In elderly and senile patients, the disease is characterized by a predominance of destructive forms. This is due, on the one hand, to reduced reactivity of the body, and on the other, to atherosclerotic vascular damage, which becomes the direct cause of rapid disruption of blood supply with the development of necrosis and gangrene of the appendix. It is in elderly people that the so-called primary gangrenous appendicitis occurs, which develops immediately, bypassing the stage of catarrhal and phlegmonous inflammation.
The symptom complex of acute appendicitis in patients in this group often has a blurred picture. Due to physiological increase threshold pain sensitivity patients often do not pay attention to the epigastric phase of abdominal pain at the onset of the disease. Nausea and vomiting occur more often; stool retention is not critical, since old age there is a tendency for delayed bowel movements.
Examination of the abdomen reveals only moderate tenderness in the right iliac region even with destructive forms of appendicitis. Due to age-related muscle relaxation abdominal wall muscle tension in the lesion is insignificant, but the Shchetkin-Blumberg symptom is usually pronounced. Voskresensky and Sitkovsky symptoms are often positive.
Body temperature, even with destructive appendicitis, increases moderately or remains normal. The number of leukocytes is normal or slightly increased - within 10-12-109/l, the neutrophil shift in the blood count is not pronounced.
In elderly and senile people, appendiceal infiltration, characterized by slow development, occurs much more often. Patients often notice a tumor-like formation in the right iliac region a few days after an attack of mild pain, which forces them to pay special attention to the differential diagnosis between appendiceal infiltrate and cecal tumor.
The peculiarity of the course of acute appendicitis in the elderly leads to the fact that accurate recognition of one or another clinical form acute appendicitis before surgery is difficult. This indicates the need for active surgical tactics, especially since the risk of appendectomy in old age is often exaggerated. When choosing a method of pain relief, preference is given to local anesthesia, especially in patients with concomitant diseases respiratory and cardiovascular systems.
Managing the postoperative period in elderly patients is no less important than the operation itself. Dynamic control required functional state critical systems body. The main activities should be aimed at the prevention and treatment of respiratory and circulatory disorders, metabolic changes and renal failure. Should be paid special attention for prevention infectious complications and TELA.
Savelyev V.S.
Surgical diseases
In elderly people, acute appendicitis is diagnosed quite rarely. This is due to the fact that the worm-like organ undergoes obliteration (grows connective tissue), follicles atrophy, which often cause blockage of the opening between the appendage and the intestine. On the other hand, these changes change the course of the inflammatory process, and appendicitis can develop almost asymptomatically, which is fraught with dangerous complications.
Causes of complications and unfavorable outcome intestinal inflammation in older people:
Rehabilitation after appendicitis lasts about two months, during which the patient must adhere to certain restrictions. Its duration depends on general condition the patient’s health, his age and the presence of complications before or after surgery.
At the end of the operation, the patient is transported on a gurney to the ward, where he will be under close supervision of medical staff to monitor the process of recovery from anesthesia. In order to prevent suffocation if vomiting occurs, which may be caused by side effect drug, the patient is turned on his healthy side. If there are no complications, then 8 hours after the operation the patient can sit up in bed and make careful movements. After appendicitis is removed, injectable painkillers are prescribed for several days, as well as antibiotics to prevent infectious complications. If you follow all the doctor's recommendations, recovery after appendicitis surgery usually occurs without complications. The first day is the most difficult for the patient. The time spent in hospital, as a rule, does not exceed 10 days. During this period the following is carried out:
When removing appendicitis postoperative period, namely its duration, severity and the presence of complications, largely depends on the chosen method surgical intervention(laparoscopy or abdominal surgery).
Rehabilitation after appendicitis includes following a certain diet for at least two weeks. On the first postoperative day you cannot eat; you are only allowed to drink plain and mineral water without gas or kefir with 0% fat content. On the second day, you need to start eating to restore the gastrointestinal tract. You should eat foods that do not cause bloating and a feeling of heaviness in the intestines. The diet should be fractional: it is recommended to eat food in small portions, divided into 5 or 6 meals.
For the first three days after surgery, you need to take easily digestible food with a jelly-like or liquid consistency. Allowed to use following products:
On the fourth day you can add black or bran bread, baked apples, puree soups with dill and parsley, hard porridges, boiled meat and lean fish. With each subsequent day, it will be possible to expand the list of products more and more, gradually returning to the patient’s usual diet. The diet used should be in mandatory agreed with the attending physician. Despite some restrictions, a complete diet rich in vitamins and minerals is necessary, since during the rehabilitation period the body needs additional support. Drinks allowed include rosehip decoction, freshly squeezed diluted juices, compotes, mineral water flat, herbal or weak black tea. The amount of liquid consumed per day should total 1.5-2 liters.
When discharged from the hospital, for another 14 days of the postoperative period after removal of appendicitis, it is not allowed to consume foods that lead to irritation of the mucous membrane, the formation of gases and fermentation processes in the intestines. First of all, the purpose of such a diet is to prevent rupture internal seams and reducing the food load on the body. It is necessary to adhere to the following rules: limit the amount of salt; do not add spices and seasonings when cooking, as well as ketchup and mayonnaise; exclude legumes from the diet; refuse sweets bakery products; avoid eating vegetables such as tomatoes, peppers, cabbage and raw onions; completely eliminate smoked meats, sausages, fatty meats and fish. During the postoperative period, it is also not allowed to drink carbonated drinks, juices from grapes and cabbage, and any drinks containing alcohol.
