Acute appendicitis is one of the most common diseases in abdominal surgery, and most patients are able to seek timely medical attention and obtain good results. However, sometimes the diagnosis is quite difficult and some serious complications can occur when it is not treated properly. So far, acute appendicitis still has a mortality rate of 0.1-0.5%, so it is still worth paying attention to how to improve the efficacy and reduce misdiagnosis.
I. Morbidity
It is estimated that acute appendicitis will occur in one out of every 1,000 inhabitants every year. According to general hospital statistics, acute appendicitis accounts for about 0.1-15% of all abdominal surgery admissions during the same period, and remains the number one surgical emergency abdomen. Acute appendicitis can occur at any age, from newborn to 80-90 years of age, but it is more common in adolescents, especially in the 20-30 age group, which accounts for 40% of the total.
The incidence of appendicitis is generally higher in males than in females, with a male:female ratio of 2 to 3:1. Statistics show that the incidence is equal in both sexes before puberty and decreases in males after adulthood. The incidence of appendicitis is not related to occupation, region or season.
Pathogenesis
Although acute appendicitis is often manifested as a purulent infection caused by varying degrees of bacterial attack on the appendiceal wall, the pathogenesis is a more complex process.
1, obstruction of the lumen of the appendix.
2, bacterial infection.
3, nerve reflex.
III. Pathological types
Acute appendicitis can be broadly divided into three types pathologically, representing different stages of inflammation development.
1. Acute simple appendicitis: the appendix is mildly swollen and the plasma membrane is congested with a small amount of fibrinous exudate. There may be small ulcers and bleeding spots in the appendiceal mucosa and a small amount of inflammatory exudate in the abdominal cavity. There is edema and neutrophilic leukocyte infiltration in all layers of the appendiceal wall, most notably in the mucosa and submucosa. Inflammation of the organs and tissues surrounding the appendix was not yet evident.
2. Acute purulent (cellulitis) appendicitis: the appendix is significantly swollen and thickened, the plasma membrane is highly congested, and the surface is covered with purulent exudate. The mucosal surface of the appendix is ulcerated and enlarged, pus accumulates in the lumen, and small abscesses are also formed in the wall. There is purulent exudate in the abdominal cavity, and the inflamed appendix is wrapped by the greater omentum and the adjacent intestinal canal, which limits the development of inflammation.
3. Acute perforated (gangrenous) appendicitis: a heavy appendicitis with total or partial total necrosis of the appendiceal wall, with dark red or blackish purple plasma membrane, which may be locally perforated. Most of the perforations are in the distal part of the appendix where blood flow is poor, but they can also be localized in the area directly compressed by fecal stones. At this time, most of the appendiceal mucosa is ulcerated and the pus in the lumen is bloody.
4. Periappendiceal abscess: Acute appendicitis with septic gangrene or perforation, if this process progresses slowly, the greater omentum can move to the right lower abdomen, wrapping the appendix and forming adhesions, forming an inflammatory mass or periappendiceal abscess.
Outcome: It can also be roughly divided into three possibilities
1. Dissipation of inflammation: Simple appendicitis can be dissipated and completely cured by non-surgical treatment, but a few patients can be left with scars and even narrowing of the lumen, which can become the basis for re-occurrence. Some patients with purulent appendicitis can form a local restrictive abscess after conservative treatment, which will be cured by absorption.
2.Limited infection: In purulent appendicitis and perforated appendicitis, the infection can be confined to the periappendiceal area, or appear as a limited inflammatory mass, or form a periappendiceal abscess. Most patients can be completely absorbed after treatment, but there are patients with abscesses that gradually increase in size and even break down, causing serious consequences.
3.Infection spread: When perforation occurs before acute appendicitis is wrapped by the omentum, it can cause diffuse peritonitis, and improper treatment can form residual abscesses in the abdominal cavity such as subphrenic abscesses in light cases, or life-threatening in heavy cases. In rare patients, bacterial emboli may enter the portal vein with blood flow to cause inflammation, and furthermore, abscesses may be formed in the liver, and patients may develop severe sepsis with clinical phenomena such as high fever, jaundice, and hepatomegaly.
IV. Clinical manifestations
Most patients with acute appendicitis, regardless of the pathological type, have similar early clinical symptoms, and there is no difficulty in diagnosis, and most of them can be treated promptly and correctly.
(A) Symptoms.
The main manifestations are abdominal pain, gastrointestinal reactions and systemic reactions.
1, abdominal pain: the main reason for forcing patients with acute appendicitis to seek medical attention immediately early on and abdominal pain, except for a very small number of patients with combined transverse myelitis, all have abdominal pain present.
2, gastrointestinal tract reactions: nausea, vomiting is the most common, early vomiting is mostly reflexive, often occurs at the peak of abdominal pain, vomit is food residue and gastric juice, late vomiting is related to peritonitis. About 1/3 of patients have symptoms of constipation or diarrhea, and the increased frequency of stools in the early stages of abdominal pain may be the result of increased bowel movements. In pelvic appendicitis, direct stimulation of the rectal wall by the tip of the appendix may also be accompanied by an increase in the number of stools, while in pelvic abscesses after appendiceal perforation, not only are there more stools, but there may even be a posteriori urgency.
