LECTURE ACUTE APPENDICITIS

Acute appendicitis till now is one of the most important surgical problems. It's

enough to say, that appendectomy constitutes about 20 -30% of all surgery. In Ukraine

about 500.000 appendectomies are performed annually without marked downtrend (A.A.

Shalimov, 1989). Studies of appendix had passed many stages before the modern system

of etiology, pathogenesis, clinical picture and treatment was created. This disease is

insidious one. The existent conception about it as about of slight indisposition is easily

disproved by statistics. Lethality seems to be not high, taking into consideration the

incidence of the disease; it is rarely exceeds 0,2-0,3%, but these figures mean dozens of

thousands lives.

The first appendectomies had been performed by Kronlein in 1883, by Malomed in

1884, and by A.A. Troyanov in 1890.

Brief Anatomo-Topographic Sketch

Vermiform appendix (appendix vermiformis) is the constituent of the iliocaecal

angle, which presents morphological integrity of four intestinal departments: the caecum,

terminal end of the ileum, initial part of the ascending colon, and the vermiform process.

All the constituents of the iliocaecal angle are in strict correlation and perform the

function of "internal analyzer", coordinating the most important function of the intestine

— conduction of chyme from the small to large intestine (A.M. Maximenkov, 1972).

The important element of iliocaecal angle is the iliocaecal (Bauhin's) valve (valva

ileocaecalis) with very intricate structure. Its function is to accomplish regulation in

transition of intestinal content to the caecum in little portions and to prevent its return

from the caecum to the small intestine.

The iliocaecal angle is situated in the right ileac fossa. Fundus of the caecum is

projected on the distance of 4-5 cm upwards the center of the inguinal ligament; under

condition of its filling, fundus of caecum is located just above the center of the inguinal

ligament or may even descend to the small pelvis. Great variability in anatomo-

topographic situation of the caecum and the vermiform process explains in many respects

such a diversity of clinical picture, which may be observed in acute appendicitis.

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The most frequent and practically important deviations from the normal position of

the caecum are the following (V. I. Kolesov,1959):

1) high, or hepatic position, when the caecum and the vermiform process are

situated high, sometimes reaching the lower border of the liver;

2) low, or pelvic position, when the caecum and the vermiform process are situated

below normal, i.e. descends to the pelvis.

Other variants of it localization, such as its left-side position, location along the

middle line of the abdomen, in the umbilical region, in the left hypochondrium, in the

hernial sac, etc. occur rather infrequently.

The vermiform process is located intraperitoneally. It has its own mesentery

(mesenteriolum), which supplies it with vessels and nerves.

Blood supply of the iliocaecal angel is provided owing to the superior mesenteric

artery — a. ileocolica, which is subdivided into the anterior and posterior iliac arteries.

The natural artery of vermiform process — a. appendicularis, which may have a loose,

arterial or mixed structure, branches off from a. ileocolica or from its branch. Artery of

the vermiform process goes through its mesenteries, along its free edge, to the end of the

process. Though its small caliber (from 1 to 3 mm), post-operative hemorrhages from a.

appendicularis may be very intensive, as a rule, they require relaparotomy.

Veins of the caecum and the vermiform process are the tributaries of the ileocolic

vein (v. ileocolica), which flows in the superior mesenteric vein (v. mesenterica superior).

Innervation of the iliocaecal angle is performed by the superior mesenteric plexus,

which is connected with the celiac (solar) plexus, which takes part in innervation of all

digestive organs. The iliocaecal angle is considered to be "the junction depot" of all

abdominal organs innervation. Running from here impulses influence functions of many

organs. The peculiarity of innervation of the iliocaecal angle and the vermiform process

explains the onset of pain in the epigastrium and their spreading over the abdomen in

acute appendicitis.

