Etiology. Pathogenesis

Acute appendicitis develops in response to an attack of a non-specific type of infection with inflammatory phenomena in the appendix - the appendix. The reason for the invasion of infection is a violation of the normal relationship between the human body and the environment of microorganisms. Connection to the "conflict" of exogenous and endogenous factors accelerates the urgent need for immediate removal of the process. There are several manifestations of inflammation of the appendix, systematized by the nature of the disease, the course and distribution. More often than others, the pathological and clinical classification of acute appendicitis is used.

Classification of acute appendicitis

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

In practice, there are such forms of inflammation of the appendix:

• Acute simple appendicitis, its second name is superficial in the concept of many doctors.
• Acute destructive appendicitis:
  • simple phlegmonous;
  • beginning ulcers with phlegmonous form;
  • abscesses that replace ulcers - apostematous appendicitis with and without perforation;
  • gangrenous type with perforation and without perforation.
• Acute complicated:
  • peritonitis, which can be local delimited (undelimited) or widespread diffuse (less often diffuse);
  • located in different places appendicular infiltrate;
  • appendicular and periappendicular abscess;
  • pylephlebitis;
  • local abscess in the liver;
  • sepsis;
  • unlimited inflammatory phenomena of a purulent nature in the retroperitoneal tissue.

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

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

Children are inconsistent clinical picture illness and pathological changes tissues of the affected organ.

Etiology and pathogenesis of inflammation

Nonspecific inflammation

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

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

Occurs in children special shape inflammation - hemorrhagic appendicitis. To start inflammation of any etiology, several conditions for its course must be maintained:

• damage to the mucosa and impaired performance of its protective functions;
• increase in the number of pathogenic microorganisms and activation of the microflora of the secondary and conditional level of pathogenicity;
• downgrade immune response organism against invading pathogenic bacteria.

specific inflammation

With inflammation of the appendix of a specific nature, provoking factors are included that do not have a negative effect during the normal functioning of the body. These include helminthic invasions (flat and roundworms, Giardia, etc.), protozoa (amoebae, trichomonas, etc.), fungi (actinomycetes, dimorphic yeast fungi).

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

For children, helminthic etiology is more characteristic, since helminthic invasions (pinworms, baby roundworms) are more common in children.

Acute appendicitis (acute inflammation of the appendix of the caecum) 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%, occurs at any age, more often from 10 to 30 years old, men and women get sick with approximately the same frequency.

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

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

1. Obstructive (stagnation theory)

2. Infectious (Aschoff, 1908)

3. Angioedema (Rikker, 1927)

4. Allergic

5. Alimentary

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

Classification of acute appendicitis

Uncomplicated appendicitis.

1. Simple (catarrhal)

2. Destructive

• phlegmonous
• gangrenous
• perforative

Complicated appendicitis

Complications of acute appendicitis are divided into preoperative and postoperative.

I. Preoperative complications of acute appendicitis:

1. Appendicular infiltrate

2. Appendicular abscess

3. Peritonitis

4. Phlegmon of retroperitoneal tissue

5. Pylephlebitis

II. Postoperative complications of acute appendicitis:

Early(appeared within the first two weeks after surgery)

1. Complications from the surgical wound:

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

2. Complications from the abdominal cavity:

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

3. Complications of a general nature:

• pneumonia
• thrombophlebitis, thromboembolism pulmonary artery
• cardiovascular insufficiency, etc.

Late

1. Postoperative hernia

2. Adhesive intestinal obstruction (adhesive disease)

3. Ligature fistulas

The causes of complications of acute appendicitis are:

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

Clinic and diagnosis of acute appendicitis

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

Another important symptom that occurs in patients with acute appendicitis is nausea and vomiting, which is more often single, stool retention is possible. General symptoms of intoxication in the initial stage of the disease are mild and are manifested by malaise, weakness, subfebrile temperature. It is important to assess the sequence of occurrence of symptoms. The classic sequence is the initial occurrence of abdominal pain and then vomiting. Vomiting prior to the onset of pain calls into question the diagnosis of acute appendicitis.

The clinical picture in acute appendicitis depends on the stage of the disease and the location of the appendix. On the early stage there is a slight increase in temperature and increased heart rate. Significant hyperthermia and tachycardia indicate the occurrence of complications (perforation of the appendix, the formation of an abscess). With the usual location of the appendix, there is local tenderness at the McBurney point on palpation of the abdomen. With pelvic localization, pain is detected in the suprapubic region, dysuric symptoms are possible (frequent painful urination). Palpation of the anterior abdominal wall is uninformative, it is necessary to perform a digital rectal or vaginal examination to determine the sensitivity of the pelvic peritoneum (“Douglas cry”) and assess the condition of other organs of the small pelvis, especially in women. With a retrocecal location, the pain is shifted to the right flank and the right lumbar region.

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

Diagnosis facilitates identification of the characteristic symptoms of acute appendicitis:

• Razdolsky - soreness on percussion over the focus of inflammation
• Rovsinga - the appearance of pain in the right iliac region when pushing in the left iliac region in the projection of the descending colon
• Sitkovsky - when the patient turns to the left side, there is an increase in pain in the ileocecal region due to the movement of the appendix and the tension of its mesentery
• Voskresensky - with a quick slide of the hand over a stretched shirt from the xiphoid process to the right iliac region, a significant increase in pain is noted in the latter at the end of the movement of the hand
• Bartomier - Michelson - palpation of the right iliac region in the position of the patient on the left side causes a more pronounced pain reaction than on the back
• Obraztsova - on palpation of the right iliac region in the position of the patient on the back, the pain intensifies when raising the right straightened leg
• Coupa - hyperextension right foot the patient, when positioned on his left side, is accompanied by a sharp pain

Laboratory data. A blood test usually reveals moderate leukocytosis (10 -16 x 10 9 /l) with a predominance of neutrophils. However, a normal peripheral blood leukocyte count does not rule out acute appendicitis. In the urine, there may be single erythrocytes in the field of view.

Special research methods usually carried out in cases where there is doubt about the diagnosis. In case of inconclusive clinical manifestations of the disease in the presence of an organized specialized surgical service, it is advisable to start the additional examination with non-invasive ultrasound (ultrasound), during which attention is paid not only to the right iliac region, but also to the organs of other parts of the abdomen and retroperitoneal space. An unambiguous conclusion about the destructive process in the organ allows us to correct the operative approach and the option of anesthesia with an atypical location of the process.

