Definition: acute appendicitis
Acute nonspecific inflammation of the appendix.
Pathological forms of acute appendicitis
There are three forms of morphological changes in acute appendicitis:
- simple form of acute appendicitis;
- phlegmonous form of acute appendicitis;
- gangrenous form of acute appendicitis.
A) Simple form of acute appendicitis (on examination):
- appendix is slightly tense; its serosa is hyperemic and edematous;
- in the appendix lumen odourless serous fluid;
- microscopically: mucosal edema, single erosions.
B) Phlegmonous form of acute appendicitis (on examination):
- thickened appendix, tense, hyperemic , covered with fibrin
- in the appendix lumen -pus
- in the abdominal cavity turbid serous or purulent exudates, peritoneum is sometimes lackluster
- microscopically: leukocyte infiltration of the appendix tissue purulent destruction of its
walls.
C) Gangrenous form of acute appendicitis (on examination):
- necrosis of a section of the wall of the appendix, possible perforation of its walls;
- in the lumen of the appendix necrotic detritus;
- in the abdominal cavity purulent necrotic content;
- microscopically: thrombosis of the vessels of the appendix, necrotic changes in its walls
Clinical signs of acute appendicitis
A) Complaints:
a) pain in the right iliac region:
- constant;
- moderate;
- without irradiation;
b) nausea;
c) onetime vomiting;
d) delayed defecation.
B) Medical history :
a) acute onset;
b) pain occurs in the healthy state of patient;
c) pain occurs without provoking factors;
g) epigastric pain or diffuse pain throughout the abdomen , which is 2-3 hours shifts in the right iliac region (Volkovych-Kocher’s sign).
C) Objective evidence of disease:
a) general clinical signs:
- general weakness;
- subfebrile fever ( 37,2-37,6 °C);
- tachycardia;
- the tongue is coated, moist, with the development of the destructive process in the appendix - dry.
b) local clinical signs:
• examination of the abdominal wall:
- abdomen is symmetrical;
- abdominal wall lags behind in the act of breathing in the right iliac region;
• palpation of the abdominal wall:
- at superficial palpation muscle tension and tenderness in the right iliac region
- at deep palpation increased tenderness in the right iliac region;
• Pathognomonic signs of acute appendicitis:
- Rovzing’s sign - appearing or worsening of pain in the right iliac region as a result of jerky movements of the right hand of the surgeon of the abdominal wall in projection of descending part of the colon counterclockwise and simultaneous compression of the sigmoid colon with the left hand through the anterior abdominal wall;
- Razdolsky’s sign - pain on percussion of the anterior abdominal wall in the right iliac region;
- Sitkovskiy’s sign - the emergence or amplification of pain in the right iliac region by changing the position of the patient from supine position to the left lateral decubitus;
- Bartome-Michelson’s sign - increased pain with deep palpation in the right iliac region with the patient in the left lateral decubitus;
- Obraztsov’s sign (psoas sign) - increased pain in the right iliac region at palpation while the patient elevate straightening the the knee right leg;
- Yaure-Rozanov’s sign - increased pain when pressure is applied in the triangle of Petit (the sign of retrocecal locatation of inflamed appendix).
• Symptoms of peritoneal irritation in the right iliac region:
- Shchetkin-Blumberg’s sign - increased pain with an abrupt hand withdrawal from the abdominal wall after pressing it in the right iliac region;
- Voskresensky’s sign (symptom of “shirt“) - the feeling of pain in the right iliac region with rapid passage of right palm of the surgeon along the anterior abdominal wall from the right costal margin down on the stretched with the left surgeon’s hand patient’s shirt.
The clinical course of acute appendicitis in the elderly
- less pronounced pain syndrome;
- more pronounced dyspeptic disorders;
- lack of temperature reaction;
- more pronounced general symptoms (fatigue, malaise, decreased appetite);
- less pronounced muscle tension and pain in the right iliac region;
- absence or unexpressed symptoms of peritoneal irritation;
- less pronounced leukocytosis with more severe changes in the leucocyte count with a shift to the left.
N.B.! Elderly patients with abdominal pain require particular attention!
The clinical course of acute appendicitis in the elderly due to:
- age-dependent hyporeactivity of the organism;
- violations of the general and regional blood circulation because of vascular sclerosis;
- low pain threshold;
- decrease in muscle tone;
- changes in the psychoemotional reactions.
The clinical course in elderly is facilitated by:
Acute Appendicitis
- development of destructive and complicated forms of acute appendicitis;
- delays in seeking of medical care;
- errors in the diagnosis and late operation;
- increase in the number of postoperative complications;
- increase in the duration of hospital stay;
- percentage increase in mortality.
The clinical course of acute appendicitis in children:
- more severe abdominal pain that does not correspond inflammatory and morphological changes of the process;
- restless behavior of the patient during the inspection;
- repeated vomiting;
- multiple watery stool;
- high temperature (38.5-39.5 °C);
- high leukocytosis;
- resistance to inspection due to low consciously willed child opportunities
N.B.! Examination of a child should be performed during sleep (physiological or medical), at abdominal palpation one should pay attention to the positive signs: pulling the right leg and repulsion of examiner’s hand.
The clinical features of acute appendicitis in a child are due to:
- age-dependent hyperreactivity;
- small size of vermiform process and its wide mouth;
- weak plastic properties of the peritoneum, short greater omentum;
- increased psychological and emotional excitability.
