Apendicits (1)

Appendicitis is the inflammation of the appendix, located in the caecum, which is the portion where the large intestine. Usually cases of acute appendicitis requiring an appendectomy or surgical procedure called laparoscopic or laparotomy is nothing more than removing the inflamed appendix. In untreated cases, the mortality rate is high, mainly due to complications such as peritonitis and septic shock (see: Systemic inflammatory response syndrome - SIRS) [1], particularly when the inflamed appendix ruptures.

Acute appendicitis was first described in 1886 by Reginald Fitz, [2] and the contributions of Charles McBurney in 1889, recognized as one of the most frequent causes of acute abdominal pain or sudden in the world. Approximately 7% of the population will be operated by an appendectomy due to acute appendicitis [3].
Content
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1 Epidemiology
* 2 Aetiology
* 3 Pathogenesis
* 4 Diagnosis
4.1 Signs and diagnosis
4.2 or sign Rovsing
or 4.3 Psoas sign
4.4 sign or shutter
4.5 Diagnosis and paraclinical
or 4.6 scale Alvarado
or 4.7 Differential Diagnosis
* 5 Treatment
6 * Forecast
* 7 Trivia
* 8 References
* 9 External links

Epidemiology [edit]

Appendicitis can occur at any age, although the peak incidence of acute appendicitis occurs most often in the second and third decades of life [4] which, except strangled hernias is the most frequent cause of pain sudden and intense abdominal and emergency abdominal surgery in many countries. [5] It is also an important cause of pediatric surgery, common in preschool and school children with a predominance in men and a familial predisposition.

The appendectomy rate is about 12% in men and 25% in women in the general population by the apenicectomías appendicitis occur in 10 out of 10,000 patients each year and mortality rates are less than 1 per 100,000 patients since 1970 [3].

In the world, the incidence of appendicitis is much lower in developing countries, especially in parts of Africa and in the lower socioeconomic groups. [4] Despite the emergence of new and improved diagnostic techniques, appendicitis is misdiagnosed in 15% of cases and has not noticed a decrease in the rate of rupture of an inflamed appendix from the 1990s [3].

The epidemiological data has shown that the polyps and diverticulitis adenomatosis not seen in communities free of appendicitis and that the onset of colon cancer is extremely rare in these populations. [6] [7] Otherwise seen in patients with appendicitis , the latter occurring as antecedent to cancer of the colon and rectum [8].

Etiology [edit]
Cross section of an appendix with oxiuros (pink). Note the spines outgoing pathognomonic of the nematode.
See also: Acute abdomen

The main theory of the pathophysiology of appendicitis, based on experimental evidence points to a blockage of light by an appendix apendicolito. [9] [10] infections (Ascaris lumbricoides, Enterobius vermicularis and Taenia larvae) may also occlude the Appendix-light the presence of seeds is very unusual, thus causing an obstruction with increased pressure by the production of mucus in the body itself. Rarely, obstruction of the appendix occurs because of a tumor. [11] The gradual increase in pressure will intraapendicular occluding the light of the body and by external pressure resulting in thrombosis and occlusion first lymph capillaries, venous and then at the end, the artery, leading to ischemia evolves to gangrene, necrosis and subsequent perforation. Perforation leads to peritonitis and this increases the risk of patient mortality. This route of disease progression is interrupted with the surgery and very rarely recovers spontaneously.

Intestinal bacteria escaping through the walls of the appendix, pus forms within and around the appendix and the result of a rupture of this type is peritonitis, which can lead to a sepsis infection and multiple organ dysfunction and possibly death . [5] Among the agents that cause blockage of the appendix are foreign bodies, physical trauma, intestinal worms, and lymphadenitis. Block accumulation of feces, called fecaloma, has caused concern in recent research etiologic agent of appendicitis. Fecalomas incidence is higher in developed than in developing countries, [12] often associated with complicated appendicitis. [13] apendicolitos and in the appendix fecalomas probably due to fecal retention in the right colon and an extension fecal transit time in this region [14].
Taenia saginata eggs in an appendix, tinición pathology [15].

