REPORT

APPENDICITIS

DISUSUN OLEH :

Anggi Wibisono NIM P07120112043

Annisa Rahmatiah NIM P071201120

Clara Tyas Eviningrum NIM P071201120

Eka Yuliana Fatimah NIM P071201120

Febrita Laysa Susana NIM P07120112060

Khoirul Mustofa NIM P07120112063

Normalasari Dwinugraheni NIM P07120112067

Utita Agustina NIM P071201120

KEMENTRIAN KESEHATAN REPUBLIK INDONESIAPOLITEKNIK KESEHATAN YOGYAKARTA

JURUSAN KEPERAWATAN2014

A. Definition

Appendicitis (also called epityphlitis) is inflammation of the appendix and is a

surgical emergency. Many cases of appendicitis require removal of the inflamed

appendix by laparotomy or laparoscopy due to the high mortality associated with

rupture of the appendix, which may lead to severe complications such as peritonitis

and sepsis. Appendicitis was first described by Reginald Fitz in 1886, and is today

recognized as one of the most common and significant causes of severe acute

abdominal pain worldwide.

Appendicitis is a medical emergency that requires prompt surgery to remove the

appendix. Left untreated, an inflamed appendix will eventually burst, or perforate,

spilling infectious materials into the abdominal cavity. This can lead to peritonitis, a

serious inflammation of the abdominal cavity's lining (the peritoneum) that can be

fatal unless it is treated quickly with strong antibiotics.

Sometimes a pus-filled abscess (infection that is walled off from the rest of the

body) forms outside the inflamed appendix. Scar tissue then "walls off" the appendix

from the rest of the abdomen, preventing infection from spreading. An abscessed

appendix is a less urgent situation, but unfortunately, it can't be identified without

surgery. For this reason, all cases of appendicitis are treated as emergencies, requiring

surgery.

In the U.S., one in 15 people will get appendicitis. Although it can strike at any

age, appendicitis is rare under age 2 and most common between ages 10 and 30.

B. Etiology

On the basis of experimental evidence, acute appendicitis seems to be the end

result of a primary obstruction of the appendix lumen (the inside space of a tubular

structure). Once this obstruction occurs, the appendix subsequently becomes filled

with mucus and swells, increasing pressures within the lumen and the walls of the

appendix, resulting in thrombosis and occlusion of the small vessels, and stasis of

lymphatic flow. Rarely, spontaneous recovery can occur at this point. As the former

progresses, the appendix becomes ischemic and then necrotic. As bacteria begin to

leak out through the dying walls, pus forms within and around the appendix

(suppuration). The end result of this cascade is appendiceal rupture (a 'burst

appendix') causing peritonitis, which may lead to septicemia and eventually death.

The causative agents include foreign bodies, trauma, intestinal worms,

lymphadenitis, and, most commonly, calcified fecal deposits known as appendicoliths

or fecaliths. The occurrence of obstructing fecaliths has attracted attention since their

presence in patients with appendicitis is significantly higher in developed than in

developing countries, and an appendiceal fecalith is commonly associated with

complicated appendicitis. Also, fecal stasis and arrest may play a role, as

demonstrated by a significantly lower number of bowel movements per week in

patients with acute appendicitis compared with healthy controls. The occurrence of a

fecalith in the appendix was thought to be attributed to a right-sided fecal retention

reservoir in the colon and a prolonged transit time, although a prolonged transit time

was not observed in subsequent studies. From epidemiological data, it has been stated

that diverticular disease and adenomatous polyps were unknown and colon cancer

exceedingly rare in communities exempt from appendicitis. Also, acute appendicitis

has been shown to occur antecedent to cancer in the colon and rectum. Several

studies offer evidence that a low fiber intake is involved in the pathogenesis of

appendicitis. This is in accordance with the occurrence of a right-sided fecal reservoir

and the fact that dietary fiber reduces transit time.

