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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.
Periappendicular Mass 2
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 :
Periappendicular Mass 3
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
Periappendicular Mass 4
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
Periappendicular Mass 5
Liver:
Not enlarged, sharp edges, flat surfaces, smooth texture homogeneous parenchyma, capsule
Periappendicular Mass 6
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?
Periappendicular Mass 7
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
Periappendicular Mass 8
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.
Periappendicular Mass 9
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
Periappendicular Mass 10
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
Periappendicular Mass 11
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
Periappendicular Mass 12
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
Periappendicular Mass 13
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
Periappendicular Mass 14
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
Periappendicular Mass 15
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)
Periappendicular Mass 16
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
Periappendicular Mass 17
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
Periappendicular Mass 18
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
Periappendicular Mass 19