1. What is acute appendicitis?
Acute appendicitis is a common surgical disease, ranking first among various acute abdominal diseases. 1886 Fitz first named, in 1889 McBurney proposed the idea of surgical treatment of acute appendicitis. Over the past century, due to improvements in surgical techniques, anesthesia, antimicrobial therapy and care, the vast majority of patients have been cured and the mortality rate has been reduced to about 0.1%. 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 there is still a certain rate of misdiagnosis and misdiagnosis in the diagnosis and treatment of acute appendicitis, which still needs to be treated seriously.
Although acute appendicitis is often manifested as a purulent infection caused by varying degrees of bacterial invasion of the appendiceal wall, its pathogenesis is a more complex process, which is summarized in relation to the following factors.
(A) Appendiceal lumen obstruction: The lumen of the appendix is narrow and slender, and the distal end is closed to the blind end, and the lumen obstruction is the basis for the induction of acute appendicitis. After the obstruction of the appendiceal lumen, a large amount of mucus is retained in the lumen, which gradually increases the pressure in the lumen. The excessive pressure can compress the mucosa, causing necrosis and ulceration, which creates conditions for bacterial invasion. If the intracavitary pressure continues to increase, the appendiceal wall is also pressurized, firstly, the venous return is blocked, venous thrombosis is formed, the appendiceal wall is edematous and ischemic, and the intracavitary bacteria can penetrate into the abdominal cavity. In severe cases, the artery is also obstructed, causing necrosis of part or even the whole appendix.
The site of appendiceal lumen obstruction is mostly at the root of the appendix, but of course it can also be at the middle and distal segments of the appendix, and the causes of obstruction are.
(1) Proliferation of lymphoid follicles: The appendix has abundant lymphoid tissue in the submucosa, and any cause of swelling of these tissues can cause narrowing of the appendiceal lumen. In adolescents with acute appendicitis, about 60% are induced by swelling of lymphoid tissues. It has been observed that the occurrence of appendicitis is closely related to the number of lymphoid follicles in the appendix.
(2) Fecal stone obstruction: About 35%, fecal stones are formed by mixing and concentrating feces, bacteria and secretions in the appendiceal cavity, and are the main cause of acute appendicitis in adults.
(3) Foreign body: about 4%, such as residues in food, parasitic worms and eggs, etc.
(4) Congenital factors or inflammatory adhesions: the appendix can be twisted and folded, and compression by cords and masses can narrow the appendiceal lumen.
(5) Lesions of the cecum and appendix wall: inflammation of the cecum wall near the opening of the appendix, tumors and the appendix itself with polyps and overlapping can lead to obstruction of the appendix lumen.
(B) Bacterial infection: There are a large number of bacteria in the appendiceal cavity, including aerobic bacteria and anaerobic bacteria, and the species are the same as those in the colon, mainly Escherichia coli, Enterococcus and Bacteroides fragilis. Bacteria invade the appendix wall in the following ways.
(1) direct invasion: bacteria are invaded by the ulcer on the mucosal surface of the appendix and gradually develop to all layers of the appendiceal wall, causing purulent infection.
(2) Hematogenous infection: bacteria reach the appendix via the blood circulation, and the incidence of acute appendicitis can be increased in children with upper respiratory tract infections.
(3) Spread of adjacent infections: Less commonly, acute inflammation of the organs surrounding the appendix spreads directly to the appendix and can cause appendicitis secondary to the infection.
(3) Nerve reflexes: Stomach and intestinal dysfunction of various causes can reflexively cause spasmodic contractions of the appendicularis circumflexus and appendicular artery. The former can aggravate the obstruction of the appendiceal cavity and make the drainage more poor, while the latter can lead to ischemia and necrosis of the appendix, accelerating the onset and development of acute appendicitis.
2. What are the classifications of acute appendicitis? What is the difference between the consequences of different classifications of appendicitis?
Acute appendicitis can be divided into several special types of appendicitis such as appendicitis in elderly patients, appendicitis in pediatric patients and appendicitis in pregnant women according to the patient’s condition, and here we will first introduce the classification according to its pathological manifestations, which can be roughly divided into 3 categories.
(1) Simple appendicitis: the appendix is mildly swollen, the plasma membrane surface is congested, loses its normal luster and has a small amount of fibrinous exudate, all layers of tissue are congested, edematous and infiltrated with neutrophilic polymorphonuclear leukocytes, most notably the mucosa and submucosa, small ulcers can still appear on the mucosa, and there can be a small amount of inflammatory exudate in the lumen.
(2) Purulent appendicitis: Also known as cellulitis appendicitis, the appendix is visibly swollen, the plasma membrane surface is highly congested, and purulent or fibrinous exudates are present. In addition to congestion, edema and massive neutrophil infiltration in all layers of tissue, there are often small intermural abscesses, ulceration and necrosis on the mucosal surface, and pus often accumulates in the lumen. There is a small amount of cloudy exudate in the abdominal cavity.