C. Pathophysiology

The main thrust of events leading to the development of acute appendicitis lies in

the appendix developing a compromised blood supply due to obstruction of its lumen

and becoming very vulnerable to invasion by bacteria found in the gut normally.

Obstruction of the appendix lumen by faecolith, enlarged lymph node, worms,

tumour, or indeed foreign objects, brings about a raised intra – luminal pressure,

which causes the wall of the appendix to become distended.

Normal mucus secretions continue within the lumen of the appendix, thus

causing further build up of intra-luminal pressures. This in turn leads to the occlusion

of the lymphatic channels, then the venous return, and finally the arterial supply

becomes undermined.

Reduced blood supply to the wall of the appendix means that the appendix gets

little or no nutrition and oxygen. It also means a little or no supply of white blood

cells and other natural fighters of infection found in the blood being made available

to the appendix.

The wall of the appendix will thus start to break up and rot. Normal bacteria

found in the gut gets all the inducement needed to multiply and attack the decaying

appendix within 36 hours from the point of luminal obstruction, worsening the

process of appendicitis. This leads to necrosis and perforation of the appendix. Pus

formation occurs when nearby white blood cells are recruited to fight the bacterial

invasion.

A combination of dead white blood cells, bacteria, and dead tissue makes up pus.

The content of the appendix (faecolith, pus and mucus secretions) are then released

into the general abdominal cavity, bringing causing peritonitis. So, in acute

appendicitis, bacterial colonisation follows only when the process have commenced.

D. Sign and Symptoms

The following signs and symptoms may accompany appendicitis :

1. Pain, starting around the navel, then moving down and to the right side of the

abdomen. The pain gets worse when moving, taking deep breaths, coughing,

sneezing, or being touched in this area.

2. Loss of appetite

3. Nausea

4. Vomiting

5. Change in bowel movements, including diarrhea or not being able to have a bowel

movement or pass gas

6. Low fever that starts after other symptoms

7. Urinating often, or difficult or painful urination

E. Diagnostic Examination

1. Blood and urine test

While there is no laboratory test specific for appendicitis, a complete blood

count (CBC) is done to check for signs of infection. Although 70-90 percent of

people with appendicitis may have an elevated white blood cell count, there are

also many other abdominal and pelvic conditions that can cause the white cell

count to elevate.

A urinalysis generally does not show infection but it is important for

determining the pregnancy status, especially the possibility of an ectopic

pregnancy in childbearing females, and for ruling out urinary tract infection.

However, there is a possibility of a microscopic pyuria, the condition of urine

containing pus, or hematuria, urine containing red blood cells, caused by the

proximity of the appendix to the ureter and bladder in acute appendicitis. The

presence of more than 20 WBC per high-power field in the urine is more

suggestive of a urinary tract disorder.

2. Imaging

Appendicitis in children is common enough to merit special attention.

Because of the health risks of exposing children to radiation, many medical

societies recommend that in confirming a diagnosis with children the ultrasound

is a preferred first choice with x-rays being a legitimate follow-up when

warranted. CT scan is more accurate than ultrasound for the diagnosis of

appendicitis in adults and adolescents. CT scan has a sensitivity of 94%,

specificity of 95%. Ultrasonography had an overall sensitivity of 86%, a

specificity of 81%.

3. X–Ray

In general, plain abdominal radiography (PAR) is not useful in making the

diagnosis of appendicitis. Plain abdominal films may be useful for the detection

of ureteral calculi, small bowel obstruction, or perforated ulcer, but these

conditions are rarely confused with appendicitis. An opaque fecalith can be

identified in the right lower quadrant in less than 5% of patients. A barium enema

has proven to be a poor diagnostic tool because, while failure of the appendix to

fill during a barium enema has been associated with appendicitis, this finding

lacks both sensitivity and specificity because up to 20% of normal appendices

also do not fill.

