Appendicitis

The appendicitis indicates a Inflammation Appendice iléo-cæcal. Appendicitis can occur at any age but especially before 30 years. Its evolution is unforeseeable, the majority of the cases of appendicitis require to withdraw by surgery the appendix (Appendicectomie) by Laparotomie or Coelioscopie. Untreated, it can be mortal, mainly by Péritonite and Septicémie.

Appendicitis is the surgical urgency most frequent. The clinical pictures can take various, complex forms (symptomatic polymorphism) but do not have parallelism anatomo-private clinic. The diagnosis of typical appendicitis is clinical.

History

Until 1886, one believed in a clogging of the cæcum by the feces which can lead to an ulceration, the perforation and the peritonitis. One thus employed the term Typhlite.
Le term appendicitis was created in 1886 by the American surgeon Fitz (FITZ R.H - Perforating ignition off the vermiform appendix: with special refers to its early diagnosis and treatment).

Anatomical recall

The appendix is located on the Cæcum, proximale end of the Côlon. It forms an outgrowth of ten centimetres length and does not have a clean role.

Epidemiology

It is about the abdominal surgical urgency most current. It generally reaches the person between 10 and 20 years, with a discrete male prevalence. Exceptional before 3 years, it remains rare in the young child.

Pathological anatomy

Appendicular lesions

  • Appendicitis catarrhale: congestion
  • suppurée Appendicitis
    • Pseudo
phlegmoneuse: small boxes
appendicular Empyème: appendix distended by a collection of pus
  • gangreneuse Appendicitis: sphacele
  • Appendicitis perforee

Lesions péritonéales

  • the séreuse one red, is œdématiée, épanchement the péritonéal is variable
  • false membranes join internal organs and epiploon. Visceral agglutination carries out the drill plate and sometimes a Iléus. The insulation of a collection of pus collects an abscess.

Visceral lesions

  • the edema infiltrates and weakens the walls of the cæcum

Bacteriology

polymorphic Total colony count: E-coli, Bactéroïdes
Can be caused by Yersinia enterolytica

Positive diagnosis

Private clinic

The type of description which is taken is that of iliaque acute appendicitis noncomplicated in a young adult
  • functional Signes
Its beginning is discrete.
the pain is progressive, with type of colic, begins on the level from the epigastric area then is located secondarily with the right iliaque pit. Increased by: cough, breathing, effort. Irradiation: umbilical point, thigh, lumbar pit. This pain is however present only in one case out of two.
the vomiting is food then bilieux, rather rare. More frequently one notes only nauseas.
the intestinal disorders are unusual
  • general Signes
Anorexie
Nombre of white globules higher than 10.000/mm3
moderate Fièvre: 38 has 38°5
Tachycardie in connection with the fever
  • physical Signes
    • Inspection: the abdomen breathes normally, the language is Saburrale
    • Palpation notes:
a pain caused with the palpation of the right iliaque pit: the maximum sits on the level of the Point of Mc Burney (more precisely of the area of Mc Burney).
  • One objectifies a defense right iliaque pit: parietal reaction to palpating deep overcome by a soft palpation.
  • the sign of Blumberg: pain with the brutal decompression of the right iliaque pit.
  • the sign of Rovsing: the compression of the left iliaque pit is responsible for one pain to the right iliaque pit.
      • the pelvic Touchers find a pain in top and on the right the Douglas one. They note the integrity of the appendices

    At this stage the diagnosis of appendicitis is posed and the intervention is essential in urgency. the complementary examinations find their interest in the clinical forms of difficult diagnosis.

    The diagnosis is however less easy at the extreme ages of the life.

    Paraclinique

    • Numeration of the blood picture: moderate hyperleucocytosis (lower than 15.000 elements per mm3) with polynuclear neutrophiles.

    • a preoperative assessment must be systematic made, comprising in addition to numeration, a blood Ionogramme, an assessment of coagulation, a determination of the Blood group.

    • At the woman in age to procreate, a immunological Réaction of pregnancy is requested from systematic title, a extra-uterine Grossesse being able to present itself with a close table.

