CASE 3 TG Appendicitis 2013

8/19/2019 CASE 3 TG Appendicitis 2013

http://slidepdf.com/reader/full/case-3-tg-appendicitis-2013 1/35

Semester : 6

160

TUTOR GUIDE

Gastrointestinal System

Case 5

(APPENDI ITI )

3rd Year FACULTY OF MEDICINE

UNIVERSITAS PADJADJARAN

BANDUNG

2013-2014



System : Gastrointestinal

Week theme : small intestine and appendix

Trigger case : acute appendicitis and peritonitis (SKDI competency level 3B)

Differential diagnoses :

Week schedule : tree meetin!s

Week obecti!es

At the end of the week, the student will be able to:1. Review the patho-physiology of abdominal pain (C-2.2. Compa!e and "ont!ast between somati" pain and vis"e!al abdominal pain (C-#$. %&plain the developmental anatomy of the appendi& (C-2'iomed#. Review the anatomy of the appendi& (C-2'anatomy). *es"!ibe the mi"!ost!u"tu!es of the appendi& (C-2'histology+. %&plain the definition of appendi"itis (C-2. %&plain the histo-pathologi"al featu!es of appendi"itis, in"luding a"ute, "h!oni" and a"ute

e&a"e!bation on "h!oni" appendi"itis. (C-2'A

. %&plain the histo-pathologi"al featu!es of "a!"inoid of the appendi&. (C-2'A/. *is"uss the patho-physiology of appendi"itis (C-210. Compa!e and "ont!ast the histo-pathologi"al featu!es and "lini"al pi"tu!es between a"ute

appendi"itis and "h!oni" appendi"itis, a"ute e&a"e!bation on "h!oni" appendi"itis. (C-2'A11. *es"!ibe the natu!al "ou!ses and "ompli"ations of appendi"itis. (C-212. *es"!ibe the signs and symptoms of a"ute appendi"itis (C-21$. *is"uss the diffe!ential diagnosis of a"ute appendi"itis (C-2.1#. App!aise the steps taken to diagnose a"ute appendi"itis (C-#.1). %&plain the !ole of abdominal imaging in diagnosing appendi"itis (C-21+. *is"uss the management of simple a"ute appendi"itis, and "ompli"ated appendi"itis (C-2.1. *es"!ibe the anatomy of the pe!itoneum and pe!itoneal "avity, in"luding the basi" p!in"iples of

abdominopelvi" "avity, and the division of pe!itoneum and pe!itoneal "avity.(C-21. *es"!ibe the physiology of the pe!itoneum.(C-2

1/. %&plain the "on"epts of pe!itonitis, epsis, and ystemi" nflammato!y Responses ynd!ome( C-2

20. *es"!ibe the etiology and "lassifi"ation of pe!itonitis (C-221. %&plain the patho-physiology of se"onda!y pe!itonitis (C-222. *is"uss the "ompli"ation of pe!itonitis (C-22$. %&plain the signs and symptoms of p!ima!y and se"onda!y pe!itonitis (C-22#. App!aise the steps taken to diagnose se"onda!y pe!itonitis (C-#2). *is"uss the diffe!ential diagnosis of se"onda!y pe!itonitis (C-#2+. nte!p!et plain abdominal 3-!ay of the a"ute abdomen (C-#2. *is"uss the suppo!tive and definitive t!eatments of se"onda!y pe!itonitis (C-22. ethi"al issues on su!gi"al "ompli"ations2/. fo!mulate !esea!"h p!oblem of the "ase

161



CASE 3

Page 1

4ate at night, 5s. 6dilia, a 20-yea!-old woman, "omes to you when you a!e doing you! evening dutyat 7asanadikin 7ospital andung.

he tells you that she "omplains of !ight lowe! abdominal pain.

Question:1. 8hat is 5s. 6dilia p!oblem92. 8hat is you! hypothesis9$. 8hat fu!the! info!mation do you need9

TUTOR MANUAL:

tudent is e&pe"ted to identify:

• Chief "omplaint: !ight lowe! abdominal pain

• *iffe!ential diagnosis of !ight abdominal pain in female patients:1. A"ute appendi"itis2. %"topi" p!egnan"y$. 6va!ial Cyst to!sion#. 5ittels"hme!). Renal;u!ete!al "oli"+. 5esente!i" adenitis: tube!"ulosis, non tube!"ulosis. leitis te!minalis. *ive!ti"ulitis 5e"kel/. Adne&itis10. <ubo-ova!ial abs"ess11. Abdominal in=u!y12. 5alignan"y of the "ae"um: "a!"inoma, lymphoma, "a!"inoid

Page 2

5s. 6dilia has suffe!ed the pain sin"e 2 days ago. t was p!e"eded by epigast!i" pain and withinseve!al hou!s the pain moved towa!ds the !ight abdomen. <he pain be"ame steady and mo!eseve!e.

in"e seve!al hou!s ago 5s. 6dilia has got feve!. he also "omplains of nausea, vomiting, and he! appetite is !edu"ed. he is still able to have he! bowel movement and denies having histo!y of dia!!hea and "hanges in bowel habit.

5s. 6dilia has no histo!y of abno!mal mi"tu!ition and vaginal dis"ha!ge.

he neve! had any abdominal su!ge!y befo!e. he denies having !e"ent abdominal in=u!y.7e! menst!uation is !egula!, about eve!y 2 days, and he! last menst!uation was 2 days ago.

QUESTION:

1. 8hat is 5s. 6dilia p!oblem now92. *o you "hange you! hypothesis9$. 8hat fu!the! info!mation do you need9

TUTOR MANUAL:


• 6nset, "ha!a"te!isti"s, and a""ompanying symptoms of the abdominal pain

16"



• <he "onve!sion of initial vis"e!al pain into somati" pain

• athophysiology of a"ute abdominal pain

Page 3

>ou e&amine 5s. 6dilia with the do"to! in "ha!ge at the %me!gen"y ?nit.

@ene!al imp!ession shows that 5s. 6dilia is mode!ately ill. <he blood p!essu!e is 100;+0 mm 7g,and she looks pe!spi!ing. <he pulse !ate is 10#&;minutes, !espi!ato!y !ate is 2#;minutes, and he!

body tempe!atu!e is $°C. <he "on=un"tiva is not anemi".

6n abdominal e&amination you en"ounte! that the abdomen is not distended, but tende!ness and!ebound tende!ness a!e eli"ited at the !ight lowe! uad!ant. <he!e is no s"a! at the abdomen. >oudo not find any mass no! mus"ula! !igidity at the 5" u!ney !egion. <he bowel sound is de"!eased.<he live!, gall bladde!, and spleen a!e not palpable. soas sign and "ough sign a!e positive, as wellas RovsingBs sign. >ou do not find any abno!mality at the flank !egions.

>ou also pe!fo!m the digital !e"tal e&amination, and you find no!mal sphin"te! tone, inta"t mu"osa,no "ollapsed ampulla, and pain espe"ially at the / to 12 oB"lo"k position. <he!e is no abno!mality inthe *ouglas "avity and no pain eli"ited when the po!tio is moved.

aginal e&amination is not done.

QUESTION:

1. 8hat is 5s. 6dilia p!oblem now92. *o you "hange you! hypothesis9$. 8hat fu!the! info!mation do you need9

TUTOR MANUAL:


• <ypi"al physi"al signs of a"ute appendi"itis.

• *iagnosti" e&"lusions of gyne"ologi"al p!oblems

• <he needs of spe"ial investigations

Page 4

<he do"to! in "ha!ge o!de!s supplementa!y diagnosti" info!mation and tests of 5s. 6dilia.

Do!mal values7b: 12,1g! E 12.$ F 1).$ mg;d48C: 1).200;mm$ # #00 F 11 $00 ;

asophil: 0 0-1 E%osinophil: 1 2-# Eatang: 0 $-) Eegmentation: 0 )0-0 E4impho"yte: 12 2)-#0 E5ono"yte: 2- E

%R: #0mm;h! 10-20 mm;h!

?!ine sediment: 4euko"yte: 1-2 0-2;hpf

163





tudent is e&pe"ted to be able to :

• *efinition, pathophysiology, natu!al "ou!ses and "ompli"ations of appendi"itis

• nitial management of a"ute appendi"itis

• u!gi"al management of a"ute appendi"itis

• Compa!e and "ont!ast the histopathologi"al featu!es and "lini"al pi"tu!es between a"ute

appendi"itis and "h!oni" appendi"itis, in"luding a"ute e&a"e!bation on "h!oni" appendi"itis

• 7istopathologi"al featu!es of "a!"inoid of the appendi&

Page

e"ause of a ve!y busy night in ope!ating !oom, 5s 6dilia has to wait seve!al hou!s to get theope!ation. 8hile waiting, she feels ve!y painful in all of he! abdomen. he look pale and

pe!spi!ated, but still "ons"ious. 7e! tempe!atu!e is $,+°C. <he blood p!essu!e was 100;+0 mm7g,

and the pulse !ate is 120beats;minute. <he !espi!ato!y !ate is $2&;minute. 6n abdominale&amination, you find the abdomen was !athe! distended, but symmet!i"al. <he pe!istalti" is s"a!"e.

*iffuse tende!ness in uppe! abdomen is eli"ited, but live! dullness p!esented with va!ying tymphany.6n palpation, the mus"ula! !igidity and !ebound tende!ness was e&e!ted.

*igital Re"tal %&amination en"ounte!s weak sphin"te! tone, inta"t mu"osa, "ollapsed ampulla andtende!ness upon upwa!d th!ust*u!ing ope!ation, you find the appendi& is gang!enous, with sie of 10 "m length and 1.) "m indiamete!, and is filled with fe"alith at the p!o&imal thi!d. >ou also find bad smell pus "olle"tionsu!!ounding the appendi& and in the pe!itoneal "avity app!o&imately #0 "". <he do"to! also takesswab f!om the pe!iappendi& !egion and blood sample fo! "ultu!e

<he appendi& tissue is e&amined histopathologi"ally and the !esult "onfi!ms the diagnosis :pe!fo!ated a"ute appendi"itis

lood "ultu!e is negative and the swab "ultu!e !esult is positive E.coli and Bacteroidesfragilis .

QUESTION:

1. 8hat is you! imp!ession to the ope!ation findings9$. 8hat do you e&pe"t f!om the histopathologi"al e&amination9#. 8hat is you! plan afte! su!ge!y9

GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG

E!i"ogue:

Afte! the su!ge!y 5s. 6dilia !e"ove!s well and she is dis"ha!ged on the fifth day afte! su!ge!y. n thefollowing week she is able to !esume he! no!mal daily a"tivities.

16$



#ui$ing Questions an$ %an$outs:

1& '(at is Ms& A"iena)s !*o+"e, -<he patient suffe!s f!om a"ute !ight lowe! abdominal pain, of whi"h has been happening fo! twodays. <he pain is initially a vis"e!al pain in natu!e and lo"ated in the epigast!i" !egion. <he followinghou!s it moves to the !ight lowe! abdominal !egion and be"omes steady and in"!easingly mo!e

painful. <hus, the pain be"omes somati" pain in natu!e as a !esult f!om inflammation of the ad=a"entpa!ietal pe!itoneum of the appendi&. <he a""ompanying symptoms in this patient "ome f!om the"ompli"ation of appendi"itis, whi"h in"lude gang!enous appendi"itis and sepsis. ystemi"inflammato!y !esponses synd!omes o""u! in sepsis and in this patient, they manifest as feve!, lossof appetite, nausea and vomiting. 7oweve!, as seve!e sepsis has not yet imposed, dysfun"tion of gast!ointestinal and othe! o!gan systems has not happened.

2& List .ou* (.!ot(esis/*iffe!ential diagnosis of !ight abdominal pain in female patients:

1. A"ute appendi"itis2. %"topi" p!egnan"y$. 6va!ial Cyst to!sion#. 5ittels"hme! (Ruptu!e of the Holli"le @!aaft

). Renal;u!ete!al "oli"+. 5esente!i" adenitis: tube!"ulosis, non tube!"ulosis. leitis te!minalis. 5e"kelBs *ive!ti"ulitis/. Adne&itis10. <ubo-ova!ial abs"ess11. Abdominal in=u!y12. 5alignan"y of the "ae"um: "a!"inoma, lymphoma, "a!"inoid

6the! "auses of abdominal pain:

Abdominal pain is defined as:

• ICondition whi"h !eui!es immediate t!eatmentJ (H* 5oo!e, 1/: s it likely to!eui!e su!ge!y9 8hen to pe!fo!m9

• (uku A=a! lmu edah, 1//: IClini"al "ondition whi"h a!ises f!om a"ute "!iti"al

"ondition in the abdominal "avity, and usually manifests as pain.

• A"ute abdominal pain: Chief "omplaint: a"ute pain (Dyhus, itello, Condon, 1//)

• A"ute abdominal pain is loosely defined as pain p!esent fo! less than hou!s.

(@!eenfield, 1//

t is impo!tant be"ause patients with a"ute abdomen suffe! f!om sudden onset of pain withun"lea! etiology but likely to !eui!e immediate diagnosis K t!eatment to p!event mo!bidity Kmo!tality. <he diagnosis "an be established by good and meti"ulous histo!y taking in +0 F0 E of "ases.

n medi"al histo!y, the patient has been suffe!ing f!om sudden onset of pain on theepigast!i" !egion with in"!easing in seve!ity and p!og!essing th!oughout the abdomen lessthan 2# hou!s.

