Laporan Kasus appendicitis

Case Report

ACUTE APPENDICITIS

Composer:

Jessica Stephanie S

07120100019

FK UPH 2010

Preceptor :

dr. Setiawan William, Sp.B

CLINICAL CLERKSHIP-SURGERY DEPARTMENT

FACULTY OF MEDICINE UPH

RUMAH SAKIT MARINIR CILANDAK

PERIOD 1st JUNE 2015 – 8th AUGUST 2014

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PATIENT’S IDENTITY

Medical Record : 34 77 47

Name : Mrs. I

Gender : Female

Place, Date of birth : Jakarta, 21st of December 1952

Age : 62 years old

Religion : Muslim

Address : Pondok Labu, Cilandak

Job : Housewifes

HISTORY TAKING

Autoanamnesis was performed at Emergency Unit RS Marinir Cilandak on 7th of July

2015, 00.20 AM.

CC : Right lower abdominal pain 1 day prior to hospital admission.

HPI : Patient complains pain in her right lower abdomen 1 day prior to hospital

admission. The pain is continously. At first the pain is on the area around the

umbilicus, and then the pain was migrating to the right lower part of the

abdomen. Fever is also present since 3 days prior to hospital admission. The

fever is unstable with periods of high and normal temperature. The patient

denies chills accompanying the fever.

Aside from the pain and fever, the patient also complains about loss of her

appetite. She felt nausea and vomiting. She had vomited twice, containing clear

liquid, roughly the total of liquid was half an aqua cup. The patient is not

taking anymedication before. She denied allergy towards any medicine or any

kind of food.

PI : The patient denies any history of the same condition in the past. She never

had any abdominal pain before. She denies having any medical problems prior

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to this hospital admission. She denied any history about hypertension, diabetes

mellitus, dyslipidemia, or heart disease.

Medication history : Patient never consume any routine medications before.

Family history : All members in her family that lived together with her never

experienced the same condition as the patient. They denied any

familial diseases such as hypertension and diabetes.

Social history : Patient lives with her son, daughter in law, and her

grandchildrens. She never smoke cigarette, or consume alcohol.

PHYSICAL EXAMINATION

Physical examination was performed on 7th of July 2015, 00.20 AM at Emergency Unit

RSMC.

General cond. : Moderately ill

Consciousness : Compos mentis

BP : 120/80 mmHg (lying down)

Pulse : 102 x/min regular, strong, equal

Respiration : 20 x/min regular

Temperature : 37,7°C (axilla)

STATUS GENERALIS

Eyes : RCL +/+, RCTL +/+, isocor 3mm, CA-/-, SI -/-

ENT : hyperemia phanynx (-), T1/T1

Thorax : - Heart : Ictus cordis (N)

Regular S1 S2 heart sound

Murmur (-) Gallop S3 S4 (-)

- Lungs : Chest expansion R=L

Sonor on percussion

Vesicular breath sound ; wheezing -/- ronchi -/-

Exremities : warm, edema -/-, CRT< 2s

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LOCAL STATUS:

Abdomen :

Inspection : distended, surgical scars (-)

Auscultation : Bowel sound (+) normal

Palpation : Muscular defense (-), tenderness (+) & rebound tenderness (+) on right

lower quadrant.

Percussion : Timpanic (+) on all abdominal regions

- McBurney’s sign (+)

- Rovsing’s sign (+)

- Psoas sign (+)

- Obturator sign (-)

- Dunphy sign (+)

WORKUP

- Laboratory examination was performed on 7th of July 2015, 00.30 AM at RSMC,

with results as following:

TEST RESULT UNIT NORMAL

Hemoglobin 12,7 g/dL 12 – 16

Hematokrit 36 % 37 – 54

Leukosit 9500 /µL 5.000 – 10.000

Trombosit 75.000 /µL 150.000 – 400.000

CT 4 menit 2 – 6

BT 2 menit 1 – 3

Glukosa Sewaktu 130 mg/Dl <200

SGOT 19 u/l <35

SGPT 19 u/l <35

Ureum 21 Mg/dl 20-50

Creatinin 0,75 Mg/dl 0,8-1,1

5

Hasil Nilai Normal

Warna Kuning Kuning

Kekeruhan Jernih Jernih

pH 6,5 6-8

Protein - -

Reduksi - -

Berat jenis 1,005 1,015-1,025

Bilirubin - -

Urobilin + +

Keton/ Blood -/- -/-

Nitrit - -

SEDIMEN

leukosit 2-3 <5 / LPB

Eritrosit 1-2 <3 / LPB

EPITEL + <1 / LPK

Silinder - -

K. Ca Oxalat - -

K. As. Urat - -

K. Tripel Phosphat - -

Amorf - -

- Electrocardiogram :

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SUMMARY

A 62 year-old woman came to Emergency Unit RS Marinir Cilandak on 7th of July

2015, 00.20 AM, with complaint of right lower abdominal pain 1 days prior to hospital

admission. The patient was also have fever for 3 days prior to hospital admission, chills

(-). Loss of appetite, nausea and vomiting was present. She had vomited twice, half an

cup of clear liquid. The patient is not taking any medication before. Allergy (-),

hypertension(-), DM (-), heart disease (-), or another chronic disease. On physical

examination, the patient seems moderately ill, temperature of 37,7°C. Abdominal

examination reveals distended surface and no surgical scars on inspection, normal

bowel sound on auscultation. On palpation, muscular defense (-),but tenderness and

rebound tenderness on right lower quadrant are found. On percussion, all abdominal

regions are timpanic. Special tests performed revealed all positive results, they are

McBurney’s, Rovsing’s, Dunphy’s and psoas sign. Laboratory examination performed

on 00.30 AM on the same day reveals there is thrombocytopenia but no leukocytosis.

And for the result of urinalysis and ECG were normal.

DIAGNOSIS

Based on history taking, physical examination and laboratory examination, the working

diagnosis of the patient can be established.

Working diagnosis:

• Thrombocytopenia e.c. susp. Dengue fever

• Acute appendicitis

MANAGEMENT

Instructions from dr.Sinarta , Sp.PD:

- IVFD RL 20 gtt/min

- Consult general surgeon (dr. Setiawan W., Sp.B) à scheduling for surgery

- Consult anesthesiologist (dr.Eka, Sp.An)

- Stop per oral for 8 hours pre-operative.

MEDICATIONS

- Inj. Ondancentron 3 x 4 mg IV

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- Inj. Ceftriaxone 2 x 1 gr IV / drip in NaCl 0,9% 100cc. à skin test

- Ulsafat syrup 3 x C1 PO

- Paracetamol 3 x 500 mg tab PO

SURGICAL INTERVENTION

Appendictomy was performed on 8th of July 2015, 08.00 AM at OK 1 RSMC with

team as following:

Operator : dr. Setiawan, Sp.B

Instrument : Nunung

Surgical assistant : Coass

Onloop : Lela

Anesthesiologist : dr. Eka, Sp.An

Operation Report :

Spinal anesthesia was performed

by dr. Eka, Sp.An

After septic-antiseptic procedure using

povidone iodine has been done, incision

was made on Mc.Burney point. +/-

10cm.

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Visualization of the peritoneum

Exploration of the peritoneal content to

find the appendix.

The apendix was found.

The rest of mesoappendix was ligated

and cut.

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Using polypropylene thread, the

surrounding of the cut appendix was

sutured. And then we did

appendectomy.

Appearance of the resected appendix.

We used pivodine iodine to the tip of

appendix where we cut it.

And also used cauterization to the tip of

appendix.

10

The remaining part of the cut appendix

were inserted into the caecum while the

surrounding sutured were pulled to

from the “Tabaczac” or “tobacco

pouch”-like suture.

