An abscess after appendicitis is dangerous. Most common complications in patients with acute appendicitis

Refers to organ diseases abdominal cavity, characterized by a tendency to develop various complications. It is their presence that determines the unfavorable outcomes of appendectomy.

Complications are divided according to the periods of occurrence into preoperative and postoperative. Preoperative complications include appendicular infiltrate, appendicular abscess, retroperitoneal phlegmon, and peritonitis. Postoperative complications of acute appendicitis are classified according to the clinical and anatomical principle.

According to the timing of development, postoperative complications of acute appendicitis are divided into early and late. Early complications occur within two weeks from the moment. This group includes the majority of complications from the postoperative wound (purulent-inflammatory processes, divergence of the wound edges without or with eventration; bleeding from the wound of the anterior abdominal wall) and all complications from adjacent organs.

Late postoperative complications of acute appendicitis are diseases that develop after a two-week postoperative period. Among them, the most common are:

• Of the complications from the postoperative wound - infiltrate, abscess, ligature fistula, postoperative, keloid scars, cicatricial neuromas.
• From acute inflammatory processes in the abdominal cavity - infiltrates, abscesses, cultitis.
• Of the complications from the gastrointestinal intestinal tract- acute mechanical,.

The causes of postoperative complications of acute appendicitis are:

• Untimely treatment of patients for medical care.
• Late diagnosis of acute appendicitis (due to the atypical course of the disease, incorrect interpretation of the available clinical data typical for inflammation of the appendix).
• Tactical errors (lack of dynamic monitoring of patients with a dubious diagnosis of acute appendicitis, underestimation of the prevalence of the inflammatory process in the abdominal cavity, incorrect definition of indications for the abdominal cavity).
• Errors in the technique of the operation (tissue injury, unreliable ligation of vessels, incomplete removal of the appendix, poor drainage of the abdominal).
• Progression of chronic or onset acute diseases related organs.

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Appendicitis is an inflammation of the appendix called the appendix. Symptoms of acute appendicitis: pain in the abdomen, indigestion, high fever.

When the first symptoms are detected, you should seek help from the hospital. The only treatment is removal of the inflamed appendix. In some cases, complications of appendicitis occur.

Signs of complications

As mentioned above, appendicitis is an inflammation of the appendix. The appendix is ​​the blind outlet of the large intestine.

When it overflows with all sorts of waste, inflammation can begin. In this case, only the help of a surgeon will be needed.

The appendix can manifest itself at any time. Often already in adolescence one has to face this problem.

Sometimes appendicitis does not manifest itself in any way for a lifetime. Thus, it is impossible to predict its appearance.

When the first symptoms appear, they are sent to the surgeon. To endure and even more so to start some kind of treatment at home is by no means necessary.

If you do not go to the hospital in time, then there can be a variety of consequences, up to death.

The sooner the operation is performed and outpatient treatment is prescribed, the greater the likelihood of the absence of any complications.

Already after 3-7 days of removal of the process, the person returns to ordinary life. Any physical activity is excluded.

The most popular in the list of complications is peritonitis. Such a complication occurs as a result of overflowing with pus of the process and its exit into the organs.

One of the forms of development of peritonitis is called appendicular infiltrate.

Appendicular infiltrate is a fairly common complication. An infiltrate occurs after a small amount of pus enters the body, and it tries to cope with the problem on its own.

The main danger in this is the confusion of symptoms. In this case, doctors can diagnose a delay in surgery. Further, blood poisoning is possible, which is almost impossible to cure.

Over time, the symptoms of infiltration will only intensify. Suppuration begins, and the pain increases. Naturally, the body reports an increase in temperature about the inflammatory process.

In the case of peritonitis, surgical intervention should be timely. A neglected form of appendicitis is no longer treatable, and a person is expected to die.

Only an experienced surgeon can diagnose complications. In some cases, this is the first examination of the peritoneum and palpation.

But, unfortunately, it happens that complications of the development of appendicitis are detected only during the operation.

There are the most different types complications. Each of them has its own symptoms. Any kind of consequences require an immediate solution.

Classification of complications

Various factors contribute to the occurrence of serious consequences. They are divided by time into preoperative and postoperative.

The first type of complications occurs as a result of a long intervention of doctors. Often they occur against the background of incorrect diagnosis and further therapy.

Preoperative ones include: appendicular infiltrate, pylephlebitis, peritonitis, retroperitoneal phlegmon, abscess.

Postoperative complications occur some time after the removal of the process. Sometimes they show up after a few weeks.

Postoperative include the pathology of neighboring organs and the consequences that were caused by damage during surgery.

Causes of postoperative consequences:

1. Incorrect adherence to the regimen.
2. Inaccurate diagnosis.
3. Chronic and acute outbreaks of diseases in neighboring organs.
4. Long term help.
5. Errors during the operation.

Complications after the operation also have a different location. It could be:

1. Abdomen.
2. Location of the cut.
3. Any other neighboring organs and systems.

Some problems arise almost immediately, while others take a long time to develop.

So, experts identify 2 possible options for the development of complications:

• Early. Appear within 14 days. It is worth highlighting such as: peritonitis, suture damage, bleeding, pathologies of neighboring organs.
• Late. Appear after 14 days. Allocate fistulas, keloid scars, suppuration, infiltrates, abscesses, intestinal obstruction, adhesions in the abdominal cavity.

To understand all the nuances of late and early complications, you need to consider in more detail each possible case.

