LP CKD Lp Lp Apendisitis LP Apendisitis 7. Lp Apendisitis Lp Apendisitis IBS LP Apendisitis LP apendisitis LP Apendisitis. LAPORAN PENDAHULUAN PADA KLIEN “A” DENGAN DIAGNOSA MEDIS APENDISITIS PERFORASI A. Konsep Dasar Penyakit 1. Definisi Apendistis adalah. Appendicitis is defined as an inflammation of the inner lining of the vermiform appendix that spreads to its other parts. This condition is a.

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As the clinical diagnosis of AA remains a challenge to emergency physicians and surgeons, imaging apendkisitis have gained major importance in the diagnostic work-up of patients with suspected AA in order to keep both the negative appendectomy rate and the perforation rate low.

Introduced ingraded-compression ultrasound US has well-established direct and indirect signs for diagnosing AA.

In our opinion, US should be the first-line imaging modality, as graded-compression US has excellent apendisitis both in the paediatric and adult patient populations.

Accordingly, both ionizing radiation to our patients and cost of pre-therapeutic diagnosis of AA will be low, with low negative appendectomy and perforation rates.

Acute appendicitis AA is a disease with a high prevalence, requiring rapid and accurate diagnosis to confirm apenxiksitis exclude perforation. The clinical diagnosis remains difficult, both in the paediatric and adult population, as the presentation is often atypical [ 2 ].

Symptoms are frequently apendikwitis and overlap with various other diseases [ 3 ]. Despite all improvements in clinical and laboratory diagnosis and the publication of various scoring systems to guide clinical decision-making, the fundamental decision whether to operate or not remains challenging.

In an ideal medical world, we would like to optimally diagnose and treat all patients with suspected AA without unnecessary appendectomies. A negative appendectomy might not only expose the patient to the risk of the surgical procedure. Recently, a higher risk of acute myocardial infarction related to surgical removal of the tonsils and appendix before age 20 has been reported [ 4 ].

Further studies are needed, as the authors point out, but subtle alterations in immune function following these operations may alter the cardiovascular risk [ 4 ]. Accordingly, the rapid and now widely used application lo imaging methods in the diagnostic armamentarium for AA is demonstrated by an increasing number of publications, starting from the first report on compression ultrasound US by JB Puylaert in [ 5 apendikstis.

Multi-detector computed tomography MDCT is considered the gold standard technique to evaluate patients with suspected AA, because of its high sensitivity and specificity [ 23 ].

Magnetic resonance imaging MRI has also shown high accuracy in the detection of AA, especially when radiation protection in children and in pregnant patients is of major importance [ 23 ]. Apendiksltis the other hand, research focusing on various aspects of US imaging in the diagnoses of AA has gained major importance over recent years as radiation protection [ 6 ], broad availability and cost-effectiveness became increasingly important aspects of modern imaging techniques in the diagnosis of AA.

Accordingly, this paper will focus apsndiksitis on the state of the art of US imaging in patients with a clinical suspicion of AA and will try to make a case for US as the first-line imaging modality in this clinical setting. There is a male preponderance, with a male to female ratio of 1. The overall lifetime risk is 6. We do not know the cause of AA, but there are probably many contributing factors.

The primary cause is probably luminal obstruction, which may result from fecaliths, lymphoid hyperplasia, foreign bodies, parasites and primary neoplasms or metastasis as detailed in [ 9 apensiksitis. According to [ 2 ], AA might be called simple AA in the absence of gangrene, perforation or abscess around the inflamed appendix, or complicated AA when perforation, gangrene or aendiksitis abscess are present.

Abdominal pain is apendiksitls primary presenting complaint, followed by vomiting with migration of the pain to the right iliac fossa, described first by J Murphy in [ 10 ]. However, this classical presentation is quite often absent, either due to variation in the anatomic position of pp appendix or the age of the patient, with atypical presentations seen often in infants and elderly patients [ 2 ]. The degree of white blood cell elevation, the value of C-reactive protein, apendiositis proportion of polymorphonuclear cells, a history of fever and other factors have been studied extensively for the diagnosis of AA, but lack sufficient specificity either alone or in combination.


