Appendicitis

plan 

•         1. The definition of "acute appendicitis".

•         2. Anatomical and physiological features.•         

       3. Classification of appendicitis.

       4. Clinical symptoms of appendicitis.

•         5. Atypical forms of acute appendicitis.

•         6. Differential diagnosis.

•         6. medical tactics and choice of treatment.

•         7. Complications of acute appendicitis, clinical features, diagnosis, treatment.

•         8. Chronic appendicitis, clinic, diagnostics, treatment.

•         9. Movie.

Acute appendicitis - nonspecific (often phlegmonous-purulent), inflammation of the appendix, which arises as a result of (preferably jointly) a number of factors: non-specific primary infection, and local changes in the general reactivity of circulatory disorders caused by dysfunction neurohumoral local unit or a common origin.
A term coined by R. Fitz in 1886

Acute appendicitis - one of the most common acute surgical diseases of the abdominal cavity. The incidence is prevalent in women, mostly it depends on age and is (VG Zaitsev, 1989): children up to 1 year - 3.48 cases per 10 thousand population, in children 1 to 14 years - 11.4, from 15 to 59 years - 114.9, from 60 to 69 years - 29.7, 70 years and more - 15.8. Thus, if the conditional life expectancy is 60 years, then every 12-15 face the appendix is ​​removed before the end of life.
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       Anatomical and physiological features

Placement options of the caecum (fig1 )pt ions placement of the cecumoptions placement of the cecum

Blood supply of ileocecal angle(fig 2)

Left hand placement appendix (fig 3)

Optional accommodations of the appendix (fig 4)

Retroperitoneal location of the appendix (fig 5)

The pathogenesis of acute appendicitis

1.   Cortico-visceral, viscero-visceral, autovistseralnye (of the process), neuro-regulatory disturbances (5)
2. Vascular and muscular spasms, thrombosis, embolism branches appendicular artery
3. Violation of the general and local reactivity
4. Ischemia and trophic disorders or zones of the process(5)
5. Activation of non-specific infection (Escherichia coli, enterococci)
6.  Acute appendicitis (2, 4, 5.-also a direct cause of appendicitis)

Clinical classification (VI Kolesov, 1959).

      I. Acute simple (surface) appendicitis:

      a) without general clinical signs and pronounced rapidly disappearing, local manifestations;

      b) with minor and general clinical signs of severe, local manifestations of disease.

      II. Destructive appendicitis (phlegmonous, Gangrenous, ruptured):

      a) with an average clinical severity of the disease and symptoms of local peritonitis;

      b) with severe clinical signs and local peritonitis.

      III. Complicated appendicitis:

      a) appendicular infiltration;

      b) with appendicular abscess;

      c) with diffuse peritonitis;

      g) other complications (pileflebitom, Sepsis).

     

clinical classification

      I. Acute simple appendicitis.

      II. Acute destructive appendicitis:

      1. neotgranichennym local peritonitis.

      2. Complications:

          a) appendicular infiltration different localization;

          b) appendicular abscesses of different localization;

          c) diffuse purulent peritonitis;

          g) pileflebitom;

          d) Liver abscesses;

          e) sepsis.

Patanatomical classification of acute appendicitis (AI Abrikosov, 1957).

      I. Bluetongue (surface) appendicitis, primary affect.

      II. Phlegmonous appendicitis:

1. Simple phlegmonous appendicitis.

      2. abscess ulcerative appendicitis.

      3. Apostematozny appendicitis:

          a) without perforation;

          b) with perforation.

      III. Gangrenous appendicitis (primary or secondary):

          a) without perforation;

          b) with perforation.

fig 6 

1. catarrhal amended appendix. 2. abscess  amended appendix.  3. gangrenous  amended appendix

.
 Clinical symptoms:

  a) Subjective symptoms

1. Abdominal pain

2. dyspeptic syndrome

3. General signs of disease

objective evidence

General. 1. Restriction of movements in the right hip joint during walking, maintaining the right hand ileal region, mainly in bed is on the right side with a slightly flexed hip joint of the right lower limb:

 2. Tongue is often dry and furred

 3. Body temperature is moderately increased (up to 38°C) constant; rectal temperature - increased by more than one degree of body temperature (Lenandera symptom);

 4. Pulse - an adequate increase in body temperature - tachycardia.

Local - 1. Restriction respiratory movements of the anterior abdominal wall in the right ileal area and the right side of the abdomen

 2. Skin hyperesthesia the right ileal the

3. Stresses the muscles of the anterior abdominal wall to the right ileal and the right half region of the abdomen during palpation surface, often in combination with high sensitivity and moderate soreness

 4. Severe local pain on deep palpation in the right ileal area, sometimes radiating to the periomphalic and epigastraluyu area

5. To reduce bowel sounds with abdominal auscultation

6. Positive appendicular symptoms

Rovsing's sign (fig 7)

Psoas sign (fig 8)

Sitkovskiy sign/ Rosensteins sings (fig 9)

Symptom Bartholomew-Michelson  (fig 10)

symptom Voskresenskoye (fig 11)

Atypical forms of acute appendicitis

Retrotsekalny and retroperitoneal

Pelvic

The medial (mescocoeciliac)

Left (sinistral)  

Acute appendicitis in children

Acute appendicitis in the elderly

Acute appendicitis in pregnant women

The position of the cecum at different stages of pregnancy (fig 12)

  

Phase clinical course

 Epigastric, local manifestations Phase, phase complications,

appendicular ruptured diffuse peritonitis, appendicular infiltrate,  appendicular abscess,  pylophlebitis, liver abscesses, sepsis

