Appendicitis

　　The vermiform appendix communicates with the cecum, with a length of about 6 to 8 cm, and a narrow lumen of about 0.5 cm. The wall of the appendix is rich in lymphoid tissue, which constitutes the anatomical basis for the appendix being prone to inflammation. This anatomical feature also makes it easy for the appendix to become obstructed, with about 70% of patients showing obstruction in the appendix lumen due to various reasons, such as fecal masses, fecal stones (which are formed by the mixture and coagulation of long-stayed feces and appendiceal secretions, and may contain calcium and other minerals), food residues, torsion of the appendix itself, and parasites (such as ascaris and pinworms).

　　The common causes of appendicitis include:

　　(1) Obstruction of the appendix lumen. Due to the retention of fecal stones, food residue, hair balls, and intestinal parasites in the narrow lumen of the appendix, the appendix becomes damaged, swells, and twists.

　　(2) There is a rich lymphoid tissue in the wall of the appendix, and bacteria can enter the appendix through the blood circulation, causing acute inflammation with redness, swelling, and pain.

　　(3) Unwholesome and cold food, impurities, constipation, rapid running, and mental stress can lead to intestinal dysfunction, obstructing the blood circulation and emptying of the appendix, creating conditions for bacterial infection. Common pathogenic bacteria include Escherichia coli and anaerobic bacteria.

　　(4) In addition, dietary habits and lifestyle are also related to the occurrence of appendicitis.

　　The complications of appendicitis after surgery are closely related to the timing of the surgical procedure and the pathological type of appendicitis. Common complications include:

　　1. Internal hemorrhage

　　Bleeding within 24 hours after surgery is primary bleeding, often due to incomplete hemostasis of the appendiceal mesentery or the loosening of ligatures. The main manifestations are symptoms of intra-abdominal bleeding, such as abdominal pain, distension, shock, and anemia. Blood transfusion and reoperation for hemostasis should be performed immediately. Sometimes, bleeding may stop spontaneously, but secondary infection may form an abscess, which also requires surgical drainage.

　　2. Pelvic abscess

　　After appendectomy for perforated appendicitis, incomplete absorption of peritoneal pus can lead to residual abscesses in different parts of the peritoneum. Pelvic abscess is the most common, usually occurring around 5-10 days after surgery, with symptoms such as a rise in body temperature, increased frequency of bowel movements, urgency, and tenesmus. Examination may show relaxation of the sphincters and bulging of the anterior rectal wall. Immediate anti-inflammatory and physical therapy should be performed, and if these are ineffective, incision and drainage should be considered.

　　3. Adhesive intestinal obstruction

　　There is a higher chance of intestinal adhesion after appendectomy, which is related to surgical injury, foreign body stimulation, and late removal of drainage materials. According to clinical statistics, the incidence of adhesive intestinal obstruction after appendectomy is about 2%, making it the leading cause of postoperative adhesive intestinal obstruction (accounting for 32%). Comprehensive conservative treatment is generally performed first.

　　4. Fecal fistula

　　It can occur in improperly treated appendiceal残端，or it can be caused by rough surgery and accidental injury to the cecum and ileum. The main manifestations are long-term wound infection that does not heal, with feces and gas leakage. Since the infection is localized around the ileocecal area when a fecal fistula forms, there is less loss of body fluids and nutrition. Conservative treatment can be attempted first, and most patients with fecal fistula can heal spontaneously. If the course of the disease exceeds 3 months and it has not healed, surgery should be arranged.

　　5. Complications of the incision

　　It includes incision infection, chronic sinus tract, and incision hernia, all of which have certain intrinsic connections. Incision infection often occurs 4-7 days after surgery, and sometimes it appears two weeks later. The main manifestations are jumping pain at the incision site, local redness and swelling with tenderness, and a rise in body temperature. Immediate suture removal, wound drainage, removal of necrotic tissue, and promoting healing through dressing changes, or waiting for the granulation tissue inside the wound to be fresh for secondary suture, should be performed.

　　The typical clinical manifestations of acute appendicitis are gradual onset of dull pain in the upper abdomen or around the umbilicus, which shifts to the lower right abdomen after several hours. It is often accompanied by loss of appetite, nausea, or vomiting. In the early stage of the disease, in addition to low fever and fatigue, there are usually no obvious systemic symptoms.