A study done in 1999 concluded that "plain abdominal radiographs in

patients with suspected appendicitis are neither sensitive nor specific, are

frequently misleading, are costly per specific and correct diagnosis, and should

not be routinely obtained on patients with suspected appendicitis. Another study

came to the same conclusion, but said they may be useful in a small number of

people with suspected small bowel obstruction or urinary symptoms.

4. Ultrasound

Ultrasonography and Doppler sonography provide useful means to detect

appendicitis, especially in children, and shows free fluid collection in the right

iliac fossa, along with a visible appendix without blood flow in color Doppler. In

some cases (15% approximately), however, ultrasonography of the iliac fossa

does not reveal any abnormalities despite the presence of appendicitis. This is

especially true of early appendicitis before the appendix has become significantly

distended and in adults where larger amounts of fat and bowel gas make actually

seeing the appendix technically difficult. Despite these limitations, sonographic

imaging in experienced hands can often distinguish between appendicitis and

other diseases with very similar symptoms, such as inflammation of lymph nodes

near the appendix or pain originating from other pelvic organs such as the ovaries

or fallopian tubes.

5. CT/CAT/Computed tomography Scan

Where it is readily available, CT scan has become frequently used,

especially in adults whose diagnosis is not obvious on history and physical

examination. Concerns about radiation, however, tend to limit use of CT in

pregnant women and children. A properly performed CT scan with modern

equipment has a detection rate (sensitivity) of over 95%, and a similar specificity.

Signs of appendicitis on CT scan include lack of oral contrast (oral dye) in the

appendix, direct visualization of appendiceal enlargement (greater than 6 mm in

cross-sectional diameter), and appendiceal wall enhancement with IV contrast

(IV dye). The inflammation caused by appendicitis in the surrounding peritoneal

fat (so called "fat stranding") can also be observed on CT, providing a

mechanism to detect early appendicitis and a clue that appendicitis may be

present even when the appendix is not well seen. Thus, diagnosis of appendicitis

by CT is made more difficult in very thin patients and in children, both of whom

tend to lack significant fat within the abdomen. The utility of CT scanning is

made clear, however, by the impact it has had on negative appendectomy rates.

For example, use of CT for diagnosis of appendicitis in Boston, MA has

decreased the chance of finding a normal appendix at surgery from 20% in the

pre-CT era to only 3% according to data from the Massachusetts General

Hospital.

F. Risk Factors 

1. Age <20 years, white cell count >10 × 103/mm

In the study to evaluate the impact of timing of appendectomy and other

potential risk factors on progression of acute appendicitis, by searching the

relevant databases of a tertiary medical center identified 1,604 patients with

verified acute appendicitis who underwent appendectomy in 2004-2007with

demographic and clinical data and time from symptom onset to emergency room

admission (“patient interval”) and from emergency room admission to surgery

(“hospital interval”) and their combination were analyzed by pathological grade,

indicated that on multivariate analyses, independent risk factors for appendiceal

perforation were age <20 years (OR = 1.58, 95 % CI 1.07-2.35) or >50 years

(OR = 2.84, 95 % CI 1.82-4.45) (relative to 20-50 years), white cell count >10 × 

103/mm(3) (OR = 4.45, 95 % CI 2.05-9.67), body temperature >37.8 °C (OR = 

2.23, 95 % CI 1.45-3.41), hospital interval >24 h (OR = 2.84, 95 % CI 1.49-5.4),

patient interval >48 h (OR = 3.84, 95 % CI 2.35-6.29), and combined interval

>48 h (OR = 4.29, 95 % CI 2.2-8.36).

2. Gender different, among young

According to study appendicitis is common among young, healthy

populations; appendectomy is one of the most common surgical procedures

performed in the United States. Among active and reserve component members,

there were 31,610 cases of appendicitis and 30,183 appendectomies during 2002

to 2011. The overall incidence rate of appendicitis in the active component was

18.4 per 10,000 person-years (p-yrs). Active component males reported greater

rates of perforated appendicitis (2.6 per 10,000 p-yrs). Active component

females had higher rates of incidental appendectomies (2.6 per 10,000 p-yrs).

