What are the symptoms of acute gangrenous appendicitis. Gangrenous form of appendicitis

Inflammation of the appendix in an acute gangrenous form leads the appendix to purulent processes, to the destruction of its walls.

Medicine classifies gangrenous appendicitis as a type of destructive form of inflammation.

This is an acute condition that should be operated on in a timely manner, otherwise general intoxication of the body may occur due to the penetration of purulent elements into the peritoneum from a burst appendix.

Gangrenous appendicitis

Appendicitis - acute inflammation appendix of the caecum. It involves the passage of several stages, if you do not seek medical help in a timely manner.

Omitting the onset of the disease, it should immediately be said that the penultimate stage of purulent appendicitis acute form characterized by the development of necrosis of the walls of the intestinal process.

Perforation of the walls is very dangerous, purulent contents break into the abdominal cavity. Therefore, it is important to go to the hospital in time to start treatment.

Gangrenous appendicitis in acute form is the most dangerous type of inflammatory form of the appendix.

It develops if the patient went to the hospital late, if the specialists have not identified phlegmonous form intestinal process, preceding acute gangrenous appendicitis.

Specialists evaluate the patient's condition according to outward signs and symptoms, carry out urgent diagnostics, begin therapeutic treatment.

If a drug therapy does not give a quick improvement in the condition, surgical intervention is recommended, removal of the intestinal process, which at any time can develop into gangrene of appendicitis, or burst and create serious complications.

Perforation of the appendix causes sharp pain due to rupture of the intestinal process, after which the pain spreads throughout the abdomen.

The only true treatment in such a situation is an operation so that gangrenous perforated appendicitis does not end with peritonitis or appendicular abscess.

Pathoanatomy of gangrenous appendicitis

Inflammation begins with the stage of catarrhal changes:

• capillaries expand;
• the influx of lymphocytes increases - a protective reaction of the body to stop and localize the disease;
• edema and infiltration of the wall are formed;
• small purulent areas appear.

This stage develops rapidly - within 6 hours from the first attack of pain, therefore, it is repeatedly reminded that one should not brush aside pains in the abdomen, drink No-shpa and wait for improvement while continuing to work.

During the day, the appendix increases, its cavities are filled with purulent contents. So far, this is regarded as gangrenous perforative appendicitis with phlegmon - a limited abscess.

All layers of appendix tissues are melted from necrosis. It increases, becomes dirty green, the walls lose their elasticity, hemorrhages occur in flabby areas, and necrosis develops. The necrosis also occurs very quickly - in three days.

An intermediate picture of inflammation of the appendix is ​​a gangrenous perforative appendicitis with clearly visible phlegmonous-gangrenous changes in the tissues of the appendix.

The stage of gangrenous appendicitis is characterized by the transformation of inflammation to neighboring organs. Because of this, the tissues of the intestinal loop, the sheets of the peritoneum suffer.

At autopsy abdominal cavity surgeons see a fibrin plaque, areas of hemorrhage, hyperemia on the omentums, tissues of the caecum and ileum.

With a diagnosis such as gangrenous appendicitis, especially dangerous consequence considered diffuse peritonitis.

This means that the purulent contents of the appendix are poured directly into the abdominal cavity.

Peritonitis is localized when there are adhesions that do not allow the pathological fluid to spread.

This complication is very specific, can change the clinical picture, lubricate the symptoms.

It is clear that this is a very dangerous condition and the patient should be urgently hospitalized.

The absence of partial localization, the spread of purulent fluid throughout the abdominal cavity increases pain.

They spread over the entire surface of the peritoneum. These are clear signs that acute gangrenous appendicitis is developing, which should be treated with all caution, and immediately consult a doctor.

Deteriorating and general state patient:

• tachycardia is identified;
• a whitish coating appears on the tongue;
• consciousness becomes sluggish, inhibited.

In this case, the patient is tormented by multiple vomiting, but they do not bring relief.

They stop only after the operation, and before the operation, the surgeon must specify how long it lasts pathological condition, which is specified as acute gangrenous appendicitis.

Need to know! At the primary attack of appendicitis, it is necessary to observe its manifestations. The pain will be pronounced, sharp, but not constant, but arising from time to time. The condition of a sick person worsens from an increase in temperature, tension and soreness of the abdominal muscles.

Gangrenous appendicitis is characterized by clinical manifestations:

• lack of intestinal peristalsis;
• abdominal tension;
• irritation of the peritoneum;
• paralytic intestinal obstruction.

Blood tests show a significant increase in the number of leukocytes, an increase in ESR to a critical level - 40-60 mm per hour.

Urinalysis shows the presence a large number protein, various cylinders - waxy, others. This indicates a toxic form of gangrenous inflammation.

Causes of gangrenous inflammation of the appendix

Formed in the appendix inflammatory process- it develops gangrenous appendicitis.

It is important for doctors to know the duration of the condition, so when acute pain in the stomach, no matter how hard it may be, to detect the time of the first attack.

The main risk factors for the development of gangrenous inflammation of the appendix of the primary form:

• middle age, when changes occur in the structure of blood vessels;
• children's age, when there is a genetically determined hypoplasia or displacement of the arteries that make up the structure of the appendix;
• atherosclerosis of the arterial walls of the intestine;
• development of blood clots in the arteries and veins of the appendix.

The direct causes of appendix inflammation are the acute formation of disorders associated with microcirculatory functions.

