Chapter 1 Acute appendicitis
Acute appendicitis is nonspecific inflammation of the inner lining of the vermiform appendix that spreads to its other parts. Appendicitis is the most common acute surgical emergency of the abdomen. The incidence of acute appendicitis is around 7% of the population in the United States and in European countries. In Asian and African countries, the incidence is probably lower because of the dietary habits. Appendicitis occurs more frequently in males than in females, with a male-to-female ratio of 1.7:1.
From without inwards the structure of appendix is as follows:
1. Serous coat is composed of peritoneal coat, which covers the whole of the appendix except along the narrow line of attachment of the mesoappendix.
2. Muscle coat. It consists of outer longitudinal muscles and inner circular muscles as seen in case of small intestine. The longitudinal muscle is formed by coalescence of the three taeniae coli at the junction of the caecum and appendix. Thus the taeniae, particularly the anterior taenia may be used as a guide to locate an elusive appendix. The inner circular muscle is continuation of the same muscle in the caecum. The peculiarity of the musculature of the appendix is that there are a few gaps in the muscular layer called “hiatus muscularis”. Through this infection from the submucosal coat directly comes to peritoneum and regional peritonitis occurs.
3. Submucosal coat. The submucous coat of the appendix is very rich in lymphoid tissue. It contains lymphoid follicles which are known as “abdominal tonsil”.
4. The mucous coat resembles that of large intestine.
Various anatomical positions of appendix are:
l. Retrocaecal position (the commonest irregular position – 70%) – the appendix lies behind the caecum although in majority of cases in an intraperitoneal location. Only in case of long retrocaecal appendix the tip of the appendix remains in the retroperitoneal tissue close to the ureter.
2. Pelvic position (second most common irregular position – 25%).
3. Subcaecal (2%).
4. Subhepatic (3%) – that means the tip of the appendix is towards the liver.
Aetiology of acute appendicitis:
1. Obstruction of the appendix lumen (fecoliths, hyperplasia of submucosal lymphoid follicle, intestinal helminthes, vegetables, fruit seeds, barium from previous X-rays).
2. The bacteriology flora. Most frequently seen organisms are Escherichia coli, enterococci, bacteroides (gram-negative rod), nonhaemolytic streptococci, anaerobic streptococci and CI. Welchii.
3. Diet which is relatively rich with fish and meat.
Appendicitis usually has 3 stages:
Ooedematous stage. Appendicitis may have spontaneous regression or may evolve to the second stage. The mesoappendix is commonly involved with inflammation.
Purulent (phlegmonous) stage. Spontaneous regression rarely occurs. Appendicitis usually evolves beyond perforation. Peritonitis may be possible.
Gangrenous stage. Spontaneous regression never occurs.
Kolesov’s classification of acute appendicitis (1952):
1. Appendicular colic.
2. Simple superficial appendicitis.
3. Destructive appendicitis:
4. Complicated appendicitis:
а) appendicular mass;
b) appendicular abscess;
c) diffuse purulent peritonitis.
5. Other complications of acute appendicitis (pylephlebitis, sepsis, retroperitoneal phlegmon, local abscesses of abdominal cavity).
Clinical diagnostics of acute appendicitis
The disease begins with a sudden pain in the abdomen. It is localized in a right iliac region, has moderate intensity, constant character and not irradiate. With 70% of patients the pain arises in epigastric region or other part of abdominal cavity – it is an “epigastric phase” of acute appendicitis. In 2–4 hours it moves to the place of appendix existence (Kocher’s sign). At coughing patients mark strengthening of pain in a right iliac region – it is a positive cough symptom.
Together with it, nausea and vomiting that have reflex character can disturb a patient. The temperature of body of most patients rises, but it is a low grade fever. The general condition of patients is usually normal and gets worse only in case of growth of destructive changes in appendix.
Painfulness is the basic and decisive signs of acute appendicitis during the examination by palpation in a right iliac region. Tension of muscle of abdominal wall is a positive symptom of peritoneum irritation.
