Chapter 1. SURGICAL PATHOLOGY OF THE APPENDIX

Appendix functions

Motoric function

Appendix performs peristaltic movements, regulates functioning of ileocaecal valve. The impairment of this function may cause ileocaecal valve spasm and dyskinetic disturbances in ileocaecal segment of the intestine resulting in caeco-iliac reflux.

Secretory and hormonal functions

Appendix releases amylase and the peristaltic hormone.

Stabilizing function

Appendix stabilizes microflora of the large intestine "incubating" E.coli in a sort of reservoir, from which microflora enters the large intestine.

Immune function

Appendix is the "intestinal tonsil" providing natural resistance of the organism, local immunity, immunologic memory, immunologic tolerance and reactions in specific pathological processes.

After appendectomy all functions of appendix, generally, are compensated by other organs.

Definition and statistical data

Acute appendicitis is an acute inflammation of the caecum appendix caused by the invasion of microflora in its wall, with a particular clinical picture.

The incidence of acute appendicitis is 7-12% of the population (M.I. Kuzin, 2014, A.F. Chernousov, 2012) and varies in different age groups. In children the morbidity consists 15%, and in 50-year-old people - 2%. Acute appendicitis occurs more frequently between the ages of 20 and 40. In women it occurs twice as frequent as in men. In recent years the tendency to incidence reduction is noted.

In Asian and African countries acute appendicitis occurs less often, which may be associated with the dietary peculiarities (prevalence of vegetables in the diet).

Acute appendicitis ranks first in the number of urgent surgery interventions (60-80%) and second place after acute cholecystitis according to the number of hospitalized patients in the Emergency surgical department (up to 30% of patients) (M.I. Kuzin, 2014, A.F. Chernousov, 2012).

Etiology and pathogenesis of acute appendicitis

Etiology of acute appendicitis

Etiological factors

Effect

Angioneuropathy: Disorders of vascular and nervous systems (atherosclerosis, systemic vasculites, diabetes mellitus, thrombophilias)

Contributes to the damage of appendix trophism.

Autoallergy

Contributes to the mucosa necrosis development.

Process occlusion (hyperplasia of lymphoid follicles, fecal stones, fecalomas, foreign bodies, helminthes)

Causes the elevation of intracavitary pressure and blood flow disturbance.

Acquired and congenital immunodeficiency

Causes mucosa and lymphoid apparatus barrier function impairment, stimulates microbes multiplication, increases flora virulence and activates chronic infection.

Infectious factors:

- nonspecific flora (streptococcus, staphylococcus, colibacillus, anaerobic non clostridial flora);

- specific flora (tuberculosis, pseudotuberculosis, bacillar dysentery, typhoid, protozoa, balantidia)

Cause damage of appendix tissues.

Clinical picture of the typical course of acute appendicitis: phlegmonous and gangrenous appendicitis without perforation (80-85%)

Complaints

The pain in the right iliac region without irradiation, nausea, malaise, weakness.

Anamnesis morbi

The disease starts with the pain in the epigastrium or throughout the abdomen accompanied by nausea, sometimes by vomiting with further pain moving into the right iliac region within 2-5 hours (Kocher's sign).

Anamnesis vitae

Absence of similar attacks in the past. Appendectomy in the case histories of close relatives.

Physical examination findings

Tenderness when palpating the right iliac region. Localized muscular tension in the right iliac region. Localized tenderness when pressing the right iliac region and pain aggravation at sharp hand removal (Blumberg's sign).

Pain aggravation in the right iliac region when coughing (Cheremskyh-Kushnerenko's sign) - a variant of Blumberg's sign.

Abdominal wall percussion reveals tenderness in the right iliac region (Mendel-Razdolsky's sign) - a variation of Blumberg's sign.

Pain aggravation in the right iliac region when suppressing the sigmoid colon and jerkily pressing the descending portion of the sigmoid colon (Rovsing's sign).

Pain starts or aggravates in the right iliac region in the patient's position on the left side (Sitkovsky's sign).

When palpating the caecum tenderness aggravates in the patient's position on the left side (Bartomier-Michelson's sign).

Pain aggravation when pressing the caecum in the patient's position with the leg lifted and straight in the knee joint (Obraztsov's sign).

