiperperistaltis often found. Heat and leukocytes less prevalent than in acute appendicitis. laboratory is usually normal because the normal count.
* Pelvic Infection
Acute salpingitis right, temperatures are usually higher than appendicitis and lower abdominal pain is more diffuse. Pelvic infections in women is usually accompanied by vaginal discharge and urinary infections. In the girls do need to plug the vagina if the differential diagnosis. Pain in the vaginal plug if the uterus is swung.
* Disorders of ovulation
Ruptured ovarian follicle that can provide lower right abdominal pain in the mid ¬ menstrual cycle. There was no sign of inflammation and pain usually disappear within 24 hours, but may be disturbing for two days, the same pain anamnesis first ever arise.
* Pregnancy outside the womb
Almost always there is a history of missed period with complaints of erratic Ruptured tubal, pregnancy outside the womb abortion is accompanied by bleeding then there will be a sudden pain in the pelvis and diffuse hypovolemic shock can occur. Douglas cavity pain and protrusion found on vaginal examination and found the kuldosintesis.
* Meckel diverticulosis
The clinical features similar to acute appendicitis. Surgery before the operation and need not only theoretical, since Meckel diverticulosis associated with similar complications in the treatment of acute appendicitis and needed surgery and the same action.
* Stone Ureter
If the estimated sediment near the appendix, appendicitis resembles retrocecal. Pain radiating to the labia, scrotum, or penis, hematuria and / or fever or leukosotosis help. Mengkofirmasi Pielography usually for diagnosis.
* Twisted ovarian cyst
Suddenly there is pain with high intensity and palpable mass in the pelvic cavity on abdominal examination, vaginal plug, or a rectal plug. There is no fever. Ultrasound examination can determine the diagnosis.

PREVENTION
Prevention of appendicitis is to reduce the risk of obstruction and inflammation of the appendix lumen. Elimination pattern of the client should be assessed, because of obstruction by fekalit can occur because there is no high-strength fiber diit. Care and treatment of worm diseases also pose risks. Rapid introduction of the symptoms and signs of appendicitis reduce the risk of gangrene, perforation and peritonitis.
MANAGEMENT
A. Sito operations: for acute appendicitis, abscess and perforation
2. Elective surgery: for chronic appendicitis
3. Conservative: - Bed rest total Fowler position
- A diet low in fiber
- Broad spectrum antibiotics
Prognosis
With accurate diagnosis and surgery, mortality and morbidity rates are very small. Delay in diagnosis increases the mortality and morbidity. Repeated attacks can occur if the appendix is ​​not removed.

REFERENCES
1. Jong, wim de dan Sjamsuhidajat, R. Apendiks Vermiformis dalam Buku Ajar Ilmu Bedah, edisi 2. Halaman 639-645. 2005. EGC
2. Reksoprodjo, Soelarto. Apendisitis Akut dan Apendisitis Perforasi dalam kumpulan kuliah Ilmu Bedah, Bagian Bedah Sraf Pengajar Fakultas Kedokteran Universitas Indonesia. Halaman 109-110. 1995. Binarupa Aksara
3. http://kudus.net78.net/2009/03/penyakit-radang-usus-buntu-appendicitis/.
4. http://kumpulan-asuhan-keperawatan.blogspot.com/2009/06/asuhan-keperawatan-appendiksitis-askep.html.
5. http://jhonkarto.blogspot.com/2009/02/apendiksitis.htm.

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