Etiological factors determining the clinic of acute appendicitis. Etiology and pathogenesis of appendicitis

Acute appendicitis is a polyetiological disease. The inflammatory process is based on a bacterial factor. By its nature, the flora can be specific and non-specific.

Specific inflammation of the appendix can be with tuberculosis, dysentery, typhoid fever. In addition, the disease can be caused by protozoa: balantidia, pathogenic amoebae, Trichomonas.

However, in the vast majority of cases, acute appendicitis is associated with a nonspecific infection of a mixed nature: E. coli, staphylococcus aureus, streptococcus, anaerobic microorganisms. The most typical causative agent is Escherichia coli. This microflora is constantly in the intestines, not only not having a harmful effect, but being a necessary factor in normal digestion. Only with the appearance of adverse conditions arising in the appendix, it manifests its pathogenic properties.

Contributing factors are:

Obstruction of the lumen of the appendix, causing stagnation of the contents or the formation of a closed cavity. Blockage can be caused by coprolites, lymphoid hypertrophy, foreign bodies, helminths, mucous plugs, process deformities.

Vascular disorders leading to the development of vascular stasis, thrombosis, the appearance of segmental necrosis.

Neurogenic disorders, accompanied by increased peristalsis, stretching of the lumen, increased mucus formation, microcirculation disorders.

There are also common factors that contribute to the development of acute appendicitis:

Alimentary factor.

The existence of a focus of infection in the body, from which hematogenous spread occurs.

Diseases accompanied by severe immune reactions.

Under the influence of etiological factors, serous inflammation begins, microcirculation is disturbed to an even greater extent, and necrobiosis develops. Against this background, the reproduction of microorganisms increases, the concentration of bacterial toxins increases. As a result, serous inflammation is replaced by destructive forms, complications develop.

Classification of acute appendicitis.

The classification of acute appendicitis is clinical and morphological in nature and is based on the severity and diversity of inflammatory changes and clinical manifestations.

Forms of acute appendicitis.

Acute simple (superficial, catarrhal) appendicitis.

Acute destructive appendicitis.

Phlegmonous (with and without perforation)

Gangrenous (with and without perforation)

Complications of acute appendicitis:

Preoperative complications:

Peritonitis (local, diffuse, diffuse, general)

Appendicular infiltrate

Periappendicular abscess

Phlegmon of the retroperitoneal tissue

Sepsis, generalized inflammatory response

Pylephlebitis

Postoperative complications (early and late) [I.M. Matyashin et al. 1974]:

Complications from the surgical wound:

Infiltrate

Suppuration

Hematoma

Ligature fistula

Complications from abdominal cavity:

Infiltrate

Abscess of the abdominal cavity (ileocecal, Douglas space, interloop, subdiaphragmatic)

Bowel obstruction

Peritonitis

intestinal fistula

Gastrointestinal and intraperitoneal bleeding

Complications not related to the operating area:

On the part of the respiratory system (ARVI, bronchitis, pneumonia)

Other complications (myocarditis, pericarditis, pyelonephritis, psychofunctional disorders).

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

The introduction of infection into the appendix can occur in several ways:

• 1) enterogenic way (from the lumen of the process);
• 2) by the hematogenous route (the introduction of microbes into the lymphoid apparatus of the process from a distant source);
• 3) lymphogenous way (carrying of microbes from infected adjacent organs and tissues).

There are always pathogenic microbes in the appendix, but fuss appendicitis

only in case of violation of the protective, barrier function of the epithelium, which is observed when the body's defense reactions are weakened and when external causes predisposing to the occurrence of a local infectious process in the tissues of the process.

Many of the theories of the pathogenesis of acute appendicitis are based on these predisposing factors.

Consider the following theories of the pathogenesis of acute appendicitis.

1. The stagnation theory links the occurrence of appendicitis with stagnation of stool. Violation of the 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 a spasm of the muscles of the appendix, lead to the formation of bedsores on the mucosa, followed by infection of the remaining layers of the appendix.

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

The essence of this theory lies in the fact 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 it is explained by the origin of appendicitis by the ingress of foreign bodies into the process - seeds from fruits, bristles from toothbrushes, helminthic invasion; which mechanically damage the mucous membrane of the process and open the entrance gate for infection.
• 4. The Infection Theory (Ashof, 1908) explains the occurrence of acute appendicitis by the influence of the microbial flora, the virulence of which, due to any reasons that Aschoff does not disclose, has increased dramatically. Under the influence of microbial flora, especially enterococcus, a primary effect is formed in the mucosa of the process in one or even several places. The epithelium 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. Malnutrition of the tissues of the process can lead to necrosis with the subsequent development of inflammatory changes.