However, the obstruction of light as a pathogen is identified in only 30 to 40% of cases. In most cases, the initial event is ulceration of the mucosa, either by viral or bacterial etiology such as the genus Yersinia [4].

It was suggested that the stasis or paralysis of the total fecal stream plays a role in appendicitis, since it has been shown that patients with acute appendicitis have fewer bowel movements per week compared with the control population [16].

Several studies provide evidence that a diet low in fiber is important in the pathogenesis of appendicitis. [17] [18] [19] This may be associated with an increase in the faecal reservoir of right colon, because the lack of fiber in the diet increases fecal transit time. [20]

Pathogenesis [edit]

Inflammation of the appendix produces, over time, an obstruction of the light organ. This obstruction leads to an accumulation of secretions from the mucosa with consequent increase in intraluminal pressure. Making the inflammation and obstruction, compress the veins and arteries, causing ischemia and bacterial invasion to the wall of the appendix with necrosis, gangrene and rupture if not treated immediately.

Based on this sequence of events, the appendix with signs of mild inflammation is known as tongue, is called the obstructive flegmon, then going to gangrene, and ultimately perforated abscess.

Diagnosis [edit]
The McBurney point (identified by the number 1), is one of the most frequent signs in the diagnosis of appendicitis [11].

The diagnosis of appendicitis is based on physical examination and clinical history, complete with blood, urine and other tests such as radiographs of the abdomen, standing and supine, abdominal ultrasound and abdominal CT simple among others.

The physical examination was based on abdominal palpation. The presentation of appendicitis usually starts as a sudden localized pain in the lower region of the epigastric or umbilical region, characterized by a moderate intensity of pain and constant cramping occasionally overlap is intermittent. [11] Then down to locate the right iliac fossa at a point located at the junction of the outer one third to two-thirds of an internal imaginary line between the umbilicus and the antero-superior iliac spine, known as McBurney point.


In 75% of cases there is a triad of Cope, which consists of the sequence abdominal pain (described above), fever and vomiting food. The classic signs are located in the right iliac fossa, where the abdominal wall becomes susceptible to pressure from a mild superficial palpation. Moreover, with the sudden decompression of the abdomen painful, a sign called Rebound sign, indicates a reaction to irritation parietal peritoneum. In cases where the appendix is located behind the blind, the deep pressure of the right lower quadrant pain may not show, silent appendix. This is because the blind man, being distended with gas, prevents the pressure of the examiner gets completely andalusia appendix. Similarly, if the appendix is located within the pelvis, there are usually no abdominal rigidity. In such cases, the DRE compression produces pain retrovesical. The cough causes pain at the point of McBurney [11] (see Dunphy sign), which is the least painful way to locate an inflamed appendix. [Citation needed] The abdominal pain may worsen when walking and it is possible that the person prefer to remain quiet due to the sudden movements that cause pain.

In children the diagnosis can be made more difficult by the patient's irritability and lack of collaboration for the physical examination in these cases the role of ultrasound is very efficient as a means of diagnosis cabinet. Sometimes appendicitis in children with pelvic localization penile erection can happen due to irritation of the peritoneum on the fascia of Waldeyer causing parasympathetic stimulation, this event is known as a sign of Eros. If palpation of the abdomen produces a rigidity involuntary, should be suspected peritonitis, which is a surgical emergency.

Deep palpation of the left iliac fossa may cause pain on the opposite side, the right iliac fossa, which describe a positive sign Rovsing, one of the signs used in the diagnosis of appendicitis. The pressure on the descending colon that is reflected in the lower right quadrant is an indication of irritation of the peritoneum. [3] The pressure in the left iliac fossa displacement generated in the gas colic in retrograde, and when you reach the gas andalusia blind is pain in the right iliac fossa. It also produces the same phenomenon on the epigastrium pressing, known as a sign of Aaron, or, if it is in the right hypochondrium, sign Cheig.

