Appendectomy is probably a procedure that trainee surgeons would dare to try, but this procedure, which is considered simple, may have a legend in every hospital that is not.
Before we talk about appendicitis, let’s talk about the “appendix” of appendicitis.
Above: The various rotations of the developing intestinal canal during embryonic life
I used this picture when I was talking about Meckel’s diverticulum. Embryology is the eternal portal to pediatric surgical diseases. Normally, at 12 weeks of embryonic life, the appendix rotates with the cecum to the lower right abdomen. This is also the final position of the appendix in the vast majority of people.
Above: Mac’s point, the outer and middle third of the line connecting the umbilicus to the right anterior superior iliac crest.
Mac’s point, which is the location of the body projection of the appendix in the vast majority of people.
Above: The location of the appendix
However, the appendix is not always located in the lower right abdomen. Individuals may have the appendix in the upper right abdomen, the pelvis, or even the left abdomen due to abnormal rotation of the intestinal canal. Even if the appendix is in the lower right abdomen, its position is variable (see above).
The variability in the location of the appendix, which does not follow the rules, determines the difficulty of diagnosing appendicitis in some people and the difficulty of finding the appendix intraoperatively. This is why the pressure point is far more important than the McLean point.
Above: anatomy of the ileocecal region, note that the appearance of the small intestine is different from that of the large intestine
The human large intestine and small intestine can still be distinguished by their appearance. The small intestine is smoother, while the colon has three characteristic markings on it: the colonic band, the colonic pouch and the intestinal fat pendant. The appendix is always at the confluence of the three colonic bands. I don’t know if the word “appendix” in appendix refers to the colonic band, but I do know that finding the colon and following the colonic band is the most reliable way to find the appendix during surgery.
Above: The anatomy of the ileocecal region, the location of the cecum and appendix
The above diagram shows that the appendix and the cecum are not the same thing, and appendicitis should not be called appendicitis; it is the appendix, not the cecum, that needs to be removed in appendicitis. The appendix and appendix are just a blind end and dead end on the main path of the digestive tract. The feces from the intestine runs into the appendix and has to be squeezed back into the main path. If a small piece of stool gets into the appendix and can’t get out, a fecal stone may form in the appendix. This can lead to appendicitis when the stool blocks the appendix cavity.
Above: The arterial blood supply to the appendix
The appendiceal artery is a branch from the ileocolic artery and is a terminal artery. What is the significance of the terminal artery? If there is a problem with the blood supply to the appendiceal artery, the appendix is susceptible to necrosis. In appendicitis, the inflammation of the appendix swells to such a degree that the blood supply to the artery decreases, and bacterial inflammation combined with appendiceal necrosis is called gangrene, and gangrenous appendicitis is easily perforated.
Above: Appendiceal venous reflux
Blood from the appendix passes through the appendiceal vein – the ileocolic vein – and enters the liver via the portal vein. It should not be difficult to understand if I say that in appendicitis, bacteria in the appendix may enter the portal vein and the liver through this route and may cause portal phlebitis and liver abscess. Thanks to advances in surgery and pharmacology, these complications are now almost invisible.
Above: Nerves of the appendix
The appendix, like other intestinal tubes, is a visceral organ and is innervated by visceral nerves. Normally, the brain does not need to know how to contract or secrete, and the brain, the command, does not care about these idle matters, but if there is something wrong with the operation of the internal organs somewhere, it should be reported to the brain for attention.
Inflammation of the appendix mostly starts from the inside, stimulating the visceral nerves to produce pain and send it to the brain to know, but the visceral nerve localization is often very inaccurate, the brain can generally feel the pain is in the abdomen, subjectively it will think it is the upper abdomen or around the umbilicus, will produce a feeling of nausea and may have vomiting. Later, as the inflammation of the appendix progresses, it spreads to the outer wall of the peritoneum, which has the endings of the somatic nerve. The characteristic of the somatic nerve is its precise localization, so that later the brain can clearly determine that the pain is coming from the appendix in the right lower abdomen.
The classic appendicitis attack is the one that starts with pain in the upper abdomen or around the umbilicus, and then (maybe for a few hours) the pain appears in the right lower abdomen and stays there, while the pain in the upper abdomen or around the umbilicus does not hurt much. This is what the textbooks call “metastatic right lower abdominal pain”.
