Acute phlegmonous appendicitis. Clinic. Diagnostics. Differential diagnosis. Etiology and pathogenesis of appendicitis Acute appendicitis in children etiology pathogenesis

Acute appendicitis (acute inflammation of the appendix of the cecum) is one of the most common causes of “acute abdomen” and the most common pathology of the abdominal organs requiring surgical treatment. The incidence of appendicitis is 0.4-0.5%, it occurs at any age, most often from 10 to 30 years, men and women are affected with approximately the same frequency.

Anatomical and physiological information. In most cases, the cecum is located in the right iliac fossa mesoperitoneally, the vermiform appendix arises from the posteromedial wall of the intestinal dome at the junction of three longitudinal muscle bands (tenia liberae) and is directed downward and medially. Its average length is 7 - 8 cm, thickness 0.5 - 0.8 cm. The vermiform appendix is ​​covered with peritoneum on all sides and has a mesentery, thanks to which it has mobility. The blood supply to the appendix occurs through a. appendicularis, which is a branch of a. ileocolica. Venous blood flows through v. ileocolica in v. mesenterica superior and v. portae. There are many options for the location of the appendix in relation to the cecum. The main ones are: 1) caudal (descending) - the most common; 2) pelvic (low); 3) medial (internal); 4) lateral (along the right lateral canal); 5) ventral (anterior); 6) retrocecal (posterior), which can be: a) intraperitoneal, when the process, which has its own serous cover and mesentery, is located behind the dome of the cecum and b) retroperitoneal, when the process is completely or partially located in the retroperitoneal retrocecal tissue.

Etiology and pathogenesis of acute appendicitis. The disease is considered as a nonspecific inflammation caused by factors of various nature. Several theories have been proposed to explain it.

1. Obstructive (stagnation theory)

2. Infectious (Aschoff, 1908)

3. Angioneurotic (Rikker, 1927)

4. Allergic

5. Nutritional

The main reason for the development of acute appendicitis is obstruction of the lumen of the appendix, associated with hyperplasia of lymphoid tissue and the presence of fecal stones. Less commonly, the cause of outflow disturbance may be a foreign body, neoplasm or helminths. After obstruction of the lumen of the appendix, a spasm of the smooth muscle fibers of its wall occurs, accompanied by vascular spasm. The first of them leads to a violation of evacuation, stagnation in the lumen of the appendix, the second leads to a local disruption of the nutrition of the mucous membrane. Against the background of activation of the microbial flora, which penetrates the appendix by enterogenous, hematogenous and lymphogenous routes, both processes cause inflammation, first of the mucous membrane, and then of all layers of the appendix.

Classification of acute appendicitis

Uncomplicated appendicitis.

1. Simple (catarrhal)

2. Destructive

• phlegmonous
• gangrenous
• perforated

Complicated appendicitis

Complications of acute appendicitis are divided into preoperative and postoperative.

I. Preoperative complications of acute appendicitis:

1. Appendiceal infiltrate

2. Appendiceal abscess

3. Peritonitis

4. Phlegmon of retroperitoneal tissue

5. Pylephlebitis

II. Postoperative complications of acute appendicitis:

Early(occurring within the first two weeks after surgery)

1. Complications from the surgical wound:

• bleeding from a wound, hematoma
• infiltrate
• suppuration (abscess, phlegmon of the abdominal wall)

2. Complications from the abdominal cavity:

• infiltrates or abscesses of the ileocecal area
  • abscess of the pouch of Douglas, subphrenic, subhepatic, interintestinal abscesses
• retroperitoneal phlegmon
• peritonitis
• pylephlebitis, liver abscesses
• intestinal fistulas
• early adhesive intestinal obstruction
• intra-abdominal bleeding

3. General complications:

• pneumonia
• thrombophlebitis, pulmonary embolism
• cardiovascular failure, etc.

Late

1. Postoperative hernias

2. Adhesive intestinal obstruction (adhesive disease)

3. Ligature fistulas

The causes of complications of acute appendicitis are:

1. 1. Failure of patients to seek medical care in a timely manner
2. 2. Late diagnosis of acute appendicitis (due to an atypical course of the disease, diagnostic errors, etc.)
3. 3. Tactical errors of doctors (neglect of dynamic monitoring of patients with a questionable diagnosis, underestimation of the prevalence of the inflammatory process in the abdominal cavity, incorrect determination of indications for drainage of the abdominal cavity, etc.)
4. 4. Technical errors of the operation (tissue injury, unreliable ligation of vessels, incomplete removal of the appendix, poor drainage of the abdominal cavity, etc.)
5. 5. Progression of chronic or occurrence of acute diseases of other organs.

Clinic and diagnosis of acute appendicitis

In the classic clinical picture of acute appendicitis, the patient's main complaint is abdominal pain. Often pain occurs first in the epigastric (Kocher's sign) or periumbilical (Kümmel's sign) region, followed by gradual movement after 3-12 hours to the right iliac region. In cases of atypical location of the appendix, the nature of the occurrence and spread of pain may differ significantly from that described above. With pelvic localization, pain is noted above the womb and in the depths of the pelvis, with retrocecal localization - in the lumbar region, often with irradiation along the ureter, with a high (subhepatic) location of the process - in the right hypochondrium.

Another important symptom that occurs in patients with acute appendicitis is nausea and vomiting, which is often one-time, and stool retention is possible. General symptoms of intoxication in the initial stage of the disease are mild and manifest as malaise, weakness, and low-grade fever. It is important to assess the sequence of symptoms. The classic sequence is the initial occurrence of abdominal pain, followed by vomiting. Vomiting preceding the onset of pain casts doubt on the diagnosis of acute appendicitis.

The clinical picture of acute appendicitis depends on the stage of the disease and the location of the appendix. At an early stage, there is a slight increase in temperature and increased heart rate. Significant hyperthermia and tachycardia indicate the occurrence of complications (perforation of the appendix, abscess formation). With the usual location of the process, palpation of the abdomen causes local pain at McBurney's point. With pelvic localization, pain is detected in the suprapubic region, dysuric symptoms (frequent painful urination) are possible. Palpation of the anterior abdominal wall is not very informative; it is necessary to perform a digital rectal or vaginal examination to determine the sensitivity of the pelvic peritoneum (“Douglas cry”) and assess the condition of other pelvic organs, especially in women. With a retrocecal location, the pain is shifted to the right flank and right lumbar region.

The presence of protective tension in the muscles of the anterior abdominal wall and symptoms of peritoneal irritation (Shchetkin - Blumberg) indicates the progression of the disease and involvement of the parietal peritoneum in the inflammatory process.

The diagnosis is facilitated by identifying the characteristic symptoms of acute appendicitis:

• Razdolsky - pain on percussion over the source of inflammation
• Rovzinga - the appearance of pain in the right iliac region when pushing in the left iliac region in the projection of the descending colon
• Sitkovsky - when the patient turns on his left side, pain in the ileocecal region intensifies due to movement of the appendix and tension of its mesentery
• Voskresensky - when the hand quickly slides along a stretched shirt from the xiphoid process to the right iliac region, in the latter there is a significant increase in pain at the end of the movement of the hand
• Bartomier-Mikhelson - palpation of the right iliac region with the patient positioned on the left side causes a more pronounced pain reaction than on the back
• Obraztsova - when palpating the right iliac region with the patient in the supine position, the pain intensifies when raising the straightened right leg
• Koupa - hyperextension of the patient's right leg when he is positioned on the left side is accompanied by sharp pain

Laboratory data. A blood test usually reveals moderate leukocytosis (10 -16 x 10 9 / L) with a predominance of neutrophils. However, a normal number of leukocytes in the peripheral blood does not exclude acute appendicitis. In the urine there may be single red blood cells in the field of view.

Special research methods usually performed in cases where there is doubt about the diagnosis. In case of inconclusive clinical manifestations of the disease, if there is an organized specialized surgical service, it is advisable to begin further examination with a non-invasive ultrasound examination (ultrasound), during which attention is paid not only to the right iliac region, but also to the organs of other parts of the abdomen and retroperitoneal space. An unambiguous conclusion regarding the destructive process in the organ allows you to adjust the surgical approach and the option of pain relief in case of an atypical location of the appendix.

In case of inconclusive ultrasound data, laparoscopy is used. This approach helps to reduce the number of unnecessary surgical interventions, and if special equipment is available, it makes it possible to move from the diagnostic stage to the therapeutic stage and perform endoscopic appendectomy.

Development acute appendicitis in elderly and senile people has a number of features. This is due to a decrease in physiological reserves, a decrease in the body’s reactivity and the presence of concomitant diseases. The clinical picture is characterized by a less acute onset, mild severity and diffuse nature of abdominal pain with the relatively rapid development of destructive forms of appendicitis. Abdominal bloating and non-passage of stool and gas are often noted. Muscle tension in the anterior abdominal wall and pain symptoms characteristic of acute appendicitis may be mild and sometimes not detectable. The overall response to the inflammatory process is weakened. A rise in temperature to 38 0 and above is observed in a small number of patients. In the blood there is moderate leukocytosis with a frequent shift of the formula to the left. Careful observation and examination with the widespread use of special methods (ultrasound, laparoscopy) are the key to timely surgical intervention.

Acute appendicitis in pregnant women. In the first 4-5 months of pregnancy, the clinical picture of acute appendicitis may not have any features, however, later the enlarged uterus displaces the cecum and the appendix upward. In this regard, abdominal pain can be determined not so much in the right iliac region, but along the right flank of the abdomen and in the right hypochondrium; irradiation of pain into the right lumbar region is possible, which can be erroneously interpreted as a pathology from the biliary tract and the right kidney. Muscle tension and symptoms of peritoneal irritation are often mild, especially in the last third of pregnancy. To identify them, it is necessary to examine the patient in a position on the left side. For the purpose of timely diagnosis, all patients are advised to monitor laboratory parameters, ultrasound of the abdominal cavity, joint dynamic observation of a surgeon and obstetrician-gynecologist, and laparoscopy can be performed if indicated. Once the diagnosis is made, emergency surgery is indicated in all cases.

Differential diagnosis for pain in the right lower abdomen, it is carried out with the following diseases:

1. 1. Acute gastroenteritis, mesenteric lymphadenitis, food toxic infections
2. 2. Exacerbation of peptic ulcer of the stomach and duodenum, perforation of ulcers of these localizations
3. 3. Crohn's disease (terminal ileitis)
4. 4. Inflammation of Meckel's diverticulum
5. 5. Gallstone disease, acute cholecystitis
6. 6. Acute pancreatitis
7. 7. Inflammatory diseases of the pelvic organs
8. 8. Rupture of ovarian cyst, ectopic pregnancy
9. 9. Right-sided renal and ureteral colic, inflammatory diseases of the urinary tract

10. Right lower lobe pleuropneumonia

Treatment of acute appendicitis

An active surgical position in relation to acute appendicitis is generally accepted. Absence of doubt about the diagnosis requires emergency appendectomy in all cases. The only exception is patients with a well-demarcated dense appendiceal infiltrate, requiring conservative treatment.

Currently, surgical clinics use various options for open and laparoscopic appendectomy, usually under general anesthesia. In some cases, it is possible to use local infiltration anesthesia with potentiation.

To perform a typical open appendectomy, the Volkovich-Dyakonov oblique variable (“slide”) access through the McBurney point is traditionally used, which, if necessary, can be expanded by dissecting the wound down the outer edge of the sheath of the right rectus abdominis muscle (according to Boguslavsky) or in the medial direction without crossing the rectus muscle (according to Bogoyavlensky) or with its crossing (according to Kolesov). Sometimes the Lenander longitudinal approach (along the outer edge of the right rectus abdominis muscle) and the transverse Sprengel approach (used more often in pediatric surgery) are used. In case of complications of acute appendicitis with widespread peritonitis, with severe technical difficulties during appendectomy, as well as erroneous diagnosis, a median laparotomy is indicated.

The vermiform appendix is ​​mobilized in an antegrade (from apex to base) or retrograde (first, the appendix is ​​cut off from the cecum, the stump is processed, then isolated from the base to the apex) method. The stump of the appendix is ​​treated with a ligature (in pediatric practice, in endosurgery), intussusception or ligature-intussusception method. As a rule, the stump is tied with a ligature of absorbable material and immersed in the dome of the cecum with purse-string, Z-shaped or interrupted sutures. Often, additional peritonization of the suture line is performed by suturing the stump of the mesentery of the appendix or fatty suspension, fixing the dome of the cecum to the parietal peritoneum of the right iliac fossa. Then the exudate is carefully evacuated from the abdominal cavity and, in the case of uncomplicated appendicitis, the operation is completed by suturing the abdominal wall tightly in layers. It is possible to install a microirrigator to the bed of the appendix for administering antibiotics in the postoperative period. The presence of purulent exudate and diffuse peritonitis is an indication for sanitation of the abdominal cavity with its subsequent drainage. If a dense inseparable infiltrate is detected, when it is impossible to perform an appendectomy, as well as in the case of unreliable hemostasis after removal of the appendix, tamponing and drainage of the abdominal cavity are performed.

In the postoperative period for uncomplicated appendicitis, antibacterial therapy is not carried out or is limited to the use of broad-spectrum antibiotics in the next 24 hours. In the presence of purulent complications and diffuse peritonitis, combinations of antibacterial drugs are used using various methods of their administration (intramuscular, intravenous, intra-aortic, into the abdominal cavity) with a preliminary assessment of the sensitivity of the microflora.

Appendicular infiltrate

Appendicular infiltrate - this is a conglomerate of loops of the small and large intestine, greater omentum, uterus with appendages, bladder, parietal peritoneum welded together around the destructively altered appendix, which reliably limit the penetration of infection into the free abdominal cavity. Occurs in 0.2 - 3% of cases. Appears 3-4 days after the onset of acute appendicitis. In its development, two stages are distinguished - early (formation of loose infiltrate) and late (dense infiltrate).

