Acute uncomplicated appendicitis. Pecularities of acute appendicitis in children, pregnant woomen and senior people. Acute complicated appendicitis (infiltrate, abscess, peritonitis, pylephlebitis). Postoperative period. chronic appendicitis.

 

Acute appendicitis

 

Acute appendicitis is an inflammation of vermiform appendix caused by festering microflora.

Anyone can get appendicitis, but it is more common among people 10 to 30 years old. Appendicitis leads to more emergency abdominal surgeries than any other cause.

 

anatomy

 

 

The cecum is the first part of the large intestine. It begins caudally from the ileocecal valve and ends blindly in the right iliac fossa. Typically the cecum is located intraperitoneally in the right lower abdomen and has a length of 5 to 7 cm. Due to an incomplete rotation of the umbilical loop during embryogenesis however it may lie quite variably. Therefore clinically one differentiates between three important variations: mobile cecum (completely covered by peritoneum), free cecum (with its own mesocecum) and fixed cecum (secondary retroperitoneal). As in the colon taeniae, haustra and semilunar folds are found in the cecum but no appendices epiploicae.

The vermiform appendix is attached dorsomedially to the end of the cecum where all three taeniae converge. It is 2 to 15 cm long and lies often intraperitoneally retrocecal (65%) or in the lesser pelvis (30%). The appendix is attached to the posterior abdominal wall by the mesoappendix. Here taeniae, haustra, semilunar folds and appendices epiploicae are all absent.

 

The cecum is supplied by the anterior and posterior cecal arteries and the appendix by the appendicular artery (all branches of the ileocolic artery from the superior mesenteric artery). The venous blood drains through the correspondent veins into the superior mesenteric vein. As the colon both the cecum and appendix are innervated by the superior mesenteric plexus whereas the parasympathetic fibers come from the vagus nerve (cranial nerve X).

The main tasks of the cecum are the absorption of water and salts and the lubrication of the feces with mucus. Especially components from plant-rich food (e.g. cellulose) are bacterially decomposed here. This explains why herbivores have considerably larger ceca in comparison to carnivores.

 The appendix is part of the GALT (gut-associated lymphatic tissue) and fulfills immunological functions. Furthermore it is assumed that it serves as a safe house for enterobacteria (e.g. in case of diarrhea). On the picture you can see an inflamed vermiform appendix which was removed operatively.

 

Etiology and pathogenesis

 

Most frequent causes of acute appendicitis are festering microbes: intestinal stick, streptococcus, staphylococcus. Moreover, microflora can be in cavity of appendix or get there by hematogenic way, and for women by lymphogenic one.

Obstruction of the appendiceal lumen causes appendicitis. Mucus backs up in the appendiceal lumen, causing bacteria that normally live inside the appendix to multiply. As a result, the appendix swells and becomes infected. Sources of obstruction include

        feces, parasites, or growths that clog the appendiceal lumen

        enlarged lymph tissue in the wall of the appendix, caused by infection in the gastrointestinal tract or elsewhere in the body

        inflammatory bowel disease, including Crohn's disease and ulcerative colitis

        trauma to the abdomen

An inflamed appendix will likely burst if not removed. Bursting spreads infection throughout the abdomena potentially dangerous condition called peritonitis.

Factors which promote the origin of appendicitis, are the following: a) change of reactivity of organism; b) constipation and atony of intestine; c) twisting or bends of appendix; d) excrement stone in its cavity; e) thrombosis of vessels of appendix and gangrene of wall as a substance of inflammatory process (special cases).

Obstruction of the lumen is the dominant etiologic factor in acute appendicitis. Fecaliths are the most common cause of appendiceal obstruction. Less common causes are hypertrophy of lymphoid tissue, inspissated barium from previous x-ray studies, tumors, vegetable and fruit seeds, and intestinal parasites. The frequency of obstruction rises with the severity of the inflammatory process. Fecaliths are found in 40% of cases of simple acute appendicitis, in 65% of cases of gangrenous appendicitis without rupture, and in nearly 90% of cases of gangrenous appendicitis with rupture.

Obstruction of the lumen is the dominant etiologic factor in acute appendicitis. Fecaliths are the most common cause of appendiceal obstruction. Less common causes are hypertrophy of lymphoid tissue, inspissated barium from previous x-ray studies, tumors, vegetable and fruit seeds, and intestinal parasites. The frequency of obstruction rises with the severity of the inflammatory process. Fecaliths are found in 40% of cases of simple acute appendicitis, in 65% of cases of gangrenous appendicitis without rupture, and in nearly 90% of cases of gangrenous appendicitis with rupture. The proximal obstruction of the appendiceal lumen produces a closed-loop obstruction, and continuing normal secretion by the appendiceal mucosa rapidly produces distention. The luminal capacity of the normal appendix is only 0.1 mL. Secretion of as little as 0.5 mL of fluid distal to an obstruction raises the intraluminal pressure to 60 cm H2O. Distention of the appendix stimulates the nerve endings of visceral afferent stretch fibers, producing vague, dull, diffuse pain in the midabdomen or lower epigastrium. Peristalsis also is stimulated by the rather sudden distention, so that some cramping may be superimposed on the visceral pain early in the course of appendicitis. Distention increases from continued mucosal secretion and from rapid multiplication of the resident bacteria of the appendix. Distention of this magnitude usually causes reflex nausea and vomiting, and the diffuse visceral pain becomes more severe. As pressure in the organ increases, venous pressure is exceeded. Capillaries and venules are occluded, but arteriolar inflow continues, resulting in engorgement and vascular congestion. The inflammatory process soon involves the serosa of the appendix and in turn parietal peritoneum in the region, which produces the characteristic shift in pain to the right lower quadrant.

The mucosa of the GI tract, including the appendix, is susceptible to impairment of blood supply; thus its integrity is compromised early in the process, which allows bacterial invasion. As progressive distention encroaches on first the venous return and subsequently the arteriolar inflow, the area with the poorest blood supply suffers most: ellipsoidal infarcts develop in the antimesenteric border. As distention, bacterial invasion, compromise of vascular supply, and infarction progress, perforation occurs, usually through one of the infarcted areas on the antimesenteric border. Perforation generally occurs just beyond the point of obstruction rather than at the tip because of the effect of diameter on intraluminal tension. This sequence is not inevitable, however, and some episodes of acute appendicitis apparently subside spontaneously. Many patients who are found at operation to have acute appendicitis give a history of previous similar, but less severe, attacks of right lower quadrant pain. Pathologic examination of the appendices removed from these patients often reveals thickening and scarring, suggesting old, healed acute inflammation. The strong association between delay in presentation and appendiceal perforation supported the proposition that appendiceal perforation is the advanced stage of acute appendicitis; however, recent epidemiologic studies have suggested that nonperforated and perforated appendicitis may, in fact, be different diseases.

 

Bacteriology

 

The bacterial population of the normal appendix is similar to that of the normal colon. The appendiceal flora remains constant throughout life with the exception of Porphyromonas gingivalis. This bacterium is seen only in adults.18 The bacteria cultured in cases of appendicitis are therefore similar to those seen in other colonic infections such as diverticulitis. The principal organisms seen in the normal appendix, in acute appendicitis, and in perforated appendicitis are Escherichia coli and Bacteroides fragilis.1821 However, a wide variety of both facultative and anaerobic bacteria and mycobacteria may be present in table.

 

Aerobic and Facultative

Anaerobic

Gram-negative bacilli

Gram-negative bacilli

Escherichia coli

Bacteroides fragilis

Pseudomonas aeruginosa

Other Bacteroides species

Klebsiella species

Fusobacterium species

Gram-positive cocci

Gram-positive cocci

Streptococcus anginosus

Peptostreptococcus species

Other Streptococcus species

Gram-positive bacilli

Enterococcus species

Clostridium species

 

Pathomorphology

Simple (superficial) and destructive (phlegmonous, gangrenous primary and gangrenous secondary) appendicitises which are morphological expressions of phases of acute inflammation that is completed by necrosis can be distinguished.

In simple appendicitis the changes are observed, mainly, in the distant part of appendix. There are stasis in capillaries and venule, edema and hemorrhages. Focus of festering inflammation of mucus membrane with the defect of the epithelium covering is formed in 12 hours (primary affect of Ashoff). This characterizes acute superficial appendicitis. The phlegmon of appendix develops to the end of the day. The organ increases, it serous tunic becomes dimmed, sanguineous, stratifications of fibrin appear on its surface, and there is pus in cavity.

