(1) Symptoms: Abdominal pain, gastrointestinal reaction and systemic reaction are the main manifestations.
1. Abdominal pain: The main reason for forcing patients with acute appendicitis to seek medical treatment immediately is abdominal pain, and all patients have abdominal pain except a few patients with transverse myelitis.
(1) Location of abdominal pain: Typical acute appendicitis patients, the location where abdominal pain begins is mostly upper abdominal pain, under xiphoid process or around umbilicus. After about 6-8 hours or more, the position of abdominal pain gradually moved down and finally fixed in the right lower abdomen. After abdominal pain is fixed, the pain in the original starting position can be obviously alleviated or even completely disappeared. This change of abdominal pain site, clinically known as metastatic right lower abdominal pain, is a unique feature of acute appendicitis and one of the main reasons for distinguishing it from other acute abdomen. About 80% patients have this feature. The traditional explanation of metastatic abdominal pain is that the pain in the early stage of the disease is the result of visceral nerve dysfunction caused by the intense peristalsis of the appendix to remove fecal stones or foreign bodies and relieve lumen obstruction, because the visceral nerve can not accurately identify the exact location of the pain; When inflammation spreads to the serosa and mesentery of the appendix, the peritoneum of the right lower abdominal wall, which is dominated by the receptor, is stimulated, and the location of pain is more accurate. There are also atypical patients in clinic. Abdominal pain may start from the whole abdomen, or the left abdomen, or even the waist and perineum. Some patients have no metastatic abdominal pain, and the first symptom is pain in the right lower abdomen. Therefore, there is no typical history of metastatic abdominal pain, and the existence of acute appendicitis cannot be completely ruled out easily.
(2) Characteristics of abdominal pain: Most patients with acute appendicitis have sudden and persistent abdominal pain, and a few may have paroxysmal abdominal pain first, and then gradually worsen. Acute appendicitis is suddenly and completely obstructed, which can be severe paroxysmal abdominal pain at the beginning. This is caused by the increase of pressure in the appendix cavity and the strong contraction of the appendix wall. After a sharp pain, it can recur at short intervals. The degree and characteristics of abdominal pain vary from person to person, but it is closely related to the pathological types of appendicitis. Simple appendicitis often shows persistent dull pain or swelling pain, while suppurative and perforated appendicitis often shows paroxysmal severe pain or jumping pain.
(3) Significance of sudden relief of abdominal pain: During the course of acute appendicitis, abdominal pain in some patients can be completely relieved suddenly. This phenomenon may occur in two situations: fecal stones and foreign bodies are discharged into the cecum, the obstruction of the appendix cavity is suddenly relieved, the pressure in the cavity is quickly relieved, and the pain is immediately relieved, indicating that the condition is getting better; In addition, after the necrosis and perforation of the appendix wall, purulent exudation enters the abdominal cavity, the pressure in the appendix cavity decreases rapidly, and abdominal pain can be relieved immediately. However, the inflammation in the abdominal cavity gradually spreads, and the pain in the right lower abdomen will gradually increase after a short relief, which is a temporary phenomenon. Therefore, the sudden relief of abdominal pain is not necessarily a sign of improvement. We must make a comprehensive judgment based on the signs and cannot give up treatment easily.
2. Gastrointestinal reaction: Nausea and vomiting are the most common. Early vomiting is mostly reflex and often occurs at the peak of abdominal pain. Vomiting is food residue and gastric juice, and late vomiting is related to peritonitis. About13 patients have constipation or diarrhea symptoms, and the frequency of defecation in the early stage of abdominal pain increases, which may be the result of enhanced intestinal peristalsis. When pelvic appendicitis occurs, the tip of the appendix directly stimulates the rectal wall, which may be accompanied by an increase in defecation times. However, pelvic abscess after appendiceal perforation not only causes frequent defecation, but also causes acute defecation.
3. Systemic reaction: In the early stage of acute appendicitis, some patients feel weak, weak limbs, or headache and dizziness. During the course of the disease, I felt a fever. The temperature of simple appendicitis is mostly between 37.5 and 38℃. In suppurative and perforated appendicitis, the temperature is higher, reaching about 39℃. Very few patients have chills and high fever, and their body temperature can rise above 40℃.
(2) Signs: During abdominal examination of acute appendicitis, common signs include abdominal tenderness, abdominal muscle tension and rebound pain. These direct signs of inflammation are the main basis for the diagnosis of appendicitis. In addition, in some patients, there will be some indirect signs such as major signs of lumbar muscles, which will help to determine the location of appendix inflammation.
1. Gait and posture: Patients like to take the posture that the upper body bends forward and leans slightly to the affected side, or gently support the right lower abdomen with the right hand to reduce the activity of abdominal muscles to relieve abdominal pain, and the gait is also slow when walking. These characteristics can be found when patients see a doctor.
2. Abdominal signs: Sometimes continuous observation and multiple comparisons are needed to make a more accurate judgment.
(1) Abdominal morphology and activity: A few hours after the onset of acute appendicitis, the respiratory activity of the lower abdomen can be found to be slightly limited. When peritonitis occurs after perforation, the whole abdominal activity can completely disappear and the abdomen gradually expands.
(2) Peritoneal stimulation: including abdominal tenderness, muscle tension and rebound pain. Although the degree of peritoneal irritation varies among patients, almost all patients have abdominal tenderness.
Right lower abdomen tenderness: tenderness is the most common and important sign. When the infection returned to the local examination, the collection of large websites was limited to the appendix cavity, and the patient still felt pain in the upper abdomen or navel and tenderness in the right lower abdomen. When the infection spreads to the tissues around the appendix, the tenderness range of the right lower abdomen is also enlarged and the tenderness degree is also aggravated. When perforated appendicitis complicated with tendinous peritonitis, although there is tenderness all over the abdomen, the right lower abdomen with the most serious infection is still the most obvious. For cecum or retroperitoneal appendicitis, the tenderness of the anterior abdominal wall may be mild.