(3) Gangrenous appendicitis and perforation: the appendiceal canal wall is fully or partially necrotic, with a dark purple or black appearance, a large amount of purulent and fibrinous exudate on the surface and around it, and pus accumulation in the appendiceal lumen. In case of embedded obstruction, the distal end of the embedded appendix is necrotic; in case of inflammatory wave or appendiceal tract vascular thrombosis, the whole appendix is necrotic and wrapped by the greater omentum. Perforation is seen in about 2/3 of cases, with bacteria and pus entering the peritoneal cavity through the necrotic area or perforation.
The above 3 pathological types of appendicitis are the 3 stages of gradual aggravation of acute appendicitis with the following possible pathological findings.
(1) Inflammation subsides: simple appendicitis before ulceration of the mucosa has formed, and timely drug treatment may allow the inflammation to subside without leaving pathological changes. Early suppurative appendicitis, if treated and the inflammation subsides, will also be scarred healing, resulting in narrowing of the appendiceal cavity, thickening of the wall, distortion of the appendix, and easy recurrence.
(2) Confinement of inflammation: After suppuration or gangrene or perforation, the appendix is wrapped by the large omentum to form a periappendiceal abscess or inflammatory mass, and the inflammation is confined. If there is not much pus it can be gradually absorbed.
(3) Inflammation spread: If the body’s defense function is poor or not treated in time, inflammation spreads and leads to appendiceal suppuration, gangrene perforation and even diffuse peritonitis, purulent portal phlebitis, etc. In rare patients, bacterial emboli can enter the portal vein with blood flow and form abscesses in the liver, resulting in severe sepsis with high fever, jaundice, hepatomegaly and infective shock.
3.What are the manifestations of acute appendicitis?
Symptoms.
(1) Abdominal pain: mostly starts from around the umbilicus and upper abdomen, the pain is not very serious at the beginning, the location is not fixed, and it is paroxysmal, which is the reflex pain of visceral nerves caused by the dilation of the lumen and the contraction of the wall muscles after the appendix is blocked. After a few hours, the abdominal pain is shifted and fixed in the right lower abdomen, and the pain is persistently aggravated, which is a somatic nerve localization pain caused by the inflammation of the appendix invading the plasma membrane and the stimulation of the mural peritoneum. About 70% to 80% of acute appendicitis is characterized by this typical metastatic abdominal pain, but there are also some cases in which the onset of the disease is characterized by right lower abdominal pain.
The site of abdominal pain also differs in different locations of appendicitis, such as posterior appendicitis in the lateral lumbar region; pelvic appendicitis in the suprapubic region; appendicitis in the subhepatic region can cause right upper abdominal pain; very rarely, left-sided abdominal appendicitis presents with left lower abdominal pain.
The abdominal pain of different pathological types of appendicitis also varies, such as simple appendicitis is mild vague pain; purulent is paroxysmal distension and severe pain; gangrenous is continuous severe abdominal pain; perforated appendicitis can temporarily reduce abdominal pain because of the sudden decrease of pressure in the appendiceal lumen, but after the appearance of peritonitis, the abdominal pain will continue to increase.
(2) Gastrointestinal symptoms: nausea and vomiting are most common. Early vomiting is mostly reflexive and often occurs at the peak of abdominal pain, while late vomiting is associated with peritonitis. About 1/3 of patients have symptoms of constipation or diarrhea, and the increased number of stools in the early stage of abdominal pain may be the result of increased bowel movements. In pelvic-site appendicitis, inflammation irritates the rectum and bladder, causing shortness of bowel movements and painful urination. Complicated peritonitis and intestinal paralysis result in abdominal distension and persistent vomiting.
(3) Systemic symptoms: Initially, there is weakness and headache. When the inflammation is aggravated, there may be fever and other systemic symptoms of toxicity, and the body temperature is mostly between 37.5-39℃. In septic or gangrenous appendicitis or peritonitis, chills and hyperthermia may occur, with body temperature up to 39℃-40℃ or more. Jaundice may be present in portal phlebitis.
Physical signs.
(1) Forced posture: Patients commonly walk bent over when they come to the clinic, and often press their hands on the right lower abdomen. When lying flat in bed, the right hip is often in a flexed position.
(2) Right lower abdominal pressure pain: It is a common and important sign of acute appendicitis, and the pressure pain point is usually at the McDonald’s point, which may change with the variation of the appendix position, but the pressure pain point is always in a fixed position. When the abdominal pain has not yet shifted to the right lower abdomen in the early stage of the lesion, the pressure pain has been fixed in the right lower abdomen. When the inflammation spreads beyond the appendix, the range of pressure pain also expands, but the pressure pain is still most obvious in the appendix.
(3) Signs of peritoneal irritation: there are abdominal muscle tension, rebound pain (Blumberg’s sign) and diminished or absent bowel sounds, etc. This is a defensive response to inflammatory stimulation of the mural peritoneum and often indicates that appendicitis has progressed to the stage of suppuration, gangrene or perforation. However, the signs of peritoneal irritation may not be obvious in children, the elderly, pregnant women, obese or weak patients or in posterior appendicitis of the appendix.
