Abdominal muscle rigidity

Introduction Abdominal rigidity is one of the clinical manifestations of acute appendicitis. The onset of acute appendicitis is often upper abdominal pain or full abdominal pain, which is gradually limited to Markov's point. The nausea and vomiting are more prominent, and the tenderness, rebound tenderness and abdominal muscle rigidity are more obvious. Acute appendicitis is the first place in various surgical acute diseases. In 1886, Fitz first named it. In 1889, McBurney proposed the surgical treatment of this disease. Over the past century, due to the improvement of surgical techniques, anesthesia and antibiotic treatment and nursing, the vast majority of patients have been cured, and the mortality rate has dropped to about 0.1%. Metastatic right lower abdominal pain and appendical tenderness and rebound tenderness are common clinical manifestations, but the condition of acute appendicitis varies widely. Therefore, every specific case should be taken seriously, detailed medical history and careful examination, so as to accurately diagnose. Early surgery to prevent complications improve the cure rate.

Cause

Causes

1, appendix lumen obstruction

The anatomical features of the appendix, such as the narrow lumen, the thick lymphatic tissue in the narrow wall of the opening, the short mesangial membrane, the curling of the appendix into a curved shape, etc. These are the factors that cause the lumen to be easily blocked. In addition, food debris, fecal foreign matter , mites, tumors, etc. often cause lumen obstruction of the lumen, the secretion of mucus in the appendix mucosa accumulates, and the pressure in the lumen rises and the blood supply becomes impeded, which increases the inflammation of the appendix.

2, the impact of gastrointestinal diseases

Some diseases of the gastrointestinal tract, such as acute enteritis, inflammatory bowel disease, schistosomiasis, etc., can spread directly to the appendix, or cause tendon wall muscle tendon to cause blood circulation disorders and inflammation.

3, bacterial invasion

After obstruction and inflammation of the appendix, mucosal ulcers, epithelial damage, bacteria in the lumen can not be discharged and opportunistic to grow and invade the wall, so that the infection-infected bacteria are mostly various Gram-negative bacilli and anaerobic bacteria in the intestine.

Pathogenesis

Although acute appendicitis often manifests as a suppurative infection caused by different degrees of bacterial invasion in the appendix wall, its pathogenesis is a relatively complicated process, which is related to the following factors.

I. Obstruction of the appendix lumen: the lumen of the appendix is narrow and slender, and the distal end is closed and blind. The obstruction of the lumen is the basis of the acute appendicitis. After the obstruction of the appendix lumen occurs, a large amount of mucus is retained in the cavity, so that the pressure in the cavity Gradually rising too high pressure can compress the mucosa, causing necrosis and ulceration, creating conditions for bacterial invasion such as continuous increase of intracavitary pressure, compression of the appendix wall, first venous thrombosis, venous thrombosis, edema of the appendix wall and ischemia. When the bacteria in the cavity can penetrate into the abdominal cavity, the artery is also blocked, so that some or even the entire appendix is necrotic. The site of the obstruction of the appendix is mostly in the root of the appendix. In the middle and the distal part of the appendix, the causes of obstruction are as follows:

1. Lymphoid hyperplasia: The submucosal layer of the appendix is rich in lymphoid tissue. Any cause of swelling of these tissues can cause stenosis of the appendix cavity. In adolescent acute appendicitis, about 60% is induced by swelling of lymphoid tissue. It has been observed that the incidence of appendicitis is closely related to the number of lymphoid follicles in the appendix.

2, fecal stone obstruction: about 35%, fecal stone is caused by the mixture of feces, bacteria and secretions in the appendix cavity, which is the main cause of acute appendicitis in adults.

3, foreign body: about 4%, such as food residues, parasites and eggs.

4, congenital factors or inflammatory adhesions: can make the appendix twisted, folded, the cable with the compression of the tumor can narrow the appendix cavity.