Lymph outflow from the vermiform process and from the iliocaecal angle performs

entirely to the lymphatic vessels, which are situated along the ileocolic artery. There is a

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chain of lymph nodes (10-20) along this artery, which extends to the central group of

mesenteric lymph nodes. Immediate proximity of the mesenteric and iliac lymph nodes

explains the similarity of clinical picture in inflammation of these nodes (acute

mesenteric adenitis) and in inflammation of the vermiform process.

Five variants of localization of the vermiform process with respect to the caecum

are distinguished: descending (caudal (is); lateral, internal (medial), anterior (ventral),

and posterior (retrocaecal). In descending, more frequent localization, the vermiform

process, directing towards the small pelvis, adjoins to certain extent the organs of the

small pelvis. In lateral position, the process lies from the outside of the caecum. Its apex

is directed to the inguinal (Poupart's) ligament. Medial localization is also rather frequent.

In those cases the vermiform process lays medially to the caecum, being localized

between the loops of the small intestine; all these provide favorable conditions for extent

inflammation inside the abdominal cavity and give rise to abscesses. The anterior

position of the process, in which it lies in front of the caecum, occurs rarely. Such

localization is favorable to anterior parietal abscess. Some of the surgeons mark out

ascending type of the process localization. Here, the two variants are possible. The first

one, in which the whole iliocaecal angle is located rather high, under the liver, and then

the term subhepatic position of the vermiform process is applied, or the second variant,

when the apex of the retrocaecal vermiform process is directed to ward the liver.

Retrocaecal position of the process, which is observed in 2-5% of the patients, two

variants of its bedding with respect to the peritoneum is characteristic: in some cases the

process, being covered with the peritoneum, lies in the iliac fossa behind the caecum,

while in other cases it projects from the leaf of the peritoneum and lies intraperitoneally.

This position of the vermiform process is termed retrocaecal (retroperitoneal) one. The

latter is considered to be the most insidious variant, especially in suppurative and

destructive appendicitis, since in the absence of the peritoneal cover of the process the

inflammatory process extends to the paraumbilical fat, causing deep retroperitoneal

phlegmon.

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Etiology, Pathogenesis, Pathologic Anatomy, and Classification

There is no consensus of opinion about etiology of acute appendicitis. But there are

some theories explaining the causes of the disease and its pathogenesis. The most

common of them is mechanical (congestion), infectious, and aponeurotic theories.

Besides that, at different periods a number of conceptions, sometimes very original, were

elaborated. All the theories and conceptions, reflecting one or another etiological agent

are not without logic and sense. At the same time, a variety of forms and stages of acute

appendicitis suggests the polyetiology of this disease, which results from the changed

correlation between the human body and microorganisms. It being known, acute

appendicitis is a non-specific inflammation of the vermiform process. The causative

agents of infections may be staphylococci, colon bacilli, and mixed and anaerobic flora.

All the efforts on choosing a particular pathogenic organism and to number acute

appendicitis among specific inflammatory disease were not successful.

Mechanical theory indicates the role of foreign bodies, infections and scary

strictures of the vermiform process in development of acute appendicitis. But these

factors occur are far from being in all the patients. Helmint invasion and angina (sore

throat) are of great, but not absolute importance in genesis of the disease. Infectious

theory correctly indicates the role of infection and the primary affect, but does not

explain what stimulates an infection, which is permanently present in the lumen of the

vermiform process. And similar weak points take place among the other theories and

conceptions. Gained scientific and practical experience proves that taking into

consideration the variety of clinical and morphological forms of the disease, there may be

several predisposing factors and their combinations. For example, the following

mechanisms and ways of development of acute appendicitis are quite logical:

1 . Obstruction of the lumen of the process and formation of a closed cavity filled

with feces, which contain toxins with highly reactive enzymes, gradually result in

suppuration, lesion of the mucous membrane, and infection penetrates inside the

vermiform process wall. Development of exudative inflammation is accompanied by

microcirculatory disturbances and degeneration of intramural neural apparatus. But

neurodystrophic changes together with the vascular factor constantly result in

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inflammatory intensification and its progressing up to formation of phlegmon or

gangrene.

