The appendix (lán wěi English name: vermiform appendix), also known as the earthworm, is a slender curved blind tube, located in the lower right side of the abdomen, between the cecum and the ileum, its root is attached to the posterior medial wall of the cecum, the distal end is free and atretic, the position of the range of motion varies greatly from person to person, and the appendix can extend to any direction in the abdominal cavity, influenced by the mesentery, etc. The tip of the appendix can point in all directions, generally with the most posterior appendix, followed by the pelvic position. The length of the appendix averages 7-9 cm, but can vary between 2 and 20 cm, with the upper end opening into the cecum, which also has a less pronounced semilunar mucosal fold. The outer diameter of the appendix is between 0.5 and 1.0 cm, and the inner diameter of the lumen is narrow, only 0.2 cm at rest.
The root of the appendix, which has a more constant position, is marked by three colonic bands downward, all extending to the root of the appendix, which serves as a marker for finding the appendix. Within the tract of the appendix are the appendiceal arteries and veins, the roots of which are at the site where the three colonic bands are concentrated. The projection of the appendiceal root on the body surface is usually in the outer 1/3 of the line from the right anterior superior iliac spine to the umbilicus, which is called the appendiceal point, also known as the McDonald’s point, and in appendicitis, there is often significant pressure pain here.
In general, the appendix of children is relatively longer than that of adults compared to their height; the appendix of adult women is larger than that of men, while that of children is larger than that of women; it gradually shrinks and becomes smaller after middle age.
In the past, it was believed that the appendix is a degenerated organ in the evolution of human beings, which has no important physiological function and has little effect on the human body, and its removal has no adverse effect on the body. Therefore, it can be removed after appendicitis, but these ideas are changing!
Modern medical research has many new insights into the function of the appendix, especially the development of immunology and transplantation surgery, which gives clinical surgeons the hint that the indications for appendectomy should be strictly controlled, and a more cautious attitude should be taken towards incidental appendectomy. The appendix is rich in lymphoid tissue and participates in the immune function of the body. According to research, human appendix has B and T lymphocytes, which are equivalent to the structure of supracapsular sac of birds, and should be classified as a central immune organ, responsible for two specific functions of cellular and humoral immunity of the body. According to the latest research results, the appendix also has secretory cells that secrete various substances and digestive enzymes, hormones that promote hyperactive intestinal peristalsis and hormones related to growth, etc. In addition, the appendix has an intact internal circular muscle and external longitudinal muscle with a certain length and diameter. With the development of microsurgery, the use of autologous appendix transplantation to replace defects and strictures of certain ducts such as ureter and urethra is becoming more and more widespread.
What is appendicitis
Appendicitis (appendicitis) is a common condition. It often presents clinically with right lower abdominal pain, elevated temperature, vomiting and neutrophilia. Appendicitis is an inflammation of the appendix, the most common abdominal surgical condition.
The typical clinical presentation of acute appendicitis is a gradual onset of vague pain in the upper abdomen or around the umbilicus, with abdominal pain shifting to the right lower abdomen after a few hours. It is often accompanied by loss of appetite, nausea or vomiting. At the beginning of the disease, there are no obvious systemic symptoms, except for low fever and malaise. If acute appendicitis is not treated early, it can progress to appendiceal gangrene and perforation, with limited or diffuse peritonitis. Acute appendicitis has a mortality rate of less than 1%, while diffuse peritonitis has a mortality rate of 5-10%.
After non-surgical treatment or cure of acute appendicitis, the appendiceal wall can be left with fibrous tissue hyperplasia and thickening, luminal narrowing and surrounding adhesions, which is called chronic appendicitis and can easily lead to another acute attack. The greater the number of attacks, the more serious the damage of chronic inflammation, which can be repeated acute attacks, without symptoms or occasional mild right lower abdominal pain in the absence of attacks, so it is also called chronic recurrent appendicitis. If the patient has no history of acute appendicitis and complains of chronic right lower abdominal pain, it is not advisable to easily diagnose chronic appendicitis and remove the appendix. Care should be taken to exclude other ileal diseases such as tumors, tuberculosis, nonspecific appendicitis, Crohn’s disease and mobile appendicitis, and psychoneurological factors should also be excluded, otherwise removal of the appendix will be difficult and may not eliminate the symptoms even if there are no other lesions.