During the rehabilitation process after appendicitis removal, it is necessary to adhere to certain restrictions on physical activity. This will speed up recovery and minimize risk possible complications. You are allowed to get out of bed and start walking three days after the operation. At first recovery period It is recommended to use a support bandage, especially for overweight patients.
A sedentary lifestyle during the rehabilitation process is no less dangerous than a high physical activity. It can cause the formation of adhesions, poor circulation, or the development of muscle atrophy. In this regard, almost immediately after the operation, in agreement with the doctor in supine position It is recommended to perform a special complex of exercise therapy.
In the first two months physical activity should be limited to daily walking And therapeutic exercises. During this period, it is prohibited to carry or lift weights weighing more than 3 kg. After 14 days after surgery, if there are no contraindications, it is allowed to resume sex life. When it heals completely postoperative scar, a visit to the pool is recommended.
Thus, as a result of studying theoretical materials, we have learned that the problem of acute appendicitis has been of keen interest for more than 100 years, but a disease that has been known for such a long time and is so widespread, despite great progress in its study and treatment results, has not yet been fully deciphered. Thus, the exact etiology is still unknown, prevention of appendicitis has not been developed, and among acute surgical diseases organs abdominal cavity appendicitis still ranks first in frequency.
It should also be noted that the features of the course of acute appendicitis, late appeal, imperfection existing methods diagnostics that cause difficulties in carrying out differential diagnosis and untimely surgical intervention determines a high incidence of complications.
Of course, postoperative complications more often occur with destructive forms of appendicitis. An important role V successful treatment and rehabilitation, the nursing process that is properly organized for appendicitis plays a role.
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Elderly people suffer from appendicitis relatively less often than young people. According to data from our hospital [Platonova O.N., 1974], among 10,700 patients operated on for acute appendicitis, only 981 people (9.1%) were over 60 years old. Other authors report approximately the same figures. The lower incidence of appendicitis in older people is usually explained by the fact that in old age the appendix often significantly atrophies, decreases in length, and its canal becomes short. In some patients, due to previous attacks of acute appendicitis, the appendix may generally represent a scar cord, completely devoid of lumen. In addition, it should be taken into account that the appendage in a significant proportion of elderly people has already been removed at one time. All this, apparently, is the reason for the lower incidence of appendicitis in older people. And this reduction in the number of diseases is quite significant. According to statistics, in Leningrad in 1972 the number of residents over 60 years of age was 14.9%, and among those operated on for appendicitis, this category of people, according to our data, amounted to only 9.1%. If we take into account that children under 14 years of age, in fact, are not admitted to our hospital at all, for a more accurate idea of the actual ratio of the number of elderly people to the number of all those operated on, the figure of 9.1% needs to be significantly reduced. In general, we must assume that people over 60 years of age get appendicitis two to three times less often than younger people.
Clinical manifestations of appendicitis in old people can be very pronounced and may not differ in any way from the manifestations of the disease in young people, completely falling within the framework of the clinical picture outlined above with all its possible features, depending on the location of the cecum, etc. However, often in old people There is a significant uniqueness in the manifestations of the disease (more than 20% according to A. N. Shabanov and R. V. Chitaeva, 1975).
Despite the fact that at the age of over 50-60 years with appendicitis, severe changes in the appendix are very often observed, clinical manifestations in individuals in this category they are usually mild in severity. Patients' complaints are often very mild. Body temperature remains normal or increases very slightly, pulse rate does not increase. Often there may be no abdominal muscle tension at all or only some resistance in the right iliac fossa. Pain, both spontaneous and occurring upon palpation, is rarely severe. Even with the development of peritonitis, pain may be insignificant, and tension in the abdominal wall, especially when it is flabby, as happens in elderly women who have given birth many times, may be completely absent.
In general, the disease here is so erased that many go to the doctor very late, often already when the infiltrate is clearly palpable in the abdominal cavity. The detection of such an infiltrate, with a low severity of the initial phenomena, often suggests the presence of a neoplasm, since a dense and tuberous tumor palpable in the right iliac region may be very slightly painful, any phenomena of peritoneal irritation may not be detected and general reaction body, characteristic of the inflammatory process, is expressed very little. Sometimes the only sign that allows you to find out inflammatory nature process are the immobility of the palpable formation and known changes in its size, if they can be traced over several days. The issue in such patients can be resolved with X-ray examination cecum. The formation of infiltrates in old age is observed very often, and a significant part of them contains a more or less abundant accumulation of pus. By the way, even then the clinical manifestations of the abscess are also very insignificant.