(4) Other signs.
① Colonic inflation test (Rovsing test): if the left lower abdomen descending colon is pressed with one hand, and then the proximal colon is repeatedly pressed with the other hand, the pneumoperitoneum in the colon can be transmitted to the cecum and appendix, causing pain in the right lower abdomen, it is positive.
②Lumbar major muscle test: after lying on the left side, the right lower limb is stretched backward, and the right lower abdominal pain is positive, indicating that the appendix is deeper or in the posterior position of the cecum near the lumbar major muscle.
③Intra-ocular muscle test: in supine position, flex the right hip and right knee at 90°, and rotate the right femur inward, which is positive if it causes right lower abdominal pain, suggesting that the appendix is in a lower position and close to the intra-ocular muscle.
④ Rectal palpation: When the appendix is located in the pelvis or the inflammation has spread to the pelvis, rectal palpation has tenderness in the right front of the rectum. If pelvic abscess occurs, a painful mass can be palpated.
(5) Abdominal mass: When a periappendiceal abscess is formed, a painful mass with tenderness can be palpated in the right lower abdomen.
(6) Skin sensory hypersensitivity: In the early stage (especially when there is obstruction in the appendiceal cavity), skin sensory hypersensitivity in the right lower abdomen may appear, and the range is equivalent to the innervation zone of the 10th to 12th thoracic medullary segment, which is located in the triangle formed by the highest point of the right iliac crest, the right pubic crest and the umbilicus, also called Sherren’s triangle, which does not change depending on the location of the appendix. If the appendix is gangrenous and perforated, the skin sensory allergy in this triangle disappears.
4.How to diagnose acute appendicitis? What diseases need to be differentiated from?
(1) Symptoms: metastatic right lower abdominal pain is a typical clinical manifestation of acute appendicitis. When metastatic left lower abdominal pain occurs due to visceral transposition of the appendix and appendix located in the left lower abdomen, the possibility of left appendicitis should also be considered. Regarding the site of the initial pain and the time required for the metastatic process, it varies from person to person. However, it should be noted that about 1/3 of patients start with right lower abdominal pain, especially in acute attacks of chronic appendicitis, so the absence of metastatic right lower abdominal pain cannot completely exclude the presence of acute appendicitis and must be judged in combination with other symptoms and signs.
Other gastrointestinal symptoms such as nausea and vomiting may be present. In the early stage, there may be no fever, but when the appendix is septic, necrotic or perforated, there will be obvious fever and other symptoms of systemic toxicity.
(2) Physical examination: fixed pressure pain in the right lower abdomen and different degrees of peritoneal irritation signs are its main signs, especially when the spontaneous abdominal pain is not yet fixed in the early stage of acute appendicitis, pressure pain exists in the right lower abdomen. In the case of appendiceal perforation combined with diffuse peritonitis, despite the wide range of abdominal pressure pain, it is still most obvious in the right lower abdomen. Sometimes the whole abdomen should be carefully examined several times and in a contrasting manner in order to grasp the exact location of the pressure pain. In acute appendicitis, the pressure pain is always in the right lower abdomen and may be accompanied by varying degrees of abdominal muscle tension and rebound pain.
(3) Ancillary tests: blood total leukocyte count and neutrophil count may be mildly or moderately increased, and stool and urine routine may be essentially normal. Chest fluoroscopy can exclude right-sided chest disease and reduce misdiagnosis of appendicitis. A standing abdominal plain film to observe the presence of free gas under the diaphragm can rule out the presence of other surgical emergencies. Ultrasound examination of the right lower abdomen for the presence of inflammatory masses can be helpful in determining the course of the disease and deciding on surgery.
(4) Young women and married women with a history of menopause should have a gynecologic consultation to rule out ectopic pregnancy and ovarian follicular rupture when there is doubt about the diagnosis of acute appendicitis.
The following tests are often required in the diagnosis of acute appendicitis.
(1) Routine blood tests: Most patients with acute appendicitis have an increased white blood cell count and neutrophil ratio, and if the inflammation has invaded the abdominal cavity, the white blood cell count often rises above 18×109/L; however, an increase is not obvious enough to negate the diagnosis, and should be repeatedly checked, and if it gradually rises, it has diagnostic value.
(2) Routine urine examination: urine examination generally has no positive findings, but posterior appendicitis of the appendix can stimulate the adjacent right ureter, and a small amount of red blood cells and white blood cells can appear in the urine.
(3) Routine stool examination: In pelvic appendicitis and perforated appendicitis combined with pelvic abscess, blood cells can also be found in the stool.
(4) X-ray examination: thoracoabdominal fluoroscopy is listed as routine. Acute appendicitis may also show positive findings on abdominal plain films: a stone or several stone shadows may be seen in the right lower abdominal appendix in about 5-6% of patients, and gas accumulation in the appendix cavity in 1.4% of patients. In acute appendicitis combined with diffuse peritonitis, standing abdominal plain film is necessary to exclude ulcer perforation and acute strangulated intestinal obstruction, etc. If there is free gas under the diaphragm, appendicitis can be basically excluded.
