Apendicits (2)

Definition

It is the acute inflammation of the cecal appendix, the specific etiology can not be established in most cases.

Insidens

Just over 60% of cases are male. The average age is 19 years and almost half of patients with acute appendicitis are between 10 and 20 years. The disease is rare below the 3 years.

It is estimated that in patients with acute abdomen, over 50% are for acute appendicitis.

Etiopathogenesis

Morphologically cecal appendix is a continuation of the blind, in the form of a lumen with me. The walls contain circular and longitudinal muscle fibers, as in the caecum, while mucosal lymphoid follicles has in its thickness. The obstruction occurs with more edema and obstruction, to close a vicious circle. Less frequently, the source of the obstruction is a fecalito, parasite or foreign body.

The position of the appendix is retrocecal retroileal and in 65% of cases, and decreasing in the pelvic retroperitoneal in 30% and 5%. Irrigation comes from the appendicular artery, a branch of the ileocólica.

Obstruction of the appendiceal lumen leads to a process that can be divided into three stages (Figure 1).

Initially, the obstruction compresses the lymphatic ducts, which leads to ischemia, edema and accumulation of mucus. This is converted by bacteria in pus and sores appear in the mucosa. This is the focal appendicitis, which is clinically characterized by symptoms that the patient is usually interpreted as "indigestion," and later, for epigastralgia. Pain in the epigastrium as early manifestation is a typical stage in the evolution of acute appendicitis.

Then the bacteria colonize and destroy the appendiceal wall. The inflammatory process reaches the serosa and the parietal peritoneum. At this stage there is an acute appendicitis draining, which is characterized by localized pain in the right iliac fossa.

Later, the thrombosis of blood vessels occurs appendiceal wall necrosis and gangrene. When this occurs, it is called acute gangrenous appendicitis. The wall allows the migration of gangrene bacteria, which is why in peritoneal contamination despite the absence of a visible perforation. The patient showed signs of localized peritoneal irritation or even widespread.

Finally, the cecal appendix is perforated where the wall is weakest. Through drilling away the purulent content, giving rise to peritonitis. If the handles near the omentum and the focus kept isolated, and localized peritonitis persists and forms a plastron or an appendiceal abscess.

When the appendix is retroperitoneal, the process tends to be more localized. However, if the appendix is intraperitoneal, and drilling is not sealed by omentum or loops, there is a generalized peritonitis. In this case the symptoms and signs relate to the irritation of a diffuse across the peritoneum.

Clinical

The classical clinical sequence is first pain, then vomiting and fever finally.

The pain began in the epigastrium or periumbilical area and then located in the right iliac fossa.


Anorexia is almost always to the point that if the patient has the appetite, the diagnosis of appendicitis should be questioned. Vomiting is present in more than 75% of cases. The fever is 38 ° to 38.5 ° C. However, in patients of extreme age infants, the elderly and fever may be absent or may have hypothermia, which is applicable to any disease for patients in this age group. Diarrhea is present in about 1 / 5 of patients and is related to the type of pelvic appendicitis.

When appendicitis is suspected, before starting the palpation of the abdomen called the patient to cough with a finger and give the most painful. If the point is more painful in the right iliac fossa, then you should look for the sign of Rovsing which is the onset of pain in FID andalusia compress the left iliac fossa. This sign alone indicates the presence of an inflammatory process in the right iliac fossa, although not specific for appendicitis (Figure 3).

Palpation of the abdomen always practice began on the least painful quadrants and moving to more painful and the surface to depth. The tables are initial pain on deep palpation in the right iliac fossa. May appear later contracture of the abdominal wall, ie involuntary defense, which is more intense the closer you are to inflammation of the anterior abdominal wall.

In the presence of localized or generalized peritonitis, it is possible to find pain rebound, ie the sudden decompression. This is Blumberg's sign, which is ultimately of significance when it is present. However, it must be very well evaluated, given the ease with which it is interpreted in the wrong way.

Palpation may also discover a body, which is a sign of an abscess or plastron, ie a localized process. Finally, when the appendix is perforated, the patient worsens immediately. Becomes more hectic, increased pulse and temperature and general condition worsened. If the process is located in loops or omentum, abdominal distension appears diffuse compromise of the peritoneum is widespread frank peritonitis. In 80% of cases the appendix is perforated prior to 36 hours of the symptoms started. When there is peritonitis, the patient is kept quiet as possible so as not to arouse pain. Coughing and movements aggravate the pain, so the patient is mobilized with characteristic caution. Andalusia was coughing while holding the iliac fossa pain complains.

DIFFERENTIAL DIAGNOSIS

The differential diagnosis in acute appendicitis is very important for any doctor, as a frequent diagnostic error and because the complications involved with high morbidity and mortality.