Bleeding treated. Intestines were put

back to place and then closing the

abdomnal layers.

The deep abdominal layers were

completely closed.

Skin sutures made using subcuticular

technique.

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The suture was done.

The wound then closed by kassa verban

POST-OP INSTRUCTIONS

- IVFD RL : Dextrose 5% = 1:3 (28 gtt/min)

- Inj. Ceftriaxone 2 x 1 gr (IV) à 2 days

- Inj. Tramadol 2 x 100 mg (IV) à 2 days

- Dulcolac supp. 1x1

- Fasting until Bowel sound (+), and flatus (+)

FOLLOW UP

Tanggal Follow Up

7/7/15 S : nausea (+), vomiting (-), loss of appetite.

Fever (+), pain in right lower quadrant of abdomen was persistent. It

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become worst when she move her right leg to flexed position.

O :

General condtion : moderately ill

Conciousness : CM

BP: 120/80 ; P : 90bpm ; RR: 20 x/m; T: 36,5

STATUS GENERALIS

Eyes : RCL +/+, RCTL +/+, isocor 3mm, CA -/-, SI -/-


Neck : lymphadenopathy (-)

Thorax :

- Heart : S1S2 regular, M (-), G (-)

- Lungs : Vesicular breath sound, Wh -/-, Rh -/-

Exremities : warm, edema -/-

STATUS LOKALIS

Abdomen :

-distended surface, bowel sound (+), tenderness (+) RLQ

Lab Result

Hb 12,7

Ht 36

Leu 7.800

Trom 85.000

A : DHF grade I

Acute Appendicitis à pro-op

P :



- Inj. Ceftriaxone 2 x 1 gr IV / drip in NaCl 0,9% 100cc.


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- Operation : appendectomy on 8/7/15. à stop oral start at 00.00.

8/7/15 S : nausea (-), vomiting (-). Headache (-). Fever (+).

O :


Conciousness : CM

BP: 120/70 ; P : 86 bpm ; RR: 20 x/m; T: 37,4

STATUS GENERALIS




Thorax :




STATUS LOKALIS

Abdomen :

-distended surface, bowel sound (+), tenderness (+) RLQ

Lab Result

Hb 12,4

Ht 35

Leu 8.900

Trom 91.000

A : DHF grade I

Acute Appendicitis à pro-op

P :



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- Appendictomy at 08.00 AM

9/7/15 S : nausea (+), vomiting (-), headache (-). Pain on surgical wound.

Flaatus (+).

O :


Conciousness : CM

BP: 120/80 ; P : 90bpm ; RR: 18 x/m; T: 36,3

STATUS GENERALIS




Thorax :




STATUS LOKALIS

Abdomen :

- Surgical wound closed by kassa verban. Leakage (-), Bowel sound

(+) minimal. Tenderness (+).

A : DHF grade I à improvement.

Post Appendictomy – Day 1.

P :

- IVFD RL: D5% = 1: 3 à 28 gtt/min


- Inj. Tramadol 2 x 100 mg IV

- Diet : drink gradually. And for afternoon : porridge.

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PROGNOSIS

Ad vitam : ad bonam

Ad sanationam : ad bonam

Ad fungsionam : ad bonam

CASE DISCUSSION

Based on clinical findings and physical examination found on the patient, the diagnosis

made is acute appendicitis. The diagnosis of acute appendicitis was confirmed using

MANTRELS/ALVARADO score:

Faetures Point Patient

Migrating of pain to the RLQ 1 +

Anorexia 1 +

Nausea 1 +

Tenderness in RLQ 2 +

Rebound tenderness 1 +

Elevated temperature 1 +

Leukocytosis 2 -

Shifting of WBC to the left 1 -

Total 7/10

So even though there is no leukocytosis in this patient the MANTRELS Score still show

that the patient can be diagnosed with acute appendictis, because the score that indicates

to acute appendicitis is >=7/10 for MANTRELS Score.