6. Hematogenous theory (Kretz, 1913).

Kretz at autopsy of patients who died of appendicitis, found 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 a metastasis of the infection.

7. Allergic theory (Fischer, Kaiserling).

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

8. Alimentary theory (Hoffman).

Proponents of this theory believe that protein-rich food contributes to the development of decay in the intestines and activates the microbial flora. The alimentary 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 the incidence due to the improvement in the well-being of the people in the post-war years.

9. Theory of bauginospasm (I.I. Grekov).

I.I. Grekov believes that prolonged spastic contraction of the bauginian valve causes pain and stagnation of the contents in the appendix, followed by 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 possible a neurogenic mechanism for the development of acute appendicitis.

10. Kortikov-vesciral theory (A.V. Rusakov, 1952).

According to this theory, the pathogenesis of acute appendicitis is based on a violation of the normal functioning of the cerebral cortex. This disturbance can be caused by both extroceptive and interoceptive pathological influences, which cause foci of stagnant excitation and inhibition in the cerebral cortex, which strengthen or weaken the reflex reactions from the internal organs or even pervert 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 internal organs(in this case, by 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 the infection joins.

The cortico-visceral theory of the genesis of acute appendicitis led to an attempt to isolate 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 again, to some extent, the expectant tactics, previously rejected by all surgeons, began to be excited. 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 an emergency operation with an established diagnosis of acute appendicitis 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 appendicopathy, which was understood as the totality of clinical manifestations of acute appendicitis without an anatomical picture of appendix inflammation. According to I.V. Davydovsky and V.S. Yudin's appendicopathy is caused by vasomotor changes in the appendix and in the region of the ileocecal angle, i.e. appendicopathy is actually a functional stage of acute appendicitis. The theory of appendicopathy has not been accepted by surgeons.

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

• 1. Changes in the reactivity of the body;
• 2. Changes in nutritional conditions;
• 3. Stagnation of contents in the caecum 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 view pathogenesis of acute appendicitis can be represented

in the following way. The pathological process begins with functional disorders, which consist in spastic phenomena from the ileocecal angle (baginospasm), the caecum and appendix. It is possible that the spastic phenomena are initially based on digestive disorders, such as increased putrefactive processes with a large amount of protein food, worm infestation, fecal stones, foreign bodies, etc. Due to the common autonomic innervation, spasm of smooth muscles is accompanied by vascular spasm. The first of them leads to a violation of evacuation, stagnation in the appendix, and the second leads to local damage to the mucous membrane, which results in the formation of the primary effect. In turn, stagnation in the appendix contributes to an increase in 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, which is 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 violent 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 suppuration enzymes - cytokinases, 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 development purulent peritonitis, as one of the most severe complications.

The infectious process in the appendix should be understood as the biological interaction of the body and microbes.

However, to see the essence of the disease only in microbes is just as wrong as to reduce it only to the reactions of the body.

In acute appendicitis, there is no specific microbial pathogen.

Theories of acute appendicitis.

1. Theory of stagnation. Violation of the peristalsis of the appendix with a narrow lumen often leads to stagnation of its contents, rich in a variety of bacterial flora, which leads to inflammatory changes in the appendix.

2. In the literature, the issue of the occurrence of acute appendicitis under the influence of helminthic invasion is discussed. In particular, Reindorf tried to provide evidence in favor of the occurrence of acute appendicitis due to the adverse effects of oxyur on the mucous membrane of the appendix. In addition, the possibility of chemical effects of toxic substances secreted by worms on the mucous membrane of the appendix is ​​not excluded. As a result of such exposure, the mucosa seems to be damaged and a picture of catarrh occurs.

3. A fundamentally new point of view was put forward by Ricker, who proposed an angioedema theory of the pathogenesis of acute appendicitis. As a result, tissue nutrition is so severely disturbed that foci of necrosis may appear in the process wall. Pathologically altered tissues become infected. In favor of vascular disorders, it is argued that acute appendicitis is often characterized by a rapid course with sharp pains in the abdomen and growth clinical symptoms. It is vascular disorders that explain the rapidly developing gangrenous appendicitis, where the necrosis of the tissues of the appendix can be noted within a few hours from the onset of the disease.

