Acute appendicitis is a common surgical condition and ranks first among various acute abdominal conditions. Metastatic right lower abdominal pain and appendicular point pressure and rebound pain are its common clinical manifestations, but the condition of acute appendicitis is variable, so each specific case should be treated seriously, with thorough history taking and careful examination, so as to make accurate diagnosis, operate early, prevent complications and improve the cure rate.
I. Symptoms and signs
Clinical manifestations are closely related to the type of pathology.
1.Abdominal pain
Typical acute appendicitis starts with pain in the middle and upper abdomen or around the umbilicus, and after a few hours the abdominal pain shifts and becomes fixed in the right lower abdomen. The early stage is a kind of visceral nerve reflex pain, so the pain in the middle and upper abdomen and around the umbilicus is more diffuse in scope and often cannot be localized exactly. When the inflammation spreads to the plasma membrane layer and the mural peritoneum, the pain is fixed in the right lower abdomen because the latter is innervated by the somatic nerves and the pain is sensitive and precisely localized, and the original pain in the middle and upper abdomen or around the umbilicus is reduced or disappears. According to statistics, 70% to 80% of patients have a history of typical metastatic right lower abdominal pain. In a small number of patients, the disease progresses rapidly and the pain may be confined to the right lower abdomen at the beginning. Therefore, the absence of a typical history of metastatic right lower abdominal pain does not exclude acute appendicitis.
Simple appendicitis often presents with paroxysmal or persistent distension and dull pain, and persistent severe pain is often indicative of septic or gangrenous appendicitis. Persistent severe pain extending to the mid-lower abdomen or both lower abdomens is often a sign of perforated gangrene of the appendix. Sometimes the pain is relieved by the loss of sensory and conduction function of the nerve endings or by the sudden decrease in intracavitary pressure, but this pain relief is temporary and other accompanying symptoms and signs do not improve or even increase. For this reason, the clinical phenomenon must be analyzed in order not to be misled by the illusion.
2. Gastrointestinal symptoms
The gastrointestinal symptoms of simple appendicitis are not prominent. In the early stage, there may be nausea and vomiting due to reflex gastric cramps. In pelvic appendicitis or perforated appendix gangrene, the number of bowel movements may increase due to perirectal inflammation. Coexisting peritonitis and intestinal paralysis may result in abdominal distention and persistent vomiting.
3.Fever
Generally, only low fever, no chills, septic appendicitis usually does not exceed 38 ℃. High fever is usually seen in cases of appendiceal gangrene, perforation or peritonitis. The presence of chills and jaundice suggests a possible complication of purulent portal phlebitis.
4.Pressure pain and rebound pain
Abdominal pressure pain is a manifestation of inflammatory stimulation of the mural peritoneum. The appendiceal pressure point is usually located at the McBurney point, which is the junction of the middle and outer 1/3 of the line between the right anterior superior iliac spine and the umbilicus. This anatomical landmark of the appendix is not fixed and can also be located at Lanz’s point at the junction of the middle and right 1/3 of the anterior superior iliac spine on both sides. As the anatomical location of the appendix varies, the pressure point may change accordingly, but the key is a fixed pressure point in the right lower abdomen. The degree and extent of pressure pain often correlates with the severity of inflammation.
Rebound pain is also known as Blumberg’s sign. In patients with obesity or posterior appendicitis of the appendix, the pressure pain may be mild, but there is significant rebound pain.
5. Abdominal muscle tension
This sign is present when the appendix is septic, and the abdominal muscle tension is particularly significant in gangrenous perforation complicated by peritonitis. But older or obese patients with weaker abdominal muscles, must also check the contralateral abdominal muscles, for comparison, in order to determine the presence of abdominal muscle tension.
6, colonic inflation test
Also known as Rovsing’s sign, first press the left lower abdomen descending colon area with one hand, then repeatedly press its upper end with the other hand, the patient complains of right lower abdominal pain is positive, only positive results have diagnostic value.
7.Lumbar major muscle test
The patient is lying on the left side and the right lower limb is hyperextended backward, causing right lower abdominal pain is positive, which is helpful for the diagnosis of posterior appendicitis of the appendix.
8.Closing muscle test
Supine position with right leg flexed forward 90°, causing right lower abdominal pain is positive and helps in the diagnosis of pelvic level appendicitis.