Etiology
The appendix is connected to the cecum at one end and is about 6-8 cm long with a narrow lumen of only 0.5 cm. The wall of the appendix is rich in lymphatic tissue, which forms the anatomical basis for the high susceptibility of the appendix to inflammation. This anatomical feature also makes it easy for the appendix to become obstructed. About 70% of patients can be found to have different causes of obstruction in the appendiceal lumen, such as fecal lumps, fecal stones (i.e. long-staying fecal lumps mixed with appendiceal secretions, and can have calcium and other minerals deposited), food debris, distortion of the appendix itself and parasites (such as roundworms and pinworms), etc. can cause appendiceal obstruction. After the inflammation of acute appendicitis subsides, scarring stenosis can form in the appendix, which can easily lead to recurrent inflammation. The presence of abundant lymphoid tissue in the appendiceal wall and the severe inflammatory response contribute to the occurrence of obstruction. When there is obstruction, the pressure in the cavity distal to the obstruction increases, the blood circulation of the appendix wall is affected, and the damage to the mucosa creates conditions for bacterial invasion. Sometimes, although fecal lumps, food residues, parasites and foreign bodies in the appendix cavity do not cause obstruction, they can cause mechanical damage to the appendix mucosa and facilitate bacterial invasion. In addition, gastrointestinal dysfunction can also cause spasm of the muscles in the appendiceal wall, which can affect the emptying of the appendix and even the blood circulation of the appendiceal wall, which is also a cause of inflammation. Bacteria can invade the appendix through the blood circulation and cause inflammation, which is a hematogenous infection.
Pathological process and clinical manifestations
At the onset of acute inflammation, the appendix is congested and swollen, with edema and neutrophilic polymorphonuclear leukocyte infiltration in the wall, small ulcers and bleeding spots in the mucosa, and a small amount of exudate in the plasma membrane. The patient feels vague pain in the upper abdomen or around the umbilicus, often accompanied by nausea and vomiting, general discomfort, and the abdominal pain gradually shifts to the right lower abdomen because the visceral pain is not localized. Localized and obvious tenderness, the clinical use of McBurney’s point indicates the site of tenderness. In the right lower abdomen, there is a limited focal pressure point in the middle and outer 1/3 of the line between the umbilicus and the right anterior superior skeletal spine, which was first discovered and described by American C. McBurney in 1889, so it is called McBurney’s point (McBurney’s point). If the disease continues to develop, the swelling and congestion of the appendix will become more obvious after a few hours, and there are often small abscesses formed in the wall of the appendix, ulcers and necrosis in the mucosa, a lot of fibrous exudate on the plasma membrane surface, and the cavity is filled with purulent fluid, which is called purulent cellulitis appendicitis. At this time, the systemic symptoms are more severe and the pain in the right lower abdomen is obvious. Finally, necrosis of the appendiceal wall can develop, and if there is obstruction, the necrosis of the distal appendix is more serious and purplish-black, and perforation often occurs here, which is called gangrenous appendicitis, and is usually combined with restrictive peritonitis, which is accompanied by obvious muscle tension and rebound pain in addition to pressure pain. The body temperature is more than 38.5°C and the peripheral blood leukocyte count is also increased. Because the proximal ends of the appendiceal cavity are swollen and closed, the overflow through the perforation is only the pus accumulated in the cavity without intestinal contents, and with the large omentum wrapping, diffuse peritonitis rarely develops secondary to periappendiceal abscess.
Diagnosis
Based on the typical clinical presentation of pain around the upper abdomen and umbilicus, with pain shifting to the right lower abdomen after a few hours and significant tenderness in the right lower abdomen, the diagnosis is generally not difficult, but there is still a misdiagnosis rate of about 20%.
The causes of misdiagnosis are two main reasons, in addition to the experience and technical problems of the physicians.