2. Due to neurological disturbances, vascular stasis occurs in the vermiform

process. It results in trophopathy of the vermiform process and formation of necrotic foci.

Pathologically changed tissues are easily infected, i.e. secondary infection takes place.

The following spread of the infectious process causes more extensive pathologic changes

with all possible severe consequences.

3. Primary formation of acute ulceration in the vermiform process, which had been

observed by Selye at general adaptation syndrome, is possible. It may be the result of

neurogenic vasospasm.

4. In those cases, when abrupt clinical picture of the disease is followed very rapidly by

gangrene of the vermiform process, it is quite possible to consider primary thrombosis of

a. appendicularis and its branches. Inflammatory component and infection join

secondarily.

Appendicular colic. It means a muscle spasm of the vermiform process, caused by

any of pathologic process and proved by pain in the right iliac area. A surgeon makes this

diagnosis in those cases, when clinical manifestations disappear quickly, or when at the

time of operation he does not see any inflammatory changes in the vermiform process.

Catarrhal (congestive) appendicitis. Exudate may be absent or it may be in very

small amount. It is transparent, odorless. The peritoneum is unchanged and is hyperemic

a little. All changes are strictly localized in the vermiform process. It is hyperemic along

the whole length or at the limited site (usually distal one), thick to the touch, slightly

edematous. The lumen of the process may be either empty, or may contain mucus,

impacted feces, and foreign bodies. The mesentery is not changed, or may be slightly

edematous and hyperemic one. Microscopically: leukocyte infiltrations in the impaired

sites of the process. Sometimes it is possible to find out a defect of the mucous membrane

(primary affect), which is covered with fibrin and cellular elements.

Phlegmonous appendicitis. Exudate may be serous, serofibrous, seropurulent one.

Fetid odor appears at perforation of the vermiform appendix. In most of cases it is

possible to speak about the local peritonitis, but in advanced cases, when the process is

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not delimited, but the amount of exudates is considerable and it baths the large sites of

the abdominal cavity, it is possible to consider diffuse and even general peritonitis. The

omentum, the caecum, and adjacent loops of the small intestine may be also involved in

the pathologic process. They are hyperemic, thickened, are covered with fibropurulent

deposit and are fused by loose adhesions. The vermiform appendix is considerably

enlarged in its sizes, is of dark red color, strained is covered with mucous fibrin. The sites

of white-yellowish pus may be often seen through the transparent serous coat. Pus, which

is inside the lumen of the organ, is gradually stretching it, and empyema is formed. The

mesentery is thickened, its leaves are hyperemic and edematous, may be easily treated.

Similar changes are frequently observed in the caecum cupola wall and considerably

complicate appendectomy. On microscopic examination it is possible to reveal leukocyte

infiltration of all the layers of the vermiform process; it is impossible to differentiate

them due to their saturation with pus. Apostematous appendicitis takes place in case of

appearance of multiple abscesses against a background of diffuse purulent inflammation

of appendix. In case of ulceration of the mucous membrane against a background of

phlegmonous appendicitis, phlegmonous-ulcerative appendicitis occurs.

Gangrenous appendicitis. Abdominal changes are similar to phlegmonous

appendicitis, but they are more pronounced. Exudate is turbid, with ichorous purulent

odor. The vermiform process is partly or completely of black, brown, brown-green,

black-brown, or dirty-gray color. Its wall is flabby with phlegmonous masses.

Gangrenous appendicitis is frequently perforating one, and then it is possible to see fetid

feces pouring through the opening in its wall inside the abdominal cavity. As a rule,

peritonitis occurs. It may be local, diffuse, or general, but according to the nature of

microflora, colibacillary, anaerobic, and mixed types are distinguished. Extensive

necrotic foci with bacteria colonies, hemorrhages, and vascular thrombosis may be

revealed on microscopic investigation. Somewhere it is possible to see the foci of

phlegmonous inflammation. The mucous membrane is ulcerated all along. As a rule,

destructive changes are pronounced up to perforation in the distal part of the organ.

