ACUTE APPENDICITIS

Acute nuncomplicated appendicitis. Pecularities of acute appendicitis in children, npregnant woomen and senior people. Acute complicated appendicitis (infiltrate, nabscess, peritonitis, pylephlebitis). Postoperative period. chronic nappendicitis.

 

Acute nappendicitis

 

Acute nappendicitis is an inflammation of vermiform appendix ncaused by festering microflora.

Anyone can get appendicitis, but it nis more common among people 10 to 30 years old. Appendicitis leads to more nemergency abdominal surgeries than any other cause.

 

anatomy

 

 

The ncecum is the first part of the large intestine. It begins caudally from the nileocecal valve and ends blindly in the right iliac fossa. Typically the cecum nis located intraperitoneally in the right lower abdomen and has a length of 5 nto 7 cm. Due to nan incomplete rotation of the umbilical loop during embryogenesis however it nmay lie quite variably. Therefore clinically one differentiates between three nimportant variations: mobile cecum (completely covered by peritoneum), free ncecum (with its own mesocecum) and fixed cecum (secondary retroperitoneal). As nin the colon taeniae, haustra and semilunar folds are found in the cecum but no nappendices epiploicae.

The vermiform appendix is attached dorsomedially to the nend of the cecum where all three taeniae converge. It is 2 to 15 cm long and lies noften intraperitoneally retrocecal (65%) or in the lesser pelvis (30%). The nappendix is attached to the posterior abdominal wall by the mesoappendix. Here ntaeniae, haustra, semilunar folds and appendices epiploicae are all absent.

 

The cecum is supplied by the anterior and posterior cecal narteries and the appendix by the appendicular artery (all branches of the nileocolic artery from the superior mesenteric artery). The venous blood drains nthrough the correspondent veins into the superior mesenteric vein. As the colon both the cecum and appendix are ninnervated by the superior mesenteric plexus whereas the parasympathetic fibers ncome from the vagus nerve (cranial nerve X).

The main tasks of the cecum are the absorption of water and salts nand the lubrication of the feces with mucus. Especially components from nplant-rich food (e.g. cellulose) are bacterially decomposed here. This explains nwhy herbivores have considerably larger ceca in comparison to carnivores.

 The nappendix is part of the GALT (gut-associated lymphatic tissue) and fulfills nimmunological functions. Furthermore it is assumed that it serves as a “safe nhouse” for enterobacteria (e.g. in case of diarrhea). On the picture you casee an inflamed vermiform appendix which was removed operatively.

 

Etiology and npathogenesis

 

Most nfrequent causes of acute appendicitis are festering microbes: intestinal stick, nstreptococcus, staphylococcus. Moreover, microflora can be in cavity of appendix or get nthere by hematogenic way, and for women – by lymphogenic one.

Obstructioof the appendiceal lumen causes appendicitis. Mucus backs up in the appendiceal nlumen, causing bacteria that normally live inside the appendix to multiply. As na result, the appendix swells and becomes infected. Sources of obstructioinclude

·        nfeces, parasites, or growths that clog the appendiceal lumen

·        nenlarged lymph tissue in the wall of the appendix, caused by infectioin the gastrointestinal tract or elsewhere in the body

·        ninflammatory bowel disease, including Crohn’s disease and ulcerative ncolitis

·        ntrauma to the abdomen

Ainflamed appendix will likely burst if not removed. Bursting spreads infectiothroughout the abdomen—a potentially dangerous condition called peritonitis.

Factors which npromote the origin of appendicitis, are the following: a) change of reactivity nof organism; b) constipation and atony of intestine; c) twisting or bends of nappendix; d) excrement stone in its cavity; e) thrombosis of vessels of nappendix and gangrene of wall as a substance of inflammatory process (special cases).

Obstruction of the lumen is the dominant etiologic factor nin acute appendicitis. Fecaliths are the most common cause of appendiceal nobstruction. Less common causes are hypertrophy of lymphoid tissue, inspissated nbarium from previous x-ray studies, tumors, vegetable and fruit seeds, and nintestinal parasites. The frequency of obstruction rises with the severity of nthe inflammatory process. Fecaliths are found in 40% of cases of simple acute nappendicitis, in 65% of cases of gangrenous appendicitis without rupture, and niearly 90% of cases of gangrenous appendicitis with rupture.

Obstruction of the lumen is the dominant etiologic factor nin acute appendicitis. Fecaliths are the most common cause of appendiceal nobstruction. Less common causes are hypertrophy of lymphoid tissue, inspissated nbarium from previous x-ray studies, tumors, vegetable and fruit seeds, and nintestinal parasites. The frequency of obstruction rises with the severity of nthe inflammatory process. Fecaliths are found in 40% of cases of simple acute nappendicitis, in 65% of cases of gangrenous appendicitis without rupture, and niearly 90% of cases of gangrenous appendicitis with rupture. The proximal nobstruction of the appendiceal lumen produces a closed-loop obstruction, and ncontinuing normal secretion by the appendiceal mucosa rapidly produces ndistention. The luminal capacity of the normal appendix is only 0.1 mL. nSecretion of as little as 0.5 mL of fluid distal to an obstruction raises the nintraluminal pressure to 60 cm H2O. Distention of the appendix stimulates the nerve nendings of visceral afferent stretch fibers, producing vague, dull, diffuse npain in the midabdomen or lower epigastrium. Peristalsis also is stimulated by nthe rather sudden distention, so that some cramping may be superimposed on the nvisceral pain early in the course of appendicitis. Distention increases from ncontinued mucosal secretion and from rapid multiplication of the resident nbacteria of the appendix. Distention of this magnitude usually causes reflex nnausea and vomiting, and the diffuse visceral pain becomes more severe. As npressure in the organ increases, venous pressure is exceeded. Capillaries and nvenules are occluded, but arteriolar inflow continues, resulting in engorgement nand vascular congestion. The inflammatory process soon involves the serosa of nthe appendix and in turn parietal peritoneum in the region, which produces the ncharacteristic shift in pain to the right lower quadrant.

The mucosa of the GI tract, including the appendix, is nsusceptible to impairment of blood supply; thus its integrity is compromised nearly in the process, which allows bacterial invasion. As progressive ndistention encroaches on first the venous return and subsequently the narteriolar inflow, the area with the poorest blood supply suffers most: nellipsoidal infarcts develop in the antimesenteric border. As distention, nbacterial invasion, compromise of vascular supply, and infarction progress, nperforation occurs, usually through one of the infarcted areas on the nantimesenteric border. Perforation generally occurs just beyond the point of nobstruction rather than at the tip because of the effect of diameter ointraluminal tension. This sequence is not inevitable, however, and some nepisodes of acute appendicitis apparently subside spontaneously. Many patients nwho are found at operation to have acute appendicitis give a history of nprevious similar, but less severe, attacks of right lower quadrant pain. nPathologic examination of the appendices removed from these patients oftereveals thickening and scarring, suggesting old, healed acute inflammation. The nstrong association between delay in presentation and appendiceal perforatiosupported the proposition that appendiceal perforation is the advanced stage of nacute appendicitis; however, recent epidemiologic studies have suggested that nnonperforated and perforated appendicitis may, in fact, be different diseases.

 

Bacteriology

 

The nbacterial population of the normal appendix is similar to that of the normal ncolon. The appendiceal flora remains constant throughout life with the nexception of Porphyromonas gingivalis. This bacterium is seen only iadults.18 The bacteria cultured in cases of appendicitis are therefore similar nto those seen in other colonic infections such as diverticulitis. The principal norganisms seen in the normal appendix, in acute appendicitis, and in perforated nappendicitis are Escherichia coli and Bacteroides fragilis.18–21 nHowever, a wide variety of both facultative and anaerobic bacteria and nmycobacteria may be present in table.

 

 

Pathomorphology

Simple (superficial) and destructive n(phlegmonous, gangrenous primary and gangrenous nsecondary) appendicitises which are morphological expressions of phases of nacute inflammation that is completed by necrosis can be distinguished.

In simple appendicitis the changes nare observed, mainly, in the distant part nof appendix. There are stasis in capillaries and venule, edema and hemorrhages. Focus of nfestering inflammation of mucus membrane with the defect of the epithelium ncovering is formed in 1–2 hours (primary affect of Ashoff). This ncharacterizes acute superficial appendicitis. The phlegmon of appendix develops nto the end of the day. The organ increases, it serous tunic becomes dimmed, sanguineous, stratifications of nfibrin appear on its surface, and there is pus in cavity.