In the early stage, an inflammatory tumor forms. Patients have a clinical picture close to the symptoms of acute destructive appendicitis. At the stage of formation of a dense infiltrate, the phenomena of acute inflammation subside. The general condition of the patients is improving.

The decisive role in diagnosis is played by a clinical history of acute appendicitis or upon examination in combination with a palpable painful tumor-like formation in the right iliac region. At the stage of formation, the infiltrate is soft, painful, has no clear boundaries, and is easily destroyed when the adhesions are separated during surgery. In the delimitation stage, it becomes dense, less painful, and clear. Infiltrate is easily determined with typical localization and large size. To clarify the diagnosis, rectal and vaginal examination, ultrasound of the abdominal cavity, and irrigography (scopy) are used. Differential diagnosis is carried out with tumors of the cecum and ascending colon, uterine appendages, and hydropyosalpix.

Tactics for appendiceal infiltrate are conservative and expectant. Complex conservative treatment is carried out, including bed rest, a gentle diet, in the early phase - cold applied to the infiltrated area, and after normalization of the temperature, physical therapy (UHF). Antibacterial, anti-inflammatory therapy is prescribed, perinephric novocaine blockade is performed according to A.V. Vishnevsky, blockade according to Shkolnikov, therapeutic enemas, immunostimulants, etc. are used.

In the case of a favorable course, the appendiceal infiltrate resolves within 2 to 4 weeks. After complete subsidence of the inflammatory process in the abdominal cavity, no earlier than 6 months later, a planned appendectomy is indicated. If conservative measures are ineffective, the infiltrate suppurates with the formation of an appendiceal abscess.

Appendiceal abscess

Appendicular abscess occurs in 0.1 - 2% of cases. It can form in the early stages (1 - 3 days) from the moment of development of acute appendicitis or complicate the course of the existing appendiceal infiltrate.

Signs of abscess formation are symptoms of intoxication, hyperthermia, an increase in leukocytosis with a shift in the white blood count to the left, an increase in ESR, increased pain in the projection of a previously identified inflammatory tumor, a change in consistency and the appearance of softening in the center of the infiltrate. An abdominal ultrasound is performed to confirm the diagnosis.

The classic treatment option for an appendiceal abscess is opening the abscess using an extraperitoneal approach according to N.I. Pirogov with a deep, including retrocecal and retroperitoneal location. In case of a tight fit of the abscess to the anterior abdominal wall, the Volkovich-Dyakonov approach can be used. Extraperitoneal opening of the abscess avoids the entry of pus into the free abdominal cavity. After sanitizing the abscess, a tampon and drainage are inserted into its cavity, and the wound is sutured to drainage.

Currently, a number of clinics use extraperitoneal puncture sanitation and drainage of the appendiceal abscess under ultrasound control, followed by washing the abscess cavity with antiseptic and enzyme preparations and prescribing antibiotics, taking into account the sensitivity of the microflora. For large abscesses, it is proposed to install two drains at the upper and lower points for the purpose of flow-through rinsing. Considering the low invasiveness of puncture intervention, it can be considered the method of choice in patients with severe concomitant pathology and weakened by intoxication against the background of a purulent process.

Pylephlebitis

Pylephlebitis is purulent thrombophlebitis of the branches of the portal vein, complicated by multiple liver abscesses and pyaemia. It develops as a result of the spread of the inflammatory process from the veins of the appendix to the ileocolic, superior mesenteric, and then portal veins. More often it occurs with a retrocecal and retroperitoneal location of the appendix, as well as in patients with intraperitoneal destructive forms of appendicitis. The disease usually begins acutely and can be observed both in the preoperative and postoperative periods. The course of pylephlebitis is unfavorable and is often complicated by sepsis. Mortality rate is more than 85%.

The clinical picture of pylephlebitis consists of hectic temperature with chills, heavy sweating, and icteric discoloration of the sclera and skin. Patients are bothered by pain in the right hypochondrium, often radiating to the back, lower chest and right collarbone. Objectively, enlarged liver and spleen and ascites are found. An X-ray examination reveals a high position of the right dome of the diaphragm, an enlarged liver shadow, and a reactive effusion in the right pleural cavity. Ultrasound reveals areas of altered echogenicity of the enlarged liver, signs of portal vein thrombosis and portal hypertension. In the blood - leukocytosis with a shift to the left, toxic granularity of neutrophils, increased ESR, anemia, hyperfibrinemia.

Treatment consists of performing an appendectomy followed by complex detoxification intensive therapy, including intra-aortic administration of broad-spectrum antibacterial drugs, the use of extracorporeal detoxification (plasmapheresis, hemo- and plasmasorption, etc.). Long-term intraportal administration of drugs is carried out through a cannulated umbilical vein. Liver abscesses are opened and drained, or punctured under ultrasound guidance.

Pelvic abscess

Pelvic localization of abscesses (abscesses Douglas space) occurs most often in patients who have undergone appendectomy (0.03 - 1.5% of cases). They are localized in the lowest part of the abdominal cavity: in men excavatio retrovesicalis, and in women in excavatio retrouterina. The occurrence of ulcers is associated with poor sanitation of the abdominal cavity, inadequate drainage of the pelvic cavity, and the presence of an abscess infiltrate in this area when the appendix is ​​located in the pelvis.

An abscess of the pouch of Douglas forms 1 to 3 weeks after surgery and is characterized by the presence of general symptoms of intoxication, accompanied by pain in the lower abdomen, behind the womb, dysfunction of the pelvic organs (dysuric disorders, tenesmus, mucus discharge from the rectum). Per rectum, tenderness of the anterior wall of the rectum and its overhang are found; a painful infiltrate along the anterior wall of the intestine with areas of softening can be palpated. Per vaginam there is pain in the posterior fornix and intense pain when the cervix is ​​displaced.

To clarify the diagnosis, ultrasound and diagnostic puncture are used in men through the anterior wall of the rectum, and in women through the posterior vaginal fornix. After obtaining pus, the abscess is opened using a needle. A drainage tube is inserted into the abscess cavity for 2 - 3 days.

A pelvic abscess that is not diagnosed in time can be complicated by a breakthrough into the free abdominal cavity with the development of peritonitis or into adjacent hollow organs (bladder, rectum and cecum, etc.)

Subphrenic abscess

Subdiaphragmatic abscesses develop in 0.4 - 0.5% of cases, and can be single or multiple. According to localization, they distinguish between right and left-sided, anterior and posterior, intra- and retroperitoneal. The reasons for their occurrence are poor sanitation of the abdominal cavity, infection through the lymphatic or hematogenous route. They can complicate the course of pylephlebitis. The clinical picture develops 1-2 weeks after surgery and is manifested by pain in the upper abdominal cavity and lower parts of the chest (sometimes radiating to the scapula and shoulder), hyperthermia, dry cough, and symptoms of intoxication. Patients can take a forced semi-sitting position or on their side with their legs adducted. The chest on the affected side lags behind when breathing. The intercostal spaces at the level of 9 - 11 ribs above the abscess area bulge (V.F. Voino-Yasenetsky's symptom), palpation of the ribs is sharply painful, percussion - dullness due to reactive pleurisy, or tympanitis over the area of ​​the gas bubble with gas-containing abscesses. On a survey X-ray, there is a high position of the dome of the diaphragm, a picture of pleurisy, a gas bubble with a liquid level above it can be determined. Ultrasound reveals a limited accumulation of fluid under the dome of the diaphragm. The diagnosis is clarified after a diagnostic puncture of the subdiaphragmatic formation under ultrasound guidance.

Treatment consists of opening, emptying and draining the abscess using extrapleural, extraperitoneal access, less often through the abdominal or pleural cavity. Due to the improvement of ultrasound diagnostic methods, abscesses can be drained by inserting single- or double-lumen tubes into their cavity through a trocar under ultrasound guidance.

Interintestinal abscess

Interintestinal abscesses occur in 0.04 - 0.5% of cases. They occur mainly in patients with destructive forms of appendicitis with insufficient sanitation of the abdominal cavity. In the initial stage, symptoms are scant. Patients are bothered by abdominal pain without clear localization. The temperature rises, intoxication symptoms increase. In the future, a painful infiltrate in the abdominal cavity and stool disorders may appear. On a survey radiograph, areas of darkening are found, in some cases with a horizontal level of liquid and gas. To clarify the diagnosis, lateroscopy and ultrasound are used.

Interintestinal abscesses adjacent to the anterior abdominal wall and adherent to the parietal peritoneum are opened extraperitoneally or drained under ultrasound guidance. The presence of multiple abscesses and their deep location is an indication for laparotomy, emptying and drainage of abscesses after preliminary delimitation with tampons from the free abdominal cavity.

Intra-abdominal bleeding

The causes of bleeding into the free abdominal cavity are poor hemostasis of the appendix bed, slipping of the ligature from its mesentery, damage to the vessels of the anterior abdominal wall and insufficient hemostasis when suturing the surgical wound. Disorders of the blood coagulation system play a certain role. Bleeding can be profuse and capillary.

With significant intra-abdominal bleeding, the condition of the patients is serious. There are signs of acute anemia, the abdomen is somewhat swollen, tense and painful on palpation, especially in the lower parts, symptoms of peritoneal irritation may be detected. Percussion reveals dullness in sloping areas of the abdominal cavity. Per rectum is determined by the overhang of the anterior wall of the rectum. To confirm the diagnosis, ultrasound is performed, in difficult cases - laparocentesis and laparoscopy.

For patients with intra-abdominal bleeding after appendectomy, urgent relaparotomy is indicated, during which an inspection of the ileocecal area, ligation of the bleeding vessel, sanitation and drainage of the abdominal cavity are performed. In case of capillary bleeding, tight packing of the bleeding area is additionally performed.

Limited intraperitoneal hematomas give a more sparse clinical picture and can manifest themselves in the presence of infection and abscess formation.

Abdominal wall infiltrates and wound suppuration

Infiltrates of the abdominal wall (6 - 15% of cases) and wound suppuration (2 - 10%) develop as a result of infection, which is facilitated by poor hemostasis and tissue injury. These complications often appear on days 4–6 after surgery, sometimes at a later date.

Infiltrates and abscesses are located above or below the aponeurosis. By palpation, a painful lump with unclear contours is found in the area of ​​the postoperative wound. The skin over it is hyperemic, its temperature is elevated. When suppuration occurs, a symptom of fluctuation can be detected.

Treatment of infiltration is conservative. Broad-spectrum antibiotics and physical therapy are prescribed. A short novocaine blockade of the wound with antibiotics is performed. Suppurating wounds are opened wide and drained, and subsequently treated taking into account the phases of the wound process. Wounds heal by secondary intention. For large granulating wounds, the application of secondary early (8-15) days or delayed sutures is indicated.

Ligature fistulas

Ligature fistulas observed in 0.3 - 0.5% of patients who have undergone appendectomy. Most often they occur in the 3rd to 6th week of the postoperative period due to infection of the suture material, suppuration of the wound and its healing by secondary intention. A clinic of recurrent ligature abscess appears in the area of ​​the postoperative scar. After repeated opening and drainage of the abscess cavity, a fistula tract is formed, at the base of which there is a ligature. In case of spontaneous rejection of the ligature, the fistula tract closes on its own. Treatment consists of removing the ligature during instrumental revision of the fistula tract. In some cases, the entire old postoperative scar is excised.

Other complications after appendectomy (peritonitis, intestinal obstruction, intestinal fistulas, postoperative ventral hernia, etc.) are discussed in the relevant sections of private surgery.

Control questions

1. 1. Early symptoms of acute appendicitis
2. 2. Clinical features of acute appendicitis with atypical location of the appendix
3. 3. Features of the clinic of acute appendicitis in the elderly and pregnant women
4. 4. Surgeon’s tactics for a questionable picture of acute appendicitis
5. 5. Differential diagnosis of acute appendicitis
6. 6. Complications of acute appendicitis
7. 7. Early and late complications after appendectomy
8. 8. Surgeon’s tactics for appendiceal infiltrate
9. 9. Modern approaches to the diagnosis and treatment of appendiceal abscess

10. Diagnosis and treatment of pelvic abscesses

11. Surgeon’s tactics when detecting Meckel’s diverticulum

12. Pylephlebitis (diagnosis and treatment)

13. Diagnosis of subphrenic and interintestinal abscesses. Treatment tactics

14. Indications for relaparotomy in patients operated on for acute appendicitis

15. Examination of work capacity after appendectomy

Situational tasks

1. A 45-year-old man has been ill for 4 days. I am worried about pain in the right iliac region, temperature 37.2. On examination: The tongue is moist. The abdomen is not swollen, participates in the act of breathing, is soft, painful in the right iliac region. Peritoneal symptoms are inconclusive. A tumor-like formation 10 x 12 cm, painful and inactive, is palpated in the right iliac region. Regular stool. Leukocytosis - 12 thousand.

What is your diagnosis? Etiology and pathogenesis of this disease? What pathology should be considered for differential pathology? Additional examination methods? Treatment tactics for this disease? Treatment of a patient at this stage of the disease? Possible complications of the disease? Indications for surgical treatment, nature and extent of the operation?

2. Patient K., 18 years old, was operated on for acute gangrenous-perforated appendicitis, complicated by diffuse serous-purulent peritonitis. An appendectomy and drainage of the abdominal cavity were performed. The early postoperative period occurred with symptoms of moderately severe intestinal paresis, which were effectively relieved by the use of drug stimulation. However, by the end of 4 days after the operation, the patient’s condition worsened, increasing bloating and cramping pain throughout the abdomen appeared, gases stopped passing, nausea and vomiting appeared, general signs of endogenous intoxication.