Above: Metastatic right lower abdominal pain
In the early stages of appendicitis, a careful physical examination with pressure will also help to localize the true location of the pain. It is not at all surprising that in the early stages of appendicitis epigastric or periumbilical pain is likely to be thought of as gastroenteritis, so it is a dynamic process to see a doctor and wait until the right lower abdominal pain is thought of as appendicitis.
Does the appendix work or not? I don’t know. One theory is that the appendix is a lymphatic immune organ because there are many lymphatic follicles in the appendix. One theory is that the appendix is the place where the intestinal strains are kept, and that there are many bacteria that grow in the appendix and intestine that we cannot live without. This is also the source of bacteria in case of appendicitis.
Is the appendix useful or not? As someone who has had my appendix removed, I don’t feel any difference at all between when I have an appendix and when I don’t have one, at least not on the scale. I am still a firm believer that I was born with an appendix, so prophylactic appendectomy is almost always unnecessary. Pediatric surgery only removes the appendix prophylactically when there is poor bowel rotation because the appendix is in an abnormal position and it can be extremely difficult to diagnose appendicitis in the future, so cutting it can prevent future problems.
Okay, here is the “inflammation” of appendicitis.
Appendicitis can occur at any age, as long as the appendix is still present. Adolescents are at the peak of the disease, probably because they are also the most powerful lymphatic organs in the body, and the proliferation of lymphatic follicles in the appendix causes the appendiceal cavity to be relatively small.
What is “inflammation”? Inflammation is nothing but “redness”, “swelling”, “heat” and “pain”.
Above: Appendiceal stone, appendicitis
Why does the appendix become inflamed?
Two main causes: blockage of the appendiceal cavity, which can be fecal stones, food debris, roundworms, or problems with the appendix than itself, such as lymphatic follicular hyperplasia in young people, or problems outside the appendix, compression, twisting, folding, etc. Bacterial invasion, often gram-negative bacilli and anaerobic bacteria that originally live in the appendix. Sometimes appendicitis, which is not seen for months, can be encountered in a few on a given day, and perhaps there is the effect of the weather. Perhaps there is also a relationship between the body’s reduced resistance to the bacteria.
Top: pathological manifestation of appendicitis, bottom: edema and inflammatory cell infiltration are evident
Under certain conditions, bacteria invade the appendiceal mucosa, causing a progression of submucosal inflammation, the appendix becomes congested and swollen (simple appendicitis), as the inflammation increases, more leukocytes gather in the appendix to fight with bacteria (cellulitis or called suppurative appendicitis), the swelling of the appendix makes it difficult for blood to enter the appendix, the bacteria cause more serious damage, making the structural destruction of the appendiceal wall severe (gangrenous appendicitis ), and eventually the pus in the appendix will perforate at the weakest point (appendiceal perforation), and when the pus enters the abdominal cavity, the greater omentum will try to wrap it and confine the inflammation to the right lower abdomen (appendiceal abscess), and once it is not able to form an effective wrap and the inflammation cannot be confined, it will spread to the abdominal cavity (peritonitis).
This is why appendicitis is a continuous process, from early to late, from mild to severe. The types of simple, purulent, gangrenous and appendiceal abscesses are artificial: in fact there is no such absolute division.
When you have appendicitis, don’t hesitate too much, cut it early. If you do not stop, you will suffer from its disruption.
Above: Diagnostic points of appendicitis
Having done the above “appendix” and “inflammation” pavement, let’s directly summarize the classic appendicitis diagnostic points.
1. Abdominal pain. It can be the classic metastatic right lower abdominal pain (70%-80% of cases), or it can be the right lower abdominal pain at the beginning.
2, fever. Mostly after abdominal pain, moderate fever is more frequent, and after perforation can also be high fever.
3, vomiting. This is a protective nerve reflex, nausea and vomiting when there is a problem in the gastrointestinal tract, which can prevent you from continuing to fill food in, thus reducing the burden on the intestines.
In accordance with the textbook get sick person, combined with the examination of the point of pressure pain in the wheat, and then a blood test, there are elevated white blood cells and neutrophils, the diagnosis is basically confirmed. It is as simple as that.
If the disease does not start according to the textbook and is delayed, the presentation will be very diverse, with high fever, full abdominal pain, diarrhea, and abdominal distention, which will be difficult to determine. It will be diagnosed as peritonitis, intestinal obstruction, etc., and perhaps the root cause will be found to be appendicitis only when the abdomen is explored by dissection. Fortunately, there are still some auxiliary diagnostic methods, such as ultrasound, such as CT, which can be used when the diagnosis is not clear.