Tenderness at palpation and, possibly, overhanging of posterior

and right lateral vagina vault in women.

Tenderness when palpating the anterior-right rectum wall in

men.

Laboratory and instrumental investigations

Leukocytosis with the shift of leukocyte formula to the left. Hyperthermia. The difference between rectal and axillary temperatures is more than 0.5 °С.

Factors influencing the characteristics of clinical picture

Phase of the disease

Solar

(up to 4 hours from the beginning of the disease)

Persistent aching pain in the epigastrium or throughout the abdomen. Malaise, weakness, nausea, unitary vomiting. The tongue is moist and coated. The abdomen is soft, moderately tender at palpation of epigastrium. Normal rhythm or bradycardia. Normothermia. The difference between the rectal and axillary temperatures is less than 0.5 °С. Normocytosis

Appendicular

(4-7 hours since the onset of the disease)

The pain moves to the right iliac region. Tongue is moist and coated. The abdomen is soft, tender in the right iliac region. Rovsing's, Obraztsov's, Sitkovsky's, Mendel-Razdolsky's, Bartomier-Michelson's signs are positive. Peristalsis is preserved. The pulse is up to 90 beats per minute. The body temperature is subfebrile. The difference between the rectal and axillary temperatures is 0.5-0.6 °С. Leukocytosis (up to 11x10⁹/l) without the formula shift to the left. The signs of peritoneum irritation are negative.

Peritoneal - local peritonitis

(7-10 hours since the onset of the disease)

Intensive continuous pain in the right iliac region. The tongue is dry and coated. The abdomen is tender at palpation in the right iliac region. The anterior abdominal wall muscles in the right iliac region are tense. Blumberg's sign in the right iliac region is positive. The pulse is more than 90 beats per minute. The body temperature is 38 °С and higher. The difference between the rectal and axillary temperatures is more than 0.6 °С. Leukocytosis (more than 11 x10⁹/l) with the formula shift to the left.

Age

Children

Prevalence of general symptoms over local, fever (above 39 °С), frequent vomiting. Leukocytosis up to 18x10⁹/l with neutrophilic shift.

Elderly and senile patients

Prevalence of destructive forms. Clinical manifestations are effaced; solar phase, pain syndrome and peritoneum irritation signs are not pronounced. The body temperature and the leukocyte count elevate insignificantly even in destructive appendicitis.

Constitution

Obese patients

Difficulties when determining localization and intensiveness of the tenderness, as well as peritoneum irritation symptoms.

Comorbid conditions

Atherosclerosis

Primary-gangrenous appendicitis prevails. Solar and appendicular phases are absent. The pain fades before peritonitis manifestations development.

Diabetes mellitus

Fast development of clinical manifestations. Primary-gangrenous appendicitis is also possible. High risk of complications development.

Pregnancy

Manifestations of symptoms are reduced due to hormonal, metabolic and physiological alterations. Anterior abdominal wall muscle relaxation. The appendix and caecum displacement hampers the process localization and peritoneum irritation symptoms determination. Diagnostics is complicated by physiological leukocytosis, frequent nausea and vomiting associated with pregnancy.

Appendix localization

Medial

Rapid development of clinical symptoms is conditioned by close localization of the appendix to the small colon mesentery root. Frequent vomiting and fever. Local tenderness, abdominal muscles tension and Blumberg's sign are more pronounced around the umbilicus and to the right of it.

Retrocecal

The appendix lies behind the right kidney, ureter, and lumbar muscles. The pain is localized in the right lateral or lumbar region, aggravates at walking and right hip joint movement. Dysuria. Lack of anterior abdominal wall muscles tension. Lumbar muscles rigidity in the right. Maximum tenderness region is localized in the right lateral abdominal region. Blumberg's sign in the right lumbar triangle area (Petit) is positive. Obraztsov's sign is typical, tenderness when percussing and palpating right lumbar region. Leukocytes, fresh and alkaline erythrocytes in urinalysis.

Pelvic

The pain is localized either in the pelvic region or immediately above the inguinal fold. Localization of the inflamed appendix close to the rectum and urinary bladder may cause tenesmus and dysuria, resulting in changes in urinalysis. Abdominal wall muscles tension and Blumberg's sign are not pronounced. Rectal examination reveals sharp tenderness and rectum anterior wall overhanging.