Perforation

It occurs at an early stage. This is a complication resulting from acute inflammation appendix, its suppuration and melting of the walls.

The pus enters the abdominal cavity, causing irritation. Perforation is accompanied by peritonitis.

Based clinical picture pathology, signs can be distinguished:

1. Nausea and vomiting.
2. Severe pain in the abdomen.
3. All symptoms of intoxication.
4. Fever.
5. Signs of peritonitis.

Naturally, the earlier medical therapy the lower the risk of perforation. Often occurs in those people who seek help at a late stage.

Appendicular infiltrate

According to statistics, this complication is distinguished by no more than 3% of patients diagnosed with acute appendicitis. Appendicular infiltrate is a fairly common complication.

It is also formed due to the late appeal for help. Occurs no later than 5 days after the onset of the inflammatory process in the process. Inflammation affects neighboring organs and tissues.

Initial signs:

• Fever.
• Intoxication.
• Pronounced pain in the abdomen.
• General features of the manifestation of peritonitis.

Late signs are characterized by the blurring of their symptoms. This is an important danger, because it becomes difficult to diagnose the problem. An inexperienced surgeon may simply miss it due to the lack of symptoms.

At this point, the patient begins to feel relief, the pain goes away, and the general well-being is getting better. The only thing left is the temperature. Its mark should not be lowered.

On examination, the surgeon does not notice muscle tension in the abdominal region. The only thing that can reveal this type of complication is a painful, dense and inactive formation in the right iliac region.

You need to understand that the operation in this case is no longer important. The problem is solved by a conservative method.

Antibiotic group medicines are taken as a basis. Strong drugs will be required to prevent serious development.

The appendicular infiltrate may resolve or an abscess will begin inside the body. In the best case, if there is no suppuration in the inflamed area, then the treatment will take no more than 5 weeks.

Otherwise, decay may continue, leading to peritonitis.

Appendicular abscess

Such severe forms The development of pathologies can occur at any stage of progression.

Locations may be:

• Right iliac region.
• Retroperitoneal space.
• Diaphragm. It is located in the right subdiaphragmatic recess. Symptoms: clear and strong manifestations of intoxication, dry cough, chest pain, heavy and labored breathing. On palpation, the specialist notes: pain, a large volume of the liver, a soft stomach. Breathing is practically not felt in the right lung.
• For men, a place between bladder and rectum, in women - between the rectum and the uterus. Signs: dysuric manifestations, pain in the rectum, perineum, frequent urge to empty. Suppuration can be diagnosed through the rectum or vagina.
• In intestinal loops. It is very difficult to diagnose this problem at an early stage of development. Further, the symptoms become more vivid: the temperature rises, paroxysmal pain, the muscles of the abdominal wall become tense, the infiltrate is palpated.

Common signs include:

1. Hyperthermia.
2. Intoxication.
3. Strong pain.
4. High level of leukocytes and ESR in the blood.

Ultrasound is used for diagnosis. The treatment is surgery.

A purulent formation with an appendicular abscess is opened, and the affected cavity is washed. Drainage is installed in it and the wound is sutured.

After the operation, the necessary time is spent washing the cavity through the drains. This is necessary to remove the accumulated remnants of pus. Also, the necessary medicines are introduced into the cavity.

Pylephlebitis

This is one of the most severe complications of acute appendicitis. Pylephlebitis is a severe purulent-septic inflammation of the portal vein of the liver. Several abscesses form on the organ.

Main features:

1. The patient has a sharp deterioration in well-being.
2. Severe symptoms of intoxication.
3. Pale skin.
4. Breathlessness.
5. Hypotension.
6. Enlargement of the spleen and liver.
7. Fever.

Treatment includes both surgery and drug treatment. When abscesses form, they are opened and washed.

From conservative treatment, the emphasis is on taking anticoagulants and antibiotics.

Important! In 97% of the patient can not be saved. High probability of death.

Peritonitis

As a result of an acute inflammatory process of the appendix, the abdominal cavity is affected. Signs:

1. Hyperthermia.
2. Severe pain in the abdominal area.
3. Pallor.
4. Tachycardia.

Only an experienced doctor can identify such a complication. On palpation, some features were noticed: the pain increases after the doctor has pressed on the abdominal region and sharply released.

At the same time, the pressure itself does not bring much discomfort.

Therapy must be comprehensive. It includes methods:

• Symptomatic.
• Antibacterial.
• Surgical.
• Detoxification.

Fistulas in the intestines

To the latest postoperative complications include fistulas. With such a pathology, the walls of the nearest intestinal loops are affected, followed by destruction.

1. Pressing with dense gauze bandages on the abdominal cavity.
2. Non-compliance with the rules for the processing of the appendix.

If the wound is sutured, then the symptoms are pronounced and severe. With an incompletely sutured wound, intestinal contents protrude, which subsequently forms fistulas.

Signs:

• Paroxysmal pain in the right iliac region.
• In the same part, a deep infiltrate is revealed.
• Symptoms of bowel dysfunction.
• Signs of peritonitis.

Treatment will directly depend on the individual course of the pathology. Therapy includes both the usual medical method and the surgical one.

Mandatory use of anti-inflammatory, antibacterial drugs. Formed intestinal fistulas are immediately removed.

Fistulas can open on their own. Under no circumstances should this be allowed. This happens 10-25 days after the removal of appendicitis. There is a small risk of death.