 

 

In gangrenous appendicitis the nappendix is thickened, the its serous tunic nis covered by dimmed nfibrinogenous tape, ndifferentiating of the layer structure through destruction is not succeeded.

 

 

Classification

(by V.I. Kolesnikov)

1. Appendiceal colic.

2. Simple superficial appendicitis.

3. Destructive appendicitis:

а) phlegmonous;

б) ngangrenous;

в) perforated.

4. Complicated appendicitis:

а)  nappendicular infiltrate;

б)  appendicular abscess;

в) diffuse purulent peritonitis.

5. Other complications of acute nappendicitis (pylephlebitis, sepsis, retroperitoneal phlegmon, local abscesses of abdominal cavity).

 

Symptoms and clinical course

 

The classic nsymptoms of appendicitis include:

·        nDull paiear the navel or the nupper abdomen that becomes sharp as it moves to the lower right abdomen. This nis usually the first sign.

·        nLoss of appetite

·        nNausea and/or vomiting soon after nabdominal pain begins

·        nAbdominal swelling

·        nFever of 99-102 degrees nFahrenheit

·        nInability to pass gas

·        nAlmost half the time, other nsymptoms of appendicitis appear, including:

·        nDull or sharp pain anywhere ithe upper or lower abdomen, back, or rectum

·        nPainful urination

·        nVomiting that precedes the nabdominal pain

·        nSevere cramps

·        nConstipation or diarrhea with gas

 

Four phases are distinguished iclinical course of acute appendicitis: 1) epigastric; 2) local symptoms; 3) ncalming down; 4) complications.

The disease begins with a sudden paiin the abdomen. It is localized in a right iliac area, has moderate intensity, npermanent character and not irradiate. With 70 % of patients the pain arises ia epigastric area – it is an epigastric phase of acute appendicitis. In 2–4 nhours it moves to the place of appendix existance (the Kocher’s symptom). At coughing patients mark nstrengthening of pain in a right iliac area – it is a positive cough symptom.

Pain first, vomiting next and fever nlast has been described as the classic presentation of acute appendicitis. nSince the innervation of the appendix enters the spinal cord at the level T10, nthe same level as the umbilicus (belly button), the pain begins mid-abdomen. nLater, as the appendix becomes more inflamed and irritates the adjoining nabdominal wall, it tends to localize over several hours into the right lower nquadrant, except in children under three years. This pain can be elicited nthrough various signs and can be severe. Signs include localized findings ithe right iliac fossa. The abdominal wall becomes very sensitive to gentle pressure n(palpation). Also, there is severe pain on sudden release of deep pressure ithe lower abdomen (rebound tenderness). In case of a retrocecal appendix n(appendix localized behind the cecum), however, even deep pressure in the right nlower quadrant may fail to elicit tenderness (silent appendix), the reasobeing that the cecum, distended with gas, protects the inflamed appendix from nthe pressure. Similarly, if the appendix lies entirely within the pelvis, there nis usually complete absence of abdominal rigidity. In such cases, a digital nrectal examination elicits tenderness in the rectovesical pouch. Coughing ncauses point tenderness in this area (McBurney’s point) and this is the least npainful way to localize the inflamed appendix. If the abdomen on palpation is nalso involuntarily guarded (rigid), there should be a strong suspicion of nperitonitis, requiring urgent surgical intervention.

 

The abdominal pain usually:

 

Abdominal pain is the prime nsymptom of acute appendicitis. Classically, pain is initially diffusely ncentered in the lower epigastrium or umbilical area, is moderately severe, and nis steady, sometimes with intermittent cramping superimposed. After a period nvarying from 1 to 12 hours, but usually within 4 to 6 hours, the pain localizes nto the right lower quadrant. This classic pain sequence, although usual, is not ninvariable. In some patients, the pain of appendicitis begins in the right nlower quadrant and remains there. Variations in the anatomic location of the nappendix account for many of the variations in the principal locus of the nsomatic phase of the pain. For example, a long appendix with the inflamed tip nin the left lower quadrant causes pain in that area. A retrocecal appendix may ncause principally flank or back pain; a pelvic appendix, principally suprapubic npain; and a retroileal appendix, testicular pain, presumably from irritation of nthe spermatic artery and ureter. Intestinal malrotation also is responsible for npuzzling pain patterns. The visceral component is in the normal location, but the nsomatic component is felt in that part of the abdomen where the cecum has beearrested in rotation.

·        noccurs suddenly, often causing a person to wake up at night;

·        noccurs before other symptoms;

·        nbegins near the belly button and then moves lower and to the right;

·        nis new and unlike any pain felt before;

·        ngets worse in a matter of hours;

·        ngets worse when moving around, taking deep breaths, coughing, or nsneezing.

 

Other symptoms of appendicitis may include

 

Anorexia nearly always naccompanies appendicitis. It is so constant that the diagnosis should be nquestioned if the patient is not anorectic. Although vomiting occurs iearly n75% of patients, it is neither prominent nor prolonged, and most patients vomit nonly once or twice. Vomiting is caused by both neural stimulation and the npresence of ileus.

Most patients give a nhistory of obstipation beginning before the onset of abdominal pain, and many nfeel that defecation would relieve their abdominal pain. Diarrhea occurs isome patients, however, particularly children, so that the pattern of bowel nfunction is of little differential diagnostic value.

The sequence of nsymptom appearance has great significance for the differential diagnosis. I>95% of patients with acute appendicitis, anorexia is the first symptom, nfollowed by abdominal pain, which is followed, in turn, by vomiting (if nvomiting occurs). If vomiting precedes the onset of pain, the diagnosis of nappendicitis should be questioned.

·     loss of appetite

·     nausea

·     vomiting

·     constipation or diarrhea

·     inability to pass gas

·     a low-grade fever that follows other nsymptoms

·     abdominal swelling

·     the feeling that passing stool will nrelieve discomfort

 

Signs

 

Together with it, nausea and vomiting nthat have reflex character can disturb a patient. Often there is a delay of ngases. The temperature of body of most patients rises, but high temperature caoccur rarely and, mainly, it is a low grade fever. nThe general condition of patients gets worse only in case of growth of ndestructive changes in appendix.

Physical findings are ndetermined principally by what the anatomic position of the inflamed appendix nis, as well as by whether the organ has already ruptured when the patient is nfirst examined.

Vital signs are minimally nchanged by uncomplicated appendicitis. Temperature elevation is rarely >1°C (1.8°F) and the pulse rate is normal or slightly elevated. nChanges of greater magnitude usually indicate that a complication has occurred nor that another diagnosis should be considered.25

Patients with appendicitis nusually prefer to lie supine, with the thighs, particularly the right thigh, ndrawn up, because any motion increases pain. If asked to move, they do so nslowly and with caution.

The classic right lower quadrant physical signs are present when the ninflamed appendix lies in the anterior position. Tenderness often is maximal at nor near the McBurney point.8 Direct rebound tenderness usually is present. Iaddition, referred or indirect rebound tenderness is present. This referred ntenderness is felt maximally in the right lower quadrant, which indicates nlocalized peritoneal irritation. The Rovsing sign—pain in the right lower nquadrant when palpatory pressure is exerted in the left lower quadrant—also indicates nthe site of peritoneal irritation. Cutaneous hyperesthesia in the area supplied nby the spinal nerves on the right at T10, T11, and T12 frequently accompanies nacute appendicitis. In patients with obvious appendicitis, this sign is nsuperfluous, but in some early cases, it may be the first positive sign. nHyperesthesia is elicited either by needle prick or by gently picking up the nskin between the forefinger and thumb.

Muscular resistance to palpation of the abdominal wall roughly parallels nthe severity of the inflammatory process. Early in the disease, resistance, if npresent, consists mainly of voluntary guarding. As peritoneal irritatioprogresses, muscle spasm increases and becomes largely involuntary, that is, ntrue reflex rigidity due to contraction of muscles directly beneath the ninflamed parietal peritoneum.

