Acute Appendicitis - PDF

# Chapter 2. ACUTE APPENDICITIS ## ETIOLOGY, PATHOGENESIS, PATHOLOGIC ANATOMY, AND CLASSIFICATION Acute appendicitis is still one of the most important surgical problems. Appendectomy constitutes about 20-30% of all surgeries performed annually without marked downtrend. Studies of the appendix hav...

# Chapter 2. ACUTE APPENDICITIS ## ETIOLOGY, PATHOGENESIS, PATHOLOGIC ANATOMY, AND CLASSIFICATION Acute appendicitis is still one of the most important surgical problems. Appendectomy constitutes about 20-30% of all surgeries performed annually without marked downtrend. Studies of the appendix have passed many stages before the modern system of etiology, pathogenesis, clinical picture, and treatment was created. This disease is insidious. Contrary to the conception of it as a slight indisposition, its lethality seems to be not high, considering the incidence of the disease; it rarely exceeds 0.2-0.3%, but these figures mean dozens of thousands lives. Our knowledge of this "harmless" disease is not enough. The previous centuries had the seal of tragedy of many millions of people. Only a hundred years ago a brilliant professor of Harvard, R. Fitz (1886), had said the word "acute appendicitis" for the first time and recommended the surgeons to operate on such patients immediately. The first appendectomies were performed by Kronlein in 1883, by Malomed in 1884, and by A.A. Troyanov in 1890. ## BRIEF ANATOMO-TOPOGRAPHIC SKETCH The vermiform appendix (appendix vermiformis) is a constituent of the ileocecal angle, which presents morphological integrity of four intestinal departments: the caecum, terminal end of the ileum, initial part of the ascending colon, and the vermiform process. All the constituents of the ileocecal angle are in strict correlation and perform the function of "internal analyzer", coordinating the most important function of the intestine - conduction of chyme from the small to large intestine (A.N. Maximenkov, 1972). The important element of the ileocecal angle is the ileocecal (Bauhin's) valve (valva ileocaecalis) with very intricate structure. Its function is to accomplish regulation in transition of intestinal content to the cecum in little portions and to prevent its return from the cecum to the small intestine. The ileocecal angle is situated in the right iliac fossa. Fundus of the cecum is projected on the distance of 4-5 cm upwards the center of the inguinal ligament; under condition of its filling, fundus of the cecum is located just above the center of the inguinal ligament or may even descend to the small pelvis. Great variability in anatomo-topographic situation of the cecum and the vermiform process explains in many respects such a diversity of clinical picture, which may be observed in acute appendicitis. The most frequent and practically important deviations from the normal position of the cecum are the following: 1. High, or hepatic, position, when the cecum and the vermiform process are situated high, sometimes reaching the lower border of the liver; 2. Low, or pelvic, position, when the cecum and the vermiform process are situated below normal, i.e., descend to the pelvis. Other variants of its localization, such as its left-side position, location along the middle line of the abdomen, in the umbilical region, in the left hypochondrium, in the hernial sac, etc., occur rather infrequently. According to data of F.I. Valker, there are some age-related changes in position of the cecum and the vermiform process; in infants they are situated rather high, but in elderly age they exhibit a tendency to descent below the normal position. It is necessary to take into consideration the changes in position of the cecum and the vermiform process associated with pregnancy. Beginning from the 4-5 months of pregnancy, the cecum and the vermiform process begin to shift gradually towards the lower border of the liver. Following labor, the ileocecal angle returns to its previous position, however, it becomes more mobile. ## Peritoneal pockets Peritoneal pockets in the area of ileocecal angle are of great importance: recessus ileocaecalis superior and inferior, and ressus retrocaecalis. Internal abdominal hernias, which are able to malinger appendicitis, may originate in these pockets. In adults the vermiform process begins from the medial-posterior or medial side of the cecum and represents blindly ended segment of intestinal tube. In most cases the process is of stem-like form and characterized by equal diameters along the whole length. So, the process was termed according to its shape. But sometimes variants occur. According to data of T.F. Lavrova (1960), in 17% of cases the vermiform process converges in the direction of the apex and resembles a cone. In 15% of cases the so-called embryonic form is observed, in