Chronic appendicitis - sluggish form of the inflammatory process in the appendix of the cecum, most often associated with previously suffered an attack of acute appendicitis. The clinical picture of chronic appendicitis is characterized by discomfort, aching pain in the right iliac region, aggravated by physical exertion, nausea, flatulence, diarrhea or constipation, urinary bladders, vaginal or rectal symptoms. Diagnosis of chronic appendicitis is based on the exclusion of other possible causes of this symptom and may include the study of anamnesis, a review X-ray, irrigoscopy, colonoscopy, ultrasound and other differential diagnostic examinations of the abdominal cavity. Treatment of chronic appendicitis with unexpressed manifestations is conservative, with persistent pain syndrome, appendectomy is indicated.
Chronic appendicitis, unlike its acute form, is quite rare in gastroenterology. In chronic appendicitis on the background of sluggish inflammation can develop atrophic and sclerotic changes in the appendix, the growth of granulation tissue, scars and adhesions, leading to obliteration of the lumen and deformity of the appendix, its fusion with adjacent organs and surrounding tissues.
There are three forms of chronic appendicitis: residual, recurrent and primary chronic. The residual (residual) form of chronic appendicitis is characterized by the presence of a single acute attack in the patient's history, which ended in recovery without surgical intervention. In chronic recurrent form, repeated attacks of acute appendicitis are noted with minimal clinical manifestations in the remission stage. A number of authors also identify primary chronic (impenetrable) appendicitis, which develops gradually, without preceding an acute attack.
The residual (residual) form of chronic appendicitis is a consequence of a previously suffered attack of acute appendicitis, which was stopped without surgical removal of the appendix. At the same time, after the abatement of acute manifestations in the cecum, conditions are maintained to maintain the inflammatory process: adhesions, cysts, appendix bends, hyperplasia of the lymphoid tissue, making it difficult to empty.
Impaired blood circulation in the affected blind process contributes to the reduction of local immunity of the mucous membrane and activation of pathogenic microflora. A relapse of appendicitis is possible, both in the absence of its operative treatment, and after subtotal appendectomy, while the process of a length of 2 cm is left.
Symptoms of chronic appendicitis
The clinical picture of chronic appendicitis is characterized by the predominance of implicitly expressed, blurred symptoms. Chronic appendicitis is manifested by a feeling of discomfort and heaviness, dull aching pains in the right iliac region, constant or occasionally arising, after exercise and errors in the diet. Patients with chronic appendicitis may complain of digestive disorders: nausea, flatulence, constipation, or diarrhea. The temperature at the same time often remains normal, sometimes in the evenings rises to subfebrile.
In chronic appendicitis, other symptoms may be observed: bladder (painful and frequent urination), vaginal (gynecological pain), rectal pain (rectal pain). Repeated attacks of acute inflammation of the blind appendix are manifested by symptoms of acute appendicitis.
Diagnosis of chronic appendicitis causes difficulties due to the lack of objective clinical symptoms of the disease. It is easiest to diagnose chronic recurrent appendicitis, with very important data history (the presence of several acute attacks). During the next acute attack diagnosed with acute appendicitis, and not exacerbation of chronic.
Indirect signs of chronic appendicitis with palpation of the abdomen can be local pain in the right iliac region, often a positive symptom Obraztsova, sometimes - positive symptoms of Rovzing, Sitkovsky.
In order to diagnose chronic appendicitis, a radiographic contrast irrigoscopy of the large intestine is necessarily performed, which makes it possible to detect the absence or partial filling of the blind appendix with barium and slowing its emptying, which indicates a change in the shape of the appendix, deformation, narrowing of its lumen. Colonoscopy helps to reject the presence of tumors in the caecum and colon, and radiography and ultrasound in the abdominal cavity. Clinical analyzes of blood and urine of a patient with chronic appendicitis, as a rule, without marked changes.
In case of primary chronic appendicitis, the diagnosis is made by excluding other possible diseases of the abdominal organs that give similar symptoms. It is necessary to carry out differential diagnosis of chronic appendicitis with gastric ulcer, Crohn's disease, irritable bowel syndrome, chronic cholecystitis, spastic colitis, abdominal toad, yersiniosis, tiflitom and ileotiflitom another etiology (e.g., tuberculosis, cancer), kidney disease, and urinary tract, gynecological, helminthic invasion in children, etc.
Treatment of chronic appendicitis
With an established diagnosis of chronic appendicitis and persistent pain syndrome, surgical treatment is indicated: removal of the blind appendix - appendectomy by open method or by laparoscopic method. During the operation, an audit of the abdominal organs is also performed to identify other possible causes of pain in the right iliac region.
In the postoperative period antibiotic therapy is required. Long-term results after surgical treatment of chronic appendicitis are somewhat worse than after acute appendicitis, since the development of adhesions is more often noted.