Generalization of infection in a form of endotoxic shock occur in gangrenous

appendicitis more frequently than in other forms of inflammation.

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Appendicular infiltrate is one of the complications of acute appendicitis. The

vermiform appendix, being destructively changed, becomes an epicenter of adhesion

process. A conglomerate of chaotically fused neighboring organs and tissues is formed

around it. The greater omentum, loops of the small intestine, the caecum and ascending

intestine, the peritoneum become involved in the pathologic process. The wall of these

organs are subjected to inflammatory infiltration, the boundaries between them become

gradually lost. Infiltrate rapidly increases in sizes, being compactly connected to the

anterior, posterior, and lateral walls of the abdomen. Sometimes infiltrate is of vast sizes,

occupying the whole right side of the abdomen.

Classification

But there are two classifications, which are used by the present and make it easier

to choose the policy of treatment. They are the classification according to A.I. Abrikosov

(1946), in which he wanted to reflect the problems of acute appendicitis pathologic

anatomy, and the classification according to V.I. Kolesov (1959), where he tried to reflect

clinical forms of acute appendicitis and its complications.

Classification according to A.I. Abrikosov:

I Superficial appendicitis (primary affect);

II Phlegmonous appendicitis:

1) simple phlegmonous appendicitis;

2) ulcer phlegmonous appendicitis;

3) apostematous appendicitis;

a) with perforation;

b) without perforation;

c) empyema of the vermiform appendix;

III Gangrenous appendicitis:

1)primary gangrenous appendicitis;

a) with perforation;

b) without perforation;

2) secondary gangrenous appendicitis:

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a) with perforation;

b) without perforation.

Classification according to V.I. Kolesov:

I. Acute simple (superficial) appendicitis;

A) Without general clinical signs, but with mild local, quickly disappearing,

manifestations of the disease.

B) With insignificant general clinical signs and local manifestations of the disease.

II. Destructive acute appendicitis (phlegmonous, gangrenous, perforating):

A) With clinical picture of moderate severity and the signs of local peritonitis;

B) With severe clinical picture and the signs of local peritonitis;

III. Complicated appendicitis:

A) With appendicular infiltrate;

B) With appendicular abscess;

C) With diffuse peritonitis.

The Main Principles of Medical Aid in Acute Appendices

1) On suspicion of acute appendicitis the patient is subjected to urgent hospitalization to

the surgical unit, he is to be under constant medical care and to undergo additional

examination.

2) Recognized acute appendicitis requires an urgent surgical invention, irrespective to

manifestation of clinical picture, the age of a patient, duration of the disease (with the

exception of delimited infiltrates).

3) In vague cases, in the presence of suspicion of acute appendicitis, it is necessary to

perform laparoscopy or explorative laparotomy.

4) In the absence of changes in the vermiform appendix during the operation, or in case

of not corresponding of revealed changes with clinical picture, it is necessary to perform

revision of the abdominal cavity.

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Clinical Picture, Diagnostics, and Treatment

Acute appendicitis is characterized by variety of clinical manifestations. I.I. Grekov

figuratively called it "a chameleon-like disease", and Y.Y. Dzhanelidze called it as

insidious one. Almost all the symptoms of acute appendicitis are non-specific, i.e. occur

in many other abdominal diseases. That is why the symptom is not important by itself,

but its characteristics, combination with other symptoms and the consequence of its

appearance are very important in diagnostics. One and the same symptom at different

stages of the disease and at different forms of it has its own features.

There are three main forms of acute appendicitis: 1) early stage (up to 12 hours); 2)

stage of development of destructive changes in the vermiform appendix (from 12 to 48

hours); 3) stage of complications (48 hours and more). This division at stages is rather

relative one, and the disease may run by its own, much more transient scenario, however,

more frequently it proceeds exactly in such a way.