 

 

In gangrenous appendicitis the appendix is thickened, the its serous tunic is covered by dimmed fibrinogenous tape, differentiating of the layer structure through destruction is not succeeded.

 

 

Classification

(by V.I. Kolesnikov)

1. Appendiceal colic.

2. Simple superficial appendicitis.

3. Destructive appendicitis:

) phlegmonous;

) gangrenous;

) perforated.

4. Complicated appendicitis:

) appendicular infiltrate;

) appendicular abscess;

) diffuse purulent peritonitis.

5. Other complications of acute appendicitis (pylephlebitis, sepsis, retroperitoneal phlegmon, local abscesses of abdominal cavity).

 

Symptoms and clinical course

 

The classic symptoms of appendicitis include:

        Dull pain near the navel or the upper abdomen that becomes sharp as it moves to the lower right abdomen. This is usually the first sign.

        Loss of appetite

        Nausea and/or vomiting soon after abdominal pain begins

        Abdominal swelling

        Fever of 99-102 degrees Fahrenheit

        Inability to pass gas

        Almost half the time, other symptoms of appendicitis appear, including:

        Dull or sharp pain anywhere in the upper or lower abdomen, back, or rectum

        Painful urination

        Vomiting that precedes the abdominal pain

        Severe cramps

        Constipation or diarrhea with gas

 

Four phases are distinguished in clinical course of acute appendicitis: 1) epigastric; 2) local symptoms; 3) calming down; 4) complications.

The disease begins with a sudden pain in the abdomen. It is localized in a right iliac area, has moderate intensity, permanent character and not irradiate. With 70 % of patients the pain arises in a epigastric area - it is an epigastric phase of acute appendicitis. In 24 hours it moves to the place of appendix existance (the Kocher's symptom). At coughing patients mark strengthening of pain in a right iliac area it is a positive cough symptom.

Pain first, vomiting next and fever last has been described as the classic presentation of acute appendicitis. Since the innervation of the appendix enters the spinal cord at the level T10, the same level as the umbilicus (belly button), the pain begins mid-abdomen. Later, as the appendix becomes more inflamed and irritates the adjoining abdominal wall, it tends to localize over several hours into the right lower quadrant, except in children under three years. This pain can be elicited through various signs and can be severe. Signs include localized findings in the right iliac fossa. The abdominal wall becomes very sensitive to gentle pressure (palpation). Also, there is severe pain on sudden release of deep pressure in the lower abdomen (rebound tenderness). In case of a retrocecal appendix (appendix localized behind the cecum), however, even deep pressure in the right lower quadrant may fail to elicit tenderness (silent appendix), the reason being that the cecum, distended with gas, protects the inflamed appendix from the pressure. Similarly, if the appendix lies entirely within the pelvis, there is usually complete absence of abdominal rigidity. In such cases, a digital rectal examination elicits tenderness in the rectovesical pouch. Coughing causes point tenderness in this area (McBurney's point) and this is the least painful way to localize the inflamed appendix. If the abdomen on palpation is also involuntarily guarded (rigid), there should be a strong suspicion of peritonitis, requiring urgent surgical intervention.

 

The abdominal pain usually:

 

Abdominal pain is the prime symptom of acute appendicitis. Classically, pain is initially diffusely centered in the lower epigastrium or umbilical area, is moderately severe, and is steady, sometimes with intermittent cramping superimposed. After a period varying from 1 to 12 hours, but usually within 4 to 6 hours, the pain localizes to the right lower quadrant. This classic pain sequence, although usual, is not invariable. In some patients, the pain of appendicitis begins in the right lower quadrant and remains there. Variations in the anatomic location of the appendix account for many of the variations in the principal locus of the somatic phase of the pain. For example, a long appendix with the inflamed tip in the left lower quadrant causes pain in that area. A retrocecal appendix may cause principally flank or back pain; a pelvic appendix, principally suprapubic pain; and a retroileal appendix, testicular pain, presumably from irritation of the spermatic artery and ureter. Intestinal malrotation also is responsible for puzzling pain patterns. The visceral component is in the normal location, but the somatic component is felt in that part of the abdomen where the cecum has been arrested in rotation.

        occurs suddenly, often causing a person to wake up at night;

        occurs before other symptoms;

        begins near the belly button and then moves lower and to the right;

        is new and unlike any pain felt before;

        gets worse in a matter of hours;

        gets worse when moving around, taking deep breaths, coughing, or sneezing.

 

Other symptoms of appendicitis may include

 

Anorexia nearly always accompanies appendicitis. It is so constant that the diagnosis should be questioned if the patient is not anorectic. Although vomiting occurs in nearly 75% of patients, it is neither prominent nor prolonged, and most patients vomit only once or twice. Vomiting is caused by both neural stimulation and the presence of ileus.

Most patients give a history of obstipation beginning before the onset of abdominal pain, and many feel that defecation would relieve their abdominal pain. Diarrhea occurs in some patients, however, particularly children, so that the pattern of bowel function is of little differential diagnostic value.

The sequence of symptom appearance has great significance for the differential diagnosis. In >95% of patients with acute appendicitis, anorexia is the first symptom, followed by abdominal pain, which is followed, in turn, by vomiting (if vomiting occurs). If vomiting precedes the onset of pain, the diagnosis of appendicitis should be questioned.

     loss of appetite

     nausea

     vomiting

     constipation or diarrhea

     inability to pass gas

     a low-grade fever that follows other symptoms

     abdominal swelling

     the feeling that passing stool will relieve discomfort

 

Signs

 

Together with it, nausea and vomiting that have reflex character can disturb a patient. Often there is a delay of gases. The temperature of body of most patients rises, but high temperature can occur rarely and, mainly, it is a low grade fever. The general condition of patients gets worse only in case of growth of destructive changes in appendix.

Physical findings are determined principally by what the anatomic position of the inflamed appendix is, as well as by whether the organ has already ruptured when the patient is first examined.

Vital signs are minimally changed by uncomplicated appendicitis. Temperature elevation is rarely >1C (1.8F) and the pulse rate is normal or slightly elevated. Changes of greater magnitude usually indicate that a complication has occurred or that another diagnosis should be considered.25

Patients with appendicitis usually prefer to lie supine, with the thighs, particularly the right thigh, drawn up, because any motion increases pain. If asked to move, they do so slowly and with caution.

The classic right lower quadrant physical signs are present when the inflamed appendix lies in the anterior position. Tenderness often is maximal at or near the McBurney point.8 Direct rebound tenderness usually is present. In addition, referred or indirect rebound tenderness is present. This referred tenderness is felt maximally in the right lower quadrant, which indicates localized peritoneal irritation. The Rovsing signpain in the right lower quadrant when palpatory pressure is exerted in the left lower quadrantalso indicates the site of peritoneal irritation. Cutaneous hyperesthesia in the area supplied by the spinal nerves on the right at T10, T11, and T12 frequently accompanies acute appendicitis. In patients with obvious appendicitis, this sign is superfluous, but in some early cases, it may be the first positive sign. Hyperesthesia is elicited either by needle prick or by gently picking up the skin between the forefinger and thumb.

Muscular resistance to palpation of the abdominal wall roughly parallels the severity of the inflammatory process. Early in the disease, resistance, if present, consists mainly of voluntary guarding. As peritoneal irritation progresses, muscle spasm increases and becomes largely involuntary, that is, true reflex rigidity due to contraction of muscles directly beneath the inflamed parietal peritoneum.

Anatomic variations in the position of the inflamed appendix lead to deviations in the usual physical findings. With a retrocecal appendix, the anterior abdominal findings are less striking, and tenderness may be most marked in the flank. When the inflamed appendix hangs into the pelvis, abdominal findings may be entirely absent, and the diagnosis may be missed unless the rectum is examined. As the examining finger exerts pressure on the peritoneum of Douglas' cul-de-sac, pain is felt in the suprapubic area as well as locally within the rectum. Signs of localized muscle irritation also may be present. The psoas sign indicates an irritative focus in proximity to that muscle. The test is performed by having the patient lie on the left side as the examiner slowly extends the patient's right thigh, thus stretching the iliopsoas muscle. The test result is positive if extension produces pain. Similarly, a positive obturator sign of hypogastric pain on stretching the obturator internus indicates irritation in the pelvis. The test is performed by passive internal rotation of the flexed right thigh with the patient supine.

