The appendix is a histological remaining worm-shaped ( vermiform ) hanging from the lower aspect of the beginning of the large intestine or ascending colon ( the cecum) that is commonly found in the right and lower abdomen .
The intestine is divided into two , the small (jejunum and ileum ) and large (colon), and in total has an average length of 7 meters. At the end of the small intestine the ileocecal valve is , this is a kind of gateway between the small intestine and large , this is where the small intestine makes continuity with the large intestine , this first portion of the colon is called blind .
The appendix has an elongated cylindrical shape , like a small tunnel in continuity with the blind , some define it as an elongated sac and can measure from 1-25 cm. In the first stage of life appendix is a lymphoid organ ( serves for defense) , insofar as it grows and becomes an adult individual function irrelevant. It is, is absolutely essential organ.
When the appendix is blocked or occluded at its output, inflammation occurs with edema or swelling, bacteria grow inside and infection occurs , at which point the process is progressive and irreversible , and as the hours pass situation worsens blood circulation is compromised and necrosis and perforation , perforation of the appendix drains colonic contents (feces) to the abdominal cavity causing abdomen wide infection ( peritonitis ) .
The causes of obstruction of the appendix we mention , hardened stool trapped in the opening of the appendix , foreign bodies (seeds or undigested food ) , parasites , inflammatory mucosal diseases , among others.
Appendicitis is the medical term used to indicate that the vermiform appendix was inflamed and this is synonymous with infection in the appendix. The swelling and infection decrease the flow of blood to the walls of the appendix, this causes the death of the tissues causing it to burst or puncture. A ruptured appendix can output and excrete bacteria into the abdominal cavity in the patient causing a generalized infection of the abdomen or peritonitis, peritonitis can be fatal.
Appendicitis occurs in one in every thousand people, is more frequent between 10 and 30 years of age. It is the most common cause of abdominal pain requiring surgery. It is seen relatively frequently in children and in pregnant women.
Appendectomy is the treatment, and involves the removal of the appendix through surgery.
Unfortunately, many people do not realize that you have appendicitis until the picture is complicated. The appendix to swell enters an evolutionary process in which the hours count, going more than 36 hours with pain and inflammation of the appendix is very likely to happen drilling, if this happens the problems are serious and can range from peritonitis, formation of intra-abdominal abscess, sepsis (generalized infection) and death.
The incidence of perforation of the appendix is 270 per 1000 patients. This figure is higher among children, the elderly, pregnant women and diabetics.
The most common symptoms of appendicitis are :
• Sensation and perception of pain in the process of appendicitis can be different for each person , and this is because the appendix may be in different positions within the abdomen and may be playing different structures or organs. This greatly hinders diagnosis and creates confusion. Usually the pain starts around the navel or in the stomach and then moves to the right and bottom side of the abdomen.
Pain tends to worsen when walking , coughing, even when talking , sometimes it is observed that the patient adopts a position that is comfortable and keeps moving. During pregnancy diagnosis is challenging change their pain pattern because the appendix is usually found in a much higher position than usual.
In elderly patients the diagnosis is difficult because the sensitivity and the level of inflammation is less as the individual grows older .
• Loss of appetite ( nine of 10 ) . Sometimes it is difficult for the individual to understand the fact that he has not felt a real desire to eat food , some people are motivated to eat simply because it’s breakfast, lunch or dinner , but eat food without desire. The lack of desire to eat is known as anorexia.
• mild to moderate fever , the inflammation process causes fever, once established the infectious process and peritonitis may be high.
• Nausea and vomiting sometimes , these are only the direct reflection of the irritation of the intestines within the abdomen. These symptoms are seen in about 20 to 35 % of patients
• Constipation and diarrhea sometimes .
Physical examination and laboratory studies
Everything should be focused on identifying the cause of abdominal pain. The diagnosis of appendicitis is primarily clinical, the account of what happened from the onset of pain (history ) is of paramount importance , as well as physical examination that determines the location and type of pain , certain maneuvers are performed which the physician focuses on locating the source of pain .
Rectal examination is performed in order to identify if there are any problems within the rectum causing this pain , there is also the consistency and characteristics of the feces to rule out other diseases that may be causing the pain.
The gynecological examination or vaginal examination : should determine the presence or absence of a pelvic inflammatory process, mainly in adolescents and women of reproductive age . The uterus and adnexa are also valued , rule out the possibility of pregnancy
Blood tests help us to confirm the presence of an inflammatory or infectious process , they show changes during the course of the disease.
