Appendicitis

Appendicitis, Acute appendicitis is the most common abdominal surgical emergency. This condition commonly occurs between the ages of 10 and 30 years, but its occurrence is possible at any age, are known cases of particular events in elderly patients (pseudotumor forms or pseudoocluziva).

Acute appendicitis is a disease in which there is an inflammation of the appendix. Once on the inflammatory process can not be stopped medication, treatment of this condition is surgical. As surgical intervention is faster, the patient’s pain is lower and more easily realizable surgery complications as reduced frequency and severity. I

n If surgery is delayed, the disease may be complicated: the catarrhal stage (early), the state phlegmon, gangrenous later (necrosis body) with its perforation and peritonitis initially localized and then generalized and can cause the patient’s death.

Anatomy

Vermiform appendix is a tubular structure attached to the first portion of the large intestine (colon), section called check. Appendix base is implanted in the cecum, the most common medial and inferior to the union of the three tapeworms (smooth muscle strips), the most common being mezocecala position.

But also may have atypical positions (subhepatic, pelvic, etc.). The abdominal wall, it is projected on the right side of the abdomen in the lower, right iliac fossa region called.
Is lymphoid structure (hollow organ abundant lymphatic tissue), but its function is not well known and is considered primarily a vestige embryo. Removal to the appendectomy (surgery that is extracted when it is inflamed appendix) does not alter digestive function.

Causes

Because this disease can be, in many cases, obstruction of the lumen, the body cavity or due to bacterial proliferation stimulated lymphatic or small foreign body (stone fruits, seeds).

This blockage of the lumen causes an increase in intraluminal pressure (inside the body), a disorder of blood circulation and inflammation in the body walls it can evolve without treatment until gangrene and perforation (rupture).
Can be discussed and a genetic predisposition to obstruction causing appendicitis appendicular lumen, starting from the observation that there are families with more subjects apendicectomizati (surgery for appendicitis) than others.

Symptoms

These are varied but have certain characteristics:
– Pain – is initially located in the epigastrium (the chest) and around the navel, and later to modify based right iliac fossa, often radiating to the right lower limb, pain intensity is different and variable from one stage to another; if initially looks like a discomfort, then it can become intense and even defensive muscle (abdomen becomes hard to the touch)
– Inappetence (lack of appetite), nausea and vomiting, constipation or diarrhea are other symptoms that may occur
– Subfebrilitatea is possible – not very high fever.

In some cases, symptoms can develop very quickly without representative, therefore presenting to an emergency doctor, these cases are the immunosuppressive therapies used in patients with organ transplants and certain diseases, patients with HIV, patients with diabetes mellitus, neoplastic disease treated with chemotherapy obese patients.
If pelvic appendix to these symptoms can be associated rectal tenesmus (cramps) with diarrhea.

During pregnancy

Also pregnant women, young children and the elderly may have particular forms of manifestation of this disease. Women during pregnancy often have symptoms such as pain, nausea and vomiting, but when they have special shapes and intensities, the patient must be present to emergency surgeon for examination.

Young children

Appearance of the disease raises special concerns because of their inability to communicate pain doctor. They may have atypical symptoms – just vomiting, drowsiness, difficulty in feeding, constipation, etc.. Also, specialized medical consultation should be done as quickly, especially if small children are often quick evolution, often even without intermediate phases.

Elderly patients

Manifestations may differ, diagnosis is more difficult. May take the form pseudoocluzive – with symptoms like intestinal obstruction and pseudo – Ceca tumor-like symptoms. To them, a feature represents comorbidities (diseases associated with old age Typical): ischemic heart disease, hypertension, type 2 diabetes, kidney failure and so on, conditions that worsen the prognosis of the disease and that can and they decompensate during disease evolution .

Diagnosis

In the diagnosis of this disease, an important role is occupied by history, medical history and physical examination.

History

Physician should carefully formulate questions, questions of which to deduce the nature of symptoms, when they occur and time evolution, their location, severity of symptoms. Also the patient will be asked by the existence of other diseases in history (personal or family), any ongoing treatments, allergies to medications or substances (elements to be taken into consideration in drug therapy during hospitalization), alcohol consumption, smoking and possible drug use must be mentioned, which is important information.

Physical

This involves inspection and can uncover a possible rash, swollen lymph (lymph increase), other skin lesions, respiratory movements mobility with the wall (peritonitis important for diagnosis, stage the patient shows a rigid abdomen movements without mobility Respiratory – abs “wood”).
Palpation can detect right iliac fossa pain that radiates frequently right leg, pain intensity is variable from discomfort to push deep muscle pain with defense. Entire abdomen should be palpated.

There are certain signs with more specificity:
– Sign Blumberg, push deep and then immediate release of the abdominal wall sign followed by a short-lasting pain at this level, which is evidence of peritoneal irritation, acute abdominal pain or implicitly a Heightened
– Psoas sign – palpation of the iliac fossa and the patient’s recommendation to raise the right leg stretched, noticing an increase in pain at this level.