Treatment of complications

As a preventive measure, therapy is carried out even at the stage of diagnosing appendicitis.

Methods of treatment and prevention of consequences:

• Hematomas. It is the most popular type of complication development. The main symptom is pain at the suture site. When diagnosing a hematoma, the doctor prescribes an opening of the wound and its cleansing. Further, immunotherapy, physiotherapy and anti-inflammatory drugs are prescribed.
• Follow the prescribed regimen, especially in the early days.
• If complications are detected, nutrition is supplied through injections and droppers. After the condition improves, it is allowed to eat mashed cereals and liquid foods.
• To restore tissue, the patient may be prescribed antibiotics and anti-inflammatory drugs.
• In the first months, any physical activity, bending and sudden movements are contraindicated.
• Symptoms must be closely monitored. Any new manifestation should be discussed with the attending physician. You cannot self-medicate.

Only the correct and timely intervention of specialists can prevent the development of complications after appendicitis.

It is impossible to reach a late stage of development. Only attentiveness to your body can prompt you to seek help.

Useful video

The inflammatory process in the process of the appendix leads to a common disease of the abdominal cavity - appendicitis. Its symptoms are soreness in the abdominal region, fever and disorders of the digestive function.

the only the right treatment in the case of an attack of acute appendicitis is an appendectomy - surgical removal of the process. If this is not done, severe complications can develop, leading to death. What threatens untreated appendicitis - our article is just about that.

Preoperative consequences

The inflammatory process develops at different speeds and symptoms.

In some cases, it goes into and may not manifest itself for a long time.

Sometimes between the first signs of the disease before the onset of a critical condition, 6-8 hours pass, so you should not hesitate in any case.

For any pain of unknown origin, especially against the background of fever, nausea and vomiting, you should definitely seek medical help, otherwise the consequences can be the most unpredictable.

Common complications of appendicitis:

• Perforation of the walls of the appendix. The most common complication. In this case, ruptures of the walls of the appendix are observed, and its contents enter the abdominal cavity and lead to the development of sepsis. internal organs. Depending on the duration of the course and the type of pathology, severe infection can occur, even death. Such conditions account for approximately 8-10% of the total number of patients diagnosed with appendicitis. With purulent peritonitis, the risk of death increases, as well as exacerbation of concomitant symptoms. Purulent peritonitis, according to statistics, occurs in approximately 1% of patients.
• appendicular infiltrate. Occurs when adhesions of the walls of nearby organs. The frequency of occurrence is approximately 3 - 5% of cases clinical practice. It develops approximately on the third - fifth day after the onset of the disease. The beginning of the acute period is characterized by a pain syndrome of indistinct localization. Over time, the intensity of pain decreases, the contours of the inflamed area are felt in the abdominal cavity. The inflamed infiltrate acquires more pronounced boundaries and a dense structure, the tone of the muscles located near it slightly increases. After about 1.5 - 2 weeks, the tumor resolves, abdominal pain subsides, general inflammatory symptoms decrease ( fever and biochemical parameters blood returns to normal). In some cases, the inflammatory area can cause the development of an abscess.
• . It develops against the background of suppuration of the appendicular infiltrate or after surgery with previously diagnosed peritonitis. Usually the development of the disease occurs on the 8th - 12th day. All abscesses must be opened and sanitized. Drainage is performed to improve the outflow of pus from the wound. Antibacterial therapy is widely used in the treatment of abscess.

The presence of such complications is an indication for urgent surgical operation. rehabilitation period also takes a lot of time and an additional course of drug treatment.

Complications after removal of appendicitis

Surgery, even if performed before the onset of severe symptoms, can also lead to complications. Most of them are the cause of death in patients, so any alarming symptoms should alert.

Common complications after surgery:

• . Very often occur after the removal of the appendix. Characterized by the appearance of pulling pains and tangible discomfort. Adhesions are very difficult to diagnose, because they are not seen by modern ultrasound and X-ray devices. Treatment usually consists of absorbable drugs and laparoscopic removal.
• . Quite often appears after surgery. It manifests itself as a prolapse of a fragment of the intestine into the lumen between the muscle fibers. Usually appears when the recommendations of the attending physician are not followed, or after physical activity. It visually manifests itself as a swelling in the area of ​​​​the surgical suture, which over time can significantly increase in size. Treatment is usually surgical, consisting of suturing, truncation, or complete removal of the intestine and omentum.

Photo of a hernia after appendicitis

• postoperative abscess. Most often manifested after peritonitis, can lead to infection of the whole organism. Antibiotics are used in the treatment, as well as physiotherapy procedures.
• . Fortunately, these are quite rare consequences of an appendectomy operation. The inflammatory process extends to the region of the portal vein, the mesenteric process and the mesenteric vein. Accompanied high temperature, acute pain in the abdominal cavity and severe liver damage. After acute stage arises, and, as a result, death. Treatment of this ailment is very difficult and usually involves the introduction of antibacterial agents directly into the portal vein system.
• . In rare cases (in about 0.2 - 0.8% of patients), the removal of the appendix provokes the appearance of intestinal fistulas. They form a kind of "tunnel" between the intestinal cavity and the surface of the skin, in other cases - the walls of internal organs. The reasons for the appearance of fistulas are poor sanitation of purulent appendicitis, gross errors of the doctor during the operation, as well as inflammation of the surrounding tissues during drainage of internal wounds and abscess foci. Intestinal fistulas are very difficult to treat, sometimes resection of the affected area or removal of the upper layer of the epithelium is required.