But the patient was operated on the second day of hospitalizaton. The reason is because

her thrombocytopenia. She diagnose with DHF grade I, and it means when we push for

appendictomy to be done in the first day, t may increase the risk of heavy bleeding. So

we took the safest way, dr.Setiawan did the appendictomy in the second day, the

laboratorium result of the platelets count of patient has increased, which was orignally

75.000/ul into 91.000/ul.

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However there is some literature that says that the normal limit of platelets for surgery

procedure is 70.000/ul. and the minimum limit for surgery procedures is 50.000/ul with

an increased risk for complcation intraoperative or post-operative. If platelets count

below 50.000/ul we must not to do surgery, because it would create a risk and requires

some pre-operative preparations.

LITERATURE REVIEW

1. Introduction

All physicians should have a thorough knowledge of appendicitis. Although most

patients with acute appendicitis can be easily diagnosed, there are many in whom the

signs and symptoms are quite variable, and a firm clinical diagnosis may be difficult to

establish. It is for this reason that the diagnosis is made rather liberally, with the full

expectation that some patients will be operated on and found to have a normal appendix.

It is preferable to maintain broad indications, as this tends to include the group of

patients with indefinite signs and symptoms who actually have the disease but do not

fulfill the classic criteria for the diagnosis. Following this course, patients who might

proceed to perforation of the appendix, with a host of possible secondary complications,

are spared that fate. Therefore, it is generally agreed that 10% to 15% of patients having

a diagnosis of acute appendicitis by acceptable standards in most hospitals will actually

be found at operation to have a normal appendix.

2. Anatomy

The vermiform appendix is located in the right lower quadrant, arises from the cecum,

and is generally 6 to 10 cm in length. It has a separate mesoappendix with an

appendicular artery and vein that are branches of the ileocolic vessels. The appendix is

lined with colonic epithelium characterized by many lymph follicles numbering

approximately 200, with the highest number occurring in the 10- to 20-year-old age

group. After the age of 30, the number of lymph follicles is reduced to a trace, with total

absence of lymphoid tissue occurring after the age of 60. The appendix may lie in a

number of locations, essentially at any position on a clock wise rotation from the base

of the cecum. It is important to emphasize that the anatomic position of the appendix

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determines the symptoms and the site of the muscular spasm and tenderness when the

appendix becomes inflamed.

3. Pathophysiology

It is widely accepted that the inciting event in most instances of appendicitis is

obstruction of the appendiceal lumen. This may be due to lymphoid hyperplasia,

inspissated stool (a fecalith), or some other foreign body. Given the correlation with the

incidence of appendicitis by age and the size and distribution of the lymphoid tissue, it

is likely that lymphoid obstruction or partial obstruction of the lumen is a common

cause. Obstruction of the lumen leads to bacterial overgrowth as well as continued

mucous secretion. This causes distention of the lumen, and the intraluminal pressure

increases. This may lead to lymphatic and then venous obstruction. With bacterial

overgrowth and edema, an acute inflammatory response ensues. The appendix then

becomes more edematous and ischemic. Necrosis of the appendiceal wall subsequently

occurs along with translocation of bacteria through the ischemic wall. This is

gangrenous appendicitis. Without intervention, the gangrenous appendix will perforate

with spillage of the appendiceal contents into the peritoneal cavity. If this sequence of

events occurs slowly, the appendix is contained by the inflammatory response and the

omentum, leading to localized peritonitis and everntually an appendiceal abscess. If the

body does not wall off the process, the patient may develop diffuse peritonitis.

4. Clinical diagnosis

The diagnosis of acute appendicitis is made primarily on the basis of the history and the

physical findings, with additional assistance from laboratory examinations. The typical

history is one of onset of generalized abdominal pain followed by anorexia and nausea.