Under the liver (epigastric)

The pain and peritoneum irritation signs are localized in the right hypochondrium.

Left-sided

This localization is conditioned by the inverted arrangement of the inner organs or by excessive mobility of the right colon's part. The only difference in clinical pattern of the disease is that all local signs of appendicitis are localized in the left iliac region. Situs viscerum inverses diagnostics is facilitated when dextrocardia and liver localization in the right hypochondrium are detected.

Special form of acute appendicitis

Appendix empyema

It occurs in 1-2% of cases of acute appendicitis. Morphologycally it is most similar to phlegmonous appendicitis. The pain originates in the right hypochondrium, slowly progresses, and reaches its maximum by the third-fifth day of the disease. The general condition changes insignificantly. Peritoneal symptoms are lacking.

Appendicular infiltrate

Appendicular infiltrate is a dense adhesive conglomerate consisting of the appendix and inflammatory infiltrated formations surrounding it: small intestine, caecum and ascending colon, omentum, parietal peritoneum. Biologically the infiltrate is aimed to circumscribe the inflammation focus from free abdominal cavity. It occurs in 3-5% of cases.

Clinical picture of appendicular infiltrate

1. Acute appendicitis 3-5 days prior to the examination in the case history.

2. Palpable formation (dense, painful, immovable, uneven, adjacent to the iliac bone).

3. Additional instrumental methods of examination are necessary for diagnosis verification (ultrasonic investigation, CT, irrigoscopy).

Clinical picture of pylephlebitis

Manifests more frequently after appendectomy. The patient's condition (health improvement interval) does not improve after operation.

Temperature elevation appears from the first day after the operation - hectic fever and peritoneal irritation. Systemic inflammation reactions aggravate quickly.

Meteorism, uniform tenderness in the right abdomen without well pronounced symptoms of peritoneum irritation.

Jaundice appears, the liver is enlarged due to purulent cholangitis development and multiple liver abscesses. Hepatorenal insufficiency progresses on the background of the patient's general septic condition.

Generalized peritonitis

Generalized peritonitis is an acute inflammation of visceral and parietal peritoneum having no tendency to circumscribe and be controlled by itself.

Generalized peritonitis complicates the course of acute appendicitis in about 1% of cases. In perforative appendicitis it occurs in 8-10% of cases.

Clinical picture of generalized peritonitis

Pallor, adynamia, frequent vomiting, tachycardia, dry tongue, dehydration.

Abdominal wall tension, positive Blumberg's sign, acute tenderness at rectal and vaginal examination.

Signs and symptoms of dynamic intestinal occlusion: abdominal distention, lack of peristaltic sounds, fecal and gas evacuation retention; levels of liquids in the intestine on the X-ray.

Signs of polyorganic insufficiency, sepsis.

Differential diagnostics and diagnosis

Diagnosis of acute appendicitis in typical cases (when most of the major signs of appendicitis are present and signs of other diseases are absent) is made on the basis of the clinical picture analysis. This variant of the clinical course of appendicitis occurs in the majority of patients.

In some cases (when most of the major symptoms of appendicitis and signs of other diseases are present) clinical differential diagnostics is necessary and sufficient.

In the atypical course of the disease (when most of the major symptoms of appendicitis are absent, but signs of other diseases are present) additional instrumental methods of investigation (ultrasonic examination, CT, laparoscopy) are required to verify the diagnosis.

