Appendicitis - Signs And Symptoms Of Acute And Chronic Appendicitis. Where Is Appendicitis Located?

2024 Author: Josephine Shorter | [email protected]. Last modified: 2023-12-16 21:43

Signs and symptoms of acute and chronic appendicitis

Content:

• What is appendicitis?
• Acute appendicitis
• Chronic appendicitis

What is appendicitis?

Appendicitis is an inflammation of the appendix. Vivid clinical symptoms and numerous nuances of acute and chronic inflammation of the appendix make the diagnosis and surgical treatment of appendicitis both an easy and difficult medical task.

Removal of appendicitis (appendectomy) is the only way of radical treatment of acute and chronic forms of this disease. In Russia, at least one million such operations are performed annually.

Out of the number of operated patients, about 5 thousand patients die from postoperative complications of appendectomy, and about 300 thousand operations are incorrectly performed due to a false diagnosis.

The paradox is that the diagnosis and removal of appendicitis is a routine and routine abdominal (abdominal) surgery.

Comparative analysis of relatively frequent postoperative lethal outcomes and `` wasted '' operations, from which even experienced surgeons are not insured, against the background of the ease of performing surgical procedures, indicates the complexity and depth of the problem.

Apart from diagnostic / operational errors and negative physiological aspects (pregnancy, age, poor condition of the patient), here are the most obvious reasons for failed appendectomy operations:

• late treatment of patients to a medical institution, when the pathogenesis has become catastrophic (rupture of the blind process in the abdominal cavity, purulent peritonitis);
• general innervation of the appendix and adjacent internal organs is accompanied by atypical manifestations and pain (outside the right iliac region)
• general lymph and blood circulation of the appendix and adjacent organs, as a result of which the pathogenesis spreads to neighboring organs.

The involvement of neighboring organs through the blood, lymph and nervous system does not allow to adequately identify inflammation of the appendix even with the help of modern instrumental methods - contrast radiography, CT, ultrasound, diagnostic laparoscopy. In addition, difficulties arise when examining pregnant women at late gestation periods, the elderly and children.

General universal recommendations for suspected inflammation of the appendix:

• Pathogenesis can develop rapidly. Do not wait for a spontaneous solution to the problem, go to the hospital! Doctors should have enough time to make the right decision.
• Use the knowledge about the features of appendicitis, obtained in the framework of health education, to timely contact a medical institution in case of illness.

We will try to provide the most useful information for people without medical education. So, in order.

Why doesn't appendicitis removal reduce quality of life?

For a long time, even among doctors, the appendix was considered an `` extra organ ''. Its purpose was unclear. Uselessness was proved by the preservation of health after removal, and subsequent human diseases did not reveal any etiological connection with the removed organ.

Histological, physiological and immunological experiments have established the importance of the appendix for the body. It consists in the participation of the body in the following processes:

• the formation of the cellular link of immunity - there is a lot of lymphoid tissue in the walls of the appendix;
• the production of hormones that stimulate peristaltic contractions of the intestine, participating in the synthesis of amylase - one of the digestive enzymes that breaks down food starch.

The absence of visible disturbances on the part of the body in persons who underwent appendectomy is explained by the inclusion of compensatory mechanisms. The functions of the lost organ are taken over by other structures. Therefore, appendectomy is a relatively safe procedure. In the absence of side pathologies, homeostasis in people with a removed appendix is preserved. However, you should be aware that the absence of the appendix reduces the "safety margin" of the body.

How does appendicitis occur?

There are several theories. We will present an alternative vision of the problem, although the root cause remains with the causative agents of common infections (staphylococci, streptococci, E. coli, other anaerobes).

The involvement of banal microflora in the pathogenesis of appendicitis is possible when several unfavorable local and general factors coincide against the background of a decrease in social and living conditions.

Local factors:

• Narrowing or blockage of the mouth of the appendix (calculi, swallowed foreign objects, worms, mucus, anatomical deformities of the appendix, inflammation), which is accompanied by stagnation of the contents of the appendix cavity and a decrease in blood circulation of the organ;
• Blood clots of the organ vessels, which cause the development of areas of stagnation and necrosis;
• Spasms, blood clots and stretching of the walls of the appendix reflexively activates the peristalsis of the small intestine, stimulates excessive mucus formation, and disrupts the microcirculation of blood and lymph in the capillaries.