The clinical course of acute appendicitis in pregnant women:
- in the first 2-3 months of pregnancy, acute appendicitis occurs without any peculiarities;
- muscle tension in the anterior abdominal wall is rarely observed;
- pathognomonic symptoms of acute appendicitis are rarely revealed;
- in the absence of leukocytosis there is leukocyte shift to the left;
- inconsistency in the absence of blood leukocytosis with changes in urine (protein, leukocytes).
Formation of the preliminary diagnosis is based on clinical data.
(acute appendicitis)
Preliminary diagnosis is formed on the basis of the patient’s complaints, history of the disease and of objective manifestations, confirmed by results of physical examination.
To confirm the diagnosis, one should perform clinical blood and urine analysis, and in clinically complex cases perform radiographic studies, sonographic studies and diagnostic laparoscopy (in the first trimester).
Diagnostic program in patients with suspected acute appendicitis:
A) Laboratory tests:
a) CBC - the presence of inflammatory changes in the blood that are manifested by leukocytosis and leukocyte shift to the left. More pronounced changes are observed in destructive forms of acute appendicitis;
b) urinalysis - in a simple form of acute appendicitis there are no changes in urinalysis, however in destructive forms there may be protein, cylinders; at retrocecal location of the appendix, fresh red
blood cells that need to be considered in the differential diagnosis.
B) Additional methods of research (applied in case of difficulties in diagnosis):
a) abdominal radiography (to exclude or confirm the obstruction of the intestine, perforated ulcer);
b) sonography (for the assessment of the gallbladder, pelvic organs in women, kidney, the presence of fluid in the abdomen). In patients with acute appendicitis, sonographic picture presents thickened appendix and the presence of fluid in the abdominal cavity
c) diagnostic laparoscopy (in confirming the diagnosis of acute appendicitis it can be completed with endoscopic removal of the appendix).
Differential diagnosis:
acute appendicitis
A) Urgent surgical diseases of the abdominal cavity:
- acute cholecystitis;
- duodenal ulcer complicated by perforation.
B) Urgent gynecological diseases:
- rupture of a cyst of the right ovary;
- ectopic pregnancy;
- acute adnexitis.
C) Urgent urological diseases:
- right-side renal colic.
D) Therapeutic diseases:
- right lower lobe pneumonia;
- right side intercostals neuralgia.
Complications of acute appendicitis
A) Appendicular infiltrate - a conglomerate of inflammatory changed loops of intestines and omentum strands , soldered together and the parietal peritoneum, which dissociates itself inflamed appendix and accumulated exudate from the free peritoneal cavity.
B) Periappendicular abscess - a limited collection of pus around the inflamed vermiform process.
C) Peritonitis - inflammation of the peritoneum due to destruction of the appendix or rupture of periappendiceal abscess into the free abdominal cavity.
D) Pylephlebitis - dissemination of microbial infection of the venous system of the appendix into the portal system and liver with the formation of phlebitis and liver abscesses.
Treatment tactics in patients with acute appendicitis:
A) Once the diagnosis of acute appendicitis is set, an urgent operation should be performed.
B) If the diagnosis of acute appendicitis is doubtful:
- conduct dynamic monitoring of patients for 4-6 hours (during this period the patient is repeatedly examined by surgeon, tests are performed, if necessary instrumental examinations and consult related professionals can be done);
- in case of confirmation of the diagnosis by observing the “acute appendicitis“ an urgent operation indicated;
- if the dynamic observation diagnosis of acute appendicitis is not confirmed, but not excluded - the Cope’s rule comes into effect the patient is subject to the operation;
- if the diagnosis of acute appendicitis is excluded, it is necessary to clarify the causes of pain syndrome.
Preparing for surgery:
acute appendicitis
A) Shaving of the surgical field.
B) Emptying the bladder.
C) Premedication.
D) Gastric lavage (in planning the operation under general anaesthesia).
Anaesthesia
acute appendicitis
(priority should be given to general anaesthesia):
A) Intravenous anaesthesia most often used.
B) Endotracheal anesthesia:
- patients with excessive weight;
- in case of peritonitis;
- for suspected destructive appendicitis;
- children;
- in patients with mental disorders;
- pregnant women.
C) Local anaesthesia novocaine infiltration anaesthesia (in case the general anesthesia not possible).
Surgical treatment of acute appendicitis:
A) Open appendectomy (access in the right iliac region or lowermiddle laparotomy).
B) Laparoscopic appendectomy.
Clinic statistical classification of acute appendicitis:
K35 Acute appendicitis
Clinical diagnosis layout: Acute appendicitis {MX form}, {complicated with OX}
Morphological forms of acute appendicitis :
M1 simple
M2 phlegmonous
M3 gangrenous
Complications: O1 appendicular infiltrate O2 periappendiceal abscess O3 local peritonitis O4 diffuse peritonitis O5 pylephlebitis
Examination of disability and rehabilitation of patients:
acute appendicitis
A) In uncomplicated postoperative period sutures are removed on the 6-7th day after surgery.
B) Outpatient treatment after surgery 3-4 weeks.
C) If the professional activity of the patient is related to heavy physical work, medical commission can limit the ability to work for 6-8 weeks, limiting physical loads up to 12 weeks
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Acute Appendicitis19
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Acute Cholecystitis19
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Acute Pancreatitis14
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Acute Intestinal Obstruction43
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Peritonitises (peritoneal syndrome)32
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Syndrome Of Gastrointestinal Bleeding79
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Abdominal Hernias52
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Chronic Diseases Of The Stomach And Pancreatobiliary System58
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Inflammatory Diseases Of The Small And Large Intestines25
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Diseases Of The Hepatopancreatobiliary Zone, Complicated By Obstructive Jaundice40
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Prolapse Of The Rectum And Chronic Proctologic Diseases54