Anatomic variations in the position of the inflamed appendix lead to ndeviations in the usual physical findings. With a retrocecal appendix, the nanterior abdominal findings are less striking, and tenderness may be most nmarked in the flank. When the inflamed appendix hangs into the pelvis, nabdominal findings may be entirely absent, and the diagnosis may be missed nunless the rectum is examined. As the examining finger exerts pressure on the nperitoneum of Douglas’ cul-de-sac, pain is felt in the suprapubic area as well nas locally within the rectum. Signs of localized muscle irritation also may be npresent. The psoas sign indicates an irritative focus in proximity to that nmuscle. The test is performed by having the patient lie on the left side as the nexaminer slowly extends the patient’s right thigh, thus stretching the niliopsoas muscle. The test result is positive if extension produces pain. nSimilarly, a positive obturator sign of hypogastric pain on stretching the nobturator internus indicates irritation in the pelvis. The test is performed by npassive internal rotation of the flexed right thigh with the patient supine.

During the examinationIt is possible nto mark, that the right half of stomach falls behind in the act of breathing, nand a patient wants to lie down on a right side with bound leg.

Painfulness is the basic and decisive signs nof acute appendicitis during the examination by palpation in a right iliac area, tension of muscle nof abdominal wall, positive symptoms of peritoneum irritation. About 100 paisymptoms characteristic of acute appendicitis are known, however only some of nthem have the real practical value.

The Blumberg’s nsymptom. nAfter gradual pressing by fingers on a front abdominal wall from the place of npain quickly, but not acutely, the hand is taken away. Strengthening of pain is nconsidered as a positive symptom in that place. Obligatory here is tension of nmuscles of front abdominal wall. Slide.

The Voskresensky’s symptom. By a left nhand the shirt of patient is drawn downward and fixed on pubis. By the taps of n2-4 fingers of right hand epigastric area is pressed and during exhalation of npatient quickly and evenly the ha nd slides in the direction of right iliac narea, without taking the hand away. Thus there is an acute strengthening of npain.

The Bartomier’s symptom nis the increase of pain intensity during the palpation in right iliac area of npatient in position on the left side. At such pose an omentum and loops of thiintestine is displaced to the left, and an appendix becomes accessible for palpation.

The Sitkovsky’s symptom. A npatient, that lies on left, feels the pain which arises or increases in a right niliac area. The mechanism of intensification of pain is explained by ndisplacement of blind gut to the left, by drawing of mesentery of the inflamed nappendix.

The nRovsing’s symptom. By a left nhand a sigmoid bowel is pressed to the back wall of nstomach. By a right hand by ballotting palpation a descending bowel is pressed. nAppearance of pain in a right iliac area is considered as a sign characteristic nof appendicitis.

The nObrazcov’s symptom. With the nposition of patient on the back by index and middle fingers the right iliac narea of most painful place is pressed and the patient is asked to heave up the nstraightened right leg. At appendicitis pain increases acutely.

The nRozdolskyy’s symptom. At percussion nthere is painfulness in a right iliac area.

The ngeneral analysis of blood does not carry specific information, which would nspecify the presence of acute appendicitis. However, much leukocytosis and change of formula to the left imost cases can point to the present inflammatory process.

 

Variants of clinical course and complication

 

Acute appendicitis in children. With children of infancy acute appendicitis can be nseen infrequently, but, quite often carries atipical character. All this is nconditioned, mainly, by the features of anatomy of appendix, insufficient of nplastic properties of the peritoneum, short omentum and high reactivity of nchild’s organism. The inflammatory process in the appendix of children quickly nmakes progress and during the first half of days from the beginning of disease nthere can appear its destruction, even perforation. The child, more frequent nthan an adult, suffers vomiting. Its general condition gets worse quickly, and nalready the positive symptoms of irritation of peritoneum can show up during nthe first hours of a disease. The temperature reaction is also expressed nconsiderably acuter. In the blood test there is high leukocytosis. nIt is necessary to remember, that during the examination of calmless childreit is expedient to use a chloral hydrate enema.

The establishment of a diagnosis of acute appendicitis is nmore difficult in young children than in the adult. The inability of young nchildren to give an accurate history, diagnostic delays by both parents and nphysicians, and the frequency of GI upset in children are all contributing nfactors.62 In children the physical examination findings of maximal tenderness nin the right lower quadrant, the inability to walk or walking with a limp, and npain with percussion, coughing, and hopping were found to have the highest nsensitivity for appendicitis.63

The more rapid progression to rupture and the inability nof the underdeveloped greater omentum to contain a rupture lead to significant nmorbidity rates in children. Children <5 years of age have a negative nappendectomy rate of 25% and an appendiceal perforation rate of 45%. These nrates may be compared with a negative appendectomy rate of <10% and a nperforated appendix rate of 20% for children 5 to 12 years of age.13,14 The nincidence of major complications after appendectomy in children is correlated nwith appendiceal rupture. The wound infection rate after the treatment of nnonperforated appendicitis in children is 2.8% compared with a rate of 11% nafter the treatment of perforated appendicitis. The incidence of intra-abdominal nabscess also is higher after the treatment of perforated appendicitis thaafter nonperforated appendicitis (6% vs. 3%).23 The treatment regimen for nperforated appendicitis generally includes immediate appendectomy and nirrigation of the peritoneal cavity. Antibiotic coverage is limited to 24 to 48 nhours in cases of nonperforated appendicitis. For perforated appendicitis IV nantibiotics usually are given until the white blood cell count is normal and nthe patient is afebrile for 24 hours. The use of antibiotic irrigation of the nperitoneal cavity and transperitoneal drainage through the wound are ncontroversial. Laparoscopic appendectomy has been shown to be safe and neffective for the treatment of appendicitis in children

Acute appendicitis of the people of declining nand old ages can be met not so often, as of the persons of middle nages and youth. This contingent of patients is hospitalized to hospital rather nlate: in 2–3 days from the beginning of a disease. Because of the promoted nthreshold of pain sensitiveness, the intensity of pain in such patients is nsmall, therefore they almost do not fix attention on the epigastric phase of nappendicitis. More frequent are nausea and vomiting, and the temperature nreaction is expressed poorly. Tension of muscles of abdominal wall is absent or ninsignificant through old-age relaxation of nmuscles. But the symptoms of irritation of peritoneum keep the diagnostic value nwith this group of patients. Thus, the sclerosis of vessels of appendix results nin its rapid numbness, initially-gangrenous appendicitis develops. Because of nsuch reasons the destructive forms of appendicitis prevail, often there is appendiceal infiltrate.

With pregnant women both nthe bend of appendix and violation of its blood flow are causes of the origiof appendicitis. Increased in sizes uterus causes such changes. It, especially nin the second half of pregnancy, displaces a blind gut together with aappendix upwards, and an overdistension abdominal wall does not create adequate ntension. It is needed also to remember, that pregnant women periodically cahave a moderate pain in the abdomen and changes in the blood test. Together nwith that, psoas-symptom and the Bartomier’s nsymptom have a diagnostic value at pregnant women.

Appendectomy for presumed appendicitis is the most commosurgical emergency during pregnancy. The incidence is approximately 1 in 766 births. Acute appendicitis can occur at any time nduring pregnancy.68 The overall negative appendectomy rate during pregnancy is napproximately 25% and appears to be higher than the rate seen ionpregnant nwomen.68,69 A higher rate of negative appendectomy is seen in the second ntrimester, and the lowest rate is in the third trimester. The diversity of nclinical presentations and the difficulty in making the diagnosis of acute nappendicitis in pregnant women is well established. This is particularly true nin the late second trimester and the third trimester, when many abdominal nsymptoms may be considered pregnancy related. In addition, during pregnancy nthere are anatomic changes in the appendix (Fig. 30-7) and increased abdominal nlaxity that may further complicate clinical evaluation. There is no nassociation between appendectomy and subsequent fertility.

Clinical course of acute appendicitis at nthe atipical location (not in a right iliac area) will differ from a classic vermiform appendix .

n

 

Variants of appendix localization

 

1.     nAppendix

2.     nAppendicular artery

3.     nAppendicular mesentery

4.     nIlium

5.     nCaecum

 

 

n

Appendicitis nat retrocecal and retroperitoneal location of appendiceal appendix can be with 8–20 % npatients. Thus an appendix can be placed both in a free abdominal cavity and retroperitoneal. An atypical clinic arises, as a nrule, at the retroperitoneal location. The patients complain at npain in lumbus or above the wing of right ileum. nThere they mark painfulness during palpation. Sometimes the pain irradiates to nthe pelvis and in the right thigh. The positive symptom of Rozanov — npainfulness during palpation in the right Pti triangle is ncharacteristic. In transition of inflammatory process on an ureter and kidney nin the urines analysis red corpuscles can be found.