which the process is the immediate prolongation of the cecum, converged in form of a funnel. ## Sizes of the vermiform process Sizes of the vermiform process vary within wide limits from 0.5 till 9 cm. However, abundantly long processes with the length of 20-30 cm are to be found sometimes. The vermiform thickness averages 0.5-1 cm. Its sizes depend considerably on the age of a patient. The largest sizes occur at the age of 10-30. At the elderly and senile age the vermiform process is subjected to the marked involution changes. In rare cases of visceral inversion the vermiform process with the cecum is located in the left iliac region with all possible anatomical variants, which may occur at its right-side position. It is necessary to remember about infrequent abnormalities, when, for example, the process protrudes from the outer wall of the cecum or from the ascending colon. I.I. Homich (1970) observed such an interesting case, when the arched vermiform process opened into the lumen of the cecum with its both ends. Duplication of the vermiform process is also possible, but, as a rule, this phenomenon is associated with other multiple defects and malformations. It is also necessary to remember about the possibility of congenital absence of the vermiform process, which occurs extremely rarely. P.I. Tihonov cites literary data, that the vermiform process may be absent in 5 per thousand persons. ## The vermiform process The vermiform process is located intraperitoneally. It has its own mesentery (mesenteriolum), which supplies it with vessels and nerves. Blood supply of the ileocecal angel is provided owing to the superior mesenteric artery a. ileocolica, which is subdivided into the anterior and posterior iliac arteries. The natural artery of the vermiform process a. appendicularis, which may have a loose, arterial or mixed structure, branches off from a. ileocolica or from its branch. Artery of the vermiform process goes through its mesenteries, along its free edge, to the end of the process. Though its small caliber (from 1 to 3 mm), post-operative hemorrhages from a. appendicularis may be very intensive, as a rule, they require relaparotomy. ## Veins Veins of the cecum and the vermiform process are the tributaries of the ileocolic vein (v. ileocolica), which flows in the superior mesenteric vein (v. mesenterica superior). ## Innervation Innervation of the ileocecal angle is performed by the superior mesenteric plexus, which is connected with the celiac (solar) plexus, which takes part in innervation of all digestive organs. The ileocecal angle is considered to be "the junction depot" of all abdominal organs innervation. Running from here impulses influence functions of many organs. The peculiarity of innervation of the ileocecal angle and the vermiform process explains the onset of pain in the epigastrium and their spreading over the abdomen in acute appendicitis. ## Lymph outflow Lymph outflow from the vermiform process and from the ileocecal angle performs entirely to the lymphatic vessels, which are situated along the iliocolic artery. There is a chain of lymph nodes (10-20) along this artery, which extends to the central group of mesenteric lymph nodes. Immediate proximity of the mesenteric and iliac lymph nodes explains the similarity of clinical picture in inflammation of these nodes (acute mesenteric adenitis) and in inflammation of the vermiform process. In 3% of women there are common lymphatic (and sometimes blood) vessels and nerves for the vermiform process and the right uterine appendages. In that case an inflammation easily spreads from one organ to another, and differential diagnostics of diseases of the vermiform process and female genitals on the right side is especially difficult. ## Localization Five variants of localization of the vermiform process with respect to the cecum are distinguished: descending (caudal (is); lateral, internal (medial), anterior (ventral), and posterior (retrocecal). In descending, more frequent localization, the vermiform process, directing towards the small pelvis, adjoins to certain extent the organs of the small pelvis. In lateral position, the process lies from the outside of the cecum. Its apex is directed to the inguinal (Poupart's) ligament. Medial localization is also rather frequent. In those cases the vermiform process lays medially to the cecum, being localized between the loops of the small intestine; all these provide favorable conditions for extent inflammation inside the abdominal cavity and give rise to abscesses. The anterior position of the process, in which it lies in front of the cecum, occurs rarely. Such localization is favorable to anterior parietal abscess. Some of the surgeons mark out ascending type of the process localization. Here, the two variants are possible. The first