During the examinationIt is possible to mark, that the right half of stomach falls behind in the act of breathing, and a patient wants to lie down on a right side with bound leg.

Painfulness is the basic and decisive signs of acute appendicitis during the examination by palpation in a right iliac area, tension of muscle of abdominal wall, positive symptoms of peritoneum irritation. About 100 pain symptoms characteristic of acute appendicitis are known, however only some of them have the real practical value.

The Blumberg's symptom. After gradual pressing by fingers on a front abdominal wall from the place of pain quickly, but not acutely, the hand is taken away. Strengthening of pain is considered as a positive symptom in that place. Obligatory here is tension of muscles of front abdominal wall. Slide.

The Voskresensky's symptom. By a left hand the shirt of patient is drawn downward and fixed on pubis. By the taps of 2-4 fingers of right hand epigastric area is pressed and during exhalation of patient quickly and evenly the ha nd slides in the direction of right iliac area, without taking the hand away. Thus there is an acute strengthening of pain.

The Bartomier's symptom is the increase of pain intensity during the palpation in right iliac area of patient in position on the left side. At such pose an omentum and loops of thin intestine is displaced to the left, and an appendix becomes accessible for palpation.

The Sitkovsky's symptom. A patient, that lies on left, feels the pain which arises or increases in a right iliac area. The mechanism of intensification of pain is explained by displacement of blind gut to the left, by drawing of mesentery of the inflamed appendix.

The Rovsing's symptom. By a left hand a sigmoid bowel is pressed to the back wall of stomach. By a right hand by ballotting palpation a descending bowel is pressed. Appearance of pain in a right iliac area is considered as a sign characteristic of appendicitis.

The Obrazcovs symptom. With the position of patient on the back by index and middle fingers the right iliac area of most painful place is pressed and the patient is asked to heave up the straightened right leg. At appendicitis pain increases acutely.

The Rozdolskyys symptom. At percussion there is painfulness in a right iliac area.

The general analysis of blood does not carry specific information, which would specify the presence of acute appendicitis. However, much leukocytosis and change of formula to the left in most cases can point to the present inflammatory process.

 

Variants of clinical course and complication

 

Acute appendicitis in children. With children of infancy acute appendicitis can be seen infrequently, but, quite often carries atipical character. All this is conditioned, mainly, by the features of anatomy of appendix, insufficient of plastic properties of the peritoneum, short omentum and high reactivity of child's organism. The inflammatory process in the appendix of children quickly makes progress and during the first half of days from the beginning of disease there can appear its destruction, even perforation. The child, more frequent than an adult, suffers vomiting. Its general condition gets worse quickly, and already the positive symptoms of irritation of peritoneum can show up during the first hours of a disease. The temperature reaction is also expressed considerably acuter. In the blood test there is high leukocytosis. It is necessary to remember, that during the examination of calmless children it is expedient to use a chloral hydrate enema.

The establishment of a diagnosis of acute appendicitis is more difficult in young children than in the adult. The inability of young children to give an accurate history, diagnostic delays by both parents and physicians, and the frequency of GI upset in children are all contributing factors.62 In children the physical examination findings of maximal tenderness in the right lower quadrant, the inability to walk or walking with a limp, and pain with percussion, coughing, and hopping were found to have the highest sensitivity for appendicitis.63

The more rapid progression to rupture and the inability of the underdeveloped greater omentum to contain a rupture lead to significant morbidity rates in children. Children <5 years of age have a negative appendectomy rate of 25% and an appendiceal perforation rate of 45%. These rates may be compared with a negative appendectomy rate of <10% and a perforated appendix rate of 20% for children 5 to 12 years of age.13,14 The incidence of major complications after appendectomy in children is correlated with appendiceal rupture. The wound infection rate after the treatment of nonperforated appendicitis in children is 2.8% compared with a rate of 11% after the treatment of perforated appendicitis. The incidence of intra-abdominal abscess also is higher after the treatment of perforated appendicitis than after nonperforated appendicitis (6% vs. 3%).23 The treatment regimen for perforated appendicitis generally includes immediate appendectomy and irrigation of the peritoneal cavity. Antibiotic coverage is limited to 24 to 48 hours in cases of nonperforated appendicitis. For perforated appendicitis IV antibiotics usually are given until the white blood cell count is normal and the patient is afebrile for 24 hours. The use of antibiotic irrigation of the peritoneal cavity and transperitoneal drainage through the wound are controversial. Laparoscopic appendectomy has been shown to be safe and effective for the treatment of appendicitis in children

Acute appendicitis of the people of declining and old ages can be met not so often, as of the persons of middle ages and youth. This contingent of patients is hospitalized to hospital rather late: in 23 days from the beginning of a disease. Because of the promoted threshold of pain sensitiveness, the intensity of pain in such patients is small, therefore they almost do not fix attention on the epigastric phase of appendicitis. More frequent are nausea and vomiting, and the temperature reaction is expressed poorly. Tension of muscles of abdominal wall is absent or insignificant through old-age relaxation of muscles. But the symptoms of irritation of peritoneum keep the diagnostic value with this group of patients. Thus, the sclerosis of vessels of appendix results in its rapid numbness, initially-gangrenous appendicitis develops. Because of such reasons the destructive forms of appendicitis prevail, often there is appendiceal infiltrate.

With pregnant women both the bend of appendix and violation of its blood flow are causes of the origin of appendicitis. Increased in sizes uterus causes such changes. It, especially in the second half of pregnancy, displaces a blind gut together with an appendix upwards, and an overdistension abdominal wall does not create adequate tension. It is needed also to remember, that pregnant women periodically can have a moderate pain in the abdomen and changes in the blood test. Together with that, psoas-symptom and the Bartomier's symptom have a diagnostic value at pregnant women.

Appendectomy for presumed appendicitis is the most common surgical emergency during pregnancy. The incidence is approximately 1 in 766 births. Acute appendicitis can occur at any time during pregnancy.68 The overall negative appendectomy rate during pregnancy is approximately 25% and appears to be higher than the rate seen in nonpregnant women.68,69 A higher rate of negative appendectomy is seen in the second trimester, and the lowest rate is in the third trimester. The diversity of clinical presentations and the difficulty in making the diagnosis of acute appendicitis in pregnant women is well established. This is particularly true in the late second trimester and the third trimester, when many abdominal symptoms may be considered pregnancy related. In addition, during pregnancy there are anatomic changes in the appendix (Fig. 30-7) and increased abdominal laxity that may further complicate clinical evaluation. There is no association between appendectomy and subsequent fertility.

Clinical course of acute appendicitis at the atipical location (not in a right iliac area) will differ from a classic vermiform appendix .


 

Variants of appendix localization

 

1.     Appendix

2.     Appendicular artery

3.     Appendicular mesentery

4.     Ilium

5.     Caecum

 

 


Appendicitis at retrocecal and retroperitoneal location of appendiceal appendix can be with 820 % patients. Thus an appendix can be placed both in a free abdominal cavity and retroperitoneal. An atypical clinic arises, as a rule, at the retroperitoneal location. The patients complain at pain in lumbus or above the wing of right ileum. There they mark painfulness during palpation. Sometimes the pain irradiates to the pelvis and in the right thigh. The positive symptom of Rozanov painfulness during palpation in the right Pti triangle is characteristic. In transition of inflammatory process on an ureter and kidney in the urines analysis red corpuscles can be found.

Appendicitis at the pelvic location of appendix can be met in 1130 % cases. In such patients the pain is localized above the right Poupart's ligament and above pubis. At the very low placing of appendix at the beginning of disease the reaction of muscles of front abdominal wall on an inflammatory process can be absent. With transition of inflammation on an urinary bladder or rectum either the dysuric signs or diarrhea developes, mucus appears in an excrement. Distribution of process on internal genital organs provokes signs characteristic of their inflammation.

Appendicitis at the medial placing of appendix. The appendix in patients with such pathology is located between the loops of intestine, that is the large field of suction and irritation of peritoneum. At these anatomic features mesentery is pulled in the inflammatory process, acute dynamic of the intestinal obstruction develops in such patients. The pain in the abdomen is intensive, widespread, the expressed tension of muscles of abdominal wall develops, that together with symptoms of the irritation of peritoneum specify the substantial threat of peritonitis development.

For the subhepatic location of appendix the pain is characteristic in right hypochondrium. During palpation painfulness and tension of musclescan be marked.