Pain is the first and most common symptom of acute appendicitis. It occurs

predominantly at night, becomes constant, gradually intensifying. Patients may

characterize pain as piercing, cutting, burning, dull, acute one. At the first stage of the

disease the intensity of pain is not significant, it is quite tolerable. Patients do not cry or

moan, but also do not show superfluous motive activity, as jerky movements of the body,

for example, at cough (the cough shock symptom) intensify the pain. Cramping pain

occur very rarely.

Localization of pain is different. In typical cases it is localized at once in the right

iliac area, but it also may not be localized, but spreading all over the abdomen.

Approximately in a half of patients it locates at first it the epigastric area (Kocher —

Volkovich's sign), and only in 1-2 hours descends to the right iliac area. Sometimes this

symptom lasts for more prolonged time, and it considerably hampers differential

diagnosis. At the second stage of the disease, on developing of destructive changes in the

vermiform process, pain increases, causing the patients to suffer. The most severe pain is

in empyema, when pressure increases in the lumen of the vermiform process. In those

cases the patients rush about, they could not find a place for themselves. On the

background of constant pain a patient suddenly feels the increase of pain — perforating

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symptom. But paradoxical reaction is rather frequent too, when during the process of

destruction pains subside up to their complete disappearance; this is associated with

gangrene of the vermiform appendix wall. Discrepancy of severe condition of the patient

and clinical picture is evident. At the third stage clinical picture of either appendicular

infiltrate or abscess or peritonitis is revealed.

Pain may radiate to different parts of the abdomen: to the umbilicus, to the

epigastric area, and to the loin. It depends on position of the caecum and the vermiform

process.

Nausea and vomiting is observed in 60 -80% of patients (V.I. Kolesov, 1972).

Nausea usually precedes vomiting, but sometimes it may be an independent symptom. It

is important that these symptoms do not ever precede pains, but arises during the first or

the second hour of the disease. At the first stage vomiting is of reflex nature, with mucous

and eaten food. At the second and third stages vomiting occurs again, but now its

frequency and nature depend predominantly upon expressiveness of peritonitis,

intoxication and developing dynamic (paralytic) intestinal insufficiency.

Gas and stools retention. They are immutable concomitants of acute appendicitis.

At the first stage of the disease retention of gas and stools occurs as physiologic, reflex

reaction to outside stimulants, but later it results from paralytic ileus in peritonitis. Loose

stools is rather infrequent, it may be observed mainly in children in case of spreading of

inflammatory process on the sigmoid colon or the large intestine. In case of pelvic

location of the vermiform appendix and its contiguity with the urinary bladder wall

disuric disturbances are possible.

At the onset of the disease temperature averages 37-38°C. Pulse rate corresponds to

the temperature-80 -100 beats per minute. Only in destructive forms of appendicitis

temperature may be 38,5-39°C, but tachycardia becomes 130 -140 beats per minute.

Thermometer readings under the armpit and into the rectum are to be compared because

of certain diagnostic importance. Revealing of considerable difference (over 1 /5°C)

objectively testifies an acute pathology in the abdomen.

Examination of the abdomen. At an onset of the disease the abdomen usually of

normal form, moves with breathing, symmetrical. In lean patients it is possible to notice

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the lag of the right side of the abdomen in respiratory movements due to muscular strain

(Ivanov's symptom). In perforating of the vermiform appendix the respiratory

movements of the anterior abdominal wall disappear. In a man of athletic type it is

possible to notice the relief of strained abdominal muscles. Abdominal distention is the

late symptom. It testifies the development of peritonitis. Muscular tension (defanse

musculare) is the main symptom in acute appendicitis. In severe cases the site of the most

tenderness and local tension of the abdominal wall is in the right iliac area; the degree of

the muscular tension increases in accordance with intensity of the inflammatory process

inside the peritoneum. Revealing of the symptom requires a certain experience.

