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Sabtu, 21 April 2012

Management of Appendicitis


 John Karlie, Adra Firmansyah, Glenda Angeline, Bariah Agil
Budhi Arifin Noor, Dion Ade Putra, Oktaviati, Ridho Ardhi Syaiful, Rizky Amaliah, Rachmawati
General Surgery, Department of Surgery, FKUI/RSCM, Jakarta, Indonesia,
April 2012


CASE ILLUSTRATION

A  26 year old male came into the hospital with lower right abdominal pain and worsen 1 day before admission. Three days before, the patient complaint of epigastric pain which spreads into middle and lower right abdomen. The patient also had a fever and nausea.  There were no complaint about urinating and defecation. The Patient had a history of lower right abdominal pain two years ago.  On the physical examination there were not unusual finding except muscular defense on lower right region of the abdomen. Digital rectal examination shows no abnormalities, except for the tenderness between 10 – 11 clock direction.

The laboratory result shows that the leukocyte increased to15.700 whereas others were normal. The patient was diagnosed as chronic appendicitis and undergone an appendectomy surgery by administering antibiotics and analgesic. The Patient was treated for two days post-surgery and were treated as out patient.


Operative

A Gridiron incision through McBurney’s were undergone on a patient with spinal anesthesia.  The Omentum was attached on the lower right section. The Cecal wall was identified as being thickened and hyperemic. The appendix was located at Retrocecal, Retroperitoneal, gangrenous with fibrins surrounding as well as the appendix were visibly attached to its surrounding colon. The appendix were detached, then undergone an appendectomy procedure and a double ligation sutured. The bleeding was being treated and the abdominal cavity was being cleansed using a sterilized warm saline. The surgical wound were sutured layer by layer.






Literature Review

Acute appendicitis is an inflammation of the vermiform appendix and this case is the most common intraabdominal surgery that requires surgery.1
The exact cause of appendicitis is not known for sure. Some studies pointed out that there are hereditary tendencies. The others revealed that due to eating habits, genetic resistance of bacterial flora. Eating habits of low-fiber, high sugar and fat also predispose disturbance of bowel movements that are not much food in the intestinal transit time is much longer, and increase pressure within the lumen of the intestine. 2.3

Figure 4. Pathophisiology of Apendicitis



Diagnosis

Clinical character of appendicitis can be vary, but generally is shown with a history of vague abdominal pain, which is first felt in the gut. Possibly followed by nausea, vomiting, and mild fever. The pain usually moves from right iliac fossa after several hours, up to 24 hours. The point of maximum pain is a third from umbilicus to right iliac fossa, it's called Mc Burney point. Pain is usually sharp and aggravated by movement (such as cough and running). Pain at Mc Burney point is also felt when pressure applied in the left iliac, commonly called Rovsing’s sign. Patient’s position is affected by the position of the appendix. If the appendix is found at retrocecal side (exposed between the cecum and the psoas muscle), the patient does not feel pain at Mc Burney point, but found over the lateral hip. If the appendix is located at retrocecal , the patient doesn’t feel pain when pressure applied at left iliac. When the appendix is close to the psoas muscle, patient come with flexed hip and if we try to straighten out, there will be pain in the location of the appendix (psoas sign). When the appendix is located retrocecal it can cause irritation of the ureter so that the blood and protein may be found in urinalysis. If the appendix is located in the pelvis, the clinical signs are too less, so it must be done rectal examination, found pain and swelling on the right of inspection. If the appendix is located near the obturator internus muscle, the rotation of the waist increases the patient's pain (obturator sign). Cutaneous Hiperestesia in the area supplied by the right spinal nerves T10, T11 and T12 are usually also follow the events of acute appendicitis. If the appendix is located in front of the terminal ileum close to the abdominal wall, the pain is very clear. If the appendix is located behind the terminal ileum is very difficult diagnosis, the signs are vague and the pain is located at upper abdomen.5-6

Rovsing’s sign
Positive if done palpation with pressure on the lower left quadrant and there is pain on the right side.
Psoas sign atau Obraztsova’s sign
The patient was placed on the left side, then do the extension of the right hip. Positive if there is pain on the bottom right.
Obturator sign
The patient was placed on the left side, then do the extension of the right hip. Positive if there is pain on the bottom right.
Dunphy’s sign
Accretion of pain in the lower right testis with cough
Ten Horn sign
Pain arising from the time when do soft traction at right spermatic cord
Kocher (Kosher)’s sign
Pain in the epigastric region beginning on the center, then move to the right lower quadrant.
Sitkovskiy (Rosenstein)’s sign
Increasing pain in the right lower quadrant abdomen while the patient is lie down on the left side
Bartomier-Michelson’s sign
Increasing pain in the lower right quadrant when patient is lie down on the left side compared with the supine position
Aure-Rozanova’s sign
Increased pain with petit finger on the right triangle (to be positive-Shchetkin Bloomberg's sign)
Blumberg sign
Also called off pain. Palpation in the right lower quadrant  then released suddenly
Table 1. Sign of Appendicitis6-7