9.rectal finger examination
In the case of inflammation of the appendix located in the pelvis, there may be no obvious pressure pain in the abdomen, but there is tenderness at the right anterior wall of the rectum, and in the case of pus accumulation around the rectum in gangrene perforation, there is not only obvious tenderness, but also a feeling of fullness around the rectum. Rectal examination can also help to exclude pelvic and uterine adnexal inflammatory lesions.
10. Skin sensory sensitization
In the early stage, especially when there is obstruction in the appendix cavity, skin sensory hypersensitivity in the right lower abdomen may appear, which is equivalent to the 10th to 12th thoracic medullary segment innervation area, located in the triangle formed by the highest point of the right iliac crest, right pubic crest and umbilicus, also called Sherren’s triangle, which does not change depending on the location of the appendix.
II. Treatment with medication
The currently accepted treatment for acute appendicitis is surgical removal of the appendix and management of its complications. However, the pathological changes of appendiceal inflammation are complex, and non-surgical treatment still has its place in the treatment of acute appendicitis and should not be ignored.
1. Non-surgical treatment
When acute appendicitis is in the early stage of simple inflammation, once the inflammation absorbs and subsides, the appendix can return to normal and no longer recur, so the appendix does not need to be removed and non-surgical treatment can be used to promote the early disappearance of appendiceal inflammation. When the diagnosis of acute appendicitis is clear and there are indications for surgery, but the patient’s circumstance or objective conditions do not allow, non-surgical treatment can be taken first to delay surgery. If acute appendicitis has combined with limited peritonitis and formed inflammatory masses, non-operative treatment should also be used to make the inflammatory masses absorb and then consider elective appendectomy. If the inflammatory mass turns into an abscess, the appendix should be drained by incision first and then elective appendectomy should be performed later. When the diagnosis of acute appendicitis is not yet confirmed and needs to be observed, non-operative treatment can also be used while observing the change in condition. In addition, non-operative treatment can be used as a preparation for appendectomy. In conclusion, non-operative treatment has an important place. Non-operative treatment includes
(1) General treatment: mainly bed rest, fasting, intravenous input of water, electrolytes and calories, etc.
(2) Antibiotic application: The application of antibiotics is very important in the non-surgical treatment. The choice and dosage of antibiotics should be determined according to the specific situation. The majority of appendicitis is a mixed infection, the past use of penicillin, streptomycin combined application, the effect is satisfactory, later found that the increase in drug-resistant strains and anaerobic bacterial infection rate increased, then changed to use the “golden triad” that is ampicillin (ampicillin), gentamicin and metronidazole combination, its antibacterial coverage is large, the price is not expensive, very popular. In recent years, new high-efficiency antibiotics have emerged, and cephalosporin is constantly updated. Therefore, the combination of cephalosporin or other new β-lactam antibiotics with metronidazole is often used now. The advantages are a broader antibacterial spectrum, stronger resistance to drug-resistant bacteria, and less toxicity and side effects. In mild acute appendicitis, the antibiotic application is almost prophylactic in nature and can be applied for a short time with general antibiotics. Only for patients with severe inflammation is a formal therapeutic application appropriate. For severe appendicitis (gangrenous or perforated), the use of third-generation cephalosporin plus metronidazole or imipenem is currently advocated to receive good results.
(3) Analgesic application: Pain relief is sometimes very necessary. Intense pain can increase mental terror, reduce the body’s immune function, thus weakening the patient’s ability to resist disease. The application of morphine-like drugs can be considered but must be cautious and can be applied to patients who have decided to have surgery, but is prohibited in general, especially for the frail.
(4) Symptomatic treatment: such as sedation, antiemetic, placement of gastric decompression tube if necessary, etc.
2.Surgical treatment
In principle, acute appendicitis, except for the mucosal edema type which can be cured after conservative treatment, should be treated by appendectomy to remove the lesion in order to achieve
① rapid recovery.
②preventing the occurrence of complications.
③Good therapeutic results can also be obtained for appendicitis that has developed complications.
④ removal of lesions that are likely to recur later.
⑤ To obtain correct pathological results. However, acute appendicitis is extremely complicated due to the severity of the disease, the age and physical strength of the patient, and so on, and it is sometimes difficult to distinguish between many diseases and appendicitis. Complications due to improper operation are 5%-30%, and the mortality rate is about 1%. If the appendectomy is performed incorrectly due to wrong diagnosis and aggravates the primary disease, the risk is even greater.
Appendectomy is a frequently performed operation in abdominal surgery. Generally speaking, it is not complicated, but sometimes it is also difficult.
(1) Indications for surgery.
