Appendicitis is an acute, rarely chronic form of inflammation of the appendage of the caecum – appendix (appendix). Depending on the form, it may occur with pain in the right iliac region of varying severity, digestive disorders (nausea, vomiting, delayed stools and gases), increased body temperature. When recognizing appendicitis, they rely on positive diagnostic symptoms (Sitkovsky, Bartomier — Michelson, Blumberg — Shchetkin), data from a finger examination of the rectum and vaginal examination, a detailed clinical blood test. Surgical intervention (appendectomy) is indicated.
ICD 10
K35 K36
Meaning
Appendicitis is one of the most common pathologies of the abdominal cavity, which accounts for 89.1% of the total number of hospitalizations in a surgical hospital. Disease occurs in men and women, can develop at any age; the peak incidence occurs at the age of 10 to 30 years. Inflammation of the appendix is detected in about 5 people out of 1000 per year. Pathology is treated by specialists in the field of abdominal surgery.
What causes appendicitis
As a rule, polymicrobial flora, represented by E. coli, staphylococci, enterococci, streptococci, anaerobes, takes part in the occurrence of the disease. Pathogens enter the wall of the appendix enterogenically, i.e. from its lumen.
Conditions for the development of appendicitis arise when intestinal contents stagnate in the vermiform process due to its inflection, the presence of foreign bodies in the lumen, appendicular stones, hyperplasia of lymphoid tissue. Mechanical blockade of the lumen of the process leads to an increase in intraluminal pressure, circulatory disorders in the wall of the appendix, which is accompanied by a decrease in local immunity, activation of pyogenic bacteria and their introduction into the mucous membrane.
A certain role predisposing to the development of this disease is played by the nature of nutrition and the location of the process. It is known that with abundant consumption of meat food and a tendency to constipation, an excessive amount of protein breakdown products accumulates in the intestinal contents, which creates a favorable environment for the reproduction of pathogenic flora. In addition to mechanical causes, infectious and parasitic diseases can lead to the development of appendicitis – yersiniosis, typhoid fever, amoebiasis, intestinal tuberculosis, etc.
A higher risk of appendicitis exists in pregnant women, which is associated with an enlarged uterus and displacement of the cecum and appendix. In addition, constipation, restructuring of the immune system, and changes in the blood supply to the pelvic organs can serve as predisposing factors to the development of appendicitis in pregnant women.
Pathological anatomy
The appendix is a rudimentary appendage of the caecum, having the shape of a narrow elongated tube, the distal end of which ends blindly, the proximal one communicates with the caecum cavity through a funnel–shaped hole. The wall of the vermiform process is represented by four layers: mucous, submucosal, muscular and serous. The length of the process is from 5 to 15 cm, the thickness is 7-10 mm. The appendix has its own mesentery, which holds it and provides relative mobility of the process.
The functional purpose of the appendix is not completely clear, but it has been proven that the appendix performs secretory, endocrine, barrier functions, and also participates in the maintenance of intestinal microflora and the formation of immune reactions.
Classification of appendicitis
There are two main forms of appendicitis – acute and chronic, each of which has several clinical and morphological variants. During acute appendicitis, there are simple (catarrhal) and destructive forms (phlegmonous, phlegmonous-ulcerative, apostematous, gangrenous appendicitis). Catarrhal form is characterized by signs of circulatory and lymphatic circulation disorders in the process, the development of foci of exudative-purulent inflammation in the mucous layer. The appendix swells, its serous membrane becomes full-blooded.
The progression of catarrhal inflammation leads to acute purulent appendicitis. 24 hours after the onset of inflammation, leukocyte infiltration spreads to the entire thickness of the appendix wall, which is regarded as phlegmonous appendicitis. In this form, the wall of the process is thickened, the mesentery is hyperemic and edematous, a purulent secret is secreted from the lumen of the appendix.
If multiple microabcesses form with diffuse inflammation, apostematous appendicitis develops; with ulceration of the mucosa, phlegmonous-ulcerative appendicitis develops. Further progression of destructive processes leads to the development of gangrenous appendicitis. Involvement in the purulent process of the tissues surrounding the vermiform process is accompanied by the development of periappendicitis; and its own mesentery – the development of mesenteriolitis. Complications of acute (more often phlegmonous-ulcerative) appendicitis include perforation of the process, leading to diffuse or delimited peritonitis (appendicular abscess).
Among the forms of chronic appendicitis, there are residual, primary-chronic and recurrent. The course of chronic form is characterized by atrophic and sclerotic processes in the appendix, as well as inflammatory and destructive changes with subsequent growth of granulation tissue in the lumen and wall of the appendix, the formation of adhesions between the serous membrane and surrounding tissues. When serous fluid accumulates in the lumen of the process, a cyst forms.
Symptoms of appendicitis
In a typical clinic of acute inflammation, there is pain in the iliac region on the right, a pronounced local and general reaction. A painful attack with acute appendicitis, as a rule, develops suddenly. At first, the pain has a diffuse character or is mainly localized in the epigastrium, in the umbilical region. Usually, after a few hours, the pain is concentrated in the right iliac region; with an atypical location of the appendix, it can be felt in the right hypochondrium, in the lumbar region, pelvis, above the pubis. Pain syndrome in acute appendicitis is expressed constantly, it increases with coughing or laughing; decreases in the lying position on the right side.