Blumberg’s sign. After gradual pressing by fingers on a front abdominal wall from the place of pain quickly, but not acutely, the hand is taken away. Strengthening of pain is considered as a positive symptom in that place. Obligatory here is tension of muscles of front abdominal wall.
Voskresensky’s sign. By a left hand the shirt of patient is drawn downward and fixed on pubis. By the taps of 2–4 fingers of right hand epigastric region is pressed and during exhalation of patient quickly and evenly the hand slides in the direction of right iliac region, without taking the hand away. Thus there is an acute strengthening of pain.
Rovsign’s sign (fig. 1). By a left hand a sigmoid bowel is pressed to the back wall of stomach. By a right hand by balloting palpation a descending bowel is pressed. Appearance of pain in a right iliac region is considered as a sign characteristic of appendicitis.
Sitkovsky’s sign (fig. 2). A patient, that lies on left, feels the pain which arises or increases in the right iliac region. The mechanism of intensification of pain is explained by displacement of blind gut to the left, by drawing of mesentery of the inflamed appendix.
The Obrazcov’s sign (fig. 3). With the position of patient on the back by index and middle fingers the right iliac region of most painful place is pressed and the patient is asked to heave up the straightened right leg. At appendicitis pain increases acutely.
Bartomier’s sign (fig. 4) is the increase of pain intensity during the palpation in right iliac region of patient in position on the left side. At such pose an omentum and loops of small intestine is displaced to the left, and an appendix becomes accessible for palpation.
Rozdolsky’s sign. At percussion there is painfulness in a right iliac region.
The psoas (Roup’s) sign. This test is performed by having the patient lie on his left side. The examiner men slowly extends the patient’s right thigh, thus stretching the ileopsoas muscle. This will produce pain to make the sign positive. This indicates presence of irritative inflamed appendix in close proximity to the psoas muscle. This is possible in retrocaecal appendicitis.
Acute appendicitis in children. With children of infancy acute appendicitis can be seen infrequently, but, quite often carries atypical character. All this is conditioned, mainly, by the features of anatomy of appendix, insufficient of plastic properties of the peritoneum, short omentum and high reactivity of child’s organism. The inflammatory process in the appendix of children quickly makes progress and during the first half of days from the beginning of disease there can appear its destruction, even perforation. The child, more frequent than an adult, suffers vomiting. Its general condition gets worse quickly, and already the positive symptoms of irritation of peritoneum can show up during the first hours of a disease. The temperature reaction is also expressed considerably acuter. In the blood test there is high leukocytosis.
Acute appendicitis of the people of declining and old ages can be met not so often, as of the persons of middle ages and youth. This contingent of patients is hospitalized to hospital rather late: in 2–3 days from the beginning of a disease. Because of the promoted threshold of pain sensitiveness, the intensity of pain in such patients is small, therefore they almost do not fix attention on the epigastric phase of appendicitis. More frequent are nausea and vomiting, and the temperature reaction is expressed poorly. Tension of muscles of abdominal wall is absent or insignificant through old-age relaxation of muscles. But the symptoms of irritation of peritoneum keep the diagnostic value with this group of patients. Thus, the sclerosis of vessels of appendix results in its rapid numbness, initially gangrenous appendicitis develops. Because of such reasons the destructive forms of appendicitis prevail, often there is appendicular infiltrate.
With pregnant women both the bend of appendix and violation of its blood flow are causes of the origin of appendicitis. Increased in sizes uterus causes such changes. It, especially in the second half of pregnancy, displaces a blind gut together with an appendix upwards, and an overdistension abdominal wall does not create adequate tension. Together with that, psoas sign and Kocher’s sign, Bartomier’s sign have a diagnostic value at pregnant women.
