appendicitis
Introduction
Introduction to appendicitis Appendicitis refers to an inflammatory change in the appendix due to a variety of factors. It is a common disease whose prognosis depends on timely diagnosis and treatment. Early diagnosis and treatment, patients can recover in a short period of time, the mortality rate is extremely low (o.1% - 0.2%); if the diagnosis and treatment delay can cause serious complications, and even cause death. Appendicitis is a common disease. Clinically, there are often lower right abdominal pain, elevated body temperature, vomiting and neutrophilia. Appendicitis is inflammation of the appendix, the most common abdominal surgical disease. Poor emptying of the appendix is one of the main causes of appendicitis. Mainly due to the curved blind tube, the opening is small, the lumen is narrow, and the peristalsis is extremely slow, so that the appendix lumen is easily blocked, often due to obstruction of feces (stone), food fragments, mites or foreign bodies. Simple acute appendicitis is treated with non-surgical therapy. Chronic appendicitis is treated with conservative treatment of the appendix. Most patients can be cured, but those with chronic inflammation or narrow lumen are prone to recurrence. Therefore, if the diagnosis of acute appendicitis is clear, the emergency diagnosis will be performed. Excision of the appendix. Due to pelvic congestion during pregnancy, appendicitis develops faster, so surgery should be performed promptly. basic knowledge The proportion of illness: 0.3% (this disease is a common disease, can occur in any age group, the incidence rate is about 50%) Susceptible people: no special people Mode of infection: non-infectious Complications: indigestion
Cause
The cause of appendicitis
Physical factors (30%):
Poor emptying of the appendix is one of the main causes of appendicitis. Mainly due to the curved blind tube, the opening is small, the lumen is narrow, and the peristalsis is extremely slow, so that the appendix lumen is easily blocked, often due to obstruction of feces (stone), food fragments, mites or foreign bodies.
Physiological factors (30%):
The appendix is short, the appendix is twisted, and the opening is small. When the gastrointestinal motility is disordered, the appendix peristalsis will be less reflective and slower, which will also cause obstruction. At this time, bacteria invade the lumen, causing inflammation.
Pathological factors (30%):
Adhesion outside the appendix, fibrous cords, and tumor compression can also cause obstruction and cause inflammation.
Prevention
Appendicitis prevention
Prevention common sense
1. Enhance physical fitness and pay attention to hygiene.
2. Be careful not to suffer from cold and diet.
3. Timely treatment of constipation and intestinal parasites.
Precautions
1. Abdominal pain can not be used painkillers without a clear diagnosis. Because the condition is covered up after pain relief, it is easy to delay the diagnosis and cause serious consequences.
2. After acute appendicitis, if the family treatment has no effect, send it to the hospital in time.
3. According to the current medical level and technical conditions, the surgical treatment of acute appendicitis is better. Even after conservative treatment, it is easy to re-emerge. Therefore, acute appendicitis is mainly treated with surgery under conditional conditions.
4. Non-surgical treatment should be thorough when taking the medicine. After the disappearance of symptoms and signs, the drug-week is still applied to consolidate the curative effect and reduce recurrence.
5. Hospitalization should be arranged by the doctor. The accompanying staff should cooperate with the medical staff to do the work of the patient.
6. The disease and physical signs of appendicitis vary greatly, and many patients have atypical performance. If you are not sure, it is best to go to the hospital. So as not to delay diagnosis and treatment.
Complication
Appendicitis complications Complications, indigestion
1. Complications of acute appendicitis
(1) abdominal abscess: it is the consequence of appendicitis without timely treatment. Abscess around the appendix around the appendix is the most common form, and abscess can also be formed in other parts of the abdomen. Common parts include pelvic cavity, 99 iliac crest or intestinal space. Clinical manifestations of bloating symptoms of paralytic ileus, tender masses and symptoms of systemic infections. B-ultrasound and CT scan can assist in positioning. Once diagnosed, puncture or drainage should be performed under ultrasound guidance, or surgical drainage should be performed if necessary. Because the inflammation adhesion is heavier, care should be taken to prevent the secondary injury when incision and drainage, especially the intestinal injury. Chinese medicine has a good effect in the treatment of abscess around the appendix, and can be applied. The recurrence rate of appendix abscess after non-surgical treatment is high. Therefore, the surgical treatment of the appendix should be performed 3 months after the cure, which is better than the emergency surgery.