(5) Ultrasound examination of the abdomen: in case of longer duration of disease, an ultrasound examination of the right lower abdomen is urgently performed to understand the presence of inflammatory masses. When deciding to cut and drain an appendiceal abscess, ultrasound can provide the specific site, depth and size of the abscess to facilitate the selection of an incision.
The clinical misdiagnosis rate of acute appendicitis is quite high, ranging from 4%-5% in China to 30% in some foreign countries. There are many diseases that need to be differentiated from acute appendicitis, the most important of which are the following dozen diseases.
(A) Differentiation from acute abdominal diseases of internal medicine.
(1) Right lower pneumonia and pleurisy: inflammatory lesions in the right lower lung and thorax can reflexively cause right lower abdominal pain, which can sometimes be misdiagnosed as acute appendicitis. However, pneumonia and pleurisy often have obvious respiratory symptoms such as cough, sputum and chest pain, and chest signs such as altered breath sounds and wet rales. Abdominal signs are not obvious, and right lower abdominal pressure pain is mostly absent. Chest X-ray, which can make a clear diagnosis.
(2) Acute mesenteric lymphadenitis: Most often seen in children, often secondary to upper respiratory tract infection. Because of the extensive enlargement of the small intestinal mesenteric lymph nodes, which is especially obvious in the ileocecal uncinate, the clinical manifestation may be right lower abdominal pain and pressure pain, similar to acute appendicitis. However, unlike acute appendicitis, it is often accompanied by high fever, and the abdominal pain and pressure are more widespread and irregular, and sometimes enlarged lymph nodes can be palpated.
(3) Restricted ileitis: the lesion mainly occurs at the end of the ileum and is a non-specific inflammatory disease, more common in young people aged 20-30. In the acute phase of limited ileitis, the intestinal canal at the lesion is congested, edematous and oozing, which stimulates the peritoneum of the right lower abdominal wall layer and causes abdominal pain and pressure pain, similar to acute appendicitis. However, the location is limited to the ileum and is not characterized by metastatic abdominal pain, and the abdominal signs are more extensive, and sometimes the enlarged intestinal canal can be palpated. In addition, the patient may have diarrhea, and stool examination has obvious abnormal components.
(B) Differentiation from obstetrical and gynecological emergencies.
(1) Right-sided tubal pregnancy: After rupture of right-sided ectopic pregnancy, intra-abdominal bleeding stimulates the peritoneum of the right lower abdominal wall layer, and clinical features similar to those of acute appendicitis may appear. However, ectopic pregnancy often has a history of menopause and early pregnancy and may be preceded by vaginal bleeding. The patient has perineal and anal swelling following abdominal pain, along with internal bleeding and hemorrhagic shock. Gynecologic examination shows positive signs such as blood in the vagina, slightly enlarged uterus with tenderness, enlarged right adnexa and blood in the posterior fornix puncture.
(2) Ovarian cyst torsion: After torsion of the right ovarian cyst tip, cyst circulation is impaired, necrosis, and hemorrhagic exudation, causing inflammation of the right abdomen, similar to appendicitis. However, what distinguishes it from acute appendicitis is that there is often a history of pelvic mass, and the onset is sudden, with paroxysmal colic, which may be accompanied by mild shock symptoms. During gynecological examination, a cystic mass can be palpated with tenderness, and abdominal ultrasound confirms the presence of a cystic mass in the right lower abdomen.
(3) Ovarian follicular rupture: It occurs mostly in unmarried young women, often with onset two weeks after menstruation, due to intra-abdominal bleeding, causing right lower abdominal pain. It is distinguished from acute appendicitis by milder local signs in the right lower abdomen, and diagnostic laparotomy may draw out bloody exudate.
(4) Acute adnexitis: Acute inflammation of the right fallopian tube can cause symptoms and signs similar to those of acute appendicitis. However, tubal inflammation mostly occurs in married women with a history of excessive leukorrhea, and the onset is mostly before the onset of menstruation. Although there is right lower abdominal pain, it is not typically metastatic and the abdominal pressure is low, almost near the pubic bone. Gynecologic examination reveals purulent vaginal discharge, marked tenderness on both sides of the uterus, and a tenderness swelling in the right adnexa.
(C) Differentiation from surgical acute abdomen.
(1) Acute perforation of ulcer disease: After perforation of ulcer disease occurs, part of the gastric contents flows into the right iliac fossa along the right paracolic sulcus, causing acute inflammation of the right lower abdomen, which can be mistaken for acute appendicitis. However, acute perforation of ulcer disease mostly has a history of chronic ulcer disease, and before the onset of the disease, there are many triggers of overeating and drinking, and the onset of abdominal pain is sudden and severe. On examination, the abdominal wall was seen to be plate-like, and the signs of peritoneal irritation were most obvious under the fenestra. On abdominal fluoroscopy, free gas can be seen under the diaphragm, and diagnostic laparotomy can extract upper gastrointestinal fluid.
