DEFINITION
Acute Appendicitis is a sudden condition in which appendix becomes inflamed and fills with pus at vermiform appendix (Right Iliac Fossa).
Appendix is a finger-shaped pouch that projects out from colon on the lower right side of abdomen.
PROGNOSIS
Perforation: In patients under age 10 or over age 30 (50%), Other (10%)
Without surgery or antibiotics, mortality is > 50%.
With early surgery, the mortality rate is < 1%, and convalescence is normally rapid and complete. With complications (rupture and development of an abscess or peritonitis), the prognosis is worse: Repeat operations and a long convalescence may follow.
ETIOLOGY
The cause of appendicitis isn't always clear. Sometimes acute appendicitis can occur as a result of:
· An obstruction.
Food waste or a hard piece of stool (fecal stone, hardened stool), calculus, worm, neoplasm can block the opening of the cavity that runs the length of appendix.
· Adhesion
Adhesion at appendix walls or nearby structure because of disease or fibrosis.
· “Kinking” appendix
The appendix becomes inflamed and edematous as a result of becoming kinked.
· An infection.
Appendicitis may also follow an infection, such as a gastrointestinal viral infection, or it may result from other types of inflammation. The most common bacteria in the appendix are Bacteroides fragilis and Escherichia Coli.
PATOPHYSIOLOGY
Acute appendicitis seems to be the end result of a primary obstruction of the appendix lumen. Once this obstruction occurs the appendix subsequently becomes filled with mucus and swell, increasing pressures within the lumen and the walls of the appendix, resulting in thrombosis and occlusion of the small vessels, and stasis of the lymphatic flow. As the former progresses, the appendix becomes ischemic and then necrotic. As bacteria begin to leak out through the dying walls, it inflamed. Pus forms within and around the appendix. The end result of this is appendicle rupture causing gangrene, peritonitis, which may lead to septicemia and eventually death.
CLINICAL MANIFESTATION
1. Pain
· Acute pain suddenly in the right iliac fossa. Characterized by Colicy
· Pain usually begins in the center of the abdomen, around the navel area. Later, the pain may move downward and to the right, to an area called McBurney's point and pain when pressure is released (Rebound Tenderness)
· Rovsing’s sign – deep palpation will cause pain in the right iliac fossa
· Pain increased when moving/coughing.
2. Nausea and Vomiting
Due to pain in the abdomen
3. Anorexia
Due to prolonged pain
4. Fever (37.8oC – 38.3oC), Tachypnea, Tachycardia
Due to inflammatory process and dehydration
5. Constipation/Diarrhea
Inflammatory process disrupt peristalsis movement
6. Dehydration
Coated tongue/halitosis
7. Lethargic, Malaise
Due to fever
TEST AND DIAGNOSIS
1) Physical Examination
· Rebound Tenderness at Right Iliac Fossa.
· Gentle pressure on the painful area. When the pressure is suddenly released, appendicitis pain will often feel worse, signaling that the adjacent peritoneum is inflamed. Other signs, watch for include abdominal rigidity and a tendency to stiffen abdominal muscles in response to pressure over the inflamed appendix.
2) Rectal Examination
If pain means inflammation at rectocecal
3) Blood Test
To check for a high White Blood Cell Count, which may indicate an infection. (Leukocytosis = >12.000 – 20.000)
4) Urine F.E.M.E (Full Examination Microscopic Examination)
Urinalysis to make sure that a urinary tract infection or a kidney stone isn’t causing pain.
5) Imaging Test
An abdominal X-ray (feacalith), an Ultrasound scan or a computerized tomography (CT) scan to help confirm appendicitis.
TREATMENT
1. CONSERVATIVE
a) Reduce Pain
Complete Rest In Bed, comfort position
· No analgesic before diagnosis of appendicitis because it will lose sign
· No hot water bag. It will cause rupture
b) Nil By Mouth (6-8hours)
To avoid aspiration pneumonia
c) Treat Fever
>37.5 oC = cold compress, >38oC = tepid sponging
d) Observation
Vital Sign, general condition (vomit- amount and content, record and do mouth toilet
e) Antibiotic to kill microorganism
f) Intake output chart
Due to lost of appetite and weight (LOA & LOW)
2. SURGICAL (APPENDICECTOMY)
· Appendicectomy is the surgical procedure for removal of the appendix.
· The operation can be performed via a laparoscopic approach or via 3 small incision with camera to visualize the area of interest in abdomen.
· Open laparotomy may be necessary of findings reveal suppurative appendicitis with complications such as rupture, abscess, adhesions.
PREOPERATIVE CARE
1. Consent form
As a medico legal from patient
2. Skin Prep
From nipple line to mid thigh to avoid microorganism from skin
3. Electrocardiogram if more 40 years old
4. Investigation
- Hb, TWBC, Urine FEME
- BUSE, RBS if more 40 years old
5. Anesthetist
Under general anesthesia to give pre medication and reduce anxiety such as valium, morphine
6. Weight for calculate the dose of medication
POST OP CARE
(1) IMMEDIATE CARE
a. Keep Nil By Mouth to avoid aspiration pneumonia
Give IV Drip cause of KNBM
b. Observation
· Vital Sign
- Hyperpyrexia, tachycardia (sign of infection)
- Hypotension (sign of hypovolemic shock)
· General condition = pale, weak, pain
· Inspection of Surgical Wound to prevent infection and hypovolemic shock
c. Medication
· Analgesic to reduce pain, example: IM Voltaren 50mg sta
· Antibiotic to kill microorganism (E.coli), example: IV Cloxacillin 1g
d. Ryle’s Tube
· Aspiration/free flow, measure and record
e. Drainage Tube (for perforated appendix)
· Hang the drainage bottle safely
· Monitor amount, color and record
· Avoid tangled/twisted
f. Position
· Supine first and lateral position to secretion out
· Give a pillow when patient conscious
(2) SUBSEQUENT CARE
a. Nutrition
· Clear fluid if there’s bowel sound
· Continue with nourishing fluid, then Soft diet and Normal diet
b. Continued observation
c. Continued Medication, such as antibiotic, analgesic
d. Early ambulation
· Seated after 24hour to avoid hypostatic pneumonia
e. Breath and coughing exercise to expanse lungs and decrease of pain
f. Wound care
· Dressing under aseptic technique
· Avoid contact wound with dirty hand
· STO for 5th-7th day after op
g. Activity daily Living
Personal hygiene, elimination and avoid injury
HEALTH EDUCATION BEFORE DISCHARGE
1) Wound care
· Avoid wet wound, not to touch wound with dirty hand
2) Taking Medication
· Consume antibiotic, vitamin for healing process of the wound
3) Nutrition
· High protein (fish, meat, egg)
· Vitamin (orange, grape)
4) Personal hygiene
Clothes clean, not wet
5) Activity
Can carry the heavy thing after 6weeks
6) TCA/ FOLLOW UP
STO for 5th-7th day, monitor of healing process of the wound
COMPLICATIONS
· A ruptured appendix.
If appendix ruptures, the contents of intestines and infectious organisms can leak into abdominal cavity.
· A pocket of pus that forms in the abdomen.
If appendix has burst, infection and the seepage of intestinal contents may form an abscess-a pocket of infection around the appendix. Causing a more widespread infection of the abdominal cavity
· Appendicular Mass
Chronic inflammatory will form fibrosis and structural hardening.
· Peritonitis
Will happen if the inflammation spreads to peritoneum cavity.
· Infected Wound
Will occur when patient do not take care of appendicectomy wound.
· Adhesion may cause intestinal obstruction but this is not common.
