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ACUTE APPENDICITIS
Haydarov Navro’zbek Furqat o’g’li
Asian International University, Bukhara, Uzbekistan
https://doi.org/10.5281/zenodo.14864171
Abstract.
Acute appendicitis is the most common reason for abdominal surgery. Luminal
obstruction of the appendix progresses to suppurative inflammation and perforation, which causes
generalised peritonitis or an appendix mass/abscess. Classical features include periumbilical pain
that migrates to the right iliac fossa, anorexia, fever, and tenderness and guarding in the right
iliac fossa. Atypical presentations are particularly common in preschool children. A clinical
diagnosis is possible in most cases, after a period of active observation if necessary; inflammatory
markers and an ultrasound scan are useful investigations when the diagnosis is uncertain.
Treatment is by appendicectomy after appropriate fluid resuscitation, analgesia and
intravenous antibiotics. Laparoscopic appendicectomy is better than open appendicectomy in most
cases because it is associated with less postoperative pain and a shorter hospital stay, but recovery
after acute appendicitis is mostly dictated by whether the appendix was perforated or not.
Management of the appendix mass remains controversial and not all affected children need
an interval appendicectomy. This article discusses tips and pitfalls in diagnosis and addresses
many of the controversies that surround the management of this condition.
Key words:
abdominal pain; appendix; laparoscopic appendicectomy; surgery.
ОСТРЫЙ АППЕНДИЦИТ
Аннотация.
Острый аппендицит является наиболее частой причиной
абдоминальной хирургии. Обструкция просвета аппендикса прогрессирует до гнойного
воспаления и перфорации, что вызывает генерализованный перитонит или массу
аппендикса/абсцесс. Классические признаки включают боль в области пупка, которая
мигрирует в правую подвздошную ямку, анорексию, лихорадку, болезненность и
напряжение в правой подвздошной ямке. Атипичные проявления особенно распространены
у детей дошкольного возраста. Клинический диагноз возможен в большинстве случаев
после периода активного наблюдения, если необходимо; маркеры воспаления и
ультразвуковое сканирование являются полезными исследованиями, когда диагноз неясен.
Лечение заключается в аппендэктомии после соответствующей инфузионной
терапии, анальгезии и внутривенных антибиотиков. Лапароскопическая аппендэктомия
лучше открытой аппендэктомии в большинстве случаев, поскольку она связана с меньшей
послеоперационной болью и более коротким пребыванием в больнице, но восстановление
после острого аппендицита в основном диктуется тем, был ли аппендикс перфорирован
или нет. Лечение аппендикса остается спорным, и не всем пострадавшим детям
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требуется интервальная аппендэктомия. В этой статье обсуждаются советы и
подводные камни в диагностике и рассматриваются многие противоречия, которые
окружают лечение этого состояния.
Ключевые слова:
боль в животе; аппендикс; лапароскопическая аппендэктомия;
хирургия.
Etiology
Luminal obstruction from mucosal inflammation, lymphoid hyperplasia or faecolith causes
appendiceal distension and inflammation, which progresses to suppurative transmural
inflammation, ischaemia, infarction and perforation. Minor episodes of mucosal inflammation can
probably resolve spontaneously and may account for reports of prior self-limiting episodes of
similar pain in some patients with acute appendicitis. The inflamed appendix may become walled
off by omentum and surrounding viscera to form an inflammatory mass. The incidence of
macroscopic appendiceal perforation is variable but is around 25–35% in large series. Appendiceal
perforation progresses to generalised peritonitis or a localised walled off collection of pus. A
faecolith is found in about 28% of children with acute appendicitis. Common bacterial isolates in
perforated appendicitis include Bacteroides fragilis, Escherichia coli, Pseudomonas aeruginosa,
Peptostreptococcus species and Fusobacteria. Pinworms are found in a small but variable
proportion of appendicectomy specimens removed for suspected acute appendicitis, and there is
debate about whether these worms actually cause acute appendicitis. Since pinworms are most
often seen in non-inflamed appendices, the general perception is that they very rarely cause
appendicitis but may sometimes cause abdominal pain mimicking acute appendicitis. Twin studies
suggest that there may be a small genetic predisposition to acute appendicitis, and a positive family
history is often elicited
Presentation
Most diagnoses are made based upon the history, clinical examination and laboratory tests.
In all cases there is no value in with holding analgesia for fear of concealing symptoms.
Active monitoring is a useful strategy in systemically well patients with equivocal
symptoms, serial examinations and blood tests performed over a 24e 48 hour period significantly
improves sensitivity. Imaging is mostly performed when there is diagnostic uncertainty and widely
employed in children, young women and older adults. Particular vigilance is needed in high-risk
groups, extremes of age, immunocompromised, morbidly obese, diabetic and pregnant patients.