4. In 1908, the famous German pathologist Aschoff put forward an infectious theory of the onset of acute appendicitis, which until recently was recognized by most clinicians and pathologists.

According to Aschoff, damage to the structure of the appendix is ​​caused by exposure to microbes that are in the appendix itself. Under normal conditions, the presence of this flora does not lead to functional or morphological disorders.

According to proponents of the infectious theory, pathological process begins only if the virulence of microbes increases. The bacteria that live in the lumen of the process, for some reason, cease to be harmless: they acquire the ability to cause pathological changes in mucosal cells that lose their protective (barrier) function.

5. Krech revealed a connection between tonsillitis and acute appendicitis. The author found that in 14 cases, those who died from appendicular peritonitis had distinct changes in the tonsils. These were infectious foci, which the author considered the source of bacteremia.

Acute appendicitis in this case can be considered as the result of infection metastasis. Leuven, operating on sick children for acute appendicitis during diphtheria, found a diphtheria bacillus in the appendix.

6. I. I. Grekov attached great importance to the functional dependence of the Bauhinian valve and the pylorus, which determines the relationship between diseases of the caecum and stomach. In his opinion, various irritants (infection, food intoxication, worms, etc.) can cause spasm of the intestines and especially spasm of the Bauhin's valve. Consequently, I. I. Grekov recognized the violation of the neuroreflex function, which acts as a provocateur of the further development of the disease, as the root cause of appendicitis.

To date, the most acceptable concept of the development of acute appendicitis is as follows - acute appendicitis is caused by a primary nonspecific infection. A number of reasons predispose to the occurrence of an infectious process. These predisposing factors include the following:

1. Change in the body's reactivity after past illnesses. Angina, upper catarrh respiratory tract and various concomitant diseases weaken the body to some extent, which contributes to the occurrence of acute appendicitis.

2. Nutritional conditions, of course, can become a predisposing cause for the occurrence of an infectious process in the appendix. Exclusion from the diet of meat and fatty foods leads to a change in the intestinal microflora and contributes to a certain extent to reducing the incidence of acute appendicitis.

On the contrary, a plentiful diet with a predominance of meat food, a tendency to constipation and intestinal atony lead to an increase in acute appendicitis.

3. Stagnation of the contents of the appendix contributes to the occurrence of acute appendicitis

4. Structural features of the appendix predisposes to the occurrence of inflammatory processes in it. Namely, the inclination of the lymphoid tissue to an inflammatory reaction is important due to its so-called barrier function. The richness of the tonsils and lymphoid tissue of the appendix often leads to inflammation and even phlegmonous melting of both organs.

5. Vascular thrombosis often underlies gangrenous appendicitis. In such cases, tissue necrosis predominates due to circulatory disorders, while the inflammatory process is secondary.

However, the infectious theory should be considered the main theory of the pathogenesis of acute appendicitis. The infectious theory of the pathogenesis of acute appendicitis, supplemented by a modern understanding of infection, reflects the essence of changes in the appendix and throughout the body. The elimination of the infectious focus leads to the recovery of patients, which is the best proof that it is precisely such a focus that constitutes the starting point of the disease itself.

Despite the huge number of works on acute appendicitis, the pathogenesis of this disease has not been studied enough and is perhaps the most obscure chapter in the study of acute appendicitis. And although everyone recognizes that most cases of acute appendicitis occur with distinct inflammatory changes in the appendix, more and more new theories of the development of this common disease are being proposed.

In conclusion, it should be said that in the modern sense, acute appendicitis is a nonspecific inflammatory process. The main factor in its occurrence should be considered a change in the reactivity of the body under the influence of various conditions. Anatomical features in the structure of the appendix and its richness nerve connections determine the originality of the course of infection and, with the appropriate reaction of the body, create a characteristic clinical picture diseases that distinguish acute appendicitis from other nonspecific inflammations of the gastrointestinal tract.

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Acute appendicitis is an inflammation of the appendix of the caecum, one of the most common surgical diseases. The most common acute appendicitis occurs between the ages of 20 and 40 years, women get sick 2 times more often than men. Mortality is 0.1-0.3%, postoperative complications occur in 5-9% of cases.