one, in which the whole ileocecal angle is located rather high, under the liver, and then the term subhepatic position of the vermiform process is applied, or the second variant, when the apex of the retrocecal vermiform process is directed toward the liver. Retrocecal position of the process, which is observed in 25% of the patients, two variants of its bedding with respect to the peritoneum is characteristic: in some cases the process, being covered with the peritoneum, lies in the iliac fossa behind the cecum, while in other cases it projects from the leaf of the peritoneum and lies intraperitoneally. This position of the vermiform process is termed retrocecal (retroperitoneal) one. The latter is considered to be the most insidious variant, especially in suppurative and destructive appendicitis, since in the absence of the peritoneal cover of the process the inflammatory process extends to the paraumbilical fat, causing deep retroperitoneal phlegmonas. ## ETIOLOGY, PATHOGENESIS, AND PATHOLOGIC ANATOMY. CLASSIFICATION. There is no consensus of opinion about etiology of acute appendicitis. But there are some theories explaining the causes of the disease and its pathogenesis. The most common of them is mechanical (congestion), infectious, and aponeurotic theories. Besides that, at different periods a number of conceptions, sometimes very original, were elaborated. All the theories and conceptions, reflecting one or another etiological agent, are not without logic and sense. At the same time, a variety of forms and stages of acute appendicitis suggests the polyetiology of this disease, which results from the changed correlation between the human body and microorganisms. It being known, acute appendicitis is a non-specific inflammation of the vermiform process. The causative agents of infections may be staphylococci, colon bacilli, and mixed and anaerobic flora. All the efforts on choosing a particular pathogenic organism and to number acute appendicitis among specific inflammatory disease were not successful. ## Mechanical theory Mechanical theory indicates the role of foreign bodies, inflections and scarry strictures of the vermiform process in development of acute appendicitis. But these factors occur are far from being in all the patients. Helminthic invasion and angina (sore throat) are of great, but not absolute importance in genesis of the disease. Infectious theory correctly indicates the role of infection and the primary affect, but does not explain what stimulates an infection, which is permanently present in the lumen of the vermiform process. And similar weak points take place among the other theories and conceptions. Gained scientific and practical experience proves, that taking into consideration the variety of clinical and morphological forms of the disease, there may be several predisposing factors and their combinations. For example, the following mechanisms and ways of development of acute appendicitis are quite logical: 1. Obstruction of the lumen of the process and formation of a closed cavity filled with feces, which contain toxins with highly reactive enzymes, gradually result in suppuration, lesion of the mucous membrane, and infection penetrates inside the vermiform process wall. Development of exudative inflammation is accompanied by microcirculatory disturbances and degeneration of intramural neural apparatus. But neurodystrophic changes together with the vascular factor constantly result in inflammatory intensification and its progressing up to formation of phlegmon or gangrene. 2. Due to neurologic disturbances, vascular stasis occurs in the vermiform process. It results in trophopathy of the vermiform process and formation of necrotic foci. Pathologically changed tissues are easily infected, i.e., secondary infection takes place. The following spread of the infectious process causes more extensive pathologic changes with all possible severe consequences. 3. Primary formation of acute ulceration in the vermiform process, which had been observed by Selye at general adaptation syndrome, is possible. It may be the result of neurogenic vasospasm. 