Sitkovsky and Kocher symptoms in acute appendicitis: description, causes and consequences

Rovsing's symptom for appendicitis allows the surgeon to quickly and correctly identify acute inflammation of the appendix of the cecum. It can be triggered by blockage of the entrance with feces or a foreign body, infection by pathogens, spasm of the vessels supplying the worm-shaped ending with blood, trauma to the abdominal cavity or weak peristalsis. The pathology can be caused by frequent overeating, parasitic infection, severe stress, bad habits and poor lifestyle.

Causes of appendicitis

There are several causes of appendicitis:

Blockage of the entrance to the vermiform end of the rectum is the most common. This can happen due to the ingress of foreign bodies or feces. Blockage can also occur from compression of the upper part of the appendix by the formation of adhesive processes during enteritis and cholecystitis.
Stagnation of the contents of the appendage. This leads to a weakening of its protective functions, which is why pathogenic bacteria - staphylococci, E. coli, streptococci - begin to actively multiply in the appendix. They cause inflammation.
Spasm of the vessels that supply blood to the appendix.
Trauma to the peritoneum, which may result in displacement or damage to the appendix.
Pregnancy. The process may become displaced due to the growth of the uterus.
Tendency to constipation.
Poor intestinal motility.
Binge eating.
Lack of plant fibers, microelements, vitamins in the diet.
Gastrointestinal diseases.
Hereditary factors.
Infectious diseases.
Presence of parasites.
Bad habits.
Stress.

About diagnosing appendicitis in Russia

Appendicitis is inflammation of the appendix of the rectum. For its initial diagnosis, confirmation or refutation of the diagnosis, doctors in Russia use certain symptoms of peritoneal irritation that have been proven over the years. There are few of them, but they are the reliable “old-timers” in clinical practice. Named after the surname of their author:

Sitkovsky's symptom.
Kocher's sign.
Voskresensky's symptom.
Obraztsov's symptom.
Rovsing's sign.
Shchetkin-Blumberg symptom.

The manifestation of each of them depends on a number of factors: the location of the appendix, the cause of inflammation, the advanced stage of the disease, etc. Let's analyze Sitkovsky's symptom and others in more detail.

Kocher's sign

The surest sign by which acute appendicitis can be identified is Kocher syndrome. There is even an expression among doctors: “Kocher doesn’t lie.” Half of the patients suffering from appendicitis have this particular symptom.

It manifests itself as follows: pain from the epigastric region gradually migrates to the right iliac region. It is determined by collecting an anamnesis, interviewing the patient - clarifying the location of the pain syndrome and its nature.

Sitkovsky's symptom

In case of appendicitis, doctors still overwhelmingly give preference to this symptom. The main reason for this is that it can be quickly and easily verified.

The manipulations are as follows: the patient is asked to lie on his left side and describe his sensations. With this movement, the intestinal loops shift, dragging the inflamed appendage with them. Therefore, a patient with appendicitis will inevitably complain of increased pain.

Voskresensky's symptom

Another name is “shirt symptom.” The sign helps to diagnose not only appendicitis, but also other inflammatory processes of the abdominal cavity. Therefore, in clinical practice it is no less popular than the Sitkovsky symptom.

It is checked as follows: on a slightly stretched shirt, which is put on the patient, quickly run the edge of the palm over several areas in the abdomen. If during these actions the patient feels pain in the right iliac region, then appendicitis can be diagnosed.

Diagnostic nuances

Usually the disease does not cause difficulties in diagnosis. Appendicitis is determined based on its characteristic signs, which include positive symptoms of Rovsing, Sitkovsky, etc.

So, when determining the latter, pain on the right in the iliac region intensifies when the patient lies on his left side. According to Sitkovsky's observations, the increase in pain is due to the fact that the cecum is stretched and its deformation causes pain. The pain is aggravated by the tension of the mesentery of this process.

And Rovsing’s symptom in appendicitis is characterized by the appearance of pain in the right iliac region if the doctor performs jerky palpation in the projection of the lateral canal, in the left part of the abdomen (from left to right).

The following signs are also among the most significant:

Barthomier-Mikhelson's symptom is the appearance of pain on palpation of the cecum if the patient lies on his left side.
Obraztsov's symptom is an increase in pain when applying pressure to the cecum, with a simultaneous attempt to raise the straightened right leg.