If a patient with chronic appendicitis has unexpressed symptoms, apply a conservative treatment - taking antispasmodic drugs, physiotherapy, elimination of intestinal disorders.
Macroscopic changes in the appendix with chronic appendicitis may be so unexpressed that they can be detected only by morphological study of the remote process. If the blind appendix was unchanged, there is a possibility that surgery may further aggravate the existing pain syndrome that served as the basis for appendectomy.
Forms of the disease
There are three forms of chronic appendicitis:
- residual (residual) form - develops after previously suffered acute appendicitis, which ended in recovery without surgery,
- primary chronic form - develops slowly, without a previous attack of acute appendicitis. Some experts have questioned its presence, so the diagnosis of primary chronic appendicitis is made only with the exclusion of the presence of any other pathology that can cause a similar clinical picture,
- recurrent form - characterized by recurring symptoms of acute appendicitis in a patient, which, after the transition of the disease to the stage of remission, subside.
At any time, chronic appendicitis can turn into an acute form, and untimely execution of a surgical operation in this case threatens with the development of peritonitis - a potentially life-threatening condition.
Causes and risk factors
The main reason for the development of chronic appendicitis is a slow-flowing infectious inflammatory process in the appendix.
Violations of trophism and innervation of the appendix wall, which lead to a decrease in local immunity, contribute to the development of primary chronic inflammation. As a result, the microorganisms contained in the intestine provoke mild inflammation, which can last for many years, causing discomfort and pain in the right half of the abdomen. Under unfavorable conditions, a sluggish inflammatory process can be sharply activated, and then acute appendicitis develops.
Secondary chronic inflammation is the outcome of acute inflammation of the appendix. If, for one reason or another, surgical treatment of acute appendicitis was not performed, very dense adhesions are formed in the appendix, reducing its lumen. This causes stagnation in the vermiform process of the intestinal contents, which provokes a long-term inflammatory process of insignificant activity.
The recurrent form of chronic appendicitis can be caused by both primary and secondary chronic inflammation. Periods of exacerbation of the disease are triggered by various adverse factors (stress, hypothermia, acute infectious diseases), which reduce the overall immunity and thus create prerequisites for increased activity of the inflammatory process in the appendix.
Recurrent chronic appendicitis in very rare cases develops after prompt removal of the appendix (appendectomy). This can occur if the surgeon has left part of the appendix longer than 2 cm.
Possible consequences and complications
Long-term chronic appendicitis leads to the development of adhesions in the abdominal cavity, which, in turn, can cause intestinal obstruction.
At any time, chronic appendicitis can turn into an acute form, and untimely execution of a surgical operation in this case threatens with the development of peritonitis - a potentially life-threatening condition.
The prognosis for the timely treatment of chronic appendicitis is favorable.
Special measures for the prevention of chronic appendicitis does not exist. It is necessary to adhere to a healthy lifestyle (proper nutrition, avoiding bad habits, playing sports, adherence to work and rest), which allows to increase the activity of the immune system and thereby reduce the risk of the inflammatory process in the appendix.
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Education: She graduated from the Tashkent State Medical Institute with a degree in medicine in 1991. Repeatedly took advanced training courses.
Work experience: anesthesiologist-resuscitator of the urban maternity complex, resuscitator of the hemodialysis department.
The information is generalized and is provided for informational purposes only. At the first signs of illness, consult a doctor. Self-treatment is dangerous for health!
Structure and function of the appendix
The vermiform appendix departs from the cecum and is located almost at the very beginning of the large intestine. Most often it is located to the right and down from the navel, but sometimes it can be found to the left with the appropriate location of the gastrointestinal tract. Microscopic examination of the appendix revealed that it contains a large amount of lymphoid tissue.
In the lower abdomen on the left, in some people, another process can be found - Meckel's diverticulum, which forms in the ileum and is 10 –100 cm in length from the appendix and cecum. For this reason, the inflammation of this diverticulum (especially if it is located close to the appendix) may resemble a picture of acute or chronic appendicitis.
- Lymphopoiesis and immunogenesis. It is these appendix functions that have given the right to consider this process as an organ of the immune system, and many researchers call it the “intestinal amygdala”.
- Propagation of Escherichia coli followed by dissemination through the intestines.
- Regulation of the function of the valve that separates the small intestine from the colon.
- Secretory (produces amylase).
- Hormonal (peristaltic hormone synthesis).
- Antimicrobial. Some researchers have found that the appendix secretes a special antimicrobial substance, the action and purpose of which is not yet completely understood.
The causes of chronic appendicitis and its types
There are the following types of chronic appendicitis:
- Primary chronic appendicitis. In this case, the causes of inflammation are not precisely established, and some authors generally consider this form of the disease to be non-existent. Such a diagnosis is established only after a thorough examination and exclusion of any other pathology of the abdominal organs.