Etiology

The causes of acute appendicitis have not yet been fully established. A certain role is played by the alimentary factor. Food rich in animal protein contributes to impaired intestinal evacuation function, which should be considered a predisposing factor in the development of the disease. IN childhood some role in the occurrence of appendicitis is played by helminthic invasion.

The main route of infection of the appendix wall is enterogenic. Hematogenous and lymphogenous variants of infection are quite rare, they do not play a decisive role in the genesis of the disease. The direct causative agents of inflammation are a variety of microorganisms (bacteria, viruses, protozoa) that are in the process. Among bacteria, anaerobic non-spore-forming flora (bacteroids and anaerobic cocci) are most often (up to 90%) found. Aerobic flora is less common (6-8%), it is represented by E. coli, Klebsiella, enterococci, etc.

Classification

Clinical and morphological forms of appendicitis:

• catarrhal;
• phlegmonous;
• gangrenous.

Complications:

• perforation;
• diffuse peritonitis;
• appendicular infiltrate;
• abscesses of the abdominal cavity (periappendicular, pelvic, subdiaphragmatic, interintestinal);
• retroperitoneal phlegmon;
• pylephlebitis.

Forms of acute appendicitis reflect the degree (stage) of inflammatory changes in the appendix. Each of them has not only morphological differences, but also its inherent clinical manifestations.

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

Anatomical and physiological information. In most cases, the caecum is located in the right iliac fossa mesoperitoneally, the appendix departs from the posterior medial wall of the dome of the intestine at the confluence of the three ribbons of the longitudinal muscles (tenia liberae) and goes down and medially. Its average length is 7 - 8 cm, thickness 0.5 - 0.8 cm. The appendix is ​​covered with peritoneum on all sides and has a mesentery, due to which it has mobility. The blood supply of the appendix occurs along a. appendicularis, which is a branch of a. ileocolica. Venous blood flows through v. ileocolica v. mesenterica superior and v. portae. There are many options for the location of the appendix in relation to the caecum. The main ones are: 1) caudal (descending) - the most frequent; 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 caecum 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 non-specific inflammation caused by factors of various nature. Several theories have been proposed to explain it.

1. Obstructive (stagnation theory)

2. Infectious (Aschoff, 1908)

3. Angioedema (Rikker, 1927)

4. Allergic

5. Alimentary

The main reason for the development of acute appendicitis is the obstruction of the lumen of the appendix, associated with hyperplasia of the lymphoid tissue and the presence of fecal stones. Less often, a foreign body, a neoplasm, or helminths can become a cause of outflow disturbance. After obturation 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 process, the second - to a local malnutrition of the mucous membrane. Against the background of activation of the microbial flora penetrating into the appendix by the enterogenic, hematogenous and lymphogenous pathways, both processes cause inflammation, first of the mucosa, and then of all layers of the appendix.

Classification of acute appendicitis

Uncomplicated appendicitis.

1. Simple (catarrhal)

2. Destructive

• phlegmonous
• gangrenous
• perforative

Complicated appendicitis

Complications of acute appendicitis are divided into preoperative and postoperative.

I. Preoperative complications of acute appendicitis:

1. Appendicular infiltrate

2. Appendicular abscess

3. Peritonitis

4. Phlegmon of retroperitoneal tissue

5. Pylephlebitis

II. Postoperative complications of acute appendicitis:

Early(appeared within the first two weeks after surgery)

1. Complications from the surgical wound:

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

2. Complications from the abdominal cavity:

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

3. Complications of a general nature:

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

Late

1. Postoperative hernia

2. Adhesive intestinal obstruction (adhesive disease)

3. Ligature fistulas

The causes of complications of acute appendicitis are:

1. 1. Untimely appeal of patients for medical care
2. 2. Late diagnosis of acute appendicitis (due to atypical course of the disease, diagnostic errors, etc.)
3. 3. Tactical mistakes of doctors (neglect of dynamic monitoring of patients with a dubious 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. Chronic progression or occurrence acute diseases other organs.

Clinic and diagnosis of acute appendicitis

In the classic clinical picture of acute appendicitis, the main complaint of the patient is abdominal pain. Often, pain occurs first in the epigastric (Kocher's symptom) or paraumbilical (Kümmel's symptom) region, followed by a 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 pain - 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 more often single, stool retention is possible. General symptoms of intoxication in initial stage diseases are mild and are manifested by malaise, weakness, subfebrile temperature. It is important to assess the sequence of occurrence of symptoms. The classic sequence is the initial occurrence of abdominal pain and then vomiting. Vomiting prior to the onset of pain calls into question the diagnosis of acute appendicitis.

