Acute Appendicitis

ICD X: K 35.80
SKDI: 3B
PEDIATRIC SURGERY DEPARTMENT CASE

DESKAFIANI PUTRI
1708436518

CLINICAL CLERKSHIP OF SURGERY

DEPARTMENT
MEDICINE FACULTY OF RIAU UNIVERSITY
ARIFIN ACHMAD PUBLIC HOSPITAL
2019
 Patient’s Identity

 Name : Mrs. DTZ

 Gender : Female
 Age : 9 Years Old
 Address : Limbungan Street
 Number of MR : 01.00.72.19
 Date of Hospital Admission : March 26th, 2019
 Chief Complaint

 Abdominal pain that getting worse since 2 days ago.

 History of Present Illness

 7 Days before came to the hospital, patient complained

about intermittent abdominal pain. Pain was felt in the
epigastrium area of the stomach. After 5 days, the pain
move to the center and right lower areas stomach. Pain
is felt sharp stabbing. The conditions get worse if the
feet are moved, walked or coughed. Its accompanied by
vomitted that contains food and liquid up to 3 times.
Patient also complained about fever 6 days after the
stomach pain, bloating and decreased appetite. Patients
urination as usual, no complaint. Patient go to the Arifin
Achmad Public Hospital for get treatment.
 History of Past Illness

 There were no similar complaint before.

 History of Families Illness

 There are no related complaint.

 Physical Examination

 General Appearance : Looks moderately ill.

 Awareness : Compos mentis.
 Heart Rate : 100 Beats per minute.
 Respiration Rate : 22 Breaths per minute.
 Blood Pressure : 120/80 mmHg.
 Temperature : 37,4 ◦C.
 Generalized Status

 Head and Neck : Normal.

 Thorax : Normal.
 Stomach : Localized status.
 Extremities : Normal.
 Localized Status (Abdomen)

 Inspection : Flat belly, mass (-).

 Auscultation : Bowel sounds 3 times per minute.
 Palpation : Defans muscular (+) at the right lower
abdominal quadrant, tenderness (+) and
rebound pain (+) at lanz point, psoas
sign (+), obturator sign (+), rovsing’s
sign (-).
 Percussion : Tympanic (+), pain during percussion
(+) at the right lower abdominal
quadrant.

 Rectal Toucher : Difficult to assess.

 Working Diagnosis

 Suspected Acute Appendicitis

 Differential Diagnosis

 Peptic Ulcer Perforation

 Additional Examination

 Routine blood.
 Differential white blood cell count.
 Abdominal x-ray within 3 position.
 Routine Blood

 Hemoglobin : 12,8 g / dL (N).

 Hematocrit : 38,6% (N).
 Leukocytes : 15.320 / μL (↑).
 Basophils : 0,2% (N).
 Eosinophils : 0,3% (↓).
 Neutrophils : 83,1% (↑).
 Lymphocytes : 13,3% (↓).
 Monocytes : 3,1% (N).
 Platelets : 288.000 / μL (N).
 Diagnosis

 Acute Appendicitis
 Treatments

 Non Pharmacology→
 Hospitalized.

 Consul to pediatric surgeon.

 IVFD Ringer Lactate 20 drip per minute.

 Pharmacology→
 IV Acetaminophen 3 x 300 mg.

 IV Ceftriaxone 2 x 750 mg.

 Literature Review

 Acute appendicitis is inflammation of the vermiform

appendix.
 The most often emergency case for general surgery
department in western countries.
 The incidence increases by age (Second and third
decades).
 The mortality rate is 0.1% in uncomplicated cases
and 5% in cases with complications (Perforation).

Mcllrath DC. Kelainan Bedah Apendiks Vermiformis dan Divertikulum Meckel. In: Buku Ajar Bedah Bagian 2. Jakarta: ECG; 2005. p. 1–9.
 Pathogenesis

Inhibiting
Inhibiting lymph
Lumen Increased venous flow →
flow → Focal
obstruction of intralumen Acute
acute
the appendix pressure suppurative
appendicitis
appendicitis

Omentum and intestine

Inhibits arterial flow → Continuing
approach to the
Gangrenous and inflammation→Abscess
appendix →
perforated appendicitis appendicitis
Appendicitis infiltrates

Mansjoer A. Kapita Selekta Kedokteran. Jakarta: Media Aesculapius; 2000.