(1) Some acute appendicitis has an atypical presentation. Due to the abnormal location of the appendix, such as high appendicitis easily confused with acute cholecystitis, posterior appendicitis with mild abdominal signs, and pelvic appendicitis with diarrheal symptoms; or due to the more specific onset of appendicitis, if the appendix is suddenly blocked by a foreign body or twisted, the abdominal pain is located in the right lower abdomen at the beginning without any obvious metastatic process and is paroxysmal, and the abdominal signs are not obvious, much like urinary stones or intestinal cramps. In addition, there are also individual patient factors: patients have different nerve types and pain thresholds as well as gastrointestinal responses; elderly people have poor responses, and symptoms and signs often do not reflect the actual severity of acute appendicitis; pediatric patients have relatively large appendixes and are seen late, and it is difficult to take a clear history; pregnant women have upward, outward, or backward displacement of the appendix and an enlarged uterus, and their abdominal physical examination is different from the general population.
②Some other acute abdominal manifestations are similar to acute appendicitis, such as terminal ileal diverticulitis, acute mesenteric lymphadenitis, and certain gynecological disorders such as acute adnexitis, ovarian follicular rupture, and ovarian cyst torsion. Smaller ulcerative perforations, where the perforation is quickly closed and a small amount of duodenal contents flows into the right lower abdomen, may also manifest as metastatic right lower abdominal pain without significant upper abdominal pressure. Some medical disorders such as acute gastroenteritis, intestinal ascariasis, and abdominal purple scar also have clinical manifestations similar to acute appendicitis.
Treatment
Most patients with simple acute appendicitis can be cured by non-surgical treatment, but those with chronic inflammation or narrow lumen are prone to recurrence, so once the diagnosis of acute appendicitis is clear, the diseased appendix should still be removed by emergency surgery. During pregnancy, the inflammation of the appendix develops more rapidly due to pelvic congestion, so surgery should also be performed promptly. If the diagnosis is unknown, if the patient has localized peritonitis or obvious evidence of systemic infection, the patient should also be examined openly to avoid delaying treatment. If the appendix is found to be free of acute inflammatory manifestations during surgery, it should be explored for other acute lesions. If appendicitis has formed a peripheral abscess when the patient is seen, non-operative treatment should be given first, and the appendix should be removed after 3 or 6 months after the abscess has been absorbed.
Home care
Acute appendicitis is reducible, but it recurs in about a quarter of patients after remission. The current surgical approach is relatively safe and the majority of surgical results are good. Non-surgical treatment is mainly anti-infective (i.e., anti-inflammatory). However, one should be prepared to be hospitalized at any time to avoid delaying the treatment so that the disease develops to a serious degree causing treatment difficulties.
1, home medication: medication should be used early, preferably when the inflammation has not developed into peritonitis can be controlled.
2, Chinese medicine.
3, nutrition and diet: a liquid diet should be given, such as milk, soy milk, rice soup, broth, etc.. Or semi-liquid diet, such as porridge, thin soft noodles, etc. If you are preparing for inpatient surgery, you should fast and abstain from food and water.
4.Home care.
(1) Before surgery: The patient should be closely observed for abdominal pain, stool, body temperature and pulse. The patient should be allowed to rest well. Those with peritonitis should take a semi-sitting position (i.e., the patient sits on the bed with the back resting on the quilt). Apply hot towels or hot water bags to the abdominal pain area, which can promote the absorption of inflammation.