The occurrence of this or that complication is also facilitated by ignoring the recommendations of the doctor, non-compliance with the rules of hygiene after surgery and violation of the regimen. If the deterioration occurred on the fifth or sixth day after the removal of the appendix, most likely, we are talking about pathological processes in the internal organs.

In addition, in the postoperative period, other conditions may occur that require a doctor's consultation. They can be evidence of various ailments, and also not related to the operation at all, but serve as a sign of a completely different disease.

Temperature

An increase in body temperature after surgery can be an indicator of various complications. The inflammatory process, the source of which was in the appendix, can easily spread to other organs, which causes additional problems.

Most often, inflammation of the appendages is observed, which can make it difficult to determine the exact cause. Often the symptoms of acute appendicitis can be confused with such ailments, therefore, before the operation (if it is not urgent), a gynecologist's examination and an ultrasound examination of the pelvic organs are required.

An elevated temperature can also be a symptom of an abscess or other diseases of the internal organs. If the temperature has risen after an appendectomy, an additional examination and laboratory tests are necessary.

Diarrhea and constipation

Digestive disorders can be considered as the main symptoms and as consequences of appendicitis. Often the functions of the gastrointestinal tract are disturbed after surgery.

During this period, constipation is the worst tolerated, because the patient is forbidden to push and strain. This can lead to divergence of the seams, protrusion of the hernia and other consequences. For the prevention of digestive disorders, it is necessary to adhere to strict and prevent stool fixation.

Stomach ache

This symptom can also have a different origin. Usually, pain sensations appear for some time after the operation, but completely disappear for three to four weeks. Usually, this is how much the tissues will need for regeneration.

In some cases, abdominal pain may indicate the formation of adhesions, hernia, and other consequences of appendicitis. In any case, the best solution would be to see a doctor, and not try to get rid of uncomfortable sensations with painkillers.

Appendicitis is a common pathology requiring surgical intervention. The inflammatory process that occurs in the process of the caecum can easily spread to other organs, lead to the formation of adhesions and abscesses, and also give many more serious consequences.

To prevent this from happening, it is important to seek help from the hospital in a timely manner, and also not to ignore the alarm signals that may indicate the development of the disease. What is dangerous appendicitis, and what complications it can lead to, is described in this article.

Russian Ministry of Health

Voronezh State Medical Academy

named after N.N. Burdenko

Department of Faculty Surgery

COMPLICATIONS OF ACUTE APPENDICITIS

lecture notes for students

4 courses of the Faculty of Medicine and the International Faculty

medical education

4k.Lecture4

Voronezh, 2001

COMPLICATIONS OF ACUTE APPENDICITIS (according to the stages of the course)

Early period(the first two days) is characterized by the absence of complications, the process usually does not go beyond the process, although destructive forms and even perforation can be observed, especially often in children and the elderly.

AT interim period(3-5 days) complications usually occur: 1) perforation of the appendix, 2) local peritonitis, 3) thrombophlebitis of the veins of the mesentery of the appendix, 4) appendicular infiltrate.

AT late period (after 5 days) there are: 1) diffuse peritonitis, 2) appendicular abscesses (due to abscessing of the infiltrate or as a result of delimitation after peritonitis), 3) thrombophlebitis of the portal vein - pylephlebitis, 4) liver abscesses, 5) sepsis.

It should be noted the somewhat arbitrary nature of the division of complications according to the stages of the course.

Perforation- usually develops on the 2-3rd day from the onset of an attack in destructive forms of appendicitis, is characterized by a sudden increase in pain, the appearance of pronounced peritoneal symptoms, a picture of local peritonitis, and an increase in leukocytosis. In some cases, in the presence of mild pain in the early period, the moment of perforation is indicated by patients as the onset of the disease. The lethality at perforation according to Kuzin reaches 9%. Perforated appendicitis was observed in 2.7% of patients admitted to early dates, among those admitted to late dates- 6.3%.

Appendicular infiltrate - this is a conglomerate of inflammatoryly altered internal organs soldered around the appendix - the omentum, small and caecum, is formed according to various statistics from 0.3-4.6 to 12.5%. Rarely diagnosed at the prehospital stage, sometimes only during surgery. It develops 3-4 days after the onset of an attack, sometimes as a result of perforation. It is characterized by the presence of a dense tumor-like formation in the right iliac region, moderately painful on palpation. In this case, peritoneal symptoms subside as a result of the delimitation of the process, the abdomen becomes soft, which allows the infiltrate to be palpated. The temperature is usually kept at a level of up to 38º, leukocytosis is noted, the stool is delayed. With an atypical location of the process, the infiltrate can be palpated in accordance with the location of the process, with a low location, it can be palpated through the rectum or vagina. Diagnosis is aided by ultrasound. In doubtful cases, laparoscopy is performed.

The presence of an infiltrate is the only contraindication to surgery (as long as it has not abscessed), because an attempt to isolate a process from a conglomerate of organs soldered to it entails the danger of damage to the intestines, mesentery, omentum, which is fraught with serious complications.