    Imagery

    • the abdomen without preparation
      • Faces upright. It can find the following aspects:
        • Normal or greyness diffuses without pneumopéritoine
        • Clarté cæcale
        • Anse sentinel, spindly, slack with outline of hydroaeric levels.
        • appendicular Stercolithe
      • makes some one seeks arguments in favor of a differential diagnosis

    The other examinations are used only in case of doubt about the diagnosis.

    • the echography brings arguments of differential diagnosis, and helps with the appendicular diagnosis of abscess.
    the échograhie does not allow the diagnosis of noncomplicated appendicitis
    • the Lavement baryta water-soluble the
      • It presents risk of digestive Perforation
      • It can note:
    an imperfect filling, not visualization of the cæcum
    a irregularity of the internal edge of the cæcum
    a repression of the cæcum
    a displacement of the last handle hails
    a complete opacification makes the diagnosis improbable
    This examination finds its interest in doubtful tables
    • the abdominal scanner can show an aspect of mass of the right iliaque pit.
    • the Cœlioscopie makes it possible to help with the differential diagnosis with gynaecological pathologies.

    Differential diagnosis

    Digestive surgical affections

    • Diverticulum of complicated Meckel: the diagnosis of certainty is operational
    • Perforation of ulcer gastro-duodénal

    Gynaecological affections

    • Torsion of a cyst of the ovary: interest of echography
    • Salpingite
    One notes leucorrhées, a marked infectious syndrome, are to them bilateral signs. The pelvic touches are very important with the diagnosis
    the coelioscopy makes the diagnosis
    • Dysménorrhée

    Medical affections

    One notes mictionnelles burns, the renal shock is positive
    the test with the nitrite strips is positive
    • Adénolymphite: operational diagnosis of certainty
    • Viral hepatitis in phase pre-icterique
    • eruptive Diseases
    • Parasitoses

    Clinical forms

    Topographic forms

    • appendicitis under hepatic
    It simulates an acute Cholécystite. The pain is under-costal
    • appendicitis retro-cæcale
    One notes a Psoïtis. The free right iliaque pit
    In décubitus side left: one finds a pain and a defense above the iliaque peak according to méso-cœliaque Alders
    • Appendicite: it carries out a feverish table of occlusion
    • pelvic Appendicite
    urinary, rectal Signes
    pelvic Touchers: pain lives
    on the right the evolution is made towards the constitution of a Abcès of the bag Douglas

    Forms according to the ground

    • Infant
    exceptional Form, engraves because ignored a long time
    Diagnostic often by an abscess at the stage of peritonitis
    • toxic Appendicite of the child
    poor local Signes, deterioration of the general state marked
    Intervention must be early after patent reanimation
    • Vieillard
    Paucisymptomatique.
    2 possible forms:
    1. Occlusive feverish
    2. Pseudo-tumoral:
    feverish Masse of the right iliaque pit (problem of differential diagnosis with the cancer of the cæcum)
    Intérêt of the rectal injection baryta
    • Expectant mother
      • Poses problems of:
    positive Diagnosis: difficult at the end of the pregnancy
  • differential Diagnosis: cal, Therapeutic pyelonephritis
  • : tocolyse, anesthetic
      • the persistence of the pain in the right iliaque pit when the patient put in décubitus side left

    Complications

    the unforeseeable evolution can be done is towards a resolution of the appendicular crisis or worms of the major complications, which justifies the dogma of surgical operation

    Generalized peritonitis from the start

    It is the case in 20 to 30% of the cases, especially at the ages extrèmes where the diagnosis is not obvious and the delayed assumption of responsibility.
    • purulent Peritonitis generalisee
    violent Pain of the right iliaque pit generalized secondarily with all the abdomen abundant
    Nauseas, vomiting, stop of the matters and frequent gas, anxious facies, infectious syndrome marks
    Absence of abdominal breathing, projection musculus rectus abdominis, absence of scar laparotomy
    Contracture painful, permanent, invincible generalized prevailing on the level of the right iliaque pit
    pelvic Touchers: pain on the level of the cul-de-sac Douglas
    Numeration of the blood picture: leucocytose
    Abdomen without preparation: putrid absence of pneumopéritoine
    • Peritonitis
    By perforation of a gangrené appendix broken
    atrocious Pain
    stinking Diarrhea, facies leads, fever relatively low: 38°
    poor physical Signs
    contrast between the alarming general signs and the poverty of the physical examination must alert
    Any therapeutic delay involves a fatal risk
    • toxic Péritonite
    Grave and misleading
    the toxic syndrome erases the péritonéaux signs

