CASE PERSONAL PERIAPPENDICULAR MASS

DISUSUN OLEH : Noviana Wulandari 110.2005.180 PEMBIMBING : dr. Herry Setya Yudha Utama, SpB MHKes FinaCS

Kepaniteraan Klinik Mahasiswa Fakultas Kedokteran Universitas YARSI Bagian Ilmu Bedah BRSUD Arjawinangu
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BAB I CASE PERIAPPENDICULAR MASS

I.

Identity Name Age Gender Religion Occupation Address : Mr. Samsuri :40 Years : Male : Islam : Farmer : South Wanasaba

RS Date Added : March 18, 2012

II.

Anamnesa Main complaint Additional complaints : Abdominal pain : Fever

History of Disease Now : Hospital patients come to the emergency room complaining of abdominal pain Arjawinangun right and that the gut had been since 1 week before hospital admission. Patients are told often experience abdominal pain that is felt right intermittent since about 5 years. Patients are told often bowed when sitting and standing to relieve pain in his stomach. Complaints of abdominal pain is accompanied by fever up and down as well as nausea and vomiting, watery bowel movements from 3 days before hospital admission. Normal urination. Patients say never went to the doctor but no change. In the past history of disease: Patients admitted with no history of gout, jaundice, high blood pressure, heart disease, kidney disease, diabetes, allergies and asthma.

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Family history of disease: Patients admitted no family members who suffer from the same disease with him.
III. Physical Examination

Present Status State General : Looks sick is Awareness Vital Signs Blood pressure Pulse Temperature Status Generalis Head Shape Eyes Nose Mouth Ears Neck Inspection Palpation Lung Inspection Palpation Percussion : Form symmetrical right and left chest : Tactile Fremitus right = left : Resonant to both lung fields : No visible enlargement of the KGB : No palpable enlarged lymph nodes, no enlargement of the thyroid, : Normocephal : Conjunctiva anemis - / -, sclera jaundice - / : Normal shape, septum in the middle, no deviation : Lips do not cyanotic, the tongue is not dirty, not hiperemis : Normal form, symmetry, intact tympanic membrane : 120/80 mmHg : 84 x / minute : 36.2 C : Compos mentis

Respiratory : 24 x / minute

the JVP has not increased

Auscultation : Vesicular + / +, ronkhi - / -, wheezing - / -

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Heart Inspection Palpation Percussion The upper limit Right Limits The left boundary : Cardiac Iktus not seem : Iktus cardiac palpable rib V line between the left midclaviculla : : Sela left sternal ribs III line : Sela right sternal ribs IV line : Sela left rib V line midklavikula

Heart lung boundary: A line VI midklavikula Sela right ribs Auscultation : I-II heart sound is pure, regular, gallops - / -, murmur - / Abdomen Inspection Palpation Percussion Genitalis Extremities: - Superior : Warm Palmar erythema (- / -) Cyanosis (- / -) Clubbing (- / -) Edema (- / -) - Inferior : Warm Edema (- / -) Cyanosis (- / -)
IV. EXAMINATION SUPPORT

: Abdomen enlarged symmetrically : Abdominal tenderness (+) : Timpani in the entire field abdomen : No abnormalities

Auscultation : Bowel sounds (+) normal

laboratory Routine blood March 18, 2012 Hb Eritrosit Leukosit : 8,9 g/dl : 4,70 106/l : 23,4 103/l
4

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Trombosit

: 745 103/l

Routine blood March 21, 2012 Hb Eritrosit Leukosit Trombosit Serology Widal Widal Salmonella IgM : Negatif Widal Salmonella IgG : Negatif AP thoracic X-ray Cast: Not enlarged, sinuses and normal diaphragm Pulmo: normal Hili Increased pulmonary Corakan Software does not seem perbercakan Impression: There was no active pulmonary TB There does not appear enlarged heart Rib deformity VI - VII right-lateral Abdomen photo 3 Position Preperitoneal normal fat Right psoas line is not clear, normal left Contours of both kidneys is not clear Water appears multiple fluid level in the photo erect and LLD Impression : No visible signs of ileus There does not appear peritonitis or pneumoperitoneum : 10,8 g/dl : 5,28 106/l : 19,0 103/l : 569 103/l

