Synonyms in a broader sense
appendicitis therapy, appendicitis treatment, appendicitis detection
Introduction
The diagnosis of appendicitis can be a challenge even for an experienced doctor. The symptoms are not always so clear and there are some diagnoses that present themselves with similar symptoms (differential diagnoses). The variable position of the appendix is also a diagnostic problem. Once the diagnosis is confirmed, an appropriate therapy can be considered.
Diagnosis of appendicitis
In the doctor-patient consultation (anamnesis), it should be asked whether there has been the typical shift of pain from the middle abdomen to the right lower abdomen. Most important, however, is the result of the physical examination, in which some examination methods can be groundbreaking.
- A pressure pain in the right lower abdomen is the most important leading finding.
With the pain maximum in the McBurney point and/or Lanz point. The McBurney point is located in the outer third between the right anterior superior iliac spine (spina iliaca anterior superior) and the navel. The Lance Point is located in the right third of the line between the two anterior superior iliac spines.
- The Blumberg sign is a pain of release on the left (contralateral) abdominal side.
The left lower abdomen is slowly pressed in and then quickly released.
- If the colon is spread out towards the caecum pole, a pain can be provoked, which is called the Rovsing sign.
- If the peritoneum is already involved, an increased muscular defense tension (défense musculaire) can be noticed when feeling the abdomen.
- Of particular importance is a knocking pain (percussion pain) in the triangle between the right anterior superior iliac spine (spina iliaca anterior superior), the navel and the pubic symphysis, the so-called Sherren triangle.
- When listening (auscultation) of the abdomen with the stethoscope, at the beginning of the inflammation you will initially notice vivid intestinal sounds. The intestinal sounds fade in the course of the disease, as the development of peritonitis (inflammation of the peritoneum) can lead to a reflex paralysis of the intestine with imminent intestinal obstruction (ileus).
- In the further course of a complicated peritonitis, pain is occasionally experienced when palpating the rectum with the finger (rectal digital examination). This phenomenon suggests an abscess or inflammatory fluid accumulation in the pelvis.
- Body temperature should be measured both in the axilla and rectum.
50% of patients have an axillar-rectal difference of 1-0.8°C.
- The psoas signs appear when the appendix lies on the ileopsoas muscle, i.e. behind the appendix (retrocecal). In this case, the flexion of the leg in the hip joint is painful against resistance.
- With the Chapman sign, the patient has pain when he or she stands up from a sitting position.
In the blood test one should pay special attention to the inflammation values. These values include the white blood cells (leukocytes), which are increased in the body during an infection(>12,000 cells/μl blood (leukocytosis).
The degree of leukocytosis does not always correlate with the urgency of the disease. In young children, the leukocyte count can increase particularly rapidly, and in older people it can be very low or even absent. The C-reactive protein (CRP value) serves as an additional parameter.
The CRP formed by the liver is a so-called acute-phase protein and rises sharply in viral and especially in bacterial infections. In order to exclude a urological cause (e.g. cystitis), which can be accompanied by similar symptoms, a urine test strip (Urostix) should always be used. With sonography (ultrasound) abdominal organs can be assessed non-invasively (without physical injury) and without radiation exposure.
On the one hand, the transducer emits ultrasound waves that are absorbed or reflected by the various types of tissue it encounters. On the other hand, the transducer re-receives these reflected waves, which are converted into electrical impulses and displayed on a screen in different shades of grey. The representation of the appendix in sonography is particularly difficult and belongs in the hands of an experienced examiner.Today’s devices have a high resolution, which makes it possible to diagnose appendicitis in a very high percentage.
The examination is sometimes difficult because the appendix has a particularly variable position and is often overlaid by intestinal gases that are found in the appendix and small intestine. The examiner must “push” the air overlay away with constant pressure and a lot of patience. A healthy appendix has a diameter of approx.
6 mm and has three layers. An inflamed appendix appears swollen and is larger than 8 mm. If the appendix diameter is between 6 and 8 mm, repeated sonographic checks should be performed to quickly detect any deterioration in the findings.
Further indications of inflammation are a fluid border around the appendix, increased blood flow to the appendix wall, pain on palpation and an uncompressible appendix when pressure is applied. The most characteristic sign, however, is the “cockade” (the appendix acts like a target in cross section), which appears increasingly blurred and echo-free (darker) as the disease progresses. The reliable diagnosis of a perityphilitic abscess is particularly important.
The intestinal wall appears destroyed and echo-free cavities are impressive. In case of sudden severe abdominal pain (acute abdomen), an X-ray of the abdomen cannot directly diagnose an inflammation of the appendix, but it may rule out complications. However, an x-ray can provide certain indications of appendicitis.
For example, a highly aerated appendix (caecum meteorism) with fluid levels in the right lower abdomen can be an important indication. If the appendix is located behind the appendix (retrocecal position) and the sheath (fascia) of the muscle ileopsoas is also inflamed, the shadow of the psoas rim may have elapsed in the x-ray compared to the opposite side. In cases of advanced, diffuse peritonitis, the picture of intestinal paralysis (paraytic IIeus) may present itself, with highly aerated intestinal loops and fluid levels.
