1. Acute appendicitis is caused by obstruction of the appendix lumen leading to infection. Common causes of obstruction include lymphoid hyperplasia, fecaliths, and tumors. 2. Appendicitis progresses from mucosal ischemia to inflammation, edema, and potential perforation within 48 hours if not treated. Perforation can lead to appendiceal mass or diffuse peritonitis. 3. Diagnosis is based on symptoms of migrating abdominal pain, laboratory tests showing elevated white blood cells, and physical exam maneuvers identifying tenderness. Imaging studies like ultrasound or CT scan may help if diagnosis is unclear.

1. 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

2. 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.

3. 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%)

4. Pathophysiology
Wangensteen proposed
1. Closed loop obstruction
2. Increase in luminal pressure.
3. Exceeds capillary pressure causes mucosal ischemia
4. Luminal bacterial overgrowth and translocation bacteria across the
appendiceal wall result :
-Inflammation
-Edema
-Necrosis  perforation occur about 48 hours .
If the body successfully walls off the perforation Appendiceal Mass
If the perforation is not successfully walled off  Diffuse peritonitis will
develop.

5. 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)

6. Differential diagnosis of acute appendicitis
Surgical
• Acute Intestinalobstruction
• Intussusception
• Acute cholecystitis
• Perforated peptic ulcer
• Mesenteric adenitis
• Acute Meckel's diverticulitis
• Acute Pancreatitis
Medical
• Gastroenteritis
• Basal Pneumonia dextra
• Terminalileitis
Urological
• Rightureteric colic
• Right pyelonephritis
• Urinary tract infection
• Right Acute epididymitis
Gynaecological
• Ectopicpregnancy
• Ruptured ovarian follicle
• Torted ovarian cyst
• Salpingitis/pelvicinflammatory disease

7. Differential diagnosis of appendicitis appendicitis
can mimic several abdominal conditions.

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

9. 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 º C
•Higher fevers are associated with a perforated appendix

10. Special maneuvers
McBurney sign
McBurney's point
it is only the area
of greatest tenderness
Blumberg sign
Rovsing’s Sign
Dunphy sign Cough Test
Obturator sign
Psoas sign
Markle sign

11. Location appendix during pregnancy

12. 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.

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

14. MANTRELS SCORE
Characteristic Score
M = Migration of pain to the RLQ 1
A = Anorexia 1
N = Nausea and vomiting 1
T = Tenderness in RLQ 2
R = Rebound pain 1
E = Elevated temperature 1
L = Leukocytosis 2
S = Shift of WBC to the left 1
Total 10
A score of 7 or more is strongly predictive of acute appendicitis.
Alvarado score 1986

15. 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

16. CT scan
-Oral contrast medium
-Rectal Gastrografin enema
Reserved for patients
-Uncertain diagnosis
-Severe obesity.
more than 6 mm

17. If the clinical picture is unclear
Short period (4-6 h) of watchful waiting
USG / CT scan
-May improve diagnostic accuracy
Without a definite diagnosis
- return for continued or recurrent symptoms
- follow-up examination in 24 hours.

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

19. TREATMENT
Medical therapy
Resuscitated adequately with fluids .
Preoperative prophylactic antibiotics
-Acute Appendicitis single agent second-generation
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

20. 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

21. 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.

22. 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.

24. Acute Appendicitis Appendicitis Perforation