The characteristic early manifestations of appendicitis include signs of digestive disorders: nausea, vomiting, retention of stool and gases, diarrhea. There is subfebrility, tachycardia up to 90-100 beats. in min. Intoxication is most pronounced in destructive forms of appendicitis. The course of appendicitis can be complicated by the formation of abdominal abscess – appendicular, subdiaphragmal, intercellular, Douglas space. Sometimes thrombophlebitis of the iliac or pelvic veins develops, which can be the cause of PE.
The clinic of appendicitis in children, the elderly, pregnant women, and patients with atypical localization of the appendix has its own peculiarity. In young children with acute appendicitis, the general symptoms inherent in many childhood infections prevail: febrile fever, diarrhea, repeated vomiting. The child becomes inactive, moody, sluggish; with the increase of pain syndrome, restless behavior may be observed.
In elderly patients, the appendicitis clinic is usually erased. The disease often proceeds areactively, even with destructive forms of appendicitis. Body temperature may not rise, hypogastric pain is mild, pulse is within normal limits, symptoms of peritoneal irritation are weak, leukocytosis is small. In older people, especially in the presence of palpable infiltrate in the iliac region, differential diagnosis of appendicitis with a tumor of the cecum is necessary, which requires colonoscopy or irrigoscopy.
With appendicitis in pregnant women, pain can be localized much higher than the iliac region, which is explained by the displacement of the cecum upward by an enlarged uterus. Abdominal muscle tension and other signs of appendicitis may be poorly expressed. Acute appendicitis in pregnant women should be distinguished from the threat of spontaneous termination of pregnancy and premature birth.
Chronic appendicitis occurs with aching dull pains in the right iliac region, which can periodically worsen, especially with physical exertion. The appendicitis clinic is characterized by symptoms of digestive disorders (persistent constipation or diarrhea), feelings of discomfort and heaviness in the epigastric region. Body temperature is normal, clinical urine and blood tests are without pronounced changes. With deep palpation, soreness is felt in the right parts of the abdomen.
Diagnostics of appendicitis
When examining a patient with acute appendicitis, attention is drawn to the patient’s desire to take a forced position; increased pain with any spontaneous muscle tension – laughter, coughing, as well as lying on his left side due to the displacement of the cecum and its process to the left, tension of the peritoneum and mesentery (Sitkovsky’s symptom). The tongue is moist in the first hours, covered with a white coating, then it becomes dry. When examining the abdomen, the lower parts of the abdominal wall lag behind when breathing.
Palpation of the abdomen in case of suspected appendicitis should be carried out with caution. An important diagnostic value in appendicitis is the symptom of Roving (characterized by increased pain on the right after a push-like pressure on the abdomen in the left iliac region) and Shchetkin-Blumberg (increased pain after light pressure and rapid removal of the hand from the abdominal wall).
During the examination of the surgeon, a finger rectal examination is performed to determine the soreness and overhang of the anterior wall of the rectum with the accumulation of exudate. Gynecological examination of women determines the soreness and protrusion of the right vaginal arch. In the blood of acute appendicitis, moderate leukocytosis of 9-12×10 * 9 / l is detected with a shift of the leukocyte formula to the left and a tendency to increase changes within 3-4 hours. Abdominal ultrasound in acute appendicitis reveals the accumulation of a small amount of free fluid around the enlarged appendix.
Acute appendicitis should be differentiated from right-sided renal colic, acute cholecystitis and pancreatitis, perforated gastric and duodenal ulcers, diverticulitis, food poisoning, intestinal obstruction, right-sided pneumonia, acute myocardial infarction. Therefore, in diagnostically unclear cases, additional methods are used – biochemical blood samples, overview radiography of the lungs and abdominal cavity, ECG, diagnostic laparoscopy.
In women, it is necessary to exclude gynecological pathology – acute adnexitis, ovarian apoplexy, ectopic pregnancy. For this purpose, a gynecologist’s consultation, examination on a chair, ultrasound of the pelvic organs is carried out. In children, appendicitis is differentiated with acute respiratory viral infections, childhood infections, coprostasis, diseases of the urinary system and gastrointestinal tract.
In the diagnosis of chronic appendicitis, contrast X-ray studies are used – radiography of the passage of barium through the large intestine, irrigoscopy. Colonoscopy may be required to exclude neoplasms of the caecum.
Treatment for appendicitis
A common tactic in acute inflammatory process is the earliest possible surgical removal of the appendix. At the stage of pre-hospital care, if acute appendicitis is suspected, bed rest, exclusion of fluid intake and food, cold application to the right iliac region are shown. It is strictly forbidden to take laxatives, the use of a hot water bottle, the introduction of analgesics until the final diagnosis is made.
In acute appendicitis, appendectomy is performed – removal of the appendix through an open incision in the right iliac region or by laparoscopy. In appendicitis complicated by diffuse peritonitis, median laparotomy is performed to ensure thorough revision, sanitation and drainage of the abdominal cavity. In the postoperative period, antibiotic therapy is performed.
According to surgeons, appendectomy in chronic appendicitis is indicated if there is a persistent pain syndrome that deprives the patient of normal activity. With relatively mild symptoms, conservative tactics can be applied, including the elimination of constipation, taking antispasmodic drugs, physiotherapy.
Prognosis and prevention
With timely and technically competent surgery for appendicitis, the prognosis is favorable. Working capacity is usually restored after 3-4 weeks. Complications of appendectomy may be the formation of postoperative inflammatory infiltrate, interstitial abscess, Douglas space abscess, the development of adhesive intestinal obstruction. All these conditions require emergency re-hospitalization. The causes of complications and death in appendicitis are delayed hospitalization and untimely surgical intervention.
Literature
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