<he "auses of sudden onset of pain:

166



<he natu!e of the pain is steady ("ontinuous and sha!p, but without !efe!!ed pain. odymovement agg!avates the pain, but being steady alleviates the pain. 6the! symptoms thata""ompany the pain a!e vomiting, faintness and distended abdomen. 7oweve!, the patientis still able to have his bowel open (no yet "hange in bowel habit: no dia!!hea, "onstipationand does not yet suffe! f!om feve!.

2& List a"" !ossi+"e 0auses o a0ute a+$o,ina" !ain/

?ppe! abdominal pain :

• epti" o! gast!i" ul"e!

• A"ute Chole"ystitis, A"ute Cholangitis

• an"!eatitis

• %a!ly Appendi"itis

• 7epatitis o! live! abs"ess

• %&t!a abdominal:

i. nfe!io! leu!itis, loba! pneumonia, pneumotho!a&ii. e!i"a!ditis, 5yo"a!dial infa!"tion, anginaiii. yeloneph!itis, !enal "oli"

Cent!al abdominal pain:

• %a!ly appendi"itis

• owel obst!u"tion, st!angulated

• an"!eatitis

• @ast!oente!itis

• 5esente!ial %mboli ;<h!ombosis

• *isse"ting ao!ti" aneu!ism

• 5esente!i" adenitis

• %a!ly sigmoid dive!ti"ulitis

4owe! abdominal pain:

• %a!ly appendi"itis

• owel obst!u"tion, st!angulated

• an"!eatitis

• @ast!oente!itis

• 5esente!ial %mboli ;<h!ombosis

• *isse"ting ao!ti" aneu!ism

• 5esente!i" adenitis

• %a!ly sigmoid dive!ti"ulitis

• O+stet*i0s 0auses : %"topi" gestation, abdominal p!egnan"y, !uptu!e of the ute!us,

mola *est!uen

• #.ne0o"ogi0 0auses: * uptu!ed ova!ial "yst, ova!ial to!sion, myoma, !uptu!ed

abs"ess, pe!fo!ated ?te!us.

16%



3& '(at in$s o a+$o,ina" !ain $oes (e sue*-

<he patient suffe!s f!om somati" abdominal pain due to pe!itoneal i!!itation of the pa!ietaland vis"e!al pe!itoneum of the ad=a"ent pe!fo!ation site. @ast!i" and duodenal =ui"es that"ome out f!om the pe!fo!ated duodenal ul"e! a!e the p!ima!y sou!"es of pe!itoneal i!!itant.<he =ui"es stimulate initial inflammato!y !esponses, and as the p!o"ess "ontinues, ba"te!ial"oloniation will o""u!, that leads to p!odu"tion of pu!ulent e&udates. <he!efo!e, afte! 12hou!s infe"tion will ensue.

4& '(at is t(e ,e0(anis, o a0ute a+$o,ina" !ain-

Pain, f!om the 4atin poena, meaning punishment, penalty, o! to!ment, is the singula! senso!y e&pe!ien"e that humans use to identify disease within themselves. t is one of the

g!eatest motivational d!ives known to man.

5ost diseases of the abdominal vis"e!a a!e asso"iated with pain sometime du!ing thei! "ou!se. A b!ief !eview of abdominal emb!yology and pain physiology will assist the "lini"ianin evaluating the patient with a"ute o! "h!oni" abdominal pain.

<he gast!ointestinal t!a"t "onsists of a fo!egut, midgut, and hindgut. %a"h segment has itsown blood supply and inne!vation and !etains these !elations th!oughout development andinto adulthood. <he fo!egut e&tends f!om the o!opha!yn& to the duodenum at the level of theent!an"e of the "ommon bile du"t. t in"ludes the pan"!eas, live!, bilia!y t!ee, and spleen.<he midgut is "omposed of the distal duodenum, =e=unum, ileum, appendi&, as"ending"olon, and p!o&imal two thi!ds of the t!ansve!se "olon. <he hindgut "onsists of the

!emainde! of the "olon and !e"tum down to the "loa"al bulge, whi"h "onstitutes theinte!fa"e between the su!fa"e e"tode!m and endode!m of the "loa"a, "o!!esponding to thedentate line. <he pe!itoneum is a "ontinuous vis"e!al and pa!ietal laye!. Although both laye!s a!emesode!mally de!ived, they develop sepa!ately and have sepa!ate ne!ve supplies. <his isimpo!tant fo! diagnosti" !easons. <he vis"e!al laye! (ie, the laye! su!!ounding allint!aabdominal o!gans is supplied by autonomi" ne!ves (sympatheti" andpa!asympatheti", and the pa!ietal pe!itoneum is supplied by somati" inne!vation (spinalne!ves. <he pathways !elaying the sensation of pain diffe! fo! ea"h laye!. <hey also diffe! inuality.

is0e*a" !ain is "ha!a"te!isti"ally dull, "!ampy, deep, o! a"hing, and it may involve

sweating and nausea. Pa*ieta" !ain is sha!p, seve!e, and pe!sistent. is"e!al o!gans haveve!y little pain sensation, but st!et"hing of the mesente!y and stimulation of the pa!ietalpe!itoneum "ause seve!e pain.

16&



Do!mal emb!yologi" development of the abdominal vis"e!a p!o"eeds with bilate!alautonomi" inne!vation, !esulting in vis"e!al pain that is usually pe!"eived as a!ising f!om themidline. <he lo"ation of pain in the midline is dete!mined by the emb!yologi" o!igin of theinvolved vis"us. %pigast!i" pain is typi"al of fo!egut o!igin. e!iumbili"al pain signifies painemanating f!om the midgut. 7ypogast!i" o! lowe! abdominal midline pain indi"ates a

hindgut o!igin. elvi" pain is mo!e typi"al of disease o!iginating in st!u"tu!es de!ived f!omthe "loa"a.Ho! abdominal pain to be !e"ognied by the patient, no"i"epto!s, o! pain !e"epto!s, must beno&iously stimulated. <wo types of neu!onal fibe!s a!e involved. A-d fibe!s a!e !apidt!ansmitte!s and give !ise to sha!p, well-lo"alied pain sensations. <hese fibe!s a!edist!ibuted to mus"le and skin and a!e involved with somati" pain t!ansmission th!oughspinal ne!ves. C fibe!s a!e slow t!ansmitte!s. <hey gene!ate the sensation of dull, poo!lylo"alied pain that is g!adual in its onset and of long du!ation.<hese fibe!s a!e lo"atedint!amu!ally in hollow vis"e!a and in the "apsule of solid o!gans. <hey a!e found in mus"le,pe!iosteum, and the pa!ietal pe!itoneum and a!e involved in vis"e!al pain t!ansmissionth!ough the autonomi" ne!vous system.

*iffe!ent neu!al pathways a!e !esponsible fo! pain mediation, depending on whethe! the

sou!"e of the pain is the pa!ietal pe!itoneum o! the vis"e!al pe!itoneum. <he ante!io! andlate!al abdominal walls a!e supplied by ne!ves a!ising f!om spinal segments <- to 4-1. <heposte!io! abdominal wall is inne!vated f!om spinal segments 4-2 to 4-). ain a!ising f!omthe abdominal wall is !elayed to the spinal "o!d th!ough the spinal ne!ves. e"ause thesepain fibe!s ente! the spinal "o!d ipsilate!ally, pain is pe!"eived as o!iginating f!om that side. Also, su"h pain lo"alies to the a!ea of the abdomen f!om whi"h it o!iginates. n "ont!ast,pain a!ising f!om int!aabdominal vis"e!a is pe!"eived to a!ise in the midline be"ausesenso!y input f!om su"h vis"e!a ente!s the spinal "o!d on both sides.

16'



Neu*o"ogi0a" s.ste, o* so,ati0 !ain Neu*o"ogi0a" s.ste, o* is0e*a" !ain

A+$o,ina" !ain "an be divided into th!ee "atego!ies: is0e*a", so,ati0, and *ee**e$.

<he afo!ementioned int!amu!al senso!y !e"epto!s of the abdominal o!gans a!e !esponsiblefo! vis"e!al pain. ome dest!u"tive stimuli to the abdominal vis"e!a a!e painless. Ho! e&ample, almost all abdominal o!gans a!e insensitive to pin"hing, bu!ning, stabbing, "utting,and ele"t!i"al and the!mal stimulation. <he same is t!ue fo! the appli"ation of a"id and alkalito no!mal mu"osa.

<he fou! gene!al "lasses of vis"e!al stimulation that !esult in abdominal pain a!e thefollowing:L t!et"hing and "ont!a"tionL <!a"tion, "omp!ession, and to!sionL t!et"h aloneL Ce!tain "hemi"als

<he mediating !e"epto!s fo! these !esponses a!e lo"ated int!amu!ally in hollow o!gans, onse!osal st!u"tu!es su"h as the vis"e!al pe!itoneum and "apsule of solid o!gans, within themesente!y (espe"ially asso"iated with la!ge mesente!i" vessels and ligaments, and withinthe mu"osa. <hese !e"epto!s a!e polymodal (!esponsive to both me"hani"al and "hemi"alstimuli. 5u"osal !e"epto!s !espond p!ima!ily to "hemi"al stimulation. <he ma=o! fo!"es thatevoke vis"e!al pain a!ise f!om geomet!i" fo!"es (su"h as st*et0(ing and $istention that!esult in in"!eased wall tension.

1%0



6the! fa"to!s !esponsible fo! vis"e!al pain in"lude is0(e,ia an$ in"a,,ation. is"e!alpain almost always he!alds int!aabdominal disease but may not indi"ate the need fo! su!gi"al the!apy. 8hen vis"e!al pain is supe!seded by somati" pain, the need fo! su!gi"alinte!vention be"omes likely.

omati" o! vis"e!al pain a!ises f!om i!!itation of the pa!ietal pe!itoneum. 5ediated mainly byspinal ne!ve fibe!s that supply the abdominal wall, somati" pain is lo"alied and pe!"eivedas a!ising f!om one of the fou! uad!ants of the abdominal wall. n "ont!ast to vis"e!al pain,in whi"h geomet!i" "hanges a!e !esponsible fo! the stimulation of ne!ve endings, somati"pain a!ises as a !esponse to a"ute "hanges in p7 o! tempe!atu!e, as seen in ba"te!ial o! "hemi"al inflammation. n addition, somati" pain is felt in !esponse to sudden in"!eases inp!essu!e, as with a su!gi"al in"ision. omati" pain is pe!"eived as sha!p and p!i"king and isusually "onstant. n many "lini"al situations it is p!obable that the pe!"eption of pain !esultsf!om multiple stimuli. <he pain of pan"!eati" "an"e! p!obably a!ises f!om the "ombination of se!osal st!et"h, vas"ula! and mesente!i" "omp!ession, and di!e"t neu!al infilt!ation. <hesensitivities of vis"e!al !e"epto!s a!e also affe"ted by "i!"umstan"es. !essu!e on o! "hemi"al appli"ation to no!mal gast!i" mu"osa is usually painless, but if the mu"osa isinflamed, these same stimuli a!e uite painful.

Refe!!ed pain is felt in an a!ea of the body othe! than the site of its o!igin and is one of the"ha!a"te!isti" ualities of abdominal pain. Refe!!ed pain usually a!ises f!om a deepst!u"tu!e, is supe!fi"ial at its distant p!esenting lo"ation, and often is sha!p, lo"alied, andpe!sistent at the distant site. t o""u!s se"onda!y to the e&isten"e of sha!ed "ent!alpathways fo! affe!ent neu!ons a!ising f!om diffe!ent sites.<wo asso"iated featu!es of !efe!!ed pain a!e skin hype!algesia and in"!eased mus"le tone of the abdominal wall. A"lassi" e&ample is the !uptu!ed spleen that !esults in i!!itation of the left hemidiaph!agm,whi"h is inne!vated by the same "e!vi"al ne!ves. n this setting, !efe!!ed pain is pe!"eivedas a!ising in the left shoulde! (Meh! sign, whi"h is also supplied by those ne!ve !oots. Aknowledge of !efe!!ed pain and its patte!ns may be of diagnosti" assistan"e when othe! eviden"e of disease is la"king o! absent.

5& '(at is !e*itoneu,- '(at is t(e anato,i0a" st*u0tu*e o !e*itoneu,-

<he anatomy of the pe!itoneum and pe!itoneal "avity :

e!itoneum : "onsist of two "ontinuous laye!s : pa!ietal pe!itoneum , lining the inte!nal su!fa"e of the abdomino-pelvi"

wall vis"e!al pe!itoneum , investing vis"e!a ( o!gans su"h as the spleen and

stoma"h<he !elationship of the vis"e!a to the pe!itoneum is as follow :

int!a-pe!itoneal o!gans a!e almost "ompletely "ove!ed with vis"e!al pe!itoneum( spleen and stoma"h

e&t!ape!itoneal ( outside pe!itoneal "avity o! !et!ope!itoneal o!gans

PERITONEAL ESSELS AN NERES

a!ietal pe!itoneum is: supplied by blood vessels of the abdomino-pelvi" wall inne!vated by somati" ne!ves d!ainage by lymphati" vessels that a!e "ontinuous with those in the abdomino-

pelvi" wall. is"e!al pe!itoneum is:

supplied by the b!an"hes of blood vessels of the vis"e!a inne!vated by the vis"e!al affe!ent ( autonomi" ne!ve d!ainaged by lymphati" vessels that =oin those f!om the vis"e!a

1%1



6& '(at so*t o !e*itonitis $oes t(e !atient sue*-

<he patient suffe!s f!om int!a-abdominal infe"tion in fo!m of diffuse pe!itonitis

einition o int*aa+$o,ina" ine0tion : nflammato!y !esponses in the pe!itoneum againstinvading mi"!oo!ganisms with;without thei! p!odu"ts, su"h as to&ins, whi"h leads to pu!ulente&udates p!odu"tion within pe!itoneal "avity.