They form a destabilization of blood circulation in the process, which leads to necrosis, or partial appearance of areas of necrotic tissue.

This is joined by an infectious lesion, dysfunction of the outflow of fluid from an acute gangrenous affected appendix.

Such symptoms aggravate the course of the disease, give complications to neighboring organs in the abdominal cavity and beyond.

The main factor in the appearance of such a condition as gangrenous appendicitis is the transition of a simple form of appendicitis into a destructive one.

This happens with incorrect or late treatment. Then acute gangrenous appendicitis leads to the fact that the tissues of the appendix are melted by its own purulent contents, and the patient has to endure a long postoperative period.

The development of inflammation of the appendix goes through several stages, which include:

• phase acute appendicitis;
• stage of perforated appendicitis;
• stage of purulent appendicitis;
• phase of acute gangrenous appendicitis.

Stages are divided into catarrhal, phlegmonous, gangrenous, perforative. Most often, secondary appendicitis is diagnosed, inflammation in which necessarily leads to appendicitis gangrene.

It develops on the 2-3rd day from the onset of the disease, if not medical care, rarely characterized by a rapid acute course - 6-12 hours.

Especially quickly acute purulent appendicitis develops in children. Primary gangrenous appendicitis is rarely stated, appendicitis is more often diagnosed, inflammation is an obligatory concomitant process.

Vascular problems can provoke the development of purulent appendicitis:

• age-related damage to the walls of blood vessels;
• atherosclerosis of the arteries that feed the intestines, with the presence of cholesterol plaques;
• genetic hypoplasia of the appendicular arteries in childhood;
• thrombosis of veins and arteries of the intestinal process.

With such deviations, circulatory disorders develop, appendix tissues die off, perforated appendicitis, or phlegmonous appendicitis, is formed.

Infections of various etiologies or autoimmune functions of the intestine can accelerate their development.

Symptoms of appendicitis at different stages

Gangrenous appendicitis is characterized by the absence of severe abdominal pain. This is due to tissue necrosis and death nerve cells intestinal process.

However, the onset of gangrenous inflammation is characterized by symptoms:

• unexpressed widespread pain;
• on palpation, a soft abdomen in all leads;
• no irritation on the peritoneum;
• normal body temperature.

With gangrene of appendicitis, when the doctor palpates the abdomen, with pressure and a sharp release of hands severe pain, extending to the right iliac region, gradually decrease.

Prolonged vomiting does not bring relief. At normal temperature, tachycardia of 100-120 beats per minute is observed.

All varieties chronic inflammation appendix give a similar clinical picture. At the same time, each of the forms of appendicitis gangrene has its own characteristics.

In particular, this applies to the acute form of gangrenous appendicitis. When it is a consequence of perforated appendicitis, then characteristic symptoms there will be a subsidence of pains until their complete disappearance.

• the disappearance of symptoms is associated with the death of nerve endings due to tissue necrosis of the process;
• multiple vomiting urges are associated with high intoxication of the body;
• dryness on the tongue;
• tension of the muscles and walls of the peritoneum;
• on palpation, the iliac region on the right is very painful.

In simple forms of appendicitis, symptoms begin classically:

• the occurrence of pain in the epigastrium;
• the appearance of nausea and vomiting;
• temperature rise.

Symptoms intensify rapidly: within 2 hours, pain radiates to the iliac region and hypochondrium on the right side, to the coccyx, to the center of the abdomen.

The acute form of inflammation of the appendix manifests itself against the background of an acute gangrenous-phlegmonous type of appendicitis.

This is manifested in jerking, throbbing pains, then they subside when the nerve endings in the walls of the intestinal process are destroyed.

Phlegmonous appendicitis is often taken as gangrenous by symptoms, however, if the diagnosis precedes the removal of appendicitis, then the nuances of the diagnosis no longer have practical significance.

With gangrene of appendicitis, the symptoms increase dramatically:

• vomiting becomes repeated;
• the temperature rises, accompanied by chills;
• the skin of the patient's body turns pale, becomes pasty;
• the whole body is covered with cold sweat.

Gangrenous inflammation is characterized by local pain, increased density of the abdominal muscles, the stomach is not involved in the respiratory process.

Differential Diagnosis becomes more complicated in women when right-sided adnexitis, rupture of the ovary or cysts, ectopic pregnancy should be promptly excluded.

If appendicitis is purulent, signs of general intoxication of the body appear - weakness increases, overall muscle tone decreases, body temperature either remains normal or decreases.

Important fact! When it comes to a child's illness, the manifestations of appendicitis must be kept under control: promptly call " ambulance”, as the symptoms increase catastrophically quickly, there is very little time left to provide prompt assistance.

Treatment of acute appendicitis

Conservative methods of treatment are admissible only at a catarrhal form of appendicitis. If we are talking about acute appendicitis of a gangrenous or perforated form, then only a technique for removing appendicitis is possible.

The operation is usually carried out "cito", urgently, when a patient with a clear picture of inflammation or gangrene of appendicitis is taken by ambulance to the surgical department.

The on-duty operational team acts quickly: it is necessary to operate quickly, within 2-4 hours, starting from the first pain attack.

This is done to exclude a rupture of the appendix and a spill of purulent contents into the abdominal cavity.

Conservative treatment of gangrenous appendicitis is not carried out, when such a diagnosis is established, the issue of performing an operation to remove appendicitis is immediately decided.

