*Diagnosis & TerapiAppendisitis Akut Dr. Lesap Heru farolan, SpB.Dept. of Surgery RSUD Sidoarjo

*Definisi :Adalah proses keradangan akut pada usus buntu

Patofisiologi :Ada 2 teori yang diajukan :1. Faecalit keradangan( Obstruktif appendikuler )2. Hematogen ( infeksi diluar usus buntu

*Moore, Clinically-oriented anatomy. 4th ed.Ukuran antara 2 cm 22 cmRerata 6-9 cm

Jaringan limfoid yang dapat berproliferasi & berfungsi sekresi

lumen 0,1 mlSekret 1-2 ml/hariMampu melawan tekanan tinggi

Vaskularisasi tunggal oleh a.appendikularis

*Lokasi Atipikal

Retrosekal & retroileallokalisasi nyeri tidak jelas, nyeri epigastrium menetap atau nyeri punggung Pelvisnyeri suprapubik atau kuadran kiri bawah, nyeri pada colok dubur, urgensi BAK & BABRetroilealNyeri testisKehamilanperubahan posisi appendiks akibat dorongan uterus

*Obstruksi lumen oleh fecalith, hiperplasia limfoid, atau benda asingSekresi & distensi dinding apendiksNyeri viseral epigastrium & periumbilikusInflamasi appendiksPenyebaran inflamasi ke peritoneum parietal & organ sekitarNyeri somatik kuadran kanan bawahAnoreksia, mual & muntah

*Apendisitis mukosaKonstipasiPeningkatan flora kolonKatup ileosekal kompetenTekanan sekum tinggiErosi selaput lendirHambatan pengosongan lumen- stenosis- pita/adhesi- mesoapendiks pendekApendisitis kompletDeJong. Buku Ajar Ilmu Bedah, Edisi ke-2.

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*Gejala Klinis :

nyeri didaerah epigastrium, berpindah dan menetap di fossa iliaca kanan.anoreksia , mual dan muntah-muntahSuhu sub Febril 37,5 38,5 sampai meningkat sampai 40 C.

*Nyeri perut epigastriumNyeri tumpul epigastrium / periumbilikusKualitas sedang-berat dapat diselingi periode kram/kolik lebih hebatDalam 4-6 jam - nyeri tajam di McBurney

Nyeri memberat saat batuk, berjalan, napas dalam & mengejan

*Gejala penyerta berurutanAnoreksiaMual, kadang disertai muntah 1-2x timbul setelah nyeriKonstipasi atau diare

Populasi dengan gejala tidak khas anak-anak, wanita & lansia

*Pemeriksaan dan Diagnosis :Gejala rangsangan peritoneum dengan pusat didaerah Mc . Burney .Nyeri pada tekanan intraabdominal yang naik (batuk , jalan )Nyeri tekan dengan Defans Muskuler Lokal

*Pemeriksaan Fisik Demam ringanPerbedaan suhu aksiler rektal > 1oCNyeri tekan maksimum pada McBurneyNyeri lepas tekan / rebound tendernessTanda RovsingHiperestesi distribusi T10-T12 kananGuarding

*Rebound Phenomen : Menekan perut bagian kiri dan dilepaskan mendadak, dirasa nyeri pada perut kanan bawah.Rovsing sign : Menekan daerah Colon Descendens dan Transversum maka udara akan menekan Caecum hingga timbul rasa nyeri pada perut kanan bawah.Ten Horn Sign : Menarik testis kanan, timbul rasa nyeri perut kanan bawah.Psoas Sign : Mengangkat tungkai kanan dalam keadaan ekstensi akan timbul rasa nyeri pada perut kanan bawah.Obturator sign : Fleksi dan Endorotasi sendi panggul kanan akan timbul rasa nyeri pada perut kanan bawahGejala gejala diatas tidak semua akan positif.

