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1. Mengapa perut nyeri ketika disentuh?

Initial luminal distention triggers visceral afferent pain fibers, which enter at the 10th

thoracic vertebral level.

This pain is generally vague and poorly localized.

Pain is typically felt in the periumbilical or epigastric area

As inflammation continues, the serosa and adjacent structures become inflamed

This triggers somatic pain fibers, innervating the peritoneal structures.

Typically causing pain in the RLQ

The change in stimulation form visceral to somatic pain fibers explains the classic migration of pain

in the periumbilical area to the RLQ seen with acute appendicitis

2. Macam- macam nyeri abdomen

There are three different types of abdominal pain: visceral pain, parietal pain and referred pain.

The type of pain varies depending on the organ involved.

Visceral Pain

Visceral pain is directly related to the organ involved. The majority of organs do not have an

abundance of nerve fibers, so the patient might experience mild or less severe pain that is poorly

localized. Its important to understand this does not mean the patient is experiencing a mild or

less severe condition.

Characteristics:

Less severe pain

Poorly localized

The pain is usually dull or aching and constant or intermittent

Parietal Pain

Parietal pain occurs when there is an irritation of the peritoneal lining. The peritoneum has a

higher number of sensitive nerve fibers, so the pain is generally more severe and easier to

localize. The patient will typically present in a guarded position with shallow breathing. This

minimizes the stretch of the abdominal muscles and limits the downward movement of the

diaphragm, which reduces pressure on the peritoneum and helps ease the pain.

Characteristics:

More severe pain

Easily localized

The pain is usually sharp, constant and on one side or the other

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Referred Pain

Referred pain is visceral pain that is felt in another area of the body and occurs when organs

share a common nerve pathway. For this reason, it is poorly localized but generally constant in

nature. An example is a patient with liver problems that experiences referred pain in the neck orjust below the scapula.

Characteristics:

Poorly localized

The pain is usually constant

3. Mengapa nyerinya dijalarkan dari umbilicus ke inguinal kanan?

Initial luminal distention triggers visceral afferent pain fibers, which enter at the 10th

thoracic vertebral level.

This pain is generally vague and poorly localized.

Pain is typically felt in the periumbilical or epigastric area

As inflammation continues, the serosa and adjacent structures become inflamed

This triggers somatic pain fibers, innervating the peritoneal structures.

Typically causing pain in the RLQ

The change in stimulation form visceral to somatic pain fibers explains the classic migration of pain

in the periumbilical area to the RLQ seen with acute appendicitis

4. Mengapa jalannya bungkuk ke kanan dan kaki kanan melipat ke atas?

Psoas

sign

Pain on hyperextension of right thigh (often indicates retroperitoneal

retrocecal appendix)

So, if the appendicitis locate on retrocaecal, thats why when patient do flexion of right thigh, it will

make the m. psoas being relaxed and not touch the appendix which have an inflammation on it

5. Mengapa disertai muntah mual dan nafsu makan menghilang?

6. Mengapa demam semakin meninggi sejak 6 jam yang lalu?

7. Interpretasi dari pemeriksaan fisik ?

8. Apa DD (etiologic, patofisiologi, factor resiko, komplikasi, pemeriksaan, penatalaksanaan)

What causes appendicitis?

An obstruction, or blockage, of the appendiceal lumen causes appendicitis. Mucus backs up in the

appendiceal lumen, causing bacteria that normally live inside the appendix to multiply. As a result, the

appendix swells and becomes infected. Sources of blockage include

stool, parasites, or growths that clog the appendiceal lumen

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enlarged lymph tissue in the wall of the appendix, caused by infection in the GI tract or elsewhere

in the body

inflammatory bowel disease (IBD), which includes Crohns disease and ulcerative colitis, long-

lasting disorders that cause irritation and ulcers in the GI tract

trauma to the abdomen

An inflamed appendix will likely burst if not removed.

PATOFISIOLOGI

PATHOPHYSIOLOGY: APPENDICITIS

tumor foreign body fecal mass stricture infection

fecal movement in the earlier parts of the colon

tension

continues movement of new

materials down the digestive tract

fecal im action

backflow pressure

reaches the appendix

irritation

blood flow immune response

aggravation of

condition

imflammation edema fever pain

mass stretching of lumen

APPENDICITIS

ru ture

release of fecal materias in the abdominal cavit

reaches the eritoneum

immune res onse

PERITONITIS

a endectom

(+) abdominal incision

(McBurney)

o erative site cecum

Immune response

(WBC on the site)

inflammation ain fever risk for infection

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How is appendicitis diagnosed?A health care provider can diagnose most cases of appendicitis by taking a persons medical history

and performing a physical exam.