These levels are caused by standing fluid in the intestinal loops, above which an aerated cavity is formed. The cavities look like dark semicircles in the X-ray image. If an abscess has already formed, it may be possible to detect a fluid level inside the abscess that is not surrounded by the intestinal wall (extraintestinal).
The only causal therapy for appendicitis is surgical removal of the appendix (appendectomy). The most important thing here is to confirm the diagnosis quickly or at least a well-founded suspicion, so that surgery can be performed within 48 hours of the onset of symptoms. The physician will first order a dietary restriction (zero diet) and have the nutrition delivered through the vein (parenterally).
Cooling of the lower abdomen with an “ice bubble” can provide relief and the administration of antibiotics (bacteria-killing drugs before the operation reduces the risk of bacteria spreading. There are two options for surgical removal of the appendix: The most common approach in an appendectomy is the alternate incision. This incision runs diagonally from top right to bottom left in the right lower abdomen.
After the skin incision, the appendix is first examined and the appendix is displayed. Like the small intestine, the appendix is attached to a small mesentery on the back wall of the abdominal cavity. The vessels supplying the appendix are located in this mesentery, which are ligated during surgery and then separated.
The appendix itself is then tied off and cut off. The resulting appendix stump is sunk into the appendix using Taback’s bag suture or Z-suture. Hirsch means the removal of the appendix with the aid of the smallest constructional incisions and the use of a surgical camera (minimally invasive surgery; keyhole surgery).
The first incision is made below the navel (infraumbillical), and a mini-camera is inserted into the abdominal cavity through this incision. In this way, the abdominal cavity is inspected. Two further incisions (usually in the left and right lower abdomen) are used to insert working instruments.
The inflamed appendix is then removed via these working channels. The advantages of the laparoscopic procedure are the minimal tissue damage and the good overview in the abdominal cavity through the camera. In the case of an appendicitis that has not been surgically confirmed, it is nevertheless justifiable to perform a preventive (prophylactic) appendectomy.However, the abdominal cavity should be searched intensively for other causes of the complaints.
The small intestine should always be systematically examined for Meckel’s diverticulum. In women, the examination of the female internal genitals is of particular importance, as this is where frequent causes of lower abdominal pain are found (see above). If there is a cause for the pain other than appendicitis, the appendix should be left in place.
After the appendix has been removed, the pathologist should examine the preparation histologically under a microscope. This should exclude the possibility that a previously undetected carcinoma or carcinoid is present in the inflamed appendix. Some complications may also occur after the operation.
These include wound infections, abscesses, intestinal paralysis with intestinal obstruction (ileus) and a leakage of the stump of the appendix (fistula). A mechanical intestinal obstruction (ileus) can occur after the removal of the appendix after a few days as early intestinal paralysis (early filius) in case of adhesions caused by wound healing. But even years after the operation, a late valveus can still develop due to adhesions (clamps) in the abdominal cavity.
The postoperative mortality rate is 0.2% in uncomplicated cases and increases to 10% in diffuse peritonitis. If the signs of appendicitis are not clear, other diseases with a similar constellation of symptoms must also be considered (differential diagnosis). In infancy, the differential diagnosis is a telescopic intestinal invagination or rotation of the intestine including the intestinal crest (volvolus).
However, diabetes mellitus can also manifest itself with unspecific abdominal pain. Schoolchildren, on the other hand, may present similar symptoms with intestinal flu (enteritis) or worm diseases. With puberty and in young adulthood, diseases such as Crohn’s disease or urinary tract infections are added.
In women, gynecological diseases such as endometriosis in the intestine, inflammation of the fallopian tubes (pelvic inflammatory disease) and ectopic pregnancy (tubal pregnancy) are added. In addition, particularly pronounced menstrual pain (dysmenorrhea) can also present a similar clinical picture. In the case of abdominal pain in middle-aged people, diseases such as kidney stones (urolithiasis) and, in women, larger painful ovarian cysts (ovarian cysts) are also possible.
Older people are more likely to suffer from diseases such as intestinal diverticula (diverticula) in the caecum, a caecal carcinoma, ischemic colitis or an intestinal infarction. Certain differential diagnoses are less independent of age, such as Meckel’s diverticulum, inguinal hernia, carcinoids of the appendix and salmonella infections (typhoid, paratyphoid). An appendicitis is caused by the immigration of germs via the blood into the appendix (commonly called appendix) or by the transfer of intestinal contents (faeces) with bacteria/germ into the appendix.
Within a few hours, strong pain in the right lower abdomen, nausea and vomiting usually occur. If the symptoms get worse and worse from hour to hour, it is usually an acute appendicitis, i.e. a rapidly progressing inflammation of the appendix (appendix). Here it is important to act quickly and the doctor usually has no choice but to perform an operation to prevent the intestinal tissue from rupturing and the inflamed and germ-populated contents from entering the open abdominal cavity.
