Angina

Course of appendicular abscess. Appendiceal abscess: clinic, autopsy

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

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

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

1. Obstructive (stagnation theory)

2. Infectious (Aschoff, 1908)

3. Angioneurotic (Rikker, 1927)

4. Allergic

5. Nutritional

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

Classification of acute appendicitis

Uncomplicated appendicitis.

1. Simple (catarrhal)

2. Destructive

phlegmonous
gangrenous
perforated

Complicated appendicitis

Complications of acute appendicitis are divided into preoperative and postoperative.

I. Preoperative complications of acute appendicitis:

1. Appendiceal infiltrate

2. Appendiceal abscess

3. Peritonitis

4. Phlegmon of retroperitoneal tissue

5. Pylephlebitis

II. Postoperative complications of acute appendicitis:

Early(occurring during the first two weeks after surgery)

1. Complications from the surgical wound:

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

2. Complications from the abdominal cavity:

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

3. General complications:

pneumonia
thrombophlebitis, pulmonary embolism
cardiovascular failure, etc.

Late

1. Postoperative hernias

2. Adhesive intestinal obstruction (adhesive disease)

3. Ligature fistulas

The causes of complications of acute appendicitis are:

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

Clinic and diagnosis of acute appendicitis

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

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

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

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

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

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

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

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

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

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

Acute appendicitis in pregnant women. In the first 4-5 months of pregnancy clinical picture acute appendicitis may not have any features, however, in the future, the enlarged uterus displaces the cecum and the appendix upward. In this regard, abdominal pain can be determined not so much in the right iliac region, but along the right flank of the abdomen and in the right hypochondrium; irradiation of pain 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 a position on the left side. For the purpose of timely diagnosis, all patients are shown monitoring laboratory parameters, Ultrasound of the abdominal cavity, joint dynamic observation of the surgeon and obstetrician-gynecologist, laparoscopy can be performed if indicated. Once the diagnosis is made, emergency surgery is indicated in all cases.

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

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

10. Right lower lobe pleuropneumonia

Treatment of acute appendicitis

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

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

To perform a typical appendectomy open method Traditionally, an oblique variable (“slide”) access of Volkovich-Dyakonov is used through the McBurney point, 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 abdominis muscle (according to Bogoyavlensky) or with its intersection (according to Kolesov). Sometimes the Lenander longitudinal approach (along the outer edge of the right rectus abdominis muscle) and the transverse Sprengel approach (used more often in pediatric surgery) are used. In case of complications of acute appendicitis with widespread peritonitis, with severe technical difficulties during appendectomy, as well as erroneous diagnosis, a median laparotomy is indicated.

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

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

Appendicular infiltrate

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

At an early stage, formation occurs inflammatory tumor. Patients have a clinical picture close to the symptoms of acute destructive appendicitis. At the stage of formation of a dense infiltrate, the phenomena of acute inflammation subside. General condition patients are improving.

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

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

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

Appendiceal abscess

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

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

The classic treatment option for an appendiceal abscess is opening the abscess using an extraperitoneal approach according to N.I. Pirogov with a deep, including retrocecal and retroperitoneal location. In 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 inserted into its cavity, and the wound is sutured until drainage occurs.

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

Pylephlebitis

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

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

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

Pelvic abscess

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

The pouch of Douglas abscess forms 1 to 3 weeks after surgery and is characterized by the presence common symptoms 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, pain in the anterior wall of the rectum is found, its overhang; a painful infiltrate along the anterior wall of the intestine with areas of softening can be palpated. Per vaginam there is pain in the posterior fornix, intense pain when the cervix is displaced.

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

Undiagnosed in time pelvic abscess may be complicated by a breakthrough into the free abdominal cavity with the development of peritonitis or into adjacent hollow organs (bladder, rectum and cecum, etc.)

Subphrenic abscess

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

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

Interintestinal abscess

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

Interintestinal abscesses adjacent to the anterior abdominal wall and fused with parietal peritoneum 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, slipping of the ligature from its mesentery, damage to the vessels of the anterior abdominal wall and insufficient hemostasis when suturing the surgical wound. Disorders of the blood coagulation system play a certain role. Bleeding can be profuse and capillary.

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

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

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

Abdominal wall infiltrates and wound suppuration

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

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

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

Ligature fistulas

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

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

Security questions

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

10. Diagnosis and treatment of pelvic abscesses

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

12. Pylephlebitis (diagnosis and treatment)

13. Diagnosis of subphrenic and interintestinal abscesses. Treatment tactics

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

15. Examination of work capacity after appendectomy

Situational tasks

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

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

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

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

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

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

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

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

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

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

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

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

Sample answers

1. The patient has developed an appendiceal infiltrate, confirmed by ultrasound data. Conservative-wait-and-see tactics; in case of abscess formation, it is indicated surgical treatment.