Appendicitis at the pelvic location of appendix can be met in 11–30 % ncases. In such patients the pain is localized above the right Poupart’s ligament and above pubis. At the nvery low placing of appendix at the beginning of disease the reaction of nmuscles of front abdominal wall on an inflammatory process can be absent. With ntransition of inflammation on an urinary bladder or rectum either the dysuric nsigns or diarrhea developes, mucus appears in aexcrement. Distribution of process on internal genital organs provokes signs ncharacteristic of their inflammation.

Appendicitis at the medial placing of appendix. The appendix nin patients with such pathology is located between the loops of intestine, that nis the large field of suction and irritation of peritoneum. At these anatomic nfeatures mesentery is pulled in the inflammatory process, acute dynamic of the nintestinal obstruction develops in such patients. The pain in the abdomen is nintensive, widespread, the expressed tension of muscles of abdominal wall ndevelops, that together with symptoms of the irritation of peritoneum specify nthe substantial threat of peritonitis development.

For the subhepatic location of appendix the pain is characteristic in right nhypochondrium. During palpation painfulness and tension of musclescan be nmarked.

Left-side appendicitis appears infrequently and, as a rule, in case of the nreverse placing of all organs, however it can occur at a mobile blind gut. Ithis situation all signs which characterize acute appendicitis will be exposed nnot on the right, as usually, but on the left.

Among complications of acute nappendicitis most value have appendiceal infiltrates and abscesses.

Appendiceal infiltrate is the nconglomerate of organs and tissue not densely accrete round the inflamed vermiform nappendix. It develops, certainly, on 3–5^th day from the nbeginning of disease. Acute pain in the stomach calms down thus, the general ncondition of a patient gets better. Dense, not mobile, painful, with unclear ncontours, formation is palpated in the right iliac area. There are different nsizes of infiltrate, sometimes it occupies all right niliac area. The stomach round infiltrate during palpation nis soft and unpainful.

At reverse development of infiltrate (when resorption comes) the general ncondition of a patient gets better, sleep and appetite recommence, activity ngrows, the temperature of body and indexes of blood is normalized. Pain in the nright iliac area calms down, infiltrate ndiminishes in size. In this phase of infiltrate physiotherapeutic procedure is appointed, warmth on the iliac area.

In two months after resorption of infiltrate appendectomy is conducted.

At abscessing of infiltrate the condition of a patient gets nworse, the symptoms of acute appendicitis become more expressed, the ntemperature of body, which in most cases gains hectic character, rises, the fever appears. nNext to that, pain in the right iliac area increases. Painful formation is felt nthere. In the blood test high leukocytosis nis present with the acutely expressed change of leukocyte formula to the left.

Local abscesses of abdominal cavity, nmainly, develops as a result of the atypical nplacing of appendix or suppuration. More frequent from other there are pelvic nabscesses. Thus a patient is disturbed by pain beneath the abcupula, there are dysuric ndisorders, diarrhea and tenesmus. The temperature of body rises to n38,0–39,0^oС, and rectal — to considerably higher nnumbers. In the blood test leukocytosis, nchange of formula of blood is fixed to the left.

During the rectal examination the nweakened sphincter of anus is found. The front wall of rectum at first is only npainful, and then its overhanging is observed as dense painful infiltrate. Slide.

A subdiaphragmatic abscess develops at the nhigh placing of appendix. The pain in the lower parts of thorax and in a upper nquarter of abcupula ofn to the right, that increases at deep inhalationis nexcept for the signs of intoxication, is characteristic of it. A patient, ngenerally, occupies semisitting position. Swelling in aepigastric area is observed in heavy cases, smoothing nand painful intercostal intervals. The abcupula ofn during palpation nis soft, although tension in the area of right hypochondrium is possible. Painfulness nat pressure on bottom (9–11) ribs is the early and permanent symptom of nsubdiaphragmatic abscess (the Krukov’s symptom).

Roentgenologically the right half of ndiaphragm can fall behind from left one while breathing, and there is a present nreactive exudate in the right pleura cavity. A gas bubble is considered the nroentgenologic sign of subdiaphragmatic abscess with the horizontal level of nliquid, which is placed under the diaphragm.

Interloop abscesses are not frequent ncomplications of acute appendicitis. As well as all abscesses of abdominal ncavity, they pass the period of infiltrate and abscess nformation with the recreation of the proper clinic.

The npoured festering peritonitis develops as a result of the timely unoperated nappendicitis. Diagnostics of this pathology does not cause difficulties.

Pylephlebitis nis a complication of both appendicitis and after-operative period of nappendectomy.

The nreason of this pathology is acute retrocecal appendicitis. nAt it development the thrombophlebitis process from the veins of appendix, npasses to the veins of bowels mesentery, and then on to the portal vein. nPatients complain at the expressed general weakness, pain in right nhypochondrium, high hectic temperature of body, fever and nstrong sweating. Patients are adynamic, with nexpressed subicteritiousness of the scleras. During palpation painfulness is observed in the right half of nabcupula ofn and the symptoms of irritation of peritoneum are not acutely expressed.

In case with rapid passing of disease nthe icterus appears, the liver is increased, kidney-hepatic insufficiency makes nprogress, and patients die in 7-10 days from the beginning of disease. At ngradual subacute development of pathology the liver and spleen is increased isize, and after the septic state of organism ascites arises.

 

Diagnostic program

 

1. Anamnesis information.

2. Information of objective examination.

3. General analysis of blood and urine.

4. Vaginal examination for women.

5. Rectal examination for men.

 

Instrumental diagnosis

 

Blood and urine test.

 Most people suspected of having nappendicitis would be asked to do a blood test. Half of the time, the blood ntest is normal, so it is not that useful in diagnosing appendicitis.

Two forms of blood tests are commonly ndone: Full blood count (FBC), also known as complete blood count (CBC), is ainexpensive and commonly requested blood test. It involves measuring the blood nfor its richness in red blood cells, as well as the number of the various white nblood cell constituents in it. The number of white cells in the blood is nusually less than 10,000 cells per cubic millimeter. An abnormal rise in the nnumber of white blood cells in the blood is a crude indicator of infection or ninflammation going on in the body. Such a rise is not specific to appendicitis nalone. If it is abnormally elevated, with a good history and examinatiofindings pointing towards appendicitis, the likelihood of having the disease is nhigher. In pregnancy, elevation of white blood cells may be normal, without any ninfection present.

Mild leukocytosis, ranging from 10,000 to 18,000 ncells/mm3, usually is present in patients with acute, uncomplicated nappendicitis and often is accompanied by a moderate polymorphonuclear predominance. nWhite blood cell counts are variable, however. It is unusual for the white nblood cell count to be >18,000 cells/mm3 in uncomplicated appendicitis. nWhite blood cell counts above this level raise the possibility of a perforated nappendix with or without an abscess. Urinalysis can be useful to rule out the nurinary tract as the source of infection. Although several white or red blood ncells can be present from ureteral or bladder irritation as a result of ainflamed appendix, bacteriuria in a urine specimen obtained via catheter ngenerally is not seen in acute appendicitis.

C-reactive protein (CRP) is aacute-phase response protein produced by the liver in response to any infectioor inflammatory process in the body. Again, like the FBC, it is not a specific ntest. It is another crude marker of infection or inflammation. Inflammation at nANY site can lead to a rise in CRP. A significant rise in CRP, with ncorresponding signs and symptoms of appendicitis, is a useful indicator in the ndiagnosis of appendicitis. If the CRP continues to be normal after 72 hours of nthe onset of pain, the appendicitis likely will resolve on its own without nintervention. A worsening CRP with good history is a sure signal of impending nperforation or rupture and abscess formation.

A urine test in appendicitis is nusually normal. It may, however, show blood if the appendix is rubbing on the nbladder, causing irritation. It is important to rule out an ectopic pregnancy nin women of childbearing age.

 

Imaging studies

 

 

 

Plain films of the abdomen, although frequently obtained as part of the ngeneral evaluation of a patient with an acute abdomen, rarely are helpful idiagnosing acute appendicitis. However, plain radiographs can be of significant nbenefit in ruling out other pathology. In patients with acute appendicitis, one noften sees an abnormal bowel gas pattern, which is a nonspecific finding. The npresence of a fecalith is rarely noted on plain films but, if present, is nhighly suggestive of the diagnosis. A chest radiograph is sometimes indicated nto rule out referred pain from a right lower lobe pneumonic process.