However, if emergency diagnosis does not show the likelihood of rupture, or fullness of the appendix with purulent contents, then the technique of a “delayed” approach is used to remove appendicitis, when the operation is postponed for more late dates.

This is due to the severe general condition of the patient, which must first be stabilized so that the heart can withstand the burden of anesthesia and surgical intervention.

Quick methods, using droppers, normalize blood pressure, interruptions in the work of the heart, symptoms of intoxication are removed.

This creates normal conditions for the removal of appendicitis, so that the anesthesiologist and surgeon do not fear for the general condition of the patient.

It is easy for an ignorant person to say that appendicitis is an acute inflammation of the appendix of the caecum.

In fact, this is a rather serious operation, especially when the appendix is ​​in the stage of an acute gangrenous dangerous condition.

Preparing for surgical operation to remove gangrenous appendicitis includes detoxification of the body.

To do this, using a dropper, the patient is injected with saline, glucose. Injections of antibiotics, drugs to support heart function are given.

With the help of a probe, the contents of the stomach are washed out. It turns out the patient's tendency to allergies to drugs.

If the patient is conscious, he must sign the consent to the surgical intervention; for patients who are in an unconscious state, these documents are signed by relatives who brought him to the inpatient department.

For children, documents are signed by parents or guardians. The anesthesiologist, assessing the general condition of the patient, and how the diagnosis of gangrenous acute appendicitis went, chooses the method of anesthesia for the duration of the operation:

• create an anesthetic infiltrate;
• conduct a conductive blockade of the nerve plexuses;
• use classic general anesthesia.

The choice takes into account the age of the patient, his excitability, drug tolerance. Anesthesia should be sufficient for the surgeon to carry out the necessary manipulations according to the proposed operation plan.

How is the postoperative period

If gangrenous appendicitis was removed, the postoperative period has its own characteristics. The patient continues to receive detoxification agents and antibiotics.

The attending physician monitors temperature, urine output, daily diuresis. It is important to regularly listen to the noise in the intestines.

Appointed proper nutrition for the first postoperative days. When removing gangrenous appendicitis, the period after surgery is characterized by a longer course and the most benign diets.

In the very first days after the operation, the patient regains his strength, this is evidenced by the appearance of appetite, the restoration of defecation, and the normalization of temperature.

The postoperative period is different for all patients. It depends not only on the internal defenses of the body, but also on the psychological attitude of the patient himself for a speedy recovery.

Useful video

Gangrenous appendicitis is named according to the nature of the inflammation in the wall of the appendix. The form refers to the destructive. This means the inevitable destruction of the integrity of the wall.

In the abdominal cavity, surgeons find a fluid (effusion) of a serous or purulent nature with a rotten smell. The disease almost always proceeds with severe complications. The final diagnosis can only be made by visual inspection of the process.

The older the patient, the more likely the rapid development of gangrene. If in children and adolescents it is found in 8% of operated cases, then in older people after 60 years, the frequency reaches 33%.

Pathoanatomy of the inflamed process

The inflammatory process begins with the catarrhal stage, capillary expansion, an influx of lymphocytes trying to stop and localize the disease. Edema and infiltration of the wall are found. Small purulent foci are possible. Conventionally, this stage accounts for up to 6 hours from the onset of an attack in a patient.

Until the end of the first day, the appendix increases significantly, fills with pus. In 90% of cases, it is regarded as a phlegmon (delimited abscess).

If during this period the process is not removed, then foci of necrosis appear on the walls, and in the abdominal cavity the effusion takes on a purulent character. All layers are melted. The appendix looks dirty green in color, enlarged, the wall is flabby with areas of hemorrhage and necrosis. Up to three days are given for the development of necrosis.

An intermediate picture of appendicitis in a patient is caused by phlegmonous-gangrenous changes. In the gangrenous stage, adjacent tissues and organs join the inflammation of the process. Bowel loops, omentum, peritoneal sheets suffer. They show a plaque of fibrin, hemorrhage. Hyperemia and infiltration appear in the caecum and ileum.

The combination of an abscess and dead tissue is more often found in the very end zone of the appendix

The outcome is possible self-amputation of the appendix (detachment from the caecum) or perforation of the wall (perforation) due to rupture. Surgeons know that any manipulation against the background of a gangrenous appendix in a patient always leads to a breakthrough of purulent contents.

There is also an opinion that the speed of anatomical changes does not depend on the timing of the onset of an attack of pain. Therefore, the attitude to the given references to time is rather conditional.

What causes gangrenous disorders?

Important risk factors for the transition of inflammation to the stage of gangrene are:

• impaired blood circulation in the elderly patient due to widespread atherosclerosis;
• intestinal ischemia due to obstructed patency of the mesenteric arteries (thrombus formation);
• congenital underdevelopment feeding arteries (in pediatric patients).

These changes in the patient's body lead to the development main reason- disturbed microcirculation in the wall of the process. Further joining:

They exacerbate the course of the disease. A gradual change in the forms of inflammation from catarrhal to phlegmonous is possible, untimely provision of specialized assistance, a transition to destruction and purulent fusion.

Manifestations

Symptoms of gangrenous appendicitis begin according to classical canons with catarrhal inflammation. The patient has pain in the epigastrium, nausea, vomiting, fever. For 2 hours, the pain "descends" into the right iliac region with the normal position of the process. They can radiate to the hypochondrium on the right, to the coccyx, to the central zone of the abdomen.