Psoas sign [edit]
Main article: Psoas sign

Often, the inflamed appendix is located just over the psoas muscle called so that the patient lie down with the right hip flexed for pain relief caused by the focus on irritating the muscle. The psoas sign is confirmed by having the patient lie in the supine position while the examiner slowly extends the right thigh, causing the psoas is contracted. The test is positive if the movement causes pain to the patient. Although this sign also called sign Cope is in cases of psoas abscess.

Sign Shutter [edit]
Main article: Sign of the valve

Similar to the sign of the psoas, the inflamed appendix may be in contact with the obturator muscle, located in the pelvis, causing irritation of the same. The sign of the valve is shown by having the patient flex and rotate the hips towards the midline of the body remains in position while lying face-up or supine position. The test is positive if the maneuver causes pain to the patient, especially in the hipogastrio.

Paraclinical diagnoses [edit]

The blood count with differential count shows a mild leukocytosis (10.000-18.000/mm) with predominance of neutrophils in patients with uncomplicated acute appendicitis. The white blood cell counts greater than 18.000/mm increase the possibility of a perforated appendicitis. [3] The urine test is useful to rule out a urinary tract infection, as acute appendicitis, a urine specimen taken by bladder catheter is not characterized bacteriuria or by bacteria in the urine.

Abdominal radiograph should be taken in cases of acute abdomen and, although not relevant for the diagnosis of appendicitis, are useful to exclude other pathologies such as intestinal obstruction or a ureteral calculus. Occasionally, especially in children, the experienced radiologist can notice a radiopaque fecalito in the right iliac fossa, suggestive of appendicitis [4].

Ultrasound and Doppler ultrasound, also offer useful information to detect appendicitis, but a negligible number of cases (15%), especially those in an initial state without intraabdominal free fluid, an ultrasound of the region of iliac fossa can not reveal anything abnormal in spite of having appendicitis. Often, an ultrasound image can be distinguished which is appendicitis from other diseases with similar signs and symptoms such as swollen lymph nodes near the appendix. In situations where there is a CT (computed tomography) available, is the preferred method. TAC has a made a correct detection rate (sensitivity) by over 95 %.).[ 21] What is sought in a TAC is the lack of contrast in the appendix and signs of thickening of the wall of the appendix, usually> 6mm in a cross may also have evidence of inflammation regional so-called "fat desflecada." [3] The ultrasound scans are particularly useful for assessing the causes of gynecological right lower abdominal pain in women since the TAC is not the ideal method for these circumstances.

Scale Alvarado [edit]

The probability of correct diagnosis of appendicitis increases when the emphasis is on specific clinical manifestations, which are summarized in a scale called the rating scale Alvarado.
Most frequent abdominal pain associated with appendicitis. [3] Adapted from Gray's Anatomy.
SYMPTOMS
Right iliac fossa pain migrant 1 point
Anorexia 1 point
Nausea and vomiting 1 point
Signs
Pain in the right iliac fossa 2 points
Rebound pain on palpation 1 point
Fever 1 point
Laboratory
Leukocytosis 2 points
Immature neutrophils 1 point
Total Score 10 points

An aggregate value of 7 points or more is highly suggestive of appendicitis. When the score of 5-6 points is not, a CT scan is recommended to reduce the likelihood of false negatives discovered during appendectomy.

Other signs suggestive of appendicitis is the flagship, the Point and Morris Point Lecene. The patient may present nausea, vomiting, tachycardia, especially if accompanied by fever (between 37.5 and 38 º C) and anorexia. [5] The digital rectal examination can serve to guide the diagnosis if the right wall (where the appendix) is inflamed, it is likely that the patient has appendicitis.

Differential diagnosis [edit]

The diagnostic accuracy of appendicitis is usually between 75-80% based on clinical criteria. When erra, the most frequent alterations found in the operation are, in order of frequency, mesenteric lymphadenitis, no organic disease, acute pelvic inflammatory disease, ruptured ovarian follicle or yellow body and acute gastroenteritis [4].

