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

PATIENTS 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

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 : 37,7C (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

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
- McBurneys sign (+)
- Rovsings 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

/L

5.000 10.000

Trombosit

75.000

/L

150.000 400.000

CT

menit

26

BT

menit

13

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

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

leukosit

2-3

<5 / LPB

Eritrosit

1-2

<3 / LPB

EPITEL

<1 / LPK

Silinder

K. Ca Oxalat

K. As. Urat

K. Tripel Phosphat

Amorf

SEDIMEN

Electrocardiogram :

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 37,7C. 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
McBurneys, Rovsings, Dunphys 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) 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

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

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.

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.

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.

10

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) 2 days

Inj. Tramadol 2 x 100 mg (IV) 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

11

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 -/ENT : hyperemia phanynx (-), T1/T1
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 pro-op
P:
-

IVFD RL 20 gtt/min

Inj. Ondancentron 3 x 4 mg IV

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

Ulsafat syrup 3 x C1 PO

12

8/7/15

Paracetamol 3 x 500 mg tab PO

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

S : nausea (-), vomiting (-). Headache (-). Fever (+).

O:
General condtion : moderately ill
Conciousness : CM
BP: 120/70 ; P : 86 bpm ; RR: 20 x/m; T: 37,4
STATUS GENERALIS
Eyes : RCL +/+, RCTL +/+, isocor 3mm, CA -/-, SI -/ENT : hyperemia phanynx (-), T1/T1
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

12,4

Ht

35

Leu

8.900

Trom

91.000

A : DHF grade I
Acute Appendicitis pro-op
P:
-

IVFD RL 20 gtt/min

Inj. Ondancentron 3 x 4 mg IV

13

9/7/15

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

Ulsafat syrup 3 x C1 PO

Paracetamol 3 x 500 mg tab PO

Appendictomy at 08.00 AM

S : nausea (+), vomiting (-), headache (-). Pain on surgical wound.

Flaatus (+).
O:
General condtion : moderately ill
Conciousness : CM
BP: 120/80 ; P : 90bpm ; RR: 18 x/m; T: 36,3
STATUS GENERALIS
Eyes : RCL +/+, RCTL +/+, isocor 3mm, CA -/-, SI -/ENT : hyperemia phanynx (-), T1/T1
Neck : lymphadenopathy (-)
Thorax :
- Heart : S1S2 regular, M (-), G (-)
- Lungs : Vesicular breath sound, Wh -/-, Rh -/Exremities : warm, edema -/STATUS LOKALIS
Abdomen :
- Surgical wound closed by kassa verban. Leakage (-), Bowel sound
(+) minimal. Tenderness (+).
A : DHF grade I improvement.
Post Appendictomy Day 1.
P:
-

IVFD RL: D5% = 1: 3 28 gtt/min

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

Inj. Tramadol 2 x 100 mg IV

Diet : drink gradually. And for afternoon : porridge.

14

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

Anorexia

Nausea

Tenderness in RLQ

Rebound tenderness

Elevated temperature

Leukocytosis

Shifting of WBC to the left

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.

15

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

16

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

17

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

18

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.

19

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.

20

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.
Thirteenth Ed. New York, NY: McGraw-Hill Companies; 2010. h,615-8.

21