Acute gangrenous appendicitis, which develops from phlegmonous, first causes jerking or throbbing pains, then subsides due to the complete destruction of sensitive nerve endings in the wall. Phlegmonous appendicitis can be mistaken for gangrenous, which, with timely surgical intervention, is of no practical importance.

Vomiting becomes repeated, repeated. The temperature rises to high numbers, which is accompanied by chills. The patient turns pale, breaks out in a cold sweat. On examination, the doctor detects dryness of the tongue.

Local soreness and board-like density of the patient's abdominal muscles is a sign of peritoneal irritation, the stomach does not take part in the act of breathing

In a blood test, leukocytosis does not always rise sharply, but a significant shift draws attention leukocyte formula to the left. Differential diagnosis is particularly difficult in female patients. It is necessary to exclude right-sided adnexitis, rupture and torsion of an ovarian cyst, ectopic pregnancy, apoplexy of the appendages.

With an atypical location of the process, the disease gives a mask:

• diverticulitis of the large intestine;
• right-sided pyelonephritis;
• renal colic;
• acute cholecystitis;
• gastritis or duodenitis;
• perforated stomach ulcer;
• acute pancreatitis.

What helps in diagnosis?

The doctor has to focus on his practical experience and laboratory parameters, since ultrasound of the abdominal cavity is not an informative enough study for appendicitis. But hardware techniques make it possible to exclude gynecological pathology in women, pancreatitis, ectopic pregnancy, urolithiasis, pyelonephritis. A gynecologist is called for a consultation, a rectal examination is performed in men.

What is the difference between the gangrenous-perforative form?

Gangrenous-perforative is a form of inflammation of the process with a mandatory violation of the integrity of the wall. Its isolation emphasizes the severity of the course, substantiates complications and the risk of surgical intervention.

The danger lies in the presence of penetration of purulent contents into the abdominal cavity. There is local or diffuse peritonitis. The patient has pronounced signs of peritoneal irritation, there is no intestinal peristalsis. Disturbed by palpitations, dizziness, weakness.

In blood tests - leukocytosis and ESR are growing, the formula is shifted to the left. There are changes in the urine (cylinders, protein), which indicates toxic damage to the kidneys.

Treatment

If with catarrhal appendicitis there are still opinions about the possibility conservative treatment, then the gangrenous and gangrenous-perforative form can only be cured surgically. To stop the spread of the inflammatory process to the peritoneum, it is necessary to remove the source of pus.

The operation is most often performed according to emergency indications after 2-4 hours from the onset of the attack.

A planned approach at a later date is possible, but rather it should be called “delayed”. Time is spent on stabilizing the patient's condition with a drop in pressure, heart failure caused by intoxication, decompensation diabetes.

In preparation for a surgical operation, patients are detoxified, liquid, antibiotics, and agents to support cardiac activity are dripped. Through the probe, the contents of the stomach are removed. Doctors need to find out the patient's tendency to allergic reactions.

It is important to know this for choosing the method of processing the surgical field, anesthesia. The patient must sign his consent to the surgical intervention, for the children - this is done by parents or guardians.

For complete anesthesia, one of the methods is used:

• creation of an anesthetic infiltrate;
• conductor block of the nearest nerve plexuses;
• general anesthesia.

The anesthetist chooses it depending on the patient's age, excitability, drug tolerance. Sufficient anesthesia helps to reduce the time of surgical intervention, the risks postoperative complications, complete healing.

Local anesthesia does not apply to children, fear and excitement do not allow them to completely relax abdominal wall and inspect the cavity. For adult patients, local anesthesia is quite enough for the catarrhal form of appendicitis, but probable peritonitis and the need to expand the operation for gangrene require general anesthesia. Since it suppresses the gag reflex, it relaxes the muscles when muscle relaxants are administered.

After processing the surgical field and anesthesia, the surgeon performs a layer-by-layer dissection of the peritoneal wall. The method allows suturing bleeding vessels, injuring muscles less. The incision should be long enough to allow the doctor to examine the cavity. The muscles and their aponeuroses are manually separated along the fibers.

The omentum and intestines are brought into the open abdominal cavity. For inspection, a check of 50 cm of length on each side of the appendix is ​​necessary. The inflamed process is detected at the beginning of the large intestine ribbons.

The process is isolated very carefully so as not to cause spontaneous rupture

The appendix is ​​removed, and the remaining stump is sutured with a special hermetic purse-string suture. It consists in immersion inward and the possibility of connecting the serous membranes. If an effusion is found in the peritoneum, it is washed with sterile solutions, an antibiotic is administered. The patient's abdominal wall is sutured with dense threads that dissolve after a while.

7-10 stitches are applied to the skin. The need to combat peritoneal phenomena requires leaving a drainage tube. After stabilization of the patient's condition, the drainage is removed. The operation usually takes up to three hours. There are no special regulations. Time is determined by the severity of the condition, age, complicating factors (adhesions in the abdominal cavity, abnormal location of the process).

How is the postoperative period for the patient?

The first day is called the early postoperative period. The patient continues the introduction of detoxification agents, antibiotics. The doctor controls the temperature, urine output and daily diuresis, listens to intestinal noises.

In the following days, a gradual recovery of the patient's condition is observed: appetite and defecation appear, the temperature returns to normal. With daily dressings, the surgical suture is examined, the wound is washed through the drainage. Anxiety is caused by pain in the suture area, discrepancy, prolonged absence of stool.