If a person does not have the usual symptoms, health care providers may use laboratory and imaging

tests to confirm appendicitis. These tests also may help diagnose appendicitis in people who cannot

adequately describe their symptoms, such as children or people who are mentally impaired.

Medical History

The health care provider will ask specific questions about symptoms and health history. Answers to

these questions will help rule out other conditions. The health care provider will want to know

when the abdominal pain began

the exact location and severity of the pain when other symptoms appeared

other medical conditions, previous illnesses, and surgical procedures

whether the person uses medications, alcohol, or illegal drugs

Physical Exam

Details about the persons abdominal pain are key to diagnosing appendicitis. The health care

provider will assess the pain by touching or applying pressure to specific areas of the abdomen.

Responses that may indicate appendicitis include

Rovsings sign.A health care provider tests for Rovsings sign by applying hand pressure to the

lower left side of the abdomen. Pain felt on the lower right side of the abdomen upon the release

of pressure on the left side indicates the presence of Rovsings sign.

Psoas sign.The right psoas muscle runs over the pelvis near the appendix. Flexing this muscle

will cause abdominal pain if the appendix is inflamed. A health care provider can check for the

psoas sign by applying resistance to the right knee as the patient tries to lift the right thigh while

lying down.

Obturator sign.The right obturator muscle also runs near the appendix. A health care provider

tests for the obturator sign by asking the patient to lie down with the right leg bent at the knee.

Moving the bent knee left and right requires flexing the obturator muscle and will cause

abdominal pain if the appendix is inflamed.

Guarding.Guarding occurs when a person subconsciously tenses the abdominal muscles during

an exam. Voluntary guarding occurs the moment the health care providers hand touches the

abdomen. Involuntary guarding occurs before the health care provider actually makes contact

and is a sign the appendix is inflamed.

Rebound tenderness.A health care provider tests for rebound tenderness by applying hand

pressure to a persons lower right abdomen and then letting go. Pain felt upon the release of the

pressure indicates rebound tenderness and is a sign the appendix is inflamed. A person may

also experience rebound tenderness as pain when the abdomen is jarredfor example, when a

person bumps into something or goes over a bump in a car.

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Women of childbearing age may be asked to undergo a pelvic exam to rule out gynecological

conditions, which sometimes cause abdominal pain similar to appendicitis.

The health care provider also may examine the rectum, which can be tender from appendicitis.

Laboratory Tests

Laboratory tests can help confirm the diagnosis of appendicitis or find other causes of abdominal

pain.

Blood tests.A blood test involves drawing a persons blood at a health care providers office or a

commercial facility and sending the sample to a laboratory for analysis. Blood tests can show

signs of infection, such as a high white blood cell count. Blood tests also may show dehydration

or fluid and electrolyte imbalances. Electrolytes are chemicals in the body fluids, including

sodium, potassium, magnesium, and chloride.

Urinalysis.Urinalysis is testing of a urine sample. The urine sample is collected in a special

container in a health care providers office, a commercial facility, or a hospital and can be tested

in the same location or sent to a laboratory for analysis. Urinalysis is used to rule out a urinary

tract infection or a kidney stone.

Pregnancy test.Health care providers also may order a pregnancy test for women, which can

be done through a blood or urine test.

Imaging Tests

Imaging tests can confirm the diagnosis of appendicitis or find other causes of abdominal pain.

Abdominal ultrasound.Ultrasound uses a device, called a transducer, that bounces safe,

painless sound waves off organs to create an image of their structure. The transducer can be

moved to different angles to make it possible to examine different organs. In abdominal

ultrasound, the health care provider applies gel to the patients abdomen and moves a hand-held

transducer over the skin. The gel allows the transducer to glide easily, and it improves the

transmission of the signals. The procedure is performed in a health care providers office, an

outpatient center, or a hospital by a specially trained technician, and the images are interpretedby a radiologista doctor who specializes in medical imaging; anesthesia is not needed.

Abdominal ultrasound creates images of the appendix and can show signs of inflammation, a

burst appendix, a blockage in the appendiceal lumen, and other sources of abdominal pain.

Ultrasound is the first imaging test performed for suspected appendicitis in infants, children,

young adults, and pregnant women.

