Acute appendicitis (AA)Latin - appendicitis acuta- this is an acute inflammatory disease of appendix, the causal organism of this disease, as a rule, is unspecific purulent infection.

Patients with AA make 20-50% of all sick persons in surgical departmentsAppendectomy makes 70-80% of all surgical interventions at patients with urgent pathology. The disease is more frequent met in the age of 10-40 years. Level of postoperative lethality is 0,2-0,3%Reasons of death at AA: -late resort for medical aid - doctors’ errors in diagnostics of AA (primary care physician make 55%, doctors of first-aid - 35%, surgeons - 10% )

Anatomy and physiology of the appendixThe ileocecal part of intestine includes: - terminal part of iliac intestine; - cecum; - Baouginiy’s valve; -appendix.Appendix joins to cecum on a back- internal wall, in a place, where three ribbons of longitudinal muscles of colon meet and represents a cylinder, it’s length is 6-12 sm. and the diameter is 0,5 sm. Appendix is covered by peritoneum from all sides, it has its own mesentery - mesoappendix, vessels and nerves pass in mesoappendix. The wall of appendix consists of serous layer, muscular layer, submucous layer, where the lymphatic follicles are located, and mucous layer.Blood supply: the upper mesenteric artery this artery gives the ileocolic artery, and the last gives the appendicular artery. 2 Veins - the vein of appendix runs into the ileocolic vein, and the last runs into the upper mesenteric vein. The last with the lower mesenteric and splenic veins form the portal vein.Innervation of ileocecal part of intestine is provided by solar plexus, by upper and lower mesenteric plexus.

Variants of location of appendix in the abdominal cavity

1. Retrocaecal (12 o'clock).2. Pelvic in 20% of cases (4 o'clock).3. Preileal and postileal in about 70% patients (2 o'clock).4. Subcaecal (6 o'clock).5. Paracaecal.6. Subhepatic appendix is associated with subhepatic caecum. It occurs due to malrotation of the gut.

Physiology of appendix

• - secretory - a mucus layer produces juice, which contains mucus, tracks of such enzymes as amylase, lipase;

• - retractive - the poorly expressed peristalsis provides evacuation of contents;

• - hemopoietic, limphopoetic, • - immune, thanks to accumulation of

lymphoid tissue;

Etiology, pathogeny of AA• The microbes of purulent infection :• - aerobes, that inhabit a thick intestine (intestinal

bacillus, staphylococcus, streptococcus, protey and other entetrobacterias);

• - nonclostridial anaerobes, that inhabit the colon (peptococcus, peptostreptococcus, fousobacterias, bacteroids and others).

• - mixed aerobic-anaerobic infection; • - specific infection: tuberculosis, actinomicosis,

abdominal typhus, salmonella, sometimes Crown’s illness, tumors of appendix.

Ways of penetration of infection:

• - enterogenous way - from the lumen of appendix through mucus layer as a result of loss of barrier function;

• - lymphogenous way is rare, - on lymphatic vessels from the nearby organs. It is possible at women at right-side adnexitis through the Clado’s ligament.

• - hematogenous way at bacteriemia, when appendix with its lymphoid tissue becomes the target organ - is rare too.

Theories of pathogeny of AA• 1. Infectious. Leading role in the development of disease the

supporters of this theory give to the infection of appendix, its amount, virulence, which can be activated at favorable terms (stagnation, excrement stones, helminths, foreign body).

• 2. Neuroreflex (nervous-trophic). The reason of all is necrosis of mucus layer of appendix which is the result of its durable ischemia. The ischemia is caused by the long-standing spasms (appendicobauginiospasm), or spasms of vessels of this region.

• 3. Allergic (immunological). The supporters of this theory consider that the reason of beginning of inflammation and of defeat of mucus layer is allergic reaction antigen-antibody. Allergization is caused by penetration of alimentary and microbic antigens into the immune components of mucus layer (lymphatic follicles).