Unlike a simple form of appendicitis, the patient needs:

• stronger antibacterial agents (from the group of cephalosporins, antibiotics Levofloxacin, Ornidazole, Amikacin);
• painkillers;
• introduction to relieve intoxication Albumin, fresh frozen plasma, Rheosorbilact, Refortan;
• prevention of the development of thromboembolism and stress ulcers of the stomach.

Infusion therapy - the basis of recovery

Consequences of Delayed Surgical Care

With timely surgical intervention, if the process has not ruptured, patients quickly recover. It is noticed that they have more often than with other forms, suppuration of the wound is possible. The refusal of the operation threatens with serious consequences.

Delayed removal of the appendix provokes:

• perforation (perforation) of the wall, pus flows into the abdominal cavity;
• detachment (self-amputation) of the caecum due to tissue melting;
• the development of purulent and purulent-fecal peritonitis, while the patient's condition becomes heavier before the eyes, the temperature is rarely significant, there is no usual dependence on the pulse rate, a survey radiography of the abdominal cavity confirms peritonitis by the presence of a fluid level in the intestine;
• multiple abscesses in the organs of the abdominal cavity and pelvis;
• abdominal sepsis;
• pylephlebitis - purulent inflammation of the portal vein of the liver.

These conditions progress quickly, even lightning fast, provoke insufficiency internal organs. Irreversible damage leads to the death of the patient.

Diet after surgery

A special approach to nutrition in gangrenous appendicitis is associated with a longer violation of intestinal motility. The abdominal organs are more severely injured, which slows down the patient's digestion. In the first 24 hours, it is allowed to drink only boiled water, fat-free kefir, a decoction of dried fruits. From six to seven times a day they give small portions of liquid broth, soup with cereals.

It is allowed to drink mineral water without gas, slightly sweet weak tea, rosehip broth

On the second day, in the absence of signs of complications, mashed boiled meat is added, mashed potatoes, sausages, cottage cheese, liquid cereals with butter. Such a diet is maintained for patients until a sufficiently pronounced peristalsis appears.

From the third day, with full bowel function and defecation, it is allowed to expand the diet to table number 5. You will have to observe the exclusion of fatty and spicy dishes, smoked meats, marinades, lard, spices, eat often and little by little.

What regimens do patients need?

In an uncomplicated course, the patient can and even needs to get up 5-6 hours after the operation. Early active movements physiotherapy, deep breathing exercises prevent pneumonia.

Against the background of complications, walking is delayed for 2 days. The first rise from bed is best done in the presence of relatives or medical personnel. Expansion of the regimen is allowed by the doctor individually. It is recommended to wear a bandage or wrap tightly with a towel for less pain.

The patient is usually discharged on the tenth day. A gentle regimen is needed for a month physical activity. Heavy lifting is contraindicated for three months. Allowed exercises to strengthen the muscles of the legs, arms, leisurely walking.

Stitches are removed in the treatment room when the wound is in good condition.

Sports activities (running, weightlifting, football, volleyball) will have to be postponed for at least 3 months. The decision to allow exercise should be made with your doctor. A clear dependence of the complications and results of the operation in the patient on the neglect of the disease requires its own control over abdominal pain, the timely call of an ambulance, and observation by specialists.

If irreversible necrotic changes in the appendix begin to develop, it is worth saying that the patient's diagnosis is acute gangrenous appendicitis. During the disease, inflammation of the organ occurs, with its further suppuration and destruction of the integrity of the walls.

Treatment is possible only by surgery. If the operation is performed before the appendix ruptures, the chances of a full recovery are quite high. In the absence of timely therapy, the risk of complications increases significantly, which subsequently leads to death.

Disease catalysts

Often gangrenous appendicitis is a consequence of the progression of the purulent course of the disease. In the absence of treatment, destructive processes begin to develop in the walls of the organ, which leads to its rupture, followed by the release of purulent contents into the peritoneal cavity. But there are some reasons that provoke the gangrenous course of the disease initially.

When the disease can develop:

• reduced immunity due to autoimmune problems;
• infection of the body;
• violation of the outflow in the appendix;
• senile age, during which the blood circulation of organs and systems is disturbed;
• thrombosis of blood vessels in the appendix;
• the presence of atherosclerosis in the patient's history;
• congenital arterial hypoplasia leads to the disease in childhood.

Provoke necrotic changes in the walls can also be poor-quality diagnostics and incorrectly prescribed treatment of appendicitis. The disease develops rapidly, especially in childhood.

Symptoms

The danger of gangrenous appendicitis is that if you ignore the initial stages of the disease, the walls die off, and with them the nerve endings of the organ, as a result of which the clinical picture is smeared, and the painful symptoms gradually subside.

What you should pay attention to:

• present sharp pains in the iliac region, which gradually pass on their own without taking painkillers;
• vomiting not associated with meals;
• there is a strong tachycardia without fever;
• the patient complains of dry mouth; when examined, a white-brown coating can be seen on the tongue.

If primary inflammation has occurred, a person may be disturbed by pain on palpation of the peritoneum, and the temperature rises to stable high levels.

In childhood, inflammation develops rapidly. Parents should be vigilant if the baby began to be disturbed by pain in the abdomen, frequent stools and other changes in the functioning of the digestive tract. The child becomes lethargic, restless, whiny, he can press his legs to his stomach and stay in this position for a long time.