Magnetic resonance imaging (MRI).MRI machines use radio waves and magnets to produce

detailed pictures of the bodys internal organs and soft tissues without using xrays. The

procedure is performed in an outpatient center or a hospital by a specially trained technician, and

the images are interpreted by a radiologist. Anesthesia is not needed, though children and

people with a fear of confined spaces may receive light sedation, taken by mouth. An MRI mayinclude the injection of special dye, called contrast medium. With most MRI machines, the person

lies on a table that slides into a tunnel-shaped device that may be open ended or closed at one

end; some machines are designed to allow the person to lie in a more open space. An MRI can

show signs of inflammation, a burst appendix, a blockage in the appendiceal lumen, and other

sources of abdominal pain. An MRI used to diagnose appendicitis and other sources of

abdominal pain is a safe, reliable alternative to a computerized tomography (CT) scan.2

CT scan.CT scans use a combination of x rays and computer technology to create three-

dimensional (3-D) images. For a CT scan, the person may be given a solution to drink and an

injection of contrast medium. CT scans require the person to lie on a table that slides into a

tunnel-shaped device where the x rays are taken. The procedure is performed in an outpatientcenter or a hospital by an x-ray technician, and the images are interpreted by a radiologist;

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anesthesia is not needed. Children may be given a sedative to help them fall asleep for the test.

A CT scan of the abdomen can show signs of inflammation, such as an enlarged appendix or an

abscessa pus-filled mass that results from the bodys attempt to keep an infection from

spreadingand other sources of abdominal pain, such as a burst appendix and a blockage in the

appendiceal lumen. Women of childbearing age should have a pregnancy test before undergoing

a CT scan. The radiation used in CT scans can be harmful to a developing fetus.2Heverhagen J, Pfestroff K, Heverhagen A, Klose K, Kessler K, Sitter H. Diagnostic accuracy of

magnetic resonance imaging: a prospective evaluation of patients with suspected appendicitis

(diamond). Journal of Magnetic Resonance Imaging. 2012;35:617623.

Common Signs of Acute Appendicitis

SIGN DESCRIPTION

McBurney sign Localized right lower quadrant pain or guarding on palpation of the

abdomen (the single most important sign)

Psoas sign Pain on hyperextension of right thigh (often indicates retroperitoneal

retrocecal appendix)

Obturator sign Pain on internal rotation of right thigh (pelvic appendix)

Rovsing sign Pain in the right lower quadrant with palpation of the left lower quadrant

Dunphys sign Increased pain in the right lower quadrant with coughing

Hip flexion Patient maintains hip flexion with knees drawn up for comfort

Other peritoneal

signs

Rebound tenderness, hyperesthesia of the skin in the right lower quadrant

NOTE:The absence of these signs does not exclude appendicitis.

Information from references8,9,and15.

Prevalence of Common Signs and Symptoms of Appendicitis

SIGN OR SYMPTOM FREQUENCY (%)

Abdominal pain 99 to 100

Right lower quadrant pain or tenderness 96

Anorexia 24 to 99

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SIGN OR SYMPTOM FREQUENCY (%)

Nausea 62 to 90

Low-grade fever 67 to 69

Vomiting 32 to 75

Pain migration from periumbilical area to the right lower quadrant 50

Rebound tenderness 26

Right lower quadrant guarding 21

Information from references6and11.

How is appendicitis treated?

Appendicitis is typically treated with surgery to remove the appendix. The surgery is performed in a

hospital; general anesthesia is needed. If appendicitis is suspected, especially in patients who have

persistent abdominal pain and fever, or signs of a burst appendix and infection, a health care provider

will often suggest surgery without conducting diagnostic testing. Prompt surgery decreases the

chance that the appendix will burst.

Surgery to remove the appendix is called an appendectomy. A surgeon performs the surgery using

one of the following methods:

Laparotomy.Laparotomy removes the appendix through a single incision in the lower right area

of the abdomen.

Laparoscopic surgery.Laparoscopic surgery uses several smaller incisions and special

surgical tools fed through the incisions to remove the appendix. Laparoscopic surgery leads to

fewer complications, such as hospital-related infections, and has a shorter recovery time.

With adequate care, most people recover from appendicitis and do not need to make changes to diet,

exercise, or lifestyle. Surgeons recommend limiting physical activity for the first 10 to 14 days after a

laparotomy and for the first 3 to 5 days after laparoscopic surgery.

[Top]

The treatment of appendicitis:-

The treatment can be summed up in one word - Appendicectomy.

Appendicectomy:-

In early cases the operation is straightforward. An incision is made overMcBurney's point. McBurney's point is centred along a line joining the

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umbilicus with the anterior superior iliac spine. It is situated at a point 2/3ofthe way along this line - rather closer to the iliac spine than to theumbilicus.

An oblique incision is made centred over this point, and slopes downwardsand inwards, not quite parallel with the more horizontal skin creases. Theincision is taken down to the aponeurosis of the external oblique muscle.