 History Taking

 Visceral pain→Persistent periumbilical pain,

diffuse. Accompanied by nausea, vomiting and
anorexia.
 (A few hours later) Somatic pain→Right lower
abdomen quadrant pain (At Mc Burney's point) that
is clear and sharp. Pain get worse when it move,
cough or sneeze.
 History of constipation or diarrhea.
 Fever.
 Depends the position of appendix.

Mcllrath DC. Kelainan Bedah Apendiks Vermiformis dan Divertikulum Meckel. In: Buku Ajar Bedah Bagian 2. Jakarta: ECG; 2005. p. 1–9.
Mansjoer A. Kapita Selekta Kedokteran. Jakarta: Media Aesculapius; 2000.
 Physical Examination

 Inspection : Walking bent, difficult to reach the

supine position.
 Auscultation : Decreased bowel sounds or none at all.
 Palpation : Defans muscular (+) at the lower right
quadrant of the abdomen, tenderness (+)
and rebound pain (+) at Mc Burney's
point, rovsing’s sign (+), psoas sign (+),
obturator sign (+).
 Percussion : Pain during percussion(+).

 Rectal Toucher : Pain (+) especially in the direction of 9-

12 hours.

Mcllrath DC. Kelainan Bedah Apendiks Vermiformis dan Divertikulum Meckel. In: Buku Ajar Bedah Bagian 2. Jakarta: ECG; 2005. p. 1–9.
Mansjoer A. Kapita Selekta Kedokteran. Jakarta: Media Aesculapius; 2000.
 Additional Examination

 Laboratory test→Increased leukocytes, shift to the

left.
 Radiological examination→
 Abdomen x-ray: Abnormal right psoas shadow, there is gas in
the appendix lumen, more prominent ileus.
 USG: Identifies dilation and fluid in the appendix or abscess
formation.

Mcllrath DC. Kelainan Bedah Apendiks Vermiformis dan Divertikulum Meckel. In: Buku Ajar Bedah Bagian 2. Jakarta: ECG; 2005. p. 1–9.
Bickley LS. BATES Buku Ajar Pemeriksaan Fisik dan Riwayat Kesehatan. Jakarta: ECG; 2009.
 Differential Diagnosis

 Gastroenteritis
 Mesenteric Lymphadenitis
 Peptic Ulcer Perforation
 Intestinal Obstruction
 Colonic Diverticulitis
 Meckel Diverticulitis
 Colon Carcinoma Perforation
 Rupture of the Ovarian Cyst
 Ectopic Pregnancy
 Torsion of the Ovarian Neoplasm
 Pelvic Inflammation Disease
 Salpingitis
 Ureter Stone

Mcllrath DC. Kelainan Bedah Apendiks Vermiformis dan Divertikulum Meckel. In: Buku Ajar Bedah Bagian 2. Jakarta: ECG; 2005. p. 1–9.
 Treatments

 Appendectomy
 Antibiotic

Craig S. Appendicitis. In: Medscape. 2018.

 Prognosis

 Depends on→
 Age of patient.

 Pre-surgical preparation.

 The stadium of disease when surgical intervention.

Mcllrath DC. Kelainan Bedah Apendiks Vermiformis dan Divertikulum Meckel. In: Buku Ajar Bedah Bagian 2. Jakarta: ECG; 2005. p. 1–9.
 Complications

 Peritonitis
 Surgical Wound Infection
 Adhesion

Mcllrath DC. Kelainan Bedah Apendiks Vermiformis dan Divertikulum Meckel. In: Buku Ajar Bedah Bagian 2. Jakarta: ECG; 2005. p. 1–9.
Thank you