40. Acute appendicitis. Clinic. Action tactics
Acute appendicitis is a nonspecific inflammatory process in the appendix.
Etiology and pathogenesis.
The development of appendicitis usually involves polymicrobial flora characteristic of the contents of a healthy intestine (Escherichia coli, streptococci, staphylococci). This is the microbial factor that is always present here.
There is an enterogenous theory, when the occurrence of appendicitis is associated with infection of the appendix from the lumen of the cecum.
The vermiform appendix is a cavity organ that produces mucus in its lumen and removes its contents. It is known that if an obstacle arises in the path of organ excretion, the infection very quickly, easily and freely begins to develop there, its virulence increases, resulting in inflammation of the organ.
Clinical classification of appendicitis
(M.I. Kuzin et al.).
I. Acute appendicitis
1) simple (catarrhal, superficial) appendicitis;
2) destructive appendicitis:
a) phlegmonous,
b) empyema of the process,
c) gangrenous,
d) perforated (perforated),
3) complicated appendicitis:
Appendicular infiltrate,
Abscessed appendicular infiltrate,
Periappendicular abscess,
Local, diffuse, diffuse peritonitis,
Peritoneal sepsis,
Pylephlebitis.
II. Chronic appendicitis (periappendicular adhesions).
III. Appendicular carcinoid is a benign epithelial tumor at the apex of the appendix; removed along with the shoot with a favorable outcome.
Clinical picture and diagnosis of acute appendicitis.
Symptoms of acute appendicitis can be divided into two groups:
1. Subjective signs - complaints and anamnestic signs.
2. Objective signs - pulse, body temperature, provoked pain, skin hyperesthesia, muscle protection, symptoms of peritoneal irritation, rectal and vaginal examination data, clinical blood and urine tests.
1. Simple (catarrhal ) appendicitis - there is moderate swelling and hyperemia of the serous membrane and its mesentery. The mucous membrane is swollen, hyperemic, loose, and there may be areas of epithelial destruction. There may be a clear, odorless serous effusion (inflammatory exudate) periappendicularly.
2. Phlegmonous appendicitis - the appendix is sharply thickened and tense, its serous membrane is hyperemic and covered fibrinous plaque. There is pus in the cavity of the appendix. There is leukocyte infiltration of the walls of the appendix, and there are ulcerations on the mucous membrane. Serous or purulent exudate is observed near the process abdominal cavity.
3. Gangrenous appendicitis - a serous or purulent effusion with an unpleasant odor is found in the abdominal cavity. The process is dirty gray in color; there are areas of necrosis of the wall of the process, rarely the entire process. Necrosis of the mucous membrane is more common in the distal sections. The peritoneum next to the process has hemorrhages and is covered with fibrin. Morphologically, ischemia of the mucous membrane, muscular layer, serous membrane, small abscesses, point necrosis, thrombosis of mesenteric vessels is determined. It is in this form that perforation of the process wall and the occurrence of local peritonitis are observed.
For the occurrence of gangrene of the appendix, a preliminary stage of phlegmonous inflammation is not necessary; with thrombosis of the mesenteric vessels or their prolonged spasm of coins, primary gangrene of the appendix immediately develops.
4. Perforated appendicitis - 2-3 days after an attack of acute appendicitis, purulent melting of the wall of the appendix or necrosis of a section of the wall with its perforation may be observed, in which the contents of the appendix are poured into the abdominal cavity, which leads to local, diffuse or diffuse peritonitis. In this case, a through defect is always found in the wall of the process.
Clinic
Symptoms of acute appendicitis can be divided into two groups:
1) subjective signs (complaints and anamnestic signs),
2) objective signs.
Objective signs include: pulse (the pulse quickens in parallel with the increase in temperature. A pulse of 120 per minute at a temperature of more than 38 ○ C indicates complications that have already occurred. The presence of scissors - the temperature decreases and the pulse quickens - more often indicates already developed peritonitis.), body temperature, provoked pain (felt by the patient in the navel area, in the epigastric region - Kocher-Volkovich symptom, and then gradually the pain moves down and to the right and over time (sometimes after a few hours) is limited to the area of the cecum and appendix, i.e. predominantly concentrating in the right iliac region.
In children is more severe than in adults. The pain is cramping in nature, repeated vomiting and diarrhea are observed. Characterized by high body temperature up to 39 - 40 ○ C. Leukocytosis is usually high. In children, non-localized, widespread forms of peritonitis of appendicular origin are much more common.
In old people, the clinic of acute appendicitis assumes a mild course due to weakened reactivity of the body. All this causes late admission of the patient to the hospital, and subsequently a large number of complications.
