I. Concept
Appendicitis is an inflammatory change of the appendix due to a variety of factors and is a common surgical condition, clinically divided into acute and chronic appendicitis, and is the most common acute abdominal condition.
Anatomy: The appendix is located in the right iliac fossa, earthworm-shaped, about 5-10cm long and 0.5-0.7cm in diameter. The appendix starts from the root of the cecum and is attached to the posterior medial wall of the cecum, the confluence of three colonic bands. Its body projection is about in the outer and middle 1/3 of the line between the umbilicus and the right anterior superior iliac spine, which becomes the point of Mai.
Etiology
(1) Obstruction of the lumen of the appendix (most common)
The appendix is a long and thin duct, 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 appendix wall and obstructing the distal blood flow. The most common cause of obstruction is the obvious proliferation of lymphoid follicles, followed by fecal stones, while foreign bodies, roundworms, tumors, food residues, etc. are less common.
(2) Bacterial invasion
The main factor is direct infection due to bacteria in the appendiceal lumen. If the appendiceal mucosa is slightly damaged, bacteria invade the canal wall and cause different degrees of infection.
III. Clinical manifestations
Symptoms.
(1) Abdominal pain
The typical abdominal pain attack starts in the epigastrium, gradually moves to the umbilicus, and shifts and is confined to the right lower abdomen after several hours (6-8 hours) —- Typical metastatic right lower abdominal pain (70% – 80%). Some patients present with right lower abdominal pain at the onset of the disease. When the inflammation spreads to the plasma layer and the wall peritoneum, the pain becomes fixed in the right lower abdomen and the original mid-upper abdominal or periumbilical pain is reduced or disappears. 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 middle and lower abdomen or both sides of the lower abdomen is often a sign of gangrenous perforation of the appendix.
(2) Gastrointestinal symptoms
Early on, there may be mild anorexia, nausea, and vomiting. Some may have diarrhea. Inflammation of pelvic appendicitis irritates the rectum and bladder, causing defecation and posterior urgency symptoms. In diffuse peritonitis, paralytic intestinal obstruction, abdominal distension, reduced defecation and exhaustion may result.
(3) Systemic symptoms
Early weakness, toxic symptoms when inflammation is heavy, increased heart rate, fever, up to about 38 ℃. In case of appendiceal perforation, the body temperature will be higher, reaching 39℃ or 40℃. Chills, high fever and mild jaundice may occur in case of portal phlebitis.
Signs.
1, pressure pain in the right lower abdomen: the most common. The pressure point is usually located at the McDonald’s point, which may change with the variation of the appendix position, but the pressure point is always in a fixed position.
2, signs of peritoneal irritation: rebound pain, abdominal muscle tension, and diminished or absent bowel sounds. It is a defensive response of the mural peritoneum stimulated by inflammation.
3, right lower abdominal mass: consider periappendiceal abscess.
2, signs of peritoneal irritation: rebound pain, abdominal muscle tension, and diminished or absent bowel sounds. It is a defensive response of the mural peritoneum stimulated by inflammation.
3. Right lower abdominal mass: consider periappendiceal abscess.
Four, auxiliary examination
1, blood routine: most patients with acute appendicitis have increased white blood cell count and neutrophil ratio. As inflammation increases, the leukocyte count increases and may even exceed 20×109/L. However, the leukocyte count does not necessarily increase in elderly and frail patients or those with suppressed immune function. The increase in leukocyte count is accompanied by an increase in neutrophil count. The two are often seen together, but there are cases where only neutrophils are significantly increased, with the same importance.
2.Urinary routine: usually no positive finding, if a few red blood cells appear in the urine, it indicates that the inflamed appendix is close to the ureter or bladder.
3.Abdominal plain film: dilated appendix and liquid-air planes are seen, occasionally calcified fecal stones are seen.
4.B ultrasound: enlarged appendix and abscess are found.
V. Differential diagnosis
(1) Right ureteral calculus
The pain radiates to the external genitalia of the perineum, and there is no obvious pressure pain in the right lower abdomen. A large number of red blood cells can be found in the urine, and ultrasound and radiographs can show stone shadows in the ureteral travel area.
(2) Gastroduodenal ulcer perforation
The overflowing gastric contents from the perforation may flow into the right lower abdomen along the paracolic sulcus of the ascending colon, which can be easily mistaken for metastatic abdominal pain from acute appendicitis. The patient mostly has a history of ulcer and presents with a sudden onset of severe abdominal pain. Signs include pain and pressure in the epigastrium in addition to pressure in the right lower abdomen. Peritoneal irritation symptoms such as abdominal wall plate tonicity are also more obvious. Free gas under the diaphragm can be found on chest and abdominal X-ray.
(3) Obstetrical and gynecological diseases
Ruptured ectopic pregnancy, ruptured ovarian follicular or corpus luteum cysts, acute tubal inflammation, acute pelvic inflammatory disease, and torsion of ovarian cysts.
(4) Acute mesenteric lymphadenitis
Most often seen in children, often preceded by a history of upper whistle infection, abdominal pressure pain is medial, less fixed and more widespread, and can change with body position.
(5) Other
Acute gastroenteritis, ileocecal tumor, infectious disease of the biliary system, open ventriculitis or perforation of the meconium, pediatric intussusception, etc.
VI. Treatment
(1) Surgical treatment.
In most cases of acute appendicitis, appendectomy should be performed as soon as possible once the diagnosis is confirmed. Early surgery refers to the surgical removal of the appendix when the inflammation is still in the obstruction of the lumen or when there is only congestion and edema, which is simple and has few postoperative complications.
(2) Non-surgical treatment.
It is only applicable to simple appendicitis and the early stage of acute appendicitis, which mainly involves effective antibiotic and rehydration treatment.