yulius hermanto
Appendicitis, First Line of Therapy
Introduction
Appendicitis or an inflammation within appendix, is common disease in population with a lifetime occurrence of 7%. Appendicitis can occurs in all age groups but is most common in children, peaking in the second decade of life. It appears to affect males slightly more often than females.
Eventhough our technologic has been advanced, the diagnosis of appendicitis is still based primarily on the patient's history and the physical examination. Prompt diagnosis and surgical referral may reduce the risk of perforation and prevent complications. The mortality rate in nonperforated appendicitis is less than 1 percent, but it may be as high as 5 % or more in young and elderly patients, in whom diagnosis may often be delayed, thus making perforation more likely.
Pathophysiology of Appendicitis
Inflammation in appendix that leads into appendicitis is begin with obstruction of appendiceal lumen. An obstruction of the appendiceal lumen by any causes initiates the serial of events in acute appendicitis.
Obstruction can be caused by lymphoid hyperplasia (related to viral illnesses, including upper respiratory infection, mononucleosis, gastroenteritis), fecaliths, parasites, foreign bodies, Crohn's disease, primary or metastatic cancer and carcinoid syndrome. Lymphoid hyperplasia is more common in children and young adults, accounting for the increased incidence of appendicitis in these age groups.
Signs and Symptoms
Abdominal pain is the most common symptom of appendicitis. Usually the pain is moderately, dull-pain in the beginning, poorly localized in the abdomen. Then, migrated to right-lower quadrant of the abdomen, the pain become sharp pain, and localized.
Another accompanying symptoms such as anorexia, fever, nausea, and vomiting are symptoms that are commonly associated with acute appendicitis. Duration of symptoms exceeding 24 to 36 hours is uncommon in nonperforated appendicitis.
The symptoms of appendicitis are not spesific enough for appendicitis, because can be caused by other kind of diseases. Acute abdominal pain, mostly related to emergency in surgery. Thus it is important to differentiate or at least aware of acute abdominal pain.
The diagnostic procedures of appendicitis consists of several examinations, such as physical examinations, imaging, and laboratory examinations.
Treatment of Appendicitis
Although some researchers believe antibiotics can often cure appendicitis, surgery remains the more effective treatment. Uncomplicated appendicitis may be treated with antibiotics alone, but complicated appendicitis, where the appendix is perforated, requires surgery, and it is difficult to discern between the two.
"With the current technology, it is not possible to distinguish between uncomplicated and complicated appendicitis," said lead researcher Dr. Corinne Vons, of the Assistance Publique-Hopitaux de Paris and Universite Paris XI.
Most importantly, patients with appendicitis need to be given that antibiotic therapy is a perfectly acceptable option. There is a good chance that two-thirds of patients will not need an operation.
There are downsides to the operation as well, there is always the risk of anesthetic problems, of bleeding, of infections and bowel obstructions later on. In the future, patients with uncomplicated appendicitis will be treated with antibiotics first, and only if that treatment fails will the patient undergo an operation.
After all, we can conclude that the standard for management of nonperforated appendicitis remains surgery. Because prompt treatment of appendicitis is important in preventing further morbidity and mortality, a margin of error in over-diagnosis is acceptable. From the studies, the diagnostic error in management of appendicitis is about 20%, or about 20% of patients actually don't need the surgical procedure of appendectomy.
Appendectomy may be performed by laparotomy (usually through a limited right lower quadrant incision) or laparoscopy. Diagnostic laparoscopy may be helpful in equivocal cases or in women of childbearing age, while therapeutic laparoscopy may be preferred in certain subsets of patients (e.g., women, obese patients, athletes).
While laparoscopic intervention has the advantages of decreased postoperative pain, earlier return to normal activity and better cosmetic results, its disadvantages include greater cost and longer operative time. Open appendectomy may remain the primary approach to treatment until further cost and benefit analyses are conducted.
Complications
Appendiceal rupture accounts for a majority of the complications of appendicitis. Factors that increase the rate of perforation are delayed presentation to medical care, age extremes (young and old) and hidden location of appendix.
Diagnosis of a perforated appendix is usually easier (although immediately after rupture, the patient's symptoms may temporarily subside). The physical examination findings are more obvious if peritonitis generalizes, with a more generalized right lower quadrant tenderness progressing to complete abdominal tenderness. An ill-defined mass may be felt in the right lower quadrant. Fever is more common with rupture, and the WBC count may elevate to 20,000 to 30,000 per mm3 (200 to 300 3 109 per L) with a prominent left shift.