<ypes of int!a-abdominal infe"tion:

• Peritonitis: int!aabdominal infe"tion that !esults in diffuse "olle"tion of pu!ulent e&udates

th!oughout the pe!itoneal "avity

• Intra-abdominal abscess: int!aabdominal infe"tion that !esults in "onfined "olle"tion of

pu!ulent e&udates within pa!ti"ula! int!a-pe!itoneal spa"es.

<ypes of pe!itonitis:• P*i,a*. Pe*itonitis

– <he "ause is hematogeni" o! lymphati" infe"tion.• Se0on$a*. Pe*itonitis

– ou!"e of infe"tion is f!om the b!eak;in=u!y of othe! biologi" st!u"tu!es : pe!fo!ationof bilio-ente!i" st!u"tu!es, anatomosis leak, infe"ted pan"!eatitis.

• Te*tia*. Pe*itonitis: <he sou!"e of infe"tion might be :– e!sisten"e int!a-abdominal infe"tion that is not !esponsive to su!gi"al t!eatment– Doso"omial infe"tion

%isto*.:– 8hole abdominal pain– *e"!eased "ons"iousness– Heve! – Ano!e&ia, vomitus, abdominal distention, "onstipation.,

P(.si0a" iagnosis:

– ital signs: de"!eased "ons"ious, blood p!essu!e (5A ↓, ta"hypneu, ta"hy"a!dia,

subfeb!ile;feb!ile.– <ho!a&: might show signs of pneumonia, empyema.– Abdomen: distended abdomen, tende!ness, !ebound tende!ness, mus"ula! !igidity,

signs of pa!alyti" ileus: de"!eased bowel sound.– *igital Re"tal %&amination: 8eak sphin"te! tone, tende!ness at all position.– *e"!eased u!ine output.

& '(at a*e t(e s!e0ia" inestigations *e7ui*e$ to $iagnose !e*itonitis-

La+o*ato*. :

i. 7emoglobin : might be anemi"i. 4eu"o"ytosis; 4eu"openi.

iii. Compli"ations : ?!eum, k!eatinin, blood glu"ose, odium,otassium, lood @as Analysis.

v. Cultu!e: pe!itoneal fluid ; pus (abs"ess; te!tia!y pe!itonitis.

• I,aging :

i. 3-!ays : <ho!a&, Abdomen : H!ee ai!, dilatation, p!epe!itoneal fat (-.i. C<-"an,?@ G fluid "olle"tion (abs"ess.

%o8 $oes t(is ino*,ation 0(ange .ou* (.!ot(eses-

1%"



<ypi"al physi"al signs of a"ute appendi"itis a!e found in this patient:<he physi"al e&amination will gene!ally distinguish appendi"itis f!om othe! abdominal

pathologies. Right lowe! uad!ant pain on palpation is typi"ally p!esent and involves gua!ding withpe!itoneal i!!itation upon pe!"ussion. imple movement of the bed usually eli"its !ight lowe! uad!ant pain.

6the! physi"al signs asso"iated with appendi"itis in"lude the initiation of pain in the !ight

lowe! uad!ant du!ing palpation of the left lowe! uad!ant (Rovsing sign, in"!eased pain with"oughing (*unphy sign, pain on inte!nal !otation of the hip (obtu!ato! sign, and pain du!inge&tension of the !ight hip (iliopsoas sign. All !esult f!om pa!ietal pe!itoneal inflammation andsomati" pain. <he iliopsoas sign is typi"al of a !et!o"e"al appendi&, whe!eas the obtu!ato! signsuggests a pelvi" appendi&.

*u!ing a !e"tal e&amination o! pelvi" e&amination, fo"al tende!ness is eli"ited mo!e on the!ight side, but palpation of a tende! mass is indi"ative of a pelvi" abs"ess.

As all the physi"al findings suggest the e&isten"e a"ute appendi"itis, othe! "auses "angene!ally be e&"luded, 5o!eove!, p!egnan"y test shows negative !esults. n female with!ep!odu"tive age, obstet!i" "auses must always be "onside!ed as diffe!ential diagnosis. <he!efo!e,p!egnan"y test is essential.

3& '(at u*t(e* ino*,ation $o .ou nee$-

e!t&o Su*ge*.

Although diagnosis "an be established by histo!y taking and physi"al e&amination alone in 0 E of "ases, spe"ial investigations a!e still !eui!ed to "onfi!m the diagnosis. <his is pa!ti"ula!ly impo!tantin female in !ep!odu"tive age, as they "an definitely e&"lude the obstet!i" and gyne"ologi"al "auses.

Laboratory and Radiologic Diagnosis

<he "ost-effe"tiveness of va!ious tests has "ome unde! g!eat s"!utiny. 8hen the histo!y andphysi"al e&amination a!e definitive, no othe! investigation is !eui!ed. <he !eview that follows isappli"able to patients when the diagnosis is not initially "lea!. Afte! the histo!y and physi"al

e&amination, a white blood "ell (8C "ount with a pe!iphe!al smea! is helpful. About two thi!ds of patients with appendi"itis p!esent with an elevated 8C "ount (mo!e than

10,000 8C;m4, whe!eas feve! is absent in most "ases. %lde!ly patients with appendi"itis tend tohave no!mal 8C "ounts, but fewe! than #E to )E will have a no!mal diffe!ential "ount of 8Cs. Almost /)E of patients with a"ute appendi"itis p!esent with a p!edominan"e of polymo!phonu"lea! leuko"ytes and !elative lymphopenia.

A u!inalysis is "ommonly obtained in the eme!gen"y !oom when the diagnosis of appendi"itisis ente!tained. n one study, an abno!mal u!inalysis was dis"ove!ed in #E of patients with a"uteappendi"itis befo!e appende"tomy. <his !emained abno!mal in 12E on postope!ative day +.#7ematu!ia, pyu!ia, and p!oteinu!ia a!e f!euently found in patients with a"ute appendi"itis.

<hese findings should not ne"essa!ily lead the su!geon away f!om the initial diagnosissuspe"ted f!om the histo!y and physi"al e&amination.

Radiologic examinations

Radiologi" e&aminations should be used in uestionable "ases. Abdominal !adiog!aphs a!e!a!ely useful in "hild!en, but in adults, fe"aliths may o""asionally be visualied along with a pau"ityof gas in the !ight lowe! uad!ant of the abdomen (Hig. )#-#. A pe!fo!ated o! gang!enous appendi&may e&hibit e&t!aluminal gas on !adiog!aphs, but this o""u!s in only 1E of "ases. 4oss of the !ightpsoas shadow usually !ep!esents late appendi"itis with !et!ope!itoneal inflammation.

1%3



Hig. )#-#: He"olith in plain abdominal &-!ays

Ultrasonograpy

Re"ent developments in the te"hniue and inte!p!etation of ult!asonog!aphy have made this avaluable ad=un"t to physi"al e&amination in young women and in patients with atypi"al symptoms.@!aded abdominal "omp!ession is used to displa"e the "e"um and as"ending "olon, e&posing!et!o"e"al and pelvi" lo"ations. A typi"al ta!get appea!an"e identifies the appendi& by "ha!a"te!isti"!efle"ting p!ope!ties of wall elements (Hig. )#-).

Hig. )#-): <a!get sign on ?@ of the appendi&Hindings asso"iated with appendi"itis in"lude wall thi"kening beyond the no!mal to 10 mm,luminal distention, and a la"k of "omp!essibility. <he visualied appendi& usually "oin"ides with thesite of lo"alied pain and tende!ness. Advan"ed appendi"itis is indi"ated sonog!aphi"ally by

asymmet!i" wall thi"kening, abs"ess fo!mation, asso"iated f!ee int!ape!itoneal fluid, su!!oundingtissue edema, and de"!eased lo"al tende!ness to "omp!ession. 5a!ked wall thi"kening withoutdistention is p!esent in C!ohnBs disease of the appendi&, often in asso"iation with ileal o! "e"aldisease. Ra!e findings, su"h as appendi"eal neoplasms and mu"o"eles, may also be wellvisualied. ?lt!asonog!aphy is "!iti"ally ope!ato! dependent, and "a!e must be taken to avoidove!inte!p!eting a te"hni"ally inadeuate e&amination. 8ith this "aveat, the sensitivity of ult!asoundin the diagnosis of appendi"itis f!om seve!al "ente!s has been !epo!ted in e&"ess of 0E, with aspe"ifi"ity of /0E.

!omputed "omograpy

Re"ent !efinements in !esolution to the 0.)- to 1-"m !ange have imp!oved the a""u!a"y of C<imaging in dete"ting the natu!e and e&tent of abdominal disease. <his has been most useful in

patients p!esenting with obs"u!e inflammato!y p!o"esses of the abdomen in whom the diagnosis of appendi"itis is not fo!emost. n the spe"ifi" evaluation of atypi"al patients fo! possible appendi"itis,the C< e&amination should be "onside!ed only if ult!asound is unavailable o! un!evealing fo!

1%#



te"hni"al !easons, most "ommonly in "ases of gaseous abdominal distention. <he !isks of !adiatione&posu!e must be "onside!ed, pa!ti"ula!ly in young, potentially p!egnant women.

<he no!mal appendi& may be diffi"ult to lo"ate on C< e&aminations not spe"ifi"ally fo"used on thisuestion. a!iability of appendi"eal lo"ation, su!!ounding fat, and s"an uality may !eui!e e&t!as"ans at fine! inte!vals.Appendi"oliths a!e seen in one fou!th of all people as a !inglike o!

homogeneous "al"ifi" density on C<. <his sensitivity is mu"h highe! than that of plain abdominal!adiog!aphs. pe"ifi" C< findings of appendi"itis be"ome mo!e p!ominent with advan"ed disease.<hey in"lude a distended, thi"k-walled, edematous appendi& seen as a ta!get st!u"tu!e,inflammato!y st!eaking of su!!ounding fat, and the p!esen"e of an appendi"olith (Hig. )#-.

Hig. )#-: C< appea!an"e in ea!ly a"ute appendi"itis

%a!ly appendi"itis may be impossible to distinguish f!om the no!mal appendi&, but this is t!ue of allmodalities, in"luding di!e"t visual inspe"tion. C< findings suggestive of appendi"itis in"lude ape!i"e"al phlegmon o! abs"ess, and small amounts of !ight lowe! uad!ant int!aabdominal f!ee ai! that signal pe!fo!ation (Hig. )#-.

Hig. )#-: C< appea!an"e in pe!fo!ated appendi"itis with abs"ess fo!mation6the! p!o"esses, su"h as "e"al dive!ti"ulitis and pe!fo!ated "e"al "a!"inoma, may "!eate a simila! appea!an"e. n the patient p!esenting with an appendi"eal mass, C< is useful in planningnonope!ative management. A phlegmon !esponsive to antibioti" t!eatment "an be distinguishedf!om abs"esses that may !eui!e d!ainage. Donappendi"eal "auses of lowe! abdominal pain "anf!euently be defined. A /0E sensitivity fo! dete"ting int!aabdominal inflammation has been!epo!ted fo! C< s"anning, and in 0E of these patients a spe"ifi" diagnosis "an be made.

Barium !ontrast #tudies

7isto!i"ally, single-"ont!ast ba!ium enema in the unp!epa!ed patient has been used fo! thediagnosis of atypi"al appendi"itis. <his !emains a simple, safe, and !eadily available test that hasst!ong p!oponents. @ene!ally, howeve!, ult!asound and C< e&aminations a!e p!efe!!ed.

A ba!ium study allows fo! the following:L Assessment of luminal paten"y of the appendi&L %&amination of the "oloni" wall fo! mass effe"ts o! se"onda!y effe"ts of appendi"itisL *iagnosis of !ight "oloni" o! te!minal ileal mu"osal disease that may simulate appendi"itis

1%$



8hen ba!ium "ont!ast fills the appendi&, appendi"itis is unlikely but not impossible. ?p to 10E to20E of no!mal appendi"es do not fill du!ing ba!ium study. a!tial filling of the appendi& withappendi"itis at the tip and appendi"itis that develops without luminal obst!u"tion a!e potential"auses of a false-negative study. ome info!mation "an be gleaned f!om su"h studies, howeve!,be"ause even with luminal paten"y the mu"osal defe"t usually leads to i!!egula!ity that "an be

outlined by ba!ium. Ce"al indentation by an inflammato!y appendi"eal mass o! e&t!avasation of ba!ium f!om a site of pe!fo!ation may also be evident (Hig. )#-/ and Hig. )#-10. Right "olonmu"osal "hanges due to infe"tious "olitis (>e!sinia ente!o"oliti"aN almonella, higella, o! Campyloba"te! spN o! the to&igeni" effe"ts of %s"he!i"hia "oli 01):7, idiopathi" inflammato!ybowel disease, o! "e"al neoplasms may be defined by a ba!ium study, although seve!e, to&i" "olitisis a "ont!aindi"ation to any "ont!ast study. Dot all !ight lowe! uad!ant inflammato!y "onditions a!edete"ted on ba!ium e&amination, howeve!. Ho! e&ample, in a la!ge se!ies of patients with euivo"alp!esentations, #0E of ba!ium studies we!e also euivo"al. a!ium enema "omplements ult!asoundand C< e&aminations in defining mu"osal lesions of the "e"um and appendi&. t should be"onside!ed in settings of "h!oni" o! !e"u!!ent abdominal pain. t should be used fo! a"uteappendi"itis when the diagnosis is suspe"ted but un"lea! and when both C< and ult!asound a!e nothelpful.