Classification of AA by V.I.Colesov• I. Acute appendicitis • 1. Acute simple (superficial) appendicitis.• 2. Acute destructive appendicitis: • а) phlegmonous, • b) gangrenous, • c) perforative,• d) empyema of appendix.• 4. Complicated acute appendicitis: а)appendicular infiltrate; • b)appendicular abscess;• c)peritonitis of appendicular’s origin; • d)other complications (pilephlebitis, sepsis and others).• II. Chronic appendicitis 1. Primary-chronic appendicitis. 2.

Residual chronic appendicitis. 3. Recurrent chronic appendicitis.

Clinic of AA• General symptomatology. The attack of acute appendicitis begins, as

a rule, from a stomach-ache. In 20-40% of cases the pain arises up at first in epigastric region, then it moves to right iliac region (s-m of Volcovich-Coher), but can be localized from the beginning in right iliac region.

• For AA are characteristic gradual growth of pain and its permanent character, absence of irradiation, moderate intensity.

• In 2-3 hours from the beginning of disease at 50% of patients nausea appears, vomit is more frequent single,

• Delay of defecation, gases is expressed. • In children at toxic forms of AA diarrhea can appear. • Temperature of body subfebrile is marked. • At objective examination of patients tachycardia is determined. In

clinical blood test moderate leukocytosis is marked (up to 10-12*10/l), neutrophilia, shift of neutrophils to the left are marked, too.

Clinic of AA• Local symptomatology. The most informing from them are:• 1. D'elofoua’s triad (classic triad of AA) • - spontaneous pain in the right iliac fosse;• - tension of muscles of right iliac region at the palpation of abdomen; • - hyperesthesia of skins of right iliac region. • 2. Rovzing’s Symptom - pain in right iliac fosse at impulse motion in the projection of

descending department of thick intestine with fixing of sigmoid intestine. • 3. Obraztsov’s symptom - it is strengthening of pain at pressure in right iliac fosse during

the bending of right leg in coxofemoral joint. • 4. Voscresenskiy’s symptom 1 - it is strengthening of pain in right iliac fosse during the

sliding palpation through the strained shirt from the epigastrium to the right iliac region (symptom of shirt).

• 5. Sitcovskit’s symptom - it is appearance of dragging pain in the right iliac fosse, if a patient lies on the left side.

• 6. Bartom'e-Mihelson’s symptom - pain at the palpation in the right iliac fosse is more expressed, if a patient lies on the left side than on the back.

• 7. Yaoure-Rozanov’s symptom - it is appearance of pain at the palpation in the region of Petit’s triangle from the right side (at retrotcecal AA).

• 8. Coup’s symptom 1 – it is appearance of pain the in right iliac fosse at passive overextension of right leg in the coxofemoral joint.

Three phases of the AA by Rusanov A.A.• - appendicular colic - functional phase of AA, when ischemia of mucus

layer of appendix does not result in necrosis. In clinical picture there is only pain syndrome and there are no expressed signs of inflammatory process - increase of temperature of body, leucocitosis, local peritoneal symptoms are absent. This phase is called by some authors an epigastral phase, because the pains in this phase are more frequent localized in the epigastral region.

• - phase of local inflammatory, or inflammatory-destructive changes. Pathomorphologicaly the process can look likes superficial, phlegmonous, or even gangrenous appendicitis, but the feature of it consists in that inflammatory process is limited by the right iliac fosse, it does not go outside of it. Clinically both general and local symptoms are expressed in this phase of appendicitis, including the local symptoms of irritation of peritoneum, but they are determined only in the right iliac fosse.

• - phase of spreading of inflammation on peritoneum. In this phase the symptoms of endogenous peritoneal intoxication are on the first plan, local and spread peritoneal symptoms in other departments of the abdomen take very important role, too.

Diagnostics of AA.• Diagnostics of AA is based on the revealing of

characteristic complaints about permanent pain in the right iliac fosse, or Volcovich-Coher’s symptom, nausea, increase of temperature of body, at objective examination –positive Rovzing’s, Voscresenskiy’s, Obraztsov’s, Sitcovskiy’s, Bartom'e-Mihelson’s symptoms.

• For the confirmation of diagnosis clinical blood test and analysis of urine are done. In the analysis of blood leucocytosis, neutrophilia, neutrophil shift to the left are determined.