The external oblique muscle is then split in the line of its fibresfor about tencentimetres. This can be made easier if the fascia over it is lightly incised

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with a scalpel before the splitting is completed with straight dissectingscissors.

The internal oblique muscle is then likewise split in the line of its fibres,again for about ten centimetres. It may be found to lie at a different anglefrom the external oblique, and again lightly incising the fascia over themuscle before it is split will help in showing where the split will be made.

Deepen the split with the points of the scissors, but by spreading the

pointsrather than by cutting in the usual way. By this means you are lesslikely to do deep damage. You may find that you have already split thetransversus abdominis muscle together with the internal oblique, but if youhave not, repeat the process with this final muscular layer to expose theperitoneum.

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When you have exposed the peritoneum, sweep it away from the overlyingmuscles with your fingers beforeopening it. This will make it easier to closeit when the time comes. Otherwise it is stuck to the overlying muscles.

Opening the peritoneum is done between two artery forceps in the usualway. Have a sucker to hand in case there is any free fluid, and if you havebacteriology, keep some for culture and sensitivity. Now it will be your jobto find the appendix. This may be done by trying to identify the caecumwhich is probably lateral to your incision.

If you find small bowel, tuck it back into the abdomen, but if you find bowelthat you think may be caecum, check that it has the typical taeniae orlongitudinal muscular bands that are characteristic of large bowel. Onceyou have identified a taeniae, that is the time to trace it down to where itmeets the other two taeniae on the caecum. At the point where the threetaeniae meet you will find the base of the appendix.

You may, if you are lucky, be able to "hook up" the appendix with yourfinger if it is lying medially or hanging down over the brim of the pelvis.Even if it is normal, you would probably be wise to remove it, because anyfuture surgeon looking at your incision will probably conclude that there isno appendix now, and if you had left it in, he could be making a fatalmistake! If the appendix that you find is swollen, covered with fibrinous orpurulent tags, discoloured, gangrenous or perforated youshould certainlyremove it!

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The appendix can be taken out retrograde or in the normal fashion. Thenormal fashion is to clamp the meso-appendix and divide it betweenclamps or between ligatures, and then to apply two clamps to the base ofthe appendix. The one nearest the caecum is removed, and a No. 1chromic catgut ligature is tied round where the clamp had been.

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The stump of the appendix is then cut through between that tie and theother clamp, and then is buried in a purse string suture. This step isnecessary, whatever you may have been taught, to prevent the rare butunfortunate development of a faecal fistula if the tie cuts through the baseof the appendix. "Retrograde removal" of the appendix can be done if the

base of the appendix is visible but the rest of the organ is hidden and lyingretrocaecally. To do this, you divide the base of the appendix and

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invaginate the stump in a purse string as before, and then, holding theappendix in the other clamp, the appendix is located by burrowing with yourfinger along it, so that the meso-appendix can be identified, ligated anddivided bit by bit until the whole of the appendix has been removed.

What do you do when the appendix is lying retrocaecally and you cannotreach it at all? It can be particularly difficult when you are in an isolatedhospital where relaxant anaesthesia is unavailable and when the usualgrid- iron incision was used (as described above). The answer is not foundin many standard textbooks. It is a muscle-cutting incision. Instead ofsplitting the muscles, layer by layer, in the line of their fibres, a longerMcBurney incision is made, and the muscles are cut (using a scalpel, notscissors) in the line of the skin incisionall the way down to the peritoneum.This incision can be extended laterally very far if necessary (indeed it canbe used for nephrectomy). It can also be extended medially as far as theedge of the rectus abdominis muscle. If further medial extension is needed,the rectus muscle canbe cut, but that is a bit untidy, and it is usually

sufficient to curve the incision down parallel to the edge of the rectus, andto displace the rectus medially with a retractor.

Once you have this extended incision, you will be able to see a great dealmore than with the grid-iron incision. If the appendix is lying retrocaecally,you can incise the peritoneal reflection on the lateral side of the caecum,and then lift the caecum, displacing it medially until you can see the wholeof its underside, and with blunt finger dissection, strip the appendix awayfrom it until you have sufficient exposure to complete the appendicectomy.

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Drainage is only necessary if you have opened an abscess cavity, in whichcase a corrugated rubber drain at least three cm. wide should be used, andshould be brought out through a separateskin incision away from theoriginal incision. This separate incision should easily admit two fingers sideby side, and if it is too tight, should be enlarged by cutting with a scalpel.Otherwise it will contract around the drain preventing rather thanencouraging the drainage of pus.