*PF (2)Lokalisasi apendiksNyeri colok duburUji psoasUji obturator

Leukositosis ringanShift to the left

*Colok rectum : nyeri pada jam 10 11Leukosistosis > 10.000Sedimen urine untuk DD: Kelainan ureterBOF : Udara di sekitar Caecum dan Ileum distal ( DD: batu ureter)

*transversalsagittal

*Diagnosa Banding :

Golongan GastroEnteritis : GE biasanya mual dan muntah dulu, baru nyeri. Appendicitis akut, nyeri baru mual muntah.Limfadenitis Mesenterik : jarang , pada anak-anak dan dewasa muda.Enterokolitis : kronis.Ileitis Terminalis : Jarang, di Asia. BOF Honeycomb Appearrance

*Diagnosis diferensialAnak BalitaIntususepsiGastroenteritisDivertikel Meckel

Anak usia sekolahGastroenteritisNyeri fungsionalKonstipasiAnemia sel sabit (krisis vasooklusi)RemajaPenyakit CrohnAnemia sel sabitKolitis ulseratif

Dewasa & LansiaKeganasan saluran cernaKeganasan saluran reproduksiDivertikulitisUlkus perforasiKolesistitis

*Kelainan Organ organ Pelvis Wanita.Folikel Ovarium pecahSalpingitis : Nyeri lebih rendah , RT / VT nyeri genetalia externaTorsi Kista OvariumKET : Amenorrhoe , Cairan bebas dan Anemia

*Diagnosis diferensialWanitaRadang panggulOvarium torsioTumor ovariumInfeksi saluran kemih

*Kelainan Saluran Air KemihBatu Ginjal kanan atau Batu Ureter Kanan : terdapat Nyeri Kolik , sedimen urine + BOF : Batu yang RadioopaquePielonefritis : Sepsis dan PyuriaKelainan-kelainan lain di dalam rongga abdomen :Ulkus Peptikum- Abcess Hepar pecahCholecytitis - Perforasi Carcinoma ColonPancreatitis- Divertikulitis

Penyakit-penyakit Di Luar Abdomen :PneumoniaPleuritisInfark Myocard

*Penyulit :

Medikamentosa sembuh krisisTimbul penyulit :1.Peri appendicular Infiltrat / PAI) 2.Periappendicular Abcess )3. Appendicitis Perforasi : menimbulkan Peritonitis Generalisata. Sepsis - febris tinggi -Leukosistosis4. Foie Appendiculare : Emboli kuman-kuman lewat sistem porta ke Hepar ---> Mikroabcess-microabcess di Hepar. Penderita Toksis + Icterus. 5. Appendicitis Kronis : Proses keradangan , hilang timbul dalam waktu lama tanpa komplikasi

*Penatalaksanaan :Prinsip : APPENDECTOMY, Persiapan pra bedah :PUASAInfusLab Lengkap , EKG dan Thorax Foto Antibiotika Profilaksis PAI : Bed Rest Posisi Fowler Stadium AFROIDPerforasi (+) : Operasi Explorasi LaparotomyAppendicitis Kronis : Elektif

Pasca Bedah : - Infus s/d Diet oral dimulai- Bising usus(+) - minum- Flatus (+), kembung (-) makanan cair - Fisioterapi atau mobilisasi segera pasca bedah- Perforasi (-) : Antibiotika hanya 1 x 24 jam- Perforasi :(+) Antibiotika 5 hari ( sesuai Kultur kuman )

*Teknik OperasiIncisi kuadran kanan bawah vs garis tengahLigasi ganda ( double ligation )vs jahitan kantung ( Tabaczaacnad ) Terbuka vs laparoskopik

*B Transverse/ Lanz/Bikini/ Rockey DavisJ Anat Soc India 2001;50(2).A McBurney/ Gridiron

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*Ann Emerg Med. 1986 May;15(5):557564.