These groups are more likely to present with subtle and atypical signs in the presence of
complex appendicitis. Diagnostic laparoscopy is an option usually reserved where symptoms
persist in patients considered low risk for surgery.
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It has the advantage of high sensitivity and specificity, particularly in young women and
diagnoses such as endometriosis, pelvic inflammatory disease and adhesions. The history,
examination and further tests are focused on discriminating between the likely differentials.
Presenting history
The primary symptom is abdominal pain, the classical history one of vague peri-umbilical
pain migrating to the right iliac fossa in the first 24 hours. Pain exacerbated on coughing and
moving may indicate some degree of peritonism. Patients often describe anorexia, nausea,
vomiting and less frequently constipation or diarrhoea. Low-grade pyrexia is common, less so a
high grade pyrexia (>39C) or rigors. The history should establish the duration, pattern and
characteristics of pain and associated symptoms. Normal bowel habits should be explored and any
change, such as diarrhoea, constipation, mucous and rectal bleeding. Night sweats, weight loss,
lethargy and other systemic signs are also particularly helpful in distinguishing between a discrete
acute episode and a chronic or recurring process. Lower urinary tract symptoms, menstrual and
sexual history assists in finding a genitourinary or gynaecological cause for the pain although an
inflamed pelvic, subcaecal and post-ileal appendix may cause pelvic, groinor testicular pain and
urinary symptoms. In children further questions around peri-natal history, immunization status and
recent viral or bacterial illnesses are relevant.
Physical examination
Patients with appendicitis are classically flushed, dehydrated, sometimes ketotic and prefer
to remain still. Physiological parameters may show a low-grade fever with tachycardia. Abdominal
tenderness in the right iliac fossa and evidence of localised peritonism such as involuntary
guarding, rebound tenderness and percussion tenderness are indicative of appendicitis. Other
means of testing for peritonism in children include blowing out and sucking in the abdomen or
hopping by the bed. In slim patients the appendix or an associated appendiceal mass may be
palpable. A number of eponymous tests exist. Testicular examination is essential in young males
to look for testicular torsion. Pelvic and rectal examinations are not routinely performed unless
there is a suspicion of an alternative diagnosis warranting examination. Ear, nose and throat
examination should be performed in younger children; concurrent or recent upper respiratory tract
infection and lymphadenopathy may suggest mesenteric adenitis. Presentation with a ‘rigid
abdomen’, diffuse abdominal guarding, indicates generalized peritonitis and a perforated
gastrointestinal tract. It may be associated with sepsis and shock necessitating immediate
resuscitation. A history of preceding right iliac fossa may raise the suspicion of a perforated
appendix. Other non-perforated causes of generalized peritonitis include pancreatitis, pelvic
inflammatory disease and spontaneous bacterial peritonitis
Other tests
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Laboratory
A rise in inflammatory markers, both white blood count (pre dominantly neutrophilia) and
CRP, are sensitive for appendicitis but not specific. The rise in inflammatory markers is not
immediate and patients particularly with a short duration of symptoms can have normal blood
tests. Sequential blood tests over a 24 hour period, provides better diagnostic sensitivity.
Imaging
X-rays are typically done to exclude other differential diagnoses, a chest X-ray may also
be performed to look for free subdiaphragmatic gas in a patient with upper abdominal peritonitis.
An abdominal X-ray may show an appendicular faecolith but has poor sensitivity and
specificity. Women and children with equivocal symptoms often undergo abdominal ultrasound,
which has reasonable sensitivity for appendicitis and useful for detecting tubo-ovarian and biliary
disease. The limitations of
Ultrasound include operator dependence, abdominal pain restricting the examination and
views impaired by obesity and overlying bowel gas. CT is highly sensitive and specific for
appendicitis, up to 96%, but is disadvantaged by its dose of ionizing radiation. It is widely used in
older adults where appendicitis is less common and alternative diagnoses such as malignancy,
right-sided diverticulitis or ischaemic colitis should be considered and requires different treatment.
Obese and immunocompromised patients and those with inflammatory bowel disease are
also groups where CT is often considered. MRI although a lower dose of radiation and being
accurate in diagnosing appendicitis is rarely used. Patients may not tolerate the longer duration of
scan and enclosed space, it is a more costly imaging modality and there is often limited
accessibility
Management
Patients with suspected appendicitis should be admitted and managed with analgesia, anti-
sickness, intravenous fluids and broad-spectrum antibiotics as indicated. Antibiotics are given just
prior to surgery or immediately in the event of delays to theatre or sepsis. Concern over
Clostridium difficile infection and antibiotic resistance has led to increasingly restricted use of
cephalosporins; the combination of amoxicillin, metronidazole and gentamicin is an alternative
strategy. Perioperative care should involve regular review of the appropriate level of care, fluid
status, infection and antibiotics, comorbidities and regular medications and thromboprophylaxis.