• CBC (complete blood count ) : we focus on the count of white blood cells and increased at the expense of these neutrophils , they are a specific type of white blood cell increases in the presence of infectious or bacterial processes .
• Glucose : an analysis of routine preoperative fasting should ideally be done to determine if the patient suffers from diabetes mellitus (high blood sugar ) .
• Kidney Tests: are performed to determine if there is kidney disease , if we are in the presence of an inflammatory process in the urinary system .
• Urine test is done to rule out an inflammatory condition of the bladder, urethra or the urinary system (acute pyelonephritis) .
• Pregnancy test: should be performed on blood and urine, sometimes the patient lies still been operated to not get pregnant , it may happen that the pain is caused by an ectopic pregnancy (pregnancy outside the uterus) .
• Abdominal ultrasound or sonography , this is a test that uses sound waves that travel through the body and create images of internal organs. It is a quick, simple study and does not produce any pain.
Consideration should be the upper abdomen and pelvis to rule out other diseases or abdominal processes that may be happening. In experienced hands can give the diagnosis of appendicitis up to 85 % of cases, no clutch, the diagnosis of appendicitis is considered clinically , sonography that report as usual does not rule out the possibility of an inflammatory process of the appendix in your step initial .
Sometimes the presence of air or gas within the intestines Appendix visibility difficult , especially when the appendix is behind the blind.
• computed tomography , this diagnosis method is quite useful when several hours have passed and the appendix is thickened , or if the appendix has burst and is present or intra-abdominal fluid collection . Not so, for the initial stage.
• Other studies : The electrocardiogram is performed on adults , elderly, or those in which there is suspicion of a heart problem .
Surgery is the only option for the treatment of acute inflammation of the appendix or appendicitis.
It is a surgical procedure in which the removal of the appendix is performed.
There are two approaches for performing appendectomy, open or laparoscopic. Open surgery is done in different ways and for different incisions; midline (exploratory laparotomy) for paramedian line (on the right side of the abdomen), or in the right iliac fossa directly.
This technique each day becomes more common for simple appendectomy in most developed countries. The surgeon makes three small incisions ( 0.5 to 1 cm ) in the abdomen through which thin tubes or cannulas (ports ) where carbon dioxide, a gas used to inflate the abdomen and create space is entered are inserted . This process allows the surgeon to visualize the appendix , the pelvic cavity and the rest of the abdominal cavity with ease .
A laparoscope ( or tubular cylindrical lens which is connected to a video camera and light source) is introduced through another port . This allows the surgeon to see inside the abdomen on a screen or monitor. Then specialized instruments are inserted through other ports to dissection, ligation of the artery supplying the appendix and ligation and division for the removal of the appendix.
The surgeon removes the appendix through an incision , the carbon dioxide is removed from the abdominal cavity through the ports , then these are closed with sutures . The surgery usually lasts between 15 and 45 minutes.
The surgeon can start laparoscopic surgery or minimally invasive manner and conversion to conventional open surgery or if technical difficulties may be necessary to perform the procedure or the patient’s own anatomical variants . The cup conversion in young people without underlying diseases is less than 1 %.
The need for conversion occurs mainly when :
• The patient has been several hours or days with pain.
• Have previous abdominal surgery with large incisions.
• If you are over 65 years old.
• have a high fever .
• Has data peritonitis ( generalized swelling of the abdomen) .
• Has limiting illnesses.
The surgeon makes an incision of about 5 cm long if the iliac fossa and 15 to 20 cm if it is in the middle line, cutting through fatty tissue , fascia and muscle to reach the abdominal cavity exposing the handles of small intestine and colon startup ( blind ) to the base of the appendage is blind . Just as in laparoscopy artery ligation with sutures and appendix is to dissect it and remove it.
The wound is closed in layers with sutures and sometimes a drain is left from the internal to the external abdomen. The drain is usually removed during detention. This procedure usually takes between 30 minutes and 1 hour.
• Infection – for simple acute appendicitis wound infections reported in 34 0a 1000 patients for laparoscopic and 1-70 in 1000 for open procedures procedure. The risk is higher in complicated cases or in cases of perforation. Antibiotics are usually used before and after the operation and the recipe prescribed for the discharge to continue with antibiotics in the house .
• Abscess – abscesses are reported in 1 percent of the laparoscopic patients and 2.5 % of open procedures .
• Intestinal obstruction – tissue inflammation around the appendix can become inflamed intestines and hinder the mobility of the same , making difficult the passage of fluids and excreta have been reported cases of transient intestinal obstruction in 4% of patients.