- Secondary chronic appendicitis. He might be:
- residual - occurs after acute appendicitis, which has not been operated on,
- recurrent - periodically there are repeated attacks of acute appendicitis with a minimum number of symptoms between them.
Recurrent appendicitis can develop even after the appendix is removed due to acute appendicitis, if its stump remains more than 2 cm long.
The development of chronic inflammation in the appendix is promoted by cysts, adhesions, hyperplasia of the lymphoid tissue, excesses of the appendix, impaired blood circulation in this organ.
Gives a good effect in the case of the development of secondary chronic forms of chronic appendicitis, but may be ineffective in the primary chronic form of the disease. It is especially recommended to remove the inflamed process in the presence of adhesions, cicatricial changes in the wall of the appendix, as well as in the first trimester of pregnancy.
Currently, appendicitis is removed in a classic and endoscopic manner.
Types of appendectomy
Typical appendectomy. A surgeon makes an incision in the right iliac region, then the vermiform process is brought into the surgical wound, his mesentery is tied up, and the appendix is then cut off. The stump of the appendix is sutured with a special type of sutures (purse-string, Z-shaped) and plunges into the cecum.
Retrograde appendectomy. This operation is used in cases where due to adhesions it is impossible to withdraw a process in the surgical wound. In this case, first, the appendix is cut off from the rectum, then its stump is sutured and plunges into the rectum, and then the surgeon gradually releases the appendix, bandages its mesentery and removes it outside.
Laparoscopic appendectomy. Small punctures are made in the abdominal wall, through which endoscopic instruments are then inserted and the appendix is cut off and taken out.
Transluminal apendectomy. This is a relatively new way to remove the appendix, when endoscopic instruments are inserted through the incision:
- in the wall of the stomach - transgastral appendectomy,
- in the wall of the vagina - transvaginal appendectomy.
In this case, there are no stitches on the skin, and recovery is much faster.
After a wound operation, sutures are applied, which are removed on the 10th day or are resolved independently. The first days may be pain in the postoperative wound, which passes after taking painkillers. Also, after the operation, antibiotics, detoxification drugs are prescribed for some time, and dressings are performed.
As a rule, the recommendations of surgeons are as follows:
- Bed rest and hunger for the first 12 hours after surgery.
- It is allowed to sit after 12 hours from the moment of the operation and drink in small sips with lemon.
- After a day you can get up and walk.
It is very important to adhere to a special diet in the first days after the removal of the appendix:
1-2 days after surgery (# 0a). Food is liquid, jelly-like, mushy and puree-like dishes, sour cream, whole milk, grape and vegetable juices, carbonated drinks are completely excluded. Allowed fat-free uncaring meat broth, fruit jelly, sweet broth hips, jelly. Meal in small portions (up to 300 g), 7–8 times per day.
3-4 day. It is allowed to eat mucous soups from grits, liquid grated rice or oatmeal, steam omelet from protein, lean meat or fish puree, raw egg.
From 5–7 day (table №1). You can rubbed soups, meat and fish pureed dishes, vegetable and fruit puree, dairy drinks, white crackers, baked apples.
From the 8th day the patient is allowed to go to the general table number 15 (excluding sharp, too fatty foods, alcohol).
The period when you can return to the usual way of life depends on the type of appendectomy and the nature of the postoperative period: after endoscopic interventions, healing is faster. On average, exercise is limited for 2 months, then running, swimming, and riding are allowed, and lifting weights is only allowed after 3–6 months. Do not refrain from visiting the bath or sauna for at least 3-4 weeks.
Complications of chronic appendicitis
- Transformation into acute appendicitis with subsequent surgical treatment.
- The appearance of appendicular infiltrate. In this case, he is treated conservatively using cold, anti-inflammatory, painkillers and antibiotics, physiotherapy. After the inflammation subsides, it is recommended to remove the appendix in 2-4 months.
- Abscess appendicular infiltrate. It is treated operatively (opening and drainage of the abscess, and after cure - removal of the appendix after a few months).
- The formation of adhesions. It is treated by physiotherapeutic methods, as well as surgically.
Most often, signs of chronic appendicitis disappear after removal of the process. However, in cases where the appendix was almost unchanged, the pain and other symptoms after surgery can only worsen.
Children, teenagers and pregnant
In children, chronic appendicitis practically does not occur. In adolescence, the likelihood of developing chronic appendicitis increases if there has already been an attack of acute appendicitis, which was not treated surgically.
Pregnancy due to the gradual displacement of the abdominal organs can provoke an exacerbation of the symptoms of chronic appendicitis, therefore, in the case of pregnancy planning, it is recommended to remove the appendix in advance.