Shchetkin-Blumberg symptom

Another sign of peritoneal irritation, not inferior in popularity to Sitkovsky’s symptom. It is considered a reliable test for peritonitis, which is why it is used for all complaints of abdominal pain.

The following actions must be performed: the doctor slowly places his palm on the patient’s anterior abdominal wall and gently, without force, presses. Then he abruptly removes his hand. If the patient felt a sharp pain, then the Shchetkin-Blumberg symptom was confirmed. In the acute form of appendicitis, the patient will feel pain during this in the right iliac region.

Rovsing's symptom

It is quite rarely used in practice, which does not negate its validity, which is why the symptoms of Rovsing and Sitkovsky are constantly mentioned in the literature. It is determined when pain occurs due to the accumulation of gases in the rectum.

The doctor performs the following manipulations: with the patient lying down, it is necessary to squeeze the colon descending colon in the left iliac part of the peritoneum with your hand. Use your right hand to apply push-like pressure slightly higher. If, with such a change in pressure in the intestinal tract, the patient feels pain in the right iliac region, then he is diagnosed with appendicitis.

Detailed consideration of Rovsing's symptom

Rovsing's symptom consists of an increase in the painful condition on the right when pressure is applied to the sigmoid colon (it is located in the left iliac region) and in the manifestation of convulsive spasms above it. When examining the abdominal wall in the left part of the iliac region, press with the fingers of the left hand, brought together, and without taking them away, with the right hand make a short push on the overlying area of the colon. Rovsing's symptom is designed to move gases during a push.

However, in some cases, when examining a patient, it is difficult to make a correct diagnosis, since Rovsing’s symptom may be absent. It is especially difficult to distinguish from the manifestations of the described disease the symptoms of a ruptured abdominal aortic aneurysm, with the spread of blood in the right iliac zone.

Rovsing's symptoms are not used very often, but, by the way, they are considered one of the most reliable for the correct diagnosis of appendicitis.

Obraztsov's symptom

After we have talked about the symptoms of Rovzing, Sitkovsky, Voskresensky, it would not be amiss to talk about Obraztsov’s sign, which helps to identify the retrocecal location of the appendix.

The patient is asked to lie on his back and raise his right leg straight at the knee. At this time, the muscles of the anterior abdominal cavity and lower back tense and begin to affect the receptors of the appendix. If the latter is inflamed, the patient will complain of pain in the right iliac region.

Diagnostic methods

On examination, there is usually soreness in the area of the right lower abdomen, as well as reflex tension of the abdominal muscles during pressure on it. Auxiliary symptoms in diagnosing inflammation of the appendix are:

Bloomberg's sign: pain when pressing on the abdomen.
Rovsing's (Rovsing's) symptom: with the fingers of one hand, the doctor presses on the abdominal wall in the left iliac region (lower left abdomen) in the projection of the descending part of the colon. With the other hand, push-like pressure is applied slightly higher along the projection of the intestine. With a positive Rovsing's symptom, pain appears in the projection of the appendix in the right iliac region - this is due to the movement of gases in the colon and irritation of the receptors of the inflamed appendix.
Yavorsky's symptom: the appearance of growing pain when lowering the leg vertically on the right.
Sitkovsky's symptom: when the patient turns on his left side, pain occurs in the right iliac region due to irritation of the receptors as a result of stretching of the mesentery of the inflamed appendix.

In laboratory studies, evidence of the presence of an acute inflammatory process will be leukocytosis, that is, an increase in the number of leukocytes, ESR and CRP, i.e. inflammation parameters.

On examination, there is usually soreness in the area of the right lower abdomen, as well as reflex tension of the abdominal muscles during pressure on it.

Additional tests that a doctor can use to confirm the diagnosis of appendicitis are visual studies - these are general photos, X-rays of the abdominal cavity, which are used to exclude other acute diseases in the abdominal cavity, and ultrasound of the abdominal cavity.

To distinguish an inflamed appendix from a healthy appendix requires enormous experience of an ultrasound specialist, so this test is rarely used in practice. If, after the examination, the doctor suspects that the patient is developing appendicitis, he will immediately refer him to the surgical department.