Hig. )#-/: a!ium enema showing appendi"eal mass

ANATOM9 O CECUM AN APPENI; <e!t& o Anato,.=

4a!ge intestine "onsist of:

• Cae"um

• Colon ( as"ending , t!ansve!se , des"ending and sigmoid pa!ts

• Re"tum

• Anal "anal

<he la!ge intestine "an be distinguished f!om the small intestine by:

-<aenia "oli: th!ee thi"kened bands of longitudinal mus"les fibe!s:• 6mental taenia

• 4ibe!a taenia

• 5eso"oli"a taenia

- 7aust!ae sa""ulations o! pou"hes of the "olon between the taenia.- 6mental appendi"es : fatty appendi"es of the "olon.

1%6



Ce0u, an$ A!!en$i>

• <he fi!st pa!t of the la!ge intestine

• <hat is "ontinuous with the as"ending "olon

• <he position of the appendi& is va!iable, but usually !et!o-"e"al.

• <he base of the appendi& most often lies deep to a point that is one Fthi!d

of the way along the obliue line =oining the !ight Ante!io! upe!io! lia" pine to theumbili"us ( pino-umbili"al o! 5" u!ney oint .

<he "e"um is supply by the ileo"oli" a!te!y ----te!minal b!an"h of the upe!io! 5esente!i" A!te!y

( 5A .

<he appendi& is supplied by the appendi"ula! a!te!y ---- the b!an"h of the ileo"oli" a!te!y.<he lymphati" vessel f!om the "ae"um and appendi& pass to nodes in the mesoappendi& and theileo"oli" lymph nodes.<he ne!ves supply to the "ae"um and appendi& de!ives f!om sympatheti"----6!iginate in the lowe! tho!a"i" pa!t of the spinal "o!d.

a!asympatheti" ne!ves f!om the upe!io! mesente!i" ple&us ----- de!ive f!om thevagus ne!ve.

1%%



<he appendi"eal length va!ies f!om 2 to 20 "m and ave!ages / "m. Child!en have longe! appendi"es that might at!ophy du!ing adulthood. <he th!ee taeniae "oli of the as"ending "olon"onsolidate at the base of the appendi& with the ante!io! taenia se!ving as a landma!k when t!a"edalong the ante!io! "e"um. <he appendi& is "onne"ted to the lowe! aspe"t of the ileal mesente!y bythe mesoappendi&. <he main appendi"ula! a!te!y is a b!an"h of the ileo"oli" a!te!y that "ou!sesbehind the ileum, th!ough the mesoappendi&, and along the appendi"eal wall until it !ea"hes the tip

of the o!gan. <he appendi"ula! a!te!y "ou!ses along the f!ee bo!de! of the mesoappendi& until it!ea"hes the distal appendi&, at whi"h time it lies along the wall of the appendi& (Hig. )#-2. *u!inga"ute inflammation, the appendi"ula! a!te!y be"omes sus"eptible to th!ombosis as the appendi&be"omes enla!ged.<he lymphati"s d!aining the appendi& in"lude vessels f!om the body and tip of the appendi& thatd!ain poste!io!ly into the uppe! and lowe! ileo"oli" nodes. <he lymph vessels f!om the base of theappendi& d!ain to the ante!io! ileo"oli" lymph nodes. <he lymph nodes along the ileo"oli" "hain maybe hype!plasti" du!ing appendi"itis.

<he neu!al inne!vation of the appendi& is f!om the autonomi" ne!vous system, without any di!e"tinne!vation f!om pain fibe!s. <he absen"e of pain fibe!s as with othe! vis"e!a, e&plains the la"k of lo"alied symptoms until an inflamed appendi& i!!itates the pe!itoneum. <he sympatheti" ne!vesupply o!iginates f!om the supe!io! mesente!i" ple&us, whe!eas the pa!asympatheti" inne!vation

a!ises f!om the vagus ne!ve. <he submu"osal ple&us and the myente!i" ple&us a!e sp!eadi!!egula!ly th!ough the appendi& on histologi" e&amination.$<he o!ifi"e of the appendi& opens to the "e"um with a semiluna! mu"osal fold fo!ming a valve. nthe adult, the lumen may be pa!tially o! enti!ely oblite!ated, but the ave!age luminal width isbetween 0.) and 1 "m. <he base of the appendi& is no!mally lo"ated at about the level of the -1ve!teb!al body, at the 5"u!ney point. <he se!osa "ove!s the enti!e appendi&, with longitudinalmus"le fibe!s fo!ming an almost "omplete laye! immediately beneath this. At the base, thelongitudinal mus"les fo!m !udimenta!y taeniae "ontinuous with the taeniae "oli of the "olon. A laye! of "i!"ula! mus"le fo!ms a thi"ke! inne! laye!. <he submu"osa "ontains lymphoid tissue that mayhype!t!ophy and obst!u"t the lumen du!ing a"ute appendi"itis. Hinally, the appendi& is linedth!oughout by a mu"osal luminal su!fa"e. <he mu"osa has featu!es simila! to those of the "olon, butlymphoid tissue is "on"ent!ated mo!e densely, !esembling the ileum.<he subepithelial laye! "ontains neu!ose"!eto!y "ells that in"!ease in numbe! in olde! patients. 8ith

the use of lead staining, few neu!ose"!eto!y "ells a!e visualied in appendi"es of "hild!en up to theage of / yea!s. As the age of the patient in"!eases, mo!e neu!ose"!eto!y "ells a!e obse!ved in thesubmu"osa.#+ <his finding "o!!elates with an age-!elated in"!ease in the numbe! of "a!"inoidtumo!s as the numbe! of neu!ose"!eto!y "ells in"!eases.

%ISTOLO#9 O T%E APPENI; <e!t&o %isto"og.=

<he appendi& is an unde!developed !esiduum of the othe!wise voluminous "e"um. <he adultappendi& ave!ages + to "m in length, is pa!tially an"ho!ed by a mesente!i" e&tension f!om thead=a"ent ileum, and has no known fun"tion. <he appendi& has the same fou! laye!s as the

!emainde! of the gut and possesses a "oloni"-type mu"osa. A distinguishing featu!e of this o!gan isthe e&t!emely !i"h lymphoid tissue of the mu"osa and sub-mu"osa, whi"h in young individuals fo!msan enti!e laye! of ge!minal folli"les and lymphoid pulp. <his lymphoid tissue unde!goes p!og!essiveat!ophy du!ing life to the point of "omplete disappea!an"e in advan"ed age. n the elde!ly theappendi&, pa!ti"ula!ly the distal po!tion, sometimes unde!goes fib!ous oblite!ation.

Region :1= A!!en$i> :

a 5u"osa :i %pithelium : imple "olumna!N sho!te! mi"!ovilliN abundant gobletii 4amina p!op!ia : 5any lymphoid nodulesiii 5us"ula!is 5u"osae : *is"ontinous

b ubmu"osa : 4ymphoid nodules

" 5us"ula!is %&te!na : e!y thind e!osa

1%&



EELOPMENT O APPENI; <e!t&! Me$i0a" ?io"og.=

*u!ing the 10th week, he!niated intestinal loops begin to !etu!n to the abdominal "avity. Although thefa"to!s !esponsible fo! this !etu!n a!e not p!e"isely known, it is thought that !eg!ession of themesoneph!i" kidney, !edu"ed g!owth of the live!, and e&pansion of the abdominal "avity playimpo!tant !oles.<he p!o&imal po!tion of the =e=unum, the fi!st pa!t to !eente! the abdominal "avity, "omes to lie onthe left side. <he late! !etu!ning loops g!adually settle mo!e and mo!e to the !ight. <he "e"al bud,whi"h appea!s at about the + th week as small "oni"al dilation of the "audal limb of the p!ima!yintestinal loop, is the last pa!t of the gut to !eente! the abdominal "avity. <empo!a!ily it lies in the!ight uppe! uad!ant di!e"tly below the !ight lobe of the live!. H!om he!e it des"ends into the !ightilia" fossa, pla"ing the as"ending "olon and hepati" fle&u!e on the !ight side of the abdominal "avity.

*u!ing this p!o"ess the distal end of the "e"al bud fo!ms a na!!ow dive!ti"ulum, t(e a!!en$i>.in"e the appendi& develops du!ing des"ent of the "olon, its final position f!euently is poste!io! tothe "e"um o! "olon. <hese position of the appendi& a!e "alled *et*o0e0a" o! *et*o0o"i0@!espe"tively. (4angman /th ed.200#, pp $0-$0

D : pd anak pangkal appendi& lebih leba! da!ipada u=ungnya sehingga be!bentuk sepe!ti "o!ong.6leh ka!ena itu, etiologi te!se!ing appendi"itis pada anak adalah infeksi yang be!asal da!i tempatlain. edangkan pada o!ang tua, bentuk appendi& sepe!ti umbai "a"ing dan etiologi te!se!ingadalah vaskula!isasi yang bu!uk dan adanya sumbatan.

SCAN PICTURE <ig& 13&2 !& 3B ig& 13&2D !& 3BD=

1%'



ie*entia" iagnoses o* A0ute A!!en$i0itis : ie*ti0u"u, Me0e"

ite""ine u0t A+no*,a"itiesn 2 to # E of people, a small po!tion of the vitelline du"t pe!sists, fo!ming an outpo"keting of theileum, Me0e")s $ie*ti0u"u, o* i"ea" $ie*ti0u"u,. n the adult, this dive!ti"ulum, app!o&imately#0 to +0 "m f!om the ileo"e"al valve on the antimesente!i" bo!de! of the ileum, does not usually

"ause any symptoms. 7oweve!, when it "ontains hete!otopi" pan"!eati" tissue o! gast!i" mu"osa, itmay "ause ul"e!ation, bleeding, o! even pe!fo!ation. (4angman / th ed. 200#, pp $11-$12

E,+*.o"og.<he appendi& develops f!om the "e"al dive!ti"ulum of the fetus. At + weeksB gestation, the "e"alp!imo!dium begins as a "oni"al outpou"hing along the antimesente!i" bo!de! of the "audal limb ofthe midgut loop. <he appendi& is delineated du!ing the fifth month of gestation when the ape& of the"e"al outpou"hing does not enla!ge as !apidly as the !est of the "e"um. a!iable positions of theappendi& o""u! when the "e"um and appendi& a!e displa"ed downwa!d into the !ight ilia" fossa asthe p!o&imal "olon enla!ges. *u!ing "oloni" elongation, the appendi& lo"alies eithe! poste!io! to the"e"um (!et!o"e"al o! poste!io! to the "olon (!et!o"oli", o! it may des"end ove! the b!im of the

pelvis (pelvi" o! des"ending. About +#E of the population have the appendi& lo"ated !et!o"e"ally,and $1E have the appendi& lo"ated ove! the pelvi" b!im.## <he appendi& elongates by bi!th, andthe "e"al wall enla!ges uneually afte! bi!th, "ausing the appendi& to be lo"ated poste!omedially.*elayed diagnosis of appendi"itis has been att!ibuted to unusual anatomi" positions. @ang!ene andpe!fo!ation of the appendi& have been !epo!ted in +/E of patients who had eithe! a delayedp!esentation of symptoms o! diagnosis when the appendi& was lo"ated in the t!ue pelvis, behind theileum o! ileo"oli" mesente!y, o! !et!o"oli" o! !et!ope!itoneal.

a!ious lo"ations of the appendi&!ongenital Abnormalities.

Ra!e !epo!ts of "ongenital appendi"eal abno!malities have been published. <hese in"lude agenesisand diffe!ing deg!ees of hypoplasia as des"!ibed by Collins.$,)+ 6the! "ongenital abno!malitiestotaling about 100 "ases in"lude appendi& multiple& and ho!seshoe anomalies of the appendi&. <he"lassifi"ation of appendi& multiple&) involves 8allb!idgeBs type A anomaly (a single-basedappendi& with va!ying deg!ees of pa!tial appendi"eal dupli"ation a!ising f!om a single "e"umN atype anomaly ("onsisting of two distin"t appendi&es a!ising f!om a single "e"umN and a type Canomaly ("ontaining a double "e"um, ea"h with its own sepa!ate appendi& and asso"iated withgenitou!ina!y o! othe! hindgut abno!malities.$

1&0





<!ue cronic inflammation of the appendi& is diffi"ult to define as a pathologi" entity, althougho""asionally g!anulation tissue and fib!osis asso"iated with a"ute and "h!oni" inflammation of theappendi& suggest an o!ganiing a"ute appendi"itis. 5u"h mo!e f!euently, !e"u!!ent a"ute atta"ksunde!lie a seemingly "h!oni" "ondition. in"e in some individuals the appendi& is a me!e fib!ous"o!d f!om bi!th, it "annot be assumed that appendi"eal fib!osis is the !esult of a p!eviousinflammation.