4. In those cases, when abrupt clinical picture of the disease is followed very rapidly by gangrene of the vermiform process, it is quite possible to consider primary thrombosis of a. appendicularis and its branches. Inflammatory component and infection join secondarily. Hence, the principal pathogenic components of acute appendicitis are neurogenic factor, inflammatory reaction, and infection. Each of them may be of primary or the secondary importance in onset of the disease. However, there is no acute appendicitis, in which all these three factors, or at least one of them is not present. ## PATHOLOGIC ANATOMY. On examining of the abdomen, the cecum and the vermiform process, the surgeon is confronted with very important task - visual evaluation of pathologic changes in the abdomen, estimation of form of the vermiform process inflammation, and extent to which peritonitis has spread. A proper conclusion determines a surgical approach and allows realizing an adequate post-operative treatment. Pathologic changes in acute appendicitis concern not only the vermiform process. The range of impairments is great, from insignificant hyperemia of the serous coat of the vermiform process in catarrhal (congestive) appendicitis to severe diffuse peritonitis in its destructive forms with involvement of all the organs of the abdominal cavity. It is necessary to remember at any time about quite real development of endotoxic shock and deep metabolic disturbances with severe anatomico-functional homeostatic shift. It necessary to estimate properly the changes in the parietal peritoneum, in the cecum, in the vermiform process, and in the loops of the small intestine, and to compare all these data with the clinical picture of the disease. Valuable information may be obtained by the exudate nature and its amount. Exudate may be serous, sero-fibrous, purulent, fibrinopurulent, hemorrhagic, and mucous one, flavoured or odorless. In the presence of creamy odorless pus, hemorrhagic exudate or exudate with admixture of bile or blood, acute appendicitis is improbable. It is necessary to remember, that changes of the vermiform process may be secondary ones, that is why in doubtful cases it should be recommended to make sure of absence of other diseases, such as inflammation of the Meckel's diverticulum, inflammation of the genital organs, regional enteritis (Crohn's disease), pancreatitis, perforating ulcer, etc. ## Appendicular colic Appendicular colic. It means a muscle spasm of the vermiform process, caused by any of the pathologic process and proved by pain in the right iliac area. A surgeon makes this diagnosis in those cases, when clinical manifestations disappear quickly, or when at the time of operation he does not see any inflammatory changes in the vermiform process. ## Catarrhal (congestive) appendicitis. Catarrhal (congestive) appendicitis. Exudate may be absent or it may be in very small amount. It is transparent, odorless. The peritoneum is unchanged and is hyperemic a little. All changes are strictly localized in the vermiform process. It is hyperemic along the whole length or at the limited site (usually distal one), thickish to the touch, slightly edematous. The lumen of the process may be either empty, or may contain mucus, impacted feces, and foreign bodies. The mesentery is not changed, or may be slightly edematous and hyperemic one. Microscopically: leukocytic infiltrations in the impaired sites of the process. Sometimes it is possible to find out a defect of the mucous membrane (primary affect), which is covered with fibrin and cellular elements. ## Phlegmonous appendicitis. Phlegmonous appendicitis. Exudate may be serous, sero-fibrous, sero-purulent one. Fetid odor appears at perforation of the vermiform appendix. In most of cases it is possible to speak about the local peritonitis, but in advanced cases, when the process is not delimited, but the amount of exudates is considerable and it baths the large sites of the abdominal cavity, it is possible to consider diffuse and even general peritonitis. The omentum, the cecum, and adjaicent loops of the small intestine may be also involved in the pathologic process. They are hyperemic, thickened, are covered with fibropurulent deposit and are fused by loose adhesions. The vermiform appendix is considerably enlarged in its sizes, is of dark red color, strained, is covered with mucoid fibrin. The sites of white-yellowish pus may be often seen through the transparent serous coat. Pus, which is inside the lumen of the organ, is gradually stretching it, and empyema is formed. The mesentery is thickened, its leaves are hyperemic and edematous, may be easily teared. Similar changes are frequently observed in the cecum cupola wall and considerably complicate appendectomy. On microscopic examination it is possible to reveal leukocytic infiltration of all the layers of the vermiform process; it is impossible to differentiate them due to their saturation with pus. Apostematous appendicitis takes place in case of appearance of multiple abscesses against a background of diffuse purulent inflammation of appendix. In case of ulceration of the mucous membrane against a background of phlegmonous appendicitis, phlegmonous-ulcerative appendicitis occurs. ## Gangrenous appendicitis. Gangrenous appendicitis. Abdominal changes are similar to phlegmonous appendicitis, but they are more pronounced. Exudate is turbid, with ichoropurulent odor. The vermiform process is partly or completely of