Infrequently the patient strains the abdominal wall by himself, preventing the pain,

especially if the investigation is carried out unskillfully and crudely. At the first stage of

the disease the muscular tension may be absent. It may be frequently observed in elder

and senile persons and in women with flabby and dilated abdominal wall, who had

experienced labors many times, and also at retrocaecal, retroperitoneal and pelvic

localization of the vermiform appendix.

Deep palpation of the most painful area is not expedient. It rarely gives additional

information, as it is usually prevented by muscular protection. But at soft abdomen deep

palpation allows to diagnose appendicular infiltrate, to determine its size and bounds,

consistency, mobility. Sometimes it is possible to feel the caecum, area of which is

always painful in case of acute appendicitis. But it is almost impossible to feel the

vermiform appendix, and it is not necessary. Revealing of painful points (McBurney's

point, points of Lanz and Kummel) is not of great diagnostic value. In acute appendicitis

tenderness of the abdomen is rarely strictly localized. Blumberg's sign (guarding

symptom) is a rebound tenderness symptom. Already at the early stage of acute

appendicitis, at mild catarrhal inflammation of the parietal peritoneum it is usually

positive. The following may check it. The tips of the fingers are introduced very gently

and gradually into the anterior abdominal wall, pressing it inside the abdomen. Then the

arm is abruptly taken away. In positive reaction the patient notes the increase of pain,

sometimes he shrivels and utters a scream.

Percussion of the abdomen allows to localize the area of the greatest tenderness

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more precisely (Razdolsky's (abductor of femur sign). These are also rebound

tenderness symptoms. A slight percussion of the abdominal wall at its different sites is

enough to determine this symptom. By means of percussion, being oriented on the

dullness of the percussion sound it is easy to estimate the bounds of appendicular

infiltrate, and in peritonitis — the presence of fluid in sloping places of the abdomen.

Auscultation of the abdomen allows to estimate the intestinal peristalsis. Already at

an early stage of the disease it is weakened, but survives for a long time. The absence of

peristalsis is a threatening symptom of peritonitis.

Appendicular symptoms. More than 100 symptoms of appendicitis had been

already described. We shall settle on only on some of them, which are the most

pathognomonic, and gained popularity among the surgeons.

Sitkovsky's sign. A patient is asked to turn on his left side. If at that the pain in the

right iliac region arises, the symptom will be considered to be positive one.

Bartomye's symptom is checked as Sitkovsky's one, but at the same time palpation

of the right iliac region is performed. At positive symptom palpatory tenderness

increases.

Rovsing's symptom. In dorsal position of a patient, a surgeon presses the sigmoid

colon to the posterior abdominal wall with the fingertips of the left arm and fixes it.

Simultaneously, a little above, by means of balloting palpation, he shakes the abdominal

wall in the sigmoid area. The onset of pain in the right half of the abdomen is the

evidence of a positive symptom.

Voskresensky's symptom. A shirt or T-shirt of a patient is tightened with the left

arm and fixed at the pubis. By fingertips of the right arm a surgeon slightly presses to the

abdominal wall in the area of the xiphisternum, and at time of expiration performs a

quick uniform sliding motion at first towards the left iliac-inguinal region, and then to the

right one, but for all that the arm is held on the abdominal wall. In the presence of

positive symptom a patient feels pain in the right side.

It is also necessary to remember some other appendicular symptoms, such as

Corn's, Britten's, Chugaev's, Cope's, Dumbadze's, Rizvash's, Gabay's, Yaure-Rozanov's,

Punin's, Bulynin's, and Promptov's symptoms.