 

Ultrasound.

Ultrasonography and Doppler nsonography provide useful means to detect appendicitis, especially in children, nand shows free fluid collection in the right iliac fossa, along with a visible nappendix without blood flow in color Doppler. In some cases (15% napproximately), however, ultrasonography of the iliac fossa does not reveal any nabnormalities despite the presence of appendicitis. This is especially true of nearly appendicitis before the appendix has become significantly distended and nin adults where larger amounts of fat and bowel gas make actually seeing the nappendix technically difficult. Despite these limitations, sonographic imaging nin experienced hands can often distinguish between appendicitis and other ndiseases with very similar symptoms, such as inflammation of lymph nodes near nthe appendix or pain originating from other pelvic organs such as the ovaries nor fallopian tubes.

 

 

Horseshoe shaped appendix

 

 

Case 1. nPerforated appendix

 

 

Increased vascularity of the appendix

 

Graded ncompression sonography has been suggested as an accurate way to establish the ndiagnosis of appendicitis. The technique is inexpensive, can be performed nrapidly, does not require a contrast medium, and can be used even in pregnant npatients. Sonographically, the appendix is identified as a blind-ending, nnonperistaltic bowel loop originating from the cecum. With maximal compression, nthe diameter of the appendix is measured in the anteroposterior dimension. Scaresults are considered positive if a noncompressible appendix ≥6 mm ithe anteroposterior direction is demonstrated. The presence of an appendicolith nestablishes the diagnosis. Thickening of the appendiceal wall and the presence nof periappendiceal fluid is highly suggestive. Sonographic demonstration of a nnormal appendix, which is an easily compressible, blind-ending tubular nstructure measuring ≤5 mm in diameter, excludes the diagnosis of acute nappendicitis. The study results are considered inconclusive if the appendix is nnot visualized and there is no pericecal fluid or mass. When the diagnosis of nacute appendicitis is excluded by sonography, a brief survey of the remainder nof the abdominal cavity should be performed to establish an alternative ndiagnosis. In females of childbearing age, the pelvic organs must be adequately nvisualized either by transabdominal or endovaginal ultrasonography to exclude ngynecologic pathology as a cause of acute abdominal pain. The sonographic ndiagnosis of acute appendicitis has a reported sensitivity of 55 to 96% and a nspecificity of 85 to 98%.28–30 Sonography is similarly effective in childreand pregnant women, although its application is somewhat limited in late npregnancy.

A nfalse-positive scan result can occur in the presence of periappendicitis from nsurrounding inflammation, a dilated fallopian tube can be mistaken for ainflamed appendix, inspissated stool can mimic an appendicolith, and, in obese npatients, the appendix may not be compressible because of overlying fat. nFalse-negative sonogram results can occur if appendicitis is confined to the nappendiceal tip, the appendix is retrocecal, the appendix is markedly enlarged nand mistaken for small bowel, or the appendix is perforated and therefore ncompressible.

Additional nradiographic studies include barium enema examination and radioactively labeled nleukocyte scans. If the appendix fills on barium enema, appendicitis is nexcluded. On the other hand, if the appendix does not fill, no determinatiocan be made. To date, there has not been enough experience with radionuclide nscans to assess their utility.

 

Computed tomography.

 Where it is readily available, CT nscan has become frequently used, especially in adults whose diagnosis is not nobvious on history and physical examination. Concerns about radiation, however, ntend to limit use of CT in pregnant women and children. A properly performed CT nscan with modern equipment has a detection rate (sensitivity) of over 95%, and na similar specificity. Signs of appendicitis on CT scan include lack of oral ncontrast (oral dye) in the appendix, direct visualization of appendiceal nenlargement (greater than 6 mm in cross-sectional diameter), and nappendiceal wall enhancement with IV contrast (IV dye). The inflammation caused nby appendicitis in the surrounding peritoneal fat (so called “fat nstranding”) can also be observed on CT, providing a mechanism to detect nearly appendicitis and a clue that appendicitis may be present even when the nappendix is not well seen. Thus, diagnosis of appendicitis by CT is made more ndifficult in very thin patients and in children, both of whom tend to lack nsignificant fat within the abdomen. The utility of CT scanning is made clear, nhowever, by the impact it has had oegative appendectomy rates. For example, nuse of CT for diagnosis of appendicitis in Boston, MA has decreased the chance nof finding a normal appendix at surgery from 20% in the pre-CT era to only 3% naccording to data from the Massachusetts General Hospital.

High-resolution helical CT also has been used to diagnose nappendicitis. On CT scan, the inflamed appendix appears dilated (>5 cm) and the wall is thickened. There is usually evidence of ninflammation, with “dirty fat,” thickened mesoappendix, and even aobvious phlegmon. Fecaliths can be easily visualized, but their presence is not nnecessarily pathognomonic of appendicitis. An important suggestive abnormality nis the arrowhead sign. This is caused by thickening of the cecum, which funnels ncontrast agent toward the orifice of the inflamed appendix. CT scanning is also nan excellent technique for identifying other inflammatory processes nmasquerading as appendicitis.

Several CT techniques have been used, including focused nand nonfocused CT scans and enhanced and nonenhanced helical CT scanning. nNonenhanced helical CT scanning is important, because one of the disadvantages nof using CT scanning in the evaluation of right lower quadrant pain is dye nallergy. Surprisingly, all of these techniques have yielded essentially nidentical rates of diagnostic accuracy: 92 to 97% sensitivity, 85 to 94% nspecificity, 90 to 98% accuracy, and 75 to 95% positive and 95 to 99% negative npredictive values. The additional use of a rectally administered contrast agent ndid not improve the results of CT scanning.

 

Pic. Acute uncomplicated appendicitis

 

Fig. Transverse CT images in 62-year-old man with perforated nappendicitis. The appendix (arrowheads) is traceable. (a)Image shows defect (straight arrow) of appendiceal wall nenhancement, abscess (Ab), and extraluminal air (curved arrow). (b) Image shows abscess (Ab) and extraluminal appendicolith n(arrow).

 

Laparoscopy can serve as both a diagnostic and therapeutic maneuver nfor patients with acute abdominal pain and suspected acute appendicitis. nLaparoscopy is probably most useful in the evaluation of females with lower nabdominal complaints, because appendectomy is performed on a normal appendix ias many as 30 to 40% of these patients. Differentiating acute gynecologic npathology from acute appendicitis can be effectively accomplished using the nlaparoscope.

 

          Table. Alvarado Scale for the nDiagnosis of Appendicitis

n

	Manifestations	Value
Symptoms	Migration of pain Anorexia	1  1
Signs	Nausea and/or vomiting Right lower quadrant tenderness	1    2
Laboratory values	Rebound Elevated temperature Leukocytosis Left shift in leukocyte count	1 1 2 1

                                                                                               Total npoints 10

 

Differential diagnostics

 

Acute appendicitis is differentiated nwith the diseases which are accompanied by pain in the abcupula ofn.

The differential diagnosis of acute appendicitis is nessentially the diagnosis of the acute abdomen. This is because clinical nmanifestations are not specific for a given disease but are specific for ndisturbance of a given physiologic function or functions. Thus, an essentially nidentical clinical picture can result from a wide variety of acute processes nwithin the peritoneal cavity that produce the same alterations of function as ndoes acute appendicitis.

The accuracy of preoperative diagnosis should be napproximately 85%. If it is consistently less, it is likely that some nunnecessary operations are being performed, and a more rigorous preoperative ndifferential diagnosis is in order. A diagnostic accuracy rate that is nconsistently >90% should also cause concern, because this may mean that some npatients with atypical, but bona fide, cases of acute appendicitis are being n”observed” when they should receive prompt surgical intervention. The nHaller group, however, has shown that this is not invariably true. Before that group’s nstudy, the perforation rate at the hospital at which the study took place was n26.7%, and acute appendicitis was found in 80% of the patients undergoing noperation. By implementing a policy of intensive inhospital observation whethe diagnosis of appendicitis was unclear, the group raised the rate of acute nappendicitis found at operation to 94%, but the perforation rate remained nunchanged at 27.5%. The rate of false-negative appendectomies is highest iyoung adult females. A normal appendix is found in 32 to 45% of appendectomies nperformed in women 15 to 45 years of age.