NON TYPICAL TABLE

Constitutes the largest group in the differential diagnosis. There are several ways:

1. Extreme ages. In the breastfed child, appendicitis is rare and usually occur with diarrhea. Moreover, because of age, the patient expresses the mal symptoms. For these reasons, every patient an infant with diarrhea, which began with abdominal pain or abdominal distension who appears, should be ruled out appendicitis. It is important to remember that in the infant and preschool, the omentum is short, and therefore fails to obliterate and identify the area of inflammation. For this reason, such patients suffer from generalized peritonitis ages earlier.

In the elderly, also is perforated appendix earlier because the blood is deficient in the appendix. Furthermore, such a patient presents with little or no fever and little or no abdominal defense. The fact that the disease develops more quickly and with fewer symptoms, makes the prognosis is reserved for the individual elderly.
2. Patients with prior treatment. In the interrogation record if received painkillers, because they mask the pain. If received, it should wait until the end to assess the patient again.

We must also find out by previous administration of antibiotics, because the patient with acute appendicitis who received it may have few or no symptoms. Therefore, if a question of having appendicitis, the patient should not receive antibiotic treatment to rule out the doubt. It is preferable to wait 12 or more hours for it to clear the table.
3. Appendix atypical location. Appendix retrocecal position may urinary symptoms by proximity to the ureter. However, no urological pathology signs of peritoneal irritation, and even if the appendix is retrocecal, there are signs of inflammation.

Appendix retrocecal, and tends to form a localized abscess at the site. This abscess, if so, gives rise to the signs of the psoas and / or shutter. In the story will find background to think about appendicitis, and on physical examination signs of psoas abscess, in addition to those of acute appendicitis.

The attachment position is manifested by pelvic pain in the pelvic area, rather than on the right iliac fossa. However, signs and their sequence remain unchanged.

However, the more difficult to diagnose appendicitis is one of retroileal location. Handles ileum inflamed appendix can trap and prevent the contact of the inflammatory process with the parietal peritoneum, which delays the onset of contracture of the wall and Mark Blumberg. The diagnosis is based more on history, due to the absence of physical signs.

Female patients

In all patients are female differential diagnosis in gynecologic pathology type. The physician should rule out this group of entities with a vaginal examination if not a virgin, or rectally if the patient is a virgin. The differential diagnosis must be made with:

1. Anexitis. Which is characterized by purulent flow, menstrual pain and recent palpation of the annexes or the mobilization of the uterus. Furthermore, there is no history of acute appendicitis.
2. Ectopic pregnancy. It is characterized by amenorrhea and palpable mass in the annex, and if broken by paleness, fainting and culdocentesis positive for blood.
3. Twisted ovarian cyst. The pain is similar to the clinical picture of acute appendicitis. However, it is not accompanied by fever and the initial gynecological examination may show a mass-dependent annexes.
4. Rupture of ovary. You can have several origins. The most frequent is the rupture of the follicle from De Graff, which occurs after 14 days of the cycle. The diagnosis is established with the culdocentesis.
5. Pregnancy. The growth of the uterus rejects the lateral appendix and headache after the third month of pregnancy. At the fifth month, the appendix is on target to rise to the umbilical scar on the extension of the midline axillary. Besides the type of location where punches are going to produce generalized peritonitis because the omentum is not sufficient to occlude the perforation.

As the abdominal wall is tense by the presence of the uterus increased in size, physical signs are bizarre. Given the height of the appendix, the differential diagnosis arises with pyelonephritis.

In pregnant patients, appendicitis has a mortality rate 5 times higher and a high incidence of abortion and premature birth.

LABORATORY TESTS

Routine examinations of greater value in acute appendicitis is the blood and urine analysis (urine sediment).

The sample leucograma leukocytosis and / or neutrophilia in more than 70% of cases of acute appendicitis. This fact serves to further ensure the diagnosis, but the absence of this finding does not exclude it.

The urinary sediment is useful if the doctor thinks of a urinary tract infection as an alternative diagnosis. The presence of leukocytes can be observed if the inflammation of the appendix is located in the vicinity of the ureter or bladder. Also useful in cases of ureteral stones, which can be found microscopic hematuria.

Diagnostic images

The plain abdominal radiography is of limited use in specific diagnosis of acute appendicitis, but it is valuable to study the pattern of bowel gas, to determine if there is a fecal impaction, and in some cases, display a radio-opaque urinary calculi.

Ultrasonography has value when the symptoms are equivocal, especially in children, and aid in the differential diagnosis of pelvic disease in women. It is a non-invasive procedure, whose success depends in large part on the skill and experience who performs the exam. The TAC for its part, shows very well the presence and abscesses, flegmon (plastron), and inflammatory masses periapendiculares.

The clinician must remember however that all these studies have a sensitivity and specificity less than 100%, ie there are false positives and false negatives.