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

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

4. The postoperative period was complicated by the development of an external small intestinal fistula. Necessary x-ray examination sick. In the presence of a formed tubular low small intestinal fistula with a small amount of discharge, measures to conservatively close it are possible; in other cases, surgical treatment is indicated.

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

LITERATURE

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Volkov V. E., Volkov S. V. Acute appendicitis - Cheboksary, 2001. - 232 p.
Gostishchev V.K., Shalchkova L.P. Purulent pelvic surgery - M., 2000. - 288 p.
Grinberg A. A., Mikhailusov S. V., Tronin R. Yu., Drozdov G. E. Diagnosis of difficult cases of acute appendicitis. - M., 1998. - 127 p.
Clinical surgery. Ed. R. Conden and L. Nyhus. Per. from English - M., Praktika, 1998. - 716 p.
Kolesov V.I. Clinic and treatment of acute appendicitis. - L., 1972.
Krieger A. G. Acute appendicitis. - M., 2002. - 204 p.
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An appendiceal abscess is an abscess in the abdominal cavity, a complication of acute appendicitis. It occurs before surgery as a result of suppuration of the appendiceal infiltrate, and can also form in the postoperative period. Development frequency 1-3%. Initially, an appendiceal infiltrate is formed, which, under the influence of treatment, resolves or abscesses.

Causes of abscess

The abscess is caused jointly by cocci, non-clostridial anaerobic flora and Escherichia coli.

Late diagnosis of an acute process and late seeking help contribute to the development of the disease.

Causes in the postoperative period:

defects in surgical technique,
decreased immunological body protection,
insensitivity of microorganisms to antibiotics used.

The infiltrate forms on days 2-3 due to fibrinous effusion and the formation of adhesions between the greater omentum, appendix, and intestinal loops. After conservative treatment, the inflammatory process in the appendix subsides. If destruction of the appendix occurs, the infection spreads beyond its boundaries and an abscess forms. Abscess formation occurs after 5-6 days.

Depending on the location of the appendix, the appendicular abscess can be located in the iliac fossa on the right or in the pelvis.

Secondary ulcers in the postoperative period are associated with the spread of pyogenic infection through the lymphatic tract.

Symptoms

Deterioration of general condition: chills, malaise, weakness, sweating, loss of appetite.
Phenomena of intoxication.
Dyspeptic symptoms: vomiting, stool disturbances, bloating.
The tongue is coated.
High temperature: especially high in the evening.
Constant pain in the abdomen (right iliac region) of a pulsating nature. They get worse with bumpy driving, walking, and coughing.
The abdominal wall is tense, painful at the location of the abscess, and lags behind when breathing. The Shchetkin-Blumberg symptom is determined. A stationary infiltrate is palpated (tumor-like formation, stationary painful), sometimes fluctuation.
When the pathological focus is located among the intestinal loops, manifestations of intestinal obstruction (vomiting, cramping pain, bloating) are possible.
With pelvic localization: pain and bloating are noted in the lower abdomen, increased urge to urinate, mucus from the rectum, pain during bowel movements.
If the abscess is close to the abdominal wall: local redness of the skin and swelling.
Breakthrough of an abscess into the intestines: improvement of condition, reduction of pain, drop in temperature, loose stools with a huge amount foul-smelling pus.
Opening of an abscess into the peritoneal cavity: development of peritonitis, formation of secondary purulent foci, fever, tachycardia, increase in intoxication phenomena.

Special diagnostic methods

Rectal examination allows you to identify a painful protrusion, often fluctuation. If the abscess is located high up, then characteristic signs may not be detected.
In some cases, a vaginal examination is also performed, which reveals pain, and sometimes the formation itself.
In the leukocyte formula there is leukocytosis and a shift to the left. Increase in ESR.
X-ray examination: does not reveal absolute signs of infiltration or abscess. In an upright position, it is possible to detect a homogeneous darkening in the ileal region with a slight shift to the midline of the intestinal loops. In advanced situations, the fluid level is visible in the area of the abscess. With intestinal obstruction - fluid in the intestinal loops.
Using ultrasound, you can determine the exact location of the abscess and its size.