Objectively: the condition is of moderate severity, pulse 92 per minute, A/D 130/80 mm Hg. Art., the tongue is wet, coated, the abdomen is evenly swollen, diffuse pain in all parts, peristalsis is increased, peritoneal symptoms are not determined, upon examination per rectum - the rectal ampulla is empty

What complication of the early postoperative period occurred in this patient? What additional examination methods will help determine the diagnosis? The role and scope of x-ray examination, interpretation of data. What are the possible reasons for the development of this complication in the early postoperative period? Etiology and pathogenesis of disorders developing in this pathology. The scope of conservative measures and the purpose of their implementation in the development of this complication? Indications for surgery, scope of surgical treatment? Intra- and postoperative measures aimed at preventing the development of this complication?

3. A 30-year-old patient is in the surgical department for acute appendicitis in the stage of appendiceal infiltration. On the 3rd day after hospitalization and on the 7th day from the onset of the disease, the pain in the lower abdomen and especially in the right iliac region intensified, the temperature became hectic.

Objectively: Pulse 96 per minute. Breathing is not difficult. The abdomen is of regular shape, sharply painful on palpation in the right iliac region, where a positive Shchetkin-Blumberg sign is determined. The infiltrate of the right iliac region increased slightly in size. Leukocytosis increased compared to the previous analysis.

Formulate a clinical diagnosis in this case? Patient treatment tactics? Nature, scope and features of surgical treatment for this pathology? Features of the postoperative period?

4. A 45-year-old man underwent appendectomy with drainage of the abdominal cavity for gangrenous appendicitis. On the 9th day after the operation, the flow of small intestinal contents from the drainage canal was noted.

Objectively: The patient’s condition is moderate. Temperature 37.2 - 37.5 0 C. The tongue is wet. The abdomen is soft, slightly painful in the wound area. There are no peritoneal symptoms. Independent stool once a day. In the drainage area there is a channel approximately 12 cm deep, lined with granulating tissue, through which intestinal contents are poured. The skin around the canal is macerated.

What is your diagnosis? Etiology and pathogenesis of the disease? Classification of the disease? Additional research methods? Possible complications of this disease? Principles of conservative therapy? Indications for surgical treatment? The nature and extent of possible surgical interventions?

5. By the end of the first day after appendectomy, the patient has severe weakness, pale skin, tachycardia, a drop in blood pressure, and free fluid is detected in the sloping areas of the abdominal cavity. Diagnosis? Surgeon's tactics?

Sample answers

1. The patient has developed an appendiceal infiltrate, confirmed by ultrasound data. The tactics are conservative and expectant; in case of abscess formation, surgical treatment is indicated.

2. The patient has a clinical picture of postoperative early adhesive intestinal obstruction; in the absence of effect from conservative measures and negative radiological dynamics, emergency surgery is indicated.

3. Abscess formation of the appendiceal infiltrate has occurred. Surgical treatment is indicated. Preferably, extraperitoneal opening and drainage of the abscess.

4. The postoperative period was complicated by the development of an external small intestinal fistula. An X-ray examination of the patient is necessary. In the presence of a formed tubular low small intestinal fistula with a small amount of discharge, measures for its conservative closure are possible; in other cases, surgical treatment is indicated.

5. The patient has bleeding into the abdominal cavity, probably due to the slippage of the ligature from the stump of the mesentery of the appendix. Emergency relaparotomy is indicated.

LITERATURE

1. Batvinkov N.I., Leonovich S.I., Ioskevich N.N. Clinical surgery. - Minsk, 1998. - 558 p.
2. Bogdanov A.V. Fistulas of the digestive tract in the practice of a general surgeon. - M., 2001. - 197 p.
3. Volkov V. E., Volkov S. V. Acute appendicitis - Cheboksary, 2001. - 232 p.
4. Gostishchev V.K., Shalchkova L.P. Purulent pelvic surgery - M., 2000. - 288 p.
5. Grinberg A. A., Mikhailusov S. V., Tronin R. Yu., Drozdov G. E. Diagnosis of difficult cases of acute appendicitis. - M., 1998. - 127 p.
6. Clinical surgery. Ed. R. Conden and L. Nyhus. Per. from English - M., Praktika, 1998. - 716 p.
7. Kolesov V.I. Clinic and treatment of acute appendicitis. - L., 1972.
8. Krieger A. G. Acute appendicitis. - M., 2002. - 204 p.
9. Rotkov I. L. Diagnostic and tactical errors in acute appendicitis. - M., Medicine, 1988. - 203 p.
10. Savelyev V.S., Abakumov M.M., Bakuleva L.P. and others. Guide to emergency surgery of the abdominal organs (edited by V.S. Savelyev). - M.: Medicine. - 1986. - 608 pp.

Acute appendicitis without mention of localized or diffuse peritonitis

Version: MedElement Disease Directory

Acute appendicitis, other and unspecified (K35.8)

Gastroenterology

general information

Short description

Acute appendicitis is an acute nonspecific inflammation of the appendix.

Note

9. Specific acute inflammation of the appendix in tuberculosis, bacillary dysentery, typhoid fever.

Period of occurrence

Minimum period of occurrence (days): not specified

Maximum period of occurrence (days): 2

Typical development of acute appendicitis(the process progresses and has no tendency to reverse):
- catarrhal stage of acute appendicitis: duration in most cases is 6-12 hours.
- phlegmonous appendicitis - 12 hours from the onset of the disease.
- gangrenous - after 24-48 hours.
- perforation of the appendix with progressive appendicitis occurs, as a rule, after 48 hours.

Note. The indicated periods are typical for most cases of progressive acute appendicitis, but they are not absolute. In clinical practice, one or another deviation in the course of the disease is often encountered.

Classification

Classification of acute appendicitis(Kolesov V.I., 1972)

1. Appendicular colic.

2. Simple (superficial, catarrhal) appendicitis.

3. Destructive appendicitis:
- phlegmonous;
- gangrenous;
- perforated.

4. Complicated appendicitis:
- appendicular infiltrate;
- abscesses of the abdominal cavity (periappendicular, interintestinal, pelvic, subphrenic);
- retroperitoneal phlegmon;
- peritonitis;
- pylephlebitis;
- sepsis.

Morphological classification of types of acute appendicitis

1. Simple (previously called catarrhal).

2. Superficial.

3. Destructive:

Phlegmonous;
- apostematous;

Phlegmonous-ulcerative;
- gangrenous;

Perforated.

Options for the location of the appendix:

1. Typical.

2. Medial.

3. Pelvic.

4. Ascending - along the right side channel.

5. Subhepatic.

6. Retrocecal.

7. Retroperitoneal.

8. Left-handed.

Etiology and pathogenesis

The etiology of acute appendicitis has not been definitively established.

Mechanical theory
According to this theory, the development of acute appendicitis is associated with impaired evacuation of contents from the lumen of the appendix. As a result of obturation of the lumen of the appendix, the lumen becomes overfilled with mucous secretion distal to the level of obstruction; Intraluminal pressure increases and excessive development of microorganisms is observed. This process causes inflammation of the mucous membrane and underlying layers, vascular thrombosis and subsequently necrosis of the wall of the appendix. The diameter of the process increases to 17-18 mm or more (normally 4-6 mm), it becomes tense.

Obstruction of the lumen of the appendix and disruption of evacuation can be caused by:

Infection theory connects the occurrence of acute appendicitis with activation of the intestinal flora and disruption of the barrier function of the appendix mucosa.

Factors that reduce wall resistance or contribute to its damage:
- fecal stones;
- helminths;
- foreign bodies;
- chronic colitis;
- intestinal dyskinesia;
- kinks and torsion of the process.

Neuro-reflex theory explains the occurrence of acute appendicitis by a disorder of trophic processes in the wall of the appendix, resulting from pathological cortico-visceral and visceral-visceral reflexes. These processes cause functional spasm and paresis of the arteries feeding the appendix, and then lead to their thrombosis. At the same time, there is a slowdown in the outflow of lymph and venous blood. Developing dystrophic and neurobiotic changes disrupt the protective barrier of the mucous membrane of the appendix, which contributes to the invasion of microbial flora.

Allergic theory
According to this theory, inflammation of the appendix is ​​considered as a local manifestation of a type III hypersensitivity reaction (classical Arthus phenomenon) and type IV (delayed hypersensitivity reaction) with an autoimmune component. The development of hypersensitivity is accompanied by a weakening of the protective barrier of the mucous membrane of the appendix, resulting in the penetration of opportunistic microflora into its wall from the intestinal lumen by hematogenous or lymphogenous route.

Vascular theory connects acute appendicitis with systemic vasculitis.

Endocrine theory assumes that the APUD system APUD-system (syn. diffuse neuroendocrine system, diffuse endocrine system) is a system of cells responsible for the consumption of proamines during metabolism and involved in the decarboxylation process. There are especially many of them in the mucous membrane of the gastrointestinal tract and pancreas, where they are capable of forming large amounts of aminoamines and oligopeptides that have hormonal effects
the appendix begins to produce a large amount of secretin, which is the main mediator of inflammation and has a direct damaging effect on the organ.

Nutritional theory(the role of constipation and “lazy bowels”) connects the development of acute appendicitis with a low content of plant fibers and the predominance of meat foods in the patients’ diet. This diet causes a decrease in the transit of intestinal contents and a decrease in intestinal motility, including the appendix.

Epidemiology

Sign of prevalence: Very common

Appendicitis can occur at any age, but is more common in patients aged 10-30 years.
The incidence of acute appendicitis is 4-5 cases per 1000 people per year.
Acute appendicitis ranks first among acute surgical diseases of the abdominal organs (75-89.1% of cases).
Men and women get sick equally often, with the exception of the age group from 12-14 to 25 years, in which the ratio of incidence between men and women is 3:2.

In children acute appendicitis can occur in all age groups, including newborns. It is extremely rare in infancy, but later the frequency of acute appendicitis gradually increases, reaching a maximum by 10-12 years. Toddler age accounts for about 5% of cases, preschool age - 13%, school age - more than 80% of cases of acute appendicitis in children.

Acute appendicitis is the most common cause of emergency surgery in pregnant women. Frequency of acute appendicitis in pregnant women: 1 case in 700-2000 pregnant women.

Risk factors and groups

Risk factors have not been determined for certain, but presumably they include:
- age 15-30 years;
- infectious enterocolitis Enterocolitis is an inflammation of the mucous membrane of the small and large intestines.
;
- helminthic infestation;
- slow intestinal motility;
- fecal stones;
- decrease in local immunity;
- inflammatory diseases of the pelvic and abdominal organs.

Clinical picture

Clinical diagnostic criteria

Tachycardia, fever 37.5-38.5 C, coated tongue, dry mouth, limited mobility, abdominal pain when coughing, local tenderness and protective reflexes in the right iliac region, abdominal muscle tension, episode of diarrhea, nausea, single vomiting, dyspepsia, dysuria, bringing the legs to the body in a supine position, pain on the right side during rectal examination

Symptoms, course

General symptoms

Acute appendicitis has a variety of clinical manifestations. This is due to various options for its location and forms of inflammatory changes in the appendix (see section "Classification"), the frequent development of complications, and the unequal state of reactivity of the body of patients. In this regard, acute appendicitis can repeat the clinical picture of almost all surgical diseases of the abdominal cavity and retroperitoneal space, as well as a number of therapeutic diseases.

The overwhelming majority of observations include the following: manifestations of acute appendicitis(the severity of clinical manifestations increases with increasing degree of inflammatory changes in the appendix).

1. Pain - main and earliest symptom. Pain appears against the background of general well-being for no apparent reason. The nature of the pain depends on the form of inflammation and the location of the appendix.
In a typical case, the onset of inflammation is characterized by pain in the center of the abdomen, near the navel, in the epigastrium Epigastrium is an area of ​​the abdomen bounded above by the diaphragm and below by a horizontal plane passing through a straight line connecting the lowest points of the tenth ribs.
. So-called “wandering” pains are noted.
In the initial period, the pain is mild, dull and constant (cramping pain is observed only in isolated cases).
After 2 to 8 hours, the pain shifts to the right iliac fossa and intensifies.


With the progression of inflammation, and especially with perforation of the appendix, the pain becomes diffuse.

There is an increase in pain when coughing, caused by jerky movements of the internal organs due to increased intra-abdominal pressure on the inflamed peritoneum of the appendix.

With a retrocecal or retroperitoneal location of the appendix, pain is determined in the lumbar region, along the right lateral canal; in the case of subhepatic - in the right hypochondrium; with the pelvic one - above the womb, in the depths of the pelvis.
Irradiation Irradiation is the spread of pain beyond the affected area or organ.
pain is not typical for acute appendicitis, but with retrocecal localization of the appendix, the pain spreads to the right thigh, and with a pelvic location - to the perineum.

2. Dyspeptic phenomena(observed in 30-40% of patients):
2.1 At the onset of the disease, single vomiting is typical. The presence of vomiting is characteristic of the destructive form of acute appendicitis. In rare cases, vomiting precedes the onset of pain.
2.2 Due to intoxication of the body, dry mouth appears.
2.3 Nausea occurs after the onset of pain and often occurs without vomiting.

Nausea and vomiting occur reflexively due to irritation of the peritoneum.

3. Dysuric disorders occur when the inflammatory appendix is ​​located in close proximity to the bladder, ureter, kidney (most often with pelvic or retroperitoneal localization of the appendix) and when these organs are involved in the inflammatory process.
Dysuric disorders are manifested by frequent painful urination or, conversely, urinary retention, microhematuria Microhematuria is the presence of red blood cells in the urine, detected only by microscopic examination
or gross hematuria Gross hematuria - the presence of blood in the urine, visible to the naked eye
.

4. Bowel dysfunction:
- diarrhea (more often) associated with irritation of the wall of the rectum or sigmoid colon by the inflammatory altered appendix adjacent to them;
- stool retention (more rarely) is short-term and is observed at the beginning of an attack of acute appendicitis or with the development of peritonitis.