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USG Abdomen

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Liver: Not enlarged, sharp edges, flat surfaces, smooth texture homogeneous parenchyma, capsule not thickened. Not dilated portal vein, hepatic vein is not dilated. Gallbladder: Large normal, normal wall, not visible stones / sludge Bile duct intra / ekstahepatal: No widening, not visible shadow hiperkholik with acustic shadow. Lien: Not enlarged, normal contour, normal parenchyma, not visible mass. Splenic vein is not dilated. Pancreas: Large normal, normal contour, texture homogeneous parenchyma, does not seem masses / calcifications. Pancreatic duct is not dilated. Kidney : Large normal, normal contour, normal parenchyma, intennsitas normal echo. Texture boundary with the central echocomplex normal parenchyma. No visible shadow hiperkholik with acustic shadow. Pelvokalises system and bilateral dilated proximal ureter light ..

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Urinary Vesica: Normal large, the walls are not thickened, regular, with no visible shadow hiperkhoik akustic shadaow / mass Appendix: In the lower right abdomen scanning shadow does not look dead-end structure of the tubular hiperkholik dengantarget sign, echo-free mass or shadow around the caecum Impression: - At this appendix is not detected, not visible mass or fluid collection in the caecum - Suspect ileitis - Ureteropelvokaliektasis bilateral mid e.c?
V. Diagnosis Of Work : Periapendicular mass VI. Different diagnosis :

Appendicitis kronik Gastroenteritis VI. Management : - Infus RL drops per minute - Ceftazidin 2x1 - Tramadol 2x1 - Ranitidin 2x1 VII. Prognosis Quo ad Vitam Quo ad functionam : dubia ad bonam : dubia ad bonam

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BAB II DISCUSSION II.1 Introduction Along with technological advances and the increasing socio-economic status increases, increasing health problems in society caused by the lack of knowledge, especially about a healthy lifestyle so that a wide range of problems began to arise from the respiratory tract, circulatory system and digestive system. Diseases of the digestive tract is one of them is appendiksitis. Appendiksitis or inflammation of the appendix is an inflammation of the appendix in the digestive tract. The impact caused appendiksitis is emerging from a variety of symptoms that can make people feel uncomfortable, ie symptoms that interfere with activities of daily living such as a sudden pain in the abdomen and solar plexus area, if allowed to continue appendiksitis can occur intestinal lumen obstruction. If Appendiksitis not done soon to be the treatment of severe infections, can cause rupture of the intestinal lumen that require special handling that is laparotomy. Appendiksitis an abdominal surgical emergencies are the most common. Highest incidence was found in the second and third decade of age, appendiksitis obtained from 1.3 to 1.6 times more often in men than in women. The cause of the form fekalit appendiksitis, worms ascariasis, and lymphoid tissue hyperplasia. Prevalence in the UK, according to a study by Douglas et al have exposed 302 patients with suspected appendiksitis after ultrasound. And to overcome apendiktomi appendiksitis has been done with a failure rate of about 9-11%, and 89% managed to cope with appendicitis. And other research conducted by Zielke et al, approximately 2000 patients say that about 6% of ultrasonography to detect appendiksitis.(2) II.2 Definition Appendicitis is an inflammation of the appendix. The inflammation is generally caused by an infection that will clog appendix.(3)

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Periappendicular mass is the body's defense efforts in limiting the inflammatory process by close appendiks the omentum and small intestine or adnekksa.(1) II.3 Anatomy