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Laboratory Diagnosis

Moderate leukocytosis is noted at an early stage of the disease. In catarrhal form of

inflammation it is from 10xl09/l to 12xl09 /I, in destructive forms it achieves 14xl09/l-

18xl09/l, but sometimes it may be even higher, It is dangerous when neutrophilic shift of

differential blood count to the left takes place. The increase of stab neutrophil up to 10-

16% and appearance of juvenile forms is the evidence of high degree intoxication.

Laboratory investigations of the blood may be widened by examination of C-

reactive blood protein (C-RP), phagocyte activity of neutrophils, investigation of alkaline

phosphatase, peroxides, oxidase, and cytochrome oxidase. However, non-specific

character and considerable labor-consuming nature of these reactions decreases their

diagnostic value in urgent surgery. Urinary tests reveal pathologic changes in severe

intoxication and peritonitis.

In uncertain diagnosis of acute appendicitis, laparoscopy is of particular value;

approximately in 90% of cases it puts an end to doubt in diagnosis. Especially often the

necessity of laparoscopy occurs at differential diagnosis with genital diseases and renal

colic.

Complications in Acute Appendicitis

Appendicular infiltrate occurs in 0.9-2.9% of patients, who had been hospitalized in

48 hours and later from the onset of the disease with evident prevalence of elder and

senile patients.

Morphologic and clinical essence of infiltrate consists in the inflammatory focus in

the vermiform appendix is delimited from the free abdomen by the omentum, and the

adjacent tissues and organs, which are also involved in the inflammatory process, united

into one conglomerate, which is connected with the anterior, posterior or lateral

abdominal wall.

The size of infiltrate may be different, from small one, with the size of a fist, to the

giant one, occupying the whole right side of the abdomen. The boundaries of infiltrate, as

a rule, are distinct; their mobility is usually limited.

As a whole, it takes about 2-5 days to form appendicular infiltrate; during this

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period it passes several stages (A.I. Krakovsky and co-authors, 1986):

1 . Loose infiltrate. In typical cases it is located in front of the caecum, with mild

peritoneal response, purulent exudate in the small pelvis, with involvement of the

caecum, phlegmonous or gangrenous appendicitis, omentum, and the loops of the small

intestine;

2. Dense infiltrate, which can be either resolved or form an abscess;

3. Periappendicular abscess.

Infrequently diagnosis is difficult. Before surgery it is possible to make a correct

diagnosis only in a half of patients. Sometimes there are quite forcible arguments, foe

example, atypical position of the vermiform appendix and, accordingly, of infiltrate in the

small pelvis or behind the caecum; excessive obesity of patients with abundant layer of

fatty tissue; impossibility of deep palpation due to acute tenderness and protective

muscular tension. Insufficiently careful and full-value investigation is the common reason

of diagnostic pitfall.

In typical cases the delimitation of the process in phlegmonous appendicitis without

any signs of perforation must coincide with gradual improvement of the patient's general

condition and control of acute manifestations. The pains gradually cease up to their

complete disappearance. Pulse becomes normal. Temperature decreases, but, however,

remains stably sub febrile. Signs of dynamic intestinal obstruction disappear rapidly.

Subsequent course of the disease may be different. Three variants are possible. The

most favorable one is resorbtion under the influence of conservative treatment. Usually it

takes approximately from 2 weeks to 1 month. The second variant is the most dangerous

of all, when peritonitis progresses simultaneously with the process of infiltrate formation.

And, finally, the third variant — infiltrate abscess formation, when in the presence of

obviously localized process, clinical manifestations of purulent septic process are

evident: increase of pain in the infiltrate area, hectic fever with chills, and intoxication.

General Appendicular Peritonitis

Difficulties and dangers of acute appendicitis at common appendicular peritonitis

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reach the apogee. Incidence of this complication averages from 0,6 to 4,1%. It is

necessary to note, that among the causes of common peritonitis acute appendicitis takes

the first position, achieving 50-55% (A.A. Shalimov, 1990). Clinical picture, diagnosis

and treatment of common peritonitis are expounded in the appropriate lecture.