Common factors:

• The nature of the diet and food preferences of the sick person (mono-diets, exclusively meat or carbohydrate food negatively affect);
• The presence of a chronic infectious process in adjacent organs (in the genitourinary system, stomach, intestines, pancreas, respiratory tract);
• Immune system defects, including allergic pathologies.

Social factors:

• Chronic stress (against the background of a labile nervous system);
• The influence of climatic conditions on the body (frequent sore throats, colds, accompanied by the activation of opportunistic microflora).

The combination of three factors leads to the active reproduction of microbes and the development of purulent processes in the appendix.

On which side is appendicitis in humans?

The appendix is located in the projection of the right iliac region.

The appendix is an extension of the cecum. It begins below the border of the transition of the ileum into the colon. The length of the blind intestine is 6-8 cm, the width is 7 cm. Due to the absence of the mesentery, this section is mobile. The appendix (appendix) is approximately 8 cm long and 0.5-1.0 cm wide. There are several options for the location of the appendix in the human abdominal cavity. Accurate topography is of great importance for the surgeon when choosing an operative access to the organ. In other possible situations not related to medical research, knowledge of the exact topography is not required.

The nature of pain with appendicitis

The earliest and most frequently mentioned symptom by patients is pain. In the debut, pain is characterized by paroxysmal manifestations against the background of the absence of precursors of the disease. Initially, the localization of pain is identified by sensations in the navel and / or solar plexus. Further, within a few hours to two days, the pain shifts to the area of the right iliac breath.

The nature of the pain is constant, it increases with coughing, is disturbing in nature, that is, its intensity is often low. The characteristic posture of the patient is on the back with bent legs. Other postures that reduce painful sensations are possible.

Related article: How to determine appendicitis in yourself?

Acute appendicitis

It develops rapidly and is characterized by vivid symptoms.

There are three main types of acute inflammation of the appendix:

• Catarrhal;
• Phlegmonous;
• Gangrenous.

The catarrhal form is characterized by morphological disorders detected by instrumental methods. In the first hours, signs of circulatory stagnation are observed at the apex of the appendix. They are accompanied by edema, lymph effusion and swelling of the mucous membrane. Cone-shaped foci of catarrhal inflammation appear. Initial period changes are reversible.

Phlegmonous appendicitis develops by the end of the first day. The walls of the organ are significantly thickened, the mucous membrane in the mouth becomes covered with pus, and multiple abscesses are found.

More about catarrhal appendicitis

Gangrenous appendicitis is manifested by destructive changes in the walls and the transition of inflammation to the surrounding tissues (periappendicitis) or mesentery (mesenteriolitis).

In some cases, appendicitis ends with the disappearance of symptoms and even recovery.

More about gangrenous appendicitis

Signs of acute appendicitis

Typical manifestations of the opening:

• Pain;
• Nausea, Vomiting caused by reflex excitement;
• Delayed bowel movements and gas;
• Diarrhea is a sign of body intoxication;
• Often hyperthermia (up to 38.0 ⁰ C), rarely the norm;
• Plaque on the tongue, wet at first and dry after a while.

The main symptom of appendicitis - pain - is determined by provocation tests. Dozens of different tests have been proposed for determining appendicitis, four main pain tests:

• Rovzing;
• Sitkovsky;
• Obraztsova;
• Shchetkin-Blumberg.

This test does not describe research methods. To perform them, it is necessary to know well the topographic anatomy of human internal organs. Surgeons, when detecting appendicitis, use more than a dozen different methods for determining the signs of the disease.

Symptoms as determined by a physician on clinical examination:

• Pulse above 100 beats / min against a background of slight hyperthermia;
• The difference in temperature determined in two places - rectally and in the armpit. Normally, the rectal temperature is higher by 0.8-1.0 ⁰ С, and appendicitis with peritonitis is characterized by a more significant difference;
• Blood pressure within the limits of the individual norm, a decrease in blood pressure is evidence of intoxication;
• Bimanual (simultaneously with two hands) palpation of the right and left sides of the abdomen is accompanied by pronounced pain in the right iliac region and reflex tension of the abdominal wall in the place of increased pain;
• Tapping fingers on different parts of the abdomen is manifested locally by increased pain.