Appendicitis at retrocecal and retroperitoneal location. Thus an appendix can be placed both in a free abdominal cavity and retroperitoneal. An atypical clinic arises, as a rule, at the retroperitoneal location. The patients complain of pain in lumbus or above the wing of right ileum. There they mark painfulness during palpation. Sometimes the pain irradiates to the pelvis and in the right thigh. The positive Rozanov’s sign – painfulness during palpation in the right Pti triangle is characteristic. In transition of inflammatory process on an ureter and kidney in the urines analysis red corpuscles can be found.
The pelvic location of appendix. In such patients the pain is localized above the right Poupart’s ligament and above pubis. At the very low placing of appendix at the beginning of disease the reaction of muscles of front abdominal wall on an inflammatory process can be absent. With transition of inflammation of an urinary bladder or rectum either the dysuria signs or diarrhaea develop. Distribution of process on internal genital organs provokes signs characteristic of their inflammation.
Appendicitis at the medial placing of appendix. The appendix in patients with such pathology is located between the loops of intestine, which is the large field of irritation of peritoneum. At these anatomic features mesentery is pulled in the inflammatory process, acute dynamic of the intestinal obstruction develops in such patients. The pain in the abdomen is intensive, widespread, the expressed tension of muscles of abdominal wall develops.
For the subhepatic location of appendix the pain is characteristic in right hypochondrium. During palpation painfulness and tension of muscles can be marked.
Left-side appendicitis appears infrequently and, as a rule, in case of the reverse placing of all organs; however it can occur at a mobile blind gut. In this situation all signs which characterize acute appendicitis will be exposed not on the right, as usually, but on the left.
White Blood Cell Count. Acute appendicitis is not the only condition that causes elevated white blood cell counts. Almost any infection or inflammation can cause this count to be abnormally high. Therefore, an elevated white blood cell count alone cannot be used as a sign of appendicitis.
Urinalysis. Urinalysis is a microscopic examination of the urine that detects red blood cells, white blood cells and bacteria in the urine. Urinalysis usually is abnormal when there is inflammation or stones in the kidneys or bladder. The urinalysis also may be abnormal with appendicitis because the appendix lies near the ureter and bladder. If the inflammation of appendicitis is great enough, it can spread to the ureter and bladder leading to an abnormal urinalysis. Most patients with appendicitis, however, have a normal urinalysis. Therefore, a normal urinalysis suggests appendicitis more than a urinary tract problem.
Abdominal X-ray. An abdominal X-ray may detect the faecalith that may be the cause of appendicitis. This is especially true in children.
Chest films may be performed to exclude any disease of the base of the right lung as disease in this region may irritate the spinal nerve to simulate the symptoms of appendicitis.
Ultrasonic (US). Ultrasonic can identify an enlarged appendix or an abscess. Nevertheless, during appendicitis, the appendix can be seen in only 50% of patients. Therefore, not seeing the appendix during an Ultrasonic does not exclude appendicitis. Ultrasonic also is helpful in patients with renal colic and in women because it can exclude the presence of conditions involving the ovaries, fallopian tubes and uterus.
Ultrasonic target sign of acute appendicitis can be detected (fig. 5). Transverse Ultrasonic scan through an inflamed appendix shows an intact echogenic submucosal layer and a fluid-filled lumen (F), resulting in a “target” appearance.
Computerized tomography (CT) scan. In patients who are not pregnant, a CT scan of the appendix region is useful in acute appendicitis and periappendicular abscesses diagnosis (fig. 6) as well as in excluding other diseases inside the abdomen and pelvis that can mimic appendicitis.
Laparoscopy. Laparoscopy is a surgical procedure in which a small fiber-optic tube with a camera is inserted into the abdomen through a small puncture made on the abdominal wall.
Laparoscopy allows a direct view of the appendix as well as other abdominal and pelvic organs. If appendicitis is found, the inflamed appendix can be removed with the laparoscope.