Attention! If a child or adult has these symptoms, you should immediately call an ambulance!

What is perforated appendicitis

When there is a perforation in the wall of the appendix, that is, a violation of its integrity, it is worth talking about gangrenous-perforated appendicitis. Such a selection of this form is necessary in order to carry out the necessary manipulations for the treatment of the disease, as well as to provide high-quality care in the postoperative period, since the risk of postoperative complications increases significantly.

Diagnostics

Often, the diagnosis of the disease is significantly difficult, this is due to the blurred clinical picture. The person is not bothered by pain, the abdomen is mild, the temperature is absent, and after examination, the doctor lets the patient go home. When there is a repeated appeal to the doctor, the patient already develops a gangrenous form of the disease.

Examinations required for diagnosis:

1. Collecting the patient's history and examining him. Allows you to set the duration of the disease, its severity, form. After the interview, the doctor conducts an examination, carefully palpating the peritoneal area.
2. General analysis of urine and blood. Increased rates leukocytes and erythrocytes in these studies indicates an inflammatory process in the body.
3. Ultrasound examination of the appendix. Allows you to assess the boundaries of the appendix, however, with a gangrenous form, diagnosis is difficult. This is due to the release of purulent contents into the peritoneal region, as a result of which the organ is not clearly visible on the monitor.
4. Radiography. Allows a specialist to evaluate the shape of the appendix, its structure.
5. CT scan. It also helps to assess the state of the body.
6. Laparoscopy. During this study you can see that the walls of the process have thickenings, there is a greenish tint, necrosis is observed on the tissues.

After an emergency diagnosis, the patient is shown surgical removal of the appendix, regardless of its form and stage of inflammation, but the sooner the operation is performed, the greater the chance of the absence of postoperative complications.

Treatment

Treatment of gangrenous-perforated appendicitis or any other form of it is possible exclusively by surgery. The victim is shown an appendectomy, that is, the complete removal of the organ. If it has ruptured, the surgeon also needs to clean the abdominal cavity from purulent contents.

Some clinics also perform laparoscopy. This operation is good because the intervention is carried out through 2-3 small holes, and the specialist sees the entire course of the procedure on the monitor. In addition, complications after such manipulation are observed much less frequently.

Attention! However, a successful operation will not be enough. It is necessary to carefully care for the patient in the postoperative period, as well as follow the necessary diet. Only an integrated approach will help cure the disease.

Recovery period after surgery

During the recovery period, the patient is prescribed various anti-inflammatory, antipyretic drugs and antibiotics. The nurse also provides care and control over the tests, the condition of the suture, discharge from it, and advises the patient on nutrition.

For quick healing of the wound, it is necessary to carry out its regular treatment and dressing, and the patient himself can perform breathing exercises and physical exercises after the doctor allows it. If the operation went without complications, then it is allowed to rise after a few hours. In case of intoxication of the body, recovery period stretches to several days of bed rest.

Diet

The success of recovery depends on the subsequent nutrition no less than on the operation itself. The first day after the intervention, the use of almost all products is prohibited, except for liquids and grated soups. On the second day, with the permission of the doctor, the diet expands. And only on the third day the food becomes complete, of course, with the exception of prohibited foods.

What is allowed to eat:

• rice or semolina porridge;
• exclusively boiled vegetables;
• light meat broths and grated soups;
• kefir;
• non-carbonated drinks, mainly compote or water.

All gastronomic garbage, multi-component dishes, fried, fatty, spicy foods are completely excluded. The first time after the operation, gas-producing foods (peas, cabbage, raw vegetables, muffins) are not recommended for consumption.

Possible postoperative complications

The postoperative consequences of gangrenous appendicitis can be extremely deplorable. Often it can be inflammation and suppuration of the suture, which is treated without re-operation. In severe cases, detachment of the appendix from the cecum, its infiltration can occur. Cases of postoperative purulent peritonitis and aseptic thrombophlebitis have been recorded, which, without timely response from the medical staff, can lead to the death of the victim.

Attention to your body and timely diagnosis, will help prevent many troubles and health problems. That is why it is necessary to immediately seek help when pain occurs in the abdomen.

Inflammation in the appendix is ​​called appendicitis. Developing, the disease goes through several stages from mild, correctable drug treatment to complex. Gangrenous appendicitis is a type of appendix lesion and the penultimate stage of the disease, dangerous topic which often leads to death.

In this position, the use of surgery is not a lifesaver. As a result of the surgeon's action, a violation of the integrity of the appendix may occur. The process bursts and the pus contained inside falls on the abdominal organs. Peritonitis develops sharply, tissue necrosis occurs.

This stage of appendicitis does not occur immediately, but after 2-3 days after the first signs of the disease appear. During this period, signs of phlegmonous-gangrenous changes in the tissues of the organ appear. The lack of therapy leads to a deterioration in the patient's condition and the development of complications. The inflamed organ changes, the outer walls collapse, die. During the operation, the smell of rot comes from the wound. The appearance of the process has characteristics last stage:

• Significant increase in size;
• The color of the appendix has changed and acquired a dirty green tint;
• Areas with blood are observed;
• Visible tissue necrosis;
• Sources of seepage of pus.

The danger of an acute lesion of the appendix is ​​that it affects the internal organs located close to the appendix. In particular, inflammation affects the organs located in the abdominal cavity. If medical assistance has not been received, gangrenous appendicitis turns into a gangrenous-perforative disease, the wall of the organ becomes perforated, pus seeps out.