The pain then becomes most prominent in the epigastrium and gradually moves toward

the umbilicus, finally localizing in the right lower quadrant. Vomiting may occur during

this time. Examination of the abdomen usually shows diminished bowel sounds, with

direct tenderness and spasm in the right lower quadrant. As the process continues, the

amount of spasm increases, with the appearance of rebound tenderness. The temperature

is usually mildly elevated (approximately 38° C.) and usually rises to higher levels in

the event of perforation. Direct tenderness is usually present in the right lower quadrant

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and may involve other parts of the abdomen, particularly if perforation has occurred.

The appendix is usually situated at or around McBurney's point (a point one third of the

way on a line drawn from the anterior superior spine to the umbilicus). However, it

must be emphasized that the exact anatomic location of the appendix can be at any

point on a 360-degree circle surrounding the base of the cecum, as shown in (Figure 1)

This is the site where the pain and tenderness are usually maximal, and the exact site

may vary from patient to patient.

Rovsing's sign, elicited when pressure applied in the left lower quadrant reflects pain to

the right lower quadrant, is often present. The psoas sign may be positive and is elicited

by extension of the right thigh with the patient lying on the left side. As the examiner

extends the right thigh with stretching of the muscle, pain suggests the presence of an

inflamed appendix overlying the psoas muscle. The obturator sign can be elicited with

the patient in the supine position with passive rotation of the flexed right thigh. Pain

with this maneuver indicates a positive sign. Rectal examination generally elicits

tenderness at the site of the inflamed appen-dix in the right lower quadrant. If the

appendix ruptures, abdominal pain becomes intense and more diffuse, the muscular

spasm increases, and there is a simultaneous increase in the heart rate above 100, with a

rise in temperature to 39° or 40° C. At this time, the patient appears toxic, and it

becomes obvious that the clinical situation has deteriorated.

Olivier Monneuse and colleague, in France from 2002-2005 review of 326 patients, this

study was designed to quantify the proportion of patients with a preoperative diagnosis

of acute appendicitis that had isolated right lower quadrant pain without biological

inflammatory sign's and then to determine which imaging examination led to the

determination of the diagnosis. The diagnosis acute appendicitis can not be excluded

when an adult patient present with isolated rebound tenderness in the right lower

quadrant evwen without fever and biological inflammatory signs.

5. Laboratory finding

The clinical history and physical examination are most important in establishing a

diagnosis of acute appendicitis, but laboratory findings may be helpful. The majority of

patients with acute appendicitis have an elevated leukocyte count of 10,000 to 20,000.

For those in whom the level is normal, there is generally a shift to the left in the

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differential leukocyte count, indicating acute inflammation. However, it should be

emphasized that a number of patients have a normal leukocyte count, especially the

elderly. Urinary analysis may show a few red cells, indicating some inflammatory

contact with the ureter or urinary bladder; a significant number of erythrocytes in the

urine indicates a primary disorder of the urinary tract.

6. Treatment

For the vast majority of patients with a diagnosis of acute appendicitis, the appropriate

management is appendectomy. For patients with simple acute appendicitis, intravenous

fluids should be initiated as well as an antibiotic agent effective against both aerobic

and anaerobic organisms. All patients are begun on antibiotics preoperatively and

maintained post-operatively as needed. If the appendix is unruptured and not

gangrenous, antibiotics can be discontinued after 24 hours. Although many agents are

effective, cefoxitin is often the agent of choice on the basis of a multicenter randomized

trial of 1735 patients. Half received 2 gm. of cefoxitin preoperatively. Three groups

were evaluated: patients with a normal appendix, those with an acutely inflamed

appendix, and those with a gangrenous appendix. The incidence of wound infection was

significantly lower in all three groups. However, the formation of intra-abdominal

abscess was not influenced by preoperative antibiotics. In a recent double-blind

controlled study, prophylactic cefotetan was compared with prophylactic cefoxitin in

the development of postoperative wound infections in patients with acute nonperforated