(2) After surgery: Because gastrointestinal activity is temporarily stopped after intestinal surgery. The food and water entering the gastrointestinal tract cannot go down and accumulate in the stomach causing abdominal distension. Therefore, you cannot eat or drink after surgery. You have to wait until the gastrointestinal activity is restored before you can eat. The sign of recovery of gastrointestinal activity is the ability to hear intra-abdominal bowel sounds (i.e. gurgling and grunting) or anal venting (farting). If the intestinal tube is not active after surgery, the surgical trauma is prone to adhesions. Therefore, the patient should be encouraged to move more. On the one hand, it can prevent intestinal adhesions, and on the other hand, it can promote the recovery of gastrointestinal activities. It is a painful thing for patients to cough after abdominal surgery. You can use some cough and expectorant drugs, such as 3 tablets of compound licorice, taken orally 3 times a day. Or use cough suppressant 50 mg orally 3 times a day. The patient has phlegm that must be coughed up. To reduce the patient’s pain, the nursing staff can assist the patient. That is, putting both hands on both sides of the incision and exerting pressure toward the middle when coughing can relieve the patient’s pain when coughing. Some complications may occur after appendectomy. Therefore, if the accompanying nurses observe any abnormal changes in the patient, such as full abdominal pain; body temperature rising instead 3 days after surgery; abdominal distension, anal non-exhaustion; bleeding from the incision, pus flow, etc., they should contact the doctor in time to obtain timely treatment. If the doctor orders the patient to be semi-sitting, the companion should cooperate with the doctor to make the patient adhere to the semi-sitting position. Strenuous exercise or heavy physical work should not be done within half a month after discharge. For example, picking water, playing basketball, etc.
(IV) Precautions
1, abdominal pain in the absence of a clear diagnosis before the casual use of painkillers. Because the pain relief covers up the condition, it is easy to delay the diagnosis and cause serious consequences.
2.After suffering from acute appendicitis, if the family treatment has no effect, send to hospital in time.
3, according to the current medical level and technical conditions, acute appendicitis surgical treatment is more effective, even after conservative treatment is cured, it is easy to reappear, so acute appendicitis in the condition of the clear situation, or mainly surgical treatment.
4, non-surgical treatment, in the medication should be thorough. After the disappearance of symptoms and signs, the drug should still be used for a week to consolidate the effect and reduce recurrence.
5.Inpatient treatment should follow the doctor’s arrangement. Chaperones should cooperate with the medical staff to do a good job with the patient.
6, appendicitis condition and signs change greatly, there are many patients with atypical performance. In the absence of certainty, it is best to go to the hospital for consultation. To avoid delays in diagnosis and treatment.
(E) prevention of common sense
1.Enhance physical fitness and hygiene.
2.Be careful not to get cold and unclean diet.
3.Treat constipation and intestinal parasites in time.
Precautions and prevention of acute appendicitis
Precautions
1, abdominal pain in the absence of a clear diagnosis should not use painkillers. Because the pain relief masks the condition, it is easy to delay the diagnosis and cause serious consequences.
2, after suffering from acute appendicitis, if the family treatment has no effect on the timely delivery to the hospital.
3, according to the current medical level and technical conditions, acute appendicitis surgical treatment is more effective, even after conservative treatment is cured, it is easy to reappear, so acute appendicitis in the condition of the clear situation, or mainly surgical treatment.
4, non-surgical treatment, in the medication should be thorough. After the disappearance of symptoms and signs, the drug should still be used for a week to consolidate the effect and reduce recurrence.
5.Inpatient treatment should follow the doctor’s arrangement. Chaperones should cooperate with the medical staff to do a good job with the patient.
6, appendicitis condition and signs change greatly, there are many patients with atypical performance. In the absence of certainty, it is best to go to the hospital for consultation. To avoid delays in diagnosis and treatment.
Common sense prevention
1.Enhance physical fitness and hygiene.
2.Be careful not to suffer from cold and poor diet.
3, timely treatment of constipation and intestinal parasites.
Characteristics of acute appendicitis in the elderly
(a) With the aging of our population, the number of acute appendicitis in elderly people over 60 years old has increased, accounting for about 10% of the total number of acute appendicitis and 10% of adults over 40 years old.
(B) The elderly often suffer from various major organ diseases such as coronary heart disease, etc. The mortality rate of acute appendicitis is higher and increases with the gradual increase of age. According to statistics, the mortality rate of acute appendicitis is 17% in the age group of 60-69 years, 40% in the age group of 70 years or older, and 13.3% in those who have immediate surgery within 12 hours of onset.