(2) internal and external sputum formation: if the abscess around the appendix is not drained in time, a few cases of abscess can be broken into the small intestine or large intestine, or can be worn through the bladder, vagina or abdominal wall to form various internal or external sputum. At this time, the pus can be discharged through repeated tubes. X-ray-tantalum examination or external catheterization can help to understand the follow-up of the tube and help to choose the appropriate treatment.
(3) pylephlebitis: Infectious thrombosis in the appendix vein in acute appendicitis, along the superior mesenteric vein to the portal vein, leading to purulent portal vein inflammation. Clinical manifestations include chills, high fever, hepatomegaly, tenderness under xiphoid, mild jaundice, etc. Although it is rare, if the condition is aggravated, it will produce septic shock and sepsis, and the treatment delay may develop into a bacterial liver abscess. Appendectomy and high-dose antibiotics are effective.
2. Complications after appendectomy
(1) Bleeding: The ligature of the appendix is loose, causing mesangial vascular bleeding. It is characterized by abdominal pain, bloating and hemorrhagic shock. The key is prevention. The appendix is well ligated. The mesenteric hypertrophy should be bundled and ligated. The ligature line should be separated from the mesenteric edge. The mesangial ligature should be cut off in time to avoid loosening. Once bleeding occurs, blood transfusion should be performed immediately, and emergency surgery should be performed to stop bleeding.
(2) Incision infection: is the most common postoperative complications. More common in suppurative or perforated acute appendicitis. In recent years, this complication has been less common due to the improvement of surgical techniques and the application of effective antibiotics. Intraoperative incision protection, incision irrigation, complete hemostasis, elimination of dead space and other measures can prevent wound infection. The clinical manifestations of wound infection include elevated body temperature 2-3 days after surgery, pain or tenderness in the incision, local redness and tenderness. Treatment principle: You can try to puncture the pus first, or remove the suture at the fluctuating place, discharge the pus, place the drainage, and change the medicine regularly. Short-term cure.
(3) Adhesive intestinal obstruction: it is also a common complication after appendectomy. It is related to various local causes such as severe local inflammation, surgical injury, foreign body incision, and bed rest after surgery. Once diagnosed with acute appendicitis, early surgery should be performed, and early postoperative detachment activities can be appropriately prevented. Patients with severe intestinal obstruction must be treated surgically.
(4) Appendicitis of the appendix: When the stump of the appendix remains more than 1 cm long, or the fecal stone remains, the residual strain may recur and relapse after surgery, and it still shows the symptoms of appendicitis. Occasionally, the lesion was not removed during the operation, but it was left behind and the inflammation recurred. A sputum enema fluoroscopy should be performed to confirm the diagnosis. When the symptoms are severe, the appendix residue should be surgically removed again.
(5) Feces repeatedly: rarely seen. There are many reasons for postoperative fecal fistula. The appendix stump is simply ligated, and the ligature is detached. The cecum is originally tuberculosis, cancer, etc.; cecal tissue edema is fragile during suturing. If the feces occur repeatedly, it will be limited, and diffuse peritonitis will not occur, similar to the clinical manifestations of abscess around the appendix. Such as non-tuberculosis or tumor lesions, etc., generally non-surgical treatment of feces can be closed and self-healing.
harm
(1) If acute appendicitis fails to be treated early, perforation of the appendix, suppuration, and severe comorbidities such as diffuse peritonitis, the mortality rate is high, and the survivors often suffer from intestinal obstruction due to intestinal adhesions, and the patient is very painful;
(2) The typical clinical manifestation of acute appendicitis is the gradual pain in the upper abdomen or around the umbilicus. After a few hours, the abdominal pain is transferred to the right lower abdomen. Often accompanied by loss of appetite, nausea or vomiting, acute appendicitis has a mortality rate of less than 1%, the mortality rate after diffuse peritonitis is 5 to 10%, which is very harmful. Acute appendicitis can be left after non-surgical treatment or cure. The fibrous tissue of the appendix wall is hyperplasia and thickening, the stenosis of the lumen and the surrounding adhesions. This is called chronic appendicitis and is likely to cause a second episode;
(3) The gastrointestinal activity was temporarily stopped after the intestinal surgery. The water that enters the gastrointestinal tract cannot go down, and it accumulates in the stomach and causes bloating. So you can't eat and drink after surgery. You must wait until the gastrointestinal activity is restored before you can eat.