(2) Acute cholecystitis and cholelithiasis: acute cholecystitis sometimes needs to be differentiated from high-grade appendicitis, the former often has a history of biliary colic attacks with right shoulder and back discharge pain; while the latter is characterized by metastatic abdominal pain. On examination, acute cholecystitis may show positive Morphy’s sign and even palpable enlarged gallbladder, and emergency abdominal ultrasonography may show enlarged gallbladder and stone sound shadow.
(3) Acute Meckel’s diverticulitis: Meckel’s diverticulum is a congenital malformation, mainly located at the end of the ileum, and its location is very close to the appendix. When acute inflammation occurs in the diverticulum, the clinical symptoms are very similar to those of acute appendicitis, and it is difficult to distinguish them before surgery. Therefore, when the clinical diagnosis of appendicitis is made and the appendix is basically normal in appearance during surgery, the terminal ileum should be carefully examined to 1 m so that the inflamed diverticulum is not missed.
(4) Right ureteral stone: Ureteral stone can cause right lower abdominal pain when it moves downward, and sometimes it can be confused with appendicitis. However, the ureteral stone attacks with severe colic, which is unbearable, and the pain dissipates along the ureter to the vulva and inner thighs. On abdominal examination, pressure pain and muscle tension in the right lower abdomen are not too obvious, and abdominal plain film can sometimes reveal positive urinary stones, while urine routine has a large number of red blood cells.
Tips: From the above we can see that although acute appendicitis is a common and frequent disease, its diagnosis is not as simple as many people think, so when the patient’s symptoms and signs are not typical, the doctor will let the patient do some additional tests other than routine examinations, such as electrocardiogram, chest X-ray and gynecological consultation for women of childbearing age, etc. The patient and the family members accompanying the patient to the clinic should actively cooperate. Do not lose your patience because of the inconvenience of abdominal pain, and do not be upset or even suspicious, which is actually a sign of the doctor’s responsibility to the patient. If there is really a misdiagnosis and misdiagnosis, patients and their families should be more understanding, because the diagnosis of acute appendicitis is really difficult in some cases.
5.What are the treatment measures for acute appendicitis?
(i) Non-surgical treatment.
It is mainly indicated for simple appendicitis, appendiceal abscess, appendicitis in early and late pregnancy and appendicitis in advanced age combined with major organ lesions.
(1) Basic treatment: bed rest, diet control, appropriate rehydration and symptomatic treatment.
(2) Antibacterial treatment: broad-spectrum antibiotics (such as ampicillin) and anti-anaerobic drugs (such as methotrexate) can be used for intravenous infusion.
(3) Traditional Chinese medicine treatment.
(B) Surgical treatment.
(1) Surgical principles: After the diagnosis of acute appendicitis is clear, early surgical treatment should be performed, which is both safe and can prevent complications. Early surgery means that the appendix is still in the lumen obstruction or only congested edema when the surgery cut down, at this time the operation is simple. If you operate after suppuration or gangrene, the operation will be difficult and the postoperative complications will increase significantly.
(2) Surgical options: The surgical methods for different clinical types of acute appendicitis are also different.
In acute simple appendicitis, appendectomy is performed and the incision is closed in one stage. In recent years, trans-laparoscopic appendectomy has been carried out for this type, but skilled techniques must be mastered.
②Acute purulent or gangrenous appendicitis, appendectomy is performed; if there is pus in the abdominal cavity, the peritoneum can be closed after removing the pus, and latex sheets are placed in the incision for drainage.
If the abscess around the appendix has no tendency to be confined, perform incision and drainage and decide whether the appendix can be removed depending on the specific situation during surgery; if the appendix has been detached, try to remove it and close the cecum wall to prevent intestinal fistula. If the abscess has been confined to the right lower abdomen and the condition is stable, do not force appendectomy, give antibiotics and strengthen systemic support therapy to promote pus absorption and abscess remission.
(3) Surgical methods.
①Anesthesia: epidural anesthesia is generally used.
(2) Incision: It is advisable to choose the site with the most obvious pressure pain in the right lower abdomen, and generally a right lower abdominal oblique incision (McBurney incision) or a right lower abdominal transverse oblique incision is used. The skin is incised in the direction of the dermatome, which causes less damage to blood vessels and nerves. This oblique incision, because the fibers of the three layers of the abdominal wall muscles are oriented differently, the incision heals firmly after surgery and incisional hernia is less likely to occur. However, because this incision is inconvenient for exploring other parts of the abdominal cavity, it is appropriate to use the right lower rectus parabasalis incision for exploratory surgery with unknown diagnosis, and the incision should not be too small.