(c) Elderly people have low resistance, appendiceal wall, vascular sclerosis, about 30% of patients have perforated appendix at the time of consultation. In addition, the large omentum has atrophied in the elderly, and the inflammation is not easily confined after perforation, so there is more chance of combined purulent peritonitis.
(iv) Atypical clinical manifestations, low responsiveness in the elderly, insignificant abdominal pain, and often no metastatic features. Since the abdominal muscles have atrophied, even if the appendix has been perforated, the signs of peritoneal irritation are not obvious. Sometimes, after the formation of periappendiceal abscess, a mass has appeared in the right lower abdomen, but it is not accompanied by acute inflammatory manifestations, which clinically resembles a malignant tumor in the ileocecal region.
(v) Elderly people often have coexisting cardiovascular diseases, chronic lung diseases, gastrointestinal diseases and metabolic diseases such as diabetes mellitus, and the symptoms of these diseases may be confused with the clinical manifestations of acute appendicitis, which increases the difficulty in diagnosis.
(f) Advanced age is not a contraindication to surgery. Except for simple appendicitis, which can be treated conservatively under close observation, other types of appendicitis must be treated surgically. However, preoperative preparation and postoperative management should be strengthened to ensure the safety of surgery and reduce the occurrence of postoperative complications.
Appendice (appendix)
Observation specimen Transverse section of appendix (H.E staining)
The transverse section of the appendix is tubular, with a small lumen and a visible filling of the contents. The wall is divided into mucosal layer, submucosal layer, muscular layer and epithelium from inside to outside. The luminal surface has no villi and no folds. Low magnification and high magnification observation.
(1) mucosa: divided into three layers.
① epithelium: a single layer of columnar epithelium, containing more cup cells, epithelium is often shed incomplete.
(2) solid layer: connective tissue containing less intestinal glands, lymph nodes and diffuse lymphoid tissue are well developed, and often break through the mucosal muscle and lymphatic tissue of the submucosa.
(3) mucosal muscle layer: thin, mucosal muscle layer is often incomplete.
(2) submucosa: rich lymphoid tissue.
(3) Myocardium: thin, with two layers of smooth muscle in the inner ring and outer longitudinal row.
(4) Outer membrane: plasma membrane.
About the appendix
The appendix, Vermiform Appendix, is a degenerative organ in humans (the appendix is well developed in herbivores), about 7-9 cm long and 0.5 cm in diameter, located in the lower right side of the abdomen, inside the cecum, with the proximal end connected to the cecum and the distal end atretic. Because the appendix lumen is small and blind. Food debris and fecal matter can easily fall into the lumen and block it, causing inflammation. It is located at the junction of the right anterior superior iliac spine and the umbilicus in the outer and middle 1/3.
In adults, the appendix is mainly related to immune function. Soon after birth, lymphoid tissue begins to accumulate in the appendix, reaching a peak around the age of 20, then declining rapidly and disappearing after the age of 60. However, during the developmental phase of the body, the appendix is able to function as a lymphatic organ, promoting the maturation of B lymphocytes (a type of white blood cell) and the production of immunoglobulin A antibodies. Researchers have also shown that the appendix is involved in the production of molecules that help lymphocytes to move to other parts of the body…
Thus, it appears that the function of the appendix is to expose leukocytes to a large number of antigens, i.e., foreign substances, in the gastrointestinal tract. Thus, the appendix may help to suppress a potentially damaging humoral antibody response, while providing a local immune effect. The appendix absorbs and responds to antigens in the intestinal tract. This local immune system plays an important role in the physiological immune response and in the control of food, drug, bacterial or viral antigens. The relationship between these local immune responses and inflammatory bowel diseases and the autoimmune response is currently being studied by scientists ……
What to know about appendicitis
Appendicitis is a common and frequent disease of the abdomen. Most patients with appendicitis seek prompt medical attention and receive good treatment. However, sometimes some serious complications can occur if they are not given enough attention or are not treated properly. To date, acute appendicitis still has a mortality rate of 0.1-0.5%. Appendicitis can occur at any age, but it is more common in young adults, with a peak incidence between 20 and 30 years of age.