On the contrary, the absence of all of these laboratory parameters can potentially rule out the diagnosis of AA [ 3 ]. An excellent overview is provided by G Thompson [ 11 ].

As these scores are quite often implemented in apendiksitjs method section of studies apendiksigis the diagnostic performance of imaging techniques in patients with a clinical suspicion of AA, knowledge of the most popular scores is mandatory. Pl Alvarado score has been reported in numerous studies in paediatric and adult patients with a suspicion of AA.

The authors recommend serial US examinations or further imaging when there is discordance between US results and the clinical assessment by the PAS score [ 13 ]. However, in clinical practice, these scores are used in only a few centres 1 out of 83 [ 14 ]. Modern apenndiksitis like interleukin 6, serum amyloid A, rinoleukograms, Calprotectin and others have been studied as diagnostic tools in AA kp 3 ]. The power of these studies is considered limited in clinical practice to date. For more details see [ 3 ].

It is crucial to avoid two potential situations in patients with suspected AA: There is agreement that imaging techniques improve both of these clinical scenarios, due to the potential for early apendiksiyis and the high sensitivities CT, MRI and specificities US, CT, MRI of these techniques [ 279 ]. A recent study demonstrated that increased use of pre-operative imaging in patients with AA resulted in apendiksits cost-effective way to decrease the negative appendectomy rate NAR [ 15 ].

Real-time compression US was first introduced by Puylaert in [ 516 ]. Although the development of US technique has led to dramatic improvements in contrast, spatial and temporal resolution, US examination technique and US signs of appendicitis in real-time US have undergone only slight apendiksifis. Graded-compression US is performed in a step-wise approach and aims to optimize visualization wpendiksitis the appendix [ 79 ].

Recently, it has been shown that the diameter of the normal appendix mean anteroposterior diameter 4. To date, there are only few reports on the use of US elastography techniques in diagnosing AA [ 1819 ]. Besides, case reports in the largest series of 50 patients with suspected acute AA, L Incesu et al.

Longitudinal real-time US scan of a normal appendix.

How to diagnose acute appendicitis: ultrasound first

Thompson [ 11 ]. RLQ right lower quadrant of the abdomen. Direct and indirect secondary signs of acute appendicitis in graded-compression, real-time US, colour Doppler and contrast-enhanced US CEUS; adopted according to references 7, 9, 20 and InTrout et al. In a systematic review including patients of 25 studies reported a sensitivity of The overall pooled estimates for the diagnostic value of CT were: One should not forget that post-test probabilities are markedly decreased when the pre-test probability is low, as has been demonstrated in this study apendikssitis 25 ].

According to this paradigm, US examinations might be false—negative a if the inflamed appendix is overlooked; b if the inflamed appendix is overlooked and other abnormalities are erroneously considered responsible for the symptoms e. A recent study demonstrated that greater abdominal wall thickness and a lower pain score were statistically associated with false—negative US examinations [ 26 ].

However, over recent years, various studies supported the hypothesis that a non-diagnostic US study without US apendikstis of the appendix might have a high NPV to rule out AA in specific patient populations and in specific clinical settings [ 27 — 32 ]. It seems quite obvious that body mass, thickness of the body wall and local pain might be factors responsible for excellent or absent visualization of the appendix by compression US.

How to diagnose acute appendicitis: ultrasound first

However, study results here are somewhat conflicting and inconsistent [ 3334 ]. In a paediatric patient population, a retrospective chart review and outcome analysis was performed between and [ 27 ]. Based on these results, the authors conclude that children with a non-diagnostic US study and without leucocytosis may safely avoid further diagnostic workup for suspected AA [ 27 ].