Left-side appendicitis appears infrequently and, as a rule, in case of the reverse placing of all organs, however it can occur at a mobile blind gut. In this situation all signs which characterize acute appendicitis will be exposed not on the right, as usually, but on the left.

Among complications of acute appendicitis most value have appendiceal infiltrates and abscesses.

Appendiceal infiltrate is the conglomerate of organs and tissue not densely accrete round the inflamed vermiform appendix. It develops, certainly, on 35th day from the beginning of disease. Acute pain in the stomach calms down thus, the general condition of a patient gets better. Dense, not mobile, painful, with unclear contours, formation is palpated in the right iliac area. There are different sizes of infiltrate, sometimes it occupies all right iliac area. The stomach round infiltrate during palpation is soft and unpainful.

At reverse development of infiltrate (when resorption comes) the general condition of a patient gets better, sleep and appetite recommence, activity grows, the temperature of body and indexes of blood is normalized. Pain in the right iliac area calms down, infiltrate diminishes in size. In this phase of infiltrate physiotherapeutic procedure is appointed, warmth on the iliac area.

In two months after resorption of infiltrate appendectomy is conducted.

At abscessing of infiltrate the condition of a patient gets worse, the symptoms of acute appendicitis become more expressed, the temperature of body, which in most cases gains hectic character, rises, the fever appears. Next to that, pain in the right iliac area increases. Painful formation is felt there. In the blood test high leukocytosis is present with the acutely expressed change of leukocyte formula to the left.

Local abscesses of abdominal cavity, mainly, develops as a result of the atypical placing of appendix or suppuration. More frequent from other there are pelvic abscesses. Thus a patient is disturbed by pain beneath the abcupula, there are dysuric disorders, diarrhea and tenesmus. The temperature of body rises to 38,039,0o, and rectal to considerably higher numbers. In the blood test leukocytosis, change of formula of blood is fixed to the left.

During the rectal examination the weakened sphincter of anus is found. The front wall of rectum at first is only painful, and then its overhanging is observed as dense painful infiltrate. Slide.

A subdiaphragmatic abscess develops at the high placing of appendix. The pain in the lower parts of thorax and in a upper quarter of abcupula ofn to the right, that increases at deep inhalationis except for the signs of intoxication, is characteristic of it. A patient, generally, occupies semisitting position. Swelling in an epigastric area is observed in heavy cases, smoothing and painful intercostal intervals. The abcupula ofn during palpation is soft, although tension in the area of right hypochondrium is possible. Painfulness at pressure on bottom (911) ribs is the early and permanent symptom of subdiaphragmatic abscess (the Krukovs symptom).

Roentgenologically the right half of diaphragm can fall behind from left one while breathing, and there is a present reactive exudate in the right pleura cavity. A gas bubble is considered the roentgenologic sign of subdiaphragmatic abscess with the horizontal level of liquid, which is placed under the diaphragm.

Interloop abscesses are not frequent complications of acute appendicitis. As well as all abscesses of abdominal cavity, they pass the period of infiltrate and abscess formation with the recreation of the proper clinic.

The poured festering peritonitis develops as a result of the timely unoperated appendicitis. Diagnostics of this pathology does not cause difficulties.

Pylephlebitis is a complication of both appendicitis and after-operative period of appendectomy.

The reason of this pathology is acute retrocecal appendicitis. At it development the thrombophlebitis process from the veins of appendix, passes to the veins of bowels mesentery, and then on to the portal vein. Patients complain at the expressed general weakness, pain in right hypochondrium, high hectic temperature of body, fever and strong sweating. Patients are adynamic, with expressed subicteritiousness of the scleras. During palpation painfulness is observed in the right half of abcupula ofn and the symptoms of irritation of peritoneum are not acutely expressed.

In case with rapid passing of disease the icterus appears, the liver is increased, kidney-hepatic insufficiency makes progress, and patients die in 7-10 days from the beginning of disease. At gradual subacute development of pathology the liver and spleen is increased in size, and after the septic state of organism ascites arises.

 

Diagnostic program

 

1. Anamnesis information.

2. Information of objective examination.

3. General analysis of blood and urine.

4. Vaginal examination for women.

5. Rectal examination for men.

 

Instrumental diagnosis

 

Blood and urine test.

Most people suspected of having appendicitis would be asked to do a blood test. Half of the time, the blood test is normal, so it is not that useful in diagnosing appendicitis.

Two forms of blood tests are commonly done: Full blood count (FBC), also known as complete blood count (CBC), is an inexpensive and commonly requested blood test. It involves measuring the blood for its richness in red blood cells, as well as the number of the various white blood cell constituents in it. The number of white cells in the blood is usually less than 10,000 cells per cubic millimeter. An abnormal rise in the number of white blood cells in the blood is a crude indicator of infection or inflammation going on in the body. Such a rise is not specific to appendicitis alone. If it is abnormally elevated, with a good history and examination findings pointing towards appendicitis, the likelihood of having the disease is higher. In pregnancy, elevation of white blood cells may be normal, without any infection present.

Mild leukocytosis, ranging from 10,000 to 18,000 cells/mm3, usually is present in patients with acute, uncomplicated appendicitis and often is accompanied by a moderate polymorphonuclear predominance. White blood cell counts are variable, however. It is unusual for the white blood cell count to be >18,000 cells/mm3 in uncomplicated appendicitis. White blood cell counts above this level raise the possibility of a perforated appendix with or without an abscess. Urinalysis can be useful to rule out the urinary tract as the source of infection. Although several white or red blood cells can be present from ureteral or bladder irritation as a result of an inflamed appendix, bacteriuria in a urine specimen obtained via catheter generally is not seen in acute appendicitis.

C-reactive protein (CRP) is an acute-phase response protein produced by the liver in response to any infection or inflammatory process in the body. Again, like the FBC, it is not a specific test. It is another crude marker of infection or inflammation. Inflammation at ANY site can lead to a rise in CRP. A significant rise in CRP, with corresponding signs and symptoms of appendicitis, is a useful indicator in the diagnosis of appendicitis. If the CRP continues to be normal after 72 hours of the onset of pain, the appendicitis likely will resolve on its own without intervention. A worsening CRP with good history is a sure signal of impending perforation or rupture and abscess formation.

A urine test in appendicitis is usually normal. It may, however, show blood if the appendix is rubbing on the bladder, causing irritation. It is important to rule out an ectopic pregnancy in women of childbearing age.

 

Imaging studies

 

 

 

Plain films of the abdomen, although frequently obtained as part of the general evaluation of a patient with an acute abdomen, rarely are helpful in diagnosing acute appendicitis. However, plain radiographs can be of significant benefit in ruling out other pathology. In patients with acute appendicitis, one often sees an abnormal bowel gas pattern, which is a nonspecific finding. The presence of a fecalith is rarely noted on plain films but, if present, is highly suggestive of the diagnosis. A chest radiograph is sometimes indicated to rule out referred pain from a right lower lobe pneumonic process.

 

Ultrasound.

Ultrasonography and Doppler sonography provide useful means to detect appendicitis, especially in children, and shows free fluid collection in the right iliac fossa, along with a visible appendix without blood flow in color Doppler. In some cases (15% approximately), however, ultrasonography of the iliac fossa does not reveal any abnormalities despite the presence of appendicitis. This is especially true of early appendicitis before the appendix has become significantly distended and in adults where larger amounts of fat and bowel gas make actually seeing the appendix technically difficult. Despite these limitations, sonographic imaging in experienced hands can often distinguish between appendicitis and other diseases with very similar symptoms, such as inflammation of lymph nodes near the appendix or pain originating from other pelvic organs such as the ovaries or fallopian tubes.