TREATMENT

The treatment of acute appendicitis involves three steps:

a) Preoperative Management. All patients received intravenous fluids should be administered in sufficient quantity to replace the patient stopped eating before consulting or lost, either by vomiting, diarrhea, fever, or "third space".

In addition, antibiotics should be administered to cover gram negative and anaerobic bacteria, at least half an hour before surgery. It is preferable to administer antibiotics to all patients, and if the case of a non-perforated appendicitis, suspended after the surgery. The usual combinations are based on metronidazole, clindamycin, or chloramphenicol to cover the negative. Instead of these combinations can be used ampicillin-sulbactam or cefoxitin sodium, which also cover these microorganisms, with the advantage of not being negrotóxicos. At present the preferred combination metronidazole and gentamicin on the basis of their lower cost.

In any patient who has decided to conduct the surgery, should be given a non-opioid analgesic. Having decided on the surgery, is not essential to keep the pain.

If the patient exhibits signs of generalized peritonitis, or at least if there is abdominal distention, add:

* A catheter to measure central venous pressure
* A bladder catheter for monitoring of urine output before, during and after surgery.
* A nasogastric tube to decompress the abdomen before surgery and to avoid an excessive relaxation afterwards.

b) Surgical Management. The incision should be horizontal if the process is located, and vertical if it is suspected generalized peritonitis or the diagnosis is not secure.


The incision includes the horizontal section of the skin in the transverse direction on the lower right quadrant, at the level of the iliac spine on the outer half of the rectus muscle above the abdomen as much as outside of it. The fascia is incident in the same direction and the transverse muscle is rejected internally. Peritoneum can be opened longitudinally to avoid injury to the epigastric vessels. When you need a better exposure, it divides the fascial edge internal oblique and transverse internal and stripping both muscles as much as necessary. As far as possible, and especially women, should try a small incision and smooth appearance, without thereby sacrificing the breadth of exposure.

Longitudinal incision crosses all levels until the peritoneal cavity. Unlike the incisions pararrectales, ie outside the rectus muscle, this access does not cross the nerves that go to the muscle and prevent its denervation and subsequent atrophy. As noted, this incision is indicated in processes that include diffuse and generalized peritonitis requiring washing the cavity. Is also indicated when the diagnosis is unclear and may be necessary to extend the incision to practice due process.

Wherever possible, we should do the appendectomy. However, in case of total destruction of the abscess and cecal appendix, must be practiced only drainage of the abscess, leaving a drainage tube contrabertura because of the possibility of a cecal fistula.

If you are a perforated appendicitis with generalized peritonitis, after an appendectomy is to wash the peritoneal cavity with normal saline until the return fluid is clear in appearance. Not be drained, even if an abscess in the cavity. You must take special caution in the appendiceal stump is well insured. The only indication for drainage is the uncertainty in the closure of the appendiceal stump.

As to the surgical wound, it is closed if the appendix was not perforated, as it is a clean contaminated wound. In case of perforation, peritonitis or abscess, closing the peritoneum and the fascia and leave the tissue and the skin open. Is applied to the wound or gauze moistened with saline solution that should not be removed until the fourth postoperative day. On the fourth postoperative day the wound is found and if it is clean, can be closed with tape or butterflies suture simple. If you are infected, healing is continuing and is expected to close by secondary intention.

c) postoperative management. The nasogastric tube remains in situ until the peristalsis and the Foley catheter until the stabilization of the diuresis.

When the appendix was not perforated suspension of antibiotics and is expected to start peristalsis orally. In these cases peristalsis usually appears at 6 or 12 hours postoperative.

If the appendix is not perforated, suspending antibiotics and is expected to appear to initiate peristalsis orally. Peristalsis appears usually at 6 or 12 hours postoperative.

If the appendix was perforated and there was generalized peritonitis, the patient must:

1. Semisentado remain in position to allow fluid to drain the contents of the peritoneum toward the Douglas bag. In this way, if you form a pelvic abscess and it will not subfrenic, the difference is that a pelvic abscess is easier diagnosis and management subfrenic an abscess.
2. Maintain a schedule of central venous pressure and diuresis.
3. Vital signs are monitored on an ongoing basis until they are stabilized. After controlling every 4 hours with the temperature. These controls allow adjustments in the management of fluids in a timely manner and detect any complication.
4. Continue the management of fluids according to the peritonitis.
5. Analgesics as needed.
6. The wound is treated as already described.

Appendicitis LAPAROSCOPIC

The method has proved effective, with the advantages of minimally invasive procedures and in addition, laparoscopy allows for the diagnosis in equivocal cases, especially in female patients. Because the appendectomy is usually a simple procedure that can be done easily through a small incision, the laparoscopic approach obviously more complex and more expensive, has not supplanted the conventional operation in most centers.

FORECAST

With this handling mortality average is 0.46% in the Hospital Universitario del Valle. This figure is higher in elderly patients, appendicitis in over 48 hours of evolution, in pregnant patients and infants.