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

Development acute appendicitis in elderly and senile patients has a number of features. This is due to a decrease in physiological reserves, a decrease in the reactivity of the body and the presence of concomitant diseases. The clinical picture is characterized by a less acute onset, mild severity and diffuse nature of abdominal pain with a relatively rapid development of destructive forms of appendicitis. Often there is bloating, non-excretion of stools and gases. Tension of the muscles of the anterior abdominal wall, pain symptoms characteristic of acute appendicitis, may be mild, and sometimes not detected. The general reaction to the inflammatory process is weakened. The rise in temperature to 38 0 and above is observed in a small number of patients. In the blood, moderate leukocytosis is noted with a frequent shift of the formula to the left. Careful observation and examination with the wide use of special methods (ultrasound, laparoscopy) are the key to a timely surgical intervention.

Acute appendicitis in pregnant women. In the first 4-5 months of pregnancy, the clinical picture of acute appendicitis may not have any features, however, in the future, the enlarged uterus displaces the caecum and appendix upwards. In this regard, pain in the abdomen 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 pathology from the biliary tract and right kidney. Muscle tension, symptoms of peritoneal irritation are often mild, especially in the last third of pregnancy. To identify them, it is necessary to examine the patient in the position on the left side. With the aim of timely diagnosis all patients are shown the control of laboratory parameters, ultrasound of the abdominal cavity, joint dynamic observation of the surgeon and obstetrician-gynecologist, according to indications, laparoscopy can be performed. When the diagnosis is made, emergency surgery is indicated in all cases.

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

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

10. Right-sided lower lobe pleuropneumonia

Treatment of acute appendicitis

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

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

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

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

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

Appendicular infiltrate

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

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

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

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

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

Appendicular abscess

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

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

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

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

Pylephlebitis

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

The pylephlebitis clinic consists of hectic temperature with chills, pouring sweat, icteric staining of the sclera and skin. Patients are concerned about pain in the right hypochondrium, often radiating to the back, lower chest and right collarbone. Objectively find an increase in the liver and spleen, ascites. An x-ray examination determined the high standing of the right dome of the diaphragm, an increase in the shadow of the liver, and a reactive effusion in the right pleural cavity. Ultrasound reveals areas of altered echogenicity of the enlarged liver, signs of portal vein thrombosis and portal hypertension. In the blood - leukocytosis with a shift to the left, toxic granularity of neutrophils, increased ESR, anemia, hyperfibrinemia.

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

pelvic abscess

Pelvic localization of abscesses (abscesses Douglasova space) in patients undergoing appendectomy is most common (0.03 - 1.5% of cases). They are localized in the lowest part of the abdominal cavity: in men, excavatio retrovesicalis, and in women, in excavatio retrouterina. The occurrence of abscesses is associated with poor sanitation of the abdominal cavity, inadequate drainage of the pelvic cavity, the presence of abscessing infiltrate in this area with the pelvic location of the process.

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

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

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

Subdiaphragmatic abscess

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

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

Interintestinal abscess

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

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

Intra-abdominal bleeding

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

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

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

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

Abdominal wall infiltrates and wound suppuration

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

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

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

Ligature fistulas

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

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

test questions

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

10. Diagnosis and treatment of pelvic abscesses

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

12. Pylephlebitis (diagnosis and treatment)

13. Diagnosis of subphrenic and interintestinal abscesses. Medical tactics

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

15. Examination of working capacity after appendectomy

Situational tasks

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

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

2. Patient K., 18 years old, was operated on for acute gangrenous-perforated appendicitis, complicated by diffuse serous-purulent peritonitis. Performed appendectomy, drainage of the abdominal cavity. The early postoperative period proceeded with the phenomena of moderately expressed intestinal paresis, which were effectively stopped by the use of drug stimulation. However, by the end of the 4th day after the operation, the patient's condition worsened, increasing bloating appeared, cramping pains throughout the abdomen, gases stopped leaving, nausea and vomiting, common signs of endogenous intoxication.

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

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

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

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

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

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

Objectively: The patient's condition moderate. Temperature 37.2 - 37.5 0 C. The tongue is wet. The abdomen is soft, slightly painful in the wound area. There are no peritoneal symptoms. Chair independent 1 time per day. In the area of ​​drainage there is a channel approximately 12 cm deep, lined with granulating tissue, through which intestinal contents are poured. The skin around the canal is macerated.

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

5. By the end of the first day after appendectomy, the patient has a sharp weakness, pale skin, tachycardia, falling blood pressure, free fluid is determined in sloping places of the abdominal cavity. Diagnosis? surgeon tactics?

Sample answers

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

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

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

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

5. The patient has a clinic of bleeding into the abdominal cavity, probably due to slipping of the ligature from the stump of the mesentery of the appendix. An emergency relaparotomy was indicated.

LITERATURE

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

Nonspecific inflammation of the appendix. The appendix is ​​a part of the gastrointestinal tract, formed from the wall of the caecum, in most cases it departs from the posteromedial wall of the caecum at the confluence of the three ribbons of the longitudinal muscles and is directed downward and medially from the caecum. The shape of the process is cylindrical. Length 7-8cm, thickness 0.5-0.8cm. Covered with peritoneum on all sides and has a mesentery, thanks to which it has mobility. Blood supply along a.appendicularis, a branch of a.ileocolica. Venous flows through v.ileocolica into v.mesenterica superior and v.porte. Sympathetic innervation of the superior mesenteric and celiac plexus, and parasympathetic - fibers of the vagus nerves.

In pre-hospital it is forbidden to apply heat locally, heating pads on the abdomen, inject drugs and other painkillers, give laxatives and use enemas.

In the absence of diffuse peritonitis, the operation is performed using McBurney (Volkovich-Dyakonov) access.

The subcutaneous fatty tissue is dissected, then the aponeurosis of the external oblique muscle is dissected along the fibers, then the external oblique itself.

After breeding the edges of the wound, the internal oblique muscle is found. In the center of the wound, the perimysium of the oblique muscle is dissected, then with two anatomical forceps, the internal oblique and transverse abdominal muscles are pushed apart along the fibers in a blunt way. The hooks are moved deeper to hold the muscles apart. In a blunt way, the preperitoneal tissue is pushed back to the edges of the wound. The peritoneum is lifted with two anatomical tweezers in the form of a cone and dissected with a scalpel or scissors for 1 cm.

The edges of the dissected peritoneum are grasped with Mikulich-type clamps and its incision expands upwards and downwards by 1.5-2 cm. Now all layers of the wound, including the peritoneum, are moved apart with blunt hooks .. As a result, an access is created that is quite sufficient to remove the caecum from the abdominal cavity and vermiform appendix.