5. General condition of patients at the beginning of acute appendicitis - satisfactory; the progression of inflammation is accompanied by the appearance of general weakness and malaise. Patients' appetite decreases and body temperature rises to 37-38.5 o C).
A typical symptom is “toxic scissors” - the temperature lags behind the pulse. In some cases, no increase in temperature is observed. The difference between rectal and skin temperatures is more than 1 o C (Lenander's symptom). With the development of purulent peritonitis Peritonitis is inflammation of the peritoneum.
or encystation of the abscess, a significant temperature range or constantly high temperature is noted.
In accordance with the increase in temperature, the pulse quickens, but this correspondence disappears with peritonitis.

Catarrhal acute appendicitis
Symptoms:

Rovsing's symptom - the occurrence or intensification of pain in the right iliac region with compression of the sigmoid colon and push-like pressure on the descending colon;
- Sitkovsky's symptom - the occurrence or intensification of pain in the right iliac region with the patient positioned on the left side;
- Bartomier-Michelson symptom - increased pain on palpation of the cecum with the patient positioned on the left side.

Phlegmonous acute appendicitis
Additional symptoms to those manifested at the catarrhal stage:
- Shchetkin-Blumberg symptom - a sharp increase in abdominal pain when the palpating hand is quickly removed from the anterior abdominal wall after pressing;

Voskresensky's symptom is pain in the right iliac region when moving the hand with moderate pressure on the abdomen from the epigastrium to the right iliac region through a stretched shirt (the doctor pulls the patient's shirt by the lower edge for uniform sliding).

Gangrenous acute appendicitis (without perforation)
Main manifestations:
- necrosis of the wall of the appendix;
- development of putrefactive inflammation;
- abdominal pain decreases or completely disappears due to the death of nerve endings in the inflamed appendix;
- gradual increase in symptoms of a systemic inflammatory reaction due to the absorption of a large number of bacterial toxins from the abdominal cavity;
- repeated vomiting is often observed;
- the abdomen is moderately swollen (most often);
- peristalsis is weakened or absent;
- severe symptoms of peritoneal irritation;
- body temperature is often normal or below normal (up to 36 o C);

When examining the abdomen, a less intense tension of the abdominal wall in the right iliac region is noted compared to the phlegmonous stage, however, when attempting deep palpation, the pain sharply intensifies.

Atypical forms of acute appendicitis

Clinical manifestations:

1. Empyema Empyema is a significant accumulation of pus in a body cavity or hollow organ
vermiform appendix(1-2% of cases of acute appendicitis).
This form of acute appendicitis is morphologically similar to phlegmonous appendicitis, but differs from it clinically.
With empyema of the appendix, dull pain in the abdomen begins directly in the right iliac region (the shift of pain from the center of the abdomen or epigastrium to the right and downward, characteristic of phlegmonous appendicitis, is not observed). The pain progresses slowly and becomes as severe as possible only on the 3-5th day of the disease. By this time, the pain often becomes throbbing. Vomiting may occur once or twice.
In the initial period, the patient’s general condition is satisfactory with normal or slightly elevated body temperature. With the development of throbbing pain, chills and an increase in temperature to 38-39 o C are noted.
An objective examination does not reveal abdominal wall tension or other symptoms of peritoneal irritation. As a rule, the symptoms of Rovzing, Sitkovsky, and Bartomier-Mikhelson are positive. With deep palpation of the right iliac region, significant pain is noted. In patients with a thin build, it is possible to palpate a painful and sharply thickened appendix.

2. Retrocecal acute appendicitis(on average 5% of cases of acute appendicitis).
In 2% of cases of this form, the appendix is ​​located completely retroperitoneally. At the same time, the vermiform appendix, located behind the cecum, may come into contact with the liver, right kidney and lumbar muscles. This situation determines the characteristics of the clinical manifestations of acute appendicitis.
The onset of the disease is characterized by pain in the epigastric region or throughout the abdomen. Subsequently, the pain is localized in the area of ​​the right lateral canal or in the lumbar region.
Nausea and vomiting are less common than with the normal position of the appendix.
Often in the initial stage there is a semi-liquid, pasty stool with mucus (2-3 times), which occurs due to irritation of the cecum by the inflamed process closely adjacent to it.
In the case of close proximity of the appendix and the kidney or ureter, dysuric phenomena may occur.
An objective examination of the abdomen does not always reveal typical symptoms of appendicitis (even with destruction of the appendix); Symptoms of peritoneal irritation are not expressed. There is pain in the area of ​​the right lateral canal or slightly above the iliac crest. When examining the lumbar region, muscle tension in the Petit triangle is often detected. The lumbar triangle (syn. Petit triangle) is a section of the posterior abdominal wall, bounded below by the iliac crest, medially by the edge of the latissimus dorsi muscle, laterally by the external oblique abdominal muscle; place of release of lumbar hernias
.
A characteristic symptom of retrocecal appendicitis is increased pain with pressure on the cecum and simultaneous raising of the right leg straightened at the knee joint (Obraztsov’s symptom).

3. Pelvic acute appendicitis.
The pelvic (low) location of the appendix occurs in 16% of men and 30% of women. Due to the fact that inflammatory diseases of the genitals often occur in women, recognition of acute appendicitis in patients with a pelvic location of the appendix is ​​difficult.
The disease has a typical onset. Pain occurs in the epigastric region or throughout the abdomen, and after a few hours is localized above the pubis or above the inguinal ligament on the right.
Nausea and vomiting are not typical.
In many cases, frequent stools with mucus and dysuric disorders associated with the proximity of the appendix, rectum and bladder are noted.
Due to the early delimitation of the inflammatory process, changes in body temperature with pelvic appendicitis are less pronounced than with the usual localization of the appendix.

An objective examination of pelvic appendicitis does not always reveal muscle tension in the abdominal wall and other symptoms of peritoneal irritation. The symptoms of Rovsing, Sitkovsky, and Bartomier-Mikhelson are uncharacteristic, but in some cases Cope's symptom (painful tension of the obturator internus muscle) is positive. It should be borne in mind that Cope's symptom can also be positive in other inflammatory processes in the pelvic area (gynecological diseases).
If pelvic appendicitis is suspected, vaginal and rectal examinations are performed. They allow you to identify pain in the area of ​​​​the pouch of Douglas Rectumuterine recess (syn. pouch of Douglas, pouch of Douglas) - a depression in the parietal peritoneum located between the uterus and rectum, limited on the sides by rectouterine folds of the peritoneum
, as well as effusion Effusion is an accumulation of fluid (exudate or transudate) in the serous cavity.
in the abdominal cavity or inflammatory infiltrate Infiltrate is an area of ​​tissue characterized by the accumulation of cellular elements that are usually unusual for it, increased volume and increased density.
.

4. Subhepatic acute appendicitis.
A high medial (subhepatic) location of the appendix is ​​rare and greatly complicates the diagnosis of acute appendicitis.
Patients experience soreness and muscle tension in the right hypochondrium, as well as other symptoms of peritoneal irritation. This localization of manifestations indicates acute cholecystitis rather than acute appendicitis. When making a diagnosis, you should pay attention to the presence of a history typical for an attack of acute appendicitis. In addition, in acute appendicitis it is not possible to palpate any pathological formation in the abdomen (except in cases of appendiceal infiltrate), and in most cases of acute cholecystitis an enlarged gallbladder is palpated.

5. Left-sided acute appendicitis.
This form of acute appendicitis is very rare. It is possible with the reverse arrangement of internal organs (situs viscerum inversus) or in the case of a mobile cecum with a long mesentery The mesentery is a fold of the peritoneum through which the intraperitoneal organs are attached to the walls of the abdominal cavity.
. Symptoms characteristic of appendicitis in this case are noted in the left iliac region.
For a mobile cecum, appendectomy Appendectomy - surgical removal of the appendix
can be performed from the usual right-sided approach. In case of true reverse position of the internal organs, it is necessary to make an incision in the left iliac region. In this regard, in the presence of clinical manifestations of left-sided acute appendicitis, the reverse position of internal organs should first be excluded, and then appendicitis should be differentiated from other acute diseases of the abdominal organs.

6. Acute appendicitis during pregnancy.
Has a blurred clinical picture of an “acute abdomen” as a result of the following factors:
- hormonal, metabolic and physiological changes;

Displacement of internal organs by the growing uterus: the appendix and cecum are displaced cranially, the abdominal wall rises and moves away from the appendix;
- progressive weakening of the muscles of the anterior abdominal wall due to their stretching by the growing uterus.

Pregnant women with acute appendicitis experience acute pain in the abdomen, which acquires a constant aching character. In typical cases of the location of the appendix, the pain moves to the right side of the abdomen, the right hypochondrium.
A positive Taranenko symptom is characteristic - increased abdominal pain when turning from the left side to the right.
Rectal and vaginal examinations have high diagnostic value.

7. Acute appendicitis in children.
The onset of acute appendicitis in young children often remains invisible to parents, since it is difficult for the child to accurately explain the initial pain and describe its location. As a result, a certain period of time passes from the onset of the disease to its detection, which creates the impression of a sudden and violent onset of appendicitis.

In the initial period, young children are characterized by a predominance of general phenomena over local ones. In children of the younger age group, in contrast to older children, repeated vomiting, high fever, and loose stools are more often observed (the severity of these phenomena depends on the characteristics of individual resistance).
As a rule, vomiting appears 12-16 hours after the onset of the disease. A febrile temperature is often noted. Diarrhea occurs in at least 25% of cases. Since these phenomena are common in children under 3 years of age with any disease, an erroneous diagnosis is possible.

In young children, the location of pain may initially be uncertain; As a rule, children point to the navel area. The pain in most cases is quite intense, so children often take a forced position on the right side with their legs brought to the body. Having chosen this position, the child lies calmly and does not complain, but you can notice a pained, wary expression on his face.

Pain localized in the right iliac region is detected in 2/3 of patients; the rest experience pain throughout the abdomen. It is important to correctly and thoroughly examine the abdomen in order to determine local soreness and the nature of the pain.
During palpation, the increased intensity of pain can be determined by the child’s facial expression and the nature of crying. When the hand moves from the left half to the right iliac region, a grimace of pain appears on the child’s face, and the crying becomes louder.
If the child resists examination, it is better to determine the symptom of muscle protection during sleep, during which muscle tension and pain when palpating the abdomen persist. In the absence of acute appendicitis, the abdomen can be freely palpated in all parts; it remains soft and painless. If there is appendicitis on the right side of the abdomen, muscle protection is observed and the child wakes up in pain.
The symptoms of Shchetkin-Blumberg, Rovzing, Razdolsky, Voskresensky and others characteristic of acute appendicitis in young children are often uninformative.

Possible clinical picture of acute appendicitis in children:
- a child with watery diarrhea and vomiting (acute appendicitis can act as a complication of gastroenteritis);
- a boy with wandering abdominal pain who refuses his favorite food;
- an 8-year-old child without pain, with confused consciousness.

8. Acute appendicitis in elderly and senile people.
Due to age-related atrophic changes in the appendix, in this age group the disease is registered 2-3 times less often than in young people.
In 30-50% of cases, along with typical variants of the course, an erased clinical picture is possible (even in the case of severe destructive changes in the appendix). In this case, pain, dyspeptic and dysuric disorders are mild, normal or slightly elevated body temperature is noted, and there is no tachycardia. Physical examination does not reveal the characteristic protective tension of the abdominal muscles.
Due to subtle clinical manifestations, patients often seek medical help when complications develop: peritonitis Peritonitis is inflammation of the peritoneum.
- appendicular infiltrate and abscess, which can often be accompanied by acute intestinal obstruction.
The presence of severe concomitant pathologies significantly aggravates the course of the postoperative period, which can lead to death.

Diagnostics

1. X-ray methods(plain radiography, retrograde contrast radiography) have a very low diagnostic value and are carried out solely for the purpose of differential diagnosis.

2. Ultrasound. The sensitivity of carefully performed ultrasound is 75-90%, specificity 86-100%, positive predictive value 89-93%, overall accuracy 90-94%. In addition, ultrasound can identify alternative diagnoses. The value of the method is limited by the subjective perception of the picture and technical errors in preparing and conducting the study.

3. Computed tomography(CT). Sensitivity is 90-100%, specificity is 91-99%, positive predictive value is 95-97%, accuracy is 94-100%.
CT signs of acute appendicitis (most often):
- enlarged appendix;
- thickening of the appendix wall;
- periappendicular inflammation.

The following alternative diagnoses can be easily identified using CT:
- colitis;
- diverticulitis;
- obstruction of the small intestine;
- inflammatory bowel diseases;
- cysts of the appendages;
- acute cholecystitis;
- acute pancreatitis;
- obstruction of the ureter.
For obvious reasons, the method is not recommended for pregnant women; limited use in children and non-pregnant women of childbearing age.

4. Diagnostic laparoscopy necessary to clarify the diagnosis in doubtful cases. Its use has been shown to reduce the number of unnecessary appendectomies.
The method is most effective for diagnosing acute appendicitis in women, since in 10-20% of patients with a primary diagnosis of acute appendicitis, pain is associated with gynecological pathology.
Laparoscopy should be performed in such a way that, if necessary, emergency surgery, including laparoscopic appendectomy, can be started immediately. However, diagnostic laparoscopy is an invasive procedure, with approximately 5% complications, most of which are anesthetic.

Diagnostic scales

Today, the most well-known is the Alvarado Score for Acute Appendicitis, which is based on a score of a number of parameters (including clinical symptoms and laboratory tests).
This scale is simple and economical to use. However, due to certain shortcomings, clinicians use this scale only as a guideline for including additional instrumental examination methods in the diagnostic algorithm.