Differential diagnosis of acute appendicitis
Food toxicoinfection. Complaints of pain in the epigastric region of the intermittent character, nausea, vomiting and liquid emptying are the first signs of disease. The state of patients progressively gets worse from the beginning. Next to that, it is succeeded to expose that a patient used meal of poorquality. However, here patients do not have phase passing, which is characteristic of acute appendicitis, and clear localization of pain. Defining the symptoms of irritation of peritoneum is not succeeded, the peristalsis of intestine is increased.
Acute pancreatitis. In anamnesis in patients with this pathology there is a gallstone disease, violation of diet and use of alcohol. Their condition from the beginning of a disease is heavy. Pain is considerably more intensive, than during appendicitis, and is concentrated in the upper half of abdomen. Vomiting is frequent and does not bring to the recovery of patients.
Acute cholecystitis. The high placing of vermiform appendix in the right half of abdomen during its inflammation can cause the clinic somewhat similar to acute cholecystitis. But unlike appendicitis, in patients with cholecystitis the pain is more intensive, has cramp-like character, is localized in right hypochondrium and irradiate in the right shoulder. Also the epigastric phase is absent. The attack of pain can arise after the reception of spicy food and, is accompanied by nausea and frequent vomiting by bile. In anamnesis patients often have information about a gallstone disease. During examination intensive painfulness in right hypochondrium, increased gallbladder and positive Murphy’s and Ortner’s signs are observed.
Perforated peptic ulcer. Diagnostic difficulties during this pathology arise up only on occasion. They can be in patients with the covered perforation, when portion of gastric juice flows out in an abdominal cavity and stays too long in the right iliac region, or in case of atypical perforations. On the abdominal X-ray gram under the right copula of diaphragm free gaze can be found.
The apoplexy of ovaryа more frequent is with young women and, as a rule, on the 10–14th day after menstruation. Pain appears suddenly and irradiate in the thigh and perineum. At the beginning of disease there can be a collapse. However, the general condition of patients suffers insignificantly. When not enough blood was passed in the abdominal cavity, all signs of pathology of abdominal cavity organs calm down after some time. Signs, which are characteristic of acute anemia, appear at considerable haemorrhage. Abdomen more frequent is soft and painful down (positive Kulenkampff’s sign: acute pain during palpation of stomach and absent tension of muscles of the front abdominal wall).
Extrauterine pregnancy. A necessity to differentiate acute appendicitis with the interrupted extrauterine pregnancy arises, when during the examination the patient complains of the pain only down in the stomach, more to the right. Taking it into account, it is needed to remember, that at extrauterine pregnancy a few days before there can be intermittent pain in the lower part of the abdomen, sometimes excretions of “coffee” colour appear from vagina. In anamnesis often there are the present gynecological diseases, abortions and pathological passing of pregnancy. For the clinical picture of such patient inherent sudden appearance of intensive pain in lower part of the abdomen. Often there is a brief loss of consciousness. During palpation considerable painfulness is localized lower, than at appendicitis, the abdomen is soft, the positive Kulenkampff’s sign is determined. Violations of menstrual cycle testify for pregnancy, characteristic changes are in milk glands, vagina and uterus. During the vaginal examination it is sometimes possible to palpate increased tube of uterus. The temperature of body more frequently is normal. If haemorrhage is small, the changes in the blood test are not present. The convincing proof of the broken extrauterine pregnancy is the dark colour of blood, taken at puncture of back fornix of vagina.
Right-side kidney colic. For this disease pain at the level of kidney and in lumbus is inherent, haematuria and dysuria signs can take place at the irritation of ureter by the inflamed appendix. Intensity of pain in kidney colic is one of the basic differences from acute appendicitis. Pain at first appears in lumbus and irradiate downward after passing of ureter in genital organs and front surface of the thigh. In diagnostics urogram survey is important, and if necessary – chromocystoscopy. Absence of right kidney function to some extent allows eliminating the diagnosis of acute appendicitis.
Diabetic abdomen indicates abdominal pain and vomiting which precede coma.