Then an appendectomy. Upon removal of the process, the mesentery is crossed between hemostatic clamps and tied with a thread; at the same time, it is necessary to ensure that the first (closest to the base of the process) branch a. appendicularis to avoid bleeding. The so-called ligature method, in which the stump is not immersed in a pouch, is too risky; adults should not use it. Around the base of the appendix, a purse-string suture is applied (without tightening) to the caecum. The base of the process is tied with a ligature, the process is cut off, its stump is immersed in the intestinal lumen, after which the purse-string suture is tightened.
After completing the removal of the process, checking hemostasis and lowering the intestine into the abdominal cavity, gauze wipes are removed.

Now laparoscopic appendectomy has become widespread - the removal of the appendix through a small puncture of the BS. 3 punctures: one 1 cm above the navel, another 4 cm below the navel and the third, depending on the location of the process.

Acute appendicitis without mention of localized or diffuse peritonitis

Version: Directory of Diseases MedElement

Acute appendicitis other and unspecified (K35.8)

Gastroenterology

general information

Short description

Acute appendicitis is an acute nonspecific inflammation of the appendix.

Note

Flow period

Minimum flow period (days): not specified

Maximum flow period (days): 2

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

Note. These terms are typical for most cases of progressive acute appendicitis, but they are not absolute. AT clinical practice often there are some deviations in the course of the disease.

Classification

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

1. Appendicular colic.

2. Simple (superficial, catarrhal) appendicitis.

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

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

Morphological classification of types of acute appendicitis

1. Simple (formerly called catarrhal).

2. Surface.

3. Destructive:

Phlegmonous;
- apostematous;

Phlegmonous and ulcerative;
- gangrenous;

Perforated.

Options for the location of the appendix:

1. Typical.

2. Medial.

3. Pelvic.

4. Ascending - along the right side channel.

5. Subhepatic.

6. Retrocecal.

7. Retroperitoneal.

8. Left side.

Etiology and pathogenesis

The etiology of acute appendicitis has not been definitively established.

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

Obturation of the lumen of the process and violation of evacuation can cause:

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

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

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

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

Vascular theory links acute appendicitis with systemic vasculitis.

endocrine theory assumes that the APUD system APUD-system (syn. diffuse neuroendocrine system, diffuse endocrine system) - a system of cells responsible for the consumption of proamines during metabolism and participating in the decarboxylation process. They are especially abundant in the mucosa of the gastrointestinal tract and pancreas, where they are able to form a large amount of ieiroamines and oligopeptides that have a hormonal effect.
the process begins to produce a large amount of secretin, which is the main mediator of inflammation and has a direct damaging effect on the organ.

Alimentary theory(the role of constipation and "lazy bowel") connects the development of acute appendicitis with a low content of plant fibers and the predominance of meat food in the diet of patients. Such a diet causes a decrease in the transit of intestinal contents and a decrease in intestinal motility, including the appendix.

Epidemiology

Prevalence: Very common

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

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

Acute appendicitis is the most common cause emergency surgical interventions in pregnant women. The frequency of acute appendicitis in pregnant women: 1 case per 700-2000 pregnant women.

Factors and risk groups

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

Clinical picture

Clinical Criteria for Diagnosis

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

Symptoms, course

General symptoms

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

The vast majority of observations include the following symptoms of acute appendicitis(severity clinical manifestations increases with an increase in the degree of inflammatory changes in the appendix).

1. Pain - main and most early symptom. Pain appears against the background of general well-being without apparent reason. The nature of the pain depends on the form of inflammation and the localization of the appendix.
In a typical case, the onset of inflammation is characterized by pain in the center of the abdomen, near the navel, in the epigastrium. Epigastrium - the region of the abdomen, bounded from above by the diaphragm, from below by a horizontal plane passing through a straight line connecting the lowest points of the tenth ribs.
. So-called "wandering" pains are noted.
In the initial period, the pain is not intense, dull and constant (cramping pains are observed only in some cases).
After a time of 2 to 8 hours, the pain shifts to the right iliac fossa and intensifies.


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

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

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

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

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

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

4. Impaired bowel function:
- diarrhea (more often) associated with irritation of the wall of the rectum or sigmoid colon with an inflammatory appendix adjacent to them;
- stool retention (more rarely) is short-term and occurs at the onset of an attack of acute appendicitis or with the development of peritonitis.

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

Catarrhal acute appendicitis
Symptoms:

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

Phlegmonous acute appendicitis
Symptoms additional to those manifested at the catarrhal stage:
- Shchetkin-Blumberg symptom - a sharp increase in abdominal pain with the rapid removal of the palpating hand from the anterior abdominal wall after pressure;

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

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

When examining the abdomen, there is a less intense tension of the abdominal wall in the right iliac region compared to the phlegmonous stage, however, when trying deep palpation the pain is getting worse.

Atypical forms acute appendicitis

Clinical manifestations:

1. empyema Empyema - a significant accumulation of pus in any body cavity or in a hollow organ
appendix(1-2% of cases of acute appendicitis).
This form of acute appendicitis is morphologically similar to phlegmonous appendicitis, but clinically differs from it.
With empyema of the appendix, dull pains in the abdomen begin directly in the right iliac region (the shift of pain from the center of the abdomen or epigastrium to the right and downwards, characteristic of phlegmonous appendicitis, is not observed). Pain progresses slowly and becomes as strong as possible only on the 3rd-5th day of the disease. By this time, the pain often becomes throbbing. There may be single or double vomiting.
In the initial period, the general condition of the patient is satisfactory with normal or slightly elevated body temperature. With the development of throbbing pains, chills and an increase in temperature up to 38-39 ° C are noted.
An objective examination does not reveal tension in the abdominal wall and other symptoms of peritoneal irritation. As a rule, the symptoms of Rovsing, Sitkovsky, Bartomier-Michelson are positive. With deep palpation of the right iliac region, significant pain is noted. In thin patients, it is possible to palpate a painful and sharply thickened appendix.

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

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

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

4. Subhepatic acute appendicitis.
The high medial (subhepatic) location of the appendix is ​​rare and makes it difficult to diagnose acute appendicitis.
Patients have pain and muscle tension in the right hypochondrium, as well as other symptoms of peritoneal irritation. Such localization of manifestations indicates acute cholecystitis rather than acute appendicitis. When making a diagnosis, attention should be paid to the presence of a history typical of an attack of acute appendicitis. In addition, in acute appendicitis, it is not possible to palpate any pathological formation in the abdomen (with the exception of cases of appendicular infiltrate), and in most cases of acute cholecystitis, an enlarged gallbladder is palpated.

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

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

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

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

7. Acute appendicitis in children.
The onset of acute appendicitis in young children often goes unnoticed by parents, as it is difficult for the child to accurately explain the initial pains and describe their localization. As a result, a certain period of time passes from the onset of the disease to its detection, which creates the impression of a sudden and rapid onset of appendicitis.