5& %o8 $oes a!!en$i0itis (a!!en-

e!t&o Su*ge*.

Pat(o!(.sio"og. o a!!en$i0itis

<he most "ommon "ause of appendi"itis is obst!u"tion of the appendi"eal lumen. n young "hild!enand young adults, the most "ommon "ause of luminal obst!u"tion is lymphoid hype!plasia f!om thesubmu"osal folli"les, whi"h a!e abundant. <he pathogenesis is "ont!ove!sial and likely multifa"to!ial,but dehyd!ation and vi!al infe"tions have been hypothesied as "auses of lymphoid hype!plasia. nolde! adults, fe"aliths a!e one "ause of luminal obst!u"tion that may be visible on abdominal

!adiog!aphs in"luding the !ight lowe! uad!ant o! the pelvi" a!ea. 4uminal obst!u"tion of theappendi& "auses an in"!ease in mu"us p!odu"tion. a"te!ia a!e t!apped in the distal appendi& in!elatively high "on"ent!ations be"ause of the !elation to the !ight side of the "olon. a"te!ialove!g!owth f!om stasis and luminal obst!u"tion "auses eventual dilatation of the appendi&. As theappendi& enla!ges, venous and lymphati" flow a!e "omp!omised, "ausing fu!the! dilatation of theappendi&. enous hype!tension and luminal distention "ont!ibute to in"!eased appendi"eal walltension a""o!ding to the 4apla"e law, whe!ein wall tension is p!opo!tional to the thi"kness of thewall divided by the !adius sua!ed. 8ith in"!easing wall tension, blood flow is eventually"omp!omised and diminishes most a"utely to the distal appendi& (flow G p!essu!e;!esistan"e. <hede"!ease in a!te!ial blood flow may "ause vessel th!ombosis with ne"!osis of the appendi"eal wall(Hig. )#-$. 8hen full-thi"kness ne"!osis o""u!s, pe!fo!ation of the appendi& takes pla"e, and itsfe"al and suppu!ative "ontents a!e !eleased into the abdominal "avity. e!itoneal i!!itation o""u!s,with appendi"eal abs"ess fo!mation o! gene!alied pe!itonitis o""u!!ing if the ente!i" spill is la!ge.

4ymphoid hype!plasia has a peak in"iden"e du!ing the teenage yea!s, "o!!elating well with thehighe! in"iden"e of a"ute appendi"itis at this age. @ast!oente!itis involving infe"tious agents su"has higella and almonella is asso"iated with lymphoid folli"le hype!plasia and a"ute appendi"itis.6the! systemi" diseases su"h as uppe! !espi!ato!y infe"tions, infe"tious mononu"leosis, andmeasles have been

1&"



shown to "ause a

Higu!e )#-$: athophysiologi" stages of appendi"itis

gene!alied lymphoid hype!plasia in the appendi&. 4ymphoid hype!plasia a""ounts fo! +0E of a"ute

appendi"itis and o""u!s mainly in the young.

n adults, fe"alith fo!mation a""ounts fo! about $0E of a"ute appendi"itis. <he fo!mation of anappendi"eal fe"alith begins with the !andom ent!apment of vegetable fibe!, with deposition of mu"us"ausing eventual "on"!etion of the mu"us ent!apment. 5ultiple laye!s of "on"!etions a!e fo!medwith a g!adual in"!ease in fe"alith diamete!. 8hen the diamete! !ea"hes 1 "m o! mo!e, obst!u"tionof the appendi& may o""u! with ensuing inflammation. 6the! "auses of appendi"eal luminalobst!u"tion in"lude pa!asites su"h as %nte!obius ve!mi"ula!is, <aenia, o! As"a!is, and tumo!s su"has "e"al adeno"a!"inoma o! "a!"inoids. %&pe!imental studies have shown that obst!u"tede&te!io!ied human appendi"es have in"!eased int!aluminal p!essu!es that "an e&"eed thepe!fusion p!essu!e in the vas"ula! ple&us within the wall of the appendi&.# 8hen mu"osalis"hemia o""u!s, sloughing and ul"e!ation of the epithelium p!og!esses with se"onda!y invasion of the mi"!oo!ganisms p!esent in the lumen. <he ba"te!ia p!esent in the appendi& tend to be

"ommensal o!ganisms f!om the "e"um and the!efo!e en"ompass a mi&ed flo!a.6n"e luminal obst!u"tion o""u!s and inflammation begins, p!og!essive and well-"ha!a"te!iedstages of a"ute appendi"itis follow (<able )#-+. <he in"!ease in int!aluminal p!essu!e "auses stasisof blood flow, eventual gang!ene of the appendi&, and finally !uptu!e.

6& '(at a*e t(e 0o,!"i0ations o a!!en$i0itis-

e!t&o Su*ge*.

<he "ompli"ations of a"ute appendi"itis a!e:

• epsis, eve!e sepsis, and septi" sho"k

• @ang!enous appendi"itis

•e!fo!ated appendi"itis• e!iappendi"ula! phlegmon (mass

• e!iappendi"ula! abs"ess

1&3





Hab!i"ius.$ <he !ole of the appendi& !emains "ont!ove!sial, but its uniue lymphoid agg!egationsand its lo"ation diffe!entiate it f!om the "olon o! "e"um.

Diagnosis of Appendicitis

<he aim of !edu"ing appendi"eal !uptu!e is a"hieved by an ea!ly diagnosis. e"ause the mo!tality

!ate of appendi"itis is low (0.+E when nonpe!fo!ated, less than )E when pe!fo!ated, the"onseuen"e of delayed diagnosis is g!eate! fo! mo!bidity than fo! mo!tality !ates. <he most usefultools in the diagnosis of appendi"itis a!e the histo!y and physi"al e&amination. Additional labo!ato!yand !adiologi" studies a!e not !outinely ne"essa!y and should be !ese!ved fo! uestionablep!esentations of abdominal pain. A histo!y of pe!iumbili"al pain followed by ano!e&ia and minimalnausea is typi"al befo!e emesis o! lo"alied pain o""u!s in the !ight lowe! uad!ant of the abdomen.<his p!esentation o""u!s in about half of the patients p!esenting with a"ute appendi"itis. <he poo! inne!vation of the vis"e!al o!gans "auses dull pe!iumbili"al o! epigast!i" pain until a suffi"ientamount of lo"al inflammation i!!itates the vis"e!al pe!itoneum in the !ight lowe! uad!ant. All patientswith appendi"itis have abdominal pain and ano!e&ia, and the la"k of these two symptoms should!aise suspi"ion !ega!ding the diagnosis of appendi"itis. n about /0E of patients, nausea is p!esentat some point in the histo!y. <he length of illness is usually less than 2# to $+ hou!s fo! a"uteappendi"itis and ave!ages seve!al hou!s. <he histo!y typi"ally in"ludes "!es"endo somati" pain

lo"alied to the !ight lowe! uad!ant. <he alte!ation of bowel movements is not a !eliable histo!i"alfeatu!e be"ause dia!!hea may !esult f!om a pelvi" appendi& i!!itating the bowel, and many patientshave no "hanges in bowel habit. Atypi"al pain o""u!s in #0E to #)E of patients. <his in"ludespatients who p!esent with lo"alied !ight lowe! uad!ant pain immediately and those with diffusepe!iumbili"al pain. <hese patients tend to be elde!ly o! those who a!e taking antibioti"s that maskthe symptoms.

<he physi"al e&amination will gene!ally distinguish appendi"itis f!om othe! abdominal pathologies.Right lowe! uad!ant pain on palpation is typi"ally p!esent and involves gua!ding with pe!itoneali!!itation upon pe!"ussion. imple movement of the bed usually eli"its !ight lowe! uad!ant pain.6the! physi"al signs asso"iated with appendi"itis in"lude the initiation of pain in the !ight lowe! uad!ant du!ing palpation of the left lowe! uad!ant (Rovsing sign, in"!eased pain with "oughing(*unphy sign, pain on inte!nal !otation of the hip (obtu!ato! sign, and pain du!ing e&tension of the

!ight hip (iliopsoas sign. All !esult f!om pa!ietal pe!itoneal inflammation and somati" pain. <heiliopsoas sign is typi"al of a !et!o"e"al appendi&, whe!eas the obtu!ato! sign suggests a pelvi"appendi&. *u!ing a !e"tal e&amination o! pelvi" e&amination, fo"al tende!ness is eli"ited mo!e onthe !ight side, but palpation of a tende! mass is indi"ative of a pelvi" abs"ess.

"reatment

4apa!os"opy

f the diagnosis of appendi"itis is un"lea!, lapa!os"opy may be ve!y helpful to !ule out appendi"itiswhile also e&amining fo! gyne"ologi" pathologies. Re"ent se!ies !epo!ted a "onfi!mation of a"uteappendi"itis in )/E of patients who p!esented with !ight lowe! uad!ant symptoms, whe!eas $)E of females with a diagnosis of suspe"ted appendi"itis had gyne"ologi" pathology noted by

lapa!os"opy.# ome have advo"ated diagnosti" lapa!os"opy in all females p!esenting withsymptoms of a"ute appendi"itis to !edu"e unne"essa!y appende"tomy. 4apa!os"opy "an be eithe! diagnosti" o! the!apeuti" fo! a"ute appendi"itis. %a"h app!oa"h has its advo"ates.#/ <he benefits of lapa!os"opi" appende"tomy in"lude de"!eased postope!ative pain, a bette! "osmeti" out"ome, anda mo!e !apid !etu!n to full a"tivities. ome of the disadvantages of lapa!os"opi" appende"tomyin"lude a slightly in"!eased ope!ative time, possibly in"!eased "ost, and in"!eased postope!ativeemesis.)0

4apa!otomy

<he standa!d management of appendi"itis !emains open appende"tomy by way of a limited !ightlowe! uad!ant in"ision. efo!e the indu"tion of anesthesia, the su!geon should note the point of ma&imal tende!ness. 8hile the patient is unde! anesthesia, masses should be palpated if possible.

<he 5"u!ney point (at the =un"tion of the middle and late!al thi!ds of a line d!awn f!om theumbili"us to the !ight ante!osupe!io! ilia" spine does not unive!sally ma!k the tip of the appendi&,

1&$



and palpation without the patient gua!ding may be useful in pla"ing the in"ision. n gene!al, aninfe!io! in"ision below the ma&imal tende! a!ea will help in !otating the "e"um into the wound.a!ious skin in"isions have been des"!ibed to give ma&imal e&posu!e. <he 5"u!ney in"ision is the"lassi"al obliue appende"tomy in"ision th!ough the 5"u!ney point to the late!al edge of the!e"tus sheath. Alte!natively, a skin line o! t!ansve!se in"ision pla"ed 1 to 2 "m medial to theante!osupe!io! ilia" spine is used. All a!e gene!ally pe!fo!med with a mus"le-splitting te"hniue

th!ough all laye!s late!al to the !e"tus abdominis mus"le as ent!an"e into the abdomen is gained.

A low ho!iontal skin in"ision also imp!oves the postope!ative appea!an"e in young patients. <hein"ision is "ontinued th!ough the supe!fi"ial fas"ia until the e&te!nal obliue mus"le aponeu!osis ise&posed. <he fibe!s of the aponeu!osis a!e opened sha!ply, and the mus"le fibe!s themselves a!ebluntly sepa!ated, as a!e the fibe!s of the inte!nal obliue and t!ansve!sus abdominis mus"les. <hepe!itoneum is in"ised, and "ultu!es "an be obtained to help di!e"t antibioti" the!apy postope!ativelyfo! !uptu!ed appendi"es. <he base of the appendi& always lies at the "onfluen"e of all th!ee taeniae.<he "e"um is mobilied into the wound, and the appendi& is mobilied into the wound as adhesionsa!e bluntly disse"ted. 4igation of the mesoappendi& is usually pe!fo!med f!om the distal tip to thebase of the appendi&. n some diffi"ult "ases involving a long appendi&, !eve!sing the ligation of themesoappendi& "an fa"ilitate appende"tomy. <he appendi"eal stump is usually "aute!ied to p!eventmu"o"ele fo!mation. <he appendi"eal stump may be inve!ted with a pu!sest!ing sutu!e in the "e"um

o! by pla"ing a O-stit"h. Copious i!!igation with saline should be pe!fo!med in "ases of pe!fo!atedappendi"itis to p!event fo!mation of a pelvi" o! subhepati" abs"ess. <he pe!itoneum and mus"ula! fas"iae a!e usually "losed with a !unning abso!bable sutu!e. <he skin "an be "losed innonpe!fo!ated "ases of appendi"itis, and delayed p!ima!y "losu!e is !outine in "ases of !uptu!edappendi"itis.

f a no!mal appendi& is en"ounte!ed du!ing appende"tomy, the te!minal ileum and pelvi" st!u"tu!es(ie, ova!ies, fallopian tubes, ute!us need to be visualied to !ule out othe! su!gi"ally t!eatablep!oblems. 5e"kelBs dive!ti"ulum may e&ist in the te!minal ileum of the young, whe!eas C!ohnBsdisease of the te!minal ileum may be dis"ove!ed in any age g!oup. f a no!mal appendi& is seen, butC!ohnBs disease affe"ts the te!minal ileum, an appende"tomy is still wa!!anted and will not affe"t the!ate of fistula fo!mation.)1