Why appendicitis develops
The appendix is very sensitive to any inflammations and diseases of the gastrointestinal tract, and when the lymphoid tissues are overloaded, they become inflamed and swell, and the contents of the process subsequently accumulate and suppuration occurs. In the classic version with appendicitis, an appendectomy is performed - removal of the appendix. Late surgery for appendicitis is fraught with serious complications, even death.
It used to be that a child’s habit of eating seeds with husks threatened with appendicitis, this is not so. Non-digestible particles cannot clog the orifice of the tube, since it is too small.
But quite adult habits, such as alcohol and nourishing feasts, are quite sufficient reason for the development of appendicitis. Some time the disease may not manifest. Both acute and chronic stages are considered dangerous.
Exacerbation of appendicitis is one of the most common problems of the gastrointestinal tract, which, moreover, has significantly “got younger” in recent decades. Fully explain the causes of acute appendicitis medicine is not yet under force, and its nature is considered to be non-specific.
There are four forms of acute appendicitis: simple, phlegmonous, gangrenous and perforated.
- A simple (catarrhal) form of acute appendicitis is a form of inflammation of the appendix, as a result of which changes may occur in the walls of the appendix, but this process is considered to be reversible.
- Phlegmonous form of acute appendicitis - the walls of the appendicular ortrostate, due to severe inflammation, begin to fester, but retain their shape. This stage of the disease develops in a matter of hours, after which the structure of the appendix begins to break down.
- Gangrenous form of acute appendicitis - within two to three days, some areas of appendicular appendix of the cecum begin to die. In rare cases, necrosis of the entire process occurs.
- Perforated (perforative) form of acute appendicitis - rupture of the tissues of the appendix with subsequent leakage of purulent effusion in the abdominal cavity, which ends purulent peritonitis or the formation of abscess. Because of the intoxication of the body, the pain can be muffled.
Symptoms of acute appendicitis
Due to the fact that the appendix can be slightly differently located in the body in different people, it is quite difficult to diagnose appendicitis. Also, not always the symptoms of the disease are pronounced and have a specific character.
A typical symptom of acute appendicitis is as follows: suddenly there are severe pains in the lower abdomen and gradually focuses only on the right side. And this is only the beginning of the disease. The attacks gradually turn into constant pain, nausea appears, and in the first hours of the patient’s exacerbation can vomit. Associated processes include fever, tachycardia, and leukocytosis.
There is no question of any kind of self-medication: the pain is so severe that even the most hardy people are already in the first stages of acute appendicitis turning into an ambulance.
Mechanical Theory Edit
Mechanical the theory believes that the main cause of the development of acute appendicitis is the activation of the intestinal flora of the appendix against the background of mechanical obstruction of its lumen. Less frequently, obturation by a foreign body, tumor or parasite occurs. This leads to the accumulation of mucus in the lumen of the appendix and excessive development of microorganisms, which causes inflammation of the mucous membrane and underlying layers, vascular thrombosis, necrosis of the wall of the appendix.
- Experimental data suggest that acute appendicitis appears to result from obturation (blockage) of the lumen of the appendix. Obturation leads to overflow of the process lumen distal to the level of obstruction by mucous secretion. The diameter of the process increases from 4-6 mm in normal to 17-18 or more millimeters, it becomes tense.
- Increasing intraluminal pressure for several hours leads to compression of intraorganic veins, impaired venous and lymphatic drainage, edema of the organ wall and sweating of transudate in its lumen with a further increase in intraluminal pressure ("vicious circle"), which leads to acute inflammation and necrosis (death) first of all in the pressure zone of a foreign body ("decubital ulcer", "bed sore", "phlegmonous and ulcerative appendicitis").
- Sometimes coproliths can be found in the lumen of the appendix in acute catarrhal or chronic appendicitis. Why they do not lead to the destruction of an organ and how long they are in its lumen is not yet clear.
- Necrosis immediately becomes highly infected with intraluminal microflora (colon microflora is the most diverse (about 500 types of bacteria and fungi) and numerous (more than 10 million microbial cells per gram) in the human body, therefore the process of bacterial destruction of the damaged wall of the vermiform process is rapid, often the development of transmural (full-wall) necrosis takes less than 12 hours (perhaps even faster in individual, so-called “lightning-fast” cases). At this stage appendix and in the lumen of the appendix there is a thick white-pink pus with colibacillosal (putrid) odor. , "Appendicitis burst," according to folk terminology) - intraperitoneal catastrophe, which leads to the outpouring of purulent contents, containing a huge number of microbes, into sterile yushnuyu cavity. There is a life-threatening complication of the patient - diffuse purulent peritonitis.
- Causes of obstruction of the lumen: the main reason is the so-called "Coprolites", they are also “feces”, they are also “fecal stones” (the cause of almost 100% of cases of empyema of the appendix, gangrenous and gangrenous-perforated appendicitis). Some external factors can also lead to obstruction of the lumen of the appendix:
- kink of the process of scar adhesions due to various chronic diseases of the abdominal organs:
- chronic colitis
- chronic cholecystitis
- chronic enteritis
- chronic adnexitis
- adhesive disease of the abdominal cavity, etc.