Abdominal muscle tension: About 70% patients have muscle tension in the right lower abdomen. It is generally believed that abdominal muscle tension test is the result of the spread of infection outside the appendix wall and the stimulation of local peritoneum by inflammation, which is more common in suppurative and perforated appendicitis and is a defensive response that the body is not dominated by consciousness. Abdominal muscle tension often exists at the same time as abdominal tenderness, and the scope and degree are roughly the same. Obese people, pregnant women and the elderly and infirm tend to have weak abdominal muscles, and their muscle tension is not obvious.
Rebound pain: patients with acute appendicitis may have rebound pain, especially in the right lower abdomen. If the patient's cooperation is obtained, the rebound pain in the right lower abdomen is positive, indicating that peritonitis must exist. When the appendix is located in the deep abdominal cavity, the tenderness and muscle tension are light, but the rebound pain is obvious, which also indicates that there is infection in the deep abdominal cavity.
(3) Right lower abdomen tenderness point: The specific location of local tenderness point of acute appendicitis is introduced in traditional textbooks, and the positive local tenderness point is listed as one of the signs of appendicitis. Although the tender points of appendicitis proposed by the author are all based on the projection of the appendix root on the body surface, the recommended local tender points are not completely consistent because of the different summary data. Clinical practice has proved that the positive rate of each tenderness point varies greatly, and it is unrealistic to diagnose acute appendicitis only by the presence or absence of a certain tenderness point. More doctors think that the existence of fixed tenderness area in the right lower abdomen is more diagnostic than positive tenderness point. Common bidding points are as follows:
① Maxwell point: the junction of umbilical cord and right anterior superior iliac spine 1/3.
② Lanzi point: the middle right 1/3 of the connecting line of the anterior superior iliac spine.
③ Song Mei Bei's point: the intersection point between the umbilical cord and the right anterior superior iliac spine and the outer edge of the right rectus abdominis.
④ Neutral point: the area between Ma point and Lang point, and the lateral edge of rectus abdominis is about 7 cm away from the right anterior superior iliac spine.
(4) Abdominal mass: When suppurative appendicitis is complicated with inflammation around appendix and intestine, omentum, small intestine and mesentery can adhere to appendix to form a mass; The localized abscess formed after appendiceal perforation can touch the right lower abdominal mass. Inflammatory mass is characterized by unclear boundary, immobility, tenderness and rebound pain. Only with the patient's full cooperation can we find the deep inflammatory mass through careful touch. The appearance of the mass indicates that the infection has been localized, and the inflamed appendix has been tightly surrounded by tissues such as omentum, which is not suitable for emergency surgery at this time.
3. Indirect signs: Other signs, such as Roche's sign, can be checked clinically. As long as the technique is correct and positive results are obtained, it has certain reference value for the diagnosis of appendicitis.
(1) Roche's sign (also known as indirect tenderness): When the patient is lying on his back, the examiner presses the left lower abdomen with his palm or presses it hard along the descending colon. If the pain in the right lower abdomen is aggravated, it is positive; Or the direction of the force is toward the right lower abdomen, which is also positive when the same result appears. When the pressure is released quickly, the pain is aggravated, which can better explain the inflammation in the right lower abdomen. As for the mechanism of positive results, the current explanation is: the former is that the gas in the left colon is transmitted to the right colon by pressure, and finally hits the cecum and enters the inflamed appendix cavity, which makes the pain worse; The latter transfers the pressure to the right lower abdomen by means of the small intestinal loop in the lower abdomen, so that the inflamed appendix is squeezed. Regarding the clinical significance of Roche's sign, the positive result can only show that there is infection in the right lower abdomen, and can not judge the pathological type and degree of appendicitis. When pain in the right lower abdomen needs to be differentiated from diseases such as right ureteral calculi, the examination of Roche's sign may be helpful.
(2) psoas major sign: Let the patient lie on the left side, and the examiner will help the patient stretch the right lower limb. For example, to detect the pain in the right lower abdomen, the website says that the pain is positive if it gets worse. The positive signs of psoas major suggest that the appendix may be located in cecum or retroperitoneum. When the lower limbs are overstretched, the psoas muscles can be squeezed into the inflamed appendix.
(3) Obturator muscle sign: After the patient lies on his back, when the right hip joint flexes, he passively rotates internally, and the pain in the right lower abdomen turns positive, indicating that the appendix is in a low position and the inflammation spreads to the obturator muscle.
(4) Skin allergy area: In the early stage of acute appendicitis, especially when there is obstruction in the appendix cavity, the skin of the right lower abdominal wall may have increased sensitivity. Cough and knocking on the abdominal wall can cause pain, and even touching the skin of the right lower abdomen can cause pain. If the appendix is perforated, the allergic phenomenon will disappear. The skin range of allergic area is triangular, and its boundary consists of three points: right iliac spine, pubic crest and navel. The area of skin allergy does not change with the position of appendix, which may be helpful for early diagnosis of atypical patients.
4. Anal digital examination: Unless it is a special case, anal digital examination should be listed as routine, and correct anal diagnosis can sometimes directly provide diagnostic basis for appendicitis. Acute appendicitis in pelvic position has obvious tenderness on the right side of rectum, even touching the inflammatory mass. When the appendix is perforated with pelvic abscess, the temperature in the rectum is high, the anterior wall of the rectum can swell and touch the lesion, and some patients are accompanied by anal sphincter relaxation. For unmarried female patients, anal finger examination can also rule out acute lesions of uterus and appendages.