black, brown, brown-green, black-brown, or dirty-gray color. Its wall is flabby with phlegmonous masses. Gangrenous appendicitis is frequently perforating one, and then it is possible to see fetid feces pouring through the opening in its wall inside the abdominal cavity. As a rule, peritonitis occurs. It may be local, diffuse, or general, but according to the nature of microflora, colibacillary, anaerobic, and mixed types are distinguished. Extensive necrotic foci with bacteria colonies, hemorrhages, and vascular thrombosis may be revealed on microscopic investigation. Somewhere it is possible to see the foci of phlegmonous inflammation. The mucous membrane is ulcerated all along. Integmentary epithelium is shelled. As a rule, destructive changes are pronounced up to perforation in the distal part of the organ. Generalization of infection in a form of endotoxic shock occur in gangrenous appendicitis more frequently than in other forms of inflammation. ## Appendicular infiltrate Appendicular infiltrate is one of the complications of acute appendicitis. The vermiform appendix, being destructively changed, becomes an epicenter of adhesion process. A conglomerate of chaotically fused neighboring organs; and tissues are formed around it. The greater omentum, loops of the small intestine, the cecum and ascending intestine, the peritoneum become involved in the pathologic process. The wall of these organs are subjected to inflammatory infiltration, the boundaries between them become gradually lost. Infiltrate rapidly increases in sizes, being compactly connected to the anterior, posterior, and lateral walls of the abdomen. Sometimes infiltrate is of vast sizes, occupying the whole right side of the abdomen. ## CLASSIFICATION. There is a great variety of acute appendicitis classification, which reflects both its pathomorphological and clinical forms. Many of them are of only historical importance, and we shall limit it only by enumeration of such names as Mc. Burney (1891), Sprengei (1906), Weinberg (1898), Sonnenburg (1900), and G.V. Shor (1935). Each of proposed by them classification, being different from each other by details, corresponded to those ideas about acute appendicitis, which had taken place at the end of XIX - beginning of XX centuries. But there are two classifications, which are used by the present and make it easier to choose the policy of treatment. They are the classification according to A.I. Abrikosov (1946), in which he wanted to reflect the problems of acute appendicitis pathologic anatomy, and the classification according to V.I. Kolesov (1959), where he tried to reflect clinical forms of acute appendicitis and its complications. ### Classification according to A.I. Abrikosov: I. Superficial appendicitis (primary affect); II. Phlegmonous appendicitis: 1) simple phlegmonous appendicitis; 2) ulcerophlegmonous appendicitis; 3) apostematous appendicitis; a) with perforation; b) without perforation; c) empyema of the vermiform appendix; III. Gangrenous appendicitis: 1) primary gangrenous appendicitis; a) with perforation; b) without perforation; 2) secondary gangrenous appendicitis: a) with perforation; b) without perforation. ### Classification according to V.I. Kolesov: I. Acute simple (superficial) appendicitis; A. Without general clinical signs, but with mild local, quickly disappearing, manifestations of the disease. B. With insignificant general clinical signs and local manifestations of the disease. II. Destructive acute appendicitis (phlegmonous, gangrenous, perforating): A. With clinical picture of moderate severity and the signs of local peritonitis; B. With severe clinical picture and the signs of local peritonitis; III. Complicated appendicitis: A. With appendicular infiltrate; B. With appendicular abscess; C. With diffuse peritonitis. We had elaborated classification of acute appendicitis (diagram 1), which does not contradict classifications according to A.I. Abrikosov and V.I. Kolesov, but somewhat simplifies them and allows to formulate exactly the diagnosis and to facilitate considerably scientific processing of statistic data. | Appendicular | Catarrhal | Destructive | Complicated | | ---------- | -------- | ----------------- | ---------------- | | colic | (superficial) | Phlegmonous (with | Peritonitis | | | | and without | Endotoxin shock | | | | perforation) | Appendicular infilltrate | | | | Gangrenous (with | Abdominal abscess | | | | and without | Sepsis | | | | perforation) | Pylephlebitis | ## THE MAIN PRINCIPLES OF MEDICAL AID IN ACUTE APPENDICITIS. In the memory of surgeons of our generation the bright description of urgent surgery for acute appendicitis will live in the works of G. Mondor (1940), V.F. Voyno-Yasenetski (1946), S.S. Yudin (1960), and P.I. Tihov (1916). It was G. Mondor who said: "The future of acute appendicitis can not be divined". These words call our generation of surgeons to early and timely performed operation. For many decades the subject of acute appendicitis excites the minds of our scientists. A great amount of works both native and foreign was dedicated to this problem. Problem of acute appendicitis is constantly examined at Congresses of surgeons. It is reflected in the following principles of surgical approach for acute appendicitis: 1) On suspicion of acute appendicitis the patient is subjected to urgent hospitalization to the surgical unit, he is to be under constant medical care and to undergo additional examination. 