Treatment of acute appendicitis
Acute appendicitis is treated by surgery to remove the appendix (appendectomy). The operation may be performed through a standard small incision in the right lower part of the abdomen, or it may be performed using a laparoscopy, which requires three to four smaller incisions. In patients with diffuse or general peritonitis middle line laparotomy is preferred.
Do not administer analgesics and antipyretics to patients with suspected appendicitis who have not been evaluated by the surgeon.
Preparation of patients undergoing appendectomy is similar for both open and laparoscopic procedures. Perform complete routine laboratory and radiologic studies before intervention. Venous access must be obtained in all patients diagnosed with appendicitis. Venous access allows administration of isotonic fluids and broad-spectrum intravenous antibiotics prior to the operation. Prior to the start of the surgical procedure, the anaesthesiologist performs endotracheal intubation to administer volatile anaesthetics and to assist respiration. The abdomen is washed, antiseptically prepared, and then draped.
Surgical incisions for open appendectomy are:
line oblique incision over the McBurney point (i.e., two thirds of the way between the umbilicus and the anterior superior iliac spine);
vertical incisions (i.e., the Battle pararectal) are rarely performed because of the tendency for herniation;
middle line laparotomy.
After cutting of peritoneum abdominal cavity is opened. Note the character of any peritoneal fluid to help confirm the diagnosis and then suction it from the field. If it is purulent, collect and culture the fluid.
The convergence of taenia coli is detected at the base of the appendix, beneath the Bauhin valve (i.e., the ileocaecal valve), and the appendix is then viewed. If the appendix is hidden, it can be detected medially by retracting the caecum and laterally by extending the peritoneal incision.
After exteriorization of the appendix, the mesoappendix is held between clamps, divided, and ligated. The appendix is clamped proximally about 5 mm above the caecum to avoid contamination of the peritoneal cavity and is cut above the clamp by a scalpel. The appendix must be ligated to prevent bleeding and leakage from the lumen. The appendix may be inverted into the caecum with the use of a purse-string suture or z-stitch.
The caecum is placed back into the abdomen. The abdomen is irrigated. When evidence of free perforation exists, peritoneal lavage with several liters of warm saline is recommended. After the lavage, the irrigation fluid must be completely aspirated to avoid the possibility of spreading infection to other regions of the peritoneal cavity. The use of a drain is not commonly required in patients with acute appendicitis, but obvious abscess with gross contamination requires drainage.
The wound closure begins by closing the peritoneum with a running suture. Then, the fibers of the muscular and fascial layers are reapproximated and closed with a continuous or interrupted absorbable suture. Lastly, the skin is closed with subcutaneous sutures or staples. In cases of perforated appendicitis, some surgeons leave the wound open, allowing for secondary closure or a delayed primary closure until the fourth or fifth day after operation. Other surgeons prefer immediate closure in these cases.
According to the preferences of the surgeon, a short supraumbilical incision is made to allow the placement of a Hasson cannula or Veress needle. Pneumoperitoneum (10 – 14 mm Hg) is established and maintained by insufflating carbon dioxide. Through the access, a laparoscope is inserted to view the entire abdomen cavity. A 10-mm port is inserted through supraumbilical incision for camera. Another two 5-mm ports are placed in the right and left inguinal regions for manipulations. The appendix is grasped and retracted upward to expose the mesoappendix. The mesoappendix is divided, ligated or coagulated. The appendix may be transected with a linear endostapler, or, alternately, the base of the appendix may be suture ligated in a usual manner to that in an open procedure. The appendix is removed using a laparoscopic pouch to prevent wound contamination.
Administer intravenous antibiotics postoperatively. The length of administration is based on the operative findings and the recovery of the patient. In complicated appendicitis, antibiotics may be required for many days or weeks.
Antiemetic’s and analgesics are administered to patients experiencing nausea and wound pain. The patient is encouraged to ambulate early.