Additional examinations - laparoscopy -diagnostic laparotomy Abdominal ultrasound

CT scan

Features of clinical run of AA and surgical tactic at children• AA at children of the first year of life meets very rarely. The diagnostics of AA at the children

of early age is very difficult because it is impossible to collect the anamnesis and to define pain symptoms which are used for adults.

• The clinical picture and run of AA at children are caused by the anatomophisiological features of child's organism: not enough developed nervous and blood system, not enough developed lymphoid system and large omentum which achieves the right iliac fosse only in 7 years. That is why there are no cases of forming of appendicular infiltrate at children of early age, and AA is more frequent complicated by the perforation of appendix and peritonitis.

• The disease begins often with the high temperature of body (39-40°C), • with repeated vomits, • quite often it is accompanied by diarrhea.• The examination of child is difficult because the palpation of abdomen results in crying and

in active strain of muscles of the abdomen walls. It is necessary to carry out the palpation on mother’s hands. Quite often at AA at children of the first year of life pain and strain of muscles of right iliac fosse are the single symptoms. Pain feelings at the palpation of the right iliac fosse are determined by the symptom of "pushing away of hand" - a child pushes away the hand of surgeon, when he carries out the palpation of the right half of abdomen. Drahter’s symptom - percussion of the right heel at peritonitis at child results in bringing child’s hands to the lower part of abdomen. AA at children is accompanied by high leucocytosis (up to 18-20*10/l) with the shift of neutrophils to the left.

• Operation - appendectomy at children is carried out under general anaesthetizing.

AA at pregnantPregnancy of the first three months has not influence on clinic of AA, but with 4- 5 month the increased uterus displaces upwards the cecum and appendix.For AA at pregnant the acute beginning of disease with the pain in lower part of right half of abdomen is characteristic. Tension of muscles of abdomen and also Shotcin-Bltomberg’s, Rovzing’s symptoms are rarely determined at objective examination. Appearance of pain, or the strengthening of pain in the right iliac fosse at pressure on the left rib of pregnant uterus (Brendo’s symptom); Strengthening of pain in the right half of abdomen, when the patient lies on the right side (Mihelson’s symptom, or Sitcovskiy’s reverse symptom). In the blood test the amount of leucocytes can be normal, and more constant sign of AA is the neutrophil shift to the left. Early operation is the single method of treatment. Anesthesia – mainly local infiltration anesthesia, narcosis is used only in case of peritonitis. In the second half of pregnancy Volcovich-D'yaconov’s operational access is used, but it is displaced upwards the more, than the term of pregnancy is greater. Carefulness of manipulations in the area of uterus and appendages, prescribing of sufficient anaesthetic and spasmolitic therapy in postoperative period are necessary for saving of pregnancy. At acute peritonitis of appendicular nature medical tactic does not differ from tactic in other case. Artificial breaking of pregnancy in such cases is the rough tactical error.

AA at the persons of old years• The temperature of body raises insignificantly, or it is

normal, the special symptoms are poorly expressed, tension of muscles of abdomen is absent in 50% of cases, Shotcin-Blumberg’s symptom is poorly expressed.

• More frequent there is paresis of intestine. • Leucocytosis is not always observed in the blood test

because the reduction of reactivity of organism is present, but often the expressed neutrophil shift to the left in leucogramma is determined.

• Appendectomy is the single method of treatment of AA. Surgical tactic consists in all patients with AA, are exposed to immediate appendectomy.

• Endotracheal narcosis is the main method of anaesthetization.

There are different operating accesses

1. Volcovich-Dyaconov’s (Mac-Berney’s) access –cut in the right iliac fosse, it is parallel to the inguinal ligament, and the center of this cut is Mac-Berney’s point.2. Lekser’s access - through the Mac-Bourney’s point, as well as the previous, but avoiding traumas of muscles, - through the Spigeliy’s line.3. Lenander’s access - right-side pararectal cut, it is carried out in case of doubt in the diagnosis (AA or cholecystitis, AA or urgent diseases of appendages of uterus).4. Lower middle laparotomy – it is carried out in case of spread peritonitis of appendicular origin.

Appendectomy