According to the time from the onset of the disease, the early and late stages of acute appendicitis are distinguished. The early stage lasts two to three days. On the third day (late stage), with an unfavorable development of the pathology, the inflammatory process spreads outside the organ, and then perforation (rupture) of the walls of the appendix is possible. With a favorable course of inflammation, the attack ends with recovery.

Signs of a favorable (abortive) course of acute inflammation:

• Temperature normalization;
• Disappearance of pain;
• Normalization of appetite.

It is possible to maintain a painful reaction for some time with deep palpation in the right iliac region. The patient, including those with a favorable course of the disease, continues to be under the supervision of a surgeon. The decision on further actions (surgery or conservative treatment) is made by the attending physician. The danger of a favorable course is the transition of the acute phase to the chronic one.

There are three scenarios of pain reactions in this form of pathogenesis:

• Strong, occurs suddenly, is acute, ends quickly;
• Moderately pronounced, takes a long time, fades out slowly;
• Progressive, growing gradually, is debilitating, spreads beyond the inflamed organ, which is associated with an effusion outside the appendix of the inflammatory infiltrate and the transition of inflammation to the organs adjacent to the appendix.

The first two scenarios can end with spontaneous recovery, or with a transition to a sluggish form. The latter ends only with appendectomy.

Localization of pain depends on the location of the appendix.

In addition to the right sigh, pain can radiate and be reflected in other places:

• When the process is displaced closer to the pelvic cavity, pain in the rectum may occur.
• When the process is located behind the cecum, acute pain is localized on the right side of the lower back, in the anatomical region called the Petit triangle (Petit).

The lumbar triangle (another name for the Petit triangle) is defined on the back of the torso, on the lower back, centered on the projection of the kidneys. Other areas of pain response are possible.

Complications of acute appendicitis

There are two main types. Associated with unsuccessful appendectomies is the first type of complication; with pathologies of not removed vermiform appendix - the second type of complications.

I. First type - postoperative complications

Distinguish:

• Early, which develop within the first three days after surgery;
• Late, they develop on the third or fourth day, sometimes after removing the stitches, on the 7-10th day.

There are probably three main options for early complications - postoperative bleeding, intestinal paresis, and acute urinary retention:

• Intraperitoneal postoperative bleeding. The reason is unsuccessful ligation of a blood vessel, bleeding of a small mesenteric vein or artery;
• Venous bleeding is characterized by wetting the edges of the surgical wound and soaking the dressing with blood;
• Arterial bleeding, in addition to the above, is manifested by a rapid deterioration in well-being, pallor of the visible mucous membranes and a decrease in body temperature.
• Postoperative intestinal paresis. The reasons are improper imposition of the intestinal suture, narrowing the intestinal lumen, and reflex stopping of peristalsis due to adhesive inflammation. Paresis is manifested:
• Vomiting undigested food some time after eating;
• Lack of bowel movements;
• Lack of peristaltic noise in the intestines.
• Acute urinary retention. The reason is reflex spasm of the sphincter of the bladder. Manifested by accumulation of urine, unsuccessful urge to urinate, overflow of the bladder, and pain in the lower abdomen.

Late postoperative complications. They develop on the third or fourth day, sometimes later. This is inflammation of the mucous membranes of the peritoneal wall, suppuration of the seams of the postoperative wound:

• Peritonitis is an inflammation of the peritoneum. The reason is the development of a purulent process. It manifests itself as soreness, tension in the walls of the abdomen, fever, vomiting of digested food or bile in its absence.
• Wetting of the stitches after an operating wound. The reason is individual intolerance to surgical threads, insufficient disinfection of the suture site on the stump of the excised appendix. It manifests itself with fever, vomiting, pain.

II. Second type of complications

They occur in persons who delay contacting a medical institution. Complications are associated with difficulties in diagnosing the complex pathogenesis of appendicitis. They are characterized by a very high risk of death. Especially in elderly and senile people.

Distinguish pathological processes accompanied by:

• Infiltration of inflammatory exudate around the inflamed appendix;
• Abscesses of the abdominal cavity and liver;
• Peritonitis due to inflammation of an unremoved organ;
• Douglas space abscess;
• Sepsis - blood poisoning through the common circulatory system and the overflow of pathogenesis to neighboring organs (uterus in women, liver, kidneys, urogenital organs).