- Usually such cases occur with less sharpness, the appearance of destructive forms is not typical (but not excluded).
- Casuistic reasons occlusion of the appendix:
- swallowed foreign bodies (grape seeds, fish, bird and other small bones, sunflower seed husks, even dental crowns and other small hard objects) are extremely rare.
- In the literature of the beginning of the 20th century, it was often reported that helminths (worms) were found in the lumen of an inflamed process, in most cases ascarids. In our time, such cases are very, very rare.
- Perhaps other, more rare causes of acute appendicitis - for example, tumors of the appendix (the most common carcinoid).
- The role of constipation and lazy bowels:
- According to some statistics, for those patients who subsequently developed acute appendicitis, chronic, perennial constipation is characteristic, they have less frequent stools than those who do not have acute appendicitis. Thus, at the turn of the 1980s and 1990s, the opinion dominates in the world literature that according to which the appendix coprolites occur when the fecal contents are retained in the right sections of the colon, with an increased passage time of the intestinal contents. Limited epidemiological studies have found that colon cancer, colon diverticulosis, and glandular colon polyps are less common in populations that do not suffer from appendicitis. There is an assumption (not yet having solid evidence) that acute appendicitis may be an early precursor to the development of colorectal cancer, one of the main factors for the development of which are considered chronic constipation.
- There is evidence that the incidence of acute appendicitis is associated with a low content of plant fiber in the diet. Indeed, plant fiber excites intestinal peristalsis, has a laxative effect and reduces the time of passage of intestinal contents.
Clinical and anatomical appendicitis
- Acute appendicitis - acute inflammatory-necrotic disease of the appendix of the cecum, usually caused by obturation of the appendix, and occurring with the participation of microflora that live in the lumen of the appendix (facultative and obligate anaerobes).
- If an acute appendicitis occurs, an emergency operation is indicated: appendectomy (removal of the appendix). Acute appendicitis for more than two days ago is the main cause of mortality in this disease. It is in acute appendicitis with a prescription of more than two days that complications arise: periappendicular infiltration, periappendicular abscess, diffuse purulent peritonitis, acute pylephlebitis, and others.
- Chronic appendicitis is a rare form of appendicitis that develops after suffering acute appendicitis and is characterized by sclerotic and atrophic changes in the wall of the appendix. Some researchers have allowed the possibility of the development of primary chronic appendicitis (without previously suffering acute), but at the same time, many authors exclude the presence of chronic appendicitis.
Clinical and morphological classification of appendicitis according to V. I. Kolesov Edit
- Acute appendicitis
- Superficial (simple) appendicitis.
- Destructive appendicitis:
- phlegmonous (with perforation, without perforation),
- gangrenous (with perforation, without perforation).
- Complicated appendicitis (appendicular infiltration, common or total peritonitis, abscesses of the abdominal cavity, pylephlebitis, liver abscesses, sepsis).
- Chronic appendicitis
- Primary chronic
- Chronic recurrent
Catarrhal - leukocyte infiltration of the mucous membrane only.
Surface - the formation of a primary affect of a triangular shape, the base facing the lumen, leukocyte infiltration of the mucous membrane only. In the lumen of blood, leukocytes.
Phlegmonous - leukocyte infiltration of all layers of chop, including the serous membrane, blood in the lumen, leukocytes, fibrin on the serous membrane, leukocytes.
Phlegmonous and ulcerative - leukocyte infiltration of all layers of the appendix, including the serous membrane. Ulcerative mucosa. In the lumen of blood, leukocytes, on the serous membrane of fibrin, leukocytes.
Apostematozny - as phlegmonous, but in the wall small abscesses are formed represented by necrotic tissue and neutrophilic leukocytes.
Gangrenous - necrosis of the process wall, diffuse neutrophil infiltration, peritonitis.
Perforated - the edges of the gap are represented by necrotic tissue with overlays of fibrin, leukocytes and erythrocytes.