Alvarado scale

Symptoms	Points
Migration of pain to the right iliac fossa	1
Lack of appetite	1
Nausea, vomiting	1
Pain in the right iliac fossa	2
Positive symptoms of peritoneal irritation	1
Fever	1
Leukocytosis	2
Leukocyte formula shift to the left	1
Total	10

Alvarado rating

Laboratory diagnostics

1. General blood analysis. In 70-90% of patients with acute appendicitis, leukocytosis is detected, the level of which depends on the morphological stage of the disease, the patient’s age and other factors. Leukocytosis has low specificity in the diagnosis of acute appendicitis, since it also occurs in other diseases with symptoms of “acute abdomen”.
It must be borne in mind that in elderly people and people with immunodeficiency in the initial stage of acute appendicitis, there may be no changes in the peripheral blood (leukocytosis, neutrophilia, increased ESR).

2. General urine analysis carried out for the purpose of differential diagnosis.
According to some studies, the level of 5-HIAA (5-hydroxyindoleacetic acid, U-5-HIAA, 5-HIAA) in urine may be a reliable marker of inflammation of the appendix. During inflammation, large amounts of serotonin produced by the cells of the appendix are released into the blood and converted into 5-hydroxyindoleacetic acid, which is then excreted in the urine.
A 5-HIAA value of 10 µmol/L is taken as the cut-off point. The sensitivity of the test is 84%, specificity is 88%. Positive predictive values ​​are 90%, negative predictive values ​​are 81%. Thus, U-5-HIAA provides higher diagnostic accuracy than other conventional laboratory tests. As inflammation progresses to necrosis of the appendix, the concentration of 5-HIAA decreases. This decrease may be a warning of perforation of the appendix.

3. Biochemistry carried out for the purpose of differential diagnosis.

4. Pregnancy tests, in particular, human chorionic gonadotropin (HCG) is required. A positive test (pregnancy) does not exclude the possibility of developing acute appendicitis.

In children and young people, a laboratory triad is considered to be a fairly accurate confirmation of the diagnosis of acute appendicitis: leukocytosis, neutrophilia, increased levels of C-reactive protein. In the group of patients over 60 years of age, the sensitivity and specificity of this combination for confirming the diagnosis decreases.

Differential diagnosis

Acute appendicitis, due to the extreme variability of the location of the appendix and the frequent absence of specific symptoms, has to be differentiated from almost all acute diseases of the abdominal cavity and retroperitoneal space.

Acute gastroenteritis
Unlike acute appendicitis, the onset of acute gastroenteritis is characterized by fairly severe cramping pain in the upper and middle parts of the abdomen. In almost all cases, when questioning the patient, a provoking factor is revealed in the form of a change in diet. Almost simultaneously with the onset of pain, repeated vomiting appears, first of the food eaten, and later of bile. If there is significant damage to the gastric mucosa, an admixture of blood may be observed in the vomit. After a few hours, frequent loose stools often occur against the background of cramping pain. Body temperature is usually normal or subfebrile.

Objective examination of the abdomen: localized tenderness, symptoms of peritoneal irritation and symptoms typical of acute appendicitis are absent.

Auscultation of the abdomen: increased peristalsis.
Digital rectal examination: the presence of liquid stool mixed with mucus, no overhang and tenderness of the anterior wall of the rectum.
Laboratory diagnosis: moderate leukocytosis, band shift is absent or slightly expressed.

Acute pancreatitis
The onset of acute pancreatitis is characterized by sharp pain in the upper abdomen (usually of a girdling nature). Often there is irradiation of back pain. There is repeated vomiting of bile, which does not bring relief.
In the initial stage of acute pancreatitis, patients are restless, but as intoxication increases, they become lethargic and adynamic. Rapid progression of the disease can cause collapse.
There is pallor of the skin, sometimes acrocyanosis. The pulse is significantly increased. The temperature remains normal (at least during the first hours).

Objective research. Pain in the epigastric region is sometimes not very pronounced, which does not correspond to the severity of the patient’s general condition. In the right iliac region there is no pain in most cases. Symptoms simulating acute appendicitis may appear only in the late stages of acute pancreatitis, as the effusion spreads from the omental bursa and the right hypochondrium towards the right lateral canal and the iliac region.

Establishing the correct diagnosis is facilitated by:
- medical history;
- the presence of maximum pain in the epigastric region;
- symptoms characteristic of acute pancreatitis: absence of pulsation of the abdominal aorta in the epigastrium, the presence of painful resistance of the abdominal wall just above the navel and pain in the left costovertebral angle.

Differential diagnosis in difficult cases is helped by laboratory testing of amylase levels in the blood and urine.
Ultrasound and laparoscopy can identify signs specific to pancreatitis.

Perforation of a stomach or duodenal ulcer
This complication of peptic ulcer disease has a characteristic clinical picture. An accurate diagnosis is established in the presence of the classic triad (gastric history, “dagger” pain in the epigastrium, widespread muscle tension). Also pathognomonic for a perforated gastric or duodenal ulcer, a symptom that is often detected is the disappearance of hepatic “dullness.” In addition, perforation of the ulcer is very rarely accompanied by vomiting.

Difficulties may arise in the differential diagnosis of acute appendicitis and covered perforation of an ulcer. With a covered perforation, the contents of the stomach that have entered the abdominal cavity and the resulting effusion gradually descend into the right iliac fossa and are retained there. In the same way, the pain shifts: after covering the perforation, the pain subsides in the epigastrium and appears in the right iliac region.
Due to this false Kocher-Volkovich symptom, an erroneous conclusion about the presence of acute appendicitis is possible. Errors in diagnosis are also facilitated by the fact that muscle tension and other symptoms of peritoneal irritation are noted in the right iliac region.

The immediate and long-term history of the disease is assessed. Evidence in favor of a perforated ulcer is:
- existing gastric discomfort;
- direct indications of a previous peptic ulcer;
- the onset of the disease is not with dull, but with very sharp pain in the epigastrium;
- not frequent vomiting.
Percussion or x-ray detection of free gas in the abdominal cavity helps resolve doubts.

Acute cholecystitis
Acute cholecystitis begins with very sharp pain in the right hypochondrium with typical irradiation to the right shoulder and scapula. Also, the onset of the disease is usually characterized by the presence of biliary (liver) colic, which is often accompanied by repeated vomiting of food and bile.

Anamnesis. When questioning the patient, it usually turns out that attacks of pain occurred more than once, and their occurrence is associated with a change in the usual diet (taking large amounts of fatty foods, alcohol, etc.). In some cases, it is possible to establish the presence of transient jaundice that appears shortly after an attack of pain.

When conducting an objective examination, it should be borne in mind that with a high position of the appendix, maximum pain and muscle tension are localized in the lateral parts of the right hypochondrium, and with cholecystitis, these signs are revealed more medially.
In acute cholecystitis, an enlarged and sharply painful gallbladder is often palpated.
Body temperature is significantly higher compared to appendicitis.
Ultrasound can reveal signs typical of gallbladder inflammation (increase in the volume of the bladder, the thickness of its walls, layering of the walls, etc.).

Right-sided renal colic
It begins not with dull, but with extremely sharp pain in the right lumbar or right iliac region. Often, against the background of pain, vomiting occurs, which is of a reflex nature. In typical cases, pain radiates to the right thigh, perineum, and genitals.
Dysuric disorders in the form of painful frequent urination are noted. It should be borne in mind that dysuric disorders are also observed in acute appendicitis (in the case of close proximity of the inflamed appendix to the right kidney, ureter or bladder), but are less pronounced than in renal colic.

Anamnesis. Unlike renal colic, with appendicitis there is never very severe paroxysmal pain with the previously mentioned irradiation.

Physical examination. A patient with renal colic does not exhibit intense pain in the abdomen and symptoms of peritoneal irritation.

To make a final diagnosis, a laboratory urine test, urgent emergency urography or chromocystoscopy are performed.

In some cases, conventional plain radiography of the urinary tract is effective, which can reveal the shadow of a radiopaque stone.
Ultrasound can detect stones in the projection of the right ureter and an increase in the size of the right kidney in a number of patients.

Right-sided pyelitis (pyelonephritis)
The disease, as a rule, has a subacute onset and is characterized by dull arching pain in the lumboiliac or mesogastric region. Vomiting and dysuria are often absent at the onset of the disease. 1-2 days after the onset of the disease, a sharp rise in body temperature is observed to 39 o C and above).

Anamnesis. Pyelitis is mainly a consequence of impaired urination caused by urolithiasis, pregnancy, prostate adenoma and other diseases.

Objective research. Sharp pain on palpation of the abdomen and symptoms of peritoneal irritation are not detected even in the presence of obvious signs of purulent intoxication. With pyelitis, there is often pain in the mesogastric region, iliac region and a positive Obraztsov sign.

Examination of urine during pyelitis reveals pyuria.
Survey and contrast urography for pyelitis often reveals unilateral or bilateral pyelectasia in the patient, which can also be determined by ultrasound.

Interrupted ectopic pregnancy and apoplexy of the right ovary
These diseases in some cases can imitate the clinical picture of acute appendicitis. Unlike the latter, they are characterized by the sudden appearance of sharp pain in the lower abdomen. There are signs of blood loss: dizziness, weakness, pale skin, tachycardia.

Anamnesis. Delayed menstruation (ectopic pregnancy) or mid-menstrual cycle (apoplexy).

Hyperthermia and leukocytosis are absent, anemia is detected.

When palpating the abdomen, tension in the muscles of the anterior abdominal wall is not detected, but withdrawal of the hand is accompanied by increased pain (Kulenkampf's symptom).

Acute adnexitis
It is an inflammatory lesion of the uterine appendages, which has manifestations similar to acute appendicitis.
Differences:
- absence of Kocher-Volkovich sign;
- presence of discharge from the genital tract;
- often high temperature.

Objective examination: discrepancy between sufficiently pronounced signs of intoxication and minimal manifestations from the abdomen; Shchetkin-Blumberg's symptom is mostly negative.

Vaginal examination reveals enlarged and painful appendages, pain with traction of the cervix.
Ultrasound and laparoscopy are also of great importance for identifying diseases of the female genital area.
;

Peritonitis;

Sepsis.

Postoperative complications:

1. According to the clinical and anatomical principle:

1.1 Complications from the surgical wound:
- bleeding from the wound;
- hematoma;
- seroma Seroma is an accumulation of serous fluid. Occurs due to the intersection of lymphatic capillaries, the lymph of which collects in the cavity between the subcutaneous fatty tissue and the aponeurosis, which is especially pronounced in obese people in the presence of large cavities between these tissues
;
- infiltrate;
- suppuration;
- postoperative hernias;
- divergence of wound edges without/with eventration Eventration - loss of internal organs from the abdominal cavity through a defect in its wall (often through a surgical wound)
;
- keloid scars;
- neuromas;
- endometriosis scars.

1.2 Acute inflammatory processes of the abdominal cavity:
- infiltrates and abscesses of the ileocecal area;
- abscesses of the rectal uterine cavity;
- interintestinal abscesses;
- retroperitoneal phlegmon;
- subphrenic abscess;
- subhepatic abscess;
- local peritonitis;
- widespread peritonitis;
- cult.

1.3 Complications from the gastrointestinal tract:
- dynamic intestinal obstruction;

- intestinal fistulas;
- gastrointestinal bleeding;
- adhesive disease.

1.4 Complications from the cardiovascular system:
- cardiovascular failure;
- thrombophlebitis;
- pylephlebitis Pylephlebitis - inflammation of the portal vein; occurs as a complication of purulent processes in the abdominal cavity, for example acute purulent appendicitis.
;
- pulmonary embolism;
- bleeding into the abdominal cavity.

1.5 Complications from the respiratory system:
- bronchitis;
- pneumonia;
- pleurisy Pleurisy - inflammation of the pleura (the serous membrane that covers the lungs and lines the walls of the chest cavity)
(dry, exudative);
- abscess and gangrene of the lungs;
- atelectasis Atelectasis is a condition of the lung or part of it in which the alveoli contain little or no air and appear collapsed.
lungs.

1.6 Complications from the excretory system:
- acute urinary retention;
- acute cystitis;
- acute pyelitis Pyelitis - inflammation of the renal pelvis
;
- acute nephritis;
- acute pyelocystitis.

1.7 Other complications (acute mumps, postoperative psychosis, etc.).

2.By development time:

2.1 Early complications - occur during the first 2 weeks after surgery. This group includes most complications from the postoperative wound and almost all complications from adjacent organs and systems.

2.2 Late complications - diseases that developed after a 2-week postoperative period:
2.2.1 From the side of the postoperative wound:
- infiltrates;
- abscesses;
- ligature fistulas;
- postoperative hernias;
- keloid scars;
- neuromas Neuroma is a benign tumor that develops from Schwann membrane cells (the sheath of the myelin nerve fiber)
scars.

2.2.2 Acute inflammatory processes in the abdominal cavity:
- infiltrates;
- abscesses;
- cult.

2.2.3 From the gastrointestinal tract:
- acute mechanical intestinal obstruction;
- adhesive disease.

Treatment abroad

Ticket 1. Question 1. Acute appendicitis. Etiology, pathogenesis, classification, clinical picture, treatment.

Acute appendicitis is a nonspecific inflammation of the appendix.

Etiopathogenesis

The disease is polyetiological. Several points can be highlighted:

Neurogenic theory - a violation of the nervous regulation of the appendix leads to the development of spasm of muscles and blood vessels, which leads to disruption of blood circulation in the appendix with the development of edema of the appendix wall;

Direct irritation of the nerve endings of the appendix by foreign bodies (helminthic infestation, coprolites), which leads to obstruction of the proximal part of the appendix and mucus, which continues to be produced in the appendix, leads to its overstretching, which is caused by an increase in pressure in it, and as a result, blood circulation in the wall of the appendix is ​​disrupted ;

Infectious moment - an infection can enter the appendix both hematogenously and lymphogenously, which, if there is a circulatory disorder in it, will lead to its inflammation

Stretching the walls of the appendix with its swelling and deterioration of blood circulation in it leads to the fact that the mucous membrane of the appendix loses resistance to microorganisms that are constantly present in it, and inflammation develops.

