1. GIS-K-25 ACUTE APPENDICITIS Appendiceal Mass / Abscess
Syahbuddin Harahap
Division of Digestive Surgery
Department of Surgery
Faculty of Medicine University of North Sumatera
Adam Malik Hospital

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

3. Etiology: Obstruction of the lumen appendix followed by infection
Catarrhal appendicitis.
-lymphoid hyperplasia (60% children)
-Gastro enteritis
-Virus
-Acute respiratory infection
-Mononucleosis
Obstructive appendicitis
-fecalith 35% adults.
-foreign body / parasites (4%)
- tumors (1%)

4. Pathophysiology Wangensteen proposed Closed loop obstruction
Increase in luminal pressure.
Exceeds capillary pressure causes mucosal ischemia
Luminal bacterial overgrowth and translocation bacteria across the appendiceal wall result :
-Inflammation
-Edema
-Necrosis  perforation occur about 48 hours .
If the body successfully walls off the perforation Appendiceal Mass
If the perforation is not successfully walled off  Diffuse peritonitis will develop.

5. Problem:
Appendicitis can mimic several abdominal conditions.
Laboratory test
Imaging investigation
Statistics report
1 of 5 cases is misdiagnosed
Normal appendix is found in
15-40% Emergency appendectomy.(Negative Appendectomy)

6. Differential diagnosis of acute appendicitis
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
Surgical
Acute Intestinal obstruction
Intussusception
Acute cholecystitis
Perforated peptic ulcer
Mesenteric adenitis
Acute Meckel's diverticulitis
Acute Pancreatitis
Medical
Gastroenteritis
Basal Pneumonia dextra
Terminal ileitis

7. Differential diagnosis of appendicitis appendicitis
can mimic several abdominal conditions.

8. Lab Studies:
Complete blood cell count
A mild elevation of WBCs (ie, >10,000/µL)
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)

9. 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 º C
Higher fevers are associated with a perforated appendix

10. Special maneuvers it is only the area McBurney sign McBurney's point
of greatest tenderness
Blumberg sign
Rovsing’s Sign
Dunphy sign Cough Test
Obturator sign
Psoas sign
Markle sign

11. Location appendix during pregnancy

12. INDICATIONS
Consider an appendectomy for patients with a history of :
Persistent abdominal pain
Fever
Clinical signs of localized or diffuse peritonitis
Especially if leukocytosis is present.

13. Imaging Studies Abdomen plain film: Fecalith within the appendix
Urolithiasis right middle third

14. A score of 7 or more is strongly predictive of acute appendicitis.
Alvarado score 1986
MANTRELS SCORE
Characteristic
Score
M = Migration of pain to the RLQ 1
A = Anorexia
N = Nausea and vomiting
T = Tenderness in RLQ 2
R = Rebound pain
E = Elevated temperature
L = Leukocytosis
S = Shift of WBC to the left
Total 10
A score of 7 or more is strongly predictive of acute appendicitis.

15. Sonography Advantages of sonography Noninvasiveness,
normal less than 6 mm
Sonography
Advantages of sonography
Noninvasiveness,
Short acquisition time
Lack of radiation exposure
Potential for diagnosis of other causes of abdominal pain
Pediatric patients
Women of childbearing age.
Pregnant women

16. CT scan -Oral contrast medium -Rectal Gastrografin enema
Reserved for patients
-Uncertain diagnosis
-Severe obesity.
more than 6 mm

17. 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.

18. Complications Perforation General Secondary Peritonitis
Appendiceal Mass
Appendiceal Abscess
Pylephlebitis is suppurative thrombophlebitis of the portal venous system
Hepatic absces
Chills
High fever
Jaundice

19. TREATMENT
Medical 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

20. 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

21. If the body successfully walls off the localized perforation
Appendiceal Mass
RLQ mass
The pain may actually improve.
Symptoms do not completely resolve.
Still have right lower quadrant pain
Decreased appetite
Change in bowel habits (eg, diarrhea, constipation)
Intermittent low-grade fever.

22. 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 placement
Intravenous 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 days.
Traditionally, interval appendectomy is performed 6-8 weeks later.

24. Acute Appendicitis
Appendicitis Perforation