5, cecal and appendix wall lesions: inflammation of the cecal wall near the appendix opening, tumor and appendix itself polyps, nesting, etc. can lead to obstruction of the appendix cavity.

Second, bacterial infection: There are a large number of bacteria in the appendix cavity, including aerobic bacteria and anaerobic bacteria. The bacteria are mainly coexisting with Escherichia coli, Enterococcus and Bacteroides. The way bacteria invade the wall of the iris is:

1. Direct invasion: The bacteria invade by the ulcer on the mucosal surface of the appendix and gradually develop into various layers of the appendix wall, causing purulent infection.

2, blood-borne infection: bacteria through the blood circulation to the appendix, children in the upper respiratory tract infection, the incidence of acute appendicitis can be increased.

3, the spread of adjacent infections: relatively rare, the acute inflammation of the organs around the appendix directly spread to the appendix, which can cause appendicitis.

Third, nerve reflex: various causes of gastric and intestinal dysfunction, can be reflective caused by the appendix ring muscle and the appendix artery spasm contraction. The former can aggravate the obstruction of the appendix cavity and make the drainage more unsatisfactory. The latter can cause the ischemia and necrosis of the appendix to accelerate the occurrence and development of acute appendicitis.

Disease classification

First, the pathological type:

1. Simple appendicitis: mild swelling of the appendix, congestion of the serosa surface, loss of normal luster and a small amount of fibrinous exudate. All layers of tissue have hyperemia, edema and neutral polynuclear leukocyte infiltration, with mucosa and submucosa most prominent mucosa. There may be small ulcers on the upper surface, and there may be a small amount of inflammatory exudate in the cavity.

2, suppurative appendicitis: also known as cellulitis inflammatory appendicitis, appendix swelling, the serosa surface is highly congested and there is purulent or fibrinous exudate attachment. In addition to congestion, edema and a large number of neutrophil infiltration, each layer of tissue often has small wall abscess, mucosal surface may have ulcers and necrosis, and there is often a small amount of turbid exudate in the abdominal cavity of the empyema.

3, gangrenous appendicitis and perforation: the wall of the appendix has been completely or partially necrotic, the appearance is dark purple or black, a large amount of purulent cellulose exudate on the surface and its surroundings, and empyema in the appendix cavity. If incarcerated obstruction, incarcerated distal necrosis; such as inflammation wave or appendix mesenteric vascular thrombosis, the entire appendix is necrotic, and perforation can be seen in about 2/3 cases of omental wrapping, bacteria and pus through the necrotic area or Perforation into the abdominal cavity.

Second, pathological outcomes:

1, inflammation subsided: simple appendicitis before the mucosa has not formed ulcers, timely drug treatment may cause inflammation to subside without leaving pathological changes. Early suppurative appendicitis, if treated, even if the inflammation subsides, it will be scar healing, resulting in narrowing of the appendix cavity, thickening of the wall and twisting of the appendix, and easy recurrence.

2, localization of inflammation: suppuration or gangrene, perforation, appendix for the omentum to form an appendix around the appendix or inflammation of the mass is limited. If the pus is not much, it can be gradually absorbed.

3, the spread of inflammation: such as the body's defense function is poor, or not treated in time, the inflammation spreads and causes the appendix purulent gangrene perforation and even diffuse peritonitis, suppurative portal phlebitis. Very few patients with bacterial emboli can enter the portal vein with blood flow and form an abscess in the liver with severe sepsis, accompanied by hyperthermia, jaundice and hepatic swelling and septic shock.

an examination

Related inspection

Abdominal wall tension abdominal shape palpation abdominal perspective abdominal CT abdominal MRI examination

symptom:

1, abdominal pain: more in the umbilical and upper abdomen, the beginning of the pain is not very serious, the position is not fixed, paroxysmal, this is the splanchnic nerve reflex pain caused by luminal dilatation and wall muscle contraction after the appendix obstruction After that, abdominal pain was transferred and fixed in the right lower abdomen, and the pain was persistently aggravated. This is the inflammation of the appendix caused by the inflammation of the appendix and the peritoneum of the parietal layer. About 70% to 80% of acute appendicitis has the characteristics of this typical metastatic abdominal pain, but some cases have right lower abdominal pain at the onset of the disease. Appendicitis in different locations has different abdominal pain sites, such as appendicitis in the genital appendix in the lateral lumbar region; pelvic appendicitis in the suprapubic region; appendicitis in the lower hepatic region can cause upper right abdominal pain; very few left abdominal appendicitis is left lower abdominal pain. Different pathological types of appendicitis have different abdominal pains such as simple appendicitis is mild dull pain; suppurative is paroxysmal pain and severe pain; gangrenous is persistent severe abdominal pain; perforated appendicitis due to sudden reduction of appendix lumen pressure, abdominal pain It can be temporarily relieved, but abdominal pain will continue to increase after peritonitis.

2, gastrointestinal symptoms: nausea, vomiting is the most common, early vomiting is mostly reflective at the peak of abdominal pain, late vomiting is associated with peritonitis. About one-third of patients have symptoms of constipation or diarrhea. Abdominal pain Increases the number of early stools, which may be the result of increased bowel movements. In the pelvic appendicitis, inflammation stimulates the rectum and bladder, causing urgency and urination and pain in the bowel movements. Abdominal palsy and persistent vomiting occur in patients with peritonitis.

3, systemic symptoms: initial fatigue, headache. When the inflammation is aggravated, there may be fever and other symptoms of systemic poisoning. The body temperature is mostly between 37.5 and 39 °C. Suppurative, gangrenous appendicitis or peritonitis can occur chills and high fever, body temperature can reach 39 ° C -40 ° C or more. Jaundice can occur during portal phlebitis.

Signs:

1. Forced position: When the patient comes to the clinic, he often bends and walks, and often presses his hands on the lower right abdomen. The right hip joint is often flexed when lying on a bed.

2, right lower abdomen tenderness: is a common important sign of acute appendicitis, the tender point is usually at the point of Mai's point, can change with the position of the appendix, but the tender point is always in a fixed position. When the early abdominal pain of the lesion has not been transferred to the right lower abdomen, the tenderness has been fixed in the right lower abdomen. When the inflammation spreads beyond the appendix, the range of tenderness also expands, but the tenderness is most obvious in the appendix.

3, signs of peritoneal irritation: abdominal muscle tension, rebound tenderness (Blumberg sign) and bowel sounds weakened or disappeared, etc., which is a defensive reaction of the wall peritoneum inflammatory stimulation often suggests that appendicitis has developed into suppuration, gangrene Or the stage of perforation. However, when the elderly, pregnant women, obese patients or appendicitis in the cecum, the signs of peritoneal irritation may not be obvious.

4, other signs:

(1) Colon aeration test (Rovsing test): press the left lower abdomen to lower the colon with one hand, and then repeatedly compress the proximal colon with another hand. The gas in the colon can be transmitted to the cecum and appendix, causing pain in the right lower quadrant. Positive.

(2) Lumbar muscle test: After the left lateral position, the right lower limb is stretched backwards, causing the right lower abdominal pain to be positive, indicating that the appendix is deep or close to the psoas muscle in the posterior cecum.

(3) Closed-pore inner muscle test: supine position, the right hip and right knee were flexed 90° and the semi-right femoral rotation was inward. If the right lower quadrant pain was caused, it was positive, suggesting that the appendix position was lower near the closed-cell inner muscle. (4) digital rectal examination: When the appendix is located in the pelvic cavity or the inflammation has spread to the pelvic cavity, the digital rectal examination has a tenderness in the right front of the rectum. If a pelvic abscess occurs, the painful mass can be touched.

5, abdominal mass: when the abscess around the appendix, the right lower abdomen can touch the painful mass.