Classification

1. Acute catarrhal appendicitis.

2. Acute phlegmonous appendicitis (simple, phlegmonous-ulcerative, empyema of the appendix, apostematous appendicitis with and without perforation).

3. Acute gangrenous appendicitis: primary with or without perforation, secondary.

Typical clinic acute appendicitis. Developing sharp, against the backdrop of prosperity. Pain appears in the right iliac region. They are aching and cutting in nature, rarely colic and cramping in nature. The pain intensifies when the parietal peritoneum is involved. There is vomiting 1-2 times, which does not alleviate the condition, vomiting is always secondary, and pain is primary. At first the condition is satisfactory. When moving (walking, turning, bending), the pain intensifies. The patient can take a position on his back or on his right side with his legs adducted. A sharp rise in temperature is not typical, usually no more than 38°C. Tachycardia. The tongue is a bit dry, maybe. covered with a white, gray-dirty coating. When examining the abdomen during breathing, the right iliac region lags behind.

In approximately 30% of patients, pain first occurs in the epigastric region (Volkovich-Dyakonov symptom), and then after 2-4 hours moves to the right iliac region (Kocher symptom).

With superficial palpation in the right iliac region, protective muscle tension is determined.

Shchetkin-Blumberg symptom. When palpating the right iliac region, we sharply release the hand, which leads to a sharp increase in pain.

Rovsing's symptom- occurs in 70%. When clamping, the sigma produces jerking movements above the point of clamping, which leads to pain in the right iliac region.

Sitkovsky's symptom- when turning to the left side, the pain in the right iliac region intensifies.

Barthomier-Mechelson's sign- when palpating the right iliac region in a position on the left side, the pain intensifies and moves closer to the navel. This symptom is important when palpating obese people, as the cecum becomes more accessible.

Voskresensky's sign (shirts). Sharp sliding movements are made along the stretched shirt from the epigastrium down to the right and left.

Obraztsov's symptom. The right iliac region is palpated and, without releasing the hand, the patient is asked to raise his right leg. This symptom cannot be used when there is significant tension in the abdominal wall, which is dangerous due to rupture of the altered process.

Symptom Mendel. Tapping is performed at different points. Tapping in the right iliac region increases the pain.

Razdolsky's symptom. When percussing the right iliac region, the pain intensifies.

Treatment of acute appendicitis

Early emergency surgery;

Limitation: presence of infiltrate and requiring preoperative preparation; pain reliever - general or local; local + N L A;

Closure of the abdominal cavity tightly or with drainage;

Postoperative period: prevention of complications

Etiology

Most often, widespread purulent peritonitis is observed. Frequent causes are:

Destructive appendicitis;

Destructive forms of acute cholecystitis;

Diseases of the stomach and duodenum;

Ulcer, cancer, complicated by perforation;

Acute pancreatitis;

Perforation of diverticula and colon cancer;

Thrombosis of the vessels of the mesentery of the small and large intestine, penetrating wounds, anastomotic failure.

An important role in the pathogenesis of peritonitis belongs to the immunological protection carried out by intestinal lymphocytes, Peyer's patches, mesenteric lymph nodes, lysothemia cells of the omentum and peritoneum, as well as immunoglobulins.

If protective mechanisms do not ensure the resorption of exudate and blood residues in the surgical area, then the fluid becomes easily infected and localized peritonitis is formed. When the body's defenses are weak, microbial aggression increases, inflammation progresses, spreads throughout the peritoneum, exudate forms, and diffuse peritonitis develops.

Peritoneum(lat. peritoneum) - a thin translucent serous membrane covering the internal walls of the abdominal cavity and the surface of the internal organs. The peritoneum has a smooth shiny surface, formed by two layers - visceral (covering the organs) and parietal (parietal), passing into each other to form a closed sac - the peritoneal cavity (lat. cavum peritonei).

The peritoneal cavity is a system of slit-like spaces filled with serous contents, formed both between individual sections of the visceral layer and between the visceral and parietal layers. The leaves of the peritoneum form folds that protrude inwards, forming the mesenteries of the hollow organs, the greater and lesser omentum.

There are organs covered with peritoneum on all sides (intraperitoneal - stomach, uterus), on three sides (mesoperitoneal - liver) and on one side (extraperitoneal - pancreas). In this case, the vessels and nerves heading to the abdominal organs from the retroperitoneal space do not pierce the peritoneum, but lie in the slit-like spaces between the layers mesentery- duplication of the peritoneum connecting the visceral peritoneum of the organ with the parietal

Ticket 3 Question 2. Gastroduodenal bleeding. Causes (peptic ulcer, erosive gastritis, Mallory-Weiss syndrome, varicose veins of the esophagus, tumors, etc.), clinical picture, diagnosis, differential diagnosis, treatment.

Causes Peptic ulcer - 71.2% Varicose veins of the esophagus - 10.6% Hemorrhagic gastritis - 3.9% Cancer and leiomyoma of the stomach - 2.9% Other: Mallory-Weiss syndrome, hiatal hernia, burns and injuries - 10, 4%.

Clinical picture Anamnesis. Chronic diseases of the stomach, duodenum, liver, blood Complaints of weakness, dizziness, drowsiness, fainting, thirst, vomiting of fresh blood or coffee grounds, tarry stools Objective data. Pale skin and visible mucous membranes, dry tongue, rapid and soft pulse, blood pressure with minor blood loss is initially increased, then normal. With significant blood loss, the pulse progressively increases, blood pressure decreases, and central venous pressure decreases already in the early stages. Rectal examination reveals tarry stool. Laboratory findings. In the first 2–4 hours there is a slight increase in Hb followed by a decrease. The decrease in Hb and Ht (the result of hemodilution) progresses with continued blood loss, BCC decreases with increasing blood loss

Diagnostics FEGDS: identify the source of bleeding and its nature, assess the risk of relapse if the bleeding has stopped. Radionuclide research is based on the introduction of serum albumin into the blood (label - radioactive isotopes of iodine or technetium) with subsequent search/study of radioactivity in the bleeding area. The method is applicable (and indicated) only if hidden bleeding continues.

Differential diagnosis. Esophageal-gastric bleeding is sometimes mistaken for pulmonary bleeding (in which part of the coughed up blood can be swallowed and then vomited in a modified form like coffee grounds), and for intestinal bleeding in women from the uterus. Differential diagnosis should also be carried out with acute bleeding into the abdominal cavity (with rupture of the liver, spleen, ectopic pregnancy, etc.), when the leading clinical picture is a suddenly developing collapse in a patient with a pathology of the digestive tract (peptic ulcer, diverticulum, tumor, etc.) .d.), It must be remembered that when bleeding from the gastrointestinal tract, some time usually passes, although relatively short, before the blood is released into the external environment.

For hemostatic therapy medications that increase blood clotting and drugs that reduce blood flow in the area of ​​bleeding are used. These events include:

1) intramuscular and intravenous fractional injection of plasma of 20–30 ml every 4 hours;

2) intramuscular administration of a 1% solution of Vikasol up to 3 ml per day;

3) intravenous administration of a 10% solution of calcium chloride;

4) aminocaproic acid (as an inhibitor of fibripolysis) intravenous drip of 100 ml of a 5% solution after 4 - 6 hours.

The use of hemostatic agents must be monitored by blood clotting time, bleeding time, fibrinolytic activity and fibrinogen concentration.

Recently, along with general hemostatic therapy, the method of local gastric hypothermia has been used to stop gastroduodenal bleeding. When performing an endoscopic examination, the bleeding vessel is clipped or coagulated.

For bleeding from arrosive varicose veins of the esophagus, the most effective is the use of an esophageal probe with Blakemore pneumatic balloons.

In the complex of measures for acute gastroduodenal bleeding, an important place belongs to blood transfusion in order to compensate for blood loss

Urgent surgical treatment is indicated for unstoppable bleeding.

COMPLICATIONS.

Acute bowel perforation It is not observed often, the occurrence of this complication is directly related to the activity of the inflammatory process and the extent of intestinal damage; this is the most dangerous complication of ulcerative colitis and has the greatest mortality.

Strictures of the rectum or colon. Obstruction caused by benign strictures occurs in approximately 10% of patients with ulcerative colitis.

Toxic megacolon(Acute toxic dilatation of the colon)
Cancer against the background of ulcerative colitis.

Clinic depends on the form of ulcerative colitis and the presence or absence of complications.

In the acute (fulminant) form (in 10% of patients) of ulcerative colitis, diarrhea (up to 40 times a day) with the release of blood and mucus, sometimes pus, severe pain throughout the abdomen, tenesmus, vomiting, and high body temperature are observed. The patient's condition is serious. Blood pressure decreases, tachycardia increases. The abdomen is swollen and painful on palpation along the colon. Leukocytosis is detected in the blood with a shift in the leukocyte formula to the left, a decrease in the level of hemoglobin, hematocrit, and the number of red blood cells. As a result of diarrhea, accompanied by the loss of large amounts of fluid, significant loss of body weight, disturbances in water-electrolyte metabolism and acid-base status, and vitamin deficiency quickly occur.

The vast majority of patients have a chronic relapsing form of ulcerative colitis (50%), characterized by alternating periods of exacerbations and remissions, and periods of remission can reach several years

An exacerbation of the disease is provoked by emotional stress, fatigue, errors in diet, the use of antibiotics, laxatives, etc. During periods of exacerbation of the disease, the clinical picture resembles that of the acute form of the process. Then all manifestations of the disease subside, diarrhea disappears, the amount of blood, pus and mucus in the feces decreases, and pathological discharge gradually stops. Remission of the disease occurs, during which patients do not present any complaints.

Complications: bleeding, perforation, toxic dilatation of the intestine, stenosis, malignancy.

Diagnostics- based on an assessment of medical history, patient complaints, results of sigmoidoscopy, irrigography, colonoscopy.

Differential diagnosis carried out with dysentery, proctitis, Crohn's disease.

Treatment: conservative therapy for ulcerative colitis includes a diet with a predominance of proteins, limiting the amount of carbohydrates, excluding milk, desensitizing and antihistamines (diphenhydramine, pipolfen, suprastin); vitamins (A, E, C, K, group B); bacteriostatic drugs (etazol, phthalazol, sulgin, enteroseptol). Treatment with salazopyridazine, which has an antimicrobial and desensitizing effect, gives good results. In the absence of effect from the therapy and in the acute form of the disease, it is advisable to use steroid hormones (prednisolone, dexamethasone).

Surgical treatment is indicated for the development of complications that threaten the patient's life (profuse bleeding, intestinal perforation, toxic dilatation). Indications for surgical treatment also arise in case of continuous or recurrent course of the disease, which is not controlled by conservative measures, with the development of cancer.

For toxic dilatation of the colon, an ileo- or colostomy is performed. In other situations, they resort to resection of the affected part of the intestine, colectomy or coloproctectomy, ending with the application of an ileostomy.

Treatment

Depending on the cause of intussusception (which, as a rule, varies significantly for different age groups), its treatment can be conservative or surgical. In infants, intussusception in most cases resolves with conservative measures. Currently, a conservative method of treating intestinal intussusception is used - pumping air into the large intestine through a gas outlet using a pressure bulb. This method is effective for small-colic intussusception for up to 18 hours. As a rule, small-intestinal intussusception cannot be straightened in this way.

Ticket 6 Question 3. Surgical treatment of acute cholecystitis. Indications for surgical intervention, preoperative preparation, types of operations. Indications and contraindications for laparoscopic cholecystectomy.

Anesthesia. In modern conditions, the main type of pain relief during operations for acute cholecystitis and its complications is endotracheal anesthesia with relaxants. Under conditions of general anesthesia, the duration of the operation is reduced, manipulations on the common bile duct are facilitated, and the prevention of intraoperative complications is ensured. Local anesthesia can only be used when performing a cholecystostomy.

Surgical approaches. To access the gall bladder and extrahepatic bile ducts, many incisions of the anterior abdominal wall have been proposed, but the most common are the Kocher, Fedorov, Cherny incisions and upper midline laparotomy. The optimal incisions are in the right hypochondrium according to Kocher and Fedorov.

Scope of surgery. In acute cholecystitis, it is determined by the general condition of the patient, the severity of the underlying disease and the presence of concomitant changes in the extrahepatic bile ducts. Depending on these circumstances, the nature of the operation may be cholecystostomy or cholecystectomy.

The final decision on the extent of surgical intervention is made only after a thorough examination of the extrahepatic bile ducts, which is carried out using simple and accessible research methods (inspection, palpation, probing through the stump of the cystic duct or the opened common bile duct), including intraoperative cholangiography. Intraoperative cholangiography is a mandatory element of surgery for acute cholecystitis. Only according to cholangiography data can one reliably judge the condition of the bile ducts, their location, width, presence or absence of stones and strictures. Based on cholangiographic data, they argue for intervention on the common bile duct and the choice of a method for correcting its damage.

Cholecystectomy. Removal of the gallbladder is the main operation for acute cholecystitis, leading to a complete recovery of the patient. As is known, two methods of cholecystectomy are used - from the neck and from the fundus. N

Cholecystostomy. Despite the palliative nature of this operation, it has not lost its practical significance. As a low-traumatic operation, cholecystostomy is used in the most severe and weakened patients, when the degree of surgical risk is especially high

Indications for cholecystectomy using laparoscopic technique:

6. chronic calculous cholecystitis;

7. polyps and cholesterosis of the gallbladder;

8. acute cholecystitis (in the first 2-3 days from the onset of the disease);

9. chronic acalculous cholecystitis;

10. asymptomatic cholecystolithiasis (large and small stones).