• Pneumonia – can be seen in any surgery under general anesthesia or surgeries that limit respiratory movements due to pain and ambulation (open surgery with large incision ) .
• Kidney and urinary tract – kidney disorders are rare and usually accompany complicated pictures. Infections of the urinary tract are seen in 1.1 % of patients , many of these cases the urinary catheter should be .
• Deep vein thrombosis – limitation of movement during surgery can lead to blood clots in the legs , clots can move and stay in the lungs. This decreases with laparoscopy enough as it is outpatient surgery and the patient remains in bed shortly .
• Bleeding – bleeding is extremely rare, only seen in patients with altered coagulation factors , the bleeding may be slightly higher in the open surgery because the incision.
• Premature labor or fetal loss – the premature labor seen in 9% of cases while the loss or fetal death was seen in 2.6% of pregnant patients with uncomplicated appendectomy and can be as high as 10% in cases of accompanying peritonitis.
• abdominal organs or intestinal injury – surgical instrumentation can damage internal organs the surgeon should have experience and caution , making sure any sign of injury to organs or obese patients with previous surgeries are more difficult to operate.
• Death – is extremely rare for this disease and is reported to be less than 0.01 % , is seen in patients with local gangrene, advanced infection , sepsis or concomitant diseases.
Preparing for operation
You must put your surgeon aware of any health problems you have. You must report all medications you use, it is important that the surgeon and anesthesiologist are aware of these.
As this procedure is usually an emergency You will meet the anesthesiologist on the day of the procedure. You need to communicate accurately if you are allergic to any medications, if you have a neurological disorder, if you have heart, if you have stomach problems if you have lung problems (asthma or emphysema), if you have any endocrine disorders (diabetes or thyroid), if you have lost a tooth, if you smoke, drink alcohol or use drugs.
What questions should you ask before surgery?
• What medications should I leave or stay?
• When should I for these drugs and for how long?
• What type of anesthesia will use me, what are my options?
• What are the risks and complications of general anesthesia?
• Do I need to take antibiotics before surgery?
• What should I do to prevent thromboembolism?
The day of surgery
DO NOT EAT OR DRINK
Do not eat or drink at least 6 hours before your surgery, you must take into account that when ingesting food or liquid puts your health at risk, since at the time of anesthesia reflexes are lost and vomiting and aspiration can happen intestinal contents into the lungs, this is a fatal complication.
What should you have with you?:
• Your insurance card.
• Authorization of insurance.
• Your ID or identification.
• Analytical and previous studies (usually these are done by emergency).
• Authorization Cardiologist (not necessary in cases of emergency).
• List of medications and drugs you use.
• Personal items such as eyeglasses and dentures.
• Clothing and shoes.
• Leave clothes and valuables at home.
At the time of placement
On admission he placed an intravenous catheter with a solution to hydrate and administering medications; Some drugs make you sleepy. It is common medications administered to protect the stomach and prophylactic antibiotics (to prevent infection).
If anesthesia is usually in the operating room, the anesthesiologist will administer medication to dormirlo, then place a tube in your throat to administer anesthetics during surgery.
The surgeon will perform the operation and eventually close the incisions, sometimes it is necessary to leave some sort of drainage. After surgery, it will remain in the recovery area for about an hour.
Recovery and discharge
After the surgery will be a few hours with the anesthetic effects, it is often not remember the first moments upon waking. These effects gradually disappear, some people can last more than 48 hours. By the time of discharge is likely to feel recovered.
Waking once have passed anesthesia , remain without food for a period of 24 to 36 hours , then once is restored peristalsis (bowel movements ) will be given beginning to tolerance of liquids, this is ingesting small amounts of liquid . If not ensue nausea or vomiting, then the diet bland diet and then start running . Then it is recommended to maintain adequate hydration eating at least 8 to 10 glasses of water per day.
Some surgeries evacuatorio produce changes in the pattern. Constipation or constipation is common for the lack of intestinal motility. Some pain medications can cause constipation. To manage this condition diet high in fiber or adding fiber to the diet , sometimes the use of laxatives is necessary is recommended.
Foods high in fiber include beans , grains , cereals , wholemeal bread , dried fruits , sweet corn , broccoli , baked potatoes with peel , pear, apple , peach, milky and nuts.
When it comes to bowel diarrhea is common procedures , if it is maintained beyond the third day, ask your doctor .
It is recommended to stay out of bed as long as possible , sitting or lying down is better than wandering . Gradually should increase their physical activity , however , we recommend no heavy lifting or strenuous activity for the first week in cases of laparoscopic surgery, and at least for 3 weeks in cases of open surgery.