The clinical picture in 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, the formation of an abscess). With the usual location of the appendix, there is local tenderness at the McBurney point on palpation of the abdomen. With pelvic localization, pain is detected in the suprapubic region, dysuric symptoms are possible (frequent painful urination). Palpation of the anterior abdominal wall is uninformative, 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 organs of the small pelvis, especially in women. With a retrocecal location, the pain is shifted to the right flank and the 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 the involvement of the parietal peritoneum in the inflammatory process.

Establishing a diagnosis makes it easier to identify characteristic symptoms acute appendicitis:

• Razdolsky - soreness on percussion over the focus of inflammation
• Rovsinga - 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 to the left side, there is an increase in pain in the ileocecal region due to the movement of the appendix and the tension of its mesentery
• Voskresensky - with a quick slide of the hand over a stretched shirt from the xiphoid process to the right iliac region, a significant increase in pain is noted in the latter at the end of the movement of the hand
• Bartomier - Michelson - palpation of the right iliac region in the position of the patient on the left side causes a more pronounced pain reaction than on the back
• Obraztsova - on palpation of the right iliac region in the position of the patient on the back, the pain intensifies when raising the right straightened leg
• Coupa - hyperextension right leg the patient, when positioned on his left side, is accompanied by a 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 peripheral blood leukocyte count does not rule out acute appendicitis. In the urine, there may be single erythrocytes in the field of view.

Special research methods usually carried out in cases where there is doubt about the diagnosis. With inconclusive clinical manifestations diseases in the case of an organized specialized surgical service, it is advisable to start additional examination with a non-invasive ultrasound(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 about the destructive process in the organ allows us to correct the operative approach and the option of anesthesia with an atypical location of the process.

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

Development acute appendicitis in elderly and senile patients has a number of features. This is due to a decrease in physiological reserves, a decrease in the reactivity of the body 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 a relatively rapid development of destructive forms of appendicitis. Often there is bloating, non-excretion of stools and gases. Tension of the muscles of the anterior abdominal wall, pain symptoms, characteristic of acute appendicitis, may be weakly expressed, and sometimes not determined. General reaction on the inflammatory process is weakened. The rise in temperature to 38 0 and above is observed in a small number of patients. In the blood, moderate leukocytosis is noted with a frequent shift of the formula to the left. Careful observation and examination with the wide use of special methods (ultrasound, laparoscopy) are the key to a 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, in the future, the enlarged uterus displaces the caecum and appendix upwards. 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 to the right lumbar region is possible, which can be erroneously interpreted as a pathology from the biliary tract and right kidney. muscle tension, 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 the position on the left side. With the aim of timely diagnosis all patients are shown the control of laboratory parameters, ultrasound of the abdominal cavity, joint dynamic observation of the surgeon and obstetrician-gynecologist, according to indications, laparoscopy can be performed. When the diagnosis is made, emergency surgery is indicated in all cases.

Differential Diagnosis for pain in the right lower abdomen is carried out with the following diseases:

1. 1. Acute gastroenteritis, mesenteric lymphadenitis, food poisoning
2. 2. Aggravation peptic ulcer 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. Cholelithiasis, acute cholecystitis
6. 6. Acute pancreatitis
7. 7. Inflammatory diseases of the pelvic organs
8. 8. Rupture of an ovarian cyst, ectopic pregnancy
9. 9. Right-sided renal and ureteral colic, inflammatory diseases urinary tract

10. Right-sided lower lobe pleuropneumonia

Treatment of acute appendicitis

A generally accepted active surgical position in relation to acute appendicitis. The absence of doubt in the diagnosis requires emergency appendectomy in all cases. The only exception is patients with well-demarcated dense appendicular infiltrate requiring conservative treatment.

Currently, various options for open and laparoscopic appendectomy are used in surgical clinics, 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 ("rocker") 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 intersection (according to Kolesov). Sometimes Lenander's longitudinal approach is used (along the outer edge of the right rectus abdominis muscle) and the Sprengel's transverse one (used more often in pediatric surgery). In case of complications of acute appendicitis with widespread peritonitis, with severe technical difficulties during appendectomy, as well as erroneous diagnosis, median laparotomy is indicated.