Range of diseases for differential diagnostics of acute appendicitis

Diseases accompanied by peritoneal inflammation

Diseases accompanied by peritoneal irritation by the blood

Diseases without peritoneal irritation

Inflammatory

Non inflammatory

1. Perforative ulcer of the stomach and duodenum

2. Pancreonecrosis

3. Acute perforative cholecystitis

4. Acute intestinal obstruction (at the late stages)

5. Mesenteric thrombosis

6. Colon perforation (tumor, fistulous form of Crone's disease, perforation by the fish bone)

7. Meckel's diverticulum, diverticulitis

8. Pelvioperitonitis

9. Purulent paranephritis

10. Twisted ovarian cyst

1. Damaged extrauterine (tubal) pregnancy

2. Ovary apoplexy

1. Colon diverticulitis

2. Pleurites and pneumonias

3. Acute gastritis, enteritis, colitis (including salmonellosis)

4. Acute edematous pancreatitis

5. Peritoneum tuberculosis

6. Acute pyelonephritis

7. Acute adnexitis

8. Endometritis and parametritis

9. Mesenteric mesadenitis

1. Exacerbation of gastric and duodenal ulcer

2. Endometriosis

3. Ovarian polycystosis

4. Urolithiasis

5. Right nephroptosis

6. Caecum and ascending colon tumors

7. Myocardial infarction

8. Hemorrhagic vasculites

9. Helminthic invasions

10. Menoalgia

11. Abdominal syndrome in diabetes mellitus, atherosclerosis (angina abdominis)

Tabular diagnostics of acute appendicitis

The data in the table is obtained by mathematical processing of a great amount of clinical material. The table is applied when patients complain of the pain in the right iliac region.

Symptoms

Balance value of symptoms

Presence of the symptom

Absence of the symptom

1. The onset of the disease with the pain in the right iliac region

5

0

2. The onset with the pain throughout the abdomen

4

0

3. Vomiting or nausea

7

-8

4. Presence of similar attacks in the past

-6

3

5. Muscular tension in the right iliac region

4

-2

6 Blumberg's sign

7

-2

7 Leukocytosis (9-10 thousand and more)

4

-8

8 The difference between axil/rect to is 0.5 °C or more

4

-2

9. The body temperature 37 °С and higher

6

0

10. Tachycardia (90 beats per minute and higher)

0

-8

11. Rovsing's sign

0

-4

12. Coated tongue

8

-8

13. Dry tongue

0

-2

At the patient's side the algebraic sum of balances of all signs is calculated.

The positive sum of the balance value of the symptoms allows diagnosing destructive appendicitis.

The negative sum of symptoms' balance value allows assuming the diagnosis of catarrhal appendicitis or other diseases, that requires additional observation and examination.

The table is used as the screening-test. Efficiency of application is up to 90%.

Instrumental methods of examination in acute appendicitis

Method

Signs

Survey roentgenoscopy of the abdominal cavity

Liquid level in the caecum and terminal portion of the ileum ("a guarding loop" sign).

Pneumatosis of an ileum and right half of the colon.

Caecum medial contour deformation.

Indistinct contour of m. ileopsoas.

Detection of the fecal stone shadow in the appendix projection is possible.

Gas in the abdominal cavity is sometimes detected in perforation.

Informative value of the method is - 75-80%.

US Scan

The appendix diameter enlargement up to 8-10 mm and more.

Thickening of the walls up to 4-6 mm and more, wall lamination damage.

The appendix rigidity, its shape alteration.

Presence of concrements in the cavity.

Mesentery infiltration.

Detection of free liquid in the abdominal cavity.

Informative value of the method is up to 90%.

Laparoscopy

Direct signs: hyperemia of the visceral and parietal peritoneum, fibrin membranulae, mesentery infiltration, rigidity of the walls.

Indirect signs: presence of a muddy exudate in the abdominal cavity, hyperemia and the caecum wall infiltration.

Informative value of the method is up to 92%.

Modern surgical tactics in acute appendicitis

In suspicion on acute appendicitis the patient must be hospitalized.

In the established diagnosis of acute destructive appendicitis urgent surgery is indicated.

The only contraindication to the operation in acute appendicitis is dense appendicular infiltrate due to the impossibility to separate the adnations between the organs.

Appendectomy in most cases is performed with general anesthesia.

It is performed by means of either open or (mainly) laparoscopic access.

Treatment of complicated acute appendicitis

Appendicular infiltrate

Conservative treatment: Cold, antibiotics, antiinflammatory roentgenotherapy.

In 2-3 months after the infiltrate resorption planned appendectomy concerning chronic residual appendicitis is recommended to prevent the repeated attack of acute appendicitis.

Local circumscribed peritonitis: periappendicular, retroperitoneal, appendicular abscesses

Periappendicular, retroperitoneal abscesses are opened and drained during the appendectomy.

The appendicular abscess (the outcome of appendicular infiltrate) is opened by extraperitoneal approach and drained. Punctures with abscess sanation under US control are also performed.

Generalized peritonitis

During appendectomy wide approach (medial laparotomy) is used.

The source of peritonitis - destructively deformed appendix is liquidated.