Symptom
Appendicitis symptoms Common symptoms Right lower abdominal pain Diffuse umbilical pain Pain nausea and vomiting Diarrhea Loss of appetite Sustained fever Neutrophil increased constipation
Typical appendicitis has the following symptoms:
1. Pain in the right lower quadrant.
2, nausea, vomiting.
3. Constipation or diarrhea.
4, low fever.
5, loss of appetite and bloating and so on.
The abdominal pain of appendicitis begins at the upper abdomen, under the xiphoid or around the navel. After about 6-8 hours, the abdominal pain gradually moves down and is finally fixed in the right lower abdomen. When you cough, sneeze or press, your lower right abdomen will be painful.
Examine
Examination of appendicitis
Acute appendicitis examination
1, blood phase: the total number of white blood cells can be increased to l. 2 ~ 14,000 / mm 3 ; and neutrophils accounted for 85% ~ 95%, such as neutrophils increased to more than 85% more than the disease is more serious, and sometimes Visible poison particles. However, there are also cases in which individual appendicitis patients do not rise significantly from the cells.
2, abdominal fistula should be done for difficult cases, and those with pus cells after microscopic examination can be diagnosed.
3, CT can directly display the appendix and surrounding soft tissue and inflammation.
4, B-ultrasound: B-ultrasound under normal appendix no image display, more than 6mm can determine the diagnosis of appendicitis, the width of the appendix cavity increases, showing the size of the abscess around the appendix.
Chronic appendicitis examination
1. X-ray barium enema examination: It can be seen that the development of the appendix is interrupted, twisted, and the emptying is slow, and it is not easy to be pushed due to adhesion. If the appendix cavity is fully occluded, it will not be developed. This test is important for those who have no typical history of seizures. Barium enema examination not only clarifies that the tender point is located at the appendix, but also excludes other diseases that can be confused with chronic appendicitis, such as ulcer disease, chronic colitis, cecal tuberculosis or cancer, and visceral droop.
2, ultrasound examination: to exclude the most difficult to be confused with chronic appendicitis, chronic cholecystitis, chronic inflammation of women and chronic urinary tract infections. About 35% of the patients diagnosed with chronic appendicitis had no improvement in postoperative symptoms, and all other diseases were misdiagnosed as chronic appendicitis. It is obvious that the rate of misdiagnosis is high and the preoperative differential diagnosis is important.
Diagnosis
Diagnosis and differentiation of appendicitis
Diagnostic points:
1. Acute metastatic right lower quadrant pain, appetite decreased significantly, nausea and vomiting, fever, etc. lasted for >6 hours.
2. The child is mostly in a protective posture, such as lying on the right side, slightly bent on both legs, and bending to the right side when walking. Abdominal limited local right lower abdomen fixed tenderness or rebound tenderness, muscle tension and so on.
3. Rectal examination can be painful and edematous or lumps in the anterior right wall or can be swollen with swollen appendix. The psoas muscle test and the obturator muscle test can help to distinguish the diagnosis of posterior cecal and pelvic appendicitis.
4. The total number of white blood cells and neutrophils increased.
The clinical misdiagnosis rate of appendicitis is quite high, the domestic statistics are 4-5%, and the foreign reports are up to 30%. There are many diseases that need to be identified with acute appendicitis, the most important of which are the following ten diseases.
Identification with medical acute abdomen:
1, right lower pneumonia and pleurisy: inflammatory lesions in the lower right lung and chest, reflex can cause right lower quadrant pain, and can be misdiagnosed as acute appendicitis. However, pneumonia and pleurisy often have obvious respiratory symptoms such as cough, cough and chest pain, and chest signs such as respiratory sound changes and wet rales. Abdominal signs are not obvious, and there is no more tenderness in the right lower quadrant. Chest X-ray, can be diagnosed.
2, acute mesenteric lymphadenitis: more common in children, often secondary to upper respiratory tract infections. Due to the extensive enlargement of the small mesenteric lymph nodes, the ileum is particularly obvious, and it can be clinically characterized as right lower quadrant pain and tenderness, similar to acute appendicitis. However, this disease is associated with high fever, abdominal pain and tenderness is widespread, and there are fashions that can reach swollen lymph nodes.