Complications of appendiceal abscess

thrombosis, thrombophlebitis of the pelvic veins,
sepsis,
perforation into the small and cecum with subsequent formation of fistulas,
spilled purulent peritonitis,
limited forms of peritonitis due to microperforation of the abscess,
perforation into the bladder, which leads to ascending urinary tract infection, as well as urosepsis,
intestinal obstruction.

Treatment

Stage of appendiceal infiltrate

Treatment is conservative. The operation is contraindicated.

Bed rest.
Cold on the stomach for the first 3 days.
A gentle diet.
Antibiotic therapy.
Narcotics and laxatives are not prescribed.
Sometimes perinephric novocaine blockades to resolve the infiltrate.

After complete resorption, appendectomy is performed routinely after 1-2 months.

Formed appendicular abscess

Surgical treatment is mandatory: opening the abscess, washing and draining it. In some cases, ultrasound-guided percutaneous drainage is performed under local anesthesia.

The classic approach is the right-sided extraperitoneal one. In the case of a pelvic location, the abscess is opened through the rectum; in women, the access is through the posterior vaginal vault. The pus is removed, the cavity is washed with antiseptics, and then drainage tubes are installed. It is preferable to remove the caecum, however, if there is a risk of damage to the inflamed intestinal wall and the spread of pus into the peritoneal cavity, then it is left.

Postoperative period:

Careful care of drains: rinsing, removing contents.
Antibiotic therapy: with aminoglycosides.
Detoxification therapy.
General strengthening agents.

Drains are left in place as long as there is purulent discharge. After this, the drainage tube is removed and the wound heals. If appendectomy was not performed, then elective surgery is indicated after 2 months.

Prognosis and prevention

The prognosis in case of appendiceal abscess is serious. The result depends on the adequacy and timeliness of the start of therapy.

Prevention of abscess involves timely diagnosis acute appendicitis and surgery in the first 2 days.

One of the most common diseases in people who need surgical intervention, is inflammation of appendicitis.

The atrophied part of the large intestine is the appendix; it looks like a vermiform appendix of the cecum. The appendix forms between the large and small intestines.

Doctors note that it is quite difficult to predict and prevent the disease. Experts do not recommend taking painkillers in case of appendicitis.

The appointment will prevent the doctor from diagnosing correct diagnosis to the patient. This should be done exclusively by a specialist who will prescribe an ultrasound.

Thanks to them, it will be possible to understand what shape the inflamed appendix has. It may be clogged or swollen. It can only be removed surgically.

Forms of appendicitis

Today, the disease is divided into acute and chronic forms. In the first case, the clinical picture is pronounced.

The patient is very ill, and therefore emergency hospitalization cannot be avoided. In the chronic form, the patient feels a condition that is caused by the transferred acute inflammation with no symptoms.

Types of appendicitis

Today there are 4 types of appendicitis known. These are: catarrhal, phlegmonous, perforative; gangrenous.

The diagnosis of catarrhal appendicitis is made by a doctor if the penetration of leukocytes into the mucous membrane of the worm-shaped organ has been noted.

Phlegmonous is accompanied by the presence of leukocytes in the mucosa, as well as other deep layers of appendix tissue.

Perforated is observed if the walls of the inflamed appendage of the cecum have been torn, but gangrenous appendicitis represents the wall of the appendix affected by leukocytes, which is completely dead.

Symptoms

Symptoms of the disease include:

acute pain in the abdominal area, or more precisely in the right half in the area of the inguinal fold;
increased body temperature;
vomiting;
nausea.

The pain will be constant and dull, but if you try to turn your body, it will become even stronger.

It should be noted that it is possible that after severe attack pain syndrome disappears.

Patients will mistake this condition for the fact that they feel better, but in fact the subsidence of pain carries with it great danger, indicating that the organ fragment died off; it was not for nothing that the nerve endings stopped reacting to irritation.

Such pain relief ends with peritonitis, which is dangerous complication after appendicitis.

Problems with the gastrointestinal tract may also be observed in symptoms. The person will feel a feeling of dryness in the mouth and may be bothered by diarrhea and loose stools.

Blood pressure may jump and heart rate may increase to 100 beats per minute. The person will suffer from shortness of breath, which will be caused by impaired heart function.

If the patient has a chronic form of appendicitis, then all of the above symptoms do not appear, with the exception of pain.

The most common complications after appendicitis

Of course, doctors set themselves the task of eliminating all complications after appendicitis removal, but sometimes they simply cannot be avoided.

Below are the most common consequences of appendicitis.

Perforation of the walls of the appendix

In this case, there are ruptures in the walls of the appendix. Its contents will end up in the abdominal cavity, and this provokes sepsis of other organs.