 

 

Horseshoe shaped appendix

 

 

Case 1. Perforated appendix

 

 

Increased vascularity of the appendix

 

Graded compression sonography has been suggested as an accurate way to establish the diagnosis of appendicitis. The technique is inexpensive, can be performed rapidly, does not require a contrast medium, and can be used even in pregnant patients. Sonographically, the appendix is identified as a blind-ending, nonperistaltic bowel loop originating from the cecum. With maximal compression, the diameter of the appendix is measured in the anteroposterior dimension. Scan results are considered positive if a noncompressible appendix ≥6 mm in the anteroposterior direction is demonstrated. The presence of an appendicolith establishes the diagnosis. Thickening of the appendiceal wall and the presence of periappendiceal fluid is highly suggestive. Sonographic demonstration of a normal appendix, which is an easily compressible, blind-ending tubular structure measuring ≤5 mm in diameter, excludes the diagnosis of acute appendicitis. The study results are considered inconclusive if the appendix is not visualized and there is no pericecal fluid or mass. When the diagnosis of acute appendicitis is excluded by sonography, a brief survey of the remainder of the abdominal cavity should be performed to establish an alternative diagnosis. In females of childbearing age, the pelvic organs must be adequately visualized either by transabdominal or endovaginal ultrasonography to exclude gynecologic pathology as a cause of acute abdominal pain. The sonographic diagnosis of acute appendicitis has a reported sensitivity of 55 to 96% and a specificity of 85 to 98%.2830 Sonography is similarly effective in children and pregnant women, although its application is somewhat limited in late pregnancy.

A false-positive scan result can occur in the presence of periappendicitis from surrounding inflammation, a dilated fallopian tube can be mistaken for an inflamed appendix, inspissated stool can mimic an appendicolith, and, in obese patients, the appendix may not be compressible because of overlying fat. False-negative sonogram results can occur if appendicitis is confined to the appendiceal tip, the appendix is retrocecal, the appendix is markedly enlarged and mistaken for small bowel, or the appendix is perforated and therefore compressible.

Additional radiographic studies include barium enema examination and radioactively labeled leukocyte scans. If the appendix fills on barium enema, appendicitis is excluded. On the other hand, if the appendix does not fill, no determination can be made. To date, there has not been enough experience with radionuclide scans to assess their utility.

 

Computed tomography.

Where it is readily available, CT scan has become frequently used, especially in adults whose diagnosis is not obvious on history and physical examination. Concerns about radiation, however, tend to limit use of CT in pregnant women and children. A properly performed CT scan with modern equipment has a detection rate (sensitivity) of over 95%, and a similar specificity. Signs of appendicitis on CT scan include lack of oral contrast (oral dye) in the appendix, direct visualization of appendiceal enlargement (greater than 6 mm in cross-sectional diameter), and appendiceal wall enhancement with IV contrast (IV dye). The inflammation caused by appendicitis in the surrounding peritoneal fat (so called "fat stranding") can also be observed on CT, providing a mechanism to detect early appendicitis and a clue that appendicitis may be present even when the appendix is not well seen. Thus, diagnosis of appendicitis by CT is made more difficult in very thin patients and in children, both of whom tend to lack significant fat within the abdomen. The utility of CT scanning is made clear, however, by the impact it has had on negative appendectomy rates. For example, use of CT for diagnosis of appendicitis in Boston, MA has decreased the chance of finding a normal appendix at surgery from 20% in the pre-CT era to only 3% according to data from the Massachusetts General Hospital.

High-resolution helical CT also has been used to diagnose appendicitis. On CT scan, the inflamed appendix appears dilated (>5 cm) and the wall is thickened. There is usually evidence of inflammation, with "dirty fat," thickened mesoappendix, and even an obvious phlegmon. Fecaliths can be easily visualized, but their presence is not necessarily pathognomonic of appendicitis. An important suggestive abnormality is the arrowhead sign. This is caused by thickening of the cecum, which funnels contrast agent toward the orifice of the inflamed appendix. CT scanning is also an excellent technique for identifying other inflammatory processes masquerading as appendicitis.

Several CT techniques have been used, including focused and nonfocused CT scans and enhanced and nonenhanced helical CT scanning. Nonenhanced helical CT scanning is important, because one of the disadvantages of using CT scanning in the evaluation of right lower quadrant pain is dye allergy. Surprisingly, all of these techniques have yielded essentially identical rates of diagnostic accuracy: 92 to 97% sensitivity, 85 to 94% specificity, 90 to 98% accuracy, and 75 to 95% positive and 95 to 99% negative predictive values. The additional use of a rectally administered contrast agent did not improve the results of CT scanning.

 

Pic. Acute uncomplicated appendicitis

 

Fig. Transverse CT images in 62-year-old man with perforated appendicitis. The appendix (arrowheads) is traceable. (a)Image shows defect (straight arrow) of appendiceal wall enhancement, abscess (Ab), and extraluminal air (curved arrow). (b) Image shows abscess (Ab) and extraluminal appendicolith (arrow).

 

Laparoscopy can serve as both a diagnostic and therapeutic maneuver for patients with acute abdominal pain and suspected acute appendicitis. Laparoscopy is probably most useful in the evaluation of females with lower abdominal complaints, because appendectomy is performed on a normal appendix in as many as 30 to 40% of these patients. Differentiating acute gynecologic pathology from acute appendicitis can be effectively accomplished using the laparoscope.

 

Table. Alvarado Scale for the Diagnosis of Appendicitis

 

Manifestations

Value

Symptoms

Migration of pain

Anorexia

1

1

Signs

Nausea and/or vomiting

Right lower quadrant tenderness

1

 

2

Laboratory values

Rebound

Elevated temperature Leukocytosis

Left shift in leukocyte count

1

1

2

1

Total points 10

 

Differential diagnostics

 

Acute appendicitis is differentiated with the diseases which are accompanied by pain in the abcupula ofn.

The differential diagnosis of acute appendicitis is essentially the diagnosis of the acute abdomen. This is because clinical manifestations are not specific for a given disease but are specific for disturbance of a given physiologic function or functions. Thus, an essentially identical clinical picture can result from a wide variety of acute processes within the peritoneal cavity that produce the same alterations of function as does acute appendicitis.

The accuracy of preoperative diagnosis should be approximately 85%. If it is consistently less, it is likely that some unnecessary operations are being performed, and a more rigorous preoperative differential diagnosis is in order. A diagnostic accuracy rate that is consistently >90% should also cause concern, because this may mean that some patients with atypical, but bona fide, cases of acute appendicitis are being "observed" when they should receive prompt surgical intervention. The Haller group, however, has shown that this is not invariably true. Before that group's study, the perforation rate at the hospital at which the study took place was 26.7%, and acute appendicitis was found in 80% of the patients undergoing operation. By implementing a policy of intensive inhospital observation when the diagnosis of appendicitis was unclear, the group raised the rate of acute appendicitis found at operation to 94%, but the perforation rate remained unchanged at 27.5%. The rate of false-negative appendectomies is highest in young adult females. A normal appendix is found in 32 to 45% of appendectomies performed in women 15 to 45 years of age.

A common error is to make a preoperative diagnosis of acute appendicitis only to find some other condition (or nothing) at operation.

Food toxicoinfection.

Complaints for pain in the epigastric area of the intermittent character, nausea, vomiting and liquid emptying are the first signs of disease. The state of patients progressively gets worse from the beginning. Next to that, it is succeeded to expose that a patient used meal of poor quality. However, here patients do not have phase passing, which is characteristic of acute appendicitis, and clear localization of pain. Defining the symptoms of irritation of peritoneum is not succeeded, the peristalsis of intestine is, as a rule, increased.

Acute gastroenteritis.

Acute gastroenteritis is common but usually can be easily distinguished from acute appendicitis. Gastroenteritis is characterized by profuse diarrhea, nausea, and vomiting. Hyperperistaltic abdominal cramps precede the watery stools. The abdomen is relaxed between cramps, and there are no localizing signs. Laboratory values vary with the specific cause.

Acute pancreatitis.

In anamnesis in patients with this pathology there is a gallstone disease, violation of diet and use of alcohol. Their condition from the beginning of a disease is heavy. Pain is considerably more intensive, than during appendicitis, and is concentrated in the upper half of abcupula ofn. Vomiting is frequent and does not bring to the recovery of patients.

Perforative peptic and duodenum ulcer.

Diagnostic difficulties during this pathology arise up only on occasion. They can be in patients with the covered perforation, when portion of gastric juice flows out in an abdominal cavity and stays too long in the right iliac area, or in case of atypical perforations. Taking it into account, it is needed to remember, that the pain in the perforative ulcer is considerably more intensive in epigastric, instead of in the right iliac area. On the survey roentgenogram of organs of abdominal cavity under the right cupula of diaphragms free gases can be found.

 

Gynecologic disorders

 

Diseases of the female internal reproductive organs that may erroneously be diagnosed as appendicitis are, in approximate descending order of frequency, pelvic inflammatory disease, ruptured graafian follicle, twisted ovarian cyst or tumor, endometriosis, and ruptured ectopic pregnancy.