3. Race, increased over time and is higher in the summer months

Appendicitis is most common in whites and Hispanics and less common in

African Americans and Asians and incidence has increased over time and is

higher in the summer months, according to the study by the University of

California San Diego.

4. Prior antibiotic administration 

Prior treatment with antibiotics was an independent risk factor for

therapeutic delay in pediatric AA, according to the study by the National Center

for Child Health and Development, Tokyo

5. Decreased bowel sounds, rebound tenderness, and presence of psoas, obturator,

or Rovsing’s signs

Factors associated with an increased likelihood of appendicitis included

decreased bowel sounds; rebound tenderness; and presence of psoas, obturator,

or Rovsing’s signs.

6. In patients with end-stage renal disease

The independent risk factors were atrial fibrillation (hazard ratio [HR],

2.08), severe liver disease (HR, 1.74), diabetes mellitus (HR, 1.58), and

hemodialysis (HR, 1.74), according to the study by the Taipei Medical

University.

7. Severity of inflammation 

CRP concentration may be a potent objective predictor of pathological

severity in appendicitis. Combination with the other diagnostic modalities may

improve the diagnostic accuracy in predicting the severity of appendicitis.

8. Other risk factors

The principal factors contributing to perforation of appendix are: age of

children, delays of surgical intervention, family anamnesis, social group and late

recognition of symptoms of appendicitis.

9. Appendicolith

Presence of an appendicolith was associated with a 72% rate of recurrent

appendicitis compared with a recurrence rate of 26% in those with no

appendicolith (chi2 test, P < .004).

G. Complications

1. Peritonitis

If the appendix ruptures and releases the infection into the abdomen the patient

may develop peritonitis. The peritoneum will become inflamed. The peritoneum

is the membrane that lines the abdominal cavity and covers most of the

abdominal organs. Peritonitis causes the bowels to shut down - bowel

movements will stop and the bowel will become blocked. The patient will

develop a fever and could go into shock. Peritonitis requires urgent treatment.

2. Abscess

If the infection seeps out of the appendix and mixes with intestinal contents, it

may form an abscess. If the abscess is not treated it can cause peritonitis.

Sometimes abscesses are treated with antibiotics. Often they are surgically

drained with the aid of a tube which is placed into the abdomen.

H. Treatments

1. Laparatomy

Laparotomy is the traditional type of surgery used for treating

appendicitis. This procedure consists in the removal of the infected appendix

through a single larger incision in the lower right area of the abdomen. The

incision in a laparotomy is usually 2 to 3 inches (51 to 76 mm) long. This type

of surgery is used also for visualizing and examining structures inside the

abdominal cavity and it is called exploratory laparotomy.

During a traditional appendectomy procedure, the patient is placed under

general anesthesia to keep the muscles completely relaxed and to keep the

patient unconscious. The incision is two to three inches (76 mm) long and it is

made in the right lower abdomen, several inches above the hip bone. Once the

incision opens the abdomen cavity and the appendix is identified, the surgeon

removes the infected tissue and cuts the appendix from the surrounding tissue.

After careful and close inspection of the infected area, and ensuring there are no

signs that surrounding tissues are damaged or infected, the surgeon will start

closing the incision. This means sewing the muscles and using surgical staples

or stitches to close the skin up. In order to prevent infections the incision is

covered with a sterile bandage.

The entire procedure does not last longer than an hour if complications

do not occur.