A periappendiceal abscess may be treated immediately by surgery or by nonoperative management. Nonoperative management consists of parenteral antibiotics with observation or CT-guided drainage, followed by interval appendectomy six weeks to three months later.
Appendicitis or an inflammation within appendix, is common disease in population with a lifetime occurrence of 7%. Appendicitis can occurs in all age groups but is most common in children, peaking in the second decade of life. It appears to affect males slightly more often than females.
Eventhough our technologic has been advanced, the diagnosis of appendicitis is still based primarily on the patient's history and the physical examination. Prompt diagnosis and surgical referral may reduce the risk of perforation and prevent complications. The mortality rate in nonperforated appendicitis is less than 1 percent, but it may be as high as 5 % or more in young and elderly patients, in whom diagnosis may often be delayed, thus making perforation more likely.
Pathophysiology of Appendicitis
Inflammation in appendix that leads into appendicitis is begin with obstruction of appendiceal lumen. An obstruction of the appendiceal lumen by any causes initiates the serial of events in acute appendicitis.
Obstruction can be caused by lymphoid hyperplasia (related to viral illnesses, including upper respiratory infection, mononucleosis, gastroenteritis), fecaliths, parasites, foreign bodies, Crohn's disease, primary or metastatic cancer and carcinoid syndrome. Lymphoid hyperplasia is more common in children and young adults, accounting for the increased incidence of appendicitis in these age groups.
Signs and Symptoms
Another accompanying symptoms such as anorexia, fever, nausea, and vomiting are symptoms that are commonly associated with acute appendicitis. Duration of symptoms exceeding 24 to 36 hours is uncommon in nonperforated appendicitis.
The symptoms of appendicitis are not spesific enough for appendicitis, because can be caused by other kind of diseases. Acute abdominal pain, mostly related to emergency in surgery. Thus it is important to differentiate or at least aware of acute abdominal pain.
The diagnostic procedures of appendicitis consists of several examinations, such as physical examinations, imaging, and laboratory examinations.
Treatment of Appendicitis
Although some researchers believe antibiotics can often cure appendicitis, surgery remains the more effective treatment. Uncomplicated appendicitis may be treated with antibiotics alone, but complicated appendicitis, where the appendix is perforated, requires surgery, and it is difficult to discern between the two.
"With the current technology, it is not possible to distinguish between uncomplicated and complicated appendicitis," said lead researcher Dr. Corinne Vons, of the Assistance Publique-Hopitaux de Paris and Universite Paris XI.
Most importantly, patients with appendicitis need to be given that antibiotic therapy is a perfectly acceptable option. There is a good chance that two-thirds of patients will not need an operation.
There are downsides to the operation as well, there is always the risk of anesthetic problems, of bleeding, of infections and bowel obstructions later on. In the future, patients with uncomplicated appendicitis will be treated with antibiotics first, and only if that treatment fails will the patient undergo an operation.
After all, we can conclude that the standard for management of nonperforated appendicitis remains surgery. Because prompt treatment of appendicitis is important in preventing further morbidity and mortality, a margin of error in over-diagnosis is acceptable. From the studies, the diagnostic error in management of appendicitis is about 20%, or about 20% of patients actually don't need the surgical procedure of appendectomy.
Appendectomy may be performed by laparotomy (usually through a limited right lower quadrant incision) or laparoscopy. Diagnostic laparoscopy may be helpful in equivocal cases or in women of childbearing age, while therapeutic laparoscopy may be preferred in certain subsets of patients (e.g., women, obese patients, athletes).
While laparoscopic intervention has the advantages of decreased postoperative pain, earlier return to normal activity and better cosmetic results, its disadvantages include greater cost and longer operative time. Open appendectomy may remain the primary approach to treatment until further cost and benefit analyses are conducted.
Complications
Appendiceal rupture accounts for a majority of the complications of appendicitis. Factors that increase the rate of perforation are delayed presentation to medical care, age extremes (young and old) and hidden location of appendix.
Diagnosis of a perforated appendix is usually easier (although immediately after rupture, the patient's symptoms may temporarily subside). The physical examination findings are more obvious if peritonitis generalizes, with a more generalized right lower quadrant tenderness progressing to complete abdominal tenderness. An ill-defined mass may be felt in the right lower quadrant. Fever is more common with rupture, and the WBC count may elevate to 20,000 to 30,000 per mm3 (200 to 300 3 109 per L) with a prominent left shift.
A periappendiceal abscess may be treated immediately by surgery or by nonoperative management. Nonoperative management consists of parenteral antibiotics with observation or CT-guided drainage, followed by interval appendectomy six weeks to three months later.