In principle, however, it is also possible to treat appendicitis conservatively, i.e. without surgery. This is rarely suggested by the doctor, but cannot be performed in the case of a serious inflammation. Especially patients who suffer from chronic appendicitis, i.e. symptoms that occur repeatedly, can use this method, but the term chronic appendicitis is not really defined, so the conservative method is used only very rarely.
If the patient wants to have a therapy without an operation, he has to keep absolute bed rest in order not to strain the abdomen unnecessarily and not to provoke a rupture of the intestinal wall. In addition, the patient must not eat anything during the entire period of the inflammation (food leave). In order to additionally promote healing, the appropriate antibiotics (depending on the bacteria) should also be taken.
In addition, the patient should be kept under strict clinical supervision so that if the symptoms get worse, surgery can be performed as soon as possible.Generally speaking, appendicitis is always a clinical emergency and should therefore always be operated on. Especially since the operation is now a routine procedure with few risks. In contrast, conservative therapy provokes an aggravation of the disease.
Appendicitis (inflammation of the appendix) is a quite common disease, which occurs mainly in young people under 23 years of age. More precisely, however, it is not the appendix (caecum) that is inflamed but only the appendix vermiformis. Nevertheless, it is generally referred to as appendicitis.
Accordingly, the surgical removal of the appendix is called appendectomy, but physicians speak of appendectomy (surgical removal of the appendix). An operation is always necessary in case of acute appendicitis. It is important to act quickly in case of appendicitis.
The patient should be operated at the latest 36 hours after the first symptoms in order to avoid a rupture of the inflamed tissue, as otherwise the inflamed tissue can penetrate into the open abdominal cavity. Before the operation, a reliable diagnosis should be made, usually by means of an ultrasound examination. During the operation, the patient must first be anaesthetized so that he or she is free of pain (analgesia) and sleeps during the operation.
General anesthesia is usually used. There are basically two types of surgery for appendicitis. One is open surgery, in which the abdominal wall is completely opened with the help of a scalpel.
The advantage of this method is the very good overview of other organ systems. Disadvantage is the larger scar and the longer follow-up treatment. Today, this method is usually only used in cases of appendectomy, because in this case the doctor has to rinse the abdomen to remove the inflamed secretion in the abdomen.
The second surgical technique is the laparoscopy, where the doctor can remove the appendix with the help of a small endoscope and a small camera. In addition, carbon dioxide is pumped into the abdomen to detach the intestine from the surrounding structures. The appendix is then removed using a stapling device.
Although the surgeon has a worse overview with this technique, the patient can be discharged home much faster after the operation and does not have a large scar, instead only three small points remain in the area of the abdomen through which the surgeon has operated. Both operations are usually performed with self-dissolving sutures to avoid suture removal after the operation. Already one day after the laparoscopic surgery the patient can take liquid food again.
With open surgery, it usually takes longer for the patient to walk normally and eat food. In case of appendicitis, one should basically differentiate between acute appendicitis and chronic appendicitis. Acute appendicitis is always an indication for surgery (rare exceptions are patients who are at high risk of surgery because they cannot tolerate an anesthetic).
A chronic appendicitis has a gradual course, the symptoms sometimes get worse and sometimes less severe. Often it is only an irritation of the appendix. Many authors therefore avoid the term chronic appendicitis and speak exclusively of irritation of the appendix.
Also here, an appendectomy can help as a therapy because the frequently occurring symptoms disappear afterwards. However, a conservative therapy can be performed instead. In this case it is important to abstain from any kind of food at the first signs of appendicitis and to keep absolute bed rest.
In addition, it is best to be monitored by a doctor and additionally receive antibiotics against the corresponding germ. Since the patient should not drink, it is important to have an infusion and possibly a feeding tube inserted. If the symptoms do not improve within the next day, one should go to the doctor immediately and undergo an appendectomy, otherwise there is a risk of a breakthrough.
An acute appendicitis is always an indication for an emergency operation as otherwise the appendix may burst.In some cases, for example in patients who do not wish to undergo surgery, for example due to intolerance to anaesthesia, it is possible to first try to prevent the operation and instead treat the patient conservatively with antibiotics. Opinions differ greatly as to whether such treatment is sensible or whether antibiotic therapy only delays the time of surgery. However, since a patient who opts for conservative antibiotic therapy must be permanently monitored in hospital and must be artificially fed during the time of treatment, surgery is usually preferred.
Especially in the case of chronic appendicitis (sometimes called appendicitis), however, one tries to avoid an operation by using antibiotics. The antibiotic is chosen depending on the pathogen and the resistance of the pathogen. Some studies have shown that if a child is given antibiotics intravenously (i.e. via the blood into the vein) for 24 hours and then swallows the antibiotic for another week (takes it orally), these children will be fit again much faster than children who have had to undergo surgery. In Germany, however, conservative antibiotic therapy for appendicitis is considered critical. If it comes to a perforation of the appendix, the patient must be treated with a high dose of antibiotics because the bacteria are then in the free abdominal cavity and must be rendered harmless by the antibiotic to prevent blood poisoning (sepsis).