Closure is easy if you have done a grid-iron incision. You just need onesuture for the peritoneum, and a few catgut sutures to approximate themuscle layers. Nylon will do for the skin. If however you have done amuscle-cutting incision, or enlarged a grid-iron incision into the musclecutting one, it is probably better to close the incision with interrupted wire(or nylon) sutures that go through the peritoneum and all the muscle layersin one, rather than suture each layer separately.

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The Appendix Mass - a special case

The only situation when it may prove wiser to delay appendicectomy for abit is the rare case when there is an appendix mass that seems to besettling. Nearly always the history will support the diagnosis, and it will beclear that the patient has clearly had appendicitis, and that the condition issettling (often without antibiotics). The pain is settling, the patient will tellyou, and examination reveals a fit patient with no pyrexia (and therefore noabscess!), no signs of peritonitis, and no mass felt per rectum. This is anunusual situation, and clearly the inflammatory process has walled itself offand no pus has accumulated. How should such a patient be treated?

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Immediate appendicectomy is a good treatment for such a patient, but itmust be admitted that the operation will be a difficult one, although notimpossible for an experienced surgeon. But the inflammation issettlingdown, and the improvement is not due to antibiotics because the patient is

not on antibiotics. (If the patient ison antibiotics, then decision making isquite difficult, because the antibiotics may well be masking the signs ofserious complications). However, if the condition isundergoing resolution,why not let it resolve and thentake the appendix out?

What to do:- Admit the patient. Forbid antibiotics if the patient is not alreadyon them, so that if complications do develop they will not be masked. If thepatient is already on them, you may have tocontinue them. Forbidaperients, which might cause perforation, and likewise forbid enemas atthis stage. With a ball-point pen or something similar, draw the outline of

the mass on the skin so that you can trace the progress from day to day.You will have to examine the patient at least once daily, and check that themass is getting smaller. Success will be marked by the pain disappearing,the temperature remaining normal, the appetite coming back, and theabdomen becoming soft and normal again. If this occurs, then book the

patient for interval appendicectomy in exactly six weeks. Six weeks is justright for adhesions to have disappeared, and it is unlikely that appendicitiswill recur before then. If you leave it longer, that chance increases, and theeventual operation may become tricky.

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What are the complications and treatment of a burst appendix?

A burst appendix spreads infection throughout the abdomena potentially dangerous condition called

peritonitis. A person with peritonitis may be extremely ill and have nausea, vomiting, fever, and severe

abdominal tenderness. This condition requires immediate surgery through laparotomy to clean the

abdominal cavity and remove the appendix. Without prompt treatment, peritonitis can cause death.

Sometimes an abscess forms around a burst appendixcalled an appendiceal abscess. A surgeon

may drain the pus from the abscess during surgery or, more commonly, before surgery. To drain an

abscess, a tube is placed in the abscess through the abdominal wall. The drainage tube is left in

place for about 2 weeks while antibiotics are given to treat infection. Six to 8 weeks later, wheninfection and inflammation are under control, surgeons operate to remove what remains of the burst

appendix.

Hasil Pemeriksaan Fisik dan Penunjang Sederhana (Objective)

Pemeriksaan Fisik

Inspeksi Penderita berjalan membungkuk sambil memegangi perutnya yang sakit, kembung (+) bila

terjadi perforasi, penonjolan perut kanan bawah terlihat pada appendikuler abses.

Palpasi 1. Terdapat nyeri tekan Mc.Burney 2. Adanya rebound tenderness (nyeri lepas tekan) 3.Adanya defens muscular. 4. Rovsing sign positif 5. Psoas sign positif 6. Obturator Sign positif

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Perkusi Nyeri ketok (+)

Auskultasi

Peristaltik normal, peristaltik(-) pada illeus paralitik karena peritonitis generalisata akibat

appendisitis perforata. Auskultasi tidak banyak membantu dalam menegakkan diagnosis apendisitis,

tetapi kalau sudah terjadi peritonitis maka tidak terdengar bunyi peristaltik usus.

Rectal Toucher / Colok dubur Nyeri tekan pada jam 9-12 Tanda Peritonitis umum (perforasi) : 1.

Nyeri seluruh abdomen 2. Pekak hati hilang 3. Bising usus hilang

Apendiks yang mengalami gangren atau perforasi lebih sering terjadi dengan gejala-gejala sebagai

berikut: a. Gejala progresif dengan durasi lebih dari 36 jam b. Demam tinggi lebih dari 38,50C c.

Lekositosis (AL lebih dari 14.000) d. Dehidrasi dan asidosis e. Distensi f. Menghilangnya bising usus g.

Nyeri tekan kuadran kanan bawah h. Rebound tenderness sign i. Rovsing sign j. Nyeri tekan seluruh

lapangan abdominal