The appendix is ​​mobilized in an antegrade (from apex to base) or retrograde (first, the appendix is ​​cut off from the caecum, treated with a stump, then isolated from the base to the apex) method. The appendix stump is treated with a ligature (in pediatric practice, in endosurgery), invagination or ligature-invagination method. As a rule, the stump is tied with a ligature of absorbable material and immersed in the dome of the caecum 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 caecum 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 micro-irrigator to the process bed for summing up 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, and also in case of unreliable hemostasis, after removal of the process, tamponing and drainage of the abdominal cavity are performed.

In the postoperative period with uncomplicated appendicitis antibiotic therapy do not carry out or are limited to the use of broad-spectrum antibiotics in the next day. In the presence of purulent complications and diffuse peritonitis, combinations are used antibacterial drugs 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 intestines, the greater omentum, the uterus with appendages, the bladder, the parietal peritoneum, welded together around the destructively altered appendix, reliably delimiting the penetration of infection into the free abdominal cavity. Occurs in 0.2 - 3% of cases. Appears on 3-4 days from the onset of acute appendicitis. In its development, two stages are distinguished - early (formation of a loose infiltrate) and late (dense infiltrate).

In the early stage, an inflammatory tumor is formed. Patients have a clinic close to the symptoms of acute destructive appendicitis. In the stage of formation of a dense infiltrate, the phenomena of acute inflammation subside. General state patients are improving.

A decisive role in the diagnosis is given to the clinic of acute appendicitis in history or on 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 the operation. In the stage of delimitation, it becomes dense, less painful, clear. The infiltrate is easily determined with typical localization and large sizes. To clarify the diagnosis, rectal and vaginal examination, abdominal ultrasound, and irrigography (scopy) are used. Differential diagnosis is carried out with tumors of the caecum and ascending intestine, uterine appendages, hydropyosalpix.

Tactics for appendicular infiltrate is conservative and expectant. A comprehensive conservative treatment is carried out, including bed rest, a sparing diet, in the early phase - cold on the infiltrate area, and after normalization of temperature, physiotherapy (UHF). They prescribe antibacterial, anti-inflammatory therapy, perform pararenal novocaine blockade according to A.V. Vishnevsky, blockade according to Shkolnikov, use therapeutic enemas, immunostimulants, etc.

In the case of a favorable course, the appendicular infiltrate resolves within 2 to 4 weeks. After complete subsidence of the inflammatory process in the abdominal cavity, not earlier than 6 months later, a planned appendectomy is indicated. If conservative measures are ineffective, the infiltrate suppurates with the formation of an appendicular abscess.

Appendicular abscess

Appendicular abscess occurs in 0.1 - 2% of cases. It can form in early dates(1 - 3 days) since the development of acute appendicitis or complicates the course of the existing appendicular infiltrate.

Signs of abscess formation are symptoms of intoxication, hyperthermia, an increase in leukocytosis with a shift in the white blood formula to the left, an increase in ESR, increased pain in the projection of a previously determined 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 option for the treatment of appendicular abscess is the opening of the abscess by extraperitoneal access according to N.I. Pirogov with a deep, including retrocecal and retroperitoneal location. In the case of a tight fit of the abscess to the anterior abdominal wall, the Volkovich-Dyakonov access 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 brought into its cavity, the wound is sutured to the drainage.

Currently, a number of clinics use extraperitoneal puncture sanitation and drainage of the appendicular 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. With large abscess sizes, it is proposed to install two drains at the upper and lower points for the purpose of flow-through washing. Given the low traumatic nature 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 - purulent thrombophlebitis of the portal vein branches, complicated by multiple liver abscesses and pyemia. It develops as a result of the spread of the inflammatory process from the veins of the appendix to the iliac-colic, superior mesenteric, and then to the portal vein. More often occurs with retrocecal and retroperitoneal location of the process, 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, it is often complicated by sepsis. Mortality is over 85%.