2) Recognized acute appendicitis requires an urgent surgical invention, irrespective to manifestation of clinical picture, the age of a patient, duration of the disease (with the exception of delimited infiltrates). 3) In vague cases, in the presence of suspicion of acute appendicitis, it is necessary to perform laparoscopy or explorative laparotomy. 4) In the absence of changes in the vermiform appendix during the operation, or in case of not corresponding of revealed changes with clinical picture, it is necessary to perform revision of the abdominal cavity. ## CLINICS, DIAGNOSTICS, TREATMENT. Acute appendicitis is characterized by variety of clinical manifestations. I.I. Grekov figuratively called it "a chameleon-like disease", and Y.Y. Dzhanelidze called it as insidious one. Almost all the symptoms of acute appendicitis are non-specific, i.e., occur in many other abdominal diseases. That is why the symptom is not important by itself, but its characteristics, combination with other symptoms and the consequence of its appearance are very important in diagnostics. One and the same symptom at different stages of the disease and at different forms of it has its own features. There are three main forms of acute appendicitis: 1) early stage (up to 12 hours); 2) stage of development of destructive changes in the vermiform appendix (from 12 to 48 hours); 3) stage of complications (48 hours and more). This division at stages is rather relative one, and the disease may run by its own, much more transient scenario, however, more frequently it proceeds exactly in such a way. The diagnostic program consists of continuously connected to each other and result one from another elements, which consist of life (past) history and present history (history of the present illness), complaints of a patient (chief and secondary ones), proved investigation carried out at strict sequence, special and diagnostic methods of investigation. Sometimes the past history allows to suppose the connection of appendicitis with lately endured acute respiratory disease, angina, and toxic infection. But the most important one is to obtain information about chronic gastritis, duodenal or peptic ulcer, chronic cholecystitis or pancreatitis, cholelithiasis or urolithiais, inflammatory genital diseases. In exacerbations all of them may simulate an onset of acute appendicitis. In a healthy person the disease begins suddenly, without any prodromal symptoms or precursors. Only a few of patients notice worsening of their general state and weakness, lack of appetite before the pains appear. As a rule, a patient complains of three main signs: abdominal pain, nausea and vomiting, retention of stools and gases. ## Pain Pain is the first and most common symptom of acute appendicitis. It occurs predominantly at night, becomes constant, gradually intensifying. Patients may characterize pain as piercing, cutting, burning, dull, acute one. At the first stage of the disease the intensity of pain is not significant, it is quite tolerable. Patients do not cry or moan, but also do not show superfluous motive activity, as jerky movements of the body, for example, at cough (the cough shock symptom) intensify the pain. Cramping pain occur very rarely. ## Localization Pain Localization of pain is different. In typical cases it is localized at once in the right iliac area, but it also may not be localized, but spreading all over the abdomen. Approximately in a half of patients it locates at first it the epigastric area (Kocher - Volkovich's sign), and only in 1-2 hours descends to the right iliac area. Sometimes this symptom lasts for more prolonged time, and it considerably hampers differential diagnosis. At the second stage of the disease, on developing of destructive changes in the vermiform process, pain increases, causing the patients to suffer. The most severe pain is in empyema, when pressure increases in the lumen of the vermiform process. In those cases the patients rush about, they could not find a place for themselves. On the background of constant pain a patient suddenly feels the increase of pain - perforating symptom. But paradoxical reaction is rather frequent too, when during