Acute appendicitis . The vermiform appendix corresponds to a prolongation of the cecum, which in turn is the initial portion of the Colon or Large Intestine . It measures approximately 9-10 cm, the average length, and its location will depend on the location that the cecum will take during its rotation in embryonic development .
It is implanted on the lower edge of the cecum about 3 cm from the ileocecal valve and in more than half of the population it has a mobile end capable of changing its position according to the states of contraction or dilation of the cecum. In other cases it is fixed in a retrocecal, retroileal, preileal , subcecal or pelvic situation. These different positions may have important clinical implications. The function of the Appendix is unknown, as some refer to it as an atrophied organ or portion of the intestine, since it is observed with a larger size in some herbivorous animals, in which it is related to the absorption of cellulose from vegetables.
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- 1 Clinical Picture
- 2 Characteristics of abdominal pain
- 3 Treatment
- 4 Source
The vast majority of the time it begins with abdominal pain located in the epigastrium or the peri-umbilical region, not well defined by the child. It can occur abruptly, or as mild or moderate intensity abdominal colic. It is often associated with nausea and can lead to vomiting. After 3 or 4 hours, the pain is located in the right iliac fossa and subsequently covers a greater extent.
It is recommended to follow the following steps when this disease is suspected:
Observe: A child with acute appendicitis presents the following: Slight limp when walking, placing his hands in the lower right quadrant. Slow to jump and settle on the examination table. Difficulty stretching the right leg. Slight scoliosis to the right.
Listening: It is necessary to pay the most attention to the information of the parents, and even question the child. It is important to know their behavior in relation to some activities, such as: Time to get up Breakfast, lunch or lunch of the day, or the day before. Attitude at school. Bowel movements .
Many times, in the interrogation, the fairly approximate moment of the beginning of the attack can be specified, if it is related to these aspects. Keep in mind that anorexia or lack of appetite is a very frequent accompanying sign and that constipation or diarrhea can be associated with acute appendicitis in children.
Feeling: It is related to the elements of the physical examination, and the following will be taken into account: Temperature. Moderate at the beginning, 37 or 37.5 degrees Celsius , can occasionally rise to 38 degrees and occurs almost always after pain. The difference of 0.5 to 1 degree between the axillary and rectal temperature is important.
Tachycardia. It is a fairly constant sign. Exceeds 100 per minute. The physical examination of the abdomen is aimed at finding or checking appendicular pain:
Inspection: In newborns and infants there may be bloating. In older children there may be pain related to coughing and respiratory movements. The presence of scars denoting previous operations should be sought to take it into account in the differential diagnosis.
Palpation: You should start with the least sensitive area, the left iliac fossa , with gentle movements, while talking with the child to gain their confidence and decrease their anxiety. It continues throughout the left hemi abdomen and passes to the right through the upper part until reaching the lower right quadrant. The maximum pain is usually found at the Mc Burney point, located at the junction of the external third and the internal two of an imaginary line that goes from the upper right anterior iliac spine to the navel and is related to the appendicular base. The degree of abdominal contracture can be seen, (which is less the younger the child is) and the peritoneal reaction when abruptly decompressing in the right iliac fossa, after a firm and sustained deep palpation, and is an expression of peritoneal compromise, is the so-called Blumberg sign. Logically, this maneuver should be performed at the end of the physical examination due to how painful it is.
Sometimes the place of maximum pain is found in the so-called Lanz point, which is located at the junction of the right third with the middle third of an imaginary line that is drawn from both iliac spines, and is related to the tip of the appendix. It is interesting to identify the DIEULAFOY TRIAD, which consists of:
Pain on palpation in the right iliac fossa Muscular defense in the right iliac fossa Cutaneous hyperesthesia
Percussion: Painful in the right iliac fossa.
Auscultation: Hydro-aerial sounds can be normal or slightly decreased, depending on the duration of the picture.
Characteristics of abdominal pain
The pain that occurs in the epigastrium or the umbilical region is vague and diffuse, is usually accompanied by nausea and vomiting, and is caused by distention of the appendix. Receptors placed in the small blood vessels of the appendix transmit the first signs of inflammation along the mesenteric nerve fibers and to the tenth thoracic spinal nerve that supplies the dermatome at the level of the umbilicus and transmitted by a reflex through the solar plexus when it occurs irritation of sympathetic endings. It is a sensitive Viscero reflex pain, whatever the situation of the appendix.
The pain is located in the right iliac fossa for 1 to 4 hours, and is produced by the inflammatory process of the appendix that has affected all the layers, including the serosa, which comes into contact with the parietal peritoneum in the area, is stable It is continuous, and constitutes a referred pain that is transmitted by the parietal sensory nerves afferent to the posterior horns of the medulla, thence to the anterior horns, and by the peripheral motor efferent nerves to the skin of the right iliac fossa. It is a Viscero Cutaneous pain . It is important to highlight that if the patient is a carrier of transverse myelitis or a similar disorder, abdominal pain does not appear due to blockage of its transmission route.
The appendectomy (surgical removal of the appendix) in the first 48 hours is the treatment of choice. If more time has elapsed and a plastron has formed, conservative medical treatment with hospitalization, bed rest, intravenous hydration and active antibiotics against aerobic and anaerobic germs is indicated. Once the inflammatory process has resolved, the elective appendectomy should be scheduled between 6 weeks and 5 months, in order to avoid recurrence.