   

Appendicular infiltrate

                                                   subjective symptoms

1. myocardial attack of acute appendicitis a few days ago with a consequent improvement in the general condition

2. moderate, mild persistent pain in the right ileal the area that can be aggravated by some movements and coughing

objective evidence

  1 low-grade Body temperature (up to 38,0-38,5 oC)

• adequate body temperature, tachycardia
• in the right ileal regions (or in another, depending on the location and position of the appendix for a particular patient on the background of a different severity voltage abdominal muscles and inflammatory signs of irritation of the peritoneum palpation determine tumor formation of irregular shape with more or less sharp contours is not entirely smooth surface, dense, few-or still, painful, ranging in size from 3-4 to 10-12 cm; such as tumor formation may be determined by the vaginal or rectal examination
• moderate leucocytosis with a slight shift to the left and leukocyte increasing Choe.

       Appendicular abscess

evidence

   1 amplification and spread of local pain (subjective and objective)

   2 deteriorations in general condition (fever, malaise, intoxication)

   3 hectic body temperature measurement at hourly, sometimes fever

   4 knots in appearance or signs of irritation of the peritoneum in the region infiltration

   5 the possible emergence of symptoms fluctuations palpation infiltration through the anterior abdominal wall or intravaginal (rectal) study

   6 pronounced growth leukocytosis and leftward shift of the leukocytes formula

   7 signs of abdominal abscess by ultrasound

pylephlebitis

evidence

      1 overall heavy, pale face, sub- or ikterichnost sclera, severe weakness

      2 constant moderate pain predominantly in the right half of the abdomen, right upper quadrant

      3, the body temperature of 39-40°c , intermittent, With severe fever, heavy sweats

      4 pulse is frequent, weak

      5 abdomen moderately distended, soft, slightly painful, negative symptoms of peritoneal irritation

      6 an enlarged, painful with palpation the liver, positive symptom Ortner, sometimes enlarged spleen

      7 High leukocytosis (15-30h10⁹) With a pronounced shift to the left, progressive anemia, hyperbilirubinemia

     8 in the right pleural cavity often appears reactive exudate that is verified radiographically or ultrasound; signs of liver abscess with SPL

Laboratory and instrumental methods diagnostics.

      To verify the diagnosis "acute appendicitis"Most often used in clinical practice:

      - CBC - find the most characteristic change leukocytosis with more or less pronounced shift to the left leukocyte (appearance of young forms of neutrophils);

      - urinalysis - normal in a simple and non-specific signs of toxicity during destructive acute appendicitis.

      Additionally, for verification of acute appendicitis in some cases it is possible to use plain film of the abdominal cavity, the measurement of skin temperature contact or Heat graph anterior abdominal wall, ultrasound examination of the abdominal cavity, celiocentesis, Laparoscopy.

differential diagnosis

Right hand basal pleuropneumonia

myocardial infarction

Intercostal neuralgia

acute gastritis

stomach abscess

Exacerbation of peptic ulcer disease

acute cholecystitis

acute pancreatitis

Acute intestinal obstruction

Acute mesenteric thrombosis

Acute diverticulitis (Meckel)

  Acute diseases of female internal genitalia (ovarian apoplexy, impaired ectopic pregnancy, ovarian cysts twisting, acute adnexitis, endometritis. pelvioperitonitis)

urinary tract disease (renal colic, pyelonephritis)

Therapeutic tactics and choice of treatment

      Conservative treatment is indicated only when appendicular infiltrationDiagnosed before or during operation and includes:

      limited driving mode;  complete high-calorie diet with the exception of diet foods rich in fiber;

      cold on the right podvzdoshuyu the area with the available local signs of peritoneal irritation (0.5-1.5 days), with the elimination of the latter - the heat (heating pad);

      complex, according to generally accepted principles of antibiotic therapy (preferably parenterally), aimed at colonic flora;

      perineal novocaine blockade with antibiotics in a day (3-5 for a course);

      detoxication infusion therapy (osmotherapy, stimulation of diuresis in the early days);

      stimulation of the body's defenses.

      If a positive result of such treatment appendicular infiltrategradually resorbed (an average of 1-2 weeks), during this period the volume of medical treatment adequately reduced. After elimination of the clinical signs of a patient discharged from hospital with the recommendation of 2-4 months to perform must be mentioned appendectomy routinely.

Therapeutic tactics and choice of treatment

 Surgery

Appendectomy

disclosure appendicular abscess

Surgery for appendicular peritonitis

  

Chronic appendicitis

      Classification

1. Primary - pathological changes in a process developed gradually with no signs of an acute attack.

      2. Secondary:

      1). residual (Residual) - pathological changes appear after an attack of acute appendicitis, appendicular infiltration. appendicular abscess;

      2). recurrent - if it occurs again acute attacks.

      clinical symptoms

      Subjective symptoms:

      - transferred last acute appendicitis (not operable) appendicular infiltrate (abscess);

      - pain in the right ileal field of the diverse nature of the top associated with food consumption, physical activity of the patient, moderate;

      - Intermittent, moderate (or minor) signs of the passage of the intestinal contents, intestinal motility;

      - the absence of signs of inflammation.

      Objective signs:

      - pain on deep palpation in the right ileal the (In the zone of the appendix);

      - the absence of local signs of inflammation and signs of peritoneal irritation;

      - the possible (no patognomonicheskih) positive appendicular symptoms