③Search for appendix: push the small intestine to the inner side with gauze pad, find the cecum first, and then trace along the three colonic bands to the top of the cecum, that is, the appendix can be found. If it is still not found, the possibility of posterior appendix of the cecum should be considered, and then the lateral retroperitoneum should be cut open and the cecum should be turned inward to search for the appendix. After the appendix is found, the appendix should be removed outside the incision by clamping the appendix with an appendiceal clamp or by clamping the appendiceal ligament with a hemostatic clamp. If it cannot be raised, the appendix should also be removed after strictly protecting all layers of the incisional tissue.
The appendiceal artery is usually located at the free edge of the appendiceal mesentery, and it is easy to be clamped when the infection and inflammation increase. If the thylakoid is broad and thick, the thylakoid should be cut and ligated section by section.
⑤ Treatment of the appendiceal root: The appendiceal root at 0.5 cm from the cecum is gently clamped and ligated with silk thread, and the appendix is cut off at the far end of the ligature, and the stump is treated with iodine and alcohol, and then buried in the wall of the cecum with a purse suture. The sutures should not be too large to prevent residual dead space in the intestinal wall. Finally, the appendix is reinforced by covering with appendiceal lining or adjacent fatty connective tissue.
Appendicectomy
(6) Appendectomy in special cases.
A. The appendix is behind the peritoneum and fixed with adhesions, so it cannot be removed reluctantly according to the conventional method, but it is advisable to perform retrograde resection method, that is, the appendix is cut at the root first, and then the appendiceal tract is cut in sections after the stump is buried, and the whole appendix is removed.
B. If the inflammatory edema of the appendix wall is serious and the appendiceal stump cannot be buried in the purse suture according to the conventional method, the appendix can be cut off at the root of the appendix and the appendiceal stump can be buried with interrupted silk sutures in the plasma muscle layer. If burial is still not possible, the stump can be covered with the appendiceal tract or nearby fatty connective tissue.
C. If the appendiceal edema is very heavy, fragile and easy to tear, and the root cannot be clamped and ligated, a purse-string suture of the cecum wall can be used to bury the unligated appendiceal stump in the cecum cavity, plus an interrupted filament pulpy muscle layer inversion suture.
6.What are the complications of acute appendicitis?
(A) Complications of acute appendicitis.
(1) Abdominal abscess: the abscess formed around the appendix is a periappendiceal abscess. However, abscesses can also be formed in other parts of the abdominal cavity, and common sites include the pelvis, subdiaphragm and intestinal space. The clinical manifestations include abdominal distension as in paralytic intestinal obstruction, signs of peritoneal irritation, painful masses and systemic symptoms of infection and toxicity, etc. B-mode ultrasonography can assist in diagnosis and localization. Once the diagnosis is made, surgical incision and drainage should be performed promptly.
(2) Internal and external fistula formation: If the periappendiceal abscess is not drained in time, in some cases the abscess may penetrate into the small intestine or large intestine, and also into the bladder, vagina or abdominal wall, forming various internal or external fistulas; pus can be drained from the fistula; barium X-ray examination can help to understand the course and scope of the fistula, and help to choose the treatment method of expanding drainage or removing the fistula.
(3) Portal phlebitis (pylephlebitis): Infectious thrombus in the appendiceal vein during acute appendicitis, along the superior mesenteric vein to the portal vein, leading to portal vein inflammation. Clinical manifestations include hepatomegaly and pressure pain, jaundice, chills, and high fever. Infectious shock and sepsis can develop if the condition worsens, and bacterial liver abscess can develop with delayed treatment.
(B) Complications of appendectomy.
(1) Incisional infection: It is the most common postoperative complication, with an incidence of less than 10% in the non-perforated group and up to 20% or more in the perforated group. It is mostly caused by contamination of the incision during surgery, retention of hematoma and foreign body, and poor drainage. The site of infection can be subcutaneous or extraperitoneal. The clinical manifestations are an increase in temperature 2 to 3 days after surgery, localized swelling or throbbing pain in the incision, and localized redness, swelling, and pressure pain. Treatment is to cut the sutures, enlarge the incision, drain the pus, remove the foreign body and drain it adequately.
(2) Peritonitis and abdominal abscess: mostly caused by poorly ligated appendiceal stump and dislodged sutures. The clinical manifestations are persistent elevation of body temperature, abdominal pain, abdominal distension and increased systemic toxic symptoms after surgery. It needs to be treated according to the principles of treating peritonitis.
(3) Bleeding: Loosening of the ligature of the appendiceal tract can cause intra-abdominal hemorrhage, manifested by abdominal pain, abdominal distension, hemorrhagic shock and other symptoms. If the ligature of the appendiceal stump is loosened and the purse-string is tight, the bleeding can flow into the intestinal canal of the cecum, causing hemorrhage in the lower gastrointestinal tract. Both cases require immediate blood and fluid transfusion and urgent reoperation to stop bleeding.