　　If acute appendicitis is not treated early, it can develop into gangrenous appendicitis and perforation, with concurrent localized or diffuse peritonitis. The mortality rate of acute appendicitis is less than 1%, and the mortality rate after the onset of diffuse peritonitis is 5～10%. After non-surgical treatment or cure of acute appendicitis, scarring and thickening of the appendiceal wall, stenosis of the lumen, and adhesions around it may occur, which is called chronic appendicitis. It is prone to recurrent acute attacks. The more frequent the attacks, the more severe the damage of chronic inflammation, and it can have recurrent acute attacks. There are no symptoms or occasional mild right lower abdominal pain during non-attack periods, so it is also called chronic recurrent appendicitis.

　　If a patient has no history of acute appendicitis and complaints of chronic right lower abdominal pain, it is not advisable to easily diagnose chronic appendicitis and remove the appendix. Attention should be paid to exclude other ileocecal diseases, such as tumors, tuberculosis, nonspecific colitis, Crohn's disease, and mobile cecum, and also to exclude psychological and neurological factors. Otherwise, the removal of the appendix may encounter difficulties, and even without other lesions, it may not necessarily eliminate the symptoms.

　　Typical appendicitis has the following symptoms:

　　1. Pain in the right lower abdomen

　　2. Nausea and vomiting

　　3. Constipation or diarrhea

　　4. Low fever

　　5. Loss of appetite and bloating

　　The onset of appendicitis pain is usually in the upper abdomen, below the sternum, or around the umbilicus. After about 6-8 hours, the pain site gradually moves downward and finally settles in the right lower quadrant. Pain in the right lower abdomen may occur during coughing, sneezing, or palpation. If the above symptoms occur, one should see a doctor nearby immediately and not take it lightly.

　　Appendicitis is divided into acute appendicitis and chronic appendicitis. The following mainly introduces the preventive measures for chronic appendicitis:

　　1) Good hygiene habits should be cultivated in daily life, pay attention to dietary regulation, eat less and more meals, avoid overeating, and do not engage in strenuous exercise immediately after meals, etc.

　　2) There are no too many dietary restrictions, but if abdominal pain occurs, see a surgeon in a timely manner.

　　3) Medications can only alleviate the symptoms, not cure them. Since it is chronic, there is a possibility of recurrence before being cured, and the possibility of recurrence is quite high. It will recur repeatedly, otherwise, it would not be called chronic appendicitis. It can also recur during pregnancy and may lead to gynecological pelvic inflammation. Surgical treatment is the only method, and preoperative barium enema imaging is required for further diagnosis.

　　Appendicitis commonly presents with right lower quadrant abdominal pain, fever, vomiting, and increased neutrophils in clinical practice. So, what examination items should be done for appendicitis?

　　1. Routine blood test

　　The total white blood cell count and neutrophils in purulent appendicitis can increase to (10～12)×10^9/L; in purulent appendicitis, it can reach up to (12～14)×10^9/L; when abscess formation or diffuse peritonitis occurs, the white blood cell count can exceed 20×10^9/L, with neutrophils ranging from 0.85 to 0.95, and there may be nuclear left shift. Neutrophils increasing to above 0.85 often indicates a severe condition, and toxic granules may also be present. However, there are individual cases of appendicitis where the white blood cell count does not rise significantly.

　　2. Urinalysis and stool routine

　　There are no special changes, such as when the appendix is located near the ureter, there may be a small amount of red blood cells in the urine. When the condition is severe, there may be a small amount of pus in the stool.

　　3. Serum

　　C-reactive protein and fibrinogen levels It has been reported that the serum C-reactive protein is significantly increased and the plasma fibrinogen level is decreased in children with acute appendicitis. These two determinations can be used as auxiliary indicators for preoperative judgment of the degree of appendicitis.

　　4. Puncture fluid examination

　　For those with suspected appendicitis and difficulty in diagnosis, especially those with symptoms of peritonitis, abdominal puncture can be attempted. Generally, a subcutaneous needle is used to puncture the right lower abdominal appendiceal point, and the puncture fluid is examined for microbiology, bacterial smear, and biochemical examination. The presence of pus cells in the smear usually indicates early purulent appendicitis; if the puncture fluid is thin, it usually indicates early localized peritonitis; if the puncture fluid is abundant and thick, or bloody, with fecal smell, and a large number of bacteria are seen in the smear, it usually indicates gangrenous appendicitis, diffuse peritonitis, or perianal abscess.