2. Laparoscopic surgery

The newer method to treat appendicitis is the laparoscopic surgery. This

surgical procedure consists of making three to four incisions in the abdomen,

each 0.25 to 0.5 inches (6.4 to 12.7 mm) long. This type of appendectomy is

made by inserting a special surgical tool called laparoscope into one of the

incisions. The laparoscope is connected to a monitor outside the patient's body

and it is designed to help the surgeon to inspect the infected area in the

abdomen. The other two incisions are made for the specific removal of the

appendix by using surgical instruments. Laparoscopic surgery also requires

general anesthesia and it can last up to two hours. The latest methods are

NOTES appendectomy pioneered in Coimbatore, India where there is no

incision on the external skin[38] and SILS (Single incision laparoscopic Surgery)

where a single 2.5 cm incision is made to perform the surgery.

3. Drug Therapies

Your health care provider may prescribe the following medications :

a. Antibiotics

b. Medications taken to ease nausea

4. Pre surgery

The treatment begins by keeping the patient away from eating or drinking

in preparation for surgery. An intravenous drip is used to hydrate the patient.

Antibiotics given intravenously such as cefuroxime and metronidazole may be

administered early to help kill bacteria and thus reduce the spread of infection in

the abdomen and postoperative complications in the abdomen or wound.

Equivocal cases may become more difficult to assess with antibiotic treatment

and benefit from serial examinations. If the stomach is empty (no food in the

past six hours) general anaesthesia is usually used. Otherwise, spinal anaesthesia

may be used.

Once the decision to perform an appendectomy has been made, the

preparation procedure takes approximately one to two hours. Meanwhile, the

surgeon will explain the surgery procedure and will present the risks that must

be considered when performing an appendectomy. With all surgeries there are

certain risks that must be evaluated before performing the procedures. However,

the risks are different depending on the state of the appendix. If the appendix has

not ruptured, the complication rate is only about 3% but if the appendix has

ruptured, the complication rate rises to almost 59%.[39] The most usual

complications that can occur are pneumonia, hernia of the incision,

thrombophlebitis, bleeding or adhesions. Recent evidence indicates that a delay

in obtaining surgery after admission results in no measurable difference in

patient outcomes.

The surgeon will also explain how long the recovery process should take.

Abdomen hair is usually removed in order to avoid complications that may

appear regarding the incision. In most of the cases patients experience nausea or

vomiting which requires specific medication before surgery. Antibiotics along

with pain medication may also be administrated prior to appendectomies.

5. After surgery

Hospital lengths of stay typically range from a few hours to a few days,

but can be a few weeks if complications occur. The recovery process may vary

depending on the severity of the condition, if the appendix had ruptured or not

before surgery. Appendix surgery recovery is generally a lot faster if the

appendix did not rupture.[41] It is important that patients respect their doctor's

advice and limit their physical activity so the tissues can heal faster. Recovery

after an appendectomy may not require diet changes or a lifestyle change.

After surgery occurs, the patient will be transferred to a postanesthesia

care unit so his or her vital signs can be closely monitored to detect anesthesia-

and/or surgery-related complications. Pain medication may also be administered

if necessary. After patients are completely awake, they are moved into a hospital

room to recover. Most individuals will be offered clear liquids the day after the

surgery, then progress to a regular diet when the intestines start to function

properly. Patients are recommended to sit up on the edge of the bed and walk

short distances for several times a day. Moving is mandatory and pain

medication may be given if necessary. Full recovery from appendectomies takes

about four to six weeks, but can be prolonged to up to eight weeks if the

appendix had ruptured.

REFERENCE

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risk-factors_7.html

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(2007). "Origin of acute appendicitis: fecal retention in colonic reservoirs: a case

control study". Surg Infect (Larchmt)

Wan, M. J.; Krahn, M.; Ungar, W. J.; Caku, E.; Sung, L.; Medina, L. S.; Doria,

A. S. (2009). "Acute Appendicitis in Young Children: Cost-effectiveness of US

versus CT in Diagnosis--A Markov Decision Analytic Model". Radiology 250

(2): 378–386.

Ellis, H (March 2012). "Acute appendicitis.". British journal of hospital medicine

(London, England : 2005) 73 (3): C46–8.