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

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

Soreness, localized in the right iliac region, is detected in 2/3 of patients; the rest have soreness, diffused throughout the abdomen. It is important to correctly and carefully examine the abdomen in order to determine local soreness and the nature of the pain.
On palpation, the increased intensity of pain can be determined by the expression of the child's face and the nature of crying. When the hand moves from the left half to the right iliac region, a grimace of pain appears on the child's face, and the crying becomes louder.
If the child resists examination, the symptom of muscular protection is best identified during sleep, during which muscle tension and tenderness to palpation of the abdomen persist. In the absence of acute appendicitis, the abdomen can be freely palpated in all departments, it remains soft and painless. In the presence of appendicitis on the right side of the abdomen, muscular protection is observed and the child wakes up from pain.
The symptoms of Shchetkin-Blumberg, Rovsing, Razdolsky, Voskresensky and others characteristic of acute appendicitis in young children are often uninformative.

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

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

Diagnostics

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

2. Ultrasound. The sensitivity of a carefully performed ultrasound is 75-90%, the specificity is 86-100%, the positive predictive value is 89-93%, and the overall accuracy is 90-94%. In addition, with the help of ultrasound it is possible to identify alternative diagnoses. The value of the method is limited by the subjective perception of the picture and technical errors in the preparation and conduct of the study.

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

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

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

Diagnosis scales

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

Laboratory diagnostics

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

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

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

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

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

Differential Diagnosis

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

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

Objective examination of the abdomen: no localized tenderness, symptoms of peritoneal irritation, and symptoms typical of acute appendicitis.

Auscultation of the abdomen: increased peristalsis.
Digital rectal examination: the presence of liquid feces with an admixture of mucus, overhanging and soreness of the anterior wall of the rectum are absent.
Laboratory diagnostics: moderate leukocytosis, stab shift is absent or slightly expressed.

Acute pancreatitis
The onset of acute pancreatitis is characterized by sharp pains in the upper abdomen (often girdle). Often there is irradiation of pain in the back. There is repeated vomiting of bile, which does not bring relief.
In the initial stage of acute pancreatitis, patients are restless, but as intoxication intensifies, they become lethargic and adynamic. The rapid progression of the disease can cause collapse.
Pallor of the skin is noted, sometimes - acrocyanosis. The pulse is greatly accelerated. The temperature remains normal (at least during the first hours).

Objective research. Soreness in the epigastric region is sometimes not very pronounced, which does not correspond to the severity general condition patient. In the right iliac region, pain in most cases is absent. Symptoms simulating acute appendicitis may appear only in the later stages of acute pancreatitis, as the effusion spreads from the omental sac and right hypochondrium towards the right lateral canal and iliac region.

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

Differential diagnosis in difficult cases helps laboratory research amylase levels in blood and urine.
Ultrasound and laparoscopy can detect signs specific to pancreatitis.

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

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

An assessment of the immediate and distant anamnesis of the disease is carried out. In favor of a perforated ulcer testify:
- existing stomach discomfort;
- direct references to the previous peptic ulcer;
- the onset of the disease is not stupid, but very sharp pains in the epigastrium;
- not frequent vomiting.
Percussion or X-ray detection of free gas in the abdominal cavity helps to resolve doubts.

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

Anamnesis. When questioning the patient, it usually turns out that the attacks of pain happened repeatedly, and their occurrence is associated with a change in the usual diet (intake of a large amount of fatty foods, alcohol, etc.). In some cases, it is possible to establish the presence of transient jaundice, which appeared shortly after an attack of pain.

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

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

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

Physical examination. In a patient with renal colic intense pain in the abdomen and symptoms of peritoneal irritation are not detected.

For the final diagnosis, a laboratory study of urine, urgent emergency urography or chromocystoscopy are performed.

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

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

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

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

Urinalysis with pyelitis reveals pyuria.
Survey and contrast urography for pyelitis reveals unilateral or bilateral pyelectasis, which is often present in the patient, which can also be established with ultrasound.

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

Anamnesis. Delayed period (ectopic pregnancy) or middle menstrual cycle(apoplexy).

Hyperthermia and leukocytosis are absent, anemia is detected.

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

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

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

Vaginal examination reveals enlarged and painful appendages, pain during traction of the cervix.
Ultrasound and laparoscopy also have great importance to detect diseases of the female genital area.
;

Peritonitis;

Sepsis.

Postoperative complications:

1. According to the clinical and anatomical principle:

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

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

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

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

1.4 External complications of cardio-vascular system:
- cardiovascular insufficiency;
- thrombophlebitis;
- pylephlebitis Pylephlebitis - inflammation of the portal vein; occurs as a complication of purulent processes in the abdominal cavity, such as acute purulent appendicitis.
;
- pulmonary embolism;
- Bleeding into the abdominal cavity.

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

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

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

2.By development time:

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

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

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

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

Treatment abroad

Etiology, pathogenesis, classification, clinic and diagnosis of acute appendicitis.

Acute appendicitis- inflammation of the appendix of the caecum. One of the most common surgical diseases. Often: between the ages of 20 and 40, women get sick 2 times more often. Lethality 0.1 - 0.3%, postoperative complications 5-9%.

Etiology. Alimentary factor: food rich in animal protein contributes to impaired intestinal evacuation function, which should be considered a predisposing factor in the development of the disease. AT childhood some role is played by helminthic invasion.

The main route of infection of the appendix wall is enterogenic. Hematogenous and lymphogenous variants are rare. Pathogens: a variety of microorganisms (bacteria, viruses, protozoa) that are in the process. Most often, 90% is anaerobic non-spore-forming flora (bacteroids and anaerobic cocci). Aerobic meet less often 6-8% - coli, Klebsiella, Enterococcus.

Vascular theory believes that systemic vasculitis is one of the causes of acute appendicitis.

Pathogenesis. Due to the fact that mucus continues to be released during occlusion, the pressure of the contents quickly increases in the cavity of the appendix. The walls of the process are stretched under the pressure of mucus, effusion and gases, therefore, first the venous and then the arterial blood supply (ischemia) is disturbed.

With a lack of blood in the walls of the appendix, comfortable conditions are formed for the settlement of pathogenic flora. Microorganisms produce a lot of toxins, which cause disruption of the epithelial tissue of the process and the formation of ulcers on the mucosa. Cells begin to fight the activity of bacteria immune system- leukocytes, lymphocytes, macrophages and others. They produce interleukins, adhesive molecules, and other inflammatory mediators. Contacting with each other, as well as with cells of epithelial tissue, they limit the inflammatory focus. As a result, the process is not generalized, and the body does not give out a general reaction to the existing problem. Interleukins are released in large quantities, which leads to a gradual destructive process in the wall of the appendix.

Classification.

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

Forms of acute appendicitis.

 Acute simple (superficial) appendicitis. Catarrhal (leukocyte infiltration of the mucous membrane only).