　　Other auxiliary examinations:

　　1. Anorectal examination

　　There is inflammatory infiltration and thickening in the right anterior rectum, and there is tenderness and the formation of inflammatory masses when there is an abscess in the pelvic cavity.

　　2. Abdominal X-ray film

　　For those with abdominal distension, X-ray examination can be performed. About 10% of cases can see appendiceal fecal calculus shadow. When appendicitis is present, the flat film shows an abnormal gas shadow in the right lower abdomen, the disappearance of the right abdominal wall line, the blurring of the psoas shadow, and the bending of the lumbar vertebra to the right. X-ray imaging lacks specificity, but it helps to differentiate bowel obstruction, gastrointestinal perforation, necrotizing enteritis, and other conditions.

　　3. CT examination

　　Under CT, the appendix and surrounding soft tissues and inflammation can be directly displayed, with a detection rate of 13% to 60%. It is manifested as symmetrical thickening of the periphery, complete occlusion of the lumen, or expansion with fluid-like density pus, and the fat around the cecum is blurred, and the density increases.

　　4. Ultrasound examination

　　Under ultrasound, normal appendix does not show any image. When appendicitis occurs, the diameter of the appendix can be increased to varying degrees, and an appendicitis diagnosis can be made when it is ≥6mm. The increase in the width of the appendix lumen shows the size of the abscess around the appendix. Gangrenous appendicitis can also show the amount of effusion in the abdominal cavity and the peristalsis of the intestinal tract around the appendix. It can also make an accurate diagnosis of ectopic appendix.

　　5. Abdominal wall electromyography examination

　　According to the strength of the electromyogram amplitude of the abdominal wall muscles, the degree of muscle tension and its extent in appendicitis children were determined by comparing the examination. The electromyogram amplitude of simple appendicitis is not significantly increased at rest; the electromyogram amplitude is slightly increased at rest in purulent appendicitis, and it can be seen that the electromyogram amplitude is significantly increased when pressing on the right lower abdomen. When appendicitis perforation peritonitis occurs, due to the presence of continuous muscle tension, the electromyogram amplitude in the left and right lower abdominal areas is significantly increased at rest.

　　What should appendicitis patients pay attention to in their diet? The following are several points to note:

　　1. Use drugs cautiously, especially some antipyretic and analgesic drugs and anti-inflammatory drugs, which can cause significant gastrointestinal irritation. In severe cases, they may even cause gastrointestinal bleeding or perforation. It is best to avoid or use them sparingly.

　　2. Prohibit drinking alcohol, avoid eating raw, cold, and spicy foods. Eat less fried and indigestible foods. Avoid overeating and try to eat small, frequent meals.

　　3. Prevent overfatigue, as excessive fatigue can weaken the body's resistance to diseases, leading to a sudden aggravation of the condition.

　　4. Drink enough water, which can neutralize stomach acid, reduce the irritation of gastric juice on the ulcer surface, and at the same time, it can also supplement the slight dehydration of the body caused by diarrhea.

　　5. Adjust the diet structure, eat more vegetables and less meat; eat more soft and less hard. Appropriately supplement nutrition and strengthen physical exercise.

　　The large amount of water-soluble dietary fiber in the gold bifid factor can enhance peristalsis and intestinal moisture, promote the excretion of metabolic waste and toxins, clean up the body waste, and effectively eliminate intestinal inflammation. Appendicitis is also a kind of enteritis, and it plays a good role in the prevention of appendicitis.

　　Appendicitis is divided into acute and chronic appendicitis. Here, the method of Western medicine for treating acute appendicitis is mainly introduced:

　　(I) Non-surgical treatment:Mainly applicable to acute simple appendicitis, appendiceal abscess, early and late pregnancy acute appendicitis, and appendicitis in elderly patients with major organ diseases.

　　1. Basic treatment: Including bed rest, dietary control, appropriate fluid replacement, and symptomatic treatment.

　　2. Antimicrobial therapy: Select broad-spectrum antibiotics (such as ampicillin) and drugs against anaerobic bacteria (such as metronidazole).

　　(II) Surgical treatment:Mainly applicable to various acute appendicitis, recurrent chronic appendicitis, patients with appendiceal abscess who still have symptoms after conservative treatment for 3-6 months, and those who are ineffective with non-surgical treatment.

　　1. Preoperative preparation: No food or drink should be taken 4-6 hours before surgery. After determining the surgery time, a moderate amount of analgesic can be administered. Broad-spectrum antibiotics should be given to those who have pus and perforation. For patients with diffuse peritonitis, gastrointestinal decompression, intravenous fluid therapy, and attention should be paid to correcting fluid and electrolyte imbalances. For patients with dysfunction of the main organs such as the heart and lungs, appropriate treatment should be carried out in collaboration with relevant departments.