A common error is to make a preoperative diagnosis of nacute appendicitis only to find some other condition (or nothing) at operation.

Food toxicoinfection.

Complaints for paiin the epigastric area of the intermittent character, nausea, vomiting and nliquid emptying are the first signs of disease. The state of patients nprogressively gets worse from the beginning. Next to that, it is succeeded to nexpose that a patient used meal of poor quality. However, here patients do not nhave phase passing, which is characteristic of acute appendicitis, and clear nlocalization of pain. Defining the symptoms of irritation of peritoneum is not nsucceeded, the peristalsis of intestine is, as a rule, increased.

Acute gastroenteritis.

Acute gastroenteritis nis common but usually can be easily distinguished from acute appendicitis. nGastroenteritis is characterized by profuse diarrhea, nausea, and vomiting. nHyperperistaltic abdominal cramps precede the watery stools. The abdomen is nrelaxed between cramps, and there are no localizing signs. Laboratory values nvary with the specific cause.

Acute pancreatitis.

Ianamnesis in patients with this pathology there is a gallstone disease, violation of diet and use nof alcohol. Their condition from the beginning of a disease is heavy. Pain is nconsiderably more intensive, than during appendicitis, and is concentrated ithe upper half of abcupula ofn. Vomiting is frequent and does not bring to the nrecovery of patients.

Perforative peptic and duodenum ulcer.

Diagnostic ndifficulties during this pathology arise up only on occasion. They can be ipatients with the covered perforation, when portion of gastric juice flows out nin an abdominal cavity and stays too long in the right iliac area, or in case nof atypical perforations. Taking it into account, it is needed to remember, nthat the pain in the perforative ulcer is considerably more intensive iepigastric, instead of in the right iliac area. On the survey roentgenogram of norgans of abdominal cavity under the right cupula of diaphragms free gases cabe found.

 

Gynecologic disorders

 

Diseases of the female internal reproductive organs that nmay erroneously be diagnosed as appendicitis are, in approximate descending norder of frequency, pelvic inflammatory disease, ruptured graafian follicle, ntwisted ovarian cyst or tumor, endometriosis, and ruptured ectopic pregnancy.

Pelvic Inflammatory Disease.

Ipelvic inflammatory disease the infection usually is bilateral but, if confined nto the right tube, may mimic acute appendicitis. Nausea and vomiting are npresent in patients with appendicitis, but in only approximately 50% of those nwith pelvic inflammatory disease. Pain and tenderness are usually lower, and nmotion of the cervix is exquisitely painful. Intracellular diplococci may be ndemonstrable on smear of the purulent vaginal discharge. The ratio of cases of nappendicitis to cases of pelvic inflammatory disease is low in females in the early nphase of the menstrual cycle and high during the luteal phase. The careful nclinical use of these features has reduced the incidence of negative findings non laparoscopy in young women to 15%.

Ruptured Graafian Follicle. Ovulatiocommonly results in the spillage of sufficient amounts of blood and follicular nfluid to produce brief, mild lower abdominal pain. If the amount of fluid is nunusually copious and is from the right ovary, appendicitis may be simulated. nPain and tenderness are rather diffuse. Leukocytosis and fever are minimal or nabsent. Because this pain occurs at the midpoint of the menstrual cycle, it is noften called mittelschmerz.

Twisted Ovarian Cyst.

Serous ncysts of the ovary are common and generally remain asymptomatic. Wheright-sided cysts rupture or undergo torsion, the manifestations are similar to nthose of appendicitis. Patients develop right lower quadrant pain, tenderness, nrebound, fever, and leukocytosis. If the mass is palpable on physical nexamination, the diagnosis can be made easily. Both transvaginal nultrasonography and CT scanning can be diagnostic if a mass is not palpable.

Torsiorequires emergent operative treatment. If the torsion is complete or nlongstanding, the pedicle undergoes thrombosis, and the ovary and tube become gangrenous nand require resection. Leakage of ovarian cysts resolves spontaneously, nhowever, and is best treated nonoperatively.

Ruptured Ectopic Pregnancy.

Blastocysts may nimplant in the fallopian tube (usually the ampullary portion) and in the ovary. nRupture of right tubal or ovarian pregnancies can mimic appendicitis. Patients nmay give a history of abnormal menses, either missing one or two periods or nnoting only slight vaginal bleeding. Unfortunately, patients do not always nrealize they are pregnant. The development of right lower quadrant or pelvic npain may be the first symptom. The diagnosis of ruptured ectopic pregnancy nshould be relatively easy. The presence of a pelvic mass and elevated levels of nchorionic gonadotropin are characteristic. Although the leukocyte count rises nslightly (to approximately 14,000 cells/mm3), the hematocrit level falls as a nconsequence of the intra-abdominal hemorrhage. Vaginal examination reveals ncervical motion and adnexal tenderness, and a more definitive diagnosis can be established nby culdocentesis. The presence of blood and particularly decidual tissue is npathognomonic. The treatment of ruptured ectopic pregnancy is emergency nsurgery.

The apoplexy of ovaryа more frequent nis with young women and, as a rule, on 10-14 day after menstruation. Paiappears suddenly and irradiate in the thigh and perineum. At the beginning of ndisease there can be a collapse. However, the general condition of patients nsuffers insignificantly. Wheot enough blood was passed in the abdominal ncavity, all signs of pathology of abdominal cavity organs calm down after some ntime. Signs, which are characteristic of acute anemia, appear at considerable hemorrhage. nAbdomen more frequent is soft and painful down, (positive Kulenkampff’s nsymptom: acute pain during palpation of stomach nand absent tension of muscles of the front abdominal wall).

During nparacentesis of back fornix the blood which does nnot convolve is got.

Extra-uterine pregnancy.

A necessity to differentiate acute nappendicitis with the interrupted extra-uterine pregnancy arises, when during nthe examination the patient complains at the pain only down in the stomack, nmore to the right. Taking it into account, it is needed to remember, that at nextra-uterine pregnancy a few days before there can be intermittent npain in the lower part of the abdomen, sometimes excretions of “coffee” colour nappear from vagina. In anamnesis often there are the present gynaecological ndiseases, abortions and pathological passing of pregnancy. For the clinical npicture of such patient inherent sudden appearance of intensive pain in lower npart of the abdomen. Often there is a brief loss of consciousness. During palpation nconsiderable painfulness is localized lower, than at nappendicitis, the abdomen is soft, the positive Kulenkampff’s nsymptom is determined. Violations of menstrual cycle testify for pregnancy, ncharacteristic changes are in milk glands, vagina and uterus. During the nvaginal examination it is sometimes possible to palpate increased tube of nuterus. The temperature of body more frequently is normal. If hemorrhage nis small, the changes in the blood test are not present. The convincing proof nof the broken extra-uterine pregnancy is the dark colour of blood, taken at npunction of back fornix of vagina.

Acute cholecystitis.

The nhigh placing of vermiform appendix in the right half of abdomeduring its inflammation can cause the clinic somewhat similar to acute ncholecystitis. But unlike appendicitis, in patients with cholecystitis the paiis more intensive, has cramp-like character, is localized in right nhypochondrium and irradiate in the right shoulder and shoulder-blade. Also the nepigastric phase is absent. The attack of pain can arise after the reception of nspicy food and, is accompanied by nausea and frequent vomiting by bile. Ianamnesis patients often have information about a gallstone disease. During nexamination intensive painfulness is observed in right nhypochondrium, increased gall-bladder and positive symptoms Murphy’s and Ortner’s.

Right-side kidney colic.

For this disease tormina at the level nof kidney and in lumbus is inherent, hematuria nand dysuric signs which can take place at the irritation of ureter by the inflamed nappendix. Intensity of pain in kidney colic is one of the basic differences nfrom acute appendicitis. Pain at first appears in lumbus and irradiate downward nafter passing of ureter in genital organs and front surface of the thigh. Idiagnostics urogram survey is important, and if nnecessary — chromocystoscopy. Absence of function of right kidney to some nextent allows to eliminate the diagnosis of acute appendicitis.

Acute mesenteric adenitis.

