Acute Appendicitis

Acute appendicitis is a rapidly progressing inflammation of a small part of the large intestine called theappendix. The appendix is a pouch-like structure located in the lower right quadrant of the abdomen near the area where the small intestine links into the large intestine. The exact function of the appendix is not known, although it might be useful in protecting beneficial bacteria of the colon.Acute appendicitis can occur when a piece of food, stool or object becomes trapped in theappendix. Acute appendicitis can also happen after a gastrointestinal infection. The appendix is a wormlike extension of the cecum and, for this reason, has been called the vermiform appendix. The average length of the appendix is 8-10 cm Etiology and pathogenesis of acute appendicitis. There will be dysfunction of the neuro-regulatory apparatus of the appendix leads to the the blood supply disturbance resulting in wall-tissue edema, accumulation of the intestinal contents in the appendix and its distension Dysfunction of the neuro-regulatory apparatus may develop as a result of food allergy, helminthic invasion gastrointestinal diseases, gall-bladder diseases foreign bodies, impacted feces The appendix is contained within the visceral peritoneum that forms the serosa, and its exterior layer is longitudinal and derived from the taenia coli; the deeper, interior muscle layer is circular. Beneath these layers lies the submucosal layer, which contains lymphoepithelial tissue. The mucosa consists of columnar epithelium with few glandular elements and neuroendocrine argentaffin cells.

Taenia coli converge on the posteromedial area of the cecum, which is the site of the appendiceal base. The appendix runs into a serosal sheet of the peritoneum called the mesoappendix, within which courses the appendicular artery, which is derived from the ileocolic artery. Sometimes, an accessory appendicular artery (deriving from the posterior cecal artery) may be found. It was held that a period of the primary affect development took 6-12 hours from the onset of the disease; a period of the phlegmon development 12-24 hours; a period of gangrenous appendicitis is 24-28 hours and the perforation of the appendix develops even later. But a prolonged experience of treating many patients with acute appendicitis may add new details to that statement. Thus, if acute appendicitis could develop in stages consequently from the slightest stages to the most severe stages, the amount of destructive complicated types of the disease at the later terms would increase in time. But this does not occur. It is also known that primary gangrene may develop in the onset of the disease before the inflammatory changes development when spasms of the appendicular vessels with the resultant thrombosis occur. It should likely be considered that in one cases acute appendicitis may develop in stages, in another cases it may develop as the primary gangrene type.

symptoms
weakness, malaize, loss of appetites are not well pronounced at the onset of the disease. The temperature is usually subfebrile; sometimes it is followed by the chill. Pulse rate is increased, but it corresponds to the body temperature. The tongue is wet and coated. The skin color is normal. classification of Acute appendicitis 1. Appendicular colic 2. Catarrhal (congestive) appendicitis 3 Destructive appendicitis: phlegmonous, gangrenous, perforated 4 Complicated appendicitis: appendix mass, abscess, diffuse suppurative peritonitis

Clinical and diagnostic features of acute appendicitis The clinical picture develops in a short period of time (from some hours to 1-2 days) and consists of a series of symptoms which can be revealed while questioning and examining a patient. The general condition of patients in case of an early admission to the clinic is satisfactory. The patients are usually calm. In 80% of studies a pain in the right iliac region can be revealed. Abdominal pain is a leading symptom, which usually develops suddenly in an otherwise healthy patient. The pain is usually dull, but rather violent and steady. Sometimes it becomes crampy and may be localized in the right iliac region at once or later. Kocher-Volkovichs symptom Pain can appear in the epigastrial region near the navel. With the clinical behavior it may shift to the right iliac region. Voskresenskiys symptom (a symptom of a shirt) Fast sliding movements with the fingers from the upper to the lower part of the abdomen on a shirt that fit closely the patients abdomen causes tenderness in the right iliac region, which is considered to be a sign of parietal peritoneum irritation Blumberg sign Deep palpation of the viscera over the suspected inflamed appendix followed by sudden release of the pressure causes the severe pain on the site indicating positive Blumberg's sign and peritonitis. Rovsings symptom is characterized by pain in the right iliac region during jerky movements in the left iliac region. Sitkovskys symptom is seen when a pain arises in the right iliac region when changing a patients position from the supine to the left lateral position due to the displacement of the caecum and the appendix in the medial direction, as well as distension of the inflamed peritoneum.

Bartomier-Mikhelsons symptom. Abdominal palpation in a patient who is in the left lateral position causes pain to increase in the right iliac region due to the displacement of the internal organs to the left and a better accessibility of the appendix for the examination Razdolskys symptom is an appearance of pain during a slight tapotement of the abdominal wall in the right iliac region. Obrazcovs symptom refers to the increase of local pain in the right iliac region on abdominal palpation when a patient raises his straight right leg. Contracting muscle psoas seems to be moving the caecum with the appendix towards the anterior abdominal wall. Appendicular colic is characterized by non-intense and aching pain in the right iliac region with the normal body temperature and satisfactory condition of a patient. Abdominal palpation reveals insignificant tenderness in the right iliac region. Acute catarrhal appendicitis is characterized by a mild pain, nausea, single vomiting. Kocher-Volkovichs symptom is often positive. The general condition of patients is usually satisfactory. The tongue is wet, the body temperature reaches 37.237.4 C. The pulse increases along with the body temperature. Abdominal palpation reveals tenderness and muscular tension in the right iliac region. Phlegmonous appendicitis is characterized by constant and intense pain in the right iliac region, nausea and sometimes vomiting. The general condition of a patient changes malaise and weakness become apparent. The right side of the abdomen fails to keep up with the left one when breathing. The body temperature reaches 38-38.5 C, The pulse rate is 80-90 beats per minute. The tongue is wet coated with white furr. Palpation of the right iliac region reveals significant tenderness and pronounced muscular tension. All symptoms as well as Shchotkin-Blumbergs symptoms are well

determined. Gangrenous appendicitis is manifested by subsided or no pain due to necrosis of the nervous apparatus of the appendix. Vomiting can be multiple and does not help patients. The general condition of a patient is severe, due to a pronounced intoxication. The temperature is usually normal, but the pulse rate is 100-120 beats per minute. The tongue is coated and dry. Palpation in the right iliac region reveals acute pain and muscular tension. Appendicular symptoms are positive Acute appendicitis in the elderly has blurry signs due to a low reactivity of the organism and the presence of expressed concommittant diseases. The clinical symptoms are as follows: non-intensive pain in the abdomen, normal temperature, a slight or no tension of the anterior abdominal wall muscles, minor leukocytosis with the shift of the differential count to the left. But skin hyperesthesia and Shchotkin-Blumbergs symptom are revealed quite often Acute appendicitis in pregnancy is seen in 0.7-1.2% of cases, i.e. more often then in other group of patients. The clinical features in the first half of pregnancy are the same. During the second half of pregnancy, the displacement of the caecum and the appendix by the increased uterine may cause a pain to shift a location to the right iliac area as well as the right subcostal area. The type of inflammation is usually phlegmonous or gangrenous, but regardless of the destruction, a pain syndrome is insignificant. Patients dons pay attention to pain, nausea and vomiting thinking them to be manifestations of pregnancy.