the process of destruction pains subside up to their complete disappearance; this is associated with gangrene of the vermiform appendix wall. ## Discrepancy of pain Discrepancy of severe condition of the patient and clinical picture is evident. At the third stage clinical picture of either appendicular infiltrate or abscess or peritonitis is revealed. Pain may radiate to different parts of the abdomen: to the umbilicus, to the epigastric area, and to the loin. ## Nausea and vomiting Nausea and vomiting is observed in 60-80% of patients. Nausea usually precedes vomiting, but sometimes it may be an independent symptom. It is important that these symptoms do not ever precede pains, but arises during the first or the second hour of the disease. At the first stage vomiting is of reflex nature, with mucous and eaten food. At the second and third stages vomiting occurs again, but now its frequency and nature depend predominantly upon expressiveness of peritonitis, intoxication and developing dynamic (paralytic) intestinal insufficiency. ## Gas and stools retention Gas and stools retention. They are immutable concomitants of acute appendicitis. At the first stage of the disease retention of gas and stools occurs as physiologic, reflex reaction to outside stimulants, but later it results from paralytic ileus in peritonitis. Loose stools is rather infrequent, it may be observed mainly in children in case of spreading of inflammatory process on the sigmoid colon or the large intestine. In case of pelvic location of the vermiform appendix and its contiguity with the urinary bladder wall dysuric disturbances are possible. ## Temperature At the onset of the disease temperature averages 37-38°C. Pulse rate corresponds to the temperature - 80-100 beats per minute. Only in destructive forms of appendicitis temperature may be 38,5-39°C, but tachycardia becomes 130-140 beats per minute. Thermometer readings under the armpit and into the rectum are to be compared because of certain diagnostic importance. Revealing of considerable difference (over 1,5°C) objectively testifies an acute pathology in the abdomen. ## Examination of a patient At the first stage of the disease the state of a patient is satisfactory. Expression of a face is quiet, skin integuments are of normal color or slightly pale. His condition and appearance become worse in case of destructive forms of appendicitis. Pallor of the integuments, feverish luster of the eyes, the air of long suffering and worry, features of a patient in development of peritonitis become sharp (Hippocratic face). Patients, as a rule, are not mobile, are apathetic, unwillingly, in one word, and with difficulty answer questions. Euphoria is a bad sign. It is necessary to remember, that in a number of cases, already at an early stage of acute appendicitis, toxic component, sharp pallor of integuments, hyperemia of sclerae, feverish luster of the eyes, high temperature, tachycardia, chill, delirium, and euphoria are clearly marked. A real danger of toxic shock takes place. It is interesting, that information about acute appendicitis with marked toxemia, which was called by G. Mondor as fulminant and fatal, are practically absent in modern literature on acute appendicitis. At the same time, toxic form of acute appendicitis is really present and harbors a considerable threat for the patient's life. ## Tongue At the first stage of the disease the tongue is humid and covered with a white fur. As destructive changes in the vermiform appendix and in peritonitis develop, the tongue becomes dry and covered with dirty-gray fur. ## Examination of the abdomen At an onset of the disease the abdomen usually of normal form, moves with breathing, symmetrical. In lean patients it is possible to notice the lag of the right side of the abdomen in respiratory movements due to muscular strain (Ivanov's symptom). In perforating of the vermiform appendix the respiratory movements of the anterior abdominal wall disappear. In a man of athletic type it is possible to notice the relief of strained abdominal muscles. Abdominal distention is the late symptom. It testifies the development of peritonitis. Muscular tension (defanse musculare) is the main symptom in acute appendicitis. In severe cases the site of the most tenderness and local tension of the abdominal wall is in the right iliac area; the degree of the muscular tension increases in accordance with intensity of the inflammatory process inside the peritoneum. Revealing of the symptom requires a certain experience. Infrequently the patient strains the abdominal wall by himself, preventing the pain, especially if the investigation is carried out unskillfully and crudely. V.F. Voyno-Yasenetsky (1946) described this phenomenon very exactly. He wrote: "Frequently we see a doctor, who crudely pokes his