Diagnostics of the acute appendicitis

The program of measures to identify appendicitis includes two stages (at home and in the hospital):

Prehospital observation of the patient. Determination of signs of appendicitis by the patient or loved ones. After confirming symptoms similar to appendicitis, you should immediately contact an ambulance and prepare in advance:

• Required documents - passport, insurance policy, possibly a medical card, if it is at home;
• A detailed oral description of the signs of the disease.

Hospital examination of the patient includes:

• physical methods (history taking, examination, palpation, percussion, thermometry);
• Instrumental imaging (diagnostic laparoscopy of the abdominal organs, plain radiography, computed tomography (CT) with contrast, ultrasound);
• Laboratory research.

In the presence of a vivid clinical picture, appendectomy is performed on the basis of physical research methods. The reason for the operation is also a high level of leukocytes - protective cells in the blood, determined by laboratory methods, as well as positive diagnostic tests:

• Bartomier-Michelson. The diagnostic value of this test is very high. The likelihood of appendicitis is 97% when a vivid response is established. The essence of the method: the subject is placed lying on the left side, while palpation of the right iliac breath manifests itself as unpleasant sensations;
• Obraztsova. The diagnostic value is 83%. The essence of the diagnostic study: the patient, while lying down, raises his right leg in a straight position. The pain increases due to muscle tension and displacement of internal organs;
• Rovzing. The diagnostic value is 79%. The essence of the method: with a fist of his left hand, the doctor presses on the projection of the descending branch of the colon. Right hand presses on the opposite side of the abdomen. Inflammation of the appendix is manifested by an unpleasant sensation on the right side of the body.

Treatment of acute appendicitis

All patients with signs of an `` acute abdomen '' are necessarily hospitalized in order to differentiate appendicitis from similar pathologies.

During this period, rectal and / or vaginal examination is mandatory, other types of visualization of the pathological process:

• In the presence of a vivid clinical picture of catarrhal appendicitis, the operation is indicated within the first two to four hours after admission to the hospital;
• Appendicular colic. Unclear signs of colic (for example, spilled loose or dense inflammatory exudate around the organ) require differentiation of the causes. At the hospital stage, additional studies are carried out, the patient is prescribed conservative inpatient (less often outpatient) treatment for 10-20 days (antispasmodics, desensitization, antibiotics). Treatment is usually carried out in a hospital. Removal of the inflamed organ with confirmation of appendicitis is performed in a planned manner after the removal of the phenomena of inflammatory infiltration;
• Appendicitis, complicated by peritonitis (diffuse, diffuse). In this case, a diagnostic laparotomy is shown - a surgical operation, during which the state of internal organs is revised. In recent years, laparoscopy has been used more often - a study of the state of internal organs using an observation device through a small puncture of the abdominal wall.

Depending on the results of laparotomy (laparoscopy), the subsequent algorithm of actions may be as follows:

1. Upon confirmation of catarrhal inflammation, the ileum and uterus are revised (in women);
2. When confirming gynecological pathology against the background of inflammation of the appendix, an operation is recommended;
3. If phlegmonous appendicitis is detected, the operation is postponed until treatment is completed, during this period antibiotics are administered intraperitoneally for 3-4 days.

After complex treatment and normalization of health, a planned operation is performed.

Emergency care for acute appendicitis

The patient and his relatives at the prehospital stage should follow several rules.

Attention! Absolutely forbidden:

• Local heating of the abdomen;
• Removal of pain with medication, alcohol, drugs and any other means;
• The use of laxatives (oil, salt, herbal and any others);
• Enemas are the introduction of fluids into the rectum.

Emergency care for the patient consists of the following activities:

• It is necessary to lay it on a horizontal surface and ensure peace;
• It is allowed to reduce pain by using local dry cooling (container with cold water or ice) on the right side of the abdomen. Between the container with cold and the skin, it is imperative to make a lining of several layers of fabric - this will reduce the risk of local negative cold effects;
• Call an ambulance immediately (tel. 03).

Urgent measures in a medical institution are regulated by service regulations.