Appendix is a narrow closed tube attached to secum (initial part of the colon). Shaped like a worm putih.Secara anatomy is often referred to as appendix vermiformis. Appendix located at the bottom right of the abdomen. Precisely in ileosecum and is the third meeting of Taenia coli. Mouth of the appendix is located next to the postero-medial secum.Dari topographical anatomy, the position of the appendix is at a point Mc.Burney, namely the point on the line between the umbilicus and the right SIAs within 1/3 of the Messiah right. As in other parts of the intestine, appendix also has a mesentery. Mesentery is a layer of membrane that attaches the appendix to other structures in the abdomen. This position allows the appendix can move. Furthermore the size of the appendix may be longer than normal. Combination of the breadth of the mesentery with a long appendix causes the appendix to move into the pelvis (the pelvic organs in women). It can also cause the appendix to move behind the colon, called retrocolic appendix. Appendix innervated by the sympathetic and parasympathetic nerves. Parasympathetic innervation from branches of n. vagus that follows a. mesenterica superior and a. appendicularis. While sympathetic innervation derived from n. thoracalis X. Because it is visceral pain in appendicitis begins around umbilicus.Vaskularisasinya derived from branches of a.ileocolica a.appendicularis, a branch of a. mesenterica superior. (3)
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II.4 Physiology Function of the appendix in humans is not known with certainty. Allegedly associated with the immune system. In the appendix produces mucus layer. Mucus is normally applied to the appendix and secum. Flow resistance of mucus in the mouth of the appendix contribute to the pathogenesis of appendicitis. Wall consists of a network lymphe appendix which is part of the immune system manufacture antibodies. Sekretoar immunoglobulin produced by Galt (Gut Associated lymphoid Tissue) is Ig A. Immunoglobulin is very effective as a protection against infection.
(3)

II.5 Etiology The occurrence of acute appendicitis is usually caused by bacterial infection. But there are many factors trigger the disease. Among obstruction that occurs in the lumen of the appendix. Obstruction in the lumen of the appendix is usually caused due to an accumulation of hard stools (fekalit), hipeplasia lymphoid tissues, worm disease, parasites, foreign bodies in the body, the primary cancer and stricture. However, the most frequent cause obstruction of the lumen of the appendix is fekalit and hyperplasia of lymphoid tissue. (6) II.6 Pathophysiology Appendicitis is generally caused by obstruction and infection of the appendix. Some state that can act as trigger factors such as blockage of the lumen of the appendix by mucus that forms a continuous or feces from coming into the appendix from secum. Stool is hard as a rock and called fecalith. Obstruction resulted in the production of mucus can not go out and accumulate in the lumen of the appendix. Appendix lumen obstruction caused by a narrowing of the lumen due to hyperplasia of submucosal lymphoid tissue. The next invasion of bacteria into the wall of the appendix resulting in the infection process. Body to take the fight to improve the body's defense against these germs. This process is called inflammation. If this inflammatory process and infection spread through the wall of the appendix, the appendix can rupture. With rupture, infection will spread the germs on the abdomen, so that will happen peritonitis. In women when the invasion of germs through the pelvic organs, the fallopian tubes and
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ovaries can participate infected and cause an obstruction in the channel so that it can happen to infertility. In the event of an invasion of germs, the body will limit the process to close the appendix with the omentum, small intestine or adnexsa, forming a peri-appendicular mass. In it can occur in the form of abscess tissue necrosis that can be perforated. A ruptured appendix can also cause bacteria to enter the bloodstream, causing septicemia. Inflamed appendix will not ever recover completely, but will form scar tissue that causes adhesions to the surrounding tissue. These adhesions caused repeated complaints in the lower right abdomen. At one time these organs can become inflamed again and called the experience an acute exacerbation. (1,3,5) II.6 Diagnosis Appendicitis Symptoms Most people with appendicitis have classic symptoms that a doctor can easily identify. The main symptom of appendicitis is abdominal pain. The abdominal pain usually

occurs suddenly, often causing a person to wake up at night occurs before other symptoms begins near the belly button and then moves lower and to the right is new and unlike any pain felt before gets worse in a matter of hours gets worse when moving around, taking deep breaths, coughing, or sneezing Other symptoms of appendicitis may include

loss of appetite nausea vomiting constipation or diarrhea inability to pass gas

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a low-grade fever that follows other symptoms abdominal swelling the feeling that passing stool will relieve discomfort. (6) a. Physical examination

