Right lower quadrant tenderness

Introduction Right lower quadrant tenderness is one of the symptoms of acute appendicitis. Acute appendicitis is the first place in various surgical acute diseases. Usually pay attention not to eat too fatty, to avoid over-stimulation. Should actively participate in physical exercise, enhance physical fitness and improve immunity. If you have a history of chronic appendicitis, you should pay attention to avoid recurrence, and usually keep the stool smooth. Enhance physical fitness and pay attention to hygiene. Be careful not to suffer from cold and diet. Timely treatment of constipation and intestinal parasites.

Cause

The cause of tenderness in the lower right abdomen:

1. Iris obstruction in the appendix: The anatomical features of the appendix, such as the narrow lumen, the abundant lymphatic tissue in the narrow wall of the opening, the short film of the meridian, 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 residues, fecal matter foreign bodies, mites, tumors, etc. often cause lumen obstruction of the lumen, and 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 the occurrence of obstruction and inflammation of the appendix, mucosal ulcers, epithelial damage in the lumen of the bacteria can not be discharged and opportunistic breeding growth, invading the wall, so that the infection exacerbates the pathogenic bacteria mostly in the gut of various Gram-negative bacilli And anaerobic bacteria.

Although acute appendicitis often manifests as a purulent 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 penetrate into the abdominal cavity, the artery is also blocked, causing necrosis of part or even the entire appendix.

Most of the sites of the appendix obstruction in the appendix are also in the middle and distal segments of the appendix. The causes of obstruction are:

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 lymph nodes 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, 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.

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 percussion fiber colonoscopy

Examination and diagnosis of tenderness in the right lower quadrant:

1. Symptoms: Metastatic right lower abdominal pain is a typical clinical manifestation of acute appendicitis. When the visceral transposition cecum and appendix are located 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: right lower abdomen fixed tenderness and different degrees of peritoneal irritation as its main signs, especially in acute appendicitis early self-conscious abdominal pain has not been fixed, the right lower abdomen has tenderness and appendix perforation 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 neutrophils can be mild or moderate increase, 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.

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. There are signs of jaundice in portal venous inflammation: 1 Forced position: Patients often walk over when they come to the clinic, and often press their 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 inflation test (Rovsing test): with one hand press the left lower abdomen descending colon, and then repeatedly compress the proximal colon with another hand, the gas in the colon can be transmitted to the cecum and appendix The right lower quadrant was 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

Identification of symptoms that are easily confused in the right lower quadrant:

One side of the lower abdomen pain: should be considered for the side of the uterine attachment lesions such as ovarian cyst pedicle torsion.

Lower abdominal pain: refers to the feeling of pain and swelling. It is a characteristic of qi stagnation. Lower abdominal pain is common in menstrual menstruation and various digestive diseases.

Lower abdominal rebound pain: is a sign of inflammation of the peritoneal wall layer, more common in the intra-abdominal organ lesions involving the adjacent peritoneum and primary peritonitis.

Abdominal tenderness: The pain that occurs when the abdominal tenderness is pressed from the shallow to the deep.

Lower abdominal cramps: It is often caused by the strong peristaltic contraction of the muscles of the abdominal tube-like organs without the will of the person. Under normal circumstances, the pipe-like organs in the human body are constantly squirming. For example, the stomach is constantly moving and contracting to digest food, pushing the chyme into the small intestine, the small intestine is constantly squirming, absorbing nutrients and moisture, and allowing intestinal contents to the large intestine. Pushing, the large intestine is also constantly moving while absorbing moisture and excreting waste; the gallbladder and bile duct are also creeping and contracting, storing and secreting bile according to the needs of the human body. Under normal circumstances, peristaltic contraction does not cause abdominal pain, however, If you want to overcome the obstruction in the pipeline, it is necessary to strengthen the contraction, and the strong and severe contraction will cause abdominal cramps. Organs capable of producing abdominal cramps include the stomach and intestine (including the appendix), the cystic duct, the hepatic duct, the common bile duct, the pancreatic duct, the ureter, the uterus or the fallopian tube, and the kidney.

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