Acute appendicitis requires urgent surgical intervention. Delaying surgery can lead to dangerous complications. If left untreated, appendicitis leads to perforation, which manifests as worsening abdominal pain. This is due to the transition of the inflammatory process to the peritoneum, that is, the serous mucosa that lines the walls of the abdominal cavity and pelvis. Diffuse peritonitis occurs, which is a serious disease. If left untreated, it can even lead to the death of the patient.

It should be remembered that an atypically located appendix can cause unusual symptoms of inflammation.

For example, inflammation of the appendix, located in the area of the urinary system, can give symptoms from the bladder - frequent urination in small portions, painful urge to urinate, the presence of white blood cells and red blood cells.

Other symptoms

We examined a number of appendicular symptoms, Sitkovsky's symptom. Let's get acquainted with less common, but existing in medical practice, methods for diagnosing acute inflammation of the appendix:

Barthomier-Michelson's sign. The patient lies on his left side, and the doctor, palpating the right side of the peritoneum, finds a painful spot.
Varlamov's symptom. When tapping in the area of the right XII rib, pain occurs in the characteristic right part of the peritoneum.
Ben-Asher's sign. The doctor presses with the tips of two fingers into the patient’s left hypochondrium. The patient is asked to breathe deeply or cough. If during this manipulation pain occurs in the right iliac region, appendicitis is suspected.
Asaturyan's symptom. The doctor presses the fist of his right hand on the patient’s left iliac region. On the bulging right area, with his free hand, the specialist palpates the cecum to localize the pain.
Bassler's sign. Soreness is determined by pressing between the superior anterior iliac spine and the navel towards the spine of this bone.
Iliescu's sign. Pain in a characteristic area occurs when pressure is applied to the cervical point of the right phrenic nerve.
Brando's sign. Used in diagnosing appendicitis in pregnant women. When pressing on the left rib of the uterus, pain occurs in the right region of the peritoneum.
Zatler's syndrome. The patient in a sitting position is asked to straighten his right leg. If the appendix is inflamed, the patient will feel pain in the right iliac region with this movement.
Cope's sign. When rotating the right hip, the pain in the right iliac zone increases.

Surgery. Crib.

13.01.2012 19620

The main symptoms of acute surgical diseases, most often encountered in the emergency room.

Acute appendicitis

* Kocher's symptom - localization of pain in the first hour in the epigastrium or throughout the abdomen, and subsequently in the right iliac region. *Rovsing's symptom is the appearance of pain in the right iliac region when pushing in the area of the descending colon in the left iliac region. *Voskresensky's symptom is the occurrence of pain when the hand slides from the epigastrium to the right iliac region. * Sitkovsky's symptom - increased pain when the patient is positioned on the left side. * Bortomier-Michelson's symptom - increased pain upon palpation of the right iliac region with the patient positioned on the left side. * Obraztsov’s symptom – upon palpation in the right iliac region with the patient in the supine position, the pain intensifies when the patient raises his straightened right leg. * Cope's symptom - increased pain in the right iliac region with rotational movements of the right leg. * Dumbadze's symptom - increased pain in the right iliac region upon palpation of the umbilical ring.

Acute cholecystitis

* Grekov-Ortner symptom – pain when tapping the edge of the palm along the right costal arch. * Zakharyin's symptom - pain when tapping or pressing on the area of the gallbladder projection. * Obraztsov’s symptom – sharp pain when inserting the hand into the area of the right hypochondrium. * Kerr's symptom - pain when inhaling during palpation of the right hypochondrium. * Murphy's sign - examined with the patient lying on his back. The left hand is placed so that the thumb is placed in the area of the projection of the gallbladder, and the hand is placed along the edge of the costal arch. The patient is asked to take a deep breath, but the patient cannot do this due to a sharp increase in pain. * Mussi's symptom - pain when pressing with a finger above the collarbone between the front legs of the m.sternocleidomast.

Strangulated abdominal hernia

* Valya's symptom - a swollen loop of intestine with high tympanitis above it is palpated above the site of the obstruction. * Symptom of the Obukhov Hospital - the ampulla of the rectum is empty, the anus is gaping (characteristic of volvulus, nodulation of the sigmoid colon) * Symptom of Tsege-Mantsifel - when the sigmoid colon is strangulated, it is possible to administer no more than 0.5-1 liter of liquid with an enema.