Pain in the abdomen, first in the epigastric region or the umbilical region, often has a non-localized nature (pain "all over the abdomen"), after a few hours the pain migrates to the right iliac region - a symptom of "movement" or a symptom of Kocher (or Kocher-Volkovich). Somewhat less frequently, the pain sensation appears immediately in the right iliac region. The pain is permanent, their intensity is usually moderate. As the disease progresses, they are somewhat amplified, although their subsidence may be observed due to the death of the nervous apparatus of the appendix with gangrenous inflammation. The pains are aggravated by walking, coughing, changing the position of the body in bed. When the parietal peritoneum becomes more and more irritated, the pain is localized in the right lower quadrant. This stage is called acute appendicitis. Irradiation in the typical form of acute appendicitis is not observed and is characteristic only for atypical forms. It is important to distinguish between spastic (spasmodic) and intermittent (intermittent) abdominal pain and progressive increasing pain. If a patient has nausea, vomiting, or diarrhea followed by spastic (spasmodic) and intermittent (intermittent) abdominal pain, there is a high probability of gastroenteritis.If the first manifestation is a febrile state, appendicitis is less likely. When appendicitis may occur a slight increase in temperature within 24 hours, the subsequent more significant increase in temperature may indicate perforated appendicitis,
- Lack of appetite (anorexia) source not specified 954 days ,
- Nausea, vomiting 1-2 times and is reflex in nature. The occurrence of nausea and vomiting before the onset of pain is not characteristic of acute appendicitis. source not specified 954 days ,
- Temperature rise to 37-38 ° C (subfebrile fever) (Murphy Triad - anorexia, vomiting, temperature) source not specified 954 days .
- Possible: loose stools, frequent urination, increased heart rate and increased pressure (very rarely) source not specified 954 days
- There are "atypical" manifestations of appendicitis in its atypical location, as well as in children, the elderly and during pregnancy source not specified 954 days .
- Clinical manifestations depend on the location of the appendix. If the appendix is retrocecal (located behind the cecum), the pain is muffled. If the appendix is in the pelvis, there is atypical pain. source not specified 954 days .
- Children may experience dysuria (urinary disorders) due to irritation with an inflamed bladder appendix. source not specified 954 days .
Physical examination Edit
When examining it is important to exclude other sources of infection. Infections of the upper respiratory tract can lead to mesadenitis, which can also cause abdominal pain. The fullness of the patient, retrocecal located appendix, the small size of the intestine make it difficult to diagnose.
Clinical signs. Symptoms of peritoneal irritation Edit
- pain in the right iliac region with palpation. Soreness with a sudden decrease in pressure during palpation in the right lower quadrant is difficult to establish in children. A simpler and more accurate method for determining the degree of peritoneal irritation is to ask the patient to walk or jump. source not specified 954 days .
- increased pain at the McBurney Point (McBurney`s point, the point between the outer and middle third of the imaginary line connecting the anterior-upper angle of the ilium with the navel),
- muscle tension in the right iliac region during palpation source not specified 954 days ,
- pain in the anterior wall of the rectal ampulla due to the presence of effusion in the pocket of Douglas, or in the Douglas space during rectal examination source not specified 954 days ,
- Aaron's symptom (Aaron) - pain, feeling of bursting in the epigastrium or precardiac area with pressure at the Macburney point,
- the symptom Bartome-Michelson (Bartomier) - pain on palpation of the cecum increases in the position of the patient on the left side,
- Bassler's symptom (Bassler) - soreness when pressing along the line from the navel to the anterior upper spine of the right iliac bone increases as you approach the bone,
- Brown's symptom (Brown) - on the anterior abdominal wall in the supine position, mark the place of the greatest pain, after which the patient is placed on the left side. After 15-20 minutes, the place of pain moves 2.5 - 5 cm medially or the pain increases,
- the symptom of Brando (Brindeau) - pain on the right with pressure on the left rib of the pregnant uterus,
- Britten's symptom (Brittain) - with palpation of the abdomen in the zone of greatest pain in the right iliac region, muscle tension and pulling of the right testicle to the upper part of the scrotum is observed. With the cessation of palpation, the testicle descends,
- Wachenheim-Raeder symptom (Wachenheim-Reder) - the appearance of pain in the right iliac region during digital examination of the rectum,
- Widmer symptom (W>,
- Obraztsov's symptom - increased pain when pressure is applied to the cecum and at the same time raising the right leg straightened in the knee joint,
- Ostrovsky's symptom - the patient lifts up the straightened right leg and holds it in that position. The doctor quickly unbends it and puts it horizontally. There is pain in the right iliac region,
- Payr's symptom (Payr) - anal sphincter hypeesthesia with tenesmus and spasms during bowel movements. Positive at the pelvic location of the process,
- Przewalsky symptom (Przewalsky) - it is difficult for a patient to lift his right leg,
- Razdolsky (Mendel-Razdolsky) symptom - when percussion of the abdominal wall pain is determined in the right iliac region,
- Rizvan's symptom - increased pain in the right iliac region with a deep breath,
- Rovsing symptom (Rovsing) - the appearance or intensification of pain in the right ileal region with compression of the sigmoid colon and jerky pressure on the descending colon,
- Samner's symptom (Samner) - increased muscle tone of the anterior abdominal wall with easy palpation,
- Sytkovsky symptom - the occurrence or intensification of pain in the right iliac region in the position of the patient on the left side,
- Soresi's symptom (Soresi) - pain in the right iliac region, arising from coughing and simultaneous palpation in the right hypochondrium in a patient lying on his back with legs bent,
- Horn symptom (Horn) - soreness in the right testicle with a slight sling for the base of the scrotum,
- Chase's symptom (Chase) - pain arising in the right iliac region with rapid and deep palpation along the transverse section of the colon when the other arm is pressed downward,
- Symptom Cheremskikh-Kushnirenko (Karavaeva) - increased pain in the right iliac region when coughing,
- Chugaev's symptom - on palpation of the anterior abdominal wall, intense beams of the external oblique abdominal muscle (“appendix string”) are palpable,
- Shilovtsev's symptom - in the supine position, determine the place of greatest pain in the right iliac region and then suggest the patient to turn on his left side. The pain is shifted lower and to the left,
- Shchyotkin's symptom - Blumberg - reverse sensitivity, increased pain during abrupt withdrawal of the arm, compared with palpation,
- Symptom Yaura-Rozanova - soreness with pressure with a finger in the triangle Petit (Petit).