3. Localized ileitis: The lesion mainly occurs at the end of the ileum and is a non-specific inflammation. Young people aged 20-30 are more common. In the acute phase of the disease, the intestinal tube of the lesion is congested, edema and exudation, stimulating the peritoneum of the right lower abdominal layer, abdominal pain and tenderness, similar to acute appendicitis. The position is limited to the ileum, without the characteristics of metastatic abdominal pain, and the abdominal signs are also extensive, and sometimes the swollen intestinal tube can be touched. In addition, the patient may be accompanied by diarrhea, and the stool examination has obvious abnormal components.
Identification of acute abdomen with obstetrics and gynecology:
1, right fallopian tube pregnancy: after the right ectopic pregnancy rupture, intra-abdominal hemorrhage stimulates the right lower abdominal wall peritoneum, clinical symptoms of acute appendicitis. However, ectopic pregnancy often has a history of menopause and early pregnancy, and there may be vaginal bleeding before the onset. After the abdominal pain, the patient has a sense of swelling of the perineum and anus, as well as internal bleeding and hemorrhagic shock. Gynecological examination showed that there was blood in the vagina, the uterus was slightly larger with tenderness, the right side of the attachment was swollen and the posterior malleolar puncture had blood and other positive signs.
2, ovarian cyst torsion: after the right ovarian cyst pedicle torsion, cyst circulation disorder, necrosis, bloody exudation, causing inflammation of the right abdomen, similar to appendicitis. However, this disease often has a history of pelvic mass, and the onset is sudden, which is paroxysmal colic, which may be associated with mild shock symptoms. Gynecological examination can reach the cystic mass, and there is tenderness. Abdominal B-ultrasound confirms the presence of cystic mass in the right lower abdomen.
3, ovarian follicular rupture: more occurs in unmarried young women, often two weeks after menstruation, due to intra-abdominal hemorrhage, causing lower right abdominal pain. The local signs of the right lower quadrant of the disease are mild, and the diagnostic abdominal puncture can extract hemorrhagic exudation.
4, acute attachment inflammation: acute inflammation of the right fallopian tube can cause symptoms and signs similar to acute appendicitis. However, tubal inflammation occurs mostly in married women, with a history of excessive vaginal discharge, and the incidence is mostly before menstruation. Although there is pain in the lower right abdomen, there is no typical metastasis, and the abdominal tenderness is lower, almost close to the pubic bone. Gynecological examination showed that the vagina had purulent secretions, the tenderness on both sides of the uterus was obvious, and the right side attachment had a tender mass.
Identification with surgical acute abdomen:
1. Acute perforation of ulcer disease: After perforation of ulcer disease, part of the stomach contents flow into the right axilla along the right colonic sulcus, causing acute inflammation of the right lower quadrant, which may be mistaken for acute appendicitis. However, this disease has a history of chronic ulcers. There are many causes of overeating before the onset, and the onset is sudden and the abdominal pain is severe. When the body was examined, the abdominal wall was plate-shaped, and the peritoneal irritation was most obvious under the xiphoid process. Free gas can be seen under the abdomen in the abdomen, and the upper digestive tract fluid can be extracted by diagnostic abdominal puncture.
2, acute cholecystitis, cholelithiasis: acute cholecystitis sometimes needs to be distinguished from high appendicitis, the former often has a history of biliary colic, with pain in the right shoulder and back; and the latter is characteristic of metastatic abdominal pain. At the time of examination, acute cholecystitis may be positive for Morphy's sign, and even the enlarged gallbladder may be touched. The emergency abdominal B-ultrasound examination may show gallbladder enlargement and calculus.
3, acute Meckel diverticulitis: Meckel's diverticulum is a congenital malformation, mainly located at the end of the ileum, its location is very close to the appendix. When acute inflammation occurs in the diverticulum, the clinical symptoms are very similar to acute appendicitis, which is difficult to identify before surgery. Therefore, when the clinical diagnosis of appendicitis and the appearance of the appendix in the operation is basically normal, the end ileum should be carefully examined to 1 meter to avoid missing the inflamed diverticulum.
4, right ureteral calculi: ureteral stones can cause lower right abdominal pain when moving down, sometimes confused with appendicitis. However, the ureteral calculi showed severe cramps and was unbearable. The pain was released along the ureter to the genitals and the inner thighs. Abdominal examination, tenderness and muscle tension in the right lower abdomen are not obvious. Abdominal plain films sometimes have positive stones in the urinary system, while urine has a large number of red blood cells.
