CASE PRESENTATION

I. IDENTITY Name Sex Age : Mr. S : Male : 25 years

Religion : Islam Address : Kedung Bunder Date of admission : 23rd April 2012

II. ANAMNESIS Chief complain Pain on the lower right stomach worsening since a days before admitted into RS arjawinangun. Present Illness history Patient came with pain on the lower right stomach worsening since a days before admitted into RS Arjawinangun. Pain started since a week ago. Pain begins in the middle area of stomach and 1 day ago move to the lower right. Patient didnt have any nausea, vomiting or fever before admitted. Patien also said that he didnt have any cough or flu. Defecation and Urination normal, with no pain nor differences in color and consistency. Past Illness history Patient never felt pain like this before Hipertension history denied DM history denied Asthma history denied

1|Page

III. PHYSICAL EXAMINATION General State Consciousness: compos mentis Vital Sign Blood Pressure : 130/80 mmHg

Temperature : 36,5 C Pulse : 94/ mnt

Respiratory Rate : 22/ mnt Head : normochepali Eye : pupil round and isochor. SI (-/-) . CA (-/-). DRL (+/+). Thoraks : Torax symmetric. Lung resonant. Breath sound vesicular with no added sound. Cardiovascular : good S1,S2, no murmur, no gallop. Abdomen : see Localis state Ekstremities : warm, no edema

Localis state Tenderness on palpation right lower quadrant, especially in Mc Burney point. Rebound tenderness (+) right lower quadrant Blumbergs sign (+) Rovsings sign (+) Bowel sound (+)

IV. SUPPORTING EXAMINATION Laboratory studies : 23rd April 2012 Hematocrite Hemoglobin Leukocyte count : 42,2 % : 13,6 gr/dL : 11.700 /L

Trombocyte count : 300.000 /L GDS Ureum Creatinin : 129 g/dl : 23,7 : 0,83
2|Page

Urine acid SGOT SGPT

: 2,71 : 37 : 61

V. WORKING DIAGNOSIS Appendictis Infiltrate

VI. MANAGEMENT Cefoperazon 2 x 1 Tramadol 2 x 1 Ranitidin 2 x 1

3|Page

APPENDICITIS INFILTRATES
Anatomy Appendix is a lymphoid organ such as the tonsils, the payer patch (analogous to the Stock Fabricus) form immunoglobulin products, tube-shaped, length about 10 cm (range 3-15 cm) in diameter and 0.5 to 1 cm, and originate in the cecum. Lumen narrow at the proximal and dilated appendix section distal. Base is located on the postero medial caecum, ileocaecal valve at the bottom. Taenia caecum meets on the third base of the appendix. Appendix vermiformis supported by mesoapendiks (mesenteriolum) who joined the small bowel mesentery to the ileum terminale. Mesenteriolum contains a. Appendicular (a.ileocolica branch).

Orificium located 2.5 cm from the ileocecal valve. Mesoapendix is a fatty tissue that has the appendiceal vessels and sometimes also have a small lymph node. Structure similar to the appendix has four layers, namely the intestinal mucosa, submucosa, muscularis externa / propria (longitudinal and circular muscle) and the serous. Between the mucosa and submucosa are lymphonodus. The mucosa consists of a single layer of epithelium collumnar and consists of a sac called crypta lieberkuhn. In the same wall and is associated with the cecum (inner circular layer). Outer wall (outer longitudinal muscle) is covered by the third meeting at the meeting colli Taenia caecum and appendix. Taenia anterior used as a handle to find appendix.

4|Page

Parasympathetic innervation comes from the following branches n.vagus a.mesenterika a.apendikularis superior and, while sympathetic innervation from n.torakalis. Therefore, the visceral pain of appendicitis begins around the umbilicus. Bleeding from the appendix a. which is the appendicular artery without collateral. If the artery is blocked, such as thrombosis of the infection, the appendix will have gangrene.