*KesimpulanAppendisitis sangat umum ditemuiPemeriksaan klinis berperan pentingDiagnosis tertunda & kesalahan diagnosis masih sering terjadi

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*Perawatan Pra dan Pasca BedahAppendisitis

*Puasa Pra PembedahanMenghindari muntah & aspirasi saat induksi anestesiPengosongan lambung dipengaruhi berbagai faktorPuasa makanan padat 6 jam pra bedahAsupan cairan jernih sampai 2 jam pra bedah

*Persiapan operasiSetelah diagnosis tegak & diputuskan operasiAnalgetikaWaspada keseimbangan cairan rehidrasi Penyakit penyertaKadar elektrolit bila ada penyakit penyerta atau perjalanan penyakit lama

*Pemulihan Pasca BedahFase pasca pembedahan & pembiusan awal

Fase intermediet

Fase konvalesensi

*Instruksi pasca bedahMonitoring tanda-tanda vital, balans cairanPenanganan nyeriAsupan oralMobilisasi

*Penderita Tanpa KomplikasiAsupan oral cair dan padat setelah penderita sadar baik. KRS setelah 24-48 jam.

Antibiotika post operasi dan pipa lambung tidak merupakan indikasi rutin.

*Perawatan LukaPenutupan epidermis dalam 48 jamPenutup luka dilepas hari ke-3 atau 4Lepas penutup luka lebih awal jika basah (hindari kontaminasi) atau ada tanda-tanda infeksiAngkat jahitan setelah hari ke-5 & 6 atau jika ada tanda infeksi

*Cairan & ElektrolitKebutuhan dipengaruhi olehKebutuhan maintenancePeningkatan kebutuhan sistemik (demam, kombustio)Produksi drainKebutuhan akibat edema dan ileus (third spacing)

*DrainBertujuan untuk menghindari penumpukan pus, serum dan darahDapat dilepas jika sudah tidak diperlukan, langsung atau bertahap Penrose drain sebaiknya tidak lebih dari 14 hari karena bahan mengeras

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***64% retrosekal. 32% pelvika. 2% retroperitoneal. 1% anteileal. 0,5% retroileal.*Atypical 1 in 4 Hamilton BaileyAtypical 1 in 2 Norman Browse30-45%********SchwartzAbdominal pain is the prime symptom of acute appendicitis. Classically the pain is initially diffusely centered in the lower epigastrium or umbilical area, is moderately severe, and is steady, sometimes with intermittent cramping superimposed. After a period varying from 1to 12 h, but usually within 4 to 6 h, the pain localizes in the right lower quadrant. This classic pain sequence, though usual, is not invariable. In some patients the pain of appendicitis begins in the right lower quadrant and remains there. Variations in the anatomic location of the appendix account for many of the variations in the principal locus of the somatic phase of the pain. For example, a long appendix with the inflamed tip in the left lower quadrant causes pain in that area; a rectrocecal appendix may cause principally flank or back pain; a pelvic appendix, principally suprapubic pain; and a retroileal appendix may cause testicular pain, presumably from irritation of the spermatic artery and ureter. Malrotation is also responsible for puzzling pain patterns. The visceral component is in the normal location, but the somatic component is felt in that part of the abdomen where the cecum has been arrested in rotation.

Anorexia nearly always accompanies appendicitis. It is so constant that the diagnosis should be questioned if the patient is not anorectic. Vomiting occurs in about 75 percent of patients, but is not prominent or prolonged, and most patients vomit only once or twice.

Most patients give a history of obstipation from before the onset of abdominal pain, and many feel that defecation would relieve their abdominal pain. However, diarrhea occurs in some patients, particularly children, so that the pattern of bowel function is of little differential diagnostic value.