ap-pendicitis. The results showed that single-dose cefotetan and multiple-dose cefoxitin

are equally effective. However, because of the greater convenience and decreased cost,

single-dose cefotetan was considered the prophylaxis of choice in appendectomy for

nonperforated appendicitis. Clindamycin with an aminoglycoside is indicated when

Bacteroides fragilis is present; metronidazole can also be used for this organism. This

meta-analysis suggest that although antibiotic may be used as primary treatment for

selected patients with suspected uncomplicated at present. Selection bias and crossover

to surgery in the RCTs suggest that appendectomy is still the gold standard therapy for

acute appendicitis.

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7. Surgical

There are two approaches to removal of the non perforated appendix: through an open

incision, usually a transverse right lower quadrant skin incision (Davis-Rockey) or an

oblique version (McArthur-McBurney) with separation of the muscles in the direction

of their fibers, or a paramedian incision, but this is not routinely done. The incision is

centered on the midclavicular line. Occasionally, where the diagnosis is uncertain, a

periumbilical midline incision can be used. Once the peritoneum is entered, the

appendix is delivered into the field. This can usually be accomplished with careful

digital manipulation of the appendix and cecum. It is important to avoid too extensive of

a blind dissection. In difficult cases, extending the incision 1 to 2 cm can greatly

simplify the procedure. Once the appendix is delivered into the wound, the

mesoappendix is sacrificed between clamps and ties. There are several ways to handle

the actual removal of the appendix. Some surgeons simply suture ligate the base of the

appendix and excise it. Others place a purse string or Z- stitch in the cecum, excise the

appendix, and invert the stump into the cecum. We have used both approaches. Once

the appendix is removed, the cecum is returned to the abdomen, and the peritoneum is

closed. The wound is closed primarily in most patients with non perforated appendicitis

because the risk of infection is less than 5%.

Acute appendicitis is one of the commonest of surgical emergencies and appendectomy

has become established as the gold standard of therapy. However as the diagnosis of

appendicitis in most centers is mainly a clinical one , based on history and examinations

diagnostic uncertainly in patients with suspected appendicitis may lead to delay in

treatment or negative surgical exploration, adding to the morbidity associated with the

condition.

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REFERENCES

1. Beauchamp RD, Evers BM, Mattox KL, Sabiston Textbook of Surgery, 16th ed.

Philadelphia, W.B.Saunders Company. 2001. P. 919.

2. Sabiston DC, Lyerly HK, Sabiston Textbook of Surgery, 15th ed. Philadelphia,

W.B.Saunders Company. 1997. P. 964.

3. Brunicardi FC, Anderson DK, Billiar TR, Dunn DL, Hunter JG, Pollock RE.

Schwartz's Principles of Surgery. 8th ed , New York , McGraw Hill, 2010. P.

1080.

4. Salari AA. Peritonitis and Intraabdominal abscess. Yazd, Tebgostar, Shahid

Sadoghi University of Medical sciences. Yazd, Iran. 2003. P. 93-110.

5. Sabiston DC, Lyerly HK, Sabiston Textbook of Surgery, 15th ed. Philadelphia,

W.B.Saunders Company. 2001. P. 961-969.

6. Schwartz SI, Shires GT, Spencer FC. Principles of Surgery. 8th ed , New York ,

McGraw Hill, 1994. P.1304-1318.

7. Ronald F. Anderson. Routine ultrasound and limited computed tomography for

the diagnosis of acute appendicitis : A surgeon perspective. World Journal of

Surgery. 2011; 35: 295-296.

8. Sjamsuhidajat R, Karnadihardja W, Prasetyono TO, Rudiman R. Apendiks

Vermiformis. Dalam: Buku Ajar Ilmu Bedah. Edisi 3. Jakarta; 2007.h.755-62.

9. Doherty GM. Appendix. Dalam: Current Diagnosis and Treatment: Surgery.

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