6, skin hypersensitivity: early (especially when there is obstruction in the appendix cavity) may appear in the right lower abdomen skin hypersensitivity phenomenon, the scope is equivalent to the 10th to 12th thoracic segmental nerve innervation area, located at the highest point of the right iliac crest, right pubic iliac crest and umbilicus The triangular area, also known as the Sherren triangle, does not change due to the different position of the appendix, such as the perforation of the appendix, and the skin hypersensitivity disappears.

Differential diagnosis

Disease identification :

The clinical misdiagnosis rate of acute appendicitis is quite high. The domestic statistics are 4-5%, and the foreign reports are up to 30%. Many of the diseases that need to be differentiated from acute appendicitis include the following ten diseases.

First, the identification of acute abdomen with internal medicine:

1. Right lower pneumonia and pleurisy: Inflammatory lesions in the right lower lung and thoracic cavity, which can cause right lower abdominal pain, which can be misdiagnosed as acute appendicitis, but pneumonia and pleurisy often have obvious respiratory symptoms such as cough, cough and chest pain. Abdominal signs such as changes in chest sounds and wet rales are not obvious, and tenderness in the right lower quadrant does not exist. Chest X-ray can be clearly diagnosed.

2, acute mesenteric lymphadenitis: more common in children, often secondary to upper respiratory tract infections. Because the small mesenteric lymph nodes are extensively swollen and the ileum is particularly obvious, it can be clinically manifested as right lower quadrant pain and tenderness, similar to acute appendicitis, but this disease is associated with high fever, abdominal pain and tenderness is widespread, and there are fashions that can reach swollen lymph nodes.

3, localized ileitis: lesions mainly occur at the end of the ileum, a non-specific inflammation, 20-30 years old young people more common in the acute phase of the disease, intestinal lesions in the lesions, edema and exudation stimulated right Abdominal pain and tenderness occur in the peritoneal layer of the lower abdominal wall. Similar to the location of acute appendicitis, it is limited to the ileum, and there is no metastatic abdominal pain. The abdominal signs are also extensive and sometimes the swollen intestinal tube can be touched. In addition, patients can be accompanied by diarrhea stool examination with obvious abnormal components.

Second, the identification of acute abdomen with obstetrics and gynecology:

1, right fallopian tube pregnancy: right ectopic pregnancy rupture, intra-abdominal hemorrhage stimulate the right lower abdominal wall peritoneum, clinical features of acute appendicitis can occur, but ectopic pregnancy often have menopause and early pregnancy history, and there may be vaginal bleeding before the onset. After the abdominal pain, the patient has swelling of the perineum and anus, as well as internal bleeding and hemorrhagic shock. Gynecological examination shows that there is blood in the vagina, the uterus is slightly larger with tenderness on the right side of the annex and the posterior malleolus puncture has blood and other positive signs.

2, ovarian cyst torsion: the right ovarian cyst pedicle torsion, cyst circulation disorder, necrotic bloody exudation, causing inflammation of the right abdomen, similar to appendicitis, but this disease often has a history of pelvic mass, and the onset is sudden, paroxysmal Colic can be associated with mild shock symptoms. Gynecological examination can reach the cystic mass, and there is a tender abdominal B-ultrasound to confirm the existence of cystic mass in the right lower abdomen.

3, ovarian follicular rupture: more occurs in unmarried young women, often two weeks after menstruation, due to intra-abdominal bleeding caused by lower right abdominal pain. The local signs of the right lower quadrant of the disease are mild, and the diagnostic abdominal puncture can extract hemorrhagic exudation.

4, acute attachment inflammation: acute inflammation of the right fallopian tube can cause symptoms and signs similar to acute appendicitis. However, tubal inflammation occurs mostly in married women, and there is a history of excessive leucorrhea before the onset of menstruation. Although there is pain in the lower right abdomen, there is no typical metastatic and the abdominal tenderness is lower, almost close to the pubic bone. Gynecological examination showed that there were purulent secretions in the vagina, and the tenderness on both sides of the uterus was obvious. The right side attachment had a tender mass.