1. Inspection

Sometimes been seen when the patient walked with a stoop and hold the stomach. The patient was in pain. On abdominal inspection found no specific features. Bloating is often seen in patients with complications of perforation. Protrusion of the lower right abdomen can be seen in the mass or abscess appendiculer. (2.6)
2. Palpation

By palpation in the region point Mc. Burney found signs of local peritonitis, namely:
- Tenderness in Mc. Burney - Pain off. - Defans local muscular. Defans muscular stimulation showed a parietal peritoneum.

In the appendix retroperitoneal location, muscular defans may not exist, that there is low back pain
3. Auscultation

Normal peristaltic often. Peristalsis may be lost because of paralytic ileus in generalized peritonitis due to perforated appendicitis
4. Digital rectal examination

We will get right quadrant pain at 9-12. At pelvika appendicitis pain will get limited when performed digital rectal 5. Special Signs

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- Sign psoas Performed with the stimulus m.psoas by the patient in supine position, right leg held straight examiner, the patient was told to hyperextension or flexion active. Psoas sign (+) when it feels pain in the lower right abdomen. - Sign Rovsing Lower left abdomen is pressed, it will feel pain in the lower right abdomen. - Sign obturator Done by asking the patient to sleep on your back, then do endorotasi movement and flexion of the hip joint. Obturator sign (+) when it feels pain in the lower right abdomen.

c. Examination Support 1. Laboratory - Blood tests: leukocytosis would be obtained in most cases of acute appendicitis, especially in cases with complications. In the appendicular infiltrates, the LED will increase. - Urine examination: to see the erythrocytes, leukocytes and bacteria in the urine. This examination is very helpful in getting rid of the differential diagnosis of urinary tract infections or kidney stones that have clinical symptoms similar to appendicitis. 2. Abdominal X-Ray Used to see the fecalith as a cause of appendicitis. This examination is performed primarily in children. 3. Ultrasound
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When the results of physical examination in doubt, an ultrasound examination can be done, especially in women, also when the abscess is suspected. With ultrasound can be used to rule out differential diagnosis such as ectopic pregnancy, adnecitis and so on. 4. Barium enema That is an X-ray examination by inserting barium into the colon via the anus. This examination may indicate complications from appendicitis in the surrounding tissue and also to rule out differential diagnosis.
5. CT-Scan

May show signs of appendicitis. It also may indicate a complication of appendicitis as in case of an abscess.
6. Laparoscopi