The authors analysed secondary US signs, like large amounts of free intrabdominal fluid, phlegmon and pericaecal inflammatory fat changes [ 29 ].

clinical pathway Apendisitis Akut

In this retrospective analysis, of patients Appendicitis was diagnosed by CT in Based on their data, the authors argued for the development of clinical triage methods that differentiate patients who are likely to benefit from short-interval CT [ 30 ]. Other investigators [ 32 ] have shown the safety of discharge of children with non-visualization of the appendix on US. In order to keep radiation dose and financial cost low, various algorithms have been recently published for the work-up of a patient with suspected AA.


Of these, patients were managed definitively without CT [ 35 ]. Another study reported on a set of clinical features that can rule out appendicitis in patients with suspected AA and non-diagnostic US results [ 37 ]. Patients were discharged after inconclusive US if less than two predictors were present: The implemented clinical decision rule reduced the probability of AA in a large subgroup of patients with negative or inconclusive US results [ 37 ].

What if not only one initial US examination is performed, and an initial equivocal US examination is followed by clinical reassessment, a short-interval US and surgical consultation?

Of apendikditis children with AA, were identified without use of CT. The authors conclude that their approach is most useful in children with an equivocal initial US [ 38 ]. Van Atta et al. Another approach to improve US in the diagnosis of AA is standardized structured reporting.

A recent meta-analysis [ 42 ] included patients published in 28 studies and reported a significant difference in the NAR, from InMDCT showed a sensitivity of When conditional CT a CT study after a negative or inconclusive US examination apendiksitix used compared to an immediate CT strategy in an adult patient population with a suspicion of AA, these conditional CT exams correctly identify as many patients with AA as an immediate CT strategy, but only half of the number of CTs is needed [ 46 ].

US and CT in acute appendicitis. apendiksktis

MRI is gaining relevance as a problem-solving technique or when US is inconclusive, mainly in populations where radiation protection is of special importance. Only 5 of these 33 patients had pathologically-proven appendicitis. This is a nice example for a study that is limited by a small study population and a low prevalence of the disease to be studied paendiksitis 48 ]. Recently, it has been shown that gadolinium-enhanced images Fig.

In children with suspected AA, a radiation-free diagnostic imaging algorithm of US first selectively followed by MRI has been shown to be feasible and performed excellent compared to CT in terms of NAR, perforation rate or length of hospital stay [ 51 ].

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In conclusion, the studies and reports detailed apendikditis give an overview of the persistent difficulties in the clinical diagnosis of AA in paediatric and adult patients, the usefulness of various clinical scores which are not commonly used in routine practice and recent developments of modern imaging techniques focusing on US imaging. To date, US imaging for suspected AA is performed world-wide by radiologists and many physicians of other medical subspecialties, with or without the support of sonographers.

Direct and indirect US signs of AA are well established, as is the examination technique itself.

In the adult and especially in the elderly patient, where the sensitivity of US might be limited and important differential diagnoses have to be considered, CT might be used as the first-line imaging technique. Regarding the patient with nonvisualization of the appendix itself on US, or other reasons for non-diagnostic US examinations in this setting, careful clinical re-assessment of the patient is recommended and complementary apendkisitis should follow, if necessary.

Depending on the local environment and apendikstiis, this might be a second US examination, an MRI examination when radiation protection is mandatory paediatric apendiksitix pregnant patients or a CT examination where diagnostic criteria and high accuracy are well-established.

It has been demonstrated in a recent meta-analysis [ 54 ] that an imaging protocol using US as a first-line imaging tool, followed by CT, offers significant cost savings over a CT-only protocol, and avoids radiation exposure. In a Markov-based decision model of paediatric appendicitis, the most cost-effective method of imaging children with suspected AA was to start with US and follow each negative US examination with a CT examination [ 55 ].

However, the economic apensiksitis radiation burden considerations have to be translated to the specific healthcare system and cannot be transformed to all clinical and geographic settings. National Center for Biotechnology Information apenndiksitis, U.

Journal List Insights Imaging v. Published online Feb Gerhard MostbeckE. Author information Article notes Copyright and License information Disclaimer. Department of Radiology, Wilhelminenspital, Montleartstr. This article has been cited by other articles in PMC.

Appendicitis, Ultrasound, Computed tomography, Magnetic resonance imaging, Diagnostic algorithm.