Treatment of the infiltrate should be conservative (performed in a hospital): I/ local cold, 2/ broad-spectrum antibiotics, 3/ bilateral pararenal blockade every other day or Shkolnikov blockade, 4/ AUFOK or laser blood irradiation, 5/ methylurapil, 6/ deaggregants blood, 7) proteolytic enzymes, 8) diet - pureed soups, liquid cereals, kissels, fruit juices, white crackers. The infiltrate resolves in 85% of cases, usually within 7-19 days to 1.5 months. Slow resorption of infiltrates is suspicious for the presence of a tumor. Before discharge, an irrigoscopy is mandatory to exclude a tumor of the caecum.

After the disappearance of all clinical signs, the patient is discharged with a mandatory indication of the need for surgery - appendectomy 2–2.5 months after the resorption of the infiltrate.

If the infiltrate was not diagnosed before the operation and was found on the operating table, it is not advisable to remove the process - the operation ends with the introduction of drainage and antibiotics into the abdominal cavity.

Appendicular abscesses - develop in the late period more often as a result of suppuration of the appendicular infiltrate (before surgery) or delimitation of the process with peritonitis (more often after surgery). It develops 8-12 days after the onset of the disease. In 2%, a consequence of complicated forms. By localization, they are distinguished: I / ileocecal (paraappendicular), 2 / pelvic (Douglas space abscess), 3 / subhepatic, 4 / subdiaphragmatic, 5 / interintestinal. All of them are subject to surgery - opening, sanitation and drainage according to the general rules of surgery (ubi pus ibi evacuo)

General signs of abscessing - a/ worsening of the general condition, b/ increased body temperature and its hectic character, sometimes with chills, g/ increase in leukocytosis and shift of the leukocyte formula to the left, leukocyte index of intoxication.

I . Ileocecal abscess - develops in most cases with an unremoved process as a result of abscessing of the appendicular infiltrate. Signs of abscess formation, in addition to general phenomena, is an increase in the size of the infiltrate or the absence of a decrease in it. You cannot count on the appearance of fluctuations, as recommended by a number of authors!

It is opened under short-term anesthesia extraperitoneally by Pirogov's incision: outwards from McBurney's point almost at the ridge ilium, the abscess cavity is entered from the side wall, the cavity is drained, examined with a finger (possibly in the presence of fecal stones that need to be removed) and drained. The wound heals by secondary intention. The process is removed after 2-3 months. With the retrocecal location of the process, the abscess is localized retroperitoneally posteriorly - psoas abscess.

All other localizations of the abscess are usually observed after appendectomy in destructive forms with peritonitis.

2. Pelvic abscess - there is 0.2-3.2% according to Kuzin, according to the materials of our clinic - in 3.5% with gangrenous appendicitis. In addition to general phenomena, it is characterized by frequent loose stools with mucus, tenesmus, gaping of the anus or increased urination, sometimes with pain (due to the involvement of perirectal or perivesical tissue in the process).

Characteristic is the difference in temperature between the armpit and rectal 1-1.5 at 0.2-0.5 is normal), a daily rectal or vaginal examination is necessary, at which the overhanging of the arches and dense infiltrate are first determined, then softening, swaying.

Treatment. Initially, in the stage of infiltration - antibiotics, warm enemas 41-50º, douching; with abscessing - the appearance of softening - opening. Emptying the bladder with a catheter is a must! Anesthesia is general. Position on the table as on a gynecological chair. The rectum or vagina is opened with mirrors, the area of ​​softening is determined with a finger - on the anterior wall of the intestine or the posterior fornix of the vagina. Here, a puncture is made with a thick needle, and when pus is obtained, without removing the needle, the abscess is opened along the needle with a small incision, which expands bluntly, after which the cavity is washed and drained. The drainage is sutured to the skin of the anus or the labia minora.

3. Subhepatic abscess - it is opened in the region of the right hypochondrium, the existing infiltrate is preliminarily fenced off from the abdominal cavity with napkins, after which it is opened and drained.

4. Subdiaphragmatic abscess - (occurs relatively rarely - in 0.2% of cases) - accumulation of pus between the right dome of the diaphragm and the liver. The infection gets here through the lymphatic pathways of the retroperitoneal space. The most severe form of abscesses, mortality in which reaches 30-40%.

Clinic: shortness of breath, pain when breathing in the right half chest, dry cough (Troyanov's symptom). On examination - lagging of the right half of the chest in breathing, pain when tapping; percussion - high standing of the upper border of the liver and lowering of the lower border, the liver becomes accessible to palpation, swelling of the intercostal spaces, phrenicus symptom on the right. General state severe, high temperature with chills, sweats, sometimes yellowness of the skin.

With fluoroscopy- high standing and limited mobility of the right dome of the diaphragm, effusion in the sinus - "concomitant exudative pleurisy". When an abscess is formed, a horizontal level of liquid with a gas bubble (due to the presence of gas-forming forms of flora).

Treatment- surgical. Access is difficult due to the risk of infection of the pleura or abdominal cavity.

1. Extrapleural access(according to Melnikov) - along the eleventh rib with its resection, the posterior periosteum is dissected, a transitional fold of the pleura (sinus) is found, which bluntly exfoliates from top surface of the diaphragm upward, the diaphragm is dissected and the abscess is opened, which is drained.

2. Extraperitoneal (according to Clermont)- along the edge of the costal arch through all layers they reach the transverse fascia, which, together with the peritoneum, exfoliates from the lower surface of the diaphragm, after which the abscess is opened. Both of these methods are dangerous with the possibility of infection of the pleura or abdominal cavity due to the presence of infiltrate and adhesions that make it difficult to excrete.