Physiology Appendix produces mucus 1-2 ml per day. Mucus in the mouth of the appendix seems to play a role in the pathogenesis of apendisitis. Sekretoar immunoglobulin produced by Galt (Gutassociated lymphoid tissue) located along the gastrointestinal tract, including appendices, is IgA. Immunoglobulin is very effective as a protection against infection. However, the removal of the appendix does not affect the body's immune system because of the number of network nodes so small here compared to the numbers in the gastrointestinal tract and throughout body. Lymphoid tissue in the appendix first appeared about 2 weeks after birth. Number increased during puberty, and settled at maturity and then decreases following the age. After the age of 60 years, no longer in the appendix lymphoid tissue and place a complete destruction of the appendix lumen.

Definitions Appendix infiltrate is the inflammation process of appendicitis, the spread can be limited by the omentum and the intestines and peritoneum around it to form a mass (appendiceal mass). Appendix mass is generally formed on day 4, since the inflammation begins to occur when no general peritonitis. The mass of the appendix is more often found in patients aged five years or more because the immune system has progressed well and the omentum was long and thick enough to wrap the inflamation.

Etiology Obstruction of the lumen is a major cause of appendicitis. Fekalit a common cause of obstruction of the appendix. Other causes hypertrophy of lymphoid tissue, the remainder of the barium x-ray examination, low-fiber diet, and helminth infections, including Ascaris. Trauma due to blunt trauma or colonoscopy can trigger inflammation in the appendix. Post appendicitis
5|Page

operation can also be a cause as a result of trauma or fecal stasis. Frequency of obstruction increased with worsening of the inflammatory process. Fekalit found in 40% of cases of acute appendicitis, about 65% was gangrenous appendicitis without rupture and about 90% of cases of gangrenous appendicitis with rupture. Another cause of appendicitis is suspected to cause mucosal erosion due to parasites such as appendix E. Histolytica. Epidemiological studies indicate the role of eating foods low in fiber and constipation effect on the incidence of appendicitis. Intrasekal constipation will increase the pressure, which cause a functional obstruction appendix and colon increased growth of normal flora bacteria. Everything will facilitate apendisits acute.

Pathophysiology Appendicitis is usually caused by blockage of the lumen of the appendix by lymphoid follicle hyperplasia, fekalit, foreign bodies, strictures due to fibrosis from previous inflammation, or neoplasm. Closed lumen obstruction caused by obstacles on the proximal and continues to increase in the normal secretion of the distended appendix mucosa. The obstruction of mucus produced by mucous cause suffered dam. More and more mucus is, but the elasticity of the wall of the appendix has limitations that lead to increased intraluminal. Normal appendix lumen capacity is only about 0.1 ml. If the secretion of 0.5 could increase pressure intalumen about 60 cmH20. Humans are one of the few animals that can compensate for the increased secretion of a high enough that it becomes gangrene or occur perforation. The increased pressure will cause the appendix to experience hypoxia, inhibiting the flow of lymph, mucosal ulceration and bacterial invasion. The infection causes swelling of the appendix increased (edema) and more ischemic due to thrombosis of intramural blood vessels (wall of the appendix). At this moment there are focal acute appendicitis is characterized by epigastric pain. Gangrene and perforation can occur in a typical 24-36 hours, but times may vary because each patient is determined to many factors. When mucus secretion continues, the pressure will continue to increase. This will cause venous obstruction, edema increased, and the bacteria will penetrate the wall. Inflammation of the peritoneum arising widespread local and giving rise to the lower right area of pain. This is called the suppurative appendicitis acute. If then disrupted arterial wall infarction appendix will

6|Page

be followed by gangrene. This stage is called appendicitis gangrenosa. When the walls that have been fragile rupture, there will be perforated appendicitis. When all of the above process is slow, omentum and the adjacent bowel will move towards an appendix to the arising of a local mob called appendicular infiltrate. Inflammation of the appendix may be an abscess or disappear. Appendicular infiltrate the pathological stage of appendicitis that began at mucosa and involve all layers of the wall of the appendix in the first 24-48 hours, this is the body's defenses attempt to limit the inflammatory process by closing the appendix to the omentum, small intestine, or adnexal masses, forming periapendikular. Tissue necrosis can occur there in the form of an abscess that can be perforated. If not formed an abscess, appendicitis will heal and calm the masses periapendikular will be henceforth would unravel itself slowly. In children, due to shorter omentum and appendix are longer, thinner wall of the appendix. The situation is coupled with the immune system is lacking facilitate the occurrence of perforation. Whereas in older people perforation easily occurs because there has been vascular blood disruption. Inflamed appendix will not ever recover completely, but will form scar tissue that causes adhesions to the surrounding tissue. These adhesions can lead to complaints over the lower right belly. At one time this organ can be acutely inflamed again and found to have acute exacerbations.