You can perform any type of activity that your body will allow , as long as no pain without the use of pain medication , avoid driving or operating heavy machinery .
You can resume sexual activity once sitting with the intention to do so , do so with caution and restraint , avoid hurting wounds.
It is normal to feel exhausted or sleepy , you will notice that you need to sleep more than usual , this is normal and usually improves with every passing day. Avoid walking in pajamas all day , try to integrate into daily activities as your body will allow.
You can work once you feel better, this may vary in patients. Laparoscopic surgery allows early entry into the daily work, usually patients who undergo a laparoscopic procedure return to work in the first week. In cases of open surgery is required between 3 and 4 weeks, sometimes it requires more time.
You must follow the instructions to the letter when it comes to wound care .
You should wash your hands before touching near the wounds .
In most cases use dermabond ( skin adhesive ) , this works as sterile dressing is waterproof and does not permit the passage of bacteria . If this product is used on your wound , you can bathe comfortably and wet their wounds.
When we use steri strips ( tapes sterile ) , is allowed to bathe in the second postoperative day . You can wet their wounds and is recommended not to remove the tapes , you better expect to fall alone. The steri strips regularly fall alone at 7 or 10 days.
In the event that you have in your wounds sterile dressings ( bandages , dressings or bandages ) not to touch these dressings until you order , sometimes the wound should be kept covered for several days. You should wait for these dressings are removed to wash his wounds.
Sometimes it is normal to see some liquid goes through his wounds, if it is yellow, amber or orange, there is nothing to fear ; If the drainage becomes thick and white , you should tell your doctor , the infection is usually accompanied by redness and swelling of the area.
If you have placed a drain in one of the incisions , this will be removed when no more liquid comes out through the drain, the time for this to happen may vary.
For most procedures , we use internal points , it is likely that you will not withdraw sutures. In cases where the skin with stitches or staples outside , these will be removed in a second date , whether the wounds are healed sutured .
Avoid wearing tight or uncomfortable , avoid rubbing the wound as this can cause injury and delayed healing .
Protect wounds, especially the Sun, this can cause thickening and darkening of the wounds . Use sunscreens to enhance the aesthetic results .
His wounds healed in about 6-8 weeks you will gradually disappear and skin tightening will be more smooth and clear . The process of healing and skin remodeling lasts about a year. The sensitivity around the wounds take weeks or months to improve.
The perception and pain intensity varies in people. Usually the pain is quite tolerable in minimally invasive surgery , even without the use of drugs. For some patients need two to three daily doses of analgesics ( pain medications ) , while in others the use of narcotics is necessary.
Each person reacts differently to pain . Pain measurement scales are used to determine the degree of pain , this scale is from 0 to 10 . Given value of 0 when there is no pain and 10 the pain but he has received in his life.
For pain control :
No narcotics – this group is composed mainly of nonsteroidal antiinflammatory drugs (NSAIDs ) are the most widely used postoperatively for control of mild to severe pain . These also decrease inflammation . Some of the unwanted effects is irritation of the stomach ( gastritis) , bowel irritation and fluid retention . These effects are only seen with prolonged use . These drugs have ibuprofen , diclofenac , naproxen, meloxicam and others.
Narcotics or opioids – are regularly used to control severe pain. Some of the unwanted effects of narcotics are drowsiness , lethargy , decreased blood pressure , heart rate and respiratory rate , itching and skin irritation , constipation , nausea , difficulty urinating . Examples of these include morphine, oxycodone and hydromorphone . There are drugs to control the side effects of narcotics .
After a laparoscopic procedure is common sense discomfort or pain in the shoulder, this is due to the irritation caused by the gas used in the abdomen during surgery, Walking and moving help lower gas within the abdomen and therefore improves pain .
In most cases antibiotic prophylaxis ( prevention ) is used . Antibiotic dose of one or half hour before surgery applies . Where the process is advanced appendiceal need more than 2 days of hospitalization for antibiotics , it is common to use several in combination.
Antibiotic prescribing for the house is very important and depends on the findings at surgery and consider what your doctor for your particular case.
You should contact your surgeon if you:
• you have severe pain that does not improve with medication .
• Feel the pain has worsened with the passing of the hours.
• Note that the pain is accompanied by fever higher than 38.5 ° C.
• develop nausea or vomiting.
• Notes that the wounds are wet , red or have pus.
• Severe pain of new onset .
• No bowel movements or feel bloated.
• No gases discharged or spend more than three days.
• Have watery diarrhea for more than three days
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