(1) Clinically definite diagnosis of acute appendicitis, recurrent appendicitis and chronic appendicitis.
(ii) Early appendicitis in which non-operative treatment has failed.
(iii) ileocecal masses formed after non-operative treatment of acute appendicitis.
④ periappendiceal abscess after healing by incision and drainage.
⑤ Other irreversible lesions of the appendix. Surgery is contraindicated in patients with very poor physical condition and severe cardiopulmonary and other concomitant diseases.
(2) Preoperative preparation: Even for acute appendicitis without complications, there should be necessary preoperative preparation, including general understanding of the patient’s vital organ functions, routine laboratory tests and short time rehydration, gastrointestinal decompression, pain relief, antibiotic application and preoperative medication, etc., to ensure smooth anesthesia and safe surgery. The situation is different for heavy appendicitis with complications, because the symptoms of appendicitis are severe, even septic gangrene, and there is also limited or diffuse peritonitis, resulting in a combination of septicemia manifestations of different degrees, or early multi-organ failure (MOF) phenomenon, the preoperative preparation should be enhanced with the aggravation of the disease. The amount of fluid infusion should be large, and sometimes a certain amount of colloid fluid is needed to replenish blood volume; antibiotics should be selected for their potency, low toxicity, broad antibacterial spectrum, effectiveness against drug-resistant strains and combined application; symptomatic treatment should also be active, including the protection and adjustment of each vital organ, with the aim of making the condition stabilize within a short period of time so that early resection of the lesion can be performed and the patient can get good treatment results early.
(3) Incision selection: A right lower abdominal oblique incision is generally used. The standard McKinsey (appendix point) oblique incision is a small 4-5 cm incision perpendicular to the line of union between the right anterior superior iliac spine and the umbilicus at the point where the outer 1/3 and middle 1/3 of the line of union meet. The incision can also be moved slightly with the estimated appendiceal site to directly expose the appendix. The advantage of an oblique incision is that the muscle is separated in the direction of the muscle fibers and there is no damage to the abdominal wall vessels and nerves, and the chance of incisional hernia is low. The incision can also be transverse, coinciding with the skin folds, and the scar is not visible. Transverse incisions were initially used in children and are now also used in adults.
The length of the incision should be adjusted according to the thickness of the abdominal wall, and the incision tends to be longer in obese patients. Any incision that is too small is bound to increase the difficulty of the procedure and may even produce unnecessary accidents, which are not worth the cost and are not worth taking.
Strict protection of the incision is an important measure to prevent postoperative incisional infection. Revealing the appendix is an important step in surgery. The appendix should be found under direct vision, and then the root of the appendix should be found along the colonic band, and the appendix should be clamped out with a ring forceps and/or long toothless forceps, and if the appendix is not revealed, the incision should be decisively extended. It is best to remove the appendix under direct vision. When the base of the appendix is easily exposed and the rest of the appendix is not well exposed or fixed with close adhesions to the surrounding tissues, retrograde appendectomy can be used. It must be determined that the appendix has been completely removed and no residual remains. If the base of the appendix is necrotic and the wall of the appendix is also necrotic, the appendix can be completely excised and the necrotic wall of the appendix can also be excised, and then the incision can be closed by inversion.
(4) Method of finding and removing the appendix: The anatomical relationship between the root of the appendix and the tip of the cecum is constant, and the appendix is traced along the colonic band to the tip of the cecum, which is the root of the appendix. If the appendix is not seen, the possibility that the appendix is located outside the peritoneum should be considered. The lateral peritoneum should be cut open and the cecum and ascending colon should be turned medially to find the appendix. The cecum and appendix can also be found by following the end of the ileum.
Conformal method of appendectomy is easy to operate and less contamination. If the inflammation is severe, the tip of the appendix adheres to deep tissues and cannot be raised, or retrograde resection, if there is difficulty, submucosal appendectomy is feasible: the root of the appendix is cut off first, the stump is buried in the cecum according to the conventional ligature load, and then the mucosa of the appendix is completely peeled off, leaving only the plasma muscle sleeve of the appendix. If the root is gangrenous and the cecum wall is edematous and fragile, it is not advisable to reluctantly perform purse-string suturing to avoid putting the abdominal drainage.
