Case Personal Appendicular Mass-noviana Wulandari-wulan-1102005180

CASE PERSONAL

PERIAPPENDICULAR MASS

DISUSUN OLEH :Noviana Wulandari

110.2005.180

PEMBIMBING :

dr. Herry Setya Yudha Utama, SpB MHKes FinaCS

Kepaniteraan Klinik Mahasiswa FakultasKedokteran Universitas YARSI Bagian

Ilmu BedahBRSUD Arjawinangu

Periappendicular Mass 1

BAB I

CASE PERIAPPENDICULAR MASS

I. Identity

Name : Mr. Samsuri

Age :40 Years

Gender : Male

Religion : Islam

Occupation : Farmer

Address : South Wanasaba

RS Date Added : March 18, 2012

II. Anamnesa

Main complaint : Abdominal pain

Additional complaints : 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.

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 : Compos mentis

Vital Signs

• Blood pressure : 120/80 mmHg

• Pulse : 84 x / minute

• Respiratory : 24 x / minute

• Temperature : 36.2 C

Status Generalis

Head

• Shape : Normocephal

• Eyes : Conjunctiva anemis - / -, sclera jaundice - / -

• Nose : Normal shape, septum in the middle, no deviation

• Mouth : Lips do not cyanotic, the tongue is not dirty, not hiperemis

• Ears : Normal form, symmetry, intact tympanic membrane

Neck

• Inspection : No visible enlargement of the KGB

• Palpation : No palpable enlarged lymph nodes, no enlargement of the

thyroid, the JVP has not increased

Lung

• Inspection : Form symmetrical right and left chest

• Palpation : Tactile Fremitus right = left

• Percussion : Resonant to both lung fields

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

Heart

• Inspection : Cardiac Iktus not seem

• Palpation : Iktus cardiac palpable rib V line between the left midclaviculla

• Percussion :


The upper limit : Sela left sternal ribs III line

Right Limits : Sela right sternal ribs IV line

The left boundary : 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 : Abdomen enlarged symmetrically

• Auscultation : Bowel sounds (+) normal

• Palpation : Abdominal tenderness (+)

• Percussion : Timpani in the entire field abdomen

Genitalis : No abnormalities

Extremities:

- Superior : Warm

Palmar erythema (- / -)

Cyanosis (- / -)

Clubbing (- / -)

Edema (- / -)

- Inferior : Warm

Edema (- / -)

Cyanosis (- / -)

IV. EXAMINATION SUPPORT

laboratory

Routine blood March 18, 2012

Hb : 8,9 g/dl

Eritrosit : 4,70 106/μl

Leukosit : 23,4 103/μl

Trombosit : 745 103/μl

Routine blood March 21, 2012

Hb : 10,8 g/dl


Eritrosit : 5,28 106/μl

Leukosit : 19,0 103/μl

Trombosit : 569 103/μl

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

USG Abdomen


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 ..

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 : dubia ad bonam

• Quo ad functionam : dubia ad bonam


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)

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)

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 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

a. 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

a low-grade fever that follows other symptoms

abdominal swelling

the feeling that passing stool will relieve discomfort. (6)

b. 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

- 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

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 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

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)

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


http://medlinux.blogspot.com/2008/12/apendisitis.html

http://sariwiryanetty.blogspot.com/2009/10/appendik.html

Case Personal Appendicular Mass-noviana Wulandari-wulan-1102005180

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