The abdominal cavity is washed with the antiseptic solution and drained in 2-4 spots.

Intraoperative injection of antibiotics is performed.

Intensive therapy in the postoperative period.

Pylephlebitis

It manifests more frequently after operation.

When the signs of pylephlebitis are detected during the operation (gray-necrotic appearance of the mesentery, a dim serous membrane, through which greenish thrombosed veins are seen) it is necessary to remove the whole mesentery up to its root.

Sometimes it is necessary to perform early ligation of the iliac-colonic veins or ileocecal angle resection.

Massive antibacterial and detoxication therapy, immunostimulation, hepatotropic preparations.

The prognosis is more frequently unfavourable.

Treatment of postoperative complications

Infiltrates, wound pyesis

Infiltrates: blockade with antibiotics, physiotherapy.

In pyesis - wound disclosing, its sanation and drainage.

Bleedings

In case of intraabdominal bleedings - diagnostic laparoscopy, then relaparotomy or laparoscopic intervention with the bleeding arrest, abdominal cavity sanation.

Blood loss compensation.

Generalized peritonitis

It is caused either by the intestinal wall defect (stump incompetence, intestine wound) or by non-controlled preoperative peritonitis. Diagnostic laparoscopy, then relaparotomy or laparoscopic intervention with the abdominal cavity sanation and drainage can be performed.

Abdominal cavity abscesses

Hypodiaphragmal, hypohepatic, interloop, pelvic abscesses are opened, better by extraabdominal approach, and drained. Punctures with abscess sanation under US control are also performed. In interloop abscesses relaparotomy or laparoscopic drainage are sometimes used.

Eventration

More frequently it is the consequence of peritonitis. Abdominal cavity sanation and drainage, abdominal wall suturing are used.

Intestinal fistulas

They are consequences of stump incompetence and intestinal wound.

Usually tubular fistulas get closed by means of conservative treatment.

Lip-like and complicated fistulas require closing by surgical means.

More frequently intestine resection with carrying the fistula away is applied.

Acute commissural intestinal occlusion

It is а consequence of the intestinal deserozing during appendectomy, peritonitis or intraabdominal bleeding. Urgent relaparotomy with permeability restoration is required. Laparoscopic adhesiolysis is possible.

Pathogenic peculiarities of various forms of chronic appendicitis

Residual

It occurs after the endured acute attack resulted in the recovery without operative intervention (catarrhal appendicitis). In this case the conditions for acute appendicitis recurrent attack occurrence remain (the appendix deformation, adhesion process), which complicate the appendix emptying.

Chronic recurrent appendicitis

It occurs after the endured acute attack, resulted in the recovery without operative intervention (appendicular infiltrate). Usually the recurrent course of the disease is observed.

Primary chronic appendicitis

It occurs without previous attack of acute appendicitis.

Signs and symptoms

Complaints of aching pain in the right iliac region without irradiation, which may occur without any cause or provocated by physical exertion or dietary violation.

The attacks of acute appendicitis or appendicular infiltrate are registered in the case histories of most patients.

Palpation of the abdomen reveals slight tenderness in the right iliac region. Sometimes Sitkovsky's sign is detected.

Laboratory and instrumental investigations do not detect the direct signs of chronic appendicitis. The indirect signs of chronic appendicitis during the instrumental investigations are: the lack of appendix filling in, slowing of its emptying, deformation, appendix lumen narrowing, fulfillment defects in its shadow (according to the roentgeno-contrast investigation of the intestine) or detection of fecal stones, the appendix shape deformation and unevenness of its lumen during ultrasonic examination), adhesion process, the appendix deformation during laparoscopy).

Differential diagnostics and the diagnosis

Considering the absence of specific clinical picture of chronic appendicitis, the diagnosis is made on the basis of the complaints and case history analysis when indirect signs obtained during the appendix roentgenocontrast and ultra-sound investigations are present.

Besides it is necessary to exclude the adjacent organs' pathology (diseases of the intestine, urinary system, gynecological disorders, retroperitoneal malformations) with compulsory application of modern diagnostic devices.

Treatment

When the diagnosis of chronic appendicitis is verified appendectomy is indicated.

When acute appendicitis has been registered in the case history, the operation is performed in 2-4 months.

The operation is performed by means of laparoscopic approach