Acute pancreatitis

* Halsted's sign - cyanosis of the skin of the abdomen. * Mondor's symptom - marbled purple spots on the skin of the body. * Gruivalle's symptom - sharp cyanosis of the navel. * Gobier's sign - tympanitis in the epigastric region along the transverse colon. *Voskresensky’s symptom is the absence of pulsation of the abdominal aorta in the epigastrium. *Mayo-Robson symptom – pain when pressing in the area of the left costovertebral angle. *Hubergritz's symptom is pain when pressing 6 cm up and to the left of the navel. *Desjardins' sign is pain when pressing 6 cm up and to the right of the navel.

Perforated ulcer

*Dieulafoy's symptom is sharp, “dagger” pain in the epigastric region. *Chuguev’s symptom is a transverse fold of skin at or above the navel. *Grekov’s symptom – bradycardia in the first hours after perforation . *Spizharsky's symptom - upon percussion - high tympanitis in the epigastric region and dullness in the lateral abdomen. *Clark's symptom is the disappearance of liver dullness or a decrease in its size as a result of gas entering the abdominal cavity. *Gustin's symptom - listening to heart sounds up to the level of the navel. *Kulenkampf's symptom - digital examination per rectum reveals overhang of the anterior wall of the rectum, sharp pain in the pouch of Douglas.

Acute gastrointestinal bleeding

*Bergmann's symptom is the disappearance of pain following the onset of bleeding (with a peptic ulcer). *M. lori-Weiss symptom – acutely occurring longitudinal ruptures of the gastric mucosa with transition to the esophagus with damage to the submucosal choroid plexus).

Renal colic

*Lorin-Epstein symptom - when pulling the testicle, increased pain is noted. *Symptom of tapping - pain occurs or intensifies when short blows are applied to the lumbar region in the projection of the kidneys. *Lloyd's symptom - upon percussion in the area of the projection of the kidney, pain is noted in the thigh.

Consequences of acute appendicitis

Complications of appendicitis are divided into two groups:

Preoperative. Their reasons: The patient delayed seeking medical help.
The attending physician made the wrong diagnosis.
The operation was carried out with errors.
Inflammation gave rise to new diseases or the development of chronic ones.

Postoperative. Their reasons:

Failure to follow doctor's recommendations after surgery.

Inflammation of the surgical wound.

Inflammation of nearby organs, peritoneum.

Thus, appendicitis is not the most dangerous inflammatory process that can be easily eliminated surgically. The following complications are scary:

Perforation is an early type of complication that develops in conjunction with peritonitis. It is characterized as purulent melting of the walls of the appendix and the outpouring of pus into the abdominal cavity.
Appendiceal infiltrate - develops in patients who seek help late. This is the spread of inflammation from the appendage to neighboring organs.
Appendiceal abscess is a rare form of complication. This is a purulent inflammation in the right iliac region, between the intestinal loops, under the diaphragm, in the retroperitoneal space.
Pylephlebitis is a severe purulent-septic inflammation of the portal vein of the liver, in which many abscesses form. Dangerous and fatal.
Peritonitis is inflammation of the peritoneum.
Intestinal fistulas are a consequence of errors during surgery. This is an accidental lesion of the intestinal loops during removal of the appendix.

We looked at what disease the symptom of Sitkovsky, Obraztsov, Voskresensky, etc. is observed. As you have seen, with the help of these diagnostics you can easily and quickly determine appendicitis in a patient.

Therapeutic measures

The operation to cut out an appendix is called an appendectomy. It is performed using an abdominal incision.

Currently, appendectomy is increasingly performed using laparoscopy. This is a method in which the surgeon makes 3 small incisions in the abdominal cavity, they serve to insert instruments - tips, a laparoscope inside. One of these tips has a camera that shows the surgical field on a monitor. This allows the surgeon to manipulate the tips of the laparoscope. The advantage of laparoscopic surgery is that the patient has a shorter recovery time and can return to full activity more quickly.

The only exception in which rapid surgical intervention is abandoned is infiltration - the so-called limited peritonitis, felt as a painful swelling in the right lower abdomen - since there is a high risk of infection spreading into the abdominal cavity during surgery. In this case, antibiotics and ultrasound-guided drainage of the infiltrate are used in treatment.

Currently, appendectomy is increasingly performed using laparoscopy.