(4) Fecal fistula: There are various reasons for postoperative fistula, such as fragility of the severed end, detachment of the ligature; injury to the cecum wall; lesions of the cecum such as tuberculosis and cancer; hard drainage material, compression of the cecum wall causing necrosis, etc. The inflammation is usually confined when the fistula is formed, so that diffuse peritonitis does not occur. The fistulas formed are located in the colon and do not cause water and electrolyte disturbances or nutritional disorders. The fistula is usually closed after non-surgical supportive treatment and heals spontaneously. If the fistula does not heal over time, biopsy of the fistula and X-ray fistulography are feasible to identify the nature and extent of the lesion and to facilitate reoperation to remove the fistula.
(5) Appendiceal stump inflammation: when the appendix is removed, if the stump is too long more than 1 cm, the stump is prone to recurring inflammation after surgery and will still show symptoms of appendicitis, further barium x-ray should be performed to clarify the diagnosis. In case of severe symptoms, it is advisable to remove the appendiceal stump by surgery again.
(6) Adhesive intestinal obstruction: Due to factors such as surgical injury or periappendiceal pus, adhesive intestinal obstruction occurs in some patients after surgery, especially after complication of perforation with an incidence of about 5%. Most of them can be treated effectively by non-surgical treatment, and those with serious conditions must be treated surgically.
7.What are the characteristics of acute appendicitis in the elderly?
The incidence of acute appendicitis in the elderly is increasing with the progress of the aging of our population. According to the Tianjin General Hospital, it is estimated that patients over 60 years old account for about 3% to 4% of all acute appendicitis. The mortality rate also increases with age and is 5% to 20%. Sometimes the symptoms of acute appendicitis in the elderly are often not prominent at the onset, and abdominal pain can occur gradually and less severely. Therefore, the typical history of nausea, vomiting and metastatic right lower abdominal pain is sometimes lacking, and even fever is not obvious, so that the diagnosis is often late and mistreatment often occurs. If the appendix perforation can be limited to form a mass, the outcome is generally good, but if perforation forms peritonitis or even intestinal paralysis or toxic symptoms, it means that the inflammation is more severe and the condition is dangerous, and the outcome is often worse.
Roughly speaking, acute appendicitis in the elderly has the following characteristics.
(1) degenerative changes in the blood vessels and lymphatic vessels of the elderly, thinning of the appendicular mucosa, fatty infiltration and fibrosis of the appendicular tissues, coupled with vascular sclerosis and a relative decrease in blood supply to the tissues. Therefore, the appendix is prone to necrosis and perforation after inflammation.
(2) In the elderly, abdominal muscle atrophy is less responsive, and the signs and symptoms are not consistent with the pathological changes. The signs and symptoms are often milder than the pathological changes. The abdominal pain is less intense and atypical. Because of the dull response to pain, the presentation may be only abdominal distension and nausea, and differential diagnosis sometimes occurs with difficulty and is easily misdiagnosed. Acute appendicitis in the elderly is often diagnosed late, and most of them are gangrenous and perforated or have formed abscesses by the time they are seen.
(3) Elderly people are often combined with pathological changes or underlying diseases of other important organs, and these diseases are often the cause of death.
8.How are intestinal roundworms transmitted?
Ascariasis is the most common intestinal parasitic disease. The source of infection is the patient with ascariasis and the infected person. A large number of eggs are excreted with the patient’s feces, contaminating vegetables and soil, and develop into mature eggs after about 2 weeks under suitable temperature and humidity. Most of the mature eggs are killed by stomach acid and a few enter the small intestine to hatch and develop into larvae. The larvae burrow into the intestinal mucosa and enter the portal vein, liver, and inferior vena cava via the lymphatic vessels or microvessels and reach the lungs; they shed their skin in the lungs and form larvae about 1 mm in size. The larvae pass through the microvessels and rise to the pharynx through alveoli, bronchi and trachea, and then are swallowed into the stomach, which constitutes ascaris larvae migration. Ascaris larvae develop into adult worms after reaching the small intestine. It takes about 75 days from the swallowing of eggs to the maturity of adult worms, and the survival period in the small intestine is about 1-2 years.
9.What are the manifestations of intestinal roundworms?
A few roundworms in the small intestine can be asymptomatic when infected, called roundworm infected, and a large number of infections cause diseases called ascariasis.
Intestinal roundworms often cause recurrent epigastric or periumbilical abdominal pain. Due to the mechanical stimulation of the worm and its secreted toxic substances and metabolites can cause digestive tract dysfunction and heterogeneous protein reaction, such as poor nausea, vomiting, diarrhea and urticaria. In children with severe infection, it can cause malnutrition, mental disturbance, insomnia, teeth grinding and night terrors.
Intestinal roundworms are generally in a quiet state, but after being subjected to various stimuli (such as high fever, indigestion, improper deworming, etc.), they are prone to stirring and drilling, which can cause serious complications, the common ones being.