Chronic appendicitis

This disease occurs much less frequently than acute appendicitis. Diagnosis is difficult due to a possible distortion of the nature of pain, unclear clinical symptoms and the absence of macrochanges on the walls of the appendix. It is believed that the chronic form of appendicitis is a continuation of acute inflammation. Repeated catarrhal benign inflammation is accompanied by the proliferation of the walls of the organ and connective tissue with the formation of adhesions.

Pathology leads to a narrowing of the process lumen. If the lumen narrows at the mouth of the organ, this causes the accumulation of pus, mucus and transudate in its cavity.

This condition is defined as:

• Empyema of the appendix - accumulation of pus;
• Dropsy of the appendix - an accumulation of transudate (fluid);
• Mucocele of the appendix is a buildup of mucus.

Pathology associated with thickening of the walls of the appendix is much less common. This process is called fibroplastic appendicitis. It resembles an infectious process - tuberculosis (tubercles on an organ), a tumor (overgrown poorly differentiated tissue), actinomycomas - fungal lesions (seals, fistulas on the organ). Sometimes diverticula (pockets) are found on the appendix.

Most often, however, there is no change. This complicates the diagnosis and makes the treatment ineffective.

Can appendicitis be chronic?

The chronic form of appendicitis is isolated as a separate disease. It is divided into:

• Primary chronic appendicitis - when sluggish symptoms, including persistent pain in the iliac region, occur in people who have never previously suffered from an acute form of the disease;
• Secondary chronic appendicitis - when symptoms develop after one or multiple acute attacks of appendicitis.

In the scientific world, there is no consensus on the legality of the nosological unit "primary chronic appendicitis". In the study, there may be no visible violations of the morphological structures of tissues, although the clinical signs of inflammation are pronounced.

In this regard, operations for chronic inflammation in about 60% of cases are `` in vain. ''

After unsuccessful operations, the pain persists, since its cause is associated with damage to other organs. Currently, histological studies are the most reliable marker of chronic inflammation.

Signs of chronic appendicitis

Pain is not a constant, mandatory sign. In some cases, it is insignificant or paroxysmal. It can manifest itself as aching, debilitating unpleasant sensations of low intensity. In some cases, it worsens after eating or exercising, sometimes accompanied by constipation and diarrhea. In women, pain is exacerbated during periods of regular hormonal changes.

They help to suspect the presence of a chronic form of appendicitis, tests that provoke a painful response, including:

• Feeling of the walls of the abdomen - pathology is manifested by pain on the right side;
• The patient on the left side is anxious when palpating the right side of the abdomen.

Other samples used for diagnostic purposes:

• Trying to lift the right leg is unpleasant;
• Decreased muscle tone on the right side of the abdomen is a sign of chronic appendicitis.
• When walking on a treadmill, the right leg gets tired much faster than the left.

The best diagnosis of chronic inflammation of the appendix is laparoscopy. Radiography, its modifications, and ultrasound have limited diagnostic value in chronic inflammation. These methods do not reveal microscopic changes in the walls of the process.

The use of radiation diagnostic methods is limited to identifying indirect signs of inflammation:

• Retention of contrast medium in the cavity for several days;
• Uneven (fragmented) filling with contrast agent.

When making a diagnosis, the exclusion of similar diseases of internal organs is carried out, such as:

• Diseases of the gastrointestinal tract (chronic forms of cholecystitis and pancreatitis);
• Diseases of the urinary system (inflammation of the kidneys, ureters);
• gynecological diseases (violation of the regularity of cycles, chronic inflammation of the appendages).

Chronic appendicitis treatment

Surgical removal of the appendix is most effective. The likelihood of a favorable outcome is lower in comparison with the removal of the appendix in the acute phase. The effectiveness is reduced due to difficult diagnostics and a high risk of developing adhesions in the abdominal cavity.

In some cases, drug treatment is indicated before the removal of the process. The patient is given intravenous antibiotics. During this period, patients need dietary nutrition in order to reduce the load on the intestines.

The author of the article: Volkov Dmitry Sergeevich | c. m. n. surgeon, phlebologist

Education: Moscow State University of Medicine and Dentistry (1996). In 2003 he received a diploma from the Educational and Scientific Medical Center of the Presidential Administration of the Russian Federation.