 Acute destructive appendicitis.

o Phlegmonous (leukocytic infiltration of all layers of the och, including the serous membrane, blood in the lumen, leukocytes, fibrin, leukocytes on the serous membrane).

o Gangrenous (with and without perforation) necrosis of the process wall, diffuse neutrophilic infiltration, peritonitis.

 Complicated acute appendicitis

o Complicated by peritonitis - local, delimited, spilled, diffuse

o Appendicular infiltrate

o Periappendicular abscess

o Phlegmon of retroperitoneal tissue

o Sepsis, a generalized inflammatory response

o Pylephlebitis

Clinic and diagnostics. The clinical picture of acute appendicitis is variable due to the peculiarities of its anatomy and various localizations of the apex of the appendix. In typical cases, the main symptom of the disease is pain, which at the beginning of the disease is localized in the epigastric or mesogastric regions or does not have a clear localization. After a few hours from the onset of the disease, the pain intensifies, shifts to the right iliac region. This characteristic displacement of pain is called the Kocher-Wolkovich symptom.

Pain is often accompanied by nausea, sometimes vomiting, which is reflex in nature and occurs in 30-40% of patients. In most cases, there is a lack of appetite.

On examination, the general condition of patients in the initial stages of the disease practically does not suffer. There is a moderate tachycardia, an increase in body temperature, as a rule, no more than 37.5 ° C.

When examining the abdomen, it is most often not possible to identify any features, it is not swollen, it participates in the act of breathing. With percussion, pain in the right iliac region is noted - a positive symptom of Razdolsky. On palpation, pain is also determined here, even at the beginning of the disease, when the patient may feel pain in the epigastric or mesogastric regions. Also, palpation can reveal a number of symptoms:

 Rovsing's sign. the appearance of pain in the right iliac region with jerky palpation of the left sections of the colon

 Sitkovsky's symptom - increased pain in the right iliac region when the patient is positioned on the left side.

 Symptom of Bartomier-Michelson - increased pain during palpation of the right iliac region in the position of the patient on the left side.

One of the most important symptoms of appendicitis is muscle tension in the right iliac region. This is the main symptom, indicating the spread of inflammation to the parietal peritoneum. Other peritoneal symptoms are the symptom of Shchetkin-Blumberg, Voskresensky (symptom of the "shirt" - a hand is quickly passed through the shirt of the patient from the costal arch to the inguinal ligament - while there is an increase in pain on the right).

Laboratory and instrumental diagnostics acute appendicitis.

In the analysis of blood in the vast majority of patients, moderate leukocytosis is detected, a shift of the leukocyte formula to the left is possible.

When radiography no specific signs of acute appendicitis can be detected in the abdominal cavity. Rather, radiography is designed to exclude some other diseases that can simulate a picture of acute appendicitis, for example, perforated gastric and duodenal ulcers, right-sided lower lobe pneumonia, etc.

CT scan is a very informative method for diagnosing appendicitis. In many cases, it is possible to visualize the appendix with signs of inflammation - an increase in its diameter and wall thickness, free fluid is detected in the abdominal cavity. Among the shortcomings of the method, it should be noted the presence of radiation exposure, which makes the use of CT impossible in some patients (pregnant women, children), as well as the insufficient availability of the method in most medical institutions.

ultrasound. Signs of acute appendicitis are an increase in the diameter of the appendix, thickening of its wall.

The most informative diagnostic method is diagnostic laparoscopy. Direct examination of the appendix allows you to make a diagnosis, and in most cases, laparoscopic intervention is not only a diagnostic, but also a therapeutic manipulation.

Symptoms of cholangitis.

The clinic of acute cholangitis develops suddenly and is characterized by Charcot's triad: high temperature body, pain in the right hypochondrium and jaundice.

Acute cholangitis manifests with fever: a sharp rise in body temperature to 38-40 ° C, chills, severe sweating. At the same time, intense pains appear in the right hypochondrium, resembling biliary colic, with irradiation to the right shoulder and shoulder blade, neck. In acute cholangitis, intoxication rapidly increases, weakness progresses, appetite worsens, headache, nausea with vomiting, and diarrhea are disturbing. A little later, with acute cholangitis, jaundice appears - a visible yellowing of the skin and sclera. Against the background of jaundice, itching develops, as a rule, it gets worse at night and disrupts normal sleep. As a result of severe itching on the body of a patient with cholangitis, scratching of the skin is determined.

In severe cases, disturbances of consciousness and shock phenomena can join Charcot's triad - in this case, a symptom complex called Reynolds' pentad develops.

Diagnosis of cholangitis.

It is usually possible to suspect cholangitis on the basis of Charcot's characteristic triad; clarifying diagnosis is carried out on the basis of laboratory and instrumental studies.

Imaging methods for diagnosing cholangitis include ultrasound of the abdominal cavity and liver, ultrasonography of the biliary tract, and CT. With their help, it is possible to obtain an image of the bile ducts, to identify their expansion, to determine the presence of structural and focal changes in the liver.

Among the instrumental methods for diagnosing cholangitis, the leading role is played by endoscopic retrograde cholangiography, magnetic resonance cholangiography (MRCP), and percutaneous transhepatic cholangiography. On the obtained radiographs and tomograms, the structure of the biliary tract is well visualized, which makes it possible to identify the cause of their obstruction.

Differential diagnosis of cholangitis is necessary with cholelithiasis, non-calculous cholecystitis, viral hepatitis, primary biliary cirrhosis, pleural empyema, right-sided pneumonia.

12\13\14\15. Acute pancreatitis.

Acute pancreatitis - very dangerous disease, which is based on complete or partial self-digestion (necrosis) of the pancreas.

Treatment of acute pancreatitis

In acute pancreatitis, hospitalization is indicated. All patients were prescribed bed rest. The main goals of therapy are to relieve pain, reduce the load on the pancreas, and stimulate the mechanisms of its self-healing.

Therapeutic measures:

novocaine blockade and antispasmodics to relieve severe pain;

Hunger, ice on the gland projection area (creating local hypothermia to reduce its functional activity), parenteral nutrition is carried out, gastric contents are aspirated, antacids and proton pump inhibitors are prescribed;

Deactivators of pancreatic enzymes (inhibitors of proteolysis);

Necessary correction of homeostasis (water-electrolyte, acid-base, protein balance) with the help of infusion of saline and protein solutions;

detoxification therapy;

Antibiotic therapy (broad-spectrum drugs in high doses) as a prophylaxis of infectious complications.

Surgical treatment is indicated if:

stones in bile ducts;

accumulation of fluid in or around the gland;

Areas of pancreatic necrosis, cysts, abscesses.