In childhood:

* Gastroenteritis, mesenteric adenitis, Meckel diverticulum, intussusception, Henoch-Schönlein purpura, lobar pneumonia and intraabdominal lymphangioma. [22]

In adults:

* Regional enteritis, renal colic, perforated peptic ulcer, testicular torsion, pancreatitis, hematoma of the sheath of the rectus muscle of the greater abdomen, pelvic inflammatory disease, ectopic pregnancy, endometriosis, torsion or rupture of an ovarian cyst.

In the elderly:

* Diverticulitis, intestinal obstruction, colon cancer, ischemia mesentéirico, aortic aneurysm with leakage.

Treatment [edit]
Inflamed appendix is removed by open surgery.

Once diagnosed acute appendicitis, the patient should receive medical and surgical treatment. The medical management is done with the patient's hydration, application of appropriate antibiotic such as cefuroxime and metronidazole and analgesics. The surgery is called an appendectomy and is to make an incision in the right iliac fossa or laparotomy depending on the severity of the patient and remove the appendix concerned, as well as drain the infected fluid, and wash the cavity with saline. There is no evidence that irrigation of the abdominal cavity with antibiotics is beneficial during or after the appendectomy. Is not usually the placement of drainage during the operation. In March 2008, a female patient had her appendix removed vaginally guided by endoscopy, the first such maneuver is reported officially. [23]

It is important to mention that if appendicitis is not addressed early can be punctured appendix and thus cause peritonitis, a condition that requires more care and appendicitis is very serious. [5], in turn, can peritonititis lead to the death of the patient for a complication known as septicemia, so it is important to call the doctor as they present any kind of acute abdominal pain (sudden) that lasts more than 6 hours (probably indicative of appendicitis). The earlier the diagnosis is, the greater the chance of receiving adequate medical care, a better prognosis, a minor inconvenience and shorter period of convalescence.

According to meta-analysis of studies comparing laparoscopy with open incisions, seem to demonstrate that laparoscopy is more advantageous, especially in the prevention of postoperative infections, although the incidence of intraabdominal abscesses was increased. [24] laparoscopy may be particularly beneficial for a subgroup of patients who are obese, and female athletes.

Debate is the fact that the emergency appendectomy (in less than 6 hours of hospitalization) or reduces the risk of perforations or complications compared with the emergency appendectomy, which tends to wait longer than 6 hours. In one study found no significant differences in the number of holes in both groups. Similarly, no difference in the appearance of other complications such as liver abscesses. [25] The same study suggests that antibiotic therapy to begin with and delaying appendectomy in patients arriving at the hospital at night, for the following day, does not increase the risk of perforation or other complications.


Most patients with appendicitis recover easily after surgery, however, complications can occur if treatment is delayed. [5] The recovery depends on the age and health condition of the patient and other circumstances, such as complications and consumption of liquor, among others. Usually the recovery after an appendectomy takes between 10 and 28 days and the children around 10 years, can take up to 3 weeks.

The possibility of peritonitis endangers the patient's life, so the behavior of appendicitis is a rapid assessment and treatment without delay. Classic appendicitis responds quickly to an appendectomy, although sometimes resolves spontaneously. Still in debate whether there are advantages in an elective appendectomy in such patients to prevent a recurrent episode. Atypical appendicitis, ie associated with a purulent or suppurative appendix, it is more difficult to diagnose and is the most frequently cause complications, even if the surgery occurs rapidly.

Mortality and severe complications, although rare, occurring especially when accompanied by peritonitis, if this persists or if the disease takes its course without treatment. One of the rare complications of an appendectomy occurs when tissue is inflamed remaining incomplete after an appendectomy. [26]


It is a disease that can appear suddenly without any signs or symptoms makes predictability. Therefore, the astronauts sent into space, researchers at the bases in Antarctica and some top athletes are subjected to a prophylactic appendectomy because it was impossible to detect in advance can not risk it. [Citation needed]

In 2008 was first reported in the literature appendicitis within an umbilical hernia in an infant 25 days old. [27] The appendicitis in other hernias are not uncommon, occurring in inguinal hernias (hernia Amyand's) and femoral (Garengeot hernia).