The pylephlebitis clinic consists of hectic temperature with chills, pouring sweat, icteric staining of the sclera and skin. Patients are concerned about pain in the right hypochondrium, often radiating to the back, lower chest and right collarbone. Objectively find an increase in the liver and spleen, ascites. An x-ray examination determined the high standing of the right dome of the diaphragm, an increase in the shadow of the liver, 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 in 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 plasma absorption, etc.). Prolonged intraportal administration medicines through the cannulated umbilical vein. Liver abscesses are opened and drained or punctured under ultrasound guidance.

pelvic abscess

Pelvic localization of abscesses (abscesses Douglasova space) in patients undergoing appendectomy is most common (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 abscesses is associated with poor sanitation of the abdominal cavity, inadequate drainage of the pelvic cavity, the presence of abscessing infiltrate in this area with the pelvic location of the process.

An abscess of the Douglas space is formed 1-3 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, soreness of the anterior wall of the rectum is found, its overhang, a painful infiltrate can be palpated along the anterior wall of the intestine with softening foci. Per vaginam, there is pain in the posterior fornix, 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, in women - through the posterior fornix of the vagina. After receiving pus, an abscess is opened along the needle. A drainage tube is inserted into the cavity of the abscess 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 neighboring hollow organs ( bladder, rectum and caecum, etc.)

Subdiaphragmatic abscess

Subdiaphragmatic abscesses develop in 0.4 - 0.5% of cases, they are single and multiple. By localization, right- and left-sided, anterior and posterior, intra- and retroperitoneal are distinguished. The reasons for their occurrence are poor sanitation of the abdominal cavity, infection by the lymph or hematogenous route. They can complicate the course of pylephlebitis. The clinic develops 1-2 weeks after surgery and is manifested by pain in the upper abdominal cavity and lower chest (sometimes with irradiation to the shoulder blade and shoulder), hyperthermia, dry cough, symptoms of intoxication. Patients can take a forced semi-sitting position or on their side with their legs adducted. Rib cage on the side of the lesion lags behind when breathing. The intercostal spaces at the level of 9-11 ribs swell above the abscess area (symptom of V.F. Voyno-Yasenetsky), palpation of the ribs is sharply painful, percussion - dullness due to reactive pleurisy, or tympanitis over the gas bubble area with gas-containing abscesses. On the survey radiograph - a high standing of the dome of the diaphragm, a picture of pleurisy, a gas bubble with a liquid level above it can be determined. With ultrasound, a delimited accumulation of fluid under the dome of the diaphragm is determined. The diagnosis is specified after a diagnostic puncture of the subdiaphragmatic formation under ultrasound control.

Treatment consists in opening, emptying and draining the abscess by extrapleural, extraperitoneal access, less often through the abdominal or pleural cavity. In connection with the improvement of methods ultrasound diagnostics abscesses can be drained by passing single- or double-lumen tubes through a trocar under ultrasound guidance into their cavity.

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, the symptoms are poor. Patients are concerned about abdominal pain without a clear localization. The temperature rises, the phenomena of intoxication increase. In the future, there may be a painful infiltrate in the abdominal cavity and stool disorders. On the survey radiograph, foci of blackout are found, in some cases - with a horizontal level of liquid and gas. To clarify the diagnosis, latheroscopy and ultrasound are used.

Interintestinal abscesses adjacent to the anterior abdominal wall and soldered to the parietal peritoneum are opened extraperitoneally or drained under ultrasound control. 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, slippage of the ligature from its mesentery, damage to the vessels of the anterior abdominal wall, and insufficient hemostasis when suturing the surgical wound. Violation of the blood coagulation system plays a certain role. Bleeding can be profuse and capillary.

With significant intra-abdominal bleeding, the condition of patients is severe. There are signs of acute anemia, the abdomen is somewhat swollen, tense and painful on palpation, especially in the lower sections, symptoms of peritoneal irritation may be detected. Percussion find dullness in sloping places 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.

Patients with intra-abdominal bleeding after appendectomy are shown urgent relaparotomy, during which the ileocecal region is revised, the bleeding vessel is ligated, the abdominal cavity is sanitized and drained. In case of capillary bleeding, tight tamponing of the bleeding area is additionally performed.

Limited intraperitoneal hematomas give a poorer clinical picture and may manifest with infection and abscess formation.

Abdominal wall infiltrates and wound suppuration

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

Infiltrates and abscesses are located above or below the aponeurosis. Palpation in the area of ​​the postoperative wound finds a painful induration with fuzzy contours. The skin above it is hyperemic, its temperature is elevated. With suppuration, a symptom of fluctuation can be determined.