    Progressive generalized peritonites

    • progressive Peritonitis by diffusion
    functional Signs and generals: persist or amend themselves in the days following an acute crisis (possibly under antibiothérapie inopportune), with persistence of the physical signs and of a hyperleucocytosis
    Then brutally the table of peritonitis is set up
    the intervention is essential
    • Péritonite in two times
    By secondary perforation of the appendix
    • Péritonite in three times
    ultimate evolutionary Terme of appendicitis neglected
    the brutal rupture on weakened ground, collapse
    attenuated péritonéaux Signes

    Localized peritonites

    • appendicular Plastron
    It occurs a limitation of the infection by the bulk-heading of the area cæcale by agglutination of the handles hails.
    It settles after an appendicular crisis, whose signs have decreases without disappearing.
    Examination: find at the end of qq. days
    indépressible Curve
    Mass painful, firm, badly limited, armouring the abdominal wall developing towards the umbilical point or the arcade crurale
    the rectal examination perceives the pole lower
    Hyperleucocytose than polynuclear increasing evocative
    Abdomen without preparation: opacity of the right iliaque pit, erasing the external edge of the psoas
    Medical care: antibiothérapie, pocket of ice
    It is against indication with the surgery
    Evolution: resorption, abcedation or appendicular peritonitis genestrolle functional Signs: pulsatile pain
    general Signs: deterioration of the general state. Oscillating temperature. Acceleration of the physical pulses
    Signs: Softening in a point of the right iliaque pit
    Numeration of the blood picture: leucocytose progressive

    preoperative Assessment

    Treatment

    Principles

    The only treatment is surgical. It must be made without delay after the diagnosis was posed, in order to avoid the complications (peritonites). The gesture is preceded by the setting under Antibiotique S.

    Means

    Description of the treatment of noncomplicated appendicitis
    • Surgical
      • After preoperative assessment and conditioning the patient is allowed with the operating room suite
      • One proceeds to the Appendicectomie
      • the way initially can be a diagonal incision on right iliaque pit (badly called incision of Mc Burney ), a horizontal incision ( incision of Rookie-Davis ) or cœlioscopic
    Recherche and externalization of the appendix (not under coelio!)
    Appendicectomie after binding section of the artery of sound méso, and the appendicular base
    It is necessary to seek the Diverticule of Meckel which will be réséqué if there exists; or of the gynaecological anomalies at the woman
    One carries out a taking away with bacteriological aiming if necessary
    Fermeture plans by plans

    • perish-operational Care

      • Antibiotic: cephalosporine + gentamicin or métronidazole + gentamicin. By parenteral way, into perish-operational and single amount. The methods and the duration of the antibiotic treatment depend on the state of the appendix and the peritoneum.
    Prophylaxie of the accidents thrombo-embolic
      • Surveillance of the bandage, débridement if local ignition or fever.

    Post-operative complications

    Operational mortality remains weak, particularly in the simple forms (0,8 per 1000). The complications can be:
    • Early Hemorrhagic common to any surgery
      • : infectious hypovolemy or hématome
      • :
    Abscess of wall: 4%
  • Abscess of the bag Douglas: can be drained by rectal way or by posterior colpotomy
  • under-phrenic Abcès
  • post-operative Péritonite by releasing of stub, necroses bottom melts cæcal
      • Thromboemboliques
    • Précoces and specific: Syndrome of the fifth day
    Fréquent in the child
    After simple continuations with resumption of the transit
    At the fifth day of post-operative is carried out a table of peritonitis with general state preserved by purulent cast iron of the stub or operational inoculation
    • Tardives
    Eventration
  • Occlusions
    In the first month: by later adherences
    by support

    References

    • ADLOFF Mr. and SCHLOEGEL Mr. - Appendicitis EMC (Paris France) Stomach-Intestine, 9066 has 10,10-1989 10p.
    • '' Acute appendicitis '', D Humes, J Simpson, BMJ 2006; 333: 530-534

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