finger into the very painful abdomen, revealing nothing and losing patients' confidence at once. And, by the way, not only in inflammatory processes in the abdomen, but at its complete tenderness, the patients sharply react with protective motions to any indelicate feeling. Our medical tasks infrequently make us to cause pain, but it is grievously when we become callous and recognize ourselves to have a right to cause pain, and patients are considered by us to be obliged to suffer pain". An experienced surgeon begins surface palpation far from the supposed painful focus, usually in the left side of the abdomen, moving from the left to the right against the run of the large intestine. Closer he approaches to the right iliac-inguinal region, more careful and spare he palpates. ## Muscular tension At the first stage of the disease the muscular tension may be absent. It may be frequently observed in elder and senile persons and in women with flabby and dilated abdominal wall, who had experienced labors many times, and also at retrocecal, retroparietal and pelvic localization of the vermiform appendix. Deep palpation of the most painful area is not expedient. It rarely gives additional information, as it is usually prevented by muscular protection. But at soft abdomen deep palpation allows to diagnose appendicular infiltrate, to determine its size and bounds, consistency, mobility. Sometimes it is possible to feel the cecum, area of which is always painful in case of acute appendicitis. But it is almost impossible to feel the vermiform appendix, and it is not necessary. Revealing of painful points (McBurney's point, points of Lanz and Kummel) is not of great diagnostic value. In acute appendicitis tenderness of the abdomen is rarely strictly localized. ## Blumberg's sign Blumberg's sign (guarding symptom) is a rebound tenderness symptom. Already at the early stage of acute appendicitis, at mild catarrhal inflammation of the parietal peritoneum it is usually positive. The following may check it. The tips of the fingers are introduced very gently and gradually into the anterior abdominal wall, pressing it inside the abdomen. Then the arm is abruptly taken away. In positive reaction the patient notes the increase of pain, sometimes he shrivels and utters a scream. It is useful to remember the rule of Felix Lezhare: "Three signs changing during the nearest hour, i.e., the increase of pain, rapid pulse, and rebound tenderness give cause to urgent abdominal operation. " ## Percussion of the abdomen Percussion of the abdomen allows to localize the area of the greatest tenderness more precisely (Razdolsky's (abductor of femur) sign). These are also rebound tenderness symptoms. A slight percussion of the abdominal wall at its different sites is enough to determine this symptom. By means of percussion, being oriented on the dullness of the percussion sound it is easy to estimate the bounds of appendicular infiltrate, and in peritonitis - the presence of fluid in sloping places of the abdomen. ## Auscultation of the abdomen Auscultation of the abdomen allows to estimate the intestinal peristalsis. Already at an early stage of the disease it is weakened, but survives for a long time. The absence of peristalsis is a threatening symptom of peritonitis. ## Appendicular symptoms Appendicular symptoms. More than 100 symptoms of appendicitis had been already described. We shall settle on only on some of them, which are the most pathognomonic, and gained popularity among the surgeons. **Sitkovsky's sign**: A patient is asked to turn on his left side. If at that the pain in the right iliac region arises, the symptom will be considered to be positive one. **Bartomye's symptom**: is checked as Sitkovsky's one, but at the same time palpation of the right iliac region is performed. At positive symptom palpatory tenderness increases. **Rovsing's symptom**: In dorsal decubitus of a patient, a surgeon presses the sigmoid colon to the posterior abdominal wall with the fingertips of the left arm and fixes it. Simultaneously, a little above, by means of balloting palpation, he shakes the abdominal wall in the sigmoid area. The onset of pain in the right half of the abdomen is the evidence of a positive symptom. **Voskresensky's symptom**: A shirt or T-shirt of a patient is tightened with the left arm and fixed at the pubis. By fingertips of the right arm a surgeon slightly presses to the abdominal wall in the area of the xiphisternum, and at time of expiration performs a quick uniform sliding motion at first towards the left iliac-inguinal region, and then to the right one, but for all that the arm is held on the abdominal wall. In the presence of positive symptom a patient feels pain in the right side. It is also necessary to remember some other appendicular symptoms, such as Gorn's,