The infection can be quite severe. A fatal end is not ruled out. Such perforation of the walls of appendicitis is observed in 8-10% of patients.

If it is purulent peritonitis, the risk of death is high, and exacerbation of symptoms cannot be ruled out. This complication after appendicitis occurs in 1% of patients.

Appendiceal infiltrate

These complications after surgery to remove appendicitis are observed in the case of adhesions of organs. The percentage of such cases is 3-5.

The development of complications begins 3-5 days after the formation of the disease. Accompanied by pain of unclear localization.

Over time, the pain subsides, and the contours of the inflamed area appear in the abdominal cavity.

The infiltrate with inflammation acquires pronounced boundaries and a dense structure, and tension in nearby muscles will also be observed.

In about 2 weeks the swelling will go away and the pain will stop. The temperature will also subside, and blood counts will return to normal.

In many cases, it is possible that the inflamed part after appendicitis will cause the development of an abscess. It will be discussed below.

Abscess

The disease develops against the background of suppuration of the appendiceal infiltrate or surgery if peritonitis is diagnosed.

As a rule, it takes 8-12 days for the disease to develop. All abscesses need to be covered and debrided.

In order to improve the outflow of pus, doctors install drainage. During the treatment of complications after appendicitis, it is customary to use antibacterial agents drug therapy.

If there is a similar complication after appendicitis, urgent surgery is necessary.

After this, the patient will have to wait a long time rehabilitation period accompanied by drug treatment.

Complications after appendectomy

Even if the operation to remove appendicitis was performed before the onset of severe symptoms, this does not guarantee that there will be no complications.

Many cases deaths after appendicitis make people pay closer attention to any warning symptoms.

Below are the most common complications that may occur after removal of an inflamed appendix.

Spikes

One of the most common pathologies that appears after removal of the appendix. Accompanied by nagging pain and discomfort.

It is difficult to diagnose, because ultrasound and x-rays cannot see them. It is necessary to carry out a course of treatment with absorbable drugs and resort to the laparoscopic method of removing adhesions.

Hernia

The phenomenon is really common after appendicitis. There is a prolapse of part of the intestine into the area of the lumen between the muscle fibers.

A hernia looks like a tumor in the suture area, increasing in size. Surgical intervention is provided. The surgeon will sew it up, trim it, or remove part of the intestine and omentum.

Abscess

Occurs in most cases after appendicitis with peritonitis. It can infect organs.

A course of antibiotics and special physiotherapeutic procedures is required.

Pylephlebitis

Very rare complication after surgery to remove appendicitis. Inflammation is observed, which spreads to the area of the portal vein, mesenteric vein and process.

Accompanied by fever, severe liver damage, and acute pain in the abdominal area.

If this acute stage pathology, then everything can lead to death. Treatment is complex, requiring the introduction of antibiotics into the portal vein systems.

Intestinal fistulas

Occurs after appendicitis in 0.2-0.8% of people. Intestinal fistulas form a tunnel in the intestines and skin, sometimes in the walls of internal organs.

The reasons for their appearance may be poor sanitation purulent appendicitis, surgeon errors, tissue inflammation during drainage internal wounds and foci of abscess development.

It is difficult to treat the pathology. Sometimes doctors prescribe resection of the affected area, as well as removal of the top layer of epithelium.

It should be noted that the occurrence of complications is facilitated by ignoring the doctor’s advice, failure to comply with hygiene rules, and violation of the regime.

Deterioration of the condition can be observed 5-6 days after surgery.

This will talk about development pathological processes in internal organs. During the postoperative period, it is possible that you will need to consult with your doctor.

You should not avoid this; on the contrary, your body gives signals that other ailments are developing, they may not even be related to the appendectomy.

It is important to pay due attention to your health and do not hesitate to seek help from a doctor.

Increased body temperature

The inflammatory process can also affect other organs, and therefore it is possible that additional health problems may arise.

Women often suffer from inflammation of the appendages, which makes diagnosis and the exact cause of the disease difficult.

Often, the symptoms of acute appendicitis can be confused with similar pathologies, and therefore doctors prescribe an examination by a gynecologist and an ultrasound of the pelvic organs if the operation is not emergency.

Also, an increase in body temperature indicates that an abscess or other diseases of the internal organs are possible.

If the temperature rises after the operation, then you need to undergo an additional examination and be tested again.

Digestive disorders

Diarrhea and constipation may indicate a malfunction of the gastrointestinal tract after appendicitis. At this time, the patient is having a hard time with constipation; he cannot push or strain, because this is fraught with protrusion of hernias, ruptured sutures and other problems.