Gangrene of the appendix often develops due to the lack of adequate treatment on the third day. Extremely rare fulminant development (6-12 hours) of the penultimate stage of appendicitis. It can also be seen in young children when the immune system incompletely formed and cannot resist the inflammatory process.

Causes leading to the onset of the disease:

• The patient's age and vascular system. With age in the vessels occur pathological changes, contributing to a decrease in the quality of supply of the process with oxygen and nutrients, and the outflow of venous blood also worsens. Often there is a development of a primary gangrenous type of disease.
• The appearance of cholesterol plaques in the arteries passing through the intestinal tract (atherosclerosis) leads to an insufficient amount of blood flowing to the intestinal tissues.
• In childhood, incomplete development of the vessels passing through the appendix is ​​capable of provoking gangrene of the appendix. Hypoplasia in a child is a congenital disease.

• The development of thrombosis in the veins and arteries that supply and drain blood in the caecum.

Insufficient blood supply leads to oxygen starvation tissues of organs, they begin to die. The rapid onset of the penultimate stage may be associated with ingestion of infection or the occurrence of autoimmune processes in the lumen of the intestinal tract.

Symptoms

Acute appendicitis in the gangrenous stage will be characterized by a special clinical picture. The perforated form of the disease enhances the intoxication of the body, more and more decay products are released into the blood (the tissue dies and releases toxins). The following symptoms appear:

• Loss of appetite and aversion appearance food.
• The patient is constantly shivering.
• Body temperature rises, the thermometer shows 39 degrees. It should be noted that this does not always happen.
• The state of nausea and the occurrence of vomiting.
• The patient's stool is broken. Periods of constipation may alternate with periods of diarrhea.
• AT oral cavity a plaque appears on the tongue, which has a white, yellow or brown color. The color change is noticeable near the root.
• More gas is produced in the intestines, the stomach becomes hard.
• The patient feels weakness in the whole body and loss of strength.
• Dry mouth.
• The pulse quickens and reaches 120 beats in one minute.
• In young patients, there is a lethargic state and capriciousness, tearfulness.

There comes a period when the patient feels that he is better, but this is only a temporary relief, which is a false indicator of recovery. This means that along with the tissues of the process, the nerve endings responsible for pain also die.

Perforated ailment

Dying tissue leaves behind small holes in the walls of the appendix. Medicine, this phenomenon is singled out as a separate and dangerous view gangrenous appendicitis, requiring certain methods of treatment, surgery and further care in the period after surgery.

A perforated appendix is ​​painful. When a tissue rupture occurs, the patient feels an intense pain syndrome on the right. At first, the pain is manifested by attacks, but gradually turns into chronic stage and radiates throughout the abdomen.

Effects

The lack of medical care in the event of gangrene of the appendix leads to a significant deterioration in the patient's condition and the development of complications:

• Pylephlebitis develops inside. This means that a purulent inflammatory process provokes the formation of blood clots in the portal vein.
• The appearance of purulent sources in the peritoneal cavity. As a rule, an abscess is located between the intestines, in the region of the diaphragm and small pelvis.
• An infiltrate consisting of tissues begins to form around the appendix. Its formation prevents the spread of inflammation to other internal organs.

by the most dangerous complication considered a gangrenous form of peritonitis. This means that there was a rupture of the walls of the appendix. This development of the disease is fraught with blood poisoning. Surgeons try to prevent the onset of this stage, since the survival rate of patients is low.

Period after surgery

The chosen method of appendectomy, the severity of the disease determine the duration of the postoperative period. On the first day after the gangrenous type of appendicitis and its removal, a nurse takes care of the patient. It does the following:

• Observes the patient and fixes the appearance of symptoms of internal bleeding.
• Measures the temperature, thereby controlling the condition of the operated.
• Periodically inspect the place of the seam.
• Conducts a survey of the patient about sensations, appetite. Monitor bowel frequency.

The postoperative period of patients with removed appendicitis of the gangrenous type has some features and will differ:

• The patient is prescribed drugs that have a strong antibacterial effect: Cephalosporin, Amikacin, Ornidazole, Levofloxacin.
• The patient is prescribed analgesics. These medicines are taken as needed.
• To support the body, various solutions are administered intravenously: saline, glucose, albumin, rheosorbilact, fresh frozen plasma.
• Held preventive actions to prevent the formation of blood clots in the vessels. Prevention is directed against the occurrence of ulcerative phenomena of the stomach, intestines against the background of stress. Operated wears elastic bandages on his shins, he is injected with anticoagulants. Medications are taken that reduce the production of bile secretions: Omez and Kvamatel.
• Blood samples are taken every day.

• Wound dressing. Dressings are changed daily, the wound is washed, the drainage system is disinfected. At the same time, there is an assessment of healing and the appearance of purulent discharge.
• Passage of therapeutic procedures: exercise therapy, breathing exercises, massage. The duration and number of procedures is determined by the patient's condition. The sooner a person activates all the functions of the body, the faster and more successful the recovery process will be.