Treatment of the infiltrate is conservative. Broad-spectrum antibiotics, physiotherapy are prescribed. Perform short novocaine blockade of the wound with antibiotics. Festering wounds are widely opened and drained, and further treated taking into account the phases of the wound process. Wounds heal by secondary intention. With large sizes of granulating wounds, the imposition of secondary early (8-15) days or delayed sutures is indicated.

Ligature fistulas

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

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

Control questions

1. 1. Early symptoms of acute appendicitis
2. 2. Features of the clinic of acute appendicitis with atypical location of the appendix
3. 3. Clinical features of acute appendicitis in the elderly and pregnant women
4. 4. Tactics of the surgeon with a dubious 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. Tactics of the surgeon with appendicular infiltrate
9. 9. Modern approaches to the diagnosis and treatment of appendicular abscess

10. Diagnosis and treatment of pelvic abscesses

11. Tactics of the surgeon when detecting Meckel's diverticulum

12. Pylephlebitis (diagnosis and treatment)

13. Diagnosis of subphrenic and interintestinal abscesses. Medical tactics

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

15. Examination of working capacity after appendectomy

Situational tasks

1. A 45-year-old man has been ill for 4 days. Disturbed by pain in the right iliac region, temperature 37.2. On examination: the tongue is wet. The abdomen is not swollen, participates in the act of breathing, soft, painful in the right iliac region. Peritoneal symptoms are inconclusive. In the right iliac region, a tumor-like formation 10 x 12 cm, painful, inactive, is palpated. The chair is regular. Leukocytosis - 12 thousand.

What is your diagnosis? Etiology and pathogenesis of this disease? What pathology should be treated with differential pathology? Additional Methods surveys? Tactics of treatment of this disease? Treatment of the patient at this stage of the disease? Possible Complications diseases? Indications for surgical treatment, the 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. Performed appendectomy, drainage of the abdominal cavity. The early postoperative period proceeded with the phenomena of moderately expressed intestinal paresis, which were effectively stopped by the use of drug stimulation. However, by the end of the 4th day after the operation, the patient's condition worsened, increasing bloating appeared, cramping pains throughout the abdomen, gases stopped leaving, nausea and vomiting, common signs of endogenous intoxication.

Objectively: a state of moderate severity, pulse 92 per minute, A/D 130/80 mm Hg. Art., the tongue is wet, lined, the abdomen is evenly swollen, diffuse soreness in all departments, peristalsis is increased, peritoneal symptoms are not detected, when examining per rectum - the ampoule of the rectum is empty

What complication of the early postoperative period occurred in this patient? What methods of additional examination will help determine the diagnosis? The role and scope of X-ray examination, data interpretation. What are possible reasons development of this complication in the early postoperative period? Etiology and pathogenesis of disorders developing in this pathology. The volume of conservative measures and the purpose of their implementation in the development of this complication? Indications for surgery, the amount of operational benefits? 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 at the stage of appendicular infiltrate. 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 increased, the temperature became hectic.

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

What is the clinical diagnosis in this case? Patient treatment strategy? The nature, volume and features of surgical aid in this pathology? Features of the postoperative period?

4. A 45-year-old man underwent an appendectomy with drainage of the abdominal cavity for gangrenous appendicitis. On the 9th day after the operation, the entry of small intestine 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. Chair independent 1 time per day. In the area of ​​drainage 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? Disease classification? Additional research methods? Possible complications of this disease? Principles 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 a sharp weakness, pale skin, tachycardia, falling blood pressure, free fluid is determined in sloping places of the abdominal cavity. Diagnosis? surgeon tactics?

Sample answers

1. The patient developed an appendicular infiltrate, confirmed by ultrasound data. Tactics are conservative-expectant, in case of abscess formation it is indicated surgical treatment.

2. The patient has a clinic of postoperative early adhesive intestinal obstruction, in the absence of the effect of conservative measures and negative X-ray dynamics, an emergency operation is indicated.

3. Abscess formation of the appendicular infiltrate has set in. Shown surgical treatment. Preferably extraperitoneal opening and drainage of the abscess.

4. Postoperative period complicated by the development of an external small bowel fistula. An X-ray examination of the patient is necessary. In the presence of a formed tubular low enteric 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 a clinic of bleeding into the abdominal cavity, probably due to slipping of the ligature from the stump of the mesentery of the appendix. An emergency relaparotomy was indicated.

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