The operations performed in acute pancreatitis with the formation of cysts or abscesses include: endoscopic drainage, marsupialization of the cyst, cystogastrostomy, etc. When areas of necrosis are formed, depending on their size, necrectomy or resection of the pancreas is performed. The presence of stones is an indication for operations on the pancreatic duct.

Surgical intervention may also be resorted to in case of doubts about the diagnosis and the likelihood of missing another surgical disease requiring surgical treatment.

The postoperative period implies intensive measures for the prevention of purulent-septic complications and rehabilitation therapy.

Light treatment forms of pancreatitis, as a rule, does not present difficulties, and positive dynamics is already noted within a week. Severe pancreatitis takes much longer to heal.

Complications of acute pancreatitis divided into early and late.

Early complications of acute pancreatitis due to the generalized action of pancreatic enzymes, biologically active amines and other vasoactive substances. These include shock, enzymatic diffuse peritonitis, acute hepatic-renal failure, early acute ulcers and gastrointestinal bleeding, jaundice, pneumonia, vascular thrombosis, intoxication psychoses.

1. Pancreatogenic peritonitis. About pancreatogenic peritonitis can be said only in the presence of effusion with high activity of pancreatic enzymes in combination with signs of inflammation of the peritoneum (hyperemia, subserous hemorrhage, foci of fat necrosis). The genesis of pancreatogenic peritonitis is complex, and is associated not only with an exudative process in the gland, the complication most likely arises as a result of the spread of an autolytic process involving peripancreatic cellular ligamentous formations, peritoneum and retroperitoneal tissue.
2. Pancreatogenic shock.

16. Infected pancreatitis: clinic, classification, diagnosis, treatment tactics.

Infected pancreatitis (pancreatic necrosis) is a complication of acute pancreatitis.

Classification:

Pancreatic necrosis is characterized by the development of local and systemic complications.

Local complications:

In the aseptic phase of pancreatic necrosis: parapancreatic infiltrate, necrotic phlegmon of retroperitoneal tissue, enzymatic (abacterial) peritonitis, pseudocyst (late complication);

In the phase of infected pancreatic necrosis: purulent-necrotic phlegmon of retroperitoneal tissue, abscesses of retroperitoneal cellular spaces or abdominal cavity, internal and external pancreatic, gastrointestinal fistulas, arrosive bleeding (intra-abdominal and in the gastrointestinal tract).

Extra-abdominal complications (systemic): pancreatogenic (enzymatic) shock, septic shock, multiple organ failure.

clinical picture.

Infected pancreatic necrosis, which is widespread, usually forms at 1-2 weeks of illness. It is characterized by hectic body temperature, chills, arterial hypotension and multiple organ disorders. The phenomena of intestinal paresis and intestinal obstruction. Objective symptom - Kerte - painful resistance in the projection of the pancreas.

Voskresensky's symptom - the absence of pulsation of the abdominal aorta in the projection of the pancreas. Mayo-Robson's symptom is pain in the left costovertebral angle.

Diagnostics.

Laboratory.research:

1.OAK - leukocytosis, shift of the formula to the left, acceleration of ESR

2.OAM-proteinuria, microhematuria, cylindruria.

3. Biochemical blood test - hyperamelasemia, hyperbilirubinemia, hyperglycemia.

4.methods allowing to diagnose infectious complications - microbiologist studies biopsy obtained from fine-angle biopsy; procalcitonin test

Instrumental:

1. Ultrasonography

3.Diagnostic laparoscopy

Treatment tactics.

Operative treatment. During the formation of infected pancreatic necrosis in combination with an abscess at the first stage, the surgeon uses minimally invasive technologies for percutaneous drainage of a purulent-necrotic lesion under ultrasound or CT control, provides optimal conditions for simultaneous and complete necrectomy and sequestrectomy with minimal intraoperative blood loss.

With widespread infected pancreatic necrosis, laparotomy is performed, necrotic tissues or sequesters are removed, the affected areas are sanitized and the retroperitoneal tissue is extensively drained.

Operational accesses: median laparotomy, two-subcostal access, lumbotomy.

Classification of bleeding

To assess the source of bleeding, the most convenient classification is J. Forrest (1987):

Ongoing bleeding:

F-I-A - jet, pulsating, arterial bleeding from an ulcer;

F-I-B - drip (venous) bleeding from an ulcer

ongoing bleeding:

F-II-A - visible large thrombosed vessel at the bottom of the ulcer;

F-II-B - clot-clot fixed to the ulcer crater;

F-II-C - small thrombosed vessels in the form of stained spots

ongoing bleeding:

no signs of bleeding

F-III - no bleeding stigmata in the ulcer crater (no stigmata).

Treatment tactics

medical

· -decide diagnostic tasks: bleeding from the stomach or other sources

hemostatic therapy, restoration of hemodynamics

replacement therapy, hospitalization

surgical

urgent hospitalization

comprehensive treatment + examination (1-24 hours)

The choice of method in accordance with the diagnosis:

urgent operation

· conservative treatment

local

The basis of therapeutic tactics for acute gastrointestinal bleeding is conservative therapy.

Endoscopic hemorrhage control: is highly effective and allows for temporary hemostasis in most patients. Provides an opportunity to adequately prepare them for urgent surgery. Therapeutic endoscopy may be the only justified method of treatment in a group of patients with an extremely high operational risk, when the operation is impossible. Methods of endoscopic hemostasis: mono- and biactive diathermocoagulation, thermocauterization, argon-plasma coagulation, endoclipping methods, injection methods for administering epinephrine, 96% ethanol solution, as well as special sclerosants.

Infusion-transfusion therapy: necessary to restore the basic parameters of hemostasis. The primary tasks are the introduction of an adequate amount of colloidal and crystalloid solutions into the vascular bed to eliminate the BCC deficiency, normalization of microcirculation and blood rheology, correction of water and electrolyte metabolism.

Drug Therapy: antisecretory drugs - parenteral forms of H2 antagonists - histamine receptors, proton pump inhibitors. Optimal conditions are created in the stomach cavity to prevent recurrence of bleeding and healing of the ulcer, the operation is postponed to the stage of a planned operation or the operation is abandoned. The effectiveness of therapy with antisecretory drugs should be monitored by 24-hour pH monitoring.

For the speedy healing of ulcerative and erosive lesions - antacids, synthetic analogues of prostaglandins. Antihelicobacter drugs accelerate regenerative processes.

Nutrition is an integral part of conservative therapy.

Surgical tactics: bleeding from gastroduodenal ulcers is an indication for emergency surgery:

Emergency if non-surgical methods fail to stop it.

Urgent. When the threat of his relapse is too great.