In patients with complicated appendicitis, a clear liquid diet may be started when bowel function returns.
After hospital discharge, patients must have a light diet and limit their physical activity for a period of 2–6 weeks based on the surgical approach (i.e., laparoscopic or open appendectomy). The patient should be evaluated by the surgeon in the clinic to determine improvement and to detect any possible complications:
wound infection especially in patients with gangrenous or perforated appendicitis;ileus;
pelvic or abdominal abscess.
Complications of acute appendicitis
Appendicular mass. In majority of cases as soon as the appendix becomes gangrenous, omentum and coils of small intestine cover the appendix all around. There is no discrete collection of pus inside. This is an attempt of the nature to prevent general peritonitis even if rupture of the appendix occurs. Usually such appendicular mass develops on die 3rd day after the commencement of an attack of acute appendicitis. This is a tender mass on the right iliac fossa. This mass usually resolves by conservative treatment. In untreated cases when the patient does not react to the conservative treatment such appendicular mass may turn into an appendicular abscess and becomes larger in size.
Treatment of the appendicular mass. In these cases conservative treatment should be started immediately. Surgery at this stage is difficult and dangerous as it is difficult to find appendix due to adhesions and ultimately faecal fistula may form.
Conservative treatment includes intravenous fluid with dextrose saline and Ringer solution as and when required; nasogastric aspiration; antibiotic therapy. A broad - spectrum antibiotic should be given intramuscularly. Metronidazole may be given intravenously.
The conditions for stopping the conservative treatment are: a) arising pulse rate; b) vomiting or increase in gastric aspiration; c) increasing abdominal pain – suggesting spreading peritonitis; d) mass becomes larger in size.
About 90% of cases resolve without any problem. The patient is kept under observation for further 4 to 5 days after resolution of the mass. Patient is instructed to have appendectomy 6 to 8 weeks after his discharge.
Appendicular abscess. A progressive supportive process in an appendicular mass forms an appendicular abscess walled off by the omentum, inflamed caecum and coils of small intestine. Such abscess may follow rupture of the appendix. The most common site of the abscess is in the lateral part of the iliac fossa (from retrocaecal appendicitis). The second common position is in the pelvis. In untreated cases lethal form of peritonitis is produced by secondary rupture of appendicular abscess.
At abscessing of infiltrate the condition of a patient gets worse, the symptoms of acute appendicitis become more expressed, the temperature of body, which in most cases gains hectic character, rises, the fever appears. Next to that, pain in the right iliac region increases. Painful formation is felt there. In the blood test high leukocytosis is present with the acutely expressed change of leukocyte formula to the left. The temperature of body rises to 38.0–39.0 °С. During the rectal examination the weakened sphincter of anus is found. The front wall of rectum at first is only painful, and then its overhanging is observed as dense painful infiltrate.
Treatment of appendicular abscess. Immediate drainage under antibiotic cover is the treatment of choice. Appendectomy is not performed. A pelvic abscess may be drained in the female into the vagina and in the male into the rectum. If the appendix is not removed when the abscess is drained, interval of appendectomy should be carried out 6 to 8 weeks after.
Pylephlebitis. Ascending septic thrombophlebitis of portal venous system (pylethrombophlebitis) is a grave but rare complication of gangrenous appendicitis. Septic clots from involved mesenteric veins produce multiple pyogenic abscesses in the liver. It is more frequent in patients with acute retrocaecal appendicitis. It is heralded by chills, hectic fever, right upper quadrant pain and jaundice. Pylephlebitis is a complication of both appendicitis and after-operative period of appendectomy.
In case with rapid passing of disease the icterus appears, the liver is increased, kidney-hepatic insufficiency makes progress, and patients die in 7–10 days from the beginning of disease.
At gradual subacute development of pathology the liver and spleen is increased in size, and after the septic state of organism ascites arises.
Peritonitis. Peritonitis is happened when bacterial and other contents of the appendix leak into the abdomen.