Acute nmesenteric adenitis is the disease most often confused with acute appendicitis nin children. Almost invariably, an upper respiratory tract infection is present nor has recently subsided. The pain usually is diffuse, and tenderness is not as nsharply localized as in appendicitis. Voluntary guarding is sometimes present, nbut true rigidity is rare. Generalized lymphadenopathy may be noted. Laboratory nprocedures are of little help in arriving at the correct diagnosis, although a nrelative lymphocytosis, when present, suggests mesenteric adenitis. Observatiofor several hours is in order if the diagnosis of mesenteric adenitis seems nlikely, because it is a self-limited disease. However, if the differentiatioremains in doubt, immediate exploration is the safest course of action.

Humainfection with Yersinia enterocolitica or Yersinia pseudotuberculosis, ntransmitted through food contaminated by feces or urine, causes mesenteric nadenitis as well as ileitis, colitis, and acute appendicitis. Many of the ninfections are mild and self limited, but they may lead to systemic disease nwith a high fatality rate if untreated. The organisms are usually sensitive to ntetracyclines, streptomycin, ampicillin, and kanamycin. A preoperative nsuspicion of the diagnosis should not delay operative intervention, because nappendicitis caused by Yersinia cannot be clinically distinguished from nappendicitis due to other causes. Approximately 6% of cases of mesenteric nadenitis are caused by Yersinia infection.

Salmonella ntyphimurium infection causes mesenteric adenitis and paralytic ileus nwith symptoms similar to those of appendicitis. The diagnosis can be nestablished by serologic testing. Campylobacter jejuni causes diarrhea nand pain that mimics that of appendicitis. The organism can be cultured from nstool.

 

Other intestinal disorders

 

Meckel’s Diverticulitis.

Meckel’s ndiverticulitis gives rise to a clinical picture similar to that of acute nappendicitis. Meckel’s diverticulum is located within the distal 2 ft of the ileum. Meckel’s diverticulitis is associated with the same ncomplications as appendicitis and requires the same treatment—prompt surgical nintervention. Resection of the segment of ileum bearing the diverticulum with nend-to-end anastomosis caearly always be done through a McBurney incision, nextended if necessary, or laparoscopically.

Crohn’s Enteritis.

The nmanifestations of acute regional enteritis—fever, right lower quadrant pain and ntenderness, and leukocytosis—often simulate acute appendicitis. The presence of ndiarrhea and the absence of anorexia, nausea, and vomiting favor a diagnosis of nenteritis, but this is not sufficient to exclude acute appendicitis. In aappreciable percentage of patients with chronic regional enteritis, the ndiagnosis is first made at the time of operation for presumed acute nappendicitis. In cases of an acutely inflamed distal ileum with no cecal ninvolvement and a normal appendix, appendectomy is indicated. Progression to nchronic Crohn’s ileitis is uncommon.

Colonic Lesions.

Diverticulitis nor perforating carcinoma of the cecum, or of that portion of the sigmoid that nlies in the right side, may be impossible to distinguish from appendicitis. nThese entities should be considered in older patients. CT scanning is oftehelpful in making a diagnosis in older patients with right lower quadrant paiand atypical clinical presentations.

Epiploic appendagitis nprobably results from infarction of the colonic appendage(s) secondary to ntorsion. Symptoms may be minimal, or there may be continuous abdominal pain ian area corresponding to the contour of the colon, lasting several days. Paishift is unusual, and there is no diagnostic sequence of symptoms. The patient ndoes not look ill, nausea and vomiting are unusual, and appetite generally is nunaffected. Localized tenderness over the site is usual and often is associated nwith rebound without rigidity. In 25% of reported cases, pain persists or nrecurs until the infarcted epiploic appendage is removed.

 

Tactics and choice of treatment method

 

Acute appendicitis is typically nmanaged by surgery however in uncomplicated cases antibiotics are both neffective and safe. While antibiotics are effective for treating uncomplicated nappendicitis 20% of people had a recurrence within a year and required eventual nappendectomy.

As experience of surgeons of the nwhole world testifies, in acute appendicitis timely operation is the unique neffective method of treatment.

 

Preparation for nopen appendectomy

 

The patient will require a general nanaesthetic and be positioned supine

• Prophylactic nantibiotics are given to reduce the incidence of wound infection

• The npatient should be draped to expose the right lower abdominal quadrant and nallowing identification of the umbilicus and right anterior superior iliac nspine (ASIS)

Pre surgery.

The treatment begins by keeping the npatient from eating or drinking in preparation for surgery. An intravenous drip nis used to hydrate the patient. Antibiotics given intravenously such as ncefuroxime and metronidazole may be administered early to help kill bacteria and nthus reduce the spread of infection in the abdomen and postoperative ncomplications in the abdomen or wound. Equivocal cases may become more ndifficult to assess with antibiotic treatment and benefit from serial nexaminations. If the stomach is empty (no food in the past six hours) general nanaesthesia is usually used. Otherwise, spinal anaesthesia may be used.

Once the decision to perform aappendectomy has been made, the preparation procedure takes approximately one nto two hours. Meanwhile, the surgeon will explain the surgery procedure and nwill present the risks that must be considered when performing an appendectomy. nWith all surgeries there are certain risks that must be evaluated before nperforming the procedures. However, the risks are different depending on the nstate of the appendix. If the appendix has not ruptured, the complication rate nis only about 3% but if the appendix has ruptured, the complication rate rises nto almost 59%. The most usual complications that can occur are pneumonia, nhernia of the incision, thrombophlebitis, bleeding or adhesions. Recent nevidence indicates that a delay in obtaining surgery after admission results ino measurable difference in patient outcomes.

 

Incision for open appendicectomy

 

 Classically the incision lies over McBurney’s npoint; which is a surface marking 1/3rd of way along an imaginary line joining nthe right ASIS and the umbilicus. An incision is made perpendicular to this nline. This is also known as a gridiron or McBurney’s incision.

The Lanz incision is more commonly nused now as it has a better cosmetic result. This incision is made horizontally nover McBurney’s point.

A lower midline incision should be nconsidered in the middle aged or elderly patient or if the diagnosis is idoubt.

Tip: It is useful and also good npractise to palpate the abdomen once the patient is anaesthetised and relaxed. nThis allows you to possibly identify an appendix mass and often the caecum cabe palpated which aids the location of your incision.

Tip: For the exams – remember that nMcBurney’s point is supposed to mark the base of the appendix, as the tip calie in many places.

Access for appendectomy must provide nimplementation of operation. McBurney’s incision is typical.

 

Procedure for open appendicectomy

 

After the skin incision the subcutaneous nfat is divided down to the external oblique aponeurosis. And it is useful to nclear the fat of the aponeurosis with a small swab at this stage.

An incision is made in the line of nthe fibres into the external oblique aponeurosis with a scalpel and extended nwith tissue scissors. Beneath this you will find the internal oblique muscle nwhich is split with a pair of curved heavy scissors. The split can be enlarged nwith either your fingers or a pair of retractors. Peritoneum should now be nvisible. It can be picked by and tented by two small clips. The peritoneum is nthen opened by stroking with the belly of a scalpel blade. Ensure there is nnothing adherent to the underlying peritoneum and extend the incision with nscissors.

Made a note of any fluid released nfrom the peritoneal cavity and if turbid then consider sending a culture swab.

In acute appendicitis it is very nlikely that the omentum will have migrated down to the right iliac fossa. This ncan be gently pushed away medially.

 Probably the easiest method of finding the nappendix is to first identify the caecum. If the caecum is not readily nidentifiable then find some small bowel and follow it back to the caecum. The ntaeniae on the caecum can then be followed down to the appendix. Attempted to ndeliver the caecum and appendix through the wound. If the appendix is very ninflammed it will be adherent to surrounding structures. Pass your index finger ndown from the base of the appendix clearing and adhesions with gentle blunt ndissection.

When during operation the appendix nwithout the special difficulties can be shown out in a wound, antegrade nappendectomy is executed. If at this stage you are unable to deliver the nappendix then enlarge your incision by dividing the fibres of internal oblique. nIf necessary rectus can be divided too.

 Once the appendix is delivered it should be nheld with a tissue holding forcep such as a babcock. The mesoappendix is theclipped and divided and the pedicles tied with an braided absorbable tie such nas vicryl.

On clamps its mesentery is cut off nand ligated. Near the basis the appendix is ligated and cut. Stump is nprocessed by solution of antiseptic and peritonized by a purse-string suture .

