notes by dr Claudio Italiano
Appendicitis is the acute inflammation of the appendix, a classic pathology in general
surgery.
Who writes, when I was young, at the age of 26, a young doctor, I had to intervene to save from a certain death an 8-year-old boy, taken care of by a pediatrician for cystitis. When the boy came to my attention, the clinical picture was the dramatic one of the perforated appendiceal abscess, with evident signs of peritonitis, resistance of the abdominal wall, fever on 39.5 ° C to 40 ° C, vomiting, prostration. It had to work in haste and already fecal and purulent material was highlighted in the abdominal cavity, drained in peritoneum, between the loops and inside the excavation of the Douglas, with a nauseating smell that spread in the operating room. Repeated washes were performed with lukewarm physiological solution of the intestinal loops to prevent septic peritonitis. Promptly the boy recovered. In the meantime, to understand each other, we will say that the appendix is, so to speak, the "tonsil" of the intestine, that is a vermiform exflexion hanging from the last tract of the cecum. The site of the appendix may vary from its right iliac position to the cecal, pelvic, and meso-celiac posterior site. The most important sign is the pain caused, intense in the right iliac fossa, often accompanied by vomiting or the tendency to nausea alone.
In general, there is also a fever on 38-38.5 ° C,
with a full pulse, tachycardia, and an impatient tongue. Sometimes abdominal
pain is located around the navel. In the next 12-24 hours, the pain, which is
the key symptom of appendicitis, moves downwards, undermining the right iliac
fossa.
the inflammation is generally caused by an obstruction inside the appendix, due
to the stagnation of undigested material or to the hypertrophy of the
appendicular lymphatic follicles, which can increase in number and size during a
local or systemic infection (mononucleosis, measles , typhus, Crohn's disease,
respiratory infections, etc.). The appendicular lymphatic follicles are
hypertrophic in adolescence, but are significantly reduced, until they disappear
around the sixth decade of life. For this reason, adulthood occlusion is often
related to the stagnation of a solidified cluster of faecal material and
inorganic salts (coprolith) or, more rarely, the presence of a foreign body (gallstones,
neoplasms or parasites). intestinal, such as taenia solium, ascaris lumbricoides,
enterobius vermicularis.
At the visit, which should be performed with a light palpation, with warmed
hands, placed flat in the abdomen, it starts from the portion of the abdomen
that does not hurt, that is from the left iliac fossa and proceeds gently going
up the descending colon, the transverse and finally going down, on the right
side, up to the right iliac fossa.
The operator tries to appreciate and evaluate:
The so-called pain caused, which is located in the right iliac fossa, in the
classic point of Mc Burney, that is tracing an imaginary line between the navel
and the iliac spine, in the middle point, pain that is evoked especially when
the hand of operator is suddenly raised, that is "decompression pain", a sign of
positive Blumberg.The signs of peritoneal irritation, with the contraction of
the reflexed abdominal wall, or the simple defense that accompanies if you
insist on palpating
Rectal exploration, in turn, will evoke pelvic pain associated with iliac
pain. The Douglas cord can be explored in the man with rectal exploration and in
the woman with the vaginal one and will evoke pain if there is liquid exudate
inside it, an expression of inflammation.
The doctor will then require a blood count, which will have to show a
neutrophilic leucocytosis and the PCR that will be elevated, expression of
nonspecific inflammation (see the gastroenterological patient's approach to the
investigations to be requested from the gastroenterological patient).
The attack can regress in the best of hypotheses, perhaps implementing a
broad-spectrum empiric antibiotic therapy, but the patient may present new
recurrences, otherwise the attack of appendicitis may evolve and in this case
intervene the peritoneal barrier, which seeks to delimit the outbreak, having
evolved towards the framework of the so-called "platoon". The latter can also
evolve towards the framework of the appendicular abscess, with risk of
perforation in peritoneum, schock, fever, leukocytosis, facies terrea and exitus
if no action is taken. It may also be that this does not happen and that
inflammation and infection spread to the entire peritoneum (peritonitis), with a
dramatic picture, within 24-48 hours, with a closed hook in feces and gas, pulse
frequent, dehydration, non-treatable abdomen (surgical abdomen) and pain
extending beyond the midline.
Primitive appendicular peritonitis, ie appendicitis that evolves into
peritonitis
Primary purulent peritonitis
Putrid peritonitis due to the perforation of a gangrenous appendix
By headquarters
Retrocecal appendix with pain in the iliac site and in the lumbar region,
this shape that evolves towards the abscess.
Pelvic appendix, which can simulate the signs of cystitis (see Urine
infections, part I Urine infections, part II
Mesocecal appendicitis , with the tip of the appendix that is in abdominal
cavity, between the loops of the tenuous.
Sub-hepatic appendicitis
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