　　2. Surgical method: Performing the operation through a right lower quadrant oblique incision under local anesthesia is most suitable. A few patients can also choose epidural anesthesia and general anesthesia through a right lower quadrant exploratory incision. The main method is appendectomy (conventional method and retrograde method). In severe adhesion, subserosal appendectomy can also be performed. In cases where conservative treatment for appendiceal abscess is ineffective, incision and drainage can be performed, and a drain should be placed when there is a lot of peritoneal effusion.

　　3. Postoperative management: Continue supportive treatment, including intravenous fluid therapy, analgesia and sedation, and anti-infection. The drain should be removed in a timely manner, the incision sutured at the scheduled time, and attention should be paid to the prevention and treatment of various complications.

　　4. Prevention and treatment of postoperative complications: Postoperative complications are closely related to the pathological type of appendicitis and the timing of surgery. The incidence of complications after the resection of non-perforated appendicitis is only 5%, but it increases to more than 30% after perforation. The rate of appendiceal perforation is 20% and 70% respectively for those operated within 24 hours and 48 hours after onset, so appendectomy should be performed immediately within 24 hours of onset to reduce the incidence of complications.

　　(1) Hemorrhage: Bleeding within 24 hours after surgery is primary hemorrhage, often caused by imperfect hemostasis of the mesentery of the appendix or by loosening of the ligature. The main symptoms are abdominal hemorrhage, such as abdominal pain, distension, shock, and anemia, and immediate blood transfusion and reoperation for hemostasis should be performed. Sometimes the bleeding may stop spontaneously, but secondary infection may occur, leading to abscess formation, which also requires surgical drainage.

　　(2) Pelvic abscess: After peritoneal appendicitis, incomplete absorption of peritoneal pus can lead to residual abscesses in different parts of the abdomen. Pelvic abscesses are the most common, usually occurring around 7-10 days after surgery, with symptoms such as a rise in body temperature, increased frequency of bowel movements, accompanied by urgent need to defecate, anal palpation showing relaxation of the anal sphincter, and bulging of the anterior rectal wall. Prompt anti-inflammatory and physical therapy should be administered, and if ineffective, incision and drainage should be performed.

　　(3) Adhesive intestinal obstruction: There is a higher chance of intestinal adhesion after appendectomy, which is related to surgical injury, foreign body stimulation, and late removal of drainage materials. According to clinical statistics, the incidence of adhesive intestinal obstruction after appendectomy is about 2%, making it the first in the total number of postoperative adhesive intestinal obstructions (accounting for 32%). Comprehensive conservative treatment is generally performed first, and surgery is performed if it is ineffective.

　　(4) Fecal fistula, which can occur at the residual end of the improperly treated appendix, or due to rough surgery that injures the cecum and ileum, causing it. The main manifestations are long-term wound infection that does not heal, with feces and gas溢出. Since the infection has localized around the ileocecal area when the fistula forms, there is a slight loss of body fluids and nutrition. Conservative treatment can be tried first, and most patients with fecal fistula can heal spontaneously. If the course of the disease exceeds 3 months and has not healed, surgery should be arranged.

　　(5) Complications of incisions: including incision infection, chronic sinus tracts, and incision hernia, which have certain intrinsic connections. Incision infection often occurs between 4-7 days after surgery, and may appear two weeks later. The main manifestations are jumping pain at the incision site, local redness and swelling with tenderness, and a rise in body temperature. Immediate removal of sutures, draining the wound, removing necrotic tissue, and promoting healing through dressing changes, or waiting for the granulation tissue inside the wound to be fresh and performing secondary suturing until healing. If foreign bodies (such as thread ends) inside the wound are not cleaned up cleanly, and the drainage is not smooth, it may not heal for a long time, leaving one or several deep and curved granulation wound channels, which are chronic sinus tracts. The course of the disease can last for several months, and some may even last for more than a year, with the wound being good and bad at times. If conservative treatment fails after 3 months, the sinus tract can be resected and sutured again. Although the infected wound has healed, the peritoneum and muscle layer have been opened, and the small intestinal loops and omentum can protrude through the incision into the subcutaneous scar tissue, which is called incision hernia. If there are obvious symptoms that affect work, surgical repair should be performed.