Contraindications. The main contraindications to laparoscopic cholecystectomy should be considered:

4. severe pulmonary-cardiac disorders;

5. disorders of the blood coagulation system;

6. late stages of pregnancy;

7. malignant lesion of the gallbladder;

8. previous operations on the upper floor of the abdominal cavity.

Ticket 7. Question 1. Acute appendicitis. Preparing for surgery. Postoperative management of patients. Ways to reduce mortality.

In patients with acute appendicitis, strangulated hernia, and ectopic pregnancy, after examination and obtaining consent for surgery, preoperative preparation is limited to the administration of morphine and cardiac drugs;

9. In case of uncomplicated course of the wound after appendectomy but due to gangrenous appendicitis, the primary delayed sutures are applied on the third or fourth day.

10. A general blood test is prescribed one day after surgery and before discharge.

11. For all forms of acute appendicitis, the sutures are removed on the 7th - 8th day, the day before the patient is discharged for treatment in the clinic.

12. In the conditions of hospital-outpatient complexes, when contacts with polyclinic surgeons have been worked out, discharge can be carried out earlier, before the sutures are removed.

13. After endovideosurgical operations, discharge can be carried out starting from 3-4 days.

14. Treatment of developing complications is carried out in accordance with their nature

Reduced mortality - laparoscopy

Causes of the disease

The development of the disease is promoted by stagnation of bile. The main cause of cholangitis is chronic inflammation of the gallbladder with subsequent spread of infection to the bile ducts.

Clinic: The disease usually begins with a painful attack reminiscent of hepatic colic (a manifestation of choledocholithiasis), after which obstructive jaundice, fever, and skin itching quickly appear. On examination, the skin is icteric, there are traces of scratching on the skin, the tongue is moist and coated, the abdomen is not distended. On palpation of the abdomen, there is some muscle rigidity in the right hypochondrium, pain; with deep palpation, an increase in the size of the liver is determined, its edge is rounded. Temperature is sometimes hectic, chills. In the blood there is leukocytosis with a shift to the left. Hyperbilirubinemia mainly due to direct bilirubin, increased alkaline phosphatase, moderate increase in liver enzymes (ALT, AST) due to toxic damage to the liver parenchyma. Ultrasound examination of the liver and biliary tract can provide significant assistance in establishing the diagnosis of cholangitis.

For diagnostics narrowing of the large bile ducts, retrograde (endoscopic) cholangiography is performed

Treatment of cholangitis

A patient with suspected cholangitis needs urgent hospitalization, since treatment is predominantly surgical. At the pre-medical stage, antispasmodic and anti-inflammatory drugs, broad-spectrum antibiotics that do not have hepatotoxic properties are prescribed.

The management of patients with cholangitis presents significant difficulties; they are caused by the presence of a purulent process, obstructive jaundice and acute destructive cholecystitis. Each of these points requires prompt resolution, but patients with obstructive jaundice cannot tolerate lengthy and traumatic surgical interventions. Therefore, it is advisable, first of all, to ensure adequate outflow of bile, which simultaneously reduces the clinical manifestations of cholangitis and intoxication. The second stage is a radical intervention aimed at eliminating the cause of cholangitis.

In the hospital, detoxification and antibacterial therapy is carried out and the patient is prepared for surgery. The most widespread in acute cholangitis are endoscopic methods of drainage of the bile ducts, ensuring normal outflow of bile. The prognosis of catarrhal cholangitis with timely treatment is favorable. With purulent, diphtheritic and necrotic cholangitis, the prognosis is more serious and depends on the severity of morphol. changes, the general condition of the patient, as well as the factor that caused cholangitis. With long-term chronic cholangitis, biliary cirrhosis of the liver or abscess cholangitis may develop, the prognosis of which is unfavorable. Prevention consists of timely detection and treatment of diseases of the biliary tract and the area of ​​the major duodenal papilla.

In order to decompress the biliary tract, endoscopic papillosphincterotomy is performed after preliminary retrograde cholangiography. With residual stones of the common bile duct after papillosphincterotomy, the passage of stones from the biliary tract is sometimes observed, the phenomena of cholangitis are stopped and the question of the need for repeated surgery disappears. The prognosis is serious.

Clinical picture.

Symptoms of colon diverticulosis may not appear for a long time and are often discovered by chance during examination of patients.
Clinically expressed uncomplicated diverticulosis of the colon manifests itself:
- abdominal pain;
- intestinal dysfunction;
The pain varies in nature, from mild tingling to severe colicky attacks. Many patients experience mild or moderate but constant pain. More often they are determined in the left half of the abdomen or above the womb.
In most patients, pain decreases after bowel movement, but in some patients, the act of defecation increases pain.
Intestinal dysfunction often manifests itself in the form of constipation, and prolonged absence of stool significantly increases the pain syndrome. Less common is loose stool (diarrhea), which is not permanent. Patients often complain of unstable stools, sometimes combined with nausea or vomiting.

Complications:

18. Diverticulitis

19. Diverticulum perforation

20. Intestinal obstruction.

21. Intestinal bleeding –

Diagnostics

Detection of diverticulosis is possible only with the help of instrumental research methods. The leaders are:
- irrigoscopy;
- colonoscopy;
- sigmoidoscopy;
The size and number of identified diverticula vary from single to multiple, distributed throughout the colon, with a diameter of 0.2-0.3 to 2-3 cm or more.
It is necessary to carry out differential diagnosis with a colon tumor.

Conservative treatment.

Asymptomatic diverticulosis of the colon, discovered by chance, does not require special treatment. Such patients are recommended to eat a diet rich in plant fiber.
For diverticulosis with clinical manifestations:
- diet (dietary fiber);
- antispasmodics and anti-inflammatory drugs;
- bacterial preparations and products;
- antibiotics (for diverticulitis);
- intestinal antiseptics;
The diet must be followed constantly, drug therapy - in courses of 2-6 weeks - 2-3 times a year. For many patients, this treatment produces a lasting, long-lasting effect.

Surgery.

Indicated in 10-20% of patients with colon diverticulosis.
Indications for urgent surgery:
- perforation of the diverticulum into the free abdominal cavity;
- breakthrough of a perifocal abscess into the free abdominal cavity;
- intestinal obstruction;
- profuse intestinal bleeding.
Indications for elective surgery:
- chronic infiltrate simulating a malignant tumor;
- colonic fistulas;
- chronic diverticulitis with frequent exacerbations;
- clinically pronounced diverticulosis, not amenable to complex conservation. treatment.

APPENDICULAR INFILTRATE

- This is limited peritonitis, caused by. inflammation c.o.

Develops 3-5 days after an acute attack. As a result, it will inflame. reactions sweat fibrin. glues the omentum, loops of the small intestine, uterine appendages, which limits the c.o. in the iliac region. Then the organs themselves became inflamed, forming an infiltrate (tumor).

Stages: 1) restriction in the abdominal cavity

2) will inflame. tissue infiltration

3) resorption (remaining adhesions) or suppuration (maybe drainage of the abscess into the abdominal cavity, intestine or out).

A tumor-like formation is palpated in the right iliac region - smooth, non-lumpy, mobile.

Required differentiation with a tumor in the cecum (irregoscopy - uneven contour and filling defect), in the ovary, uterus. (See question further)

Treatment: strict bed rest, food without a large amount of fiber, bilateral perinephric blockade with 0.25% novocaine solution according to Vishnevsky, antibiotics, when the process subsides - enemas with warm soda solution, DDT, UHF. After 4-6 weeks. in plans. order - appendectomy (possible 10 days after hospital treatment).

Clinical picture

The onset of the disease is a typical attack of acute appendicitis.

If there are signs of acute appendicitis within 2-3 days, the formation of an appendiceal infiltrate should be assumed.

Palpation - a painful, immobile tumor-like formation in the right iliac region, its lower pole is determined during vaginal or rectal examination.

There are no clinical signs of widespread peritonitis.

2 options for the development of the clinical picture: The ongoing treatment of appendiceal infiltrate is ineffective Increase in body temperature to 39-40 ° C Increase in infiltrate in size (approaching the anterior abdominal wall) Increasing intensity of throbbing pain Appearance of signs of peritoneal irritation Increasing the difference between body temperature measured in the armpit and rectum The treatment of appendicular infiltrate gives a temporary effect - local symptoms are smoothed out, but after 2-3 days (on the 5-7th day of illness) the process begins to progress. Skin hyperemia and fluctuation are late signs.

In some cases - phenomena of intestinal obstruction.

Laboratory research Gradually increasing leukocytosis with a nuclear shift to the left. Significant (up to 30-40 mm/h) increase in ESR.

Special research methods Rectal or vaginal examination - severe pain, sometimes you can palpate the lower pole of the formation. Plain radiography of the abdominal organs - fluid level in the right half of the abdominal cavity. Ultrasound allows you to determine the size of the abscess and its exact location.

Treatment- surgical: opening and drainage of the abscess cavity Anesthesia - general Access is determined by the localization of the abscess Right-sided lateral extraperitoneal Through the rectum Through the posterior vaginal fornix

Removal of the appendix is ​​not considered a mandatory procedure. The abscess cavity is washed with antiseptics.

Drainages Double-lumen tubes for washing and active aspiration of contents in the postoperative period Cigar-shaped drainages Drainages from hydrated cellulose membrane In the postoperative period - detoxification and antibacterial therapy. Diet. In the initial period - diet No. 0.

Complications Opening of an abscess into the free abdominal cavity, intestinal lumen, on the skin of the right iliac region Sepsis Pylephlebitis Liver abscess

The prognosis is serious and depends on the timeliness and adequacy of surgical intervention.

Esophageal diverticula.

The most common localization is the cervical esophagus (70%), the level of the tracheal bifurcation (20%) and the supradiaphragmatic esophagus (10%). Bifurcation diverticula are classified as tractional, while the rest are classified as pulsational (see. Diverticum disease).

Cervical esophageal diverticulum occurs as a result of weakness of the posterior wall of the pharyngoesophageal junction (Lymer's triangle) - on one side and dyskinesia of the cricopharyngeal muscle - on the other.

Among diverticula of the cervical esophagus, diverticulum is the most common Zenker. This is a sac-like protrusion of the mucous membrane of the esophagus located above the area of ​​the cricopharyngeus muscle, forming first on its posterior wall and then moving to the sides. Quite often, a saccular diverticulum filled with food masses causes external compression and obstruction of the esophagus. Large diverticula require surgical treatment.

Bifurcation diverticula are considered tractional. They are formed due to the tension of the adhesions of the peri-esophageal tissue in the middle and distal parts of the esophagus; It is believed that they occur secondary to inflammatory processes, for example, tuberculosis (scarring of lymph nodes, granulomas).

Supradiaphragmatic diverticula are usually located in the lower third of the esophagus above the esophageal opening of the diaphragm. They most often originate from the right wall of the esophagus, but grow to the left.

Clinical picture

Diverticulum Zenker. The main symptom is dysphagia. If the diverticulum is large, after eating, there is a feeling of pressure and fullness in the neck, while at the same time a palpable formation appears in front of the left sternocleidomastoid muscle. A diverticulum gradually filling with food can put pressure on the esophagus and cause its obstruction. When the diverticulum is emptied, it occurs. regurgitation of food debris into the oral cavity, accompanied by a specific noise - the patency of the esophagus is restored. When pressing on the diverticulum, regurgitation of food debris also occurs; acidic gastric contents are not released. Regurgitation can also occur at night (traces of food and mucus remain on the pillow), bad breath appears, coughing, and the voice takes on a gurgling tone.

Bifurcation diverticulum. The clinical picture is similar to cervical diverticula and is provoked by a breakdown Valsalvas

Supraphrenic diverticula are often asymptomatic.

Treatment. Surgical treatment is indicated for large diverticula that are prone to complications.

Etiology

Endogenous factors include, first of all, gender and age.

The constitutional factor apparently also plays a significant role.

Of the exogenous factors, the main role seems to be played by nutritional characteristics associated with the geographical, national and economic characteristics of the life of the population.

Symptoms

Ortner's symptom:

sign o. cholecystitis; the patient is in a supine position. When you tap the edge of your palm on the edge of the costal arch on the right, pain is detected

Murphy- Pressing evenly with the thumb on the area of ​​the gallbladder (Kera point - the intersection of the outer edge of the right rectus abdominis muscle and the right costal arch, or more precisely, with the previously found lower edge of the liver), the patient is asked to take a deep breath; at the same time, he takes away his breath and there is significant pain in this area.

Mussi-Georgievsky's symptom (phrenicus symptom):

Diagnostics

The most popular method for diagnosing cholelithiasis is ultrasound. If ultrasound is performed by a qualified specialist, there is no need for additional examinations. Although, cholecystoangiography and retrograde cholangiopancreatography can also be used for diagnosis. Computed tomography and nuclear magnetic resonance imaging are more expensive, but they allow diagnosing the course of the disease with no less accuracy.

Therapy

The Pevzner diet No. 5 is recommended. For conservative treatment, shock wave lithotripsy can be used; use is recommended in the absence of cholecystitis and the total diameter of stones up to 2 cm, good contractility of the gallbladder (at least 75%). The effectiveness of ultrasonic methods is quite low, less than 25%, since in most cases the stones are not fragile enough. Of the minimally invasive methods, laparoscopic cholecystectomy is used. These methods do not always achieve the desired result, so laparotomy cholecystectomy “from the neck” is performed. The classic abdominal surgery to remove the gallbladder, cholecystectomy, was first performed in 1882 in Berlin.

Removing the gallbladder in 99% of cases eliminates the problem of cholecystitis. As a rule, this does not have a noticeable effect on life activities, although in some cases it leads to postcholecystectomy syndrome (clinical symptoms may persist in 40% of patients after standard cholecystectomy for gallstones). The lethality of operations varies significantly for acute (30-50%) and chronic forms of the disease (3-7%).