The clinical manifestations Infiltrates appendicitis acute appendicitis was preceded by a complaint which is then accompanied by a mass periapendikular. Classic symptoms of acute appendicitis usually begins with pain in the area of the umbilicus or periumbilikus associated with vomiting. Within 2-12 hours the pain switch to right quadrant, which will persist and exacerbated when walking or coughing. There are also complaints of anorexia, malaise, and fever are not very high. Usually there is also constipation but sometimes diarrhea, nausea and vomiting. At the beginning of the onset of the disease there is no persistent abdominal complaint. But within a few hours of right lower abdominal pain will be more progressive. Acute appendicitis is often performed with typical symptoms based on the sudden inflammation of the appendix that gives the local signs, accompanied or not accompanied by stimulation of local peritoneum. Generally decreased appetite. In a few hours the pain will move
7|Page

to the lower right to the point McBurney. Here pain is felt more sharply and more clearly the location so it is a local somatic. Sometimes there is no epigastric pain but there is constipation, so people feel the need for laxatives. The move is considered dangerous because it could facilitate the occurrence of perforation. If there is a stimulation of the peritoneum of patients usually complain of abdominal pain when walking or coughing. Symptoms of acute appendicitis in children is not specific. Early symptoms are often just fussy and would not eat. Children often can not describe the pain within a few hours later there will be vomiting and the child will become weak and lethargic. Because symptoms were not typical, often known appendicitis after perforation. Symptoms in the elderly are often vague, often late diagnosis. As a result, more than half of new cases can be diagnosed after perforation. In pregnancy, the main complaint of appendicitis is abdominal pain, nausea, and vomiting. Noteworthy is that, in the first trimester of pregnancy are nausea and vomiting also occur. In a pregnancy with an appendix cecum pushed to craniolateral so the complaints are not felt in the lower right abdomen, but more to the right lumbar region. The pain started in the epigastrium or umbilical region accompanied by nausea and anorexia move to the lower right pain and showed signs of local peritoneal stimulation in McBurney's point tenderness pain off defans muscular pain stimulated indirectly peritoneum tenderness under the pressure of the left (Rovsing) the lower right pain when pressure is released on the left (Blumberg) the lower right pain when the peritoneum moves such as deep breathing, walking, coughing, straining

Inspection Physical examination Fever when the temperature is usually mild, with temperatures of about 37.5 to 38.5, perhaps perforation has occurred. The temperature difference may exist On inspection found no aksilar stomach and rectal up a specific image. Bloating is often seen in patients with complications of perforation. Infiltrates or abscesses of appendicitis appendicular seen with the protrusion on the lower right abdomen. Pain on palpation of the limited available right iliac region, accompanied by pain can be separated. Defans muscular stimulation showed parietale peritoneum. Right lower abdominal
8|Page

tenderness is the key to diagnosis. Emphasis on the lower left abdominal pain in the abdomen will felt at bottom right called Rovsing sign. Retrosekal appendicitis or palpation in retroileal necessary to determine the presence of pain. Psoas sign. Pain during the patient's right thigh is being extension. The patient is tilted left. Examining straighten the patient's right thigh, there was an obstacle to the hip / groin right (asterisk). Basic anatomy of the psoas test. Inflamed appendix is in contact with the psoas muscles are stretched when performed maneuvers (examination). Obturator test. Pain on passive rotation into the patient's thigh when flexed. Examiner moves lower leg kelateral, there was a prisoner on the side of the knee (asterisk), resulting in a rotation into the femur. Basic Anatomy of the obturator test: Inflammation of the appendix dipelvis the obturator internus muscle contacts are stretched when performed maneuvers.

Examination Support Laboratory examination, complete blood found on leukocytes is generally mild in simple appendicitis. More than 13.000/mm3 generally in perforated appendicitis. The absence of leukocytosis does not rule out appendicitis. Leukocyte counts are shifting left. On examination of the urine, the sediment can be normal or leukocytes and erythrocytes are more than normal when the inflamed appendix attached to the ureter or vesika.