Donope!ative <!eatment

f a distin"t mass in the !ight ilia" fossa is palpated at p!esentation and the patient has no systemi"manifestations su"h as feve! o! "lini"al pe!itonitis, a nonope!ative app!oa"h "an be unde!taken. $<his app!oa"h was popula!ied befo!e mode!n antibioti"s be"ame available. t is safe to !emove theappendi& with antibioti" "ove!age in vi!tually any patient. 7oweve!, this is pe!iodi"ally a usefulapp!oa"h in the nonto&i" patient with a "lea! diagnosis of an appendi"eal abs"ess. <he patient isfasted with this app!oa"h while int!avenous fluids a!e administe!ed. !oad-spe"t!um antibioti"s a!egiven to "ove! ente!i" o!ganisms while the pulse is "losely followed, be"ause ta"hy"a!dia is one of the fi!st signs that "onse!vative the!apy is not benefiting the patient. n"!easing pain, p!og!essiveta"hy"a!dia, and failu!e to !espond afte! 2# to # hou!s !eui!e ope!ative inte!vention.e!iappendi"eal abs"esses usually !esolve in 10 to 1# days without appende"tomy o! d!ainage.8ith mode!n-day C<, patients with well-fo!med pe!iappendi"eal abs"esses "an unde!go C<-guided

pla"ement of pigtail d!ainage "athete!s to help !esolve the abs"ess mo!e !apidly, !athe! thandepending on the abs"ess to d!ain inte!nally into the "e"um. f the abs"ess is palpable, it is oftenbest to e&te!nally d!ain it pe!"utaneously, although this !emains an issue that demands "lini"al =udgment. 4imitations of pe!"utaneous d!ainage in"lude the inadeua"y of d!aining multilo"ulatedabs"esses, ina""essible lo"ations, and the possible need fo! gene!al anesthesia in young patients.<his app!oa"h is vi!tually always followed by an inte!val appende"tomy. f symptoms of pain andabs"ess pe!sist afte! a "athete! d!ainage p!o"edu!e, fo!mal su!gi"al d!ainage with appende"tomymay be wa!!anted and is safe.

nte!val Appende"tomy

5ost su!geons wait about + weeks to $ months afte! the nonope!ative t!eatment of a pe!fo!atedappendi& to pe!fo!m an inte!val appende"tomy. <e"hni"al diffi"ulties du!ing inte!val appende"tomy

!ange f!om seve!e to minimal, depending on the natu!e of the initial abs"ess. <he p!ima!y benefit,howeve!, is that the ope!ation is "ondu"ted in the absen"e of f!ank pu!ulen"e. Do adeuate

1&6



p!ospe"tive t!ials have been pe!fo!med e&amining the ne"essity fo! inte!val appende"tomy afte! appendi"eal !uptu!e, but it !emains standa!d p!a"ti"e. !ospe"tive studies in "hild!en have shownthat pe!"utaneous "athete! d!ainage is benefi"ial, but it has not been !epo!ted whethe! !e"u!!en"eof appendi"itis is a "ommon entity afte! appendi"eal !uptu!e.

Antibioti" <!eatment

<he patient with appendi"itis should not be !ushed to the ope!ating !oom without adeuatehyd!ation and antibioti" t!eatment. 5ost su!geons use sho!t-"ou!se (less than 2# hou!santimi"!obial p!ophyla&is fo! a"ute appendi"itis. 6ne "ommon "ombination is "efaolin andmet!onidaole to "ove! g!am-negative o!ganisms su"h as % "oli, g!am-positive ba"te!ia, andanae!obi" a"te!oides f!agilis. Ho! p!esumably !uptu!ed appendi"es, many su!geons use t!ipleantibioti" the!apy in"luding ampi"illin, met!onidaole, and gentami"in to en"ompass a widespe"t!um of ente!i" ba"te!ia. <his may be ove!ly agg!essive and "ont!ibute to the evolution of !esistant o!ganisms. Re"ent studies have !e"ommended monothe!apy with a se"ondgene!ation,b!oad-spe"t!um "ephalospo!in su"h as "efotetan fo! patients who will unde!go su!ge!y as thedefinitive t!eatment.)2 Cefotetan is e"onomi"al and effe"tive, whe!eas aminogly"osides and othe! mo!e potent antimi"!obials have a va!iety of disadvantages, in"luding "ost, the development of !esistant o!ganisms, and to&i"ity.

pe"ial Conside!ations

Ch!oni" Appendi"itis e!sus Re"u!!ent Appendi"itis<he e&isten"e of "h!oni" appendi"itis is "ont!ove!sial. a!ious autho!s have des"!ibed "h!oni" !ightlowe! uad!ant pain o! !e"u!!en"e of mild symptoms.$ ome patients may have symptoms of pe!iappendi"eal abs"ess, "e"al dive!ti"ula! disease, o! !e"u!!ent a"ute appendi"itis that appea! toindi"ate "h!oni"ity. atients p!one to !e"u!!ent fe"aliths may have symptoms of "h!oni"ity, but thesepatients do not have "h!oni" appendi"itis in the t!uest sense. Re"ent studies have shown in"!easednumbe!s of p!otein gene p!odu"t /.) immuno!ea"tive ne!ves in inflamed appendi"es.)$ <his mayhelp to definitively diagnose "h!oni"ally !e"u!!ent appendi"itis as well as mo!e subtle "ases of appendi"itis in the futu!e.

Child!en<he diagnosis of appendi"itis is diffi"ult in young "hild!en fo! the obvious !easons that an a""u!atehisto!y of symptoms is not p!ovided by the patient and abdominal pain f!om othe! "auses is"ommon. n ea!ly "hildhood, nausea, vomiting, and abdominal tende!ness a!e f!euent signs of e&t!aabdominal disease. 5eningitis, otitis media, and pneumonia should be spe"ifi"ally e&"luded.6lde! "hild!en have diffe!ent diagnosti" alte!natives to appendi"itis. <he vomiting and voluminousdia!!hea "ommon in vi!al gast!oente!itis a!e !a!e in appendi"itis. 5esente!i" lymphadenitis is usuallyasso"iated with an ante"edent uppe! !espi!ato!y t!a"t vi!al p!od!ome, as in 7eno"h-"hPnleinpu!pu!a. <he latte! "lassi"ally has the asso"iated findings of pu!pu!i" skin lesions, a!th!itis, andneph!itis. ntussus"eption is most "ommon in "hild!en younge! than 2 o! $ yea!s of age befo!eappendi"itis be"omes "ommon. omiting and episodi" abdominal pain that is not lo"alied suggestthe diagnosis of intussus"eption in this age g!oup. <ogethe! with findings of an elongated tende! abdominal mass and guaia"-positive stool, the diagnosis of intussus"eption "an be "lea! on the

basis of histo!y and physi"al e&amination. !ima!y pe!itonitis is not !a!e in "hild!en, pa!ti"ula!lyp!epube!tal females. t is almost inva!iably mistaken fo! a"ute appendi"itis. <yphlitis, a"ute "e"alinflammation, must be "onside!ed in the neut!openi" patient with p!og!essive !ight abdominaltende!ness. <his fo"al fo!m of neut!openi" "olitis may be asso"iated with pneumatosis intestinalis of the "e"al wall, and this finding helps diffe!entiate the disease f!om appendi"itis. n the p!ofoundlyneut!openi" patient with !ight lowe! uad!ant tende!ness, the mainstay of t!eatment is systemi"antibioti" administ!ation until the neut!openia is !esolved. u!gi"al e&plo!ation is asso"iated withe&t!ao!dina!y mo!tality in these patients.

>ounge! "hild!en who "annot give histo!ies tend to p!esent to the eme!gen"y depa!tment multipletimes and eventually a!e given the diagnosis of appendi"itis when gang!ene o! pe!fo!ationo""u!s.)# n most "ontempo!a!y !eviews of "hildhood appendi"itis, the pe!fo!ation !ate is about)0E. n one study, $#E of "hild!en ()# of 1) patients with appendi"itis du!ing the fi!st $ yea!s of

life p!esented with an appendi"eal mass. Ho! this subg!oup of ve!y young "hild!en, "ompli"ation

1&%



!ates may be !edu"ed and hospital stays sho!tened if the appendi"eal mass is managednonope!atively.))

%lde!ly atients%lde!ly patients with appendi"itis have highe! mo!bidity and mo!tality !ates than the !est of thepopulation be"ause of the delay in p!esentation of symptoms and the delay in diagnosis. A highe!

in"iden"e of pe!fo!ated appendi"itis o""u!s in the elde!ly, but unlike young "hild!en, the elde!ly havemu"h less !ese!ve when "hallenged with pe!itonitis. <hese patients may have fewe! "omplaints of pain "ompa!ed with young adults, and the pain may be des"!ibed as a dull !ight lowe! uad!antpain. Hu!the!mo!e, lo"aliation to the !ight lowe! uad!ant is delayed, and an elevation in the 8C"ount may be none&istent. 6ve! $0E of elde!ly patients have a !uptu!ed appendi& at time of su!ge!y. %lde!ly patients tend to have mo!e medi"al p!oblems, whi"h "auses a delay in the definitivet!eatment of appende"tomy. As a !esult, mo!e elde!ly patients die f!om !uptu!ed appendi"esbe"ause of a delay in su!ge!y o! the absen"e of su!ge!y. <he elde!ly may have a mo!tality !ate ine&"ess of )E f!om a pe!fo!ated appendi&, in "ont!ast to a mo!tality !ate of less than 1E in othe! patients. 8hen a patient olde! than +0 yea!s of age unde!goes an appende"tomy, inspe"tion fo! a"oe&istent !ight-sided "olon "a!"inoma should be !outine du!ing lapa!otomy.

!egnan"y

Anatomi" and physiologi" "hanges alte! the p!esentation of appendi"itis du!ing the se"ond and thi!dt!imeste!s of p!egnan"y. Abdominal pain, nausea, and vomiting a!e all "ommon in ea!ly p!egnan"y.Dausea and vomiting may be diffi"ult to distinguish f!om symptoms due to the p!egnan"yN howeve!,lo"aliing !ight lowe! uad!ant tende!ness is still a !eliable sign of a"ute appendi"itis. Afte! the fifthmonth of gestation, the appendi"eal positionQand the!efo!e the site of painQis shifted supe!io!lyabove the !ight ilia" "!est, and the appendi& tip is !otated medially by the g!avid ute!us (Hig. )#-11. Abdominal tende!ness be"omes less lo"alied as distention of the abdomen lifts the pe!itoneumaway f!om the appendi& and "e"um. Deve!theless, tende!ness !emains the most impo!tant "lini"alfinding. Heve! is less "ommon, and leuko"ytosis is diffi"ult to inte!p!et given that this is a no!malfeatu!e of p!egnan"y. <he "lini"al diagnosis of appendi"itis is mo!e diffi"ult at this stage, andult!asound may be helpful in distinguishing obstet!i" pathology f!om appendi"itis. f pe!itoneal signssupe!vene in late p!egnan"y, this usually signifies pe!fo!ation and may have g!ave "onseuen"es.e!fo!ation has been asso"iated with a fetal mo!tality !ate of ove! $0E and a mate!nal mo!tality !ate

of 1E to 2E. imple a"ute appendi"itis has a negligible mate!nal mo!tality !ate, and the !isk of fetalloss is about 10E. ?!gent e&plo!ation should be unde!taken on"e the diagnosis of appendi"itis hasbeen made. <he!e is no !ole fo! nonope!ative management in this setting. A negative lapa!otomy!ate of 1)E to #0E !esulting f!om an agg!essive app!oa"h to this disease is app!op!iate. Appendi"itis !emains the most f!euent nonobstet!i" indi"ation fo! lapa!otomy du!ing p!egnan"y.

A* atients Although patients with A* a!e mo!e sus"eptible to "ytomegalovi!us-!elated bowel pe!fo!ations,the!e is no eviden"e that they have a highe! !ate of a"ute suppu!ative appendi"itis.$ !edi"tably,howeve!, mo!bidity and mo!tality !ates a!e highe! fo! this g!oup of patients, and the diagnosis of a"ute appendi"itis is mo!e diffi"ult be"ause oppo!tunisti" infe"tious agents "ausing ente!o"olitis maymimi" the disease. ome A* patients have p!esented with p!ima!y Maposi sa!"oma of theappendi&,) whi"h eli"its symptoms simila! to those of a"ute appendi"itis. 8hen pathology !epo!ts

afte! an appa!ently !outine appende"tomy show !a!e oppo!tunisti" infe"tions, a wo!kup fo! A*should be ente!tained.

n"idental Appende"tomyn"idental appende"tomy !efe!s to the p!ophyla"ti" !emoval of the no!mal appendi& du!inglapa!otomy fo! anothe! "ondition. <he de"ision to !ese"t the appendi& du!ing anothe! abdominalope!ation depends on the !isk-to-benefit !atio. t !eui!es "lini"al =udgment and !emains"ont!ove!sial. %ven though !emoval of the appendi& is the most "ommon u!gent ope!ation in the8este!n 7emisphe!e, most of the population will live a full life with a no!mal appendi&. t isestimated that 100 to 11) in"idental appende"tomies must be pe!fo!med, without "ompli"ations o! death, to p!event one needed appende"tomy in the elde!ly. ome suggest that in"identalappende"tomies "an be safely pe!fo!med in patients younge! than +0 yea!s of age. n"identalappende"tomies a!e "ont!ove!sial in a "hild o! an adult, but they a!e "lea!ly not indi"ated in the

elde!ly. <he a!gument in favo! of in"idental appende"tomy is that it is "ost-effe"tive in te!ms of

1&&



!edu"ing the mo!bidity of an additional su!ge!y, !edu"ing hospitaliation, and eliminating possiblepe!fo!ation in the futu!e.eve!al studies have looked at in"idental appende"tomies in the adult population. n t!aumapatients unde!going lapa!otomy, in"idental appende"tomy does not affe"t ove!all "ompli"ation !ates.6the! patients unde!going lapa!otomy fo! the staging of 7odgkin disease have an in"!ease inwound infe"tion !ates. n patients olde! than )0 yea!s of age unde!going "hole"yste"tomy, a

signifi"ant in"!ease in mo!bidity was obse!ved in those who had in"idental appende"tomy. <hedefi"ien"y in all past studies of this issue is the la"k of blinded long-te!m t!ials to assess the t!ue"ost and benefit. Although appende"tomies "an be safely pe!fo!med, the sub=e"tion of patients toeven a small unne"essa!y !isk is diffi"ult to =ustify in a litigious so"iety.)/ At p!esent, individual =udgment !ega!ding spe"ifi" patients !emains ne"essa!y in this a!ea.