Acute appendicitis in pregnant women the second half of pregnancy is very dangerous. An enlarged uterus, displacing the abdominal organs, can change the usual location of pain. Due to severe stretching of the abdominal muscles, there may be no symptom of protective muscle tension. But the Shchetkin-Blumberg symptom is very clearly defined.
It is better to examine a pregnant woman on her left side; blood tests may show high leukocytosis and fever. All pregnant women with acute appendicitis must undergo urgent surgery at any stage of pregnancy.
Diagnostics
Symptoms of provoked pain acute appendicitis:
Superficial palpation.
Deep palpation
Checking symptoms: Voskresensky's symptom, Mendel's symptom - Razdolsky's symptom, Rovsing's symptom, Sitkovsky's symptom, Bartomier-Michelson's symptom, Obraztsov's symptom, Krymov's symptom, Britten's symptom. Shchetkin-Blumberg symptom.
Muscular protection of the abdominal wall is the most important sign found in acute appendicitis.
Laboratory and instrumental studies
Differential diagnosis of acute appendicitis
In differential diagnosis, the most specific signs of a particular disease should be taken into account:
Perforated gastric ulcer. The following characteristic features are taken into account:
Acute cholecystitis.
Acute pancreatitis.
Crohn's disease, Meckel's diverticulum.
Acute intestinal obstruction.
Acute adnexitis.
Interrupted ectopic pregnancy.
Renal colic.
Mesadenitis (inflammation of the lymph nodes of the mesentery of the small intestine).
Surgical treatment of acute appendicitis is indicated at any age.
An oblique Volkovich-Dyakonov incision at the McBurney point or a Lenander pararectal incision is used. If there is uncertainty in the diagnosis, a midline laparotomy is often used.
Infectious complications of appendectomy.
According to the literature, various complications in the postoperative period develop in 20.3% of patients with acute appendicitis, of which 13.8% have complications of a purulent-septic nature. The main infectious complications were the following:
infiltration or abscess of the right iliac region;
abdominal abscesses of other localization (interloop, pelvis, subdiaphragmatic, etc.);
phlegmon of the retroperitoneum;
purulent thrombophlebitis of the veins of the portal system /pylephlebitis/.
Significant variability and originality clinical manifestations for acute appendicitis are caused by the presence of numerous variants and forms of the disease, which depend on the stage and duration of the inflammatory process, the topography of the appendix, its morphological changes, as well as complications. The main symptom of acute appendicitis is pain. It occurs suddenly, is permanent and can be localized in various departments belly. Most often it begins in the right iliac region without characteristic irradiation. In approximately 50% of patients, pain first appears in the epigastric (Kocher's sign) or peri-umbilical (Kümmel's sign) area and after 3-8 hours moves to the right iliac fossa. Much less often, the pain spreads throughout the abdomen, which most often indicates a rapidly ongoing form of acute appendicitis. Sometimes the pain can be atypical, which is associated with anatomical variations of the appendix. With pelvic localization, pain is noted above the womb and in the depths of the pelvis, with retrocecal localization - in the right lateral flank of the abdomen or lower back, often radiating to the right thigh. The subhepatic location is characterized by pain in the right hypochondrium. With retroileal localization, they spread along the right ureter and extend into the testicle in men and the labia in women. Sometimes, against the background of a developing clinical picture, abdominal pain may subside, which is more often observed in gangrenous forms and is associated with the death of nerve receptors. A sudden, rapid increase in pain often indicates a perforation of the appendix. The second most common symptom, observed in almost 3/4 of patients, is vomiting. Like a shadow, it follows the pain; it is often one-time, less often repeated, and is almost always accompanied by nausea.
It is believed that vomiting is reflexive in nature and is caused by local inflammation of the peritoneum. Secondary signs of acute appendicitis include loss of appetite and bowel dysfunction. Upon objective examination in initial stage disease disorders general condition the patient are expressed insignificantly or absent, but usually increase with the progression of inflammation or the development of complications. Body temperature can be normal, but more often it is elevated to 37-38°C. Chills are rare and indicate the severity of the process. The pulse is slightly increased. The appearance of tachycardia is observed with increasing intoxication and temperature, which is usually associated with destruction of the appendix or the onset of peritonitis. In acute appendicitis, the pulse rate depends on temperature. The resulting dissociation between them (tachycardia at low temperatures or bradycardia at high temperatures) is an indicator of severity pathological process. Skin in most cases the usual color. The tongue is covered with a white coating, moist, becomes dry with local or diffuse peritonitis. Patients with acute appendicitis usually do not take a forced position, do not rush about, but lie calmly on their back or right side. Examination of the abdomen may reveal limited mobility abdominal wall in the right iliac region, which most often occurs with phlegmonous and gangrenous appendicitis.