Radiological examination, Plain photo abdomen done if the anamnesis or physical examination questionable. Signs of right lower quadrant peritonitis. Perselubungan picture may look "ileal or caecal ileus" (picture of the surface of the water-air line disekum or ileum). Pathognomonic when seen pictures fekalit. Ultrasound or CT Scan. Ultrasound performed particularly to see the state of the right lower quadrant or pelvic pain in pediatric patients or women. Of inflammation of the appendix causing more than normal appendix size (6mm diameter). Other disease conditions in the lower right quadrant as inflammatory bowel disease, cecal diverticulitis, Meckel's diverticulum, endometriosis and pelvic inflammatory disease (PID) can cause false positives on the USG.On CT scans, especially apendiceal CT, is more accurate than ultrasound. In addition to identifying the inflamed appendix (diameter greater than 6 mm)
9|Page

also can see the changes due to inflammation in periappendix. Barium enema examination and colonoscopy is an initial examination to rule out the possibility of carcinoma of acute appendicitis colon. But for barium enema examination is

contraindicated because it may cause rupture apendiks.

Diagnosis Classic history of acute appendicitis, which was followed by a painful mass in the right iliac region and accompanied by fever, the diagnosis lead to a mass or abscess apendikuler. Diagnosis supported by physical examination or investigation. This situation is sometimes difficult to distinguish from carcinoma of the cecum, Crohn's disease, malignant lymphoma amuboma and intra-abdominal. It should be also ruled out the possibility of intestinal aktinomikosis, tuberculous enteritis, and abnormalities such as ectopic pregnancy gynecologist Impaired (KET), ovarian cysts Adneksitis and twisted. Key to diagnosis is usually located on the anamnesis khas. Appendix mass with an active inflammatory process characterized by: 1. Patient's general condition was still very sick, the body temperature is still high; 2. Local examination of the right lower quadrant of the abdomen there are still clear signs of peritonitis; 3. laboratory and there are still lekositosis counts contained in the shift to the left. Appendix mass in the process of inflammation has subsided with the marked : 1. general condition has improved with no visible ill, the body temperature is not high anymore; 2. Local examination of abdomen quiet, there are no signs of peritonitis and the only palpable masses with clear boundaries with mild tenderness 3. laboratory leukocyte count and counts normal.

Management The journey begins at the time of pathological diseases appendix be protected by the omentum and intestinal coils nearby. At first, the mass is formed composed of a mixture of confusing these buildings and the granulation tissue and usually can be felt clinically. If inflammation of the appendix can not be overcome obstacles so that patients continue to
10 | P a g e

experience general peritonitis, the mass had become filled with pus, initially in small amounts, but it soon became obvious abscess limit. Pathological sequence is a problem for the surgeon. This problem is encountered when the patient passed about 48 hours, the surgeon will operate to remove the appendix that may be gangrene of the mass of the loose attachment of lightweight and extremely dangerous, and if because of this mass has become more fixed and vascular, thus making it dangerous operations must waiting for the formation of an abscess that can be easily drainated. Appendix mass occurs when appendicitis gangrenosa or mikroperforation covered or wrapped by the omentum and small intestine, or dent. Pus can spread throughout the peritoneal cavity if perforation followed purulenta generalized peritonitis. Therefore, the masses are still free periapendikular recommended immediate surgery to prevent these complications. In addition, the operation easier. In children, prepared for surgery within 2-3 days. Adult patients with masses that are affixed to the fencing periappendicular perfect, it is recommended to be treated first and given antibiotics while monitored body temperature, mass size, and extent of peritonitis. If there is no fever, periappendicular mass loss, and normal leukocytes, the patient may go home and appendictomy elective can be done 2-3 months later for bleeding due to adhesions can be reduced to a minimum. In the event of perforation, abscess will form an appendix. It is characterized by the rise in temperature and pulse rate, increased pain, swelling and palpable mass, and increased numbers of leukocytes. Appendix mass with an active inflammatory process should be performed immediately after surgery the patient is prepared, because it feared would happen appendix abscess and general peritonitis. Preparation and surgery should be performed as well as possible given the complications of wound infection is higher than simple appendicitis surgery without perforations. At periapendikular infiltrates, is strictly prohibited open abdominal surgery, if done will be more difficult and more bleeding, especially when the mass of the appendix has formed more than a week since the attacks of abdominal pain. Surgery is done immediately when the treatment of abscesses occur with or without generalized peritonitis. If at the time of opening the abdomen there is periapendikular infiltrate the wound is closed again, the appendix is left alone. Conservative therapy in periapendikular infiltrates: 1. Total bed rest position fawler to pus collects in the cavity douglassi.
11 | P a g e