 

The base of the appendix is crushed nwith a heavy clip and the clip is placed slightly higher on the appendix. The nsafest method of dealing with the base is to suture ligate it. The appendix is nthen divided under the attached clip with a scalpel blade and the suture cut. nThe remaining suture can then be used to bury the stump with either a purse nstring or a ‘Z’ stitch. Now ensure that both the remaining suture and blade nused are discarded as they are dirty.

The ceacum is gently placed back into nthe peritoneal cavity and any fluid sucked out. A washout can be performed nalthough some argue that it just spreads the contaminated fluid around the nwhole abdomen.

Closure following appendicectomy

The edges of the peritoneum are nidentified and picked up with up to four clips. The peritoneum is then closed nusing a continuous 3/0 absorbable suture. The muscle fibres can be loosely napproximated with some interrupted stitches. The external oblique defect must nbe securely repaired. This is done with a continuous 3/0 absorbable suture.

A local anaesthetic agent caow be ninfiltrated to provide postoperative pain relief.

Skin can be closed with a continuous nsubcuticular absorbable suture. If the wound has been highly contaminated theconsider closing with an interrupted suture or skin clips.

 

Postoperative care

 

• Routine observation of heart rate, blood npressure and temperature

• Allow free fluids orally and full diet the next nday

• DVT prophylaxis should be commenced immediately

• Two further doses of the antibiotic used oinduction can be given postoperatively

 

Other points to note

 

• If nthe appendix looks macroscopically normal it should still be removed. Patients nwith a right iliac fossa scar will be assumed to have had a appendicectomy by nother medical staff. Additionally, 15% of macroscopically normal appendixes nprove to be acute appendicitis under microscopy.

• If nmacroscopically normal, then do remember to check for other causes, such as nmesenteric adenitis, Meckel’s diverticulitis, ovario-tibular pathology or a nsigmoid diverticulitis.

• If nan appendix mass (abscess) is present and the appendix caot be found theplace an abdominal drain to the mass and close. An interval appendicectomy cabe performed at a later date.

• Occasionally nyou will find a right colon carcinoma or terminal ileitis. This require a right nhemi-colectomy to be performed and senior help should be obtained if required.

n

 

If only the basis of appendix is ntaken in a wound, and an apex is fixed in an abdominal cavity, more rationally retrograde nappendectomy is performed. Thus the appendix near basis is cut between two nligatures. Stump is processed by antiseptic and peritonized. According to it the appendix is nremoved in the direction from basis to the apex.

According to indication operation is nconcluded by draining of abdominal cavity (destructive appendicitis, exudate ian abdominal cavity, capillary hemorrhage from the bed). In recent years the nlaparoscopy methods of appendectomy are successfully performed.

In patients with appendiceal infiltrate it is necessary to perform nconservative-temporizing tactic. Taking it into account, bed rest is appointed, nprotective diet, cold on the area of infiltrate, antibiotic ntherapy. According nto resorption of infiltrate, in two months, planned appendectomy is executed.

Treatment of appendiceal abscess must be only operative. nOpening and drainage of abscess, from retroperitoneal access, is performed. To delete here the nappendix is not necessary, and because of denger of bleeding, peritonitis and nintestinal fistula — even dangerously.

 

Laparoscopic surgery

 

The nadvent of high definition video-laparoscopy has transformed the laparoscopic nappendectomy into an elegant, reliable procedure which can be easily performed. nIn most cases it can be completed within 20 to 30 minutes, and with experience, nall clinical settings can be mastered. Critics of this procedure have claimed nthere are no significant cost savings and no improvement in the recovery of the npatient. The following results will disprove these claims. This procedure nremains invaluable in patients with undiagnosed abdominal pain requiring nfurther diagnostic intra-abdominal exploration as well as patients with nperforated appendicitis with or without an intra-abdominal abscess.

In addition, nthis technique truly makes the simple appendectomy an outpatient procedure. The npatient can resume a diet within a few hours after the “lap-appy” and nin most cases can be discharged within 24 to 36 hours. 

The nindications for a laparoscopic appendectomy are simple. Any patient suspected nto have an acute appendicitis should undergo a laparoscopic appendectomy. As nour laparoscopic skills have dramatically improved over the past decade, we now nrarely schedule a patient to undergo an “open” appendectomy.

In addition, all nsurgeons are now well aware that the introduction of spiral computerized tomography has significantly impacted the ndiagnostic management of these patients. In selected clinical settings, careful nuse of this imaging modality will improve the diagnostic acumen of the nclinician beyond the 95 percentile.

 

Technical Difficulty

 

A npneumo-peritoneum is created in the usual fashion. The trocars are inserted.

An atraumatic ngrasper [Endo Babcock or Dolphin Nose Grasper] is inserted via the right upper nquadrant  trocar . The cecum is retracted upward toward the liver. In most ncases, this maneuver will elevate the appendix in the optical field of the ntelescope. The appendix is grasped with a 5 mm claw-type ngrasper inserted via the supra-pubic trocar . It is held toward the abdominal nwall.

 

 

A dolphiose ngrasper  is used to create a mesenteric window under the base of the nappendix. The window should be made as close as possible to the base of the nappendix and should be approximately 1cm in size. 

The appendix is ntransected by inserting a MULTIFIRE ENDOGIA 30™ instrument via the RUQ trocar n(blue cartridge, 3.5), closing it around the base of the appendix and firing nit.

The base of the nappendix is inspected for hemostasis. The operator should wait a few minutes nbefore initiating measures to stop any bleeding site on the staple line as it nwill most likely stop spontaneously. The MULTIFIRE ENDOGIA 30™ cartridge is nchanged to a vascular cartridge (white, 2.5) and the meso-appendix is  ntransected with the same instrument . Several cartridges may have to be used.

The nappendix is now amputated from the gastrointestinal tract. A 10mm ENDOCATCH™ ninstrument is inserted via the RUQ trocar and deployed in the intra-abdominal ncavity. The appendix, held by the grasper (via the nsuprapubic trocar), is placed into the specimen bag. The bag is closed and the nENDOCATCH™ instrument  is removed [with the trocar] from the intra-abdominal ncavity. The ENDOCATCH™ instrument is separated from the trocar, and the trocar nis reinserted.

The intra-abdominal cavity is irrigated nthoroughly with normal saline . For perforated appendicitis with or without aintra-abdominal abscess, a Blake Drain™ is left in the right lower quadrant and npelvis.

 

 

 

video-laparoscopic

video2

video3

 

Management of Acceptable Complications

 

Post-operative Sepsis.

The irrigation of the intra-abdominal ncavity with copious amounts of normal saline under direct vision has decreased nthe number of post-operative septic episodes or postoperative intra-abdominal abscesses. nHowever, several patients were readmitted with severe abdominal pain and sepsis nwithin ten days after this procedure. Our protocol mandates the following ithis clinical setting: 1) Admission to the surgical service, 2) IV antibiotics n(Cefizox™ and Flagyl™), 3) Computerized Tomography scan (preferably Spiral) of nthe abdomen and pelvis, 4) If no localized fluid collection or abscess can be ndemonstrated on the CT, the patients will continued IV antibiotics only, 5) If nan abscess is demonstrated, the patient will undergo a CT guided drainage nversus a laparoscopic drainage.

 

Trocar Site Infection – Wound nInfection.

Prior to the introduction of the nENDOCATCH™ instrument,  a significant number of trocar site infections was nreported by our surgical team. These incisions were opened at the bedside and ndrained.

With the use of  the ENDOCATCH™ ninstrument to remove the infected specimen from the intra-abdominal cavity, we nonly reported one wound infection. The irrigation of the trocar site with nnormal saline at the end of the procedure should also always be done when gross ncontamination occurred.

 

Inability to Find the nAppendix.

In patients with severe, perforated nappendicitis, the appendix may be difficult to locate. In this clinical nsettings, the cecum should be well visualized, dissected and exposed. The base nof the appendix is at the confluence of the colic tenias. Persistence is key.

 

Severe, Acute, Necrotizing nAppendicitis.

 In some cases of severe, acute, necrotizing nappendicitis the base of the appendix may not be suitable for transection with na MULTIFIRE ENDOGIA™. It may be technically easier and safer to perform a n[partial or full] “cecectomy” using the same stapling device.

 

REFERENCES

 

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Prepared ass. Romaniuk T.