(5) Treatment of appendiceal stump: Generally, we adopt the method of ligating the severed end, coating the stump with phenol (carbolic acid), alcohol and saline, suturing it with purse-string, and burying it in the appendix by turning it inside out. This treatment ensures hemostasis, peritonealization of the wound surface to prevent adhesions, and cautery of the severed end can inactivate the gland, so that the stump does not form a mucous cyst after burial in the cecum. However, when the inflammation of the cecum wall is significant, the intestinal wall is edematous and fragile or the appendix stump is swollen and thickened, it can be simply ligated.
(6) Abdominal exploration: if the inflammation of the appendix is obvious intraoperatively, it is not necessary to explore other parts of the abdominal cavity. If the appendix is found to be normal or lightly inflamed intraoperatively, the system should be explored
Three, diet and health care
1.Food therapy
Eat more dietary fiber can achieve the prevention of intestinal diseases (including appendicitis) role.
2, should not eat
After a meal, do not run around in a hurry, the summer heat should not be too cold, especially should not drink cold beer, and other cold drinks. The usual diet should not be too fatty, avoid over-eating stimulating food.
3.Preventive care
Do not run around in a hurry after meals, and do not drink too much cold in the summer heat, especially not too much cold beer, and other cold drinks. Usually pay attention to not too fatty, avoid over-eating stimulating. You should actively participate in physical exercise to strengthen your body and improve your immune system. If you have a history of chronic appendicitis, you should pay more attention to avoid recurrence, and usually keep your bowels unobstructed.
(1) Enhance physical fitness and hygiene.
(2) Take care not to get cold and eat poorly.
(3) Timely treatment of constipation and intestinal parasites.
V. Pathogenesis
The pathogenesis of acute appendicitis is uncertain. However, most of the opinions believe that several factors occur in combination. Among them, the following factors are recognized.
1, obstruction
The appendix is a slender tube, only one end of which is connected to the cecum. Once obstructed, secretions can accumulate in the lumen and increase the internal pressure, compressing the appendiceal wall and impeding distal blood flow, on the basis of which bacteria in the lumen invade the damaged mucosa and easily cause infection. It has been found that gangrenous appendicitis almost always has obstruction present. Common causes of obstruction are.
① blockage of the appendiceal lumen by fecal stones, dried fecal masses, food debris, foreign bodies, roundworms, etc.
(ii) narrowing or adhesions of the lumen due to previous destruction of the appendiceal wall.
(iii) distortion of the appendix formed by the appendiceal tract being too short, which obstructs the passage of the duct.
(iv) Narrowing of the lumen due to hyperplasia or edema of the lymphoid tissue within the appendiceal wall.
⑤ lesions in the vicinity of the appendix opening in the cecum area, such as inflammation, polyps, tuberculosis, tumors, etc., which compress the appendix opening and obstruct emptying. Among them, fecal stone obstruction is the most common, accounting for about 1/3.
Obstruction is a common underlying factor in the development of acute appendicitis, so the initial onset of acute appendicitis is often preceded by subxiphoid or umbilical colic, which is a symptom caused by obstruction of the appendiceal canal and increased internal pressure. In addition, fecal stone obstruction of the lumen, obvious inflammation or even gangrene perforation of the distal end can often be seen in the specimens of resected appendix.
2.Infection
The main factor is direct infection caused by bacteria in the appendiceal lumen. The appendiceal cavity is connected to the cecum, so it has the same species and number of bacteria, mainly E. coli and anaerobic bacteria, as those in the cecum. If the mucosa of the appendix is slightly damaged, bacteria invade the wall of the canal and cause different degrees of infection. In a few patients, the infection occurs after an upper respiratory tract infection and is therefore also thought to be transmitted from the bloodstream to the appendix. Another part of the infection starts from a purulent infection of a neighboring organ that invades the appendix.
3. Other
Among other factors considered to be related to the pathogenesis are visceral nerve reflexes caused by gastrointestinal dysfunction (diarrhea, constipation, etc.), resulting in spasm of the appendiceal muscles and blood vessels, which, once exceeding the normal intensity, can produce narrowing of the appendiceal lumen, impaired blood supply, mucosal damage, and bacterial invasion leading to acute inflammation. In addition, it has also been suggested that the onset of acute appendicitis is related to dietary habits and genetics. The low incidence in areas with a multi-fiber diet may be associated with faster colonic emptying and reduced constipation. Habitual application of slow laxatives due to constipation may cause congestion of the intestinal mucosa, which can also affect the appendix. Genetic factors have been suggested to be associated with congenital malformations of the appendix. Excessive distortion, small lumen, excessive length, and poor blood flow are conditions that predispose to acute inflammation.