2. Diet soft pulp filter 3. Parenteral antibiotics in high doses, a combination of antibiotics active against aerobic and anaerobic bacteria. Only after a state of calm, which is about 6-8 weeks later, do appendictomy. If it happens abscess, drainage is recommended only and apendiktomi done after 6-8 weeks later. If there were no complaints or symptoms, and physical and laboratory examinations showed no signs of inflammation or abscess, cancelation of surgery can be considered. 4. Analgesics are given only when necessary only. Observations of temperature and pulse. Usually 48 hours of symptoms will subside. When the intensity of symptoms, signs occur then it should be considered appendiktomy perforation. Limit of the mass should be marked (demographic) every day. Usually on the 5th day of mass-7 began to shrink and localized. When the mass is also reduced, the sign had abscesses and masses should be opened up and didrainase.

To check for an abscess reduction in RT patients every day. Patients periapendikular infiltrates were observed for 6 weeks on: LED The number of leukocytes Mass Periapendikular infiltrates is considered quiet if: 1. Anamesa: the patient had not complained of pain or abdominal pain 2. Physical examination: people with good general condition, there is no rise in body temperature (measured rectal and axillary) Signs of appendicitis is not there The mass had shrunk or disappeared, or mass but remains smaller than the original. Laboratory: LED is less than 20, normal leukocytes

Policies for the operation periapendikular infiltrates: 1. When the LED has dropped less than 40 2. There were no leukocytosis
12 | P a g e

3. There were no masses or mass on repeated testing is no longer shrinking. If the LED remains high, it needs to be examined Does the patient have total bed rest The provision of food sufferers The use of antibiotics the patient The possibility of other causes. In 8-12 weeks when there are signs of infiltrates or no improvement, surgery is still being done. If there is a fixed mass periapendikular, this means it happens an abscess and therapy is drainase.

Complication The most common complication is perforation, either free perforation or perforation of the appendix that have experienced a mass covering consisting of a collection of the appendix, cecum, and colon dent. Perforation can cause a local abscess or a generalized peritonitis. The signs of a perforation is: local pain in the right iliac fossa abdominal pain changed into thoroughly The body temperature rises high. Takicardia a thorough muscular Defance Bowel reduced Stomach distended Due to further the establishment of generalized peritonitis: 1. Pelvic Abscesses 2. Subphrenic absess 3. Intraperitoneal abscess lokal. Peritonitis is a dangerous infection because the bacteria get kerongga abdomen, can cause organ failure and death.

13 | P a g e

REFERENCES

1. Mansjoer, A., et al. Of 2000. Selekta capita Medicine Third Edition Volume Two. Media publishers Aesculapius Medical Faculty University of Indonesia. Jakarta. 2. Schwartz, Spencer, S., Fisher, DG, 1999. Principles of Surgery sevent edition. Mc-Graw Hill a division of The McGraw-Hill Companies. An Enigma Enigma Electronic Publication. 3. Anonymous. Surgical Sciences and Engineering Operations. Bratajaya UNAIR School of Medicine. Surabaya. 4. Anonymous, 2006. Appendix Mass. GP Note Book

http://www.gpnotebook.co.uh/cache/1738145813.htm 5. De Jong,.W., Sjamsuhidajat, R., 2004. Textbook of Surgery 2nd Edition. EGC. Jakarta. 6. Itskowiz, MS, Jones, SM, 2004. Appendicitis. Emerg Med 36 (10): 10-15. www.emedmag.com 7. Anonymous, 2005. Appendix. PathologyOutlines. http://www.patholoyoutlines.com

14 | P a g e