3. transabdominal- opening the abdominal cavity in the right hypochondrium, delimiting it with napkins, followed by penetration into the abscess cavity along the outer edge of the liver.

4. Transthoracic- through the chest wall in the area of ​​10-11 intercostal space or with resection of 10-11 ribs a) simultaneous if, when reaching the pleura, it turns out to be opaque, the excursion of the lung is not visible, the sinus is sealed; a puncture is performed with a thick needle and an opening along the needle, b) two-stage- if the pleura is transparent - lung excursions are visible - the sinus is not sealed, the pleura is lubricated with alcohol and iodine, - / chemical irritation and tightly tamponed - (mechanical irritation) (1st stage) After 2-3 days, the tampon is removed and, making sure that the sinus is sealed , a puncture and opening with drainage of the abscess is performed (stage 2). In some cases, if a delay is undesirable, the opening of the abscess, the sinus is sutured to the diaphragm around a circle with a diameter of about 3 cm, with a stalk suture with an atraumatic needle, and the abscess is opened in the center of the sutured area.

5. According to Littman (see monograph),

Pylephlebitis - thrombophlebitis of the portal vein, is a consequence of the spread of the process from the veins of the mesenteric process through the mesenteric veins. It occurs in 0.015-1.35% (according to Kuzin). It is an extremely serious complication, accompanied by high, hectic temperature, repeated chills, cyanosis, and icterus of the skin. Observed sharp pains throughout the life. Subsequently - multiple liver abscesses. Usually ends with death in a few days, sometimes with sepsis. (In the clinic there were 2 cases of pylephlebitis per 3000 observations). Treatment: anticoagulants in combination with broad-spectrum antibiotics, preferably with direct injection into the portal vein system by catheterization of the umbilical vein or puncture of the spleen.

CHRONIC APPENDICITIS

As a rule, it is a consequence of an acute one, less often it develops without a previous attack.

Distinguish:I) residual or residual chronic appendicitis in the presence of one attack in history; 2) recurrent- in the presence of several seizures in history; 3) primary chronic or impregnable, arising gradually in the absence of an acute attack. Some authors exclude this possibility. Pathoanatomy - cell infiltration, scars, sclerosis of the walls, sometimes obliteration of the lumen; if the lumen at the free end remains, liquid (dropsy), mucus (mucocele) of the process can accumulate, the mesentery shortens, deforms. Macroscopically, there is a deformation of the process, adhesions with neighboring organs.

Clinic poor in symptoms, atypical: pain in the right iliac region, sometimes constant, sometimes paroxysmal, nausea, constipation, sometimes diarrhea at normal temperature and blood picture.

An objective study showed local pain in the right iliac region at the McBurney and Lanz points without protective muscle tension and peritoneal symptoms. Sometimes the symptoms of Sitkovsky, Rovsing, Obraztsov can be positive.

When making a diagnosis, the anamnesis (presence of acute attacks) is very important. In primary chronic appendicitis, the diagnosis is based on the exclusion of other possible causes of pain. Recently, great importance has been attached to the data of irrigoscopy and graphy of the large intestine - the presence of deformation of the appendix or the absence of its filling. This is regarded as direct and indirect signs of chronic appendicitis.

Differentiate chronic appendicitis is necessary from gynecological diseases, diseases of the right urinary tract, duodenal ulcer, chronic cholecystitis, spastic colitis, helminthic invasion (in children append. oxyuria), tuberculosis and cancer of the caecum.

With the established diagnosis of chronic appendicitis, the treatment is only surgical, however, long-term results after operations for chronic appendicitis are worse than after acute appendicitis (Adhesions after removal of the unchanged process are observed in 25% of patients, after destructive forms with suppuration of the abdominal cavity - in 5.5% of cases ).

Is bleeding. More often there is bleeding from the stump of the mesentery of the process, which occurs as a result of insufficiently strong ligation of the vessel supplying the process. Bleeding from this small vessel can quickly lead to massive blood loss. Quite often the picture of internal bleeding comes to light at the patient on an operating table.

No matter how insignificant bleeding into the abdominal cavity seems, it requires urgent surgical intervention. You should never hope to stop bleeding on your own. It is necessary to immediately remove all sutures from the surgical wound, if necessary, expand it, find a bleeding vessel and bandage it. If the bleeding has already stopped and the bleeding vessel cannot be detected, you need to grab the stump of the mesentery of the process with a hemostatic clamp and re-tie it at the very root with a strong ligature. The blood poured into the abdominal cavity must always be removed, since it is a breeding ground for microbes and thus can contribute to the development of peritonitis.

The vessels of the abdominal wall can also be a source of bleeding. When opening the vagina of the rectus abdominis muscle, the lower epigastric artery may be damaged. This damage may not be immediately noticed, since when the wound is diluted with hooks, the artery is compressed and does not bleed. After surgery, blood can infiltrate the tissues of the abdominal wall and enter the abdominal cavity between the peritoneal sutures.

It is quite understandable that in some patients the bleeding can stop on its own. All existing hemodynamic disturbances are gradually subsiding. However, the skin and visible mucous membranes remain pale, the hemoglobin content and the number of red blood cells in the blood are significantly reduced. When examining the abdomen, painful phenomena may not exceed the usual postoperative sensations; for percussion determination, the amount of liquid blood should be significant.