That is an action by using a fiberoptic camera is inserted in the abdomen, the appendix can be visualized in langsung.Tehnik is performed under general anesthesia. If at the time of this action is found inflammation of the appendix at the time it can also be done directly appendix removal.(3) II.7 Different Diagnoses 1. Gastroenteritis On gastroenteritis, nausea, vomiting and diarrhea preceded the pain. Abdominal pain is lighter and not demarcated. Hiperperistaltik often found. Heat and leukocytosis is less prominent than with appendicitis. 2. Lymphadenitis mesenterica Usually preceded by enteritis or gastroenteritis. Characterized by abdominal pain, especially vague on the right, and accompanied by feelings of nausea and vomiting. 3. Pelvic inflammatory Fallopian tubes and ovaries are located right near the appendix. Inflammation is often simultaneously both oergan so-called salpingo-oophoritis or adnecitis.Untuk diagnosis of
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this disease found sexsual contact history. Temperature is usually higher than the lower abdomen appendicitis dannyeri more diffuse. Usually accompanied by vaginal discharge. In the vaginal plug if the uterus is swung it will hurt. 4. Ectopic pregnancy There is a history of delayed menstruation with a complaint that is not stabilized. In the event of tubal rupture or abortion outside of the uterus with bleeding will occur suddenly diffuse pain in the pelvis and hypovolemic shock may occur. On examination found pain and vaginal plug protrusion of the pouch of Douglas, and the kuldosentesis will get the blood. 5. Diverticulitis Although diverticulitis is usually located in the left abdomen, but sometimes it can also occur on the right. If there is inflammation and rupture of the diverticulum of clinical symptoms would be difficult to distinguish from the symptoms of appendicitis. 6. Ureter stones or kidney stones A history of abdominal colic from the waist to the right inguinal menjalarr to a typical picture. Hematuria is often found. Plain abdominal or intravenous urography can memestikan disease. (3) II.8 Management If you know the results of a positive diagnosis of acute appendicitis, the action the most appropriate is to be done apendektomi. Apendektomi can be done in two ways, namely how to open and laparoscopic way. If the new Appendisitis periapendikuler known after the mass is formed, then the first action to be done is the provision / antibiotic combination therapy against patients. This antibiotic is an antibiotic that is active against aerobic bacteria and anaerobic. Once symptoms improve, which is about 6-8 weeks, then apendektomi do. If symptoms persist, which is characterized by abscess formation, it is recommended to drainage and approximately 6-8 weeks then performed appendicectomy. However, if there were no complaints or any symptoms and clinical examination and laboratory tests are not showed signs of inflammation or abscess after antibiotic therapy, then can be considered to cancel the surgery. (3) II.9 Complication Appendicitis is a disease that rarely subsides spontaneously, but the disease is unpredictable and has a tendency be progressive and perforation occurred. Perforation rarely
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occurs in 8 hours The first, by karen's observations for the diagnosis of this safe to do within time. Signs of perforation include increased pain, muscle spasm right lower quadrant abdominal wall with a sign of generalized peritonitis or abscess localized, ileus, fever, malaise, and leukocytosis more details. When perforation with generalized peritonitis or abscess formation occurred since the patient came first, with a definite diagnosis can be established. In the event of general peritonitis, specific therapy does is act surgery to close the perforation origin. While the other acts as a support the patient is expected to bed rest in the Fowler position of the medium (half sitting), installation of NGT, fasting, correction fluids and electrolytes, giving a sedative, broad-spectrum antibiotics followed by antibiotics according to culture results, transfusions for treating anemia, and when there is a treatment of septic shock can be carried out intensively. If the appendix has formed an abscess will be palpable mass in the right quadrant under which tends to bubble to the rectum and vagina. initial therapy given a combination of antibiotics, eg ampicillin, gentamicin, metronidazole, or clindamycin. The existence of this preparation abscess will soon disappear, and apendiktomi can be performed 6-12 weeks later. On a permanent progressive abscess should immediate drainage. Pelvic abscess area that stands out in the direction of the rectum or vagina with a positive fluctuation of drainage also need to be made. Suppurative thrombophlebitis of the portal system is rare but is lethal complications. This should be suspected when fever is found sepsis, chills, hepatomegaly, and jaundice
after a perforated appendix. This state is an indication of the antibiotics in combination with

drainage.(3) II.10 Prognosis When an accurate diagnosis along with surgical treatment appropriate, the level of mortality and morbidity of this disease is very small. Delay diagnosis will increase morbidity and mortality when the onset of complications. Repeated attacks can occur when the appendix is not removed. (3)

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BAB III BIBILOGRAPHY

1. Hamami, AH, dkk, Usus Halus Appendiks, Kolon, dan Anorektum, dalam Sjamsuhidajat,

R, De jong. W, Buku Ajar Ilmu bedah, Edisi Revisi, EGC, Jakarta, 1997,
2. http://sariwiryanetty.blogspot.com/2009/10/appendik.html 3. http://medlinux.blogspot.com/2008/12/apendisitis.html 4. Mansjoer Arif et all, 2000. Kapita Selekta Kedokteran. Edisi 3. Jakarta: Penerbit Buku

Media Aesculapius.
5. Price, SA, Wilson,LM. 2005. Patofisiologi Proses-Proses Penyakit. Edisi 4. Vol 1. Jakarta.

EGC 6. http://www.emedicinehealth.com/appendicitis/page2_em.htm

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