3. Systemic reaction: In the early stage of acute appendicitis, some patients feel general fatigue, weakness of limbs, or headache and dizziness. In simple appendicitis, the body temperature is mostly between 37.5°C and 38°C. In purulent and perforated appendicitis, the body temperature is higher, up to about 39°C. Very few patients have chills and high fever, and the body temperature can rise to more than 40°C.
(ii) Physical signs.
During the abdominal examination of acute appendicitis, the signs that often appear are abdominal pressure, abdominal muscle tension and rebound pain, etc. These direct signs of inflammation are the main basis for the diagnosis of appendicitis. These direct signs of inflammation are the main basis for the diagnosis of appendicitis. In addition, some indirect signs such as the psoas major muscle sign will be seen in some patients, which can be helpful in determining the location of the inflamed appendix.
1, gait and posture: patients like to take the upper body bent forward and slightly tilted to the affected side of the posture, or the right hand lightly support the right lower abdomen, to reduce the dynamics of the abdominal muscles to reduce abdominal pain, and walking gait is also slow. These characteristics can be found when the patient visits the clinic.
2, abdominal signs: sometimes need continuous observation and multiple comparisons to make a more accurate judgment.
(1) abdominal shape and motility: a few hours after the onset of acute appendicitis, a slight restriction of respiratory movement in the lower abdomen can be found during physical examination, and when perforation is accompanied by diffuse peritonitis, the whole abdominal motility can disappear completely and abdominal distension gradually appears.
(2) Signs of peritoneal irritation: including abdominal pressure pain, muscle tension and rebound pain.
V. Treatment
(a) Treatment principles
1. Acute simple appendicitis: non-surgical treatment combining Chinese and Western medicine can be given first when conditions are favorable, but careful observation is necessary, and the condition should be transferred to surgery in time if it develops. After conservative treatment, there may be narrowing of the appendiceal cavity and a high chance of another acute attack.
2.Septic, perforated appendicitis: in principle, emergency surgery should be performed immediately to remove the pathological appendix, and postoperative anti-infection should be actively pursued to prevent complications.
3.Appendicitis with several days of onset and combined with inflammatory mass: conservative treatment should be performed temporarily to promote the respiration of inflammation as soon as possible, and then consider removing the appendix after 3-6 months if there are still symptoms. If the abscess expands and may break during the conservative period, emergency drainage should be performed.
4.Senior patients, pediatric and pregnancy acute appendicitis: in principle, emergency surgery should be performed as for adult appendicitis.
(II) Non-surgical treatment.
It is mainly indicated for acute simple appendicitis, appendiceal abscess, acute appendicitis in early and late pregnancy, and appendicitis in advanced age combined with major organ lesions.
1, basic treatment: including bed rest, diet control, appropriate rehydration and symptomatic treatment, etc.
2, antibacterial treatment: use broad-spectrum antibacterial agents (such as ampicillin) and anti-anaerobic bacteria (such as methotrexate).
3, acupuncture treatment: take the foot three li and appendix points, strong stimulation, stay acupuncture for 30 minutes, twice a day, for three days.
4.Chinese medicine treatment.
(C) Surgical treatment
It is mainly suitable for all kinds of acute appendicitis, recurrent chronic appendicitis, appendiceal abscess with symptoms even after 3-6 months of conservative and non-surgical treatment is ineffective.
1. Pre-operative preparation: 4-6 hours before surgery, diet should be abstained, appropriate amount of analgesic can be given after determining the operation time, and broad-spectrum antibacterial agent should be given to those who have suppuration and perforation. For those with diffuse peritonitis, gastrointestinal decompression, intravenous fluids, and attention to correction of water and electrolyte disorders should be performed. Those with major organ dysfunction, such as heart and lung, should be treated appropriately with the relevant department office.
2.Surgical method: local anesthesia is the most appropriate way to complete the surgery through the right lower abdominal oblique incision, a few patients can also choose epidural anesthesia and general anesthesia through the right lower abdominal exploratory incision. The main way is appendectomy (with conventional and retrograde methods). Subplasmic resection of the appendix is also feasible in cases of severe adhesions. In a few cases of conservative ineffective appendiceal abscesses, incision and drainage are feasible, and drainage is placed when there is much abdominal exudation.
3.Postoperative treatment: continue supportive treatment, including intravenous fluids, analgesic sedation and anti-infection. Drainage should be removed in a timely manner, the incision should be folded on time, and attention should be paid to the prevention and treatment of various complications.
4.Postoperative complication prevention and control: postoperative complications are closely related to the pathological type of appendix and the time of surgery, the complication rate is only 5% after resection of unperforated appendicitis, but increases to more than 30% for those operated after perforation, and the appendix perforation rate is 20% and 70% for those operated after 24 hours and 48 hours after onset, so the appendix should be removed immediately within 24 hours of onset to reduce the complication rate. The incidence of complications should be reduced by immediate removal of the appendix within 24 hours of onset.