The minimization of indwelling catheters, early mobilization and nutrition may also
improve outcomes. In simple appendicitis antibiotics are not required following appendicectomy
and the patient may go home the same day if well recovered. If there is significant intra-abdominal
contamination antibiotics are usually continued intravenously for at least 48 hours and a 5-day
course completed.
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If the appendix appears normal intraoperatively most surgeons will remove it if no other
cause for the right iliac fossa pain is found; 32% of macroscopically normal looking appendixes
show signs of inflammation on histopathological examination.
This is not a universal strategy. A negative appendicectomy is associated with a
complication rate of around 15%. It is not a completely benign procedure and with limited
evidence decision-making tends to be at the surgeon’s discretion. A non-operative strategy with
antibiotics is favourable in some cases. It is most frequently considered in patients without
generalized peritonitis or sepsis who have a significant operative risk, appendicular mass or active
inflammatory bowel disease. Immediate surgery in these groups is associated with increased
morbidity and potentially avoidable ileocaecal resection.
Procedure
Laparoscopic appendicectomy is now more common than an open approach. It is a better
diagnostic procedure and other advantages include earlier return to work and fewer surgical site
infections. The open appendicectomy is safe and remains widely used, particularly in small
children, pregnancy, patients with severe cardiorespiratory disease unable to tolerate the
pneumoperitoneum or patients with multi pleprevioussur geries where port access may be risky
due to adhesion stethering bowel to the abdominal wall. Experimental approaches to the
appendicectomy includes ingle incision laparoscopic appendicectomy (SILA) and natural
orificetransluminal endoscopicsurgery (NOTES) performed by trans-vaginal or trans-gastric
routes but neither have demon strated superiority so far and involve increased complexity.
Laparoscopic appendectomy
The patient is prepared supine, the surgeon and assistant typically stand on the left side of
the patient with the stack including the screen on the opposite side. Ports are commonly placed
using the Hassan technique, emptying the bladder reduces the risk of injury during placement. A
supra- or infra-umbilical incision is made and the umbilical stalk traced down to the fascia (linea
alba). At the stalk fascial junction the peritoneum is tethered, a superficial incision is made and a
blunt instrument is gently pushed through the peritoneum. A 10 mm port is inserted and the
pneumoperitoneum is established at 12 mmHg. Additional ports are introduced; a common
approach is 5 mm ports supra pubically and in the left iliac fossa allowing triangulation of the
instruments to manipulate the appendix. They are placed under direct vision to avoid injury to the
viscera and epigastric vessels. Examination of the abdominal cavity is performed to confirm the
diagnosis. The appendix is then mobilized and manipulated with an atraumatic grasper, tilting the
table head and left side down can assist in removing small bowel from the right iliac fossa isolating
the appendix. Dissection of the mesoappendix from the appendix is performed using diathermy,
vessels particularly the appendicular artery can be cauterized or clipped when encountered.
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When the mesoappendix is dissected off at the base of the appendix an endoloop is placed
over the tip and tightened at the appendix base. A second is positioned just above the first, allowing
enough space between the loops to divide the appendix; alternatively stapling devices can be used.
To limit contamination, the appendix is placed in a retrieval bag prior to removal through
the umbilical 10 mm port and washout performed if there is contamination. Intraperitoneal gas
should be allowed to escape from the abdomen as it contributes to shoulder tip pain on emergence
from anaesthetic.
At the um bilicus the fascia is usually closed with a J-stitch to reduce the risk of port site
hernias prior to skin closure.
Outcomes
Postoperative complications occur in approximately 13% of cases. Surgical site infection
is the most common complication, occurring in approximately 3.8% of appendicectomies.
Increasing abdominal or pelvic pain, intermittent pyrexia and diarrhoea should raise
suspicion of an intra-abdominal abscess, occurring in 4% of appendicectomies. Ultrasound or CT
scans are used to detect postoperative collections and they are most frequently found in the pelvis
or subphrenic space. Depending on size and location they may be treated with intravenous
antibiotics alone or in combination with percutaneous drainage under radiological guidance or
surgical drainage. Less frequent complications include bleeding, ileus, iatrogenic bowel or bladder
injury, incisional or port site hernias and adhesions causing small bowel obstruction. Rare
complications include stump appendicitis, the inflammation of a long residual appendicular stump
that has been left in situ following appen dicectomy. Another is a faecal fistula, it occurs when the
stump reopens resulting in the leakage of faecal material which dis charges through the wound.
Most faecal fistulae will resolve with non-operative management.
Conclusion
The classic case is an adolescent or young adult diagnosed based on a typical history,
examination and laboratory findings. The mainstay of treatment is either laparoscopic or open
appendicectomy. In reality appendicitis can be a challenge to diagnose and manage. Appreciating
this and maintaining a level of suspicion is crucial, particularly for those atypical groups at risk of
poor outcomes.
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