Pelvic Inflammatory Disease.

In pelvic inflammatory disease the infection usually is bilateral but, if confined to the right tube, may mimic acute appendicitis. Nausea and vomiting are present in patients with appendicitis, but in only approximately 50% of those with pelvic inflammatory disease. Pain and tenderness are usually lower, and motion of the cervix is exquisitely painful. Intracellular diplococci may be demonstrable on smear of the purulent vaginal discharge. The ratio of cases of appendicitis to cases of pelvic inflammatory disease is low in females in the early phase of the menstrual cycle and high during the luteal phase. The careful clinical use of these features has reduced the incidence of negative findings on laparoscopy in young women to 15%.

Ruptured Graafian Follicle. Ovulation commonly results in the spillage of sufficient amounts of blood and follicular fluid to produce brief, mild lower abdominal pain. If the amount of fluid is unusually copious and is from the right ovary, appendicitis may be simulated. Pain and tenderness are rather diffuse. Leukocytosis and fever are minimal or absent. Because this pain occurs at the midpoint of the menstrual cycle, it is often called mittelschmerz.

Twisted Ovarian Cyst.

Serous cysts of the ovary are common and generally remain asymptomatic. When right-sided cysts rupture or undergo torsion, the manifestations are similar to those of appendicitis. Patients develop right lower quadrant pain, tenderness, rebound, fever, and leukocytosis. If the mass is palpable on physical examination, the diagnosis can be made easily. Both transvaginal ultrasonography and CT scanning can be diagnostic if a mass is not palpable.

Torsion requires emergent operative treatment. If the torsion is complete or longstanding, the pedicle undergoes thrombosis, and the ovary and tube become gangrenous and require resection. Leakage of ovarian cysts resolves spontaneously, however, and is best treated nonoperatively.

Ruptured Ectopic Pregnancy.

Blastocysts may implant in the fallopian tube (usually the ampullary portion) and in the ovary. Rupture of right tubal or ovarian pregnancies can mimic appendicitis. Patients may give a history of abnormal menses, either missing one or two periods or noting only slight vaginal bleeding. Unfortunately, patients do not always realize they are pregnant. The development of right lower quadrant or pelvic pain may be the first symptom. The diagnosis of ruptured ectopic pregnancy should be relatively easy. The presence of a pelvic mass and elevated levels of chorionic gonadotropin are characteristic. Although the leukocyte count rises slightly (to approximately 14,000 cells/mm3), the hematocrit level falls as a consequence of the intra-abdominal hemorrhage. Vaginal examination reveals cervical motion and adnexal tenderness, and a more definitive diagnosis can be established by culdocentesis. The presence of blood and particularly decidual tissue is pathognomonic. The treatment of ruptured ectopic pregnancy is emergency surgery.

The apoplexy of ovary more frequent is with young women and, as a rule, on 10-14 day after menstruation. Pain appears suddenly and irradiate in the thigh and perineum. At the beginning of disease there can be a collapse. However, the general condition of patients suffers insignificantly. When not enough blood was passed in the abdominal cavity, all signs of pathology of abdominal cavity organs calm down after some time. Signs, which are characteristic of acute anemia, appear at considerable hemorrhage. Abdomen more frequent is soft and painful down, (positive Kulenkampff's symptom: acute pain during palpation of stomach and absent tension of muscles of the front abdominal wall).

During paracentesis of back fornix the blood which does not convolve is got.

Extra-uterine pregnancy.

A necessity to differentiate acute appendicitis with the interrupted extra-uterine pregnancy arises, when during the examination the patient complains at the pain only down in the stomack, more to the right. Taking it into account, it is needed to remember, that at extra-uterine pregnancy a few days before there can be intermittent pain in the lower part of the abdomen, sometimes excretions of coffee colour appear from vagina. In anamnesis often there are the present gynaecological diseases, abortions and pathological passing of pregnancy. For the clinical picture of such patient inherent sudden appearance of intensive pain in lower part of the abdomen. Often there is a brief loss of consciousness. During palpation considerable painfulness is localized lower, than at appendicitis, the abdomen is soft, the positive Kulenkampff's symptom is determined. Violations of menstrual cycle testify for pregnancy, characteristic changes are in milk glands, vagina and uterus. During the vaginal examination it is sometimes possible to palpate increased tube of uterus. The temperature of body more frequently is normal. If hemorrhage is small, the changes in the blood test are not present. The convincing proof of the broken extra-uterine pregnancy is the dark colour of blood, taken at punction of back fornix of vagina.

Acute cholecystitis.

The high placing of vermiform appendix in the right half of abdomen during its inflammation can cause the clinic somewhat similar to acute cholecystitis. But unlike appendicitis, in patients with cholecystitis the pain is more intensive, has cramp-like character, is localized in right hypochondrium and irradiate in the right shoulder and shoulder-blade. Also the epigastric phase is absent. The attack of pain can arise after the reception of spicy food and, is accompanied by nausea and frequent vomiting by bile. In anamnesis patients often have information about a gallstone disease. During examination intensive painfulness is observed in right hypochondrium, increased gall-bladder and positive symptoms Murphy's and Ortner's.

Right-side kidney colic.

For this disease tormina at the level of kidney and in lumbus is inherent, hematuria and dysuric signs which can take place at the irritation of ureter by the inflamed appendix. Intensity of pain in kidney colic is one of the basic differences from acute appendicitis. Pain at first appears in lumbus and irradiate downward after passing of ureter in genital organs and front surface of the thigh. In diagnostics urogram survey is important, and if necessary chromocystoscopy. Absence of function of right kidney to some extent allows to eliminate the diagnosis of acute appendicitis.

Acute mesenteric adenitis.

Acute mesenteric adenitis is the disease most often confused with acute appendicitis in children. Almost invariably, an upper respiratory tract infection is present or has recently subsided. The pain usually is diffuse, and tenderness is not as sharply localized as in appendicitis. Voluntary guarding is sometimes present, but true rigidity is rare. Generalized lymphadenopathy may be noted. Laboratory procedures are of little help in arriving at the correct diagnosis, although a relative lymphocytosis, when present, suggests mesenteric adenitis. Observation for several hours is in order if the diagnosis of mesenteric adenitis seems likely, because it is a self-limited disease. However, if the differentiation remains in doubt, immediate exploration is the safest course of action.

Human infection with Yersinia enterocolitica or Yersinia pseudotuberculosis, transmitted through food contaminated by feces or urine, causes mesenteric adenitis as well as ileitis, colitis, and acute appendicitis. Many of the infections are mild and self limited, but they may lead to systemic disease with a high fatality rate if untreated. The organisms are usually sensitive to tetracyclines, streptomycin, ampicillin, and kanamycin. A preoperative suspicion of the diagnosis should not delay operative intervention, because appendicitis caused by Yersinia cannot be clinically distinguished from appendicitis due to other causes. Approximately 6% of cases of mesenteric adenitis are caused by Yersinia infection.

Salmonella typhimurium infection causes mesenteric adenitis and paralytic ileus with symptoms similar to those of appendicitis. The diagnosis can be established by serologic testing. Campylobacter jejuni causes diarrhea and pain that mimics that of appendicitis. The organism can be cultured from stool.

 

Other intestinal disorders

 

Meckel's Diverticulitis.

Meckel's diverticulitis gives rise to a clinical picture similar to that of acute appendicitis. Meckel's diverticulum is located within the distal 2 ft of the ileum. Meckel's diverticulitis is associated with the same complications as appendicitis and requires the same treatmentprompt surgical intervention. Resection of the segment of ileum bearing the diverticulum with end-to-end anastomosis can nearly always be done through a McBurney incision, extended if necessary, or laparoscopically.

Crohn's Enteritis.

The manifestations of acute regional enteritisfever, right lower quadrant pain and tenderness, and leukocytosisoften simulate acute appendicitis. The presence of diarrhea and the absence of anorexia, nausea, and vomiting favor a diagnosis of enteritis, but this is not sufficient to exclude acute appendicitis. In an appreciable percentage of patients with chronic regional enteritis, the diagnosis is first made at the time of operation for presumed acute appendicitis. In cases of an acutely inflamed distal ileum with no cecal involvement and a normal appendix, appendectomy is indicated. Progression to chronic Crohn's ileitis is uncommon.

Colonic Lesions.