On an emergency basis, they operate: patients with profuse ongoing bleeding, hemorrhagic shock and clinical and anamnestic data indicating bleeding of an ulcerative nature. Patients with massive bleeding, if conservative measures, including endoscopic methods, have been ineffective. Patients with recurrent bleeding in the hospital.

If the bleeding is stopped by conservative methods and the risk of its resumption is small, emergency surgery is not indicated, such patients are managed conservatively.

Elderly patients with the limiting degree of operational and anesthetic risk are not operated on. Control endoscopic examinations are carried out daily until the risk of recurrent bleeding disappears.

Choice of method of surgical intervention depends on the severity of the patient's condition, the degree of operational and anesthetic risk, on the localization of the bleeding ulcer.

Organ-preserving surgery with vagotomy- stopping bleeding from a duodenal ulcer consists in pyloroduodenotomy, excision and / or stitching of the source of bleeding with separate sutures.

Antrumectomy with vagotomy- indicated for patients with a relatively low degree of operational risk.

Pyloroplasty with excision or stitching of the ulcer without vagotomy performed involuntarily due to ongoing bleeding that cannot be stopped endoscopically, usually in elderly and senile patients with an extremely high operational and anesthetic risk.

Resection of the stomach- indicated for a bleeding ulcer, if the degree of operational risk is relatively low.

Excision of an ulcer or stitching of a gastric ulcer through a gastrotomy access (forced) can be taken in patients with an extremely high degree of operational risk.

Diagnostics.

Clinical symptoms.

Instrumental diagnostic methods

Laboratory diagnostics

Differential diagnosis.

Instrumental diagnostic methods:

x-ray examination -

in the stage of compensation, some increase in the stomach, cicatricial and ulcerative deformity of the pyloroduodenal zone, slowing down of gastric evacuation up to 12 hours.

With subcompensated stenosis, signs of the beginning decompensation of gastric motility are found - an increase in its size, a weakening of peristaltic activity. Symptom of the "three-layer stomach" (contrast substance, mucus, air). Delayed evacuation more than 12 hours.

The stage of decompensation is characterized by a significant increase in the size of the stomach, a decrease in peristalsis, a sharp narrowing of the pyloroduodenal canal, and severe disorders of gastric evacuation.

FEGDS - in the first stage, a pronounced cicatricial deformity of the pyloroduodenal canal is noted with a narrowing of its lumen to 0.5-1 cm, hypertrophy of the gastric mucosa and increased peristalsis. In the second stage - a significant narrowing of the pyloroduodenal canal, a delay in the evacuation of gastric contents, an increase in the size of the stomach. In the third stage - a sharp narrowing of the pyloroduodenal canal, thinning of the gastric mucosa, lack of peristalsis of the gallbladder and excessive expansion of the lumen of the stomach.

Study motor function ionomanometry method gives an idea of ​​the tone, frequency, amplitude of contractions of the stomach on an empty stomach and after taking a food stimulus, allows you to determine the delay time of the initial evacuation. Compensated stenosis is a rare rhythm of active gastric contractions. Subcompensated - motor function is weakened. Decompensated - a sharp decrease in the tone and motor activity of the stomach.

Ultrasound - useful for express diagnostics. Not accurate in terms of determining the stage of stenosis.

Laboratory diagnostics.

Signs of metabolic alkalosis, exicosis, hypoglycemia, hypoproteinemia are determined.

Differential diagnostics.

With a tumor lesion of the antrum of the stomach, a tumor of the head of the pancreas with germination in the duodenum.

Treatment.

Conservative therapy:

It is aimed at healing an active ulcer with the use of modern antisecretory agents and anti-Helicobacter drugs. With the help of parenteral administration of salt and protein preparations, it is necessary to ensure the correction of violations of water and electrolyte metabolism, protein composition blood plasma and weight recovery. In the late stages of stenosis, one of the most effective ways to prepare the patient for surgery is enteral tube feeding. To improve the motor function of the stomach, continuous or fractional aspiration of gastric contents, gastric lavage cold water prescribe modern prokinetic agents.

Surgical tactics:

Pyloroduodenal stenosis is an indication for surgical treatment. When choosing a method, one should take into account the stage of development of stenosis and the degree of disturbances in the motor function of the stomach and duodenum, as well as the characteristics of gastric secretion and the degree of operational risk.

Stem vagotomy in combination with stomach-draining operations– The most reasoned indications for this operation in compensated pyloroduodenal stenosis. It can also be performed with subcompensated stenosis, when adequate preoperative preparation has been carried out.

Laparoscopic stem vagotomy with mini-access pyloroplasty- with compensated stenosis.

Stem vagotomy with antrumectomy with stenosis with signs of subcompensation and decompensation.

Resection of the stomach with compensated stenosis and reduced acid-forming function of the stomach.

Gastroenterostomy as the final method of treatment is indicated for elderly patients, in serious condition, with advanced stages of stenosis.

Clinic.

With this complication, there is vomiting of scarlet blood or the color of "coffee grounds", a sharp deterioration in the general condition of the patient (tachycardia, decreased pressure, general weakness, sweating), dark feces (melena).

Diagnostics.

The diagnosis of bleeding from dilated veins of the esophagus is made on the basis of the above clinical picture and additional methods research. In order of application, they should be divided into simple diagnostic (probe insertion), radiological and instrumental methods.

X-ray methods primarily include the study of the esophagus and stomach with a barium suspension to determine the extent of the lesion. For the same purpose, esophagogastroscopy is carried out in specialized institutions.

Establishment of the localization of bleeding in the esophagus is made on the basis of anamnesis indicating the possibility of liver cirrhosis, bleeding in the form of vomiting of scarlet blood, objective signs of portal hypertension, determined by splenoportography and splenoportomanometry, portohepatography, azigography, etc.,

Laboratory data (leukopenia, thrombocytopenia, hyperbilirubinemia, hypocholesterolemia, hypoproteinemia with a shift towards gamma globulins, positive bromsulfalein test, etc.).

Treatment.

Treatment of patients with bleeding from the veins of the esophagus begins with conservative measures. With ongoing bleeding, the most effective is local exposure to the source of bleeding with a probe. Blackmore type-Sengstaken. The probe is left in the esophagus for up to 48-72 hours, while for hemostasis it is necessary to introduce 100-120 cm3 of air into the gastric balloon and up to 100 cm3 of air into the esophagus. The probe with inflated cuffs is left in the stomach for 4 hours, after which the air should be released from the esophageal cuff and the patient should be observed for 1.5-2 hours. The stomach at this time is washed through the obturator probe to clean water and complex conservative hemostatic therapy is carried out.

In cases of recurrent bleeding (40%), the obturator probe should be reintroduced, leaving it in the stomach for at least 24 hours.

Endoscopic hemostasis:

It is often used as a measure to prevent recurrence of bleeding.