A 67-year-old woman was admitted to the clinic with a tumor of the cecum. Complaints about dull pain in the right iliac region, increased body temperature, reaching 37.5-37.8 ° C in the evenings. She fell ill about 2 weeks ago. At first my stomach started to ache, I felt a little nauseous, and became constipated. On the third day the temperature increased. After the enema, I had stool, but did not feel a sufficient bowel movement. The phenomena gradually increased. From time to time, bloating began to appear. At the same time, the patient began to notice mild cramping pain in the left half of her abdomen. By the end of the second week I felt myself painful lump in the right iliac region.
On admission: the patient was somewhat low nutrition, looks appropriate for her age. She walked from the ambulance to the emergency department on her own. She is active in bed - sits up and turns around without assistance. The tongue is covered with a white coating and is moist. Pulse 90 beats per minute, satisfactory filling and tension, temperature 37.6°C. Leukocytosis, slight shift to the left. The abdomen is flabby, participates in breathing, the skin is in numerous folds, and individual slightly swollen loops of intestines are visible through the integument. With the eye it is possible to identify some tumor-like protrusion in the right iliac region, motionless during breathing, which is especially noticeable in connection with breathing movement intestinal loops located on the left. When examined by hand, the left half of the abdomen is soft and painless. On the right, corresponding to the visible protrusion, a dense and lumpy fixed formation is determined adjacent to the lateral wall of the abdomen at the upper anterior spine ilium. Its palpation is painful, and upon percussion there is dullness over it. An X-ray examination with a contrast enema did not reveal any changes in the cecum; the palpable formation is located outside it, but is not separable from the cecum.
The diagnosis is appendicular abscess. Due to the increase in symptoms, the abscess was opened the next day. About 100 ml of thick, foul-smelling pus was released. The gangrenous vermiform appendix immediately adjacent to the abdominal wound was removed.
Smooth recovery.
In old age, as a result of extensive formation of adhesions around the circumference of the inflammatory focus, intestinal obstruction easily develops, which can dominate the entire picture of the disease and lead to an incorrect diagnosis, which is often discovered only on the operating table.
Acute appendicitis poses a serious danger in old age and develops in a destructive form much more often than in young people. Diagnosis is difficult due to a decrease in the overall reactivity of the body and the lack of obviousness of symptoms.
Appendicitis in the elderly initial stages may be almost asymptomatic. Common signs of appendicitis include following symptoms: sharp pain, a sharp increase in temperature, a “tight” stomach.
Painful symptoms. Acute appendicitis is a severe inflammation characterized by acute cutting pain and high temperature. But in old age, among older people, high temperature, which is one of the signs acute inflammation, observed in only 10% of patients.
50% have low-grade fever, characteristic of chronic diseases, tonsillitis, pyelonephritis, tuberculosis and other long-term inflammations.
Pain symptoms are mild. At the same time, the development of the inflammatory process in the appendix does not slow down. The disease does not become less dangerous or sluggish due to insufficiently obvious symptoms.
Muscular protection, which is usually expressed in muscle tension in the anterior abdominal wall, is absent in most cases. The abdomen can be easily palpated, without characteristic muscle tension. It is difficult to diagnose pain during palpation as acute appendicitis.
Quite often in old people the source of pain is displaced from the right iliac region. An indistinct focus and even a displacement of the focus to the lumbar region is possible, which suggests renal or intestinal colic.
In acute appendicitis, nausea or vomiting, stool retention, and dry tongue are added to the usual symptoms in older people.
A blood test may not reveal an increase in the number of leukocytes; changes in the composition of the blood occur with a delay of 2-3 days. Also not detected in urine characteristic features inflammatory disease.
Necrotic changes in the appendix in old people often cover the entire appendix; the likelihood of peritonitis in old age is significantly increased.
Based on a superficial examination, acute appendicitis in elderly patients is difficult to diagnose. Required urgent hospitalization and diagnostics using medical technology.
It is the problem of accurate diagnosis and the presence of complications, concomitant or chronic inflammatory diseases, makes acute appendicitis especially dangerous in old age.
Refusal to hospitalize if acute appendicitis is suspected is deadly. The operation must be carried out as quickly as possible.
Acute appendicitis in old age is often complicated by appendiceal infiltrate, an inflammatory dense formation, often with abscesses surrounding the appendix. The presence of infiltrate complicates the postoperative period and requires additional examinations. Additional administration of antibiotics is necessary until the infiltrate is completely resolved.
In some cases it is observed complete atrophy and necrotic changes in the entire appendix as a whole. In these cases, the inflammation is extensive.
Treatment requires urgent surgical intervention. Due to the frequent presence of complications and widespread inflammatory processes, the operation is best performed by experienced surgeons.
In case of peritonitis spillage and complicated factors, mask anesthesia is required. Correct definition type of anesthesia for older people is important factor successful operation.
The postoperative period is characterized high danger bedsores, possible intestinal paresis, development of pneumonia. Individual intolerance to antibiotics is possible, the use of which is especially indicated for purulent inflammation.
Intestinal bloating is often observed, increased gas formation. As a result of displacement of the diaphragm, pulmonary inflammation and heart failure develop.
Good care is required, constant monitoring is recommended, special gentle treatment is recommended. breathing exercises, promoting the restoration of the body.
The recovery period and patient care in the hospital and at home is the most important condition recovery.