Diverticulitis or perforating carcinoma of the cecum, or of that portion of the sigmoid that lies in the right side, may be impossible to distinguish from appendicitis. These entities should be considered in older patients. CT scanning is often helpful in making a diagnosis in older patients with right lower quadrant pain and atypical clinical presentations.

Epiploic appendagitis probably results from infarction of the colonic appendage(s) secondary to torsion. Symptoms may be minimal, or there may be continuous abdominal pain in an area corresponding to the contour of the colon, lasting several days. Pain shift is unusual, and there is no diagnostic sequence of symptoms. The patient does not look ill, nausea and vomiting are unusual, and appetite generally is unaffected. Localized tenderness over the site is usual and often is associated with rebound without rigidity. In 25% of reported cases, pain persists or recurs until the infarcted epiploic appendage is removed.

 

Tactics and choice of treatment method

 

Acute appendicitis is typically managed by surgery however in uncomplicated cases antibiotics are both effective and safe. While antibiotics are effective for treating uncomplicated appendicitis 20% of people had a recurrence within a year and required eventual appendectomy.

As experience of surgeons of the whole world testifies, in acute appendicitis timely operation is the unique effective method of treatment.

 

Preparation for open appendectomy

 

The patient will require a general anaesthetic and be positioned supine

Prophylactic antibiotics are given to reduce the incidence of wound infection

The patient should be draped to expose the right lower abdominal quadrant and allowing identification of the umbilicus and right anterior superior iliac spine (ASIS)

Pre surgery.

The treatment begins by keeping the patient from eating or drinking in preparation for surgery. An intravenous drip is used to hydrate the patient. Antibiotics given intravenously such as cefuroxime and metronidazole may be administered early to help kill bacteria and thus reduce the spread of infection in the abdomen and postoperative complications in the abdomen or wound. Equivocal cases may become more difficult to assess with antibiotic treatment and benefit from serial examinations. If the stomach is empty (no food in the past six hours) general anaesthesia is usually used. Otherwise, spinal anaesthesia may be used.

Once the decision to perform an appendectomy has been made, the preparation procedure takes approximately one to two hours. Meanwhile, the surgeon will explain the surgery procedure and will present the risks that must be considered when performing an appendectomy. With all surgeries there are certain risks that must be evaluated before performing the procedures. However, the risks are different depending on the state of the appendix. If the appendix has not ruptured, the complication rate is only about 3% but if the appendix has ruptured, the complication rate rises to almost 59%. The most usual complications that can occur are pneumonia, hernia of the incision, thrombophlebitis, bleeding or adhesions. Recent evidence indicates that a delay in obtaining surgery after admission results in no measurable difference in patient outcomes.

 

Incision for open appendicectomy

 

Classically the incision lies over McBurney's point; which is a surface marking 1/3rd of way along an imaginary line joining the right ASIS and the umbilicus. An incision is made perpendicular to this line. This is also known as a gridiron or McBurney's incision.

The Lanz incision is more commonly used now as it has a better cosmetic result. This incision is made horizontally over McBurney's point.

A lower midline incision should be considered in the middle aged or elderly patient or if the diagnosis is in doubt.

Tip: It is useful and also good practise to palpate the abdomen once the patient is anaesthetised and relaxed. This allows you to possibly identify an appendix mass and often the caecum can be palpated which aids the location of your incision.

Tip: For the exams - remember that McBurney's point is supposed to mark the base of the appendix, as the tip can lie in many places.

Access for appendectomy must provide implementation of operation. McBurney's incision is typical.

 

Procedure for open appendicectomy

 

After the skin incision the subcutaneous fat is divided down to the external oblique aponeurosis. And it is useful to clear the fat of the aponeurosis with a small swab at this stage.

An incision is made in the line of the fibres into the external oblique aponeurosis with a scalpel and extended with tissue scissors. Beneath this you will find the internal oblique muscle which is split with a pair of curved heavy scissors. The split can be enlarged with either your fingers or a pair of retractors. Peritoneum should now be visible. It can be picked by and tented by two small clips. The peritoneum is then opened by stroking with the belly of a scalpel blade. Ensure there is nothing adherent to the underlying peritoneum and extend the incision with scissors.

Made a note of any fluid released from the peritoneal cavity and if turbid then consider sending a culture swab.

In acute appendicitis it is very likely that the omentum will have migrated down to the right iliac fossa. This can be gently pushed away medially.

Probably the easiest method of finding the appendix is to first identify the caecum. If the caecum is not readily identifiable then find some small bowel and follow it back to the caecum. The taeniae on the caecum can then be followed down to the appendix. Attempted to deliver the caecum and appendix through the wound. If the appendix is very inflammed it will be adherent to surrounding structures. Pass your index finger down from the base of the appendix clearing and adhesions with gentle blunt dissection.

When during operation the appendix without the special difficulties can be shown out in a wound, antegrade appendectomy is executed. If at this stage you are unable to deliver the appendix then enlarge your incision by dividing the fibres of internal oblique. If necessary rectus can be divided too.

Once the appendix is delivered it should be held with a tissue holding forcep such as a babcock. The mesoappendix is then clipped and divided and the pedicles tied with an braided absorbable tie such as vicryl.

On clamps its mesentery is cut off and ligated. Near the basis the appendix is ligated and cut. Stump is processed by solution of antiseptic and peritonized by a purse-string suture .

 

The base of the appendix is crushed with a heavy clip and the clip is placed slightly higher on the appendix. The safest method of dealing with the base is to suture ligate it. The appendix is then divided under the attached clip with a scalpel blade and the suture cut. The remaining suture can then be used to bury the stump with either a purse string or a 'Z' stitch. Now ensure that both the remaining suture and blade used are discarded as they are dirty.

The ceacum is gently placed back into the peritoneal cavity and any fluid sucked out. A washout can be performed although some argue that it just spreads the contaminated fluid around the whole abdomen.

Closure following appendicectomy

The edges of the peritoneum are identified and picked up with up to four clips. The peritoneum is then closed using a continuous 3/0 absorbable suture. The muscle fibres can be loosely approximated with some interrupted stitches. The external oblique defect must be securely repaired. This is done with a continuous 3/0 absorbable suture.

A local anaesthetic agent can now be infiltrated to provide postoperative pain relief.

Skin can be closed with a continuous subcuticular absorbable suture. If the wound has been highly contaminated then consider closing with an interrupted suture or skin clips.

 

Postoperative care

 

Routine observation of heart rate, blood pressure and temperature

Allow free fluids orally and full diet the next day

DVT prophylaxis should be commenced immediately

Two further doses of the antibiotic used on induction can be given postoperatively

 

Other points to note

 

If the appendix looks macroscopically normal it should still be removed. Patients with a right iliac fossa scar will be assumed to have had a appendicectomy by other medical staff. Additionally, 15% of macroscopically normal appendixes prove to be acute appendicitis under microscopy.

If macroscopically normal, then do remember to check for other causes, such as mesenteric adenitis, Meckel's diverticulitis, ovario-tibular pathology or a sigmoid diverticulitis.

If an appendix mass (abscess) is present and the appendix can not be found then place an abdominal drain to the mass and close. An interval appendicectomy can be performed at a later date.

Occasionally you will find a right colon carcinoma or terminal ileitis. This require a right hemi-colectomy to be performed and senior help should be obtained if required.


 

If only the basis of appendix is taken in a wound, and an apex is fixed in an abdominal cavity, more rationally retrograde appendectomy is performed. Thus the appendix near basis is cut between two ligatures. Stump is processed by antiseptic and peritonized. According to it the appendix is removed in the direction from basis to the apex.

According to indication operation is concluded by draining of abdominal cavity (destructive appendicitis, exudate in an abdominal cavity, capillary hemorrhage from the bed). In recent years the laparoscopy methods of appendectomy are successfully performed.

In patients with appendiceal infiltrate it is necessary to perform conservative-temporizing tactic. Taking it into account, bed rest is appointed, protective diet, cold on the area of infiltrate, antibiotic therapy. According to resorption of infiltrate, in two months, planned appendectomy is executed.

Treatment of appendiceal abscess must be only operative. Opening and drainage of abscess, from retroperitoneal access, is performed. To delete here the appendix is not necessary, and because of denger of bleeding, peritonitis and intestinal fistula even dangerously.