Third, the identification of surgical acute abdomen:

1. Acute perforation of ulcer disease: After perforation of ulcer disease, part of the stomach contents flow into the right axilla along the right colonic sulcus, causing acute inflammation of the right lower quadrant to be mistaken for acute appendicitis. However, this disease has a history of chronic ulcers. The cause of overeating before the onset is sudden and the abdominal pain is severe. When the body was examined, the abdominal wall was plate-shaped, and the peritoneal irritation was marked with the most obvious abdominal abdomen under the xiphoid. The free gas was found under the abdomen, and the diagnostic abdominal cavity puncture could extract the upper digestive tract fluid.

2, acute cholecystitis, cholelithiasis: acute cholecystitis sometimes need to be identified with high appendicitis, the former often has a history of biliary colic with the right shoulder and back pain; and the latter is characteristic of metastatic abdominal pain. At the time of examination, acute cholecystitis may be positive for Morphy's sign, and even a swollen gallbladder can be seen. The abdominal ultrasonography can show gallbladder enlargement and calculus.

3, acute Meckel diverticulitis: Meckel's diverticulum is a congenital malformation, mainly located at the end of the ileum, its location and the appendix is very close to the diverticulum acute inflammation, the clinical symptoms are very similar to acute appendicitis, difficult to identify before surgery When clinical appendicitis is diagnosed and the appearance of the appendix in the operation is basically normal, the terminal ileum should be carefully examined to 1 m to avoid missing the inflamed diverticulum.

4, right ureteral calculi: ureteral stones can cause lower right abdominal pain when moving down, sometimes confused with appendicitis. However, severe angina is unbearable when the ureteral stone is attacked. The pain is released along the ureter to the genital genital area and the inner thigh. The lower right abdomen tenderness and muscle tension are not obvious. The abdominal plain film can sometimes find urinary stones with positive stones and urine. There are a lot of red blood cells in the routine.

Disease diagnosis:

1. Symptoms: Metastatic right lower abdominal pain is a typical clinical manifestation of acute appendicitis. Because of the visceral transposition of the cecum and appendix in the left lower abdomen, metastatic left lower abdominal pain should also consider the possibility of left appendicitis. The location of the initial pain and the time required for the transfer process vary from person to person, but it should be noted that about 1/3 of the patients start with right lower abdominal pain, especially in the acute attack of chronic appendicitis, so no metastatic right lower abdominal pain can not be completely excluded. The presence of acute appendicitis must be combined with other symptoms and signs.

Others may have gastrointestinal symptoms such as nausea and vomiting. There is no fever in the early stage, and there is obvious fever and other systemic poisoning symptoms when the appendix is purulent or perforated.

2. Physical examination: fixed tenderness in the lower right abdomen and different degrees of peritoneal irritation as its main signs, especially in the early stage of acute appendicitis. When the abdominal pain is not fixed, there is tenderness in the right lower abdomen and perforation of the appendix combined with diffuse peritonitis, despite abdominal tenderness. A wide range, but still the most obvious in the right lower abdomen, sometimes in order to grasp the exact part of tenderness, should be carefully and multiple times to check the whole abdomen. The tenderness of acute appendicitis is always in the lower right abdomen and can be associated with varying degrees of abdominal muscle tension and rebound tenderness.

3. Auxiliary examination: the total number of white blood cells and the number of neutrophils can be mildly or moderately increased, and stool and urine routine can be basically normal. Chest fluoroscopy can rule out misdiagnosis of appendicitis with reduced right chest disease. The presence of free air under the armpit can be used to exclude the presence of other surgical acute abdomen. B-ultrasound examination of the right lower abdomen to understand whether there is inflammatory mass, it is helpful to determine the course of the disease and determine the operation.

4. Young women and married women with a history of menopause should have a gynaecological consultation to rule out ectopic pregnancy and ovarian follicular rupture when they have doubts about the diagnosis of acute appendicitis.

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