Compliance with dietary nutrition in the postoperative period is a factor in the speedy recovery:

1. For the first 24 hours after an appendectomy, you can not eat, only drink. Water must be clean, mineral, without gas. You can also consume weak sweet tea, compote, fat-free kefir. You can eat pureed low-fat soup or chicken broth. There are a few, but often.
2. Second 24 hours. Puree, mashed lean meat is added. They add to the menu: a casserole with cottage cheese, boiled sausages, cereals boiled in water.
3. In the following days, diet number 5 is prescribed. Exclude spicy, smoked, marinades, pickles from the diet. Eat little but often.

Complications

Conducting surgery before perforation of the walls of the appendix has occurred reduces the risk of complications. In this case, an infection occurs at the site of the seam and the appearance of pus. Treatment of these complications does not require repeated surgery.

When the patient got on the surgical table with purulent peritonitis, the consequences are possible:

• Inside the abdominal cavity, not only pus enters, but also fecal matter.
• There is a detachment of the appendix from the body of the caecum.
• Multiple formation of small purulent wounds in the pelvis, in the area of ​​the diaphragm.
• The appearance of an infiltrate. This factor becomes an obstacle to surgery. Only after resorption of the formation can appendicitis be removed.
• Peritonitis with purulent formations.

Acute gangrenous appendicitis is one of the most dangerous forms of inflammation of the appendix. Most often, it develops as a result of untimely access to a doctor and incorrect diagnosis. In fact, this is a continuation of phlegmonous appendicitis.

Gangrenous changes in the appendix can also be of a primary nature, for example, if the initial cause of the disease was thrombosis or spasm of the mesenteric vessels of the appendix.

Pathomorphology of the disease

Gangrene of the appendix is ​​the destruction of all layers of the organ wall, their melting and necrosis. During the operation, a serous or purulent effusion with a sharp putrid odor is found in the abdominal cavity. The appendix has a dirty green color, increased in size, areas of necrosis and multiple hemorrhages are visible.

With gangrenous appendicitis, surrounding organs are actively involved in the inflammatory process. Adhesions form between the omentum, intestinal loops and peritoneum, hemorrhages and fibrinous plaque appear on the surface of these organs. Often there is a self-amputation of the appendix or its perforation, that is, through perforation of the wall.

The removed appendix has a greenish color, is enlarged, foci of necrosis and hemorrhage are observed.

Symptoms of the disease

All types of appendicitis are similar to each other in terms of symptoms, but each of the forms has its own characteristics. This also applies to acute gangrenous appendicitis. If it is a consequence of phlegmonous inflammation of the appendix, then the pain subsides or even disappears. This is due to the death of nerve endings in the walls of the process as a result of necrosis. Patients develop repeated vomiting due to high intoxication of the body, while in other forms of the disease it is absent or only once. Other signs of appendicitis are described in the video at the end of the article.

Important: for any symptoms of appendicitis, you should immediately call an ambulance.

During the examination, the doctor may note the dryness of the tongue, the tension of the muscles of the abdominal wall. On palpation, the right iliac region is sharply painful. In the blood test, the level of leukocytes is moderately elevated, although the shift of the formula to the left can be significant.

What is dangerous gangrene of the appendix?

With gangrenous appendicitis, the most formidable consequence is diffuse peritonitis. It develops when there is an outflow of putrid contents from the appendix into the abdominal cavity. Sometimes it is limited (localized) if adhesions have time to form, which prevent the process from spreading. This complication is characterized by a sharp change in the clinical picture. Pain is no longer localized. They intensify and spread to the entire abdomen. The patient's condition is rapidly deteriorating:

• tachycardia is observed (pulse rate more than 100-120 per minute),
• a white coating appears on the tongue,
• consciousness becomes sluggish, inhibited,
• the stomach ceases to participate in the act of breathing,
• repeated vomiting occurs, which does not bring relief.

Gangrenous-perforative appendicitis is characterized by the absence of intestinal peristalsis, the abdomen is tense, there are signs of peritoneal irritation. Paralytic ileus may develop. In the analyzes, the number of blood leukocytes significantly increases, the ESR rises to high numbers (40-60 mm / h), there is a sharp shift to the left of the leukocyte formula. In the urine, protein and cylinders (waxy, granular) are often found, which indicates toxic nephritis.

With peritonitis, there is no parallel between tachycardia and body temperature - fever is rarely high. Plain radiographs of the abdomen show fluid levels in the intestinal loops ("Kloiber's cups").

Treatment of the disease

The main treatment for gangrenous appendicitis is emergency surgery. If peritonitis is suspected, an open laparotomy is performed under general anesthesia. Open the abdominal wall midline, remove the inflamed appendix and its parts, examine the abdominal cavity. Be sure to carry out the toilet of the internal organs and the abdominal cavity, wash it with an antiseptic solution. The surgical wound is not completely sutured, leaving drainage tubes in it. They are necessary to remove the accumulated exudate and irrigate the peritoneum with antibacterial agents.

Drainages are brought into the surgical wound - special tubes or rubber strips

Surgery is usually complementary drug therapy. To eliminate the phenomena of intoxication, infusion solutions are poured intravenously, antibiotics are prescribed.

Postoperative complications

With gangrenous appendicitis, the postoperative period is long and rather difficult. The following complications may occur:

• the formation of an infiltrate,
• suppuration of the surgical wound,
• external or internal bleeding from a wound,
• abscesses in the abdominal cavity,
• intestinal fistulas,
• divergence of sutures of the surgical wound or appendix stump,
• peritonitis.

Important: the listed complications can be with any form of appendicitis, but with gangrenous they are more common. That is why you can not delay the call of the doctor and self-medicate.