Pilephlebitis

Purulent trombophlebitis in the region of the superior mesenteric or portal vein is

one of the most severe complications of acute appendicitis. It occurs rather seldom, in

0,06-1,5% of cases from general number of patients with this disease. The course of the

disease is exclusively severe; with fatal outcome in most cases. In 1986 V.S. Savelyev

advanced the opinion that there were no reliable observations of pilephlebitis.

Information of N.V. Karamanov about successful treatment of 11 patients with

pilephlebitis seems to be more optimistic. Timeliness diagnostics is a guarantee of

success. Appearance on the background acute appendicitis clinical picture such

symptoms as chill, hectic fever, pain in the right hypochondrium, jaundice, etc., including

laboratory data, proving severe intoxication, must put a surgeon on his guard.

Treatment of Acute Appendicitis

Treatment is only operative; there is no choice. Delay of operation is dangerous by

impetuous course of the process and development of the severest complications. The only

contraindication for operation is the presence of dense appendicular infiltrate but only in

those cases when there is no signs of abscess formation and peritonitis.

Being dependable on clinical situation, the operation may be performed both under

local and general anesthesia. General anesthesia is preferable. Three main approaches to

the vermiform appendix are used: oblique (Volkovich-Dyakonov's), Lenander's

(pararectal) incisions, and midline laparotomy.

In all cases of acute appendicitis with strictly localized clinical picture in the right

iliac fossa an oblique incision is applied. At typical position of the caecum and in other

positions of the vermiform appendix, optimal conditions are produced due to this

incision.

Pararectal Lenander's incision is applied in case of vague diagnosis. It may be

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rapidly elongated up and downwards. But in case of retrocaecal position of the appendix

and at local periappendicular abscesses Leander’s incision is not so suitable.

Mid-midline or low-midline laparotomy is applied in the presence of clinical signs

of diffuse and general peritonitis.

Operation technique for appendectomy is identical on principle in various forms of

inflammation of the vermiform appendix, but each of them introduces its own features

and a number of additional tricks in performance of operation. In catarrhal appendicitis

before performance of operation it is necessary to make certain that visible morphological

changes correspond to clinical picture of the disease and are not the secondary ones. In

phlegmonous appendicitis, having evacuated the exudates from the right iliac fossa, it is

necessary to determine that the process inside the abdomen is localized; for this purpose

the surgeon examines the right lateral canal, right mesenteric sinus and cavity of the

small pelvis by means of a swab. If muddy exudate appears from these spaces of the

lower abdomen, it is necessary to suggest diffuse or general peritonitis. At the beginning

of operation for appendectomy of gangrenous appendix it is necessary to delimit carefully

the area of the iliocaecal angle from the other portions of the abdominal cavity by means

of wide gauze towels. In case of perforation, one should thoroughly wrap the vermiform

appendix with wet towel, avoiding the appearance of intestinal content inside the

abdominal cavity. Operation in conditions of appendicular infiltrate is fraught with many

dangers. In such a case it is necessary to exhibit a particular wisdom. It is on these

conditions that excessive activity of the surgeon may result in a number of serious

complications and in the growth of lethality (diffuse peritonitis, sepsis, intestinal fistula,

thromboembolism, bleedings).

Retrograde appendectomy is performed in those cases, when it becomes impossible

to draw out both the caecum and appendix into the wound due to adhesions and

inflammatory infiltration.

Ligation of the mesentery applying a purse-string suture and treatment of the

appendicle stump are the most important stages of appendectomy. It is prohibited to be in

hurry. Everything must be done carefully and safely. It is these stages of operation that

may result in such complications as postoperative abdominal hemorrhages, postoperative

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peritonitis, intestinal fistula, abdominal abscess, etc.

This is the end of our lecture for problem of acute appendicitis. Many particular

problems of this surgical disease were mentioned only in passing, and some of them did

not touched at all. An interested reader will find answers on his questions in

recommended special literature.

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