(a) Biliary ascariasis: caused by roundworms burrowing into the bile duct, manifesting as sudden paroxysmal colic or drilling pain under the raphe, which can radiate to the back and right shoulder, hard to bear and extremely restless. It is often accompanied by nausea and vomiting. The abdominal wall is soft with only mild spasms of the abdominal wall during painful episodes and obvious limited pressure pain under the fenestra. When the roundworm entering the bile duct recedes to the small intestine, the symptoms suddenly disappear. If the roundworm enters the bile duct or intrahepatic bile duct, it can cause acute purulent cholecystitis, cholangitis or acute hemorrhagic necrotizing pancreatitis secondary to bacterial infection; when it penetrates into the intrahepatic bile duct, it can produce bacterial liver abscess. When roundworm residue or roundworm eggs stay in the bile duct or gallbladder for a long time, they can be the core and gradually form gallstones.
(B) Ascaris lumbricoides intestinal obstruction: It is mostly seen in children. As the number of worms is large, they twist and form a mass to block the intestinal cavity, causing partial intestinal obstruction. Patients have paroxysmal abdominal pain, nausea, vomiting, soft abdominal wall, and thick hemp rope-like masses of different sizes can be found. If not treated in time, it can develop into complete intestinal obstruction.
(C) other typhoid or a few patients with gastric and duodenal ulcer disease infected with roundworms, the roundworms can penetrate the gastrointestinal wall of the lesion causing perforation and producing diffuse peritonitis. When the roundworm is retrograde upward, it can be discharged from the nostril or mouth, or burrowed into the eustachian tube and cause perforation of the eardrum, and discharge the worm from the external ear canal. Occasionally, roundworms may reach the larynx or trachea, causing asphyxia.
Its diagnosis relies on direct smear of stool to check whether there are roundworm eggs or even adult worms.
10.How to treat intestinal roundworms?
Direct anthelmintic treatment includes.
(a) benzimidazole compounds It is a broad-spectrum anthelmintic, which can kill roundworms and hookworms. The mechanism of killing is that the drug selectively and irreversibly inhibits the uptake of glucose by the worms, causing the endogenous glycogen depletion of the worms and inhibiting the reductase of yohimbe and impeding the production of adenosine triphosphate, which makes the worms unable to survive and reproduce and eventually die. The commonly used drugs are.
(1) Mebendazole (Mebendazole): the dosage for children is 50-150mg per day, and for adults, 100mg per time, once in the morning and once in the evening, for 3 days; if not driven out, a second course of treatment can be used after three weeks. This drug has a better effect in driving away roundworms, and side effects are rare. When a large number of infections are driven away with this drug, there can be abdominal pain and diarrhea, but they are mild.
(2) Prothiimidazole (Albendazole): the trade name of intestinal wormer, is a new broad-spectrum anthelmintic. The dose is 400mg, swallowed once. The efficacy is over 90%. However, in large-scale treatment, the reaction of oral vomiting roundworms occasionally occurred.
(3) levamisole: the dosage is 150mg, once taken, this drug is not as effective as mebendazole to drive roundworms, but better than piperazine, side effects are mild, occasionally nausea, vomiting, loss of appetite, etc., a few patients after taking the drug appeared mild impairment of liver function. It should be used with caution in early pregnancy, liver and kidney diseases.
(4) Thiabendazole: 25mg per kg of body weight for adults, once in the morning and once in the evening, for 3 days, daily dosage should not exceed 3g.
(B) thiabendazole (Pyrantel) (trade name anthelmintic, anthelmintic): is a broad-spectrum anthelmintic, can make the roundworm muscle violently contracted, causing spastic paralysis. The dosage is 5-10mg/kg, taken in one evening dose. The side effects include headache, dizziness, vomiting, etc. The administration should be suspended for pregnant women, acute hepatitis, nephritis, serious heart disease and fever patients.
(C) Ascaris lumbricoides (piperazine citrate): 3-4g per time for adults, 150mg per kg body weight per day for children (the maximum amount should not exceed 3g) at bedtime for 2 days, add laxative for constipation. Side effects are mild, with occasional vertigo, vomiting and headache. This drug has been used less and less.
(D) Bitter Dongpi: The active ingredient is Chuan Dongxin. Experiments have shown that it can paralyze the head of pig roundworm, so it also has a certain effect of driving away roundworms, but when the dosage is large, it has toxic effects. The finished product is Chuan Dong Su tablets, 200-250mg for adults, taken on an empty stomach.
(E) Other: Oxygen deworming and acupuncture deworming have been reported, sometimes with unexpected effects.
Treatment for complications of ascariasis includes.
(i) Biliary ascariasis.
① Atropine, chlorpromazine or dulcolax for antispasmodic analgesia;
(2) Deworming treatment after the abdominal pain is relieved;
③ timely use of penicillin, streptomycin and other antibiotics to control biliary tract infection.
(B) Ascaris lumbricoides intestinal obstruction: incomplete intestinal obstruction is first treated with internal medicine including sedation, antispasmodic, analgesic and gastrointestinal decompression, and then deworming after the abdominal pain is relieved. Taking 80-150ml of soybean oil or peanut oil (60ml for children) can loosen the roundworm mass and relieve the symptoms, and then deworming 1-2 days after the symptoms disappear. Oxygen therapy can also loosen roundworms, and in case of complete obstruction, surgical treatment should be performed.