 

Laparoscopic surgery

 

The advent of high definition video-laparoscopy has transformed the laparoscopic appendectomy into an elegant, reliable procedure which can be easily performed. In most cases it can be completed within 20 to 30 minutes, and with experience, all clinical settings can be mastered. Critics of this procedure have claimed there are no significant cost savings and no improvement in the recovery of the patient. The following results will disprove these claims. This procedure remains invaluable in patients with undiagnosed abdominal pain requiring further diagnostic intra-abdominal exploration as well as patients with perforated appendicitis with or without an intra-abdominal abscess.

In addition, this technique truly makes the simple appendectomy an outpatient procedure. The patient can resume a diet within a few hours after the "lap-appy" and in most cases can be discharged within 24 to 36 hours. 

The indications for a laparoscopic appendectomy are simple. Any patient suspected to have an acute appendicitis should undergo a laparoscopic appendectomy. As our laparoscopic skills have dramatically improved over the past decade, we now rarely schedule a patient to undergo an "open" appendectomy.

In addition, all surgeons are now well aware that the introduction of spiral computerized tomography has significantly impacted the diagnostic management of these patients. In selected clinical settings, careful use of this imaging modality will improve the diagnostic acumen of the clinician beyond the 95 percentile.

 

Technical Difficulty

 

A pneumo-peritoneum is created in the usual fashion. The trocars are inserted.

An atraumatic grasper [Endo Babcock or Dolphin Nose Grasper] is inserted via the right upper quadrant  trocar . The cecum is retracted upward toward the liver. In most cases, this maneuver will elevate the appendix in the optical field of the telescope. The appendix is grasped with a 5 mm claw-type grasper inserted via the supra-pubic trocar . It is held toward the abdominal wall.

 

 

A dolphin nose grasper  is used to create a mesenteric window under the base of the appendix. The window should be made as close as possible to the base of the appendix and should be approximately 1cm in size. 

The appendix is transected by inserting a MULTIFIRE ENDOGIA 30 instrument via the RUQ trocar (blue cartridge, 3.5), closing it around the base of the appendix and firing it.

The base of the appendix is inspected for hemostasis. The operator should wait a few minutes before initiating measures to stop any bleeding site on the staple line as it will most likely stop spontaneously. The MULTIFIRE ENDOGIA 30 cartridge is changed to a vascular cartridge (white, 2.5) and the meso-appendix is  transected with the same instrument . Several cartridges may have to be used.

The appendix is now amputated from the gastrointestinal tract. A 10mm ENDOCATCH instrument is inserted via the RUQ trocar and deployed in the intra-abdominal cavity. The appendix, held by the grasper (via the suprapubic trocar), is placed into the specimen bag. The bag is closed and the ENDOCATCH instrument  is removed [with the trocar] from the intra-abdominal cavity. The ENDOCATCH instrument is separated from the trocar, and the trocar is reinserted.

The intra-abdominal cavity is irrigated thoroughly with normal saline . For perforated appendicitis with or without an intra-abdominal abscess, a Blake Drain is left in the right lower quadrant and pelvis.

 

 

 

video-laparoscopic

video2

video3

 

Management of Acceptable Complications

 

Post-operative Sepsis.

The irrigation of the intra-abdominal cavity with copious amounts of normal saline under direct vision has decreased the number of post-operative septic episodes or postoperative intra-abdominal abscesses. However, several patients were readmitted with severe abdominal pain and sepsis within ten days after this procedure. Our protocol mandates the following in this clinical setting: 1) Admission to the surgical service, 2) IV antibiotics (Cefizox and Flagyl), 3) Computerized Tomography scan (preferably Spiral) of the abdomen and pelvis, 4) If no localized fluid collection or abscess can be demonstrated on the CT, the patients will continued IV antibiotics only, 5) If an abscess is demonstrated, the patient will undergo a CT guided drainage versus a laparoscopic drainage.

 

Trocar Site Infection - Wound Infection.

Prior to the introduction of the ENDOCATCH instrument,  a significant number of trocar site infections was reported by our surgical team. These incisions were opened at the bedside and drained.

With the use of  the ENDOCATCH instrument to remove the infected specimen from the intra-abdominal cavity, we only reported one wound infection. The irrigation of the trocar site with normal saline at the end of the procedure should also always be done when gross contamination occurred.

 

Inability to Find the Appendix.

In patients with severe, perforated appendicitis, the appendix may be difficult to locate. In this clinical settings, the cecum should be well visualized, dissected and exposed. The base of the appendix is at the confluence of the colic tenias. Persistence is key.

 

Severe, Acute, Necrotizing Appendicitis.

In some cases of severe, acute, necrotizing appendicitis the base of the appendix may not be suitable for transection with a MULTIFIRE ENDOGIA. It may be technically easier and safer to perform a [partial or full] "cecectomy" using the same stapling device.

 

REFERENCES

 

1.                        Franklin EW III, Hevron JE Jr, Thompson JD. Management of the pelvic abscess. Clin Obstet Gynecol 1973; 16: 6679.

2.                        Katkhouda N., Mason R., Towfigh S. et al. Laparoscopic versus open appendectomy: a prospective randomized double-blind study. Ann. Surg 2005; 242: 3: 439448.

3.                        Diagnosing Acute Appendicitis in Adults Am. J. Roentgenol. December 1, 2008 191:W315

4.                        Hardy JD, ed. Rhoads textbook of surgery; principles and pratice. 5th ed. Philadelphia: JB Lippincott, 1977: 111012.

5.                        CT Protocols for Acute Appendicitis: Time for Change Am. J. Roentgenol. November 1, 2009 193:1268-1271

6.                        Cunningham FG, McCubbin JH. Appendicitis complicating pregnancy. Obstet Gynecol 1975; 45: 41520.

7.                        Making the Diagnosis of Acute Appendicitis: Do More Preoperative CT Scans Mean Fewer Negative Appendectomies? A 10-year Study Radiology February 1, 2010 254:460-468

8.                        MDCT for Suspected Appendicitis: Effect of Reconstruction Section Thickness on Diagnostic Accuracy, Rate of Appendiceal Visualization, and Reader Confidence Using Axial Images Am. J. Roentgenol. April 1, 2009 192:893-901

9.                        Fender HR. Complications of appendicitis. Primary Care 1976 Nov 9:5963.

10.                   Marchildon MB, Dudgeon DL. Perforated appeandicitis: current experience in a childrens hospital. Ann Surg 1977; 185: 847.

11.                   Fitz RH. Perforating inflammation of the vermiform appendix with special reference to its early diagnosis and treatment. Am J Med Sci. 1886;92:321-346.

12.                   Itskowitz MS, Jones SM. Appendicitis. Emerg Med. 2004;36:10-15.

13.                   Andersen B, Nielsen TF. Appendicitis in pregnancy: diagnosis, management and complications. Acta Obstet Gynecol Scand. 1999;78:758-762.

14.                   Koepsell TD. In search of the cause of appendicitis. Epidemiology. 1991;2:319-321.

15.                   Department of Health. Hospital episode statistics; England: financial year 200405. http://www.hesonline.nhs.uk (last accessed 28 September 2012).

16.                   Owings MF, Kozak LJ. Ambulatory and inpatient procedures in the United States, 1996. Vital Health Stat 13. 1998;139:1-119. 

17.                   Arnbjornsson E. Acute appendicitis and dietary fiber. Arch Surg. 1983;118:868-870.

18.                   Korner H, Sondenaa K, Soreide JA, et al. Incidence of nonperforated and perforated appendicitis: age-specific and sex-specific analysis. World J Surg. 1997;21:313-317.

19.                   Addiss DG, Shaffer N, Fowler BS, et al. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemol. 1990;132:910-925.

20.                   Flum DR, Koepsell TD. The clinical and economic correlates of misdiagnosed appendicitis: nationwide analysis. Arch Surg. 2002;137:799-804.

21.                   Brunicardi FC, Andersen DK, Billiar TR, et al, eds. The appendix. In: Schwartz's principles of surgery. 8th ed. New York, NY: McGraw-Hill; 2005:1119-1137.

22.                   Soffer D, Zait S, Klausner J, et al. Peritoneal cultures and antibiotic treatment in patients with perforated appendicitis. Eur J Surg. 2001;167:214-216.

23.                   Gomez-Alcala AV, Hurtado-Guzman A. Early breastfeed weaning as a risk factor for acute appendicitis in children [in Spanish]. Gac Med Mex. 2005;141:501-514.

 

Prepared ass. Romaniuk T.