The possibility of appendicitis can be assured by using the Alvarado score. Scoring system is designed to improve the diagnose of apendicitis.6

The Modified Alvarado Score
Score
Symptoms
Migratory right iliac fossa pain
1

Nausea/vomiting
1

Anorexia
1
Signs
Tenderness in right iliac fossa
2

Rebound tenderness in right iliac fossa
1

Elevated temperature
1
Laboratory Findings
Leucocytosis
2

Shift to the left of neutrophils
1

Total
10
1-4     : Acute appendicitis is probably not
5-7     : Possible acute appendicitis
8-10   : Definite acute appendicitis

Table 2. The Modified Alvarado score6

On laboratory tests, we can find white blood cells raising. Pregnancy testing should be done on female patients to rule out cases of midwifery. Ultrasound examination is done if clinical signs are unclear, an ultrasound examination had 80% sensitivity and specificity of 100% .8

Table 3. Differential Diagnosis of Appendicitis


Management of appendicitis

Mostly the management of appendicitis is appendectomy. Delay in management, will increase the incidence of appendix perforation. Double ligation technique after open appendectomy will use absorbable suturing material. For most cases, surgeons will perform appendectomy with purse string (z-stich or tobacco sac) and double ligation technique. In normal condition, surgeons will use purse string. Double ligation technique is used when reversal of the stump cannot be safely done, so the surgeon will perform double ligation to the stump with two rows suturing. Nowadays, when laparoscopic technique has been well developed, this technique has been performed more frequent. This procedure has been claimed to reduce pain after the operation better than conventional procedure, it is also been claimed to get faster healing proccess and lesser wound infection, but it will increase the probability of intra abdomen abcess and prolonged operation time. Laparoscopic surgery is performed for diagnosis and therapy for patient with acute abdomen, especially for women. Few studies said that laparoscopic surgery will increase the surgeon’s skill to perform the operation.

Grid Iron Incision (McBurney Incision)11
Grid Iron incision is performed at McBurney area. Incision line is parallel with musculus obliqus externus, pass trough the McBurney area, which is located at 1/3 lateral of the line connecting right anterior superior spina illiaca and umbilicus

Description: http://3.bp.blogspot.com/-zTEItcM9OcE/TcoTkleEJ5I/AAAAAAAAAIM/OMITwn_Zt60/s200/gambar+6.png
Lanz transverse incision
Incision is performed 2 cm below umbilicus, incised transversal on midclavicula-midinguinal. It will give better cosmetic outcome than Grid Iron incision

Description: http://2.bp.blogspot.com/-yn8A02TERBc/TcoTmVfU5FI/AAAAAAAAAIQ/OJAGcsEgadI/s200/gambar+7.png
Rutherford Morisson’s incision (Suprainguinal Incision)
Is expansion from McBurney incision. It will be performed when appendix is located at paracecal or retrocecal and fixed

Description: http://4.bp.blogspot.com/-nDMN73e_WNc/TcoTs1STJ_I/AAAAAAAAAIU/RoWzW6VIrs8/s200/gambar+8.png
Low Midline Incision
Will be performed for perforated appendix and there is peritonitis
Description: http://2.bp.blogspot.com/-nFQsrqr7KDU/TcoTtWCVAnI/AAAAAAAAAIY/FxkgoABI8Q8/s200/gambar+9.png
Lower Right Paramedian Incision
Vertical incision, parallel to the midline, 2.5 cm below umbilicus to above of the pubic

Description: http://1.bp.blogspot.com/-HB7FaiI1eF8/TcoTt3oAURI/AAAAAAAAAIc/wMJjFXxl9d4/s200/gambar+10.png
Table 4. Incisions for appendectomy