TREATMENT

Preoperative preparation lasts no more than 2 - 3 hours and is aimed at reducing intoxication and correcting the activity of vital organs. To reduce intoxication and restore water-electrolyte metabolism, the patient is administered solutions of hemodez, glucose, and Ringer.

Online access should provide the opportunity to examine the entire abdominal cavity. This requirement is met by a median laparotomy above and below the navel, bypassing it on the left. If the source of peritonitis is precisely known, then other approaches are possible (for example, lower middle, in the right hypochondrium, etc.). After this, a surgical procedure is carried out, which includes eliminating the source of peritonitis. The completion of the operation consists of sanitation and drainage of the abdominal cavity.

Great value for

Acute appendicitis is a nonspecific inflammatory disease of the appendix, caused by microbes of the intestinal flora and microbes of suppuration.

Infection into the appendix can occur in several ways:

• 1) enterogenously (from the lumen of the appendix);
• 2) hematogenously (the introduction of microbes into the lymphoid apparatus of the appendix from a distant source);
• 3) lymphogenous route (introduction of microbes from infected neighboring organs and tissues).

Pathogenic microbes are always present in the appendix, but appendicitis is a problem

It occurs only when the protective, barrier function of the epithelium is disrupted, which is observed when the body’s protective reactions are weakened and when external causes appear that predispose to the occurrence of a local infectious process in the tissues of the appendix.

Many of the theories of the pathogenesis of acute appendicitis are based on taking into account the action of these predisposing factors.

Let's consider the following theories of the pathogenesis of acute appendicitis.

1. The theory of stagnation associates the occurrence of appendicitis with stagnation of feces. Impaired contractility of the appendix with a narrow lumen can lead to the formation of fecal stones, which, by exerting constant pressure on the mucosa in combination with spasm of the muscles of the appendix, lead to the formation of bedsores on the mucosa with subsequent infection of the remaining layers of the appendix.

2. The theory of closed cavities (Dieulafoy, 1898).

The essence of this theory is that as a result of the formation of adhesions, scars, and kinks in the appendix, closed cavities are formed in which conditions are created for the development of inflammation.

• 3. Mechanical theory the origin of appendicitis is explained by the ingress of foreign bodies into the appendix - fruit seeds, toothbrush bristles, helminthic infestation; which mechanically damage the mucous membrane of the appendix and open the entrance gate for infection.
• 4. Infection theory (Aschoff, 1908) explains the occurrence of acute appendicitis by the influence of microbial flora, the virulence of which, due to some reasons that Aschof does not disclose, has increased sharply. Under the influence of microbial flora, especially enterococcus, a primary effect is formed in the mucous membrane of the appendix in one or even several places. The epithelial defect is covered with a layer of fibrin and leukocytes. Then the lesion spreads to other layers of the process.
• 5. Angioneurotic theory (Rikker, 1928).

The essence of this theory is that in the appendix

Due to neurogenic disorders, vascular spasm occurs. Impaired nutrition of the tissues of the appendix can lead to necrosis with subsequent development of inflammatory changes.

6. Hematogenous theory (Kretz, 1913).

Kretz, during autopsies of patients who died of appendicitis, discovered significant changes in the tonsils. In his opinion, the tonsils in these patients were infectious foci, sources of bacteria. He considered the development of acute appendicitis in these cases as metastasis of the infection.

7. Allergic theory (Fischer, Keyserling).

The main provisions of this theory boil down to the fact that white food sensitizes the body and, under certain conditions, can become an allergen, the action of which causes a response from the vermiform appendix.

8. Nutritional theory (Hoffman).

Proponents of this theory believe that protein-rich foods promote the development of rot in the intestines and activate the microbial flora. The nutritional theory is based on statistical data indicating a sharp decrease in the incidence of appendicitis in Russia and Germany during the years of famine (1918-1922) and an increase in incidence due to the improvement in the well-being of the people in the post-war years.

9. The theory of bauginospasm (I.I. Grekov).

I.I. Grekov believes that prolonged spastic contraction of the bauginian valve causes pain and stagnation of contents in the appendix, with subsequent damage to its mucosa and the spread of infection to the walls of the appendix. Having put forward the theory of bauginospasm, I.I. Grekov actually considered a possible neurogenic mechanism for the development of acute appendicitis.

10. Cortikov-vescial theory (A.V. Rusakov, 1952).

According to this theory, the pathogenesis of acute appendicitis is based on a disruption of the normal functioning of the cerebral cortex. This disorder can be caused by both extroceptive and interoceptive pathological influences, causing foci of stagnant excitation and inhibition in the cerebral cortex, which strengthen or weaken reflex reactions from the internal organs or even distort them. An attack of appendicitis occurs only when, on the basis of an inert process of excitation in the cerebral cortex between the latter and the internal organs (in this case, the appendix), a pathological reflex arc is formed and a neuro-reflex spasm of the vessels of the appendix occurs, leading to ischemia, and then to necrosis of its tissues. Later, infection sets in.

The cortico-visceral theory of the genesis of acute appendicitis has led to an attempt to identify the functional stage of acute appendicitis, in which there are only reversible changes in the nerve elements, and inflammatory changes have not yet developed. Recognition of the existence of a functional stage of acute appendicitis led to the fact that wait-and-see tactics, previously rejected by all surgeons, began to be initiated again to some extent. Practice has shown. That on the basis of clinical data it is impossible to distinguish the functional stage of appendicitis, and expectant management leads to an increase in the number of patients with destruction of the appendix. Therefore, the principle of emergency surgery when a diagnosis of acute appendicitis is established remains unshakable.

11. The theory of appendicopathy, put forward in 1964 by I.V. Davydovsky and V.S. Yudin tried to explain why, with an obvious clinical picture of acute appendicitis, inflammatory changes are often not detected in the appendix. These authors proposed to distinguish between acute appendicitis and appendecopathy, which was understood as a set of clinical manifestations of acute appendicitis without an anatomical picture of inflammation of the appendix. According to I.V. Davydovsky and V.S. Yudina appendicopathy is caused by vasomotor changes in the appendix and in the area of ​​the ileocecal angle, i.e. appendicopathy is actually a functional stage of acute appendicitis. The theory of appendicopathy was not recognized by surgeons.

Concluding the discussion with the theory of the pathogenesis of acute appendicitis, it is necessary to highlight the leading factors leading to the development of appendicitis. These factors include:

• 1. Changes in the body's reactivity;
• 2. Changes in nutritional conditions;
• 3. Stagnation of contents in the cecum and appendix;
• 4. Spasm, and then thrombosis of blood vessels with the formation of foci of necrosis and the development of the inflammatory process.

In general, the pathogenesis of acute appendicitis can be presented

in the following way. The pathological process begins with functional disorders, which consist of spastic phenomena from the ileocecal angle (baginospasm), the cecum and the appendix. It is possible that spastic phenomena are initially based on digestive disorders, such as increased putrefactive processes with a large amount of protein food, helminthic infestation, fecal stones, foreign bodies, etc. Due to the commonality of autonomic innervation, spasm of smooth muscles is accompanied by vascular spasm. The first of them leads to impaired evacuation, stagnation in the appendix, and the second leads to local damage to the mucous membrane, which results in the primary effect. In turn, stagnation in the appendix helps to increase the virulence of the microflora, which, in the presence of a primary affect, easily penetrates the wall of the appendix. From this moment, a typical suppurative process begins, expressed in massive leukocyte infiltration at the beginning of the mucous and submucosal layers, and then all layers of the appendix, including its peritoneal cover. Infiltration is accompanied by rapid hyperplasia of the lymphoid apparatus of the appendix. The presence of necrotic tissue in the area of ​​one or more primary affects causes the appearance of pathological enzymes of suppuration - cytokinase, etc. These enzymes, having a proteolytic effect, cause destruction of the walls of the appendix, which ultimately ends with its perforation, the release of purulent contents into the free abdominal cavity and the development purulent peritonitis, as one of the most severe complications.

Acute appendicitis develops in response to an attack of a nonspecific type of infection by inflammatory phenomena in the appendix - the appendix. The cause of infection is a disruption of the normal relationship between the human body and the environment of microorganisms. Connecting exogenous and endogenous factors to the “conflict” accelerates the urgent need for immediate removal of the appendage. There are several manifestations of inflammation of the appendix, systematized by the nature of the disease, course and distribution. The pathanatomical and clinical classification of acute appendicitis is most often used.

Classification of acute appendicitis

The proposed classification includes anatomical, morphological and clinical manifestations, and also takes into account the diversity of inflammatory processes of appendicitis.

In practice, the following forms of inflammation of the appendix are encountered:

• Acute simple appendicitis, its second name, is superficial in the concept of many doctors.
• Acute appendicitis of destructive form:
  • simple phlegmonous;
  • beginning ulcers with phlegmonous form;
  • abscesses replacing ulcers - apostematous appendicitis with and without perforation;
  • gangrenous type with and without perforation.
• Acute complicated:
  • peritonitis, which can be local limited (not limited) or widespread diffuse (less often diffuse);
  • appendiceal infiltrate located in different places;
  • appendicular and periappendicular abscess;
  • pylephlebitis;
  • local abscess in the liver;
  • sepsis;
  • unrestricted inflammatory phenomena of a purulent nature in the retroperitoneal tissue.

According to the clinical course, there are 4 degrees of acute appendicitis:

• regressive type;
• no progress;
• with slow progress;
• with rapid progress.

In children, there is a discrepancy between the clinical picture of the disease and pathological changes in the tissues of the affected organ.

Etiology and pathogenesis of inflammation

Nonspecific inflammation

The etiology and pathogenesis of acute appendicitis causes a lot of controversy and evidence of different points of view, resulting in theories. To date, at least 12 theories are known that consider the possible causes, mechanism of development, termination and conditions for the development of the disease.

1. Proponents of the infectious theory believe that the source of inflammation of the appendix is ​​microorganisms that penetrate the cavity of the appendix and invade the mucous membrane of the organ.
2. According to the cortico-visceral theory, there is an increased impulse from the nervous system to the organs of the digestive system, causing contraction of the smooth muscles of certain organs. As a result, there is a decrease in the nutrition of groups of cells, causing their necrosis. The cells of the appendix mucosa are the most vulnerable. Later, infection invades the necrotic areas for the second time.
3. The etiology of acute appendicitis, according to the theory of fecal stagnation, is associated with the accumulation of fecal stones in the cavity of the appendix, and the pathogenesis considers fecalitis as the cause of microerosive phenomena in the mucous membrane of the appendix with the subsequent invasion of infection and, together, the development of the inflammatory process.
4. Closed cavity theory. When the outflow of contents from the appendix is ​​disrupted, stretching of its walls contributes to the formation of problems with blood supply. In addition, stagnant contents are an excellent environment for the proliferation of pathogenic microflora, both conditional and secondary.
5. The pathogenesis of appendicitis is associated with the invasion of pathogenic microflora from foci of infection localized in other organs. Migration of microorganisms occurs with the bloodstream (hematogenous theory).
6. The theory of nutrition as a source of inflammation. The etiology of the infection is associated with the activation of pathogenic microflora of a secondary nature and a conditional level of pathogenicity when meat foods with a small amount of fiber predominate in the diet and, as a result, appendicitis develops. Meat food takes a long time to digest and causes the development of putrefactive bacteria, which create an environment for pathogenic microorganisms. The validity of the theory is obvious, because in children under 2 years of age the insidious disease is not detected due to a diet not related to meat. If inflammation occurs in young children, the cause is associated with the intensive development of the lymphatic follicles of the appendix; normally they do not grow in children under 7 years of age. The increase in inflammatory reactions in the appendix in children over 7 years of age is explained by mature follicles.
7. The pathogenesis of acute appendicitis, according to the psychosomatic theory, is associated with frequent nervous stress, overexertion, phobias, and chronic fatigue.
8. Congenital curves cause stagnation in the lumen of the appendix and disruption of blood flow in the organ, and this is the best environment for the life of pathogenic microflora.
9. The theory of spasm of the bauhinian valve. The valve between the colon and ileum of the small intestine, under the influence of provoking factors, is capable of entering a state of spasm. In this case, the outflow of contents from the appendix is ​​disrupted, which is the cause of the onset of phlegmonous appendicitis. Inflammation increases with tissue swelling during spasms.
10. A specific virus, the effect of which is poorly understood, causes inflammation of the appendix. Occurs in most cases in children.
11. The allergy theory is similar to the nutrition theory, but has a view on the emphasized influence of food protein, against which an immune response is formed in the body. With increased protein nutrition and insufficient intake of plant fiber from food, putrefactive processes are added to the allergic reaction. Together, these factors cause the activation of a secondary infection.
12. The theory of blockage of the appendicular artery. As a result of poor blood supply to the tissues of the appendix by the appendicular artery, necrotic phenomena begin in the organ, followed by perforation of the organ.

A special form of inflammation occurs in children - hemorrhagic appendicitis. For inflammation of any etiology to begin, several conditions must be maintained:

• damage to the mucosa and disruption of its protective functions;
• an increase in the number of pathogenic microorganisms and activation of microflora of the secondary and conditional level of pathogenicity;
• reducing the body's immune response to the invasion of pathogenic bacteria.

Specific inflammation

When inflammation of the appendix is ​​of a specific nature, provoking factors are included that do not have a negative effect during the normal functioning of the body. These include helminthic infestations (flat and roundworms, Giardia, etc.), protozoa (amoebas, Trichomonas, etc.), fungi (actinomycetes, dimorphic yeasts).

Specific inflammation of the appendix is ​​detected after its removal. It is extremely rare and causes destructive appendicitis. The body responds to the aggression of microorganisms with serous inflammation, which develops in stages regardless of etiology: from the phlegmonous form to the gangrenous form.

For children, helminthic etiology is more common, since helminthic infestations (pinworms, children's roundworms) are more common in children.