Tu,o*s o t(e A!!en$i>

<he most "ommon appendi"eal tumo! is the "a!"inoid, dis"ussed ea!lie!. t is usually dis"ove!edin"identally at the time of su!ge!y o! e&amination of a !ese"ted appendi&. / <his neoplasm mostf!euently involves the distal tip of the appendi&, whe!e it p!odu"es a solid bulbous swelling up to 2to $ "m in diamete!. Although int!amu!al and t!ansmu!al e&tension may be evident, nodalmetastases a!e ve!y inf!euent, and distant sp!ead is !a!e. 6ne uniue type of appendi"eal

"a!"inoid tumo! is goblet "ell "a!"inoid (adeno"a!"inoid. 7istologi"ally, the tumo! shows a typi"al"a!"inoid patte!n, but with plump mu"in va"uole-"ontaining "ells. <he biologi" behavio! of the tumo! is between that of typi"al "a!"inoid and adeno"a!"inoma. @eneti" alte!ations have been found inboth typi"al "a!"inoid tumo!s and goblet "ell "a!"inoids./

Conventional adenomas o! non-mu"in-p!odu"ing adeno"a!"inomas of the appendi& may "ause atypi"al neoplasti" enla!gement of this o!gan. 7ype!plasti" polyps may o""u! in this lo"ation as well.enign and malignant mesen"hymal g!owths !esemble thei! "ounte!pa!ts in othe! a!eas.

MUCOCELE AND PSEUDOMYXOMA PERITONEI

5u"o"ele is the ma"!os"opi" des"!iption of a dilated appendi& filled with mu"in. <he t!ue pathologi"natu!e of mu"o"ele !uns the gamut f!om an inno"uous obst!u"ted appendi& "ontaining inspissatedmu"in, to a mu"in-se"!eting adenoma (mu"inous "ystadenoma and adeno"a!"inoma (mu"inous

"ystadeno"a!"inoma. n the last instan"e, invasion th!ough the appendi"eal wall withint!ape!itoneal seeding and sp!ead of tumo! may o""u!.

Mo*!(o"og.& All mu"inous lesions a!e asso"iated with appendi"eal dilatation se"onda!y tomu"inous se"!etions. 8ith the simple ,u0o0e"e, globula! enla!gement of the appendi& byinspissated mu"us o""u!s, usually the !esult of obst!u"tion by a fe"alith o! othe! lesion su"h as aninflammato!y st!i"tu!e. %ventually, the distention p!odu"es suffi"ient at!ophy of the mu"in-se"!eting mu"osal "ells and the se"!etions stop. Ra!ely, a fo"us of mu"in-se"!eting hype!plasti"epithelium appea!s to be the "ulp!it. <his "ondition is usually asymptomati"N !a!ely a mu"o"ele!uptu!es, spilling othe!wise inno"uous mu"us into the pe!itoneal "avity.

<he most "ommon mu"inous neoplasm is the benign ,u0inous 0.sta$eno,a, whi"h !epla"esthe appendi"eal mu"osa and is histologi"ally identi"al to analogous tumo!s in the ova!y. <heluminal dilation is asso"iated with appendi"eal pe!fo!ation in 20E of instan"es, p!odu"ing

lo"alied "olle"tions of mu"us atta"hed to the se!osa of the appendi& o! lying f!ee within thepe!itoneal "avity. 7istologi" e&amination of the mu"us, howeve!, !eveals no malignant "ells.

5alignant ,u0inous 0.sta$eno0a*0ino,as a!e one fifth as "ommon as "ystadenomas.5a"!os"opi"ally they p!odu"e mu"in-filled "ysti" dilatation of the appendi& indistinguishable f!omthat seen with benign "ystadenomas. enet!ation of the appendi"eal wall by invasive "ells andsp!ead beyond the appendi& in the fo!m of lo"alied o! disseminated pe!itoneal implants,howeve!, is f!euently p!esent (Hig. 1-+. n its fully developed state, "ontinued "ellula! p!olife!ation and mu"in se"!etion fills the abdomen with tena"ious, semisolid mu"in!seu$o,.>o,a !e*itoneii. Anaplasti" adeno"a!"inomatous "ells "an be found, distinguishingthis p!o"ess f!om mu"inous spillage. nstan"es in whi"h pseudomy&oma pe!itoneii isa""ompanied by both appendi"eal and ova!ian mu"inous adeno"a!"inomas a!e usually as"!ibedto sp!ead of an appendi"eal p!ima!y lesion.

5u"o"eles a!e gene!ally en"ounte!ed as an in"idental lesion. 5u"inous "ystadenomas and

1&'



adeno"a!"inomas may p!esent with pain, att!ibutable to distention of the vis"us. 4apa!otomy fo! p!esumed a"ute appendi"itis is a typi"al diagnosti" setting. Ho! lesions "onfined to the !ese"tedspe"imen (appendi& o! mo!e !adi"al e&"ision, the outlook is e&"ellent. seudomy&oma pe!itoneiimay be held in "he"k fo! yea!s by !epeated debulking p!o"edu!es but in most instan"es eventually!uns its ine&o!able fatal "ou!se.

1'0



#ui$ing 7uestion:7ow is the ethi"s on eme!gen"y t!iage system9 *is"uss this issue th!ough the pe!spe"tive of ethi"aland p!ofessional value

TUTOR #UIE ON ?%P

ET%ICS ON EMER#ENC9 TRIA#E S9STEM

%me!gen"y "a!e is one of the most sensitive a!eas of health "a!e. <his sensitivity is"ommonly based on a "ombination of fa"to!s su"h as u!gen"y and "!owding. ?!gen"y of "a!e!esults f!om a "ombination of physi"al and psy"hologi"al dist!ess, whi"h appea!s in all eme!gen"ysituations in whi"h a sudden, une&pe"ted agoniing and at times life th!eatening "ondition leads apatient to the eme!gen"y depa!tment (%*.

<he Aust!alasian College fo! %me!gen"y 5edi"ine (AC%5 defines %* ove!"!owding as thesituation whe!e %* fun"tion is impeded p!ima!ily be"ause the numbe! of patients waiting to beseen, unde!going assessment and t!eatment, o! waiting to leave e&"eeds the physi"al and; o! staffing "apa"ity of the %*. %* ove!"!owding is a "ommon s"ena!io a""!oss the globe and!esou!"es like staff, spa"e and euipment a!e limited. atients often have to wait fo! a long timebefo!e being seen by a do"to! and even longe! befo!e being t!ansfe!!ed to a hospital bed. <he !esult

is not me!ely in"onvenien"e but a deg!adation of the enti!e "a!e e&pe!ien"e F uality of "a!e is"omp!omised, the patientBs safety may be endange!ed, staff mo!ale is impai!ed and the "ost of "a!ein"!eases.

<he inapp!op!iate use and; o! misuse of %* se!vi"es is one of the "ommon p!oblemsleading to ove!"!owding. o"iodemog!aphi" "ha!a"te!isti"s as p!edi"to!s of nonu!gent use of eme!gen"y depa!tment. ubli" o!ientation, st!engthening and e&panding p!ima!y "a!e se!vi"es "anbe a solution to the p!oblem. 8hen e&isting needs "annot be met by the available !esou!"es asystem is needed to "ope with the situation and many hospitals use a t!iage system in o!de! to dothis. <he aim of t!iage is to imp!ove the uality of eme!gen"y "a!e and p!io!itie "ases a""o!ding tothe !ight te!ms.

<he te!m It!iageJ is de!ived f!om the H!en"h wo!d t!ie! (to so!t whi"h was o!iginally used todes"!ibe so!ting of the ag!i"ultu!al p!odu"ts. <oday, It!iageJ is almost e&"lusively used in spe"ifi"health "a!e "onte&ts. H!om the pe!spe"tive of ethi"al theo!ies, t!iage is "ommonly seen as a "lassi"

e&ample of dist!ibutive =usti"e, whi"h add!esses the uestion of how benefits and bu!dens shouldbe dist!ibuted within a population. t is t!aditionally used within the ethi"al lite!atu!e as an e&ample of a p!essing ethi"al "onfli"t between the utilita!ian p!in"iple to do the g!eatest good fo! the g!eatestnumbe!, the p!in"iple of eual !espe"t fo! all, the p!in"iple of nonmalefi"en"e, and the p!in"iple of nonabandonment.

T(e P*in0i!"e+ase$ A!!*oa0(Respect for Autonomy Respe"t fo! autonomy is a pivotal "!ite!ion fo! de"ision-making in health "a!e and p!ovides that"ompetent pe!sons have the !ight to make "hoi"es !ega!ding thei! own health "a!e. Respe"t fo! patient autonomy be"ame espe"ially impo!tant with the eman"ipation of the patient in the so"io-politi"al "onte&t of demo"!a"y and the human !ights movement. t !esulted in the de"line of thepate!nalisti" !elationship between a do"to! and patient and en"ou!aged individuals to p!ote"t thei!

pe!sonal values. <o !espe"t an autonomous agent is, at a minimum, to a"knowledge the pe!sonBs!ight to hold views, to make "hoi"es, and to take a"tions based on pe!sonal values and beliefs.

8hile "onside!ing %* t!iage, autonomy is ve!y diffi"ult to assess espe"ially when u!gentsituations a!ise. <he Ame!i"an College of %me!gen"y hysi"ians defines eme!gen"y se!vi"es asthose health "a!e se!vi"es p!ovided to evaluate and t!eat medi"al "onditions of !e"ent onset andseve!ity that would lead a p!udent lay pe!son, possessing an ave!age knowledge of medi"ine andhealth, to believe that u!gent and; o! uns"heduled medi"al "a!e is !eui!ed. A""o!ding to thisdefinition, u!gen"y is dete!mined by a lay pe!son and eme!gen"y se!vi"es have two "omponentsNfi!stly evaluation and then, t!eatment. 5ost of the patients who "ome to an eme!gen"y depa!tmentbelieve they have a p!oblem !eui!ing immediate medi"al "a!e. n su"h "ases, %* t!iage !aisesethi"al uestions pa!ti"ula!ly when the eme!gen"y se!vi"e is being denied. 6ne "an "onside! t!iageas an evaluation, although te"hni"ally it is not a "omplete medi"al evaluation. Refusal to p!ovideeme!gen"y t!eatment to a patient p!esenting to the %* "ont!adi"ts to the p!in"iple of !espe"t fo!

autonomy. <he t!iage offi"e! takes the de"ision without "onsent of the patient whi"h "an be!ega!ded as the pate!nalisti" app!oa"h of de"ision making. @iven the u!gent "ha!a"te! of

1'1



eme!gen"y situations, !espe"t fo! autonomy in the fo!m of info!med "onsent is often not the fi!stethi"al p!io!ity, whi"h is pe!fe"tly no!mal be"ause the u!gen"y of the situation does not p!ovide !oomfo! it. n su"h situations, the ne"essa!y "a!e should be p!ovided instantly.

Nonmalefcence<he p!in"iple of nonmalefi"en"e "an be des"!ibed as Ido no ha!mJ. <he 7ippo"!ati" 6ath mention

this obligation as I will use t!eatment to help the si"k a""o!ding to my ability and =udgement, but will neve! use it to in=u!e o! w!ong themJ. 6ne ought not to infli"t evil o! ha!m. 7a!m is not di!e"tlyinfli"ted by t!iage e&"ept when hopelessly in=u!ed patients a!e "onside!ed in the dead "atego!y.%ven du!ing disaste!s, unde! given "i!"umstan"esN health "a!e p!ofessionals a!e always obligatedto p!ovide the !easonable best "a!e. <he aim is to se"u!e fai! and euitable !esou!"es andp!ote"tions fo! vulne!able g!oup.