Percussion and auscultation are not highly specific in diagnosing this disease. Percussion can detect an area of ​​dullness in the iliac fossa where a plastron timpanism up or if CECA stasis in various stages of the disease. Auscultation may reveal one abdominal silence in appendicular peritonitis established.
It will measure the patient’s temperature, heart rate (pulse), respiratory rate and blood pressure.

Investigations

Laboratory

Specific for acute appendicitis are:
– Moderate leukocytosis – increase in blood leukocytes (white blood cells), usually reaching values ​​10.000/mmc but can get to 20-30.000/mmc in severe cases
– Can be highlighted changes in ionogramei in cases of vomiting and dehydration
– Urinalysis – laboratory examination is common for differential diagnosis of a urinary tract disorder
– Test task for young women presenting these symptoms.

Imaging

Common imaging tests are:
– Simple abdominal radiography or dye (Radiography or gastrointestinal radiography)
– Abdominal ultrasound
– CT

These tests are not specific for acute appendicitis.
Simple abdominal radiography may show a certain level of aerocolie (distended loops in the abdominal flank – the region check) in early stages and in cases with appendicular peritonitis due to bowel distension loops around the abdomen may reveal levels hidroaerice – mark functional occlusion.
Radiography is contraindicated in acute appendicitis, appendiceal perforation can trigger. It is only useful for differentiating elderly cecal neoplasm.
Abdominal ultrasound also is not very specific exploration, but due to low costs and lack of harm is common practice especially for the differential diagnosis of acute appendicitis with other types of diseases: the female genital (ovarian cyst, ectopic pregnancy, uterine fibroids with / without necrobiosis, Annex Acute right, and so on – which is why you should be consulted sick and gynecological), diseases of the urinary tract (renal colic right ureteral calculus, cystitis, etc..), other diseases of small pelvis or intestinal (mesenteric lymphadenitis common in children, Meckel diverticulum), etc..
CT scan is not usual in diagnosing acute appendicitis, being reserved for cases with uncertain diagnosis.

Treatment

As was mentioned above, treatment of appendicitis is surgical and consists of surgery called appendectomy. This is performed in adults in most cases under spinal anesthesia, sometimes under general anesthesia, general anesthesia in children usually is.
Incision in usual cases, uncomplicated right iliac fossa is small, – 1.5 to 3 cm and can be extended if intraoperative difficulties (atypical positioning, associated pathology – ovarian cysts, adhesions, and so on).

There are cases when appendectomy can be achieved through an incision of only 1 cm (if then will practice and intradermal suturing, the scar will be very aesthetic, resulting appreciated especially young patients).
Can practice surgery and laparoscopy, which involves three small incisions.

Postoperative treatment

Surgical treatment should be associated and appropriate medical treatment: broad-spectrum antibiotic, analgesic, sometimes gastric antisecretory (patients complaining of postoperative pain in the epigastrium which is due to ligation meso appendicular) administered by infusion during the first 24 hours and then orally.
At 12-24 hours after surgery the patient can mobilize can begin to feed on clinical and typically 48-72 hours at the hospital is considering releasing surgeon recommendations: overall diet, avoid exercise 4-6 weeks, return the patient to control and remove wires from 1 week after surgery in general.

Treatment for complications

In more severe cases or complicated (gangrenous acute appendicitis with abscess periapendicular, appendicular peritonitis) incision can be enlarged or median incision can be practiced even subombilicala. Antibiotic treatment will be much stronger and for a longer period and also the recovery will take longer. The surgeon will decide intraoperatively and need drainage peritoneal cavity lavage and frequently practicing the Douglas bag bottom drainage (region in which fluid accumulates collections) with drainage tubes, which will be suppressed from 48-72 hours, depending on the evolution patient.

Complications

Complications of the disease:
– Appendiceal perforation with abscess
– Localized and then generalized peritonitis.
The evolution of this complication in children is more rapid. This is an extremely serious complication of the disease that can lead to death within a short time without emergency surgery.

Early postoperative complications:
– Parietal suppuration (common complication in complicated cases)
– Residual abscess (occurs after generalized peritonitis is a serious complication and requires reintervention)
– Postrahianestezie headache often associated with nausea and vomiting, etc..

Late postoperative complications:
– Eventration postapendicectomie (in obese patients do not follow doctor’s recommendations or treadmill exercise after surgery and consists of a parietal defect that can be solved through surgery to restore it)
– Peritoneal adhesions (after severe cases) that can lead to opportunities volvulari with intestinal occlusion.

Information

– Appendix is a small tubular structure attached to the first portion of the colon
– Appendicitis is inflammatory disease of the body and is considered a surgical emergency
– Symptoms are abdominal pain (usually on the right, but may initially be located in “the chest”), inappetence (lack of appetite), nausea and varstaturi, fever (but not too high) but have retained , not always acute appendicitis has all the symptoms and also may present with atypical symptoms
– Diagnosis is blamed on personal history, clinical examination (performed by surgeon), laboratory tests and imaging laboratory investigations
– Disease treatment is surgical and consists of appendectomy
– Is a disease whose complications (appendicular perforation with generalized peritonitis) are of extreme gravity and may become sick.

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