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

INTRODUCTION

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

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%)

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)

Differential diagnosis of acute appendicitis

Surgical
Acute Intestinal obstruction

Urological
Right ureteric colic

Intussusception

Right pyelonephritis

Acute cholecystitis

Urinary tract infection

Perforated peptic ulcer

Right Acute epididymitis

Mesenteric adenitis

Gynaecological

Acute Meckel's diverticulitis

Acute Pancreatitis

Medical
Gastroenteritis
Basal Pneumonia dextra
Terminal ileitis

Ectopic pregnancy

Ruptured ovarian follicle

Torted ovarian cyst

Salpingitis/pelvic inflammatory
disease

Differential diagnosis of appendicitis appendicitis

can mimic several abdominal conditions.

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

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 C
Higher fevers are associated with a perforated
appendix

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

Location appendix during

pregnancy

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.

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

Sonography
Advantages of sonography
1.Noninvasiveness,
2.Short acquisition time
3.Lack of radiation exposure
4.Potential for diagnosis of
other causes of abdominal
pain
5.Pediatric patients
6.Women of childbearing
age.
7.Pregnant women

normal less than 6 mm

CT scan
-Oral contrast medium
-Rectal Gastrografin
enema
Reserved for patients
-Uncertain diagnosis
-Severe obesity.

more than 6 mm

Complications

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

TREATMENT
Medical therapy
Resuscitated adequately with fluids .
Preoperative prophylactic antibiotics
-Acute Appendicitis single agent secondgeneration 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

Two approaches to appendectomy

1.Open Emergency Appendicectomy ( Appendectomy)
2.Laparoscopic appendectomy
If normal appendix removed need to look for:
-

Meckel's diverticulum

- Acute salpingitis
- Crohn's disease

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.

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 10-14 days.
Traditionally, interval appendectomy is performed 6-8
weeks later.

Appendicitis
Perforation