Laboratory signs Edit
The diagnosis of acute appendicitis - clinical (usually it is put by the surgeon, determining testimony for emergency surgery).
The exact morphological form of the disease (catarrhal, phlegmonous, gangrenous) is detected only intraoperatively, during diagnostic laparoscopy or the first stage of laparotomy (in the national tradition this diagnosis is called “Postoperative diagnosis”).
- The remote vermiform process is examined histologically (usually it takes 5-7 working days) to confirm and detail the intraoperative diagnosis.
- Significant laboratory changes in blood, urine, and other biological fluids, allowing to determine the diagnosis of acute appendicitis without surgery, currently does not exist.
In acute appendicitis, nonspecific changes in blood tests are characteristic of the inflammatory reaction as such: an increase in the number of leukocytes in the blood, an increase in the erythrocyte sedimentation rate, an increase in C-reactive protein after the first 12 hours, a small number of erythrocytes and leukocytes in the urine ("toxic changes in urine" ). A significant increase in the number of leukocytes may indicate perforation source not specified 954 days .
- In the foreign literature of the last 2-3 years, there have been reports that with destructive forms of acute appendicitis, an increase in total serum bilirubin of more than 18.5 μmol / l may be characteristic. A possible explanation for hyperbilirubinemia is the absorption of toxic products from the appendix into the process veins, admission through the portal system to the liver, toxic changes in hepatocytes, which lead to an increase in bilirubin level. Currently, this information needs to be confirmed. In any case, this data is of an auxiliary nature and is not specific to acute appendicitis, as may be present in a number of acute and chronic diseases.
Instrumental examination Edit
Ultrasound procedure - dilatation of the lumen (diameter greater than 6 mm), lack of motility, sometimes coprolite can be located. Ultrasound should be the first instrumental examination for suspected appendicitis. A fluid-filled, incompressible tubular structure with a diameter greater than 6 mm, an appendicolite, a perpendicular pericecal fluid is detected.
- The most frequent echoprism of acute appendicitis is the presence of free fluid in the right iliac fossa (that is, around the appendix) and (or) in the pelvic cavity (the most abdominal position of the abdomen) - symptoms of local peritonitis.
- Ultrasound examination for acute appendicitis is not always specific. For lizirovaniya (detection) of the appendix are required: the presence of obstruction of the appendix, experience and apparatus of an expert class. When the gangrenous-perforated appendicitis, the contents of the appendix is poured into the abdominal cavity, the dilation disappears, the appendix can not be located. At the same time, free fluid in the abdominal cavity is necessarily localized, a “free gas” can be localized in the abdominal cavity, paretic loops of the small intestine.
Ultrasound examination is complicated by intestinal gases, obesity, protective fixation, movements. Detection of a normal appendix with ultrasound is the basis for excluding appendicitis.
Radiography the abdominal cavity in the early stages of the disease is not informative, it is possible to identify only indirect signs of the pathological process in the abdominal cavity (a symptom of the "watchdog loop"). With the development of widespread peritonitis (according to Simonyan’s classification at the paralytic and terminal stages of peritonitis), signs of paralytic intestinal obstruction appear: “Kloyber bowls”, “small bowel arches”, colon pneumatisation disappears. In 10% - 20% of cases, radiography shows coprolite.
Roentgenoscopy (irrigoscopy) indicated for suspected chronic appendicitis. Symptoms of chronic appendicitis are considered to be the lack of filling of the process lumen with a contrast agent, a clear contour or not a worm-shaped process with contrast, may be soldered to adjacent intestinal loops (palpation check for bias)
Diagnostic laparoscopy shown in doubtful cases, it can be transferred to therapeutic laparoscopy with the technical feasibility, when there are conditions for laparoscopic appendectomy, the patient’s written consent to the removal of the appendix is required.