The sequence of symptom appearance has great differential diagnostic significance. In over 95 percent of patients with acute appendicitis, anorexia is the first symptom, followed by abdominal pain, which is followed in turn by vomiting (if vomiting occurs). If vomiting precedes the onset of pain, the diagnosis should be questioned.**Sabiston

The diagnosis of acute appendicitis is made primarily on the basis of the history and the physical findings, with additional assistance from laboratory and radiographic examinations. The typical history is one of an onset of generalized abdominal pain followed by

920anorexia and nausea. The pain then becomes most prominent in the epigastrium and gradually moves toward the umbilicus, finally localizing in the right lower quadrant. Vomiting may occur during this time. Examination of the abdomen usually shows diminished bowel sounds, with direct tenderness and muscle spasm in the right lower quadrant. As the process continues, the amount of spasm increases, with the appearance of rebound tenderness. The temperature is usually mildly elevated (approximately 38C) and usually rises to higher levels in the event of perforation, although this is very variable. Direct tenderness is usually present in the right lower quadrant and may involve other parts of the abdomen, particularly if perforation has occurred. The appendix is usually situated at or around McBurney point. However, it must be emphasized that the exact anatomic location of the appendix can be at any point on a 360-degree circle surrounding the base of the cecum. This is the site at which the pain and tenderness are usually maximal, and the exact site can vary from patient to patient. Rovsing sign, which is elicited when pressure applied in the left lower quadrant reflects pain in the right lower quadrant, often is present but not specific. The psoas sign may be positive and is elicited by extension of the right thigh with the patient lying on the left side. As the examiner extends the right thigh with stretching of the muscle, pain suggests the presence of an inflamed appendix overlying the psoas muscle. The obturator sign can be elicited with the patient in the supine position with passive rotation of the flexed right hip. Pain with this maneuver indicates a positive sign. Rectal examination is of little value in establishing the diagnosis of acute appendicitis but can be useful to determine the presence or absence of a mass. [20] If the appendix ruptures, abdominal pain becomes intense and more diffuse, the muscular spasm increases, and there is a simultaneous increase in the heart rate, with a rise in temperature to 39 to 40C. At this time, the patient appears quite ill, and it becomes obvious that the clinical situation has deteriorated. Rarely, there may be a slight diminishing of pain with rupture, presumably due to the decreased distention of the appendix, but a true pain-free interval would be quite uncommon.

****Transverse graded compression transabdominal sonogram of an acutely inflamed appendix. Note the targetlike appearance due to thickened wall and surrounding loculated fluid collection. Sagittal graded compression transabdominal sonogram shows an acutely inflamed appendix. The tubular structure is noncompressible, lacks peristalsis, and measures greater than 6 mm in diameter. A thin rim of periappendiceal fluid is present. *********Classically, the McBurney incision is made at the junction of the middle third and outer thirds of a line running from the umbilicus to the anterior superior iliac spine, the McBurney point (Watts, 1991). However, if palpation reveals a mass, the incision can be placed directly over the mass. McBurney originally placed the incision obliquely, from above laterally to below medially. However, the skin incision can be placed in a skin crease transversely [Rockey-Davis Incision (Fig 4c) or Lanz Incision or Bikini Incision], which provides a better cosmetic result (Delany & Carnevale, 1976; Pleterski & Temple, 1990). Otherwise, the two incisions are similar. ***Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med. 1986 May;15(5):557564. Patients with a score of 1-4 were considered very unlikely to have acute appendicitis and were observed;those patients with a score 5-6 were considered to have a diagnosis compatible with acute appendicitis, but notconvincing enough to warrant appendicectomy and were regularly reviewed; those with a score of 7-8 wereconsidered to have a probable acute appendicitis, and those with a score of 9-10 were considered to have analmost definite acute appendicitis and were submitted to operation. The Alvarado score is dynamic and apatient's score can increase or decrease on reassessment.If after 24 hours observation, regardless of score, patients were thought on clinical reevaluation to require appendicectomy, then this was performed.