<!iage guidelines aim to avoid ha!m to the patient by so!ting the patients as ui"kly andeffi"iently as possible. 7oweve!, in eme!gen"y "a!e, espe"ially in situations of ove!"!owding,t!eating one patient might th!eaten the welfa!e of anothe! patient by not being able to take "a!e of both. tudies in diffe!ent "ent!es have found an asso"iation between ove!"!owding and !edu"eda""ess to "a!e, de"!eased uality measu!es, and poo! out"omes.

ometimes, !efe!!al to othe! "ent!es "an !esult in mo!e ui"k and effe"tive se!vi"e and thus,ha!m in the fo!m of e&"essive delays may be avoided. Hu!the!mo!e, medi"al "a!e is not only the

diagnosis and t!eatment in eme!gen"y "a!eN patients value effe"tive "ommuni"ation and sho!twaiting times ove! many othe! aspe"ts of "a!e. 4a"k of "ommuni"ation of t!iage times and"atego!ies is one of the "auses of agg!esion and violen"e of patients and a""ompanying pe!sonstowa!ds eme!gen"y staff.

%kwall et al. suggest the impo!tan"e of add!essing the psy"hoso"ial needs of patients of va!ying levels of u!gen"y th!ough thei! so"ial inte!a"tions at t!iage. %&isting t!iage guidelines miss toin"o!po!ate this aspe"t of "a!e, whi"h "an "omp!omise the p!in"iple of nonmalefi"en"e.

!enefcence7ealth "a!e p!ovide!s in the %* have an ethi"al obligation to attempt to p!ovide benefits to thepatients by taking thei! "omplaints se!iously and by managing thei! p!oblems a""o!ding to p!evailingstanda!ds of "a!e. y applying a system of t!iage, they seek to imp!ove the uality of "a!e by usingthe available !esou!"es as effe"tively and effi"iently as possible. <he ultimate goal of t!iage is to

p!ese!ve and p!ote"t endange!ed human lives as mu"h as possible by assigning p!io!ity to patientswith an immediate need fo! life-sustaining t!eatment. <hough due "onside!ation should be given tothe available !esou!"es, the life and health of patients is p!io!ity.

n t!iage, tenden"y of ove!t!iage pa!ti"ula!ly in patients with t!auma may be tenden"y fo! benefi"en"e. 7oweve!, it is an Ie!! on the side of "autionJ. 6ve!t!iage not only in"!eases the "ost of medi"al "a!e but also may !esult in wo!se out"ome. Deve!theless, this has to be done in a "onte&t"ha!a"te!ied by u!gen"y, ove!"!owding, and limited medi"al !esou!"es (time, staff, medi"aleuipment, d!ugs et", whi"h in"!eases the p!essu!e upon health p!ofessionals in the %*. n thesame line of !easoning, t!iage offi"e!s mention the fea! that an in"o!!e"t t!iage "atego!y allo"ationmay lead to a delay in t!eatment and at wo!st, the death of a patient, pa!ti"ula!ly when waiting timesa!e long.

"ustce

Susti"e, mo!e spe"ifi"ally unde!stood as dist!ibutive =usti"e, !eui!es that given limited !esou!"es,allo"ation de"isions must be made fai!ly, and that benefits and bu!dens a!e dist!ibuted in a =ust andfai! way. <!iage s"hemes systemati"ally allo"ate the benefits of !e"eiving health "a!e, and thebu!dens of limited, delayed, o! defe!!ed "a!e, among a population of si"k o! in=u!ed pe!sons. <hisdoes not mean that ea"h pe!son o! g!oup must get an eual sha!e of the s"a!"e !esou!"es(euality, but !athe! a fai! sha!e based on app!op!iate "!ite!ia and p!in"iples (euity.

@ene!ally, the "!ite!ia and p!in"iples !elevant fo! t!iage in eme!gen"y "a!e "an be "lassifiedinto th!ee gene!al "atego!ies, among whi"h a balan"e has to be "!eated. <he fi!st p!in"iple is thep!in"iple of euality. t is based on the idea that ea"h pe!sonBs life is of eual wo!th and holds thateve!yone should have an eual "han"e to !e"eive the ne"essa!y "a!e. A t!iage system based onthis p!in"iple would p!esumably ope!ate on a fi!st-"ome, fi!st se!ved basis, giving eual"onside!ation to all, no matte! how !esou!"e intensive oneBs t!eatment will be, o! even though the"a!e fo! one o! a few patients may !esult in a g!eate! bu!den fo! many. <he !elu"tan"e of physi"ians

to abandon any patient whom they believe they "an save may give impli"it suppo!t to this type of t!iage. t is also known as the !es"ue-p!in"iple o! the p!in"iple of non-abandonment. 7oweve!, giving

1'"



p!io!ity to the p!in"iple of euality in eme!gen"y "a!e situation is not an optimal st!ategy to !ealiseeffi"ient use of s"a!"e !esou!"es.

<he p!in"iple of utility, on the othe! hand, holds that a"tions should be =udged by thei! "onseuen"es and how fa! they p!odu"e the g!eatest net benefit among all those affe"ted. 6! putsimply, to do the g!eatest good fo! the g!eatest numbe!. n fa"t, utilita!ianism is the !ationale fo! t!iage systems, insofa! as they seek to use the available but s"a!"e medi"al !esou!"es as effi"iently

as possible. n itself, howeve!, the p!in"iple of utility !emains silent with !ega!d to whi"h goods o! benefits a!e to be ma&imied. n o!de! to p!odu"e the g!eatest net benefit, we must have a "lea! a""ount of whi"h kinds of benefit a!e to be p!omoted. <o ma&imie the "hosen benefits ove!all,howeve!, t!iage systems may di"tate that t!eatments fo! some patients be delayed, often !esulting inpoo!e! out"omes fo! those patients.

6ne pa!ti"ula! "!ite!ion is being !efle"ted in the thi!d p!in"iple of =usti"e, i.e. the p!in"iple of p!io!ity to the wo!st-off. 7e!e, mu"h depends on how one defines the wo!st-off g!oup. A!e they themost needy9 <he most u!gent "ases9 6! the ones with the lowest p!ospe"ts9 6! even the poo! anddisenf!an"hised people who most often use the eme!gen"y depa!tments be"ause they have noothe! "hoi"e of !e"eiving health "a!e9 uppose the wo!st possible out"ome would be death. A""o!dingly, the wo!st-off g!oup would be the seve!ely ill o! in=u!ed people whose !isk of death ishighest, and fo! whom the likelihood of su""essful t!eatment is low, i.e. the ones at the edge of lifeand death. @uided by this p!in"iple, t!iage systems would give p!io!ity to t!eatment of this "lea!ly

disadvantaged g!oup.n "on"lusion, f!om the fou! p!in"iples of biomedi"al ethi"s, we "an de!ive the following

a!eas of spe"ial attention:1. <he p!in"iple of !espe"t fo! autonomy, espe"ially in %* situations, is ve!y diffi"ult to assess,

most pa!ti"ula!ly when u!gent situations a!ise, as often is the "ase. pe"ial attention isneeded fo! pa!ti"ula! ways of !espe"ting autonomy as mu"h as possible, fo! instan"e byapp!op!iate and adeuate "ommuni"ation du!ing the t!iage p!o"ess.

2. <he p!in"iple of nonmalefi"en"e is unde! p!essu!e sin"e t!iage "an !einfo!"e the physi"al(long waiting times, in"!easing pain and suffe!ing, dete!io!ating "ondition and psy"hologi"alha!ms (st!ess, fea!, feeling negle"ted that "ome with the unde!lying pathologi"al"onditions.

$. Agg!ession and violen"e a!e "ommon phenomena in the %*. <hey agg!avate the wo!king"onditions, impai! staff mo!ale and "ompli"ate peopleBs abilities to make p!ope! de"isions.

<he p!in"iple of benefi"en"e is "omp!omised by the p!essu!e upon health p!ofessionals,whi"h in tu!n !einfo!"es thei! feelings of fea! fo! making w!ong de"isions.

#. 8ith !ega!d to the p!in"iple of =usti"e, it is finally a "ontinuous assignment to "he"k whethe! the system !ealises a fai! balan"e between the p!in"iple of eual !espe"t fo! all and effi"entuse of !esou!"es. 7e!e, it is impo!tant to see whethe! the =ust situation "an be !ealised in ahuman way.

Ree*en0e:Ramesh . Aa"ha!ya, Ch!ist @astmans, and >vonne *enie! (2011: %me!gen"y *epa!tment <!iage: An %thi"al Analysis. 5C %me!gen"y 5edi"ine. 11:1+

8hat is known about the topi"9 8hy is !esea!"h uestion impo!tant9 8hat kind of answe! will the

study p!ovide9TUTOR #UIE CRP:!oadly speaking, any uestion that we want answe!ed and any assumption o! asse!tion that wewant to "hallenge o! investigate "an be"ome a !esea!"h p!oblem o! a !esea!"h topi" fo! ou! study.<he fo!mulation of !esea!"h p!oblem is the fi!st and most impo!tant step of the !esea!"h p!o"ess. tis like the identifi"ation of a destination befo!e unde!taking a =ou!ney. A !esea!"h p!oblem is like thefoundation of a building. <he type and design of the building is dependent upon the foundation. fthe foundation is well-designed and st!ong we "an e&pe"t the building to be also. <he !esea!"hp!oblem se!ves as the foundation of a !esea!"h study, if it is well fo!mulated, we "an e&pe"t goodstudy to follow.<able 1. ou!"es of !esea!"h p!oblem (fou! of TB

As!e0t o a stu$. A+out Stu$. o

tudy opulation eople ndividuals, o!ganiation, g!oups, and "ommunitiesub=e"t a!ea !oblem ssues, situations, asso"iations, needs, population

"omposition, p!ofiles, et".

1'3



!og!am Contents, st!u"tu!e, out"omes, att!ibutes, satisfa"tion,"onsume!s, se!vi"e p!ovide!s, et"

henomenon

Cause and effe"t !elationships, the study of aphenomenon itself, et"

5ost !esea!"h on a pa!ti"ula! TB may va!y f!om study to study but gene!ally in p!a"ti"e most!esea!"h studies a!e based upon at least a "ombination of two TBs.

8hen sele"ting a !esea!"h p!oblem;topi" the!e is a numbe! of "onside!ations to keep in mind.<hese help to ensu!e that ou! study will be manageable and that you will !emain motivated. <hese"onside!ations a!e:nte!est : ele"t a topi" that !eally inte!ests youN this one of the most impo!tant

"onside!ations. A !esea!"h endeavou! is usually time-"onsuming, andinvolves ha!d wo!k and possibly unfo!eseen p!oblems. f you sele"t a topi"whi"h does not g!eatly you, it "ould be"ome e&t!emely diffi"ult to sustain the!eui!ed motivation, and hen"e the "ompletion time "ould be affe"ted

5agnitude : >ou should have suffi"ient knowledge about the !esea!"h p!o"ess to be ableto visualie the wo!k involved in "ompleting the p!oposed study. Da!!ow thetopi" down to something manageable, spe"ifi" and "lea!. t is e&t!emelyimpo!tant to sele"t a topi" that you "an manage within the time and!esou!"es at you! disposal.

5easu!ement of"on"epts

: f you a!e using a "on"ept in you! study, make su!e you a!e "lea! about itsindi"ato!s and thei! measu!ement. Ho! e&ample if you plan to measu!e theeffe"tiveness of a health p!omotion p!og!am, you must be "lea! as to whatdete!mines effe"tiveness and how it will be measu!ed. *o not use "on"ept inyou! !esea!"h p!oblem that you a!e not su!e how to measu!e. <his does notmean you "annot develop a measu!ement p!o"edu!e as the studyp!og!esses. 8hile most of the developmental wo!k will be done du!ing you!study, it is impe!ative that you! !easonably "lea! about the measu!ement ofthis "on"ept at this stage.

4evel of e&pe!tise : 5ake su!e you have an adeuate level of e&pe!tise fo! the task you a!ep!oposing. Allow fo! the fa"t that you will lea!n du!ing the study and may!e"eive help f!om you! !esea!"h supe!viso!s an othe!s, but !emembe! youneed to do most of the wo!k you!self.

Relevan"e : ele"t a topi" that is !elevan"e to you as a p!ofessional. %nsu!e that you!study ads to the e&isting body of knowledge, b!idges "u!!ent gaps o! is usefulin poli"y fo!mulation. <his will help you to sustain inte!est in the study.

Availability of data : f you! topi" entail "olle"tion of info!mation f!om se"onda!y sou!"es (offi"e!e"o!ds, "lient !e"o!ds, "ensus o! othe! al!eady-published !epo!ts, e"t.,befo!e finalising you! topi", make su!e that these data a!e available and inthe fo!mat you want.

%thi"al issues : Anothe! impo!tant "onside!ation in fo!mulating a !esea!"h p!oblem is theethi"al issues involved. n the "ou!se of "ondu"ting a !esea!"h study, thestudy population may be: adve!sely affe"ted by some of the uestion(di!e"tly indi!e"tlyN dep!ived of an inte!ventionN e&"epted to sha!e sensitiveand p!ivate info!mationN o! e&"epted to be simply e&pe!imental Tguinea pigsB.7ow ethi"al issues "an affe"t the study population and how ethi"al p!oblems

"an be ove!"ome should be tho!oughly e&amined at the p!oblem fo!mulationstage.

Refe!en"e: Muma! R. Resea!"h 5ethodology: A tep-by-tep @uide fo! eginne!s. A@% ubli"ationsN

200).

Documents

CASE 3 TG Appendicitis 2013