CT scan informative in the presence of a spiral tomograph, when obturation of the appendix, expansion of its lumen, thickening of the wall (> 1 mm) signs of free fluid (inflammatory effusion) in the abdominal cavity are detected.
Radionuclide study with leukocytes labeled 99 Tc.
If the medical history, physical and laboratory examinations do not allow to confirm or exclude appendicitis, it is recommended to follow the diet and repeat the complete blood count with repeated clinical examination with palpation the next morning. In most cases, in the absence of appendicitis, improvement occurs and the patient can be sent home. In children with appendicitis, there is an increase in pain, so antibiotics are used intravenously until appendectomy is performed.
Appendicitis during pregnancy Edit
Acute appendicitis is the most common cause of emergency surgery in pregnant women. The frequency of acute appendicitis in pregnant women: 1 case per 700-2000 pregnant women.
Anatomical and physiological features of the female body make it difficult to timely diagnosis of appendicitis. This leads to a greater frequency of development of complicated forms, which can lead to abortion and fetal death.
The correct surgical tactics is early appendectomy in pregnant women. It avoids complications and saves both the life of the mother and the child.
Features of the body of a woman during pregnancy, affecting the diagnosis and surgical tactics:
- erased clinical picture of "acute abdomen" due to hormonal, metabolic, physiological changes,
- progressive weakening of the muscles of the anterior abdominal wall due to their stretching by the growing uterus,
- displacement of internal organs of the growing uterus: the appendix and cecum are shifted cranially, the abdominal wall rises and moves away from the appendix.
In pregnant women with acute appendicitis, acute pain in the abdomen is noted, which becomes permanently aching and moves to the place of localization of the appendix (right lateral part of the abdomen, right hypochondrium). Note the presence of a positive symptom Taranenko - increased pain in the abdomen when turning from the left side to the right.
Appendicitis needs to be differentiated with the following diseases: viral mesadenitis, viral gastroenteritis, tubo-ovarian search systems, Meckel’s diverticulum, constipation, right-sided pyelonephritis, right renal colic, acute right-sided salpingo-oophoritis (adnexitis), ovarian apoplexy, cysts, cry of in-quest masters, and the search for crystroopers. endometritis, inflammation of Meckel’s diverticulum, perforated ulcer, exacerbation of peptic ulcer, enteritis, colitis, intestinal colic, cholecystitis, ketoacid oz, intestinal obstruction, lower lobe pneumonia or pleural effusion, Crohn’s disease, hemorrhagic vasculitis (Henoch-Henoch disease), food poisoning, etc.
At the prehospital stage it is forbidden to: apply local heat (hot water bottles) on the abdomen, inject drugs and other painkillers, give laxatives to patients and use enemas.
Treatment begins with the introduction of saline and broad-spectrum antibiotics intravenously. Single and double action antibiotics are as effective as triple action antibiotics. Further actions depend on whether perforated or non-perforated appendicitis is observed. If a patient has symptoms less than 24 hours, the risk of perforation is negligible. For them, therapy with antibiotics and solutions leads to stopping the progress of the disease in the direction of perforation and even to an improvement in the condition. Such patients should be prepared for appendectomy. For patients whose symptoms are observed up to 5-7 days, treatment is carried out in the same way. If symptoms are observed for more than 7 days, the probability of perforation with or without an abscess is significant. If the symptoms appear for a long time, the appendectomy becomes more complicated and the postoperative complications increase. This increases the requirements for conservative treatment. Conservative treatment includes the use of intravenous antibiotics, ensuring the flow of intra-abdominal abscess, if available, using surgical radiological techniques. At the same time, the use of conservative treatment is controversial, and many doctors practice immediate appendectomy without the use of conservative treatment.
Patients with a non-perforated appendix are treated with antibiotics for 24 hours or less. A single preoperative dose should be such as to reduce the risk of wound infection.Antibiotic treatment of patients with a perforated appendix continues until clinical symptoms are eliminated (elimination of fever, restoration of gastrointestinal tract functions, and normalization of leukocyte formula). If intravenous antibiotic treatment gave results in less than 5 days, you can switch to oral antibiotics in order to complete the 7-day course.
The diagnosis of acute appendicitis is an indication for emergency surgical treatment. In the absence of phenomena of diffuse peritonitis, MacBurney access is used, sometimes called Volkovich-Dyakonov access in Russian literature. The main stage of the operation for acute appendicitis is appendectomy (removal of the appendix).
Rupture of the appendix, periappendikulyarny infiltrate or appendicular infiltrate periappendikulyarny abscess, peritonitis, abdominal abscess, retroperitoneal abscess, pylephlebitis, thrombophlebitis of pelvic veins, pylephlebitis purulent (septic thrombophlebitis upward portal vein system), septicemia.
With timely operation, the prognosis is favorable. Mortality is 0.1% in the case of acute acute appendicitis, 3% in perforation and 15% in perforated appendicitis in elderly patients.