Typical appendicitis has some of the following symptoms.
l. Pain in the right lower abdomen.
2. nausea and vomiting.
3. constipation or diarrhea.
4. low-grade fever.
5, loss of appetite and abdominal distension.
The abdominal pain of appendicitis starts mostly in the upper abdomen, under the glabella or around the navel, and after about 6-8 hours, the abdominal pain gradually moves down and finally fixes in the right lower abdomen. The right lower abdomen is painful when coughing, sneezing or pressing. If you have any of these symptoms, you should see your nearest doctor immediately and not take it lightly.
Appendicitis in special populations
1. Pediatric acute appendicitis: Pediatric acute appendicitis develops quickly, is serious, has a high perforation rate, and has many complications. Perforation occurs in almost 100% of acute appendicitis in infants within one year of age, 70%-80% within two years of age, and 50% at five years of age. The mortality rate of acute appendicitis in pediatric patients is 2-3%, which is 10 times higher than that of adults. Moreover, children are often uncooperative during examination, and the extent and degree of abdominal pressure pain are not easily determined. After diagnosis, the appendix should be surgically removed immediately, and the preoperative preparation and postoperative comprehensive treatment should be strengthened to reduce complications.
2. Acute appendicitis in the elderly: With the aging of our population, the number of acute appendicitis in the elderly over 60 years of age has increased. Elderly people often suffer from various major organ diseases such as coronary heart disease, etc. The mortality rate of acute appendicitis is higher and increases with age. Older adults have low resistance, thin appendix walls, and sclerosis of blood vessels, and about 1/3 of patients have perforated appendixes at the time of consultation. In addition, the elderly have low responsiveness, the abdominal pressure pain is not obvious, and the clinical manifestations are not typical. Since the abdominal muscles have atrophied, even if the appendicitis has been perforated, the abdominal pressure pain is not obvious, so it is easy to misdiagnose.
3, acute appendicitis during pregnancy: due to the changes in the physiology of pregnant women, once appendicitis occurs, its risk is greater than the average adult. According to statistics, the mortality rate of acute appendicitis during pregnancy is 2%, which is 10 times higher than that of the general population, and the mortality rate of the fetus is about 20%.
In principle, the treatment of acute appendicitis during pregnancy should be based on the safety of the pregnant woman. For those who develop appendicitis during the third trimester, the treatment principles are the same as those for non-pregnant patients, and emergency removal of the appendix is best; for acute appendicitis in the middle trimester, surgery is still preferable for those with severe symptoms; for appendicitis in the late trimester, about 50% of pregnant women may deliver prematurely, and the mortality rate of the fetus is higher, so surgery should minimize the stimulation of the uterus.
The abdominal pain of appendicitis starts mostly in the upper abdomen, under the glabella or around the navel, and after about 6-8 hours, the abdominal pain gradually moves down and finally fixes in the right lower abdomen. The right lower abdomen is painful when coughing, sneezing or pressing. If you have any of the above symptoms, you should see your nearest doctor immediately and not take it lightly.
Misconceptions about the appendix
Traditional misconceptions about the appendix should be completely corrected:
1. Appendicitis is appendicitis. Since the appendix is right next to the appendix, many people confuse appendicitis with appendicitis, but in fact they are two different diseases;
2. It is believed that the appendix is a degenerated organ in the process of human evolution and has no important physiological function, so removing the appendix has no adverse effect on the organism.
Modern medical research has many new insights into the function of the appendix, especially the development of immunology and transplantation surgery, which gives clinical surgeons the hint that
The indications for appendectomy should be strictly controlled, and a more cautious attitude should be taken towards incidental appendectomy. The appendix is rich in lymphoid tissue and is involved in the immune function of the body, and should be classified as a central immune organ, which is responsible for two major functions: cellular immunity and humoral immunity of the body. The latest research results confirm that the appendix also has secretory cells that secrete various substances and digestive enzymes, as well as hormones that promote intestinal peristalsis and growth-related hormones.