The blood which has poured out in an abdominal cavity at some patients can be resolved without the rest. Then only the presence of anemia and the appearance of jaundice as a result of resorption massive hemorrhage allow us to correctly assess the existing phenomena. However, such a favorable outcome, even with minor hemorrhage, is quite rare. If the blood accumulated in the abdominal cavity becomes infected, peritonitis develops, which is usually limited.

With more significant hemorrhage, in the absence of its delimitation and with delayed intervention, the outcome may be unfavorable.

As a complication in the postoperative course, the formation of an infiltrate in the thickness of the abdominal wall should be noted. Such infiltrates, if they occur without a pronounced inflammatory reaction, are usually the result of impregnation subcutaneous tissue blood (with insufficiently thorough hemostasis during surgery) or serous fluid. If such an infiltrate is not large, then it resolves in the coming days under the influence of thermal procedures. If, in addition to infiltration, there is rippling along the suture line, indicating the accumulation of fluid between the edges of the wound, it is necessary to remove the fluid by puncture or pass a bellied probe between the edges of the wound. The latter method is more efficient.

If the formation of an infiltrate proceeds with a temperature reaction and an increase in pain in the wound, suppuration should be assumed. In order to timely diagnose this complication, each patient whose temperature does not decrease during the first two days after surgery, and even more so if it increases, must be bandaged to control the wound. The sooner 2-3 sutures are removed to drain the pus, the more favorable the course will be. In severe infections of the abdominal wall, the wound must be opened wide and drained, removing all sutures from the skin, from the aponeurosis and from the muscles, if there is an accumulation of pus under them. In the future, wound healing occurs by secondary intention.

Sometimes, after healing, the wounds form ligature fistulas. They are characterized by small size, purulent discharge and growth granulation tissue around the fistula. After removing the ligature with anatomical tweezers or a crochet hook, the fistulas heal. It is even better to use for this a large fishing hook unbent on a flame, the tip of which is bent so that a second beard is formed.

In patients, especially with a severe process in the process and the caecum, operated on in the presence of peritonitis, an intestinal fistula may form after the operation. Fistulas can form when a lesion extends from the base of the process into the adjacent part of the caecum. If this is detected during the operation, then the affected area of ​​​​the intestine is immersed with sutures that close it for the required length with the unchanged part of the wall of the caecum. If, when the process is removed, the lesion of the intestinal wall remains unidentified, with further progression of the process, its perforation may occur, which will lead to the release of feces into the free abdominal cavity or into its area limited by adhesions or tampons.

In addition, the cause of the development of intestinal fistulas can be either damage to the intestine during surgery, or a bedsore as a result of prolonged pressure from drains and tampons, or trauma to the intestinal wall during insufficiently delicate manipulations during dressing of wounds in which intestinal loops lie open. It is unacceptable to remove pus from the surface of the intestines with gauze balls and tampons, since this can very easily cause severe damage to the intestinal wall and its perforation.

In the formation of fistulas, the toxic effect of certain antibiotics, such as tetracyclines, which can lead to severe damage to the intestinal wall, up to complete necrosis of the mucous membrane, can also play a certain role. This applies to both the large and small intestines.

The formation of an intestinal fistula with a tightly sutured abdominal wound leads to the development of peritonitis, requiring immediate intervention, consisting in a wide opening of the wound and bringing drainage and delimiting tampons to the fistula. Attempts to sew up an existing hole are justified only at the earliest possible time. If the abdominal cavity has already been drained before the formation of the fistula, diffuse peritonitis may not be due to the formation of adhesions around the tampons. With a favorable course, peritoneal phenomena are more and more limited and gradually subside completely. The wound is filled with granulations surrounding the fistula, through which the intestinal contents are released.

Fistulas small intestine, transverse colon and sigmoid, the wall of which may be flush with the skin, usually labial and require prompt closure. Fistulas of the caecum, as a rule, are tubular and can close on their own with careful washing of the fistulous tract with an indifferent fluid. Surgical closure of the fistula is indicated only when unsuccessful conservative treatment within 6-7 months.

Long-term non-healing tubular fistulas of the caecum should suggest the presence of foreign body, tuberculosis or cancer, since the removal of the process in these diseases can lead to the formation of fistulas.

Postoperative peritonitis may develop gradually. Patients do not always complain of increased pain, considering them to be an understandable phenomenon after surgery. However, the pain continues to intensify, in the right iliac region during palpation, more and more severe pain, muscle tension and other symptoms characteristic of peritoneal irritation are noted. The pulse quickens and the tongue begins to dry. Sometimes the first and at first, as if the only sign of peritonitis may be vomiting or regurgitation, sometimes - increasing paresis of the intestines. Gradually, the abdomen begins to swell, the gases do not go away, peristaltic noises are not heard, and in the future the picture develops in exactly the same way as with appendicular peritonitis in non-operated patients. In some patients, only an increase in heart rate, which does not correspond to temperature, is noted at first.

Signs of peritonitis can gradually come to light during the first days after the operation, growing very slowly. But sometimes they appear quickly, and in the next few hours a picture of diffuse peritonitis develops. The development of postoperative peritonitis is always an indication for urgent relaparotomy and elimination of the source of infection. The last is either the stump of the appendix that has opened due to the failure of the sutures, or a perforation in the intestinal wall. If the intervention is made early, it is possible to close the stump or perforation with sutures. In the later stages, this is not possible due to the fact that the sutures placed on the inflamed tissues are cut through, then it is necessary to confine ourselves to the supply of drainage and tampons.

