APPENDICITIS

APPENDICITE is an inflammation of the appendectomy of the cecum, the most common disease among acute diseases of the abdominal cavity. It accounts for up to 70% of cases of an acute abdomen. On average, every year out of every 250 people one develops acute appendicitis. Mortality from acute appendicitis is 0.1% with an unperforated process and up to 3% with perforation, and the mortality rate among those hospitalized on the 1st day is 5-10 times lower than among patients admitted to the hospital at a later date. These data underscore the need for early diagnosis of this disease: in most cases, the death of patients could be prevented provided that a timely diagnosis and an immediate operation were undertaken.

In the pathogenesis of acute appendicitis, the leading role is played by occlusion of the lumen of the appendix (the cause may be the formation of stool stones in its lumen, the ingress of foreign bodies into its outgrowth, its inflection) or ulceration of its mucous membrane (possibly of viral origin).

Clinical picture . The main reason for urging a patient with acute appendicitis to seek medical help is a sudden, prolonged abdominal pain that lasts 4-6 hours. It has a diffuse character, but in the first hours, patients especially often localize it in the epigastric region (the so-called epigastric phase). In the following hours, independent pains begin to localize in the right iliac region (a symptom of the movement of Kocher-Volkovich pains). Usually they are of a permanent nature and, as a rule, are moderately expressed. The pain with appendicitis can be stronger, sometimes weaker, sometimes patient patients call it insignificant, but it does not stop even for a minute. Sudden and sharp pain intensification, as a rule, is an extremely disturbing sign and indicates the perforation of the appendix. Sharp pains, accompanied by anxiety of the patients, occur in forms of acute appendicitis characterized by the formation of a closed purulent cavity in the appendix (the so-called empyema of the appendage). As with any, even local, peritonitis, pain in acute appendicitis is enhanced by walking, movements, and also in the position on the left side. Patients cautiously step, usually holding hands with the right ileal region. The characteristic shuddering of the abdomen immediately attracts attention. Stihanie pain in acute appendicitis does not always indicate a well-being. The calm can be caused by the progressive gangrene of the appendage and the necrosis of the sensitive nerve endings of the serous cover of the appendage and its mesentery. Pain syndrome with acute appendicitis has its own peculiarities in the second half of pregnancy: it is less pronounced and localized higher than usual (due to the displacement of the appendix up and behind the enlarged uterus).

Typical loss of appetite, in about half the cases, there is nausea and vomiting once in the first hours of the disease. Repeated vomiting of gastric contents or bile in acute appendicitis indicates a progression of peritonitis. Often there is a delay in the stool. Constipation is a consequence of the paresis of the intestine, characteristic of every peritonitis. Stool retention, sometimes taken for the cause of the disease, deceives the patient, his relatives, and often the health care workers, which entails the use of unnecessary and harmful measures aimed at removing the contents of the intestine (enemas and laxatives). Dysuric dysuria can be noted in the retro-calculous appendix.

When examining the abdomen reveals a picture of local peritonitis in the right ileal region. It consists of muscle resistance and local soreness in palpation in the right iliac region (these symptoms are absent only when the appendix is ​​located behind the caecum or in the pelvic cavity). Expressed also the symptoms of local irritation of the peritoneum (symptom of Schetkina-Blumberg and percussion soreness of the anterior abdominal wall in the iliac region to the right). With effleurage, even cautious, patients notice pain in the right iliac region due to concussion of the inflamed peritoneum (Razdolsky's symptom). Any pathognomonic, i.e., characteristic only for acute appendicitis, does not exist objective symptoms. In most cases, the symptoms of local pronounced peritonitis in the right ileal region are a manifestation of acute appendicitis.

The degree of muscular resistance of the anterior abdominal wall with acute appendicitis can vary considerably. It can be very poorly expressed in old people with flabby muscles, as well as in women who have recently undergone childbirth, but a close examination almost always reveals some degree of local muscular protection. Additional signs of acute appendicitis:

• A symptom of the roving - soreness in the right iliac region with jerking of the fingers in the left iliac region (due to the movement of gases through the large intestine);

• Symptom Sitkovsky - increased pain in the position on the left side (due to the displacement of the cecum and appendix and the tension of the inflamed peritoneum);

• A symptom of Bartome-Michelson - an increase in soreness in palpation in the position on the left side;

• The symptom of Voskresensky is soreness in the right ileal region when the arm moves from the epigastrium to the right ileal region through a strained shirt;

• Symptom Obraztsova - increased soreness when lifting a straightened right leg in a supine position.

  
  

  With the exception of rare and very rapidly progressing so-called hypertoxic forms of acute appendicitis, the general state of patients in the first hours is disrupted comparatively little and almost always remains satisfactory. The temperature is usually slightly elevated, rarely reaches and even more rarely exceeds 38 ° C and higher figures, sometimes remains within normal limits. In the blood there is a moderate increase in the number of leukocytes to 10 000-12 000, less often to 15 000 in 1 μl, with a shift of the formula to the left (the appearance of an increased number of bacilli-nuclear leukocytes).

  Thus, the diagnosis of acute appendicitis is based on a characteristic clinical picture, which in typical cases includes pain, first localized in the epigastric region, moving after the appearance of nausea and vomiting in the right iliac region) and local signs of peritoneal irritation in the right ileal region. However, not always acute appendicitis occurs in a typical form. The main cause of atypical flow is the atypical location of the appendix, mainly the pelvic process (in the cavity of the small pelvis) or retro-intestinal (behind the cecum). Pelvic and retro-calcane appendicitis are characterized by the most severe course, gangrenous and perforated forms are much more frequent, they are characterized by a much greater lethality. This is not because the anomalous location of the appendix is ​​predisposed to a more severe course of the inflammatory process, but only because pelvic and retro-calcane appendicitis are often recognized late - even with severe complications (peritonitis, retroperitoneal phlegmon).

  A characteristic feature of pelvic appendicitis is the emergence of dysuric disorders (rapid, with a sharp urination), frequent loose stools, sometimes with tenesmus. These symptoms are caused by the transition of the inflammatory process from the vermiform appendage hanging down into the small pelvis to the wall of the bladder or rectum. They are the cause of frequent diagnostic errors, when instead of acute appendicitis