Main implementation options: endoscopic ligation, endoscopic

sclerotherapy (tetradecyl sulfate, ethoxysclerol); obliteration of varicose veins with adhesive compositions (tissucol, histoacrylate, bucrylate, cyanoacrylate); stenting of the esophagus.

Surgery.

The recommended intervention is the P aciora operation (transverse gastrotomy in the subcardiac part of the stomach, circular stitching and ligation over a significant extent of all dilated veins of the submucosal layer in the area of ​​the cardioesophageal junction).

Clinic.

Clinically, Malory-Weiss syndrome will be manifested by the presence of blood in the vomit. Moreover, blood may be absent during the first bouts of vomiting, when only a rupture of the mucosa occurs. It can also be accompanied by pain in the abdomen, pallor is also observed. skin, severe weakness, black stools (melena), cool clammy sweat.

Diagnostics.

Of the instrumental methods for diagnosing Malory-Weiss syndrome, endoscopic examination (fibroesophagogastroduodenoscopy) is of the greatest value. This study allows you to see the longitudinal rupture of the mucosa of the esophagus. In addition, if bleeding is detected, then it can be tried to stop it endoscopically.

In the anamnesis of patients with Malory-Weiss syndrome, one can often find mention of the use of alcoholic beverages in in large numbers resulting in vomiting.

When examining a patient with Malory-Weiss syndrome, one can find common signs of all bleeding: pallor of the skin, cold sticky sweat, lethargy, tachycardia, hypotension, and possibly even the development of shock.

AT clinical analysis blood will be a decrease in the number of red blood cells, hemoglobin levels, an increase in the number of platelets, which indicates the presence of bleeding.

Treatment.

a. Conservative therapy for Malory-Weiss syndrome is used to restore the volume of circulating blood. For this, various

Crystalloid (NaCl 0.9%, glucose 5%, Ringer's solution, etc.),

Colloidal solutions (albumin, aminoplasmal, etc.), in case of severe blood loss, it is possible to use blood transfusion (erythrocyte mass, fresh frozen plasma).

When vomiting (or the urge to vomit), metoclopramide (cerucal) is used.

In order to stop bleeding, it is possible to use

• sodium etamsylate,
• calcium chloride,
• aminocaproic acid,
• octreatide.

b. When performing fibroesophagogastroduodenoscopy and detecting a longitudinal rupture of the esophageal mucosa with bleeding, you can try to stop this bleeding endoscopically. It uses:

1. Injection of the bleeding site with adrenaline.

A solution of epinephrine hydrochloride is injected into the area of ​​bleeding, as well as around the source of bleeding. The hemostatic effect is achieved due to the vasoconstrictive action of adrenaline.

2. Argon-plasma coagulation

This method is one of the most effective and at the same time one of the most technically difficult. The use of the method of argon-plasma coagulation allows to achieve stable hemostasis.

3. Electrocoagulation

It is also a fairly efficient method. Often the use of electrocoagulation is combined with the introduction of adrenaline.

4. The introduction of sclerosants

This method lies in the fact that the hemostatic effect is achieved by the introduction of sclerosing drugs (polidocanol).

5. Vessel ligation

In Malory-Weiss syndrome, endoscopic ligation of bleeding vessels is often used. The use of endoscopic ligation of vessels is especially justified in the combination of Malory-Weiss syndrome and portal hypertension with esophageal varicose veins.

6. Clipping of vessels

In essence, this method is similar to the previous one. The only difference is that not a ligature is applied to the bleeding vessel, but a metal clip. Clips can be applied using the applicator. Unfortunately, endoscopic clipping of vessels is not always possible due to the technical difficulties of applying clips to vessels.

in. In Malory-Weiss syndrome, surgical treatment is resorted to in case of failure of conservative therapy and endoscopic methods of treatment. With Malory-Weiss syndrome, the Baye operation will be performed:

Access: median laparotomy.

Operation: gastrotomy, stitching of bleeding vessels.

25. Predisposing and producing factors for the formation of abdominal hernias. Hernia classification.

Abdominal hernia - the exit of the viscera from the abdominal cavity along with the parietal sheet of the peritoneum through natural or pathological openings under the integument of the body or into another cavity.

Classification:

Etiological characteristic:

Congenital

Acquired

Localization:

Inguinal

femoral

umbilical

White line of the abdomen

Rare (lumbar, xiphoid process, spigelian line, ischial, perineal)

Clinical course:

Uncomplicated (reducible hernia)

Complicated (infringement, irreducibility, inflammation, coprostasis)

Recurrent

The predisposing ones include the features of the human constitution (asthenic physique, tall stature), hereditary weakness of the connective tissue, gender, age, both obesity and rapid weight loss, frequent childbirth, postoperative scars, paralysis of the nerves innervating the abdominal wall.

Producers are called factors that contribute to a significant increase in intra-abdominal pressure or its sharp fluctuations. These are conditions that occur with frequent crying and screaming of a child in infancy, prolonged coughing; heavy physical labor, exceeding the degree of fitness of the muscles of a particular person; difficulty urinating, prolonged constipation, complicated pregnancy and difficult childbirth with a long straining period.

Treatment of the disease

A strangulated hernia is subject to immediate surgical treatment, regardless of the timing, type and location of the infringement. Any attempt to reduce the hernia at the pre-hospital stage or in the hospital is unacceptable. The exception is patients who are in extremely serious condition, in whom more than 2 hours have not passed since the infringement - you can try to carefully set the hernial contents into the abdominal cavity, first you need to inject atropine to the patient, empty the bladder, rinse the stomach with a probe, conduct a cleansing enema with warm water .

A patient diagnosed with a strangulated hernia is immediately referred to the emergency surgical department. The introduction of analgesics, antispasmodics is contraindicated. If a patient with a strangulated hernia has spontaneous reduction, he must also be hospitalized

It is impossible to do to a patient with a strangulated hernia:

1. wash in the bath;

2. give a laxative;

3. administer morphine;

4. repair a hernia:

May be false reduction;

Gap gr. bag;

The indentation of dead areas inside.

Classification of inguinal hernias

According to anatomical features distinguish oblique, direct and combined inguinal hernia.

oblique inguinal hernias can be congenital or acquired. In this case, the elements of the hernial content enter the inguinal canal through the internal inguinal ring and are located along the inguinal canal among the anatomical structures of the spermatic cord. Among the oblique forms inguinal hernia There are canal hernia (the bottom of the hernial sac is located at the level of the external opening of the inguinal canal), funicular (the bottom of the hernial sac is located in the inguinal canal at different levels of the spermatic cord), inguinal-scrotal hernia (the bottom of the hernial sac descends into the scrotum, leading to its increase).