From laboratory research highest value have general tests blood and urine. Most patients have leukocytosis, the degree of which depends on pathological changes in the vermiform appendix. Simple forms characterized mostly by moderate numbers - 8*109-10*109/l (8000-10000); with destructive appendicitis or complications, leukocytosis reaches 14-109-20-109/l (14000-20000). Shift leukocyte formula to the left reflects the depth of the inflammatory process. In approximately 4% of patients with acute appendicitis, leukocytosis and a shift to the left remain within normal limits. Low leukocytosis in combination with a significant shift to the left indicates severe inflammatory process. Deviations in urine composition from the norm (mild albuminuria, microhematuria and pyuria) are observed relatively rarely. They can occur with a talon or retrocecal location of the appendix due to the spread of inflammation to the organs urinary system, as well as toxic origin. To exclude urological pathology in this case, urgent additional research (plain radiography urine system, chromoinstoscopy, etc.). X-ray examination in acute appendicitis, it contributes little to diagnosis, especially in the initial stages.
Acute appendicitis in children It occurs at any age, but newborns and children under 2 years of age are rarely affected. In subsequent years of life, the incidence of acute appendicitis increases and reaches a maximum in the period from 9 to 12 years. Features of the course of acute appendicitis in children are due to the reduced resistance of the peritoneum to infection, small in size omentum, as well as increased reactivity child's body. In this regard, acute appendicitis is more severe, the disease develops faster than in adults, with a large percentage of destructive and perforated forms. U infants often noted atypical course with the onset of sudden abdominal pain, high temperature, vomiting, sometimes diarrhea. Intoxication, tachycardia, discrepancy between pulse and temperature, and water-electrolyte imbalance rapidly increase. In severe cases, the phenomena of meningism are sometimes observed. Palpation of the abdomen is painful (especially in the right half); the child reacts violently, behaves restlessly, cries, and sometimes bends the right yoga. It should be noted that the examination of young children is complicated by the fact that they do not localize pain well and this often complicates topical diagnosis. With a retroiscal location of the appendix, pain is determined by palpating the lumbar region. If it is possible to examine the abdomen, then muscle protection is often determined in the right iliac region, which has a large diagnostic value. In many cases, positive Bloomberg-Shchetkin symptoms are determined. Razdolsky, Kraspobaev, tension of the rectus abdominis muscle, etc. The clinical picture of acute appendicitis in older children is not much different from the course of this disease in adults.
Clinical picture of acute appendicitis in elderly and old age has a number of features. They are caused by reduced physiological reserves, decreased reactivity of the body and the presence of various concomitant diseases. The disease does not begin as acutely as in young people; the pain is less pronounced, often diffuse, even in destructive forms. Vomiting, bloating with difficulty passing stool and gases are often observed. In some cases, tension in the abdominal muscles is minimal or absent. Pain symptoms, characteristic of acute appendicitis, are not clearly expressed, and sometimes may not be detected. General reaction inflammation is weakened. A rise in temperature to 38°C or higher is observed in a small number of patients. On the part of white blood, moderate leukocytosis is noted, but often there is a shift in the leukocyte formula to the left. Only a targeted and careful examination of elderly patients, taking into account the uniqueness and great variability of the course of acute appendicitis, is the key to timely and correct recognition of this pathology.
Acute appendicitis in pregnant women. In the first 1-6 months of pregnancy clinical picture Acute appendicitis has a normal course, and its diagnosis does not cause any particular difficulties. However, from 4 to 6 months, the enlarged uterus rises and pushes up the cecum and vermiform appendix, impairs their nutrition and normal function. The disease often begins suddenly with the appearance acute pain in the abdomen, of a constant nature, nausea, vomiting. Due to changes in the localization of the appendix, pain in the abdomen can be detected not only in the right iliac region, but also in the right lateral flank of the abdomen, the right hypochondrium and even in the epigastric region. Muscle tension cannot always be detected, especially in the last third of pregnancy, due to severe overstretching of the anterior abdominal wall. In these cases, it is useful to examine the patient in the position on the left side (V.I. Kolosov). Of all the painful techniques, the greatest diagnostic value present the symptoms of Bloomberg - Shchetkin, Voskresensky and Razdolsky. In some patients, pain during puncture can be determined by the right costovertebral angle. Leukocytosis in acute appendicitis in pregnant women is in most cases 8*109-12*109/l (8000-12000 in 1 μl), often with a shift to the left.