When no local cause is identified, it is necessary to consider the development of peritonitis as the result of the progression of the diffuse inflammation of the peritoneum that was present before the first operation and proceed in the same way as described in the section on the treatment of peritonitis that developed before the operation.

With peritonitis that developed after surgery, the source of infection should be in the area former operation. Therefore, relaparotomy must be performed by removing all sutures from the surgical wound and opening it wide. If the source of infection is located elsewhere and the development of peritonitis is not associated with the operation, but is due to some other disease, the choice of access should be determined by the localization of the painful focus. Antibiotic therapy and other measures to combat peritonitis should be more active.

With postoperative peritonitis, as well as with peritonitis that developed before surgery, the formation of limited abscesses can be observed in the abdominal cavity. Most often, the accumulation of pus occurs in the Douglas space. The formation of such an abscess, as a rule, is accompanied by a temperature reaction and other general manifestations of a septic nature. Symptoms characteristic of this complication are frequent urge to defecate, loose, loose stools with a large admixture of mucus, tenesmus and gaping anus due to involvement in inflammatory process rectal wall and sphincter infiltration. When examining the rectum, a finger is noted in varying degrees pronounced protrusion of the anterior wall, where clear swaying is often determined.

It should be remembered that such phenomena of irritation of the rectum can develop very late, when the abscess has already reached a significant size. Therefore, with a non-smooth course of the postoperative period, it is necessary to systematically perform a digital examination of the rectum, bearing in mind that Douglas abscess is the most common of all severe intra-abdominal complications observed after surgery for appendicitis. It is opened through the rectum or (in women) through the vagina, emptying the purulent accumulation through the posterior fornix.

Abscess formation in other parts of the abdominal cavity is less common. Interintestinal abscesses at first can be shown only by the increasing septic phenomena. Sometimes it is possible to detect an infiltrate in the abdomen if the abscess is parietal. If it is not adjacent to the abdominal wall, then it is possible to probe it only when the swelling of the intestine and the tension of the abdominal muscles decrease. Abscesses must be opened with an incision corresponding to its location.

Subdiaphragmatic abscesses after appendectomy are extremely rare. A subdiaphragmatic abscess should be opened extraperitoneally. To do this, when the abscess is located in the posterior part of the subdiaphragmatic space, the patient is placed on a roller, as for a kidney operation. The incision is made along the XII rib, which is resected without damaging the pleura. The latter is carefully pushed up. Further, parallel to the course of the ribs, all tissues are dissected up to the preperitoneal tissue. Gradually separating it, together with the peritoneum, from the lower surface of the diaphragm, they penetrate with their hand between the posterolateral surface of the liver and the diaphragm into the subdiaphragmatic space and, moving their fingers to the level of the abscess, open it, breaking through the diaphragmatic peritoneum, which does not offer much resistance. The purulent cavity is drained with a rubber tube.

Pylephlebitis (thrombophlebitis of the portal vein branches) is a very severe septic complication. Pylephlebitis is manifested by chills with an increase in body temperature up to 40-41 ° C and with its sharp drops, pouring sweat, vomiting, and sometimes diarrhea. The appearance of jaundice is characteristic, which is less pronounced and appears later than jaundice with cholangitis. When examining the abdomen, mild peritoneal phenomena, some tension in the muscles of the abdominal wall are noted. The liver is enlarged and painful.

In the treatment of pylephlebitis, first of all, it is necessary to take all measures to eliminate the source of infection - emptying possible accumulations of pus in the abdominal cavity and in the retroperitoneal space, ensuring a good outflow through wide drainage. Vigorous antibiotic treatment. With the formation of abscesses in the liver - their opening.

Another rare complication of the postoperative period should be noted - acute obstruction intestines. In addition to dynamic obstruction of the intestines as a result of their paresis with peritonitis.

In addition, in the coming days after an appendectomy, mechanical obstruction may develop as a result of compression of the intestinal loops in the inflammatory infiltrate, their kinking by adhesions, and infringement by strands formed during fusion with each other. abdominal organs etc. Obstruction may develop soon after the operation, when inflammation in the abdominal cavity has not subsided, or at a later date, when it already seemed that a complete recovery had come.

Clinically, the development of obstruction is manifested by all its characteristic symptoms. The diagnosis of this complication can be very difficult, especially when the obstruction develops early in the first days after surgery. Then the existing phenomena are regarded as the result of postoperative paresis of the intestines, and the correct diagnosis may be delayed because of this. In later periods, obstruction develops more typically. The sudden appearance of "among full health" cramping pains in the abdomen, local bloating, vomiting and other signs of intestinal obstruction greatly facilitate the diagnosis.

With the ineffectiveness of conservative measures, the treatment of mechanical obstruction should be surgical.

In case of obturation obstruction caused by the bending of the intestines as a result of their constriction by adhesions, or when they are compressed in the infiltrate, adhesions are separated, if this is easily done. If this is difficult and if it is associated with trauma to the inflamed and easily vulnerable intestinal loops, a bypass inter-intestinal anastomosis is made or limited to the position of the fistula.

After an appendectomy, other, generally characteristic postoperative period complications from both respiratory organs and from other organs and systems. This is especially true for elderly patients.

Long-term results surgical treatment acute appendicitis in the vast majority of patients are good. Rarely observed poor results are mostly due to the presence of some other disease that the patient had before the attack of appendicitis or arose after the operation. Much less often, the poor condition of patients is explained by the development of postoperative adhesions in the abdominal cavity.