To avoid indigestion, you need to stick to a diet, making sure that the stool is not fixed.

Pain attacks in the abdomen

As a rule, there should be no pain for 3-4 weeks after surgery. This is how long it takes for tissue regeneration to take place.

In some cases, pain indicates hernias or adhesions, and therefore there is no need to take painkillers, you should consult a doctor.

It is worth noting that appendicitis often occurs in medical practice doctors. The pathology requires urgent hospitalization and surgery.

The thing is that inflammation can quickly spread to other organs, which will entail many serious consequences.

To prevent this from happening, it is important to visit a doctor in a timely manner and call an ambulance. Do not ignore those signals from the body that indicate the development of the disease.

Appendicitis is dangerous; even with a successful operation, deaths have been observed more than once, let alone when patients neglect their health.

Prevention

Special preventive measures appendicitis does not exist, but there are some rules that should be followed to reduce the risk of developing inflammation in the area of the appendix of the cecum.

Adjust your diet. Moderate your intake of fresh herbs (parsley, green onions, dill, sorrel, lettuce), hard vegetables and ripe fruits, seeds, fatty and smoked treats.
Take care of your health. It is worth paying attention to all signals about a malfunction in your body. There have been many cases in medical practice where inflammation of the appendix was caused by the penetration of pathogenic microorganisms into it.
Conduct identification helminthic infestations, as well as timely treatment.

Summing up

Even though appendicitis is not considered a dangerous disease, the pathology has a high risk of developing complications after surgical removal process of the cecum. Typically, they occur in 5% of people after appendicitis.

The patient can count on qualified medical care, but it is important not to miss the moment and consult a doctor in a timely manner.

You need to wear a bandage, women can wear panties. This measure will help not only to eliminate complications after appendicitis, but also to keep the suture neat, without causing it to become defective.

Pay attention to your health, and even if appendicitis has been detected, try to do everything that the doctor directs to avoid problems in the future.

Useful video

This disease is associated with pathologies in the form of purulent inflammation of the infiltrate, both inside and near the appendage of the cecum, otherwise called the appendix. There are both primary ulcers, which are caused by inflammation in the appendix itself or near it, and secondary purulent formations that arise at a distance from the appendix. Therefore, it is necessary to promptly remove the infiltrate to eliminate the formation of an abscess.

Symptoms

The symptoms of an appendix abscess are very similar to those of acute appendicitis .

However, it is worth pointing out a number of differences that speak specifically about this pathology:

nausea, in some cases accompanied by vomiting;
weak condition;
severe cramping pain in the abdomen that does not stop even with the use of strong painkillers;
increased flatulence associated with intense gas formation;
high body temperature. If with appendicitis it is usually within 37-38 degrees, then with appendiceal abscess it is fixed at 39-40 degrees in conjunction with the patient’s chills.

If this symptomatic picture, which does not completely coincide with the signs of appendicitis, remains for two or three days, then all this will indicate an abscess.

The inflammatory process can begin both before and after surgery to remove appendicitis due to suppuration of the infiltrate, the so-called standing biological fluid(blood, lymph, cell tissue), which forms various pathological compactions of the process of the cecum.

Therefore, in patients, a stationary infiltrate may be palpated in a limited area of the abdomen, which at the same time has a moderately swollen state. In some cases, there are problems with intestinal patency, and there is also bloating in the lower section abdomen, which indicates the possibility of different locations of the abscess. This is caused by the relationship between the location of the appendix and the direction of progression of the appendiceal abscess in the abdominal cavity.

Causes of appendix abscess

If we talk about the causes of this disease, then they, like the causes of most complications, lie due to misdiagnosis and loss of time for treatment. The infiltrate forms in two to three days. Development purulent abscess it begins on the fifth or sixth day from the onset of infection with pathogenic microorganisms. This is when the abscess began to progress in the preoperative period.

Regarding postoperative complications, then you can point out reasons such as:

use of defective operating instruments;
due to a decrease in the body’s protective functions;
insensitivity of the body to antibiotics.

Treatment of appendix abscess

Treatment of such an insidious disease as an appendiceal abscess cannot be delayed or delayed, since the abscess can unexpectedly burst and purulent fluid enters the abdominal cavity. The only way out, according to most specialists in purulent medicine, is to carry out emergency surgery followed by a rehabilitation course of antibiotics with periodic antiseptic treatment of the site where the abscess was, using a drainage system.

The main unpleasant feature of this operation for the patient is that after all the manipulations the wound is not sutured; it must be left open until complete healing.