Discussion

Patient with complains of lower abdominal pain in men having differential diagnosis such as appendicitis, colic, urinary tract, digestive tract disorder (diverticulitis, ileocolitis, typhoid, and malignancies. Fever in these patients was precede by a  pain so that the possibility of typhoid can be removed. If urination symptoms and abnormalities of the urinary tract colic is not found, diseases like diverticulitis, ileocolitis and malignancy can be ruled out. If on physical examination at lower right abdomen is found muscular defans with a positive psoas and rovsing’s sign, then its likely that the location of the appendix at the retrocecal side. The value of Modified Alvarado system score is 9 out of 10. So that the patient must be diagnosed with appendicitis and perform appendectomy. The working diagnosis on the patient is chronic appendicitis acute exacerbation. If we find that the patient has a history of  right lower abdominal pain since 2 years ago the patient’s diagnosis was acute exacerbation of chronic appendicitis.
On operative report, we found an appendix is located at retrocecal retroperitoneal. It is according to sign that we got on physical examination. We can also found a gangrenous appendicitis, so that the post operative diagnosis is gangrenous appendicitis. Gangrenous appendicitis is the late stadium of appendicitis whereas we found blood flow disturbance at appendix, so that it will lead to perforation of appendix. Treatment using broad spectrum antibiotic on simple appendicitis and suppurative only can use for preoperative prophylactic.              

Glossary

Appendectomy(or appendicectomy)14 : Surgical removal of the appendix
Appendix15 : worm-shaped pouch attached to the cecum
Peritonitis16 : Inflamation of the peritoneum, the membrane lining the abdomen and pelvis.
Laparascopic surgery17 : a modern surgical technique in which operations in the abdomen are performed through small incisions (usually 0.5–1.5 cm) as opposed to the larger incisions needed in laparotomy
Retrocecal18 : pertaining to the region behind the cecum

BIBLIOGRAPHY

1.  Williams B A, Schizas A M P, Management of Complex Appendicitis. Elsevier. 2010. Surgery 28:11. p544048.
2.  Andersson N, Griffiths H, Murphy J, et al. Is appendicitis familial? Br Med J 1979 Sep 22; 2: 697e8.
3.  Heaton KW. In: Br Med J, Res Clin, eds. Aetiology of acute appendicitis 1987 Jun 27; 294:1632e3.
4.  Bewes P. Appendicitis. [Internet] April 2003. [cited April 2011] E-Talc Issue 3. Available from: http://web.squ.edu.om/med-Lib/MED_CD/E_CDs/health%2520development/html/clients/beweshtml/bewes_01.htm
5.  Soybel D. Appendix. In: Norton JA, Barie PS, Bollinger RR, et al. Surgery Basic Science and Clinical Evidence. 2nd Ed. New York: Springer. 2008.
6.  Brunicardi FC, Andersen DK, Billiar TR, et al. Shwartz’s Principles of Surgery. 9th Ed. USA: McGrawHill Companies. 2010.
7.  Appendicitis [Internet] [updated September 2010; cited April 2011]. Available from: http://en.wikipedia.org/wiki/Appendicitis
8.  Puylaert JB, Rutgers PH, Lalisang RI, et al. A prospective study ofultrasonography in the diagnosis of appendicitis. N Engl J Med 1987 Sep 10; 317: 666e9.
9.  Temple CL, Huchcroft SA, Temple WJ. The natural history of appendicitis in adults. A prospective study. Ann Surg 1995 Mar; 221: 278-81.
10. Birnbaum BA, Wilson SR. Appendicitis at the millennium. Radiology 2000 May; 215: 337e48.
11. Skandalakis JE, Colborn GL, Weidman TA, et al. Editors. Skandalakis’ Surgical Anatomy. USA: McGrawHill. 2004.
12. Russell RCG, Williams NS, Bulstrode CJK. Editors. Bailey and Love’s Short Practice of Surgery. 24th Ed. London: Arnold. 2004.
13. Patnalk VG, Singla RK, Bansal VK. Surgical Incisions-Their Anatomical Basis. J Anat. Soc. India 50(2) 170-178 (2001)
14. Appendectomy. [Internet] [cited April 2011] Available from: http://en.wikipedia.org/wiki/Appendectomy
15. Vermiform Appendix. [Internet] [cited April 2011] Available from: http://en.wikipedia.org/wiki/vermiform_appendix
16. Peritonitis. [Internet] [cited April 2011] Available from: http://en.wikipedia.org/wiki/peritonitis
17. Laparascopic surgery. [Internet] [cited April 2012] Available from:
18. Retrocecal. [Internet] [cited April 2011] Available from:
     http://medical-dictionary.thefreedictionary.com/retrocecal

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