Kalan M., Rich A.J., Talbot D., Cunliffe W.J.: Evaluation of the modified Alvarado score in the diagnosis of acute appendicitis: a prospective study. Ann R. Coll. Surg. Engl 1994;76:418-419 **Pada bedah terbuka waktu operasi lebih cepat +/- 20 menit, sedang pada laparoskopi waktu kembali ke makanan padat lebih cepat. Keluaran lain hampir setara. *Komplikasi kelompok laparoskopik adalah perdarahan pasca operasi. Kejadian abses intraabdominal dan infeksi luka tidak berbeda bermakna. ****The recovery from major surgery can be divided into three phases: (1) an immediate, or postanesthetic phase; (2) an intermediate phase, encompassing the hospitalization period; and (3) a convalescent phase. During the first two phases, care is principally directed at maintenance of homeostasis, treatment of pain, and prevention and early detection of complications. The convalescent phase is a transition period from the time of hospital discharge to full recovery. * early complications and death following major surgery are acute pulmonary, cardiovascular, and fluid derangements.*Norton Postop Appendix.In uncomplicated cases, patients may take liquids and solid food as tolerated. Discharge within 24 to 48h. Postop antibiotics and NGT are not routinely indicated. Perforation, abscess or other complications have variable course. Established peritonitis or abscess formation, longer antibiotics 5-7 days post op.

Postoperative Care of the Gastrointestinal Tract (Current)Following laparotomy, gastrointestinal peristalsis temporarily decreases. Peristalsis returns in the small intestine within 24 hours, but gastric peristalsis returns more slowly. Function returns in the right colon by 48 hours and in the left colon by 72 hours. After operations on the stomach and upper intestine, propulsive activity of the upper gut remains disorganized for 3-4 days. In the immediate postoperative period, the stomach may be decompressed with a nasogastric tube. Nasogastric intubation was once used in almost all patients undergoing laparotomy to avoid gastric distention and vomiting, but it is now recognized that routine nasogastric intubation is unnecessary and may cause postoperative atelectasis and pneumonia. For example, following cholecystectomy, pelvic operations, and colonic resections, nasogastric intubation is not needed in the average patient, and it is probably of marginal benefit following operations on the small bowel. On the other hand, nasogastric intubation is probably useful after esophageal and gastric resections and should always be used in patients with marked ileus or a very low level of consciousness (to avoid aspiration) and in patients who manifest acute gastric distention or vomiting postoperatively.

The nasogastric tube should be connected to low intermittent suction and irrigated frequently to ensure patency. The tube should be left in place for 2-3 days or until there is evidence that normal peristalsis has returned (eg, return of appetite, audible peristalsis, or passage of flatus). The nasogastric tube enhances gastroesophageal reflux, and if it is clamped overnight for assessment of residual volume, there is a slight risk of aspiration.

Once the nasogastric tube has been withdrawn, fasting is usually continued for another 24 hours, and the patient is then started on a liquid diet. Opioids may interfere with gastric motility and should be stopped in patients who have evidence of gastroparesis beyond the first postoperative week.

Gastrostomy and jejunostomy tubes should be connected to low intermittent suction or dependent drainage for the first 24 hours after surgery. Absorption of nutrients and fluids by the small intestine is not affected by laparotomy, and enteral nutrition through a jejunostomy feeding tube may therefore be started on the second postoperative day even if motility is not entirely normal. Gastrostomy or jejunostomy tubes should not be removed before the third postoperative week, because firm adhesions should be allowed to develop between the viscera and the parietal peritoneum.

After most operations in areas other than the peritoneal cavity, the patient may be allowed to resume a regular diet as soon as the effects of anesthesia have completely worn off. ** (1) maintenance requirements, (2) extra needs resulting from systemic factors (eg, fever, burns), (3) losses from drains, and (4) requirements resulting from tissue edema and ileus (third space losses). Daily maintenance requirements for sensible and insensible loss in the adult are about 1500- 2500 mL depending on the patient's age, sex, weight, and body surface area. A rough estimate can be obtained by multiplying the patient's weight in kilograms times 30 (eg, 1800 mL/24 h in a 60-kg patient). Maintenance requirements are increased by fever, hyperventilation, and conditions that increase the catabolic rate. **