Above: Ultrasound presentation of appendicitis
Above: CT manifestation of appendicitis
Being a pediatric surgeon is not an easy task. Pediatric appendicitis is much more complex than adult appendicitis.
Older children could have been diagnosed as easily as adults with clear articulation, but children are children after all, and may have immature minds. We have encountered older children who deliberately pretend to be relaxed during the doctor’s examination and firmly deny abdominal pain to the doctor because they are afraid of surgery. But the unconscious frown down during right lower abdominal pressure, the painful expression caused by the rebound pain induced when the hand is released, the fever and elevated white blood cells are all things that the child cannot hide.
Although appendicitis in younger children is on the rare side, it is often a quandary when encountered. Especially if they are not yet able to express themselves and only know how to cry. The relatively short large omentum in children often makes it difficult to form effective wraps and limitations even after the appendix is perforated, thus progressing rapidly and severely, so pediatric appendicitis is almost always diagnosed only after perforation, often combined with peritonitis and even life-threatening.
Neonatal appendicitis is even more problematic, as it is almost impossible to diagnose early and can only be noticed due to peritonitis and redness of the scrotum around the umbilicus or inguinal area. In newborns with any disease, there are probably only a few signs of not eating, not drinking, not moving, no increase in temperature (or fever), and no weight gain, so it is almost impossible to see neonatal appendicitis before surgery. Fortunately, neonatal appendicitis is rarer.
So the key is diagnosis, early diagnosis.
For treatment, the principle is to perform appendectomy, either traditional open surgery or more laparoscopic surgery, depending on the experience of the surgeon and the conditions available. If available, laparoscopic surgery should be the first choice.
Above: In traditional open surgery, the incision can be very small, but if the perforated abdominal cavity accumulates pus, such an incision is difficult to cope with.
Above: laparoscopic appendectomy, which has the advantage of finding the appendix and dealing with abdominal pus
Non-surgical conservative treatment, not recommended but can be applied in the following cases.
1, early stage, with mild disease and still under observation
2.Conditions do not allow it, and it cannot be cut even if you want to, such as being in the wilderness, or the patient has other serious diseases.
3, the patient refuses to operate, the child is someone else’s, life is also someone else’s, people do not agree to surgery, the doctor can only respect the choice of others. Sometimes I really don’t understand, there are always some parents who, in the name of love, must drag their children’s appendicitis until it is perforated before they will operate, or when it is no longer appropriate to operate, they think of surgery.
If the diagnosis is delayed, the appendix is perforated and forms an abscess around the appendix, but the package is intact and the inflammation is limited, it is no longer suitable for surgery, so we can only treat it conservatively and wait for three months before removing it. Sometimes, in the course of conservative treatment, the appendiceal abscess ruptures, causing peritonitis and necessitating surgery, but the appendix often cannot be cut, and drainage of the abscess can only be done, and the appendix can be cut later.
In short, appendicitis is a small problem in the early stages, but a delay in diagnosis and treatment can be a big problem.
There are some appendicitis that recur after conservative treatment and get better after anti-infection treatment, called chronic appendicitis. Repeated inflammation will inevitably cause adhesions between the appendix and the surrounding area, hyperplasia of the appendiceal fibrous tissue and inhomogeneity of the appendiceal lumen. In these patients, a narrow and uneven appendiceal lumen will be seen on appendiculogram. Chronic appendicitis affects the quality of life and can also cause acute attacks, and in principle it is recommended to be removed.
Above: Chronic appendicitis with an appendicogram showing an uneven appendiceal lumen
Abdominal pain is a very common symptom in children. In addition to appendicitis, intestinal spasm, gastroenteritis, intestinal obstruction, intussusception, mesenteric lymphadenitis, Meckel’s diverticulitis, intestinal torsion, abdominal allergic purpura, abdominal masses, and ovarian torsion in girls, etc. Some of these diseases require surgery and some do not, so sometimes some tests are necessary and close observation of the course of the disease is also It is also necessary to closely monitor the course of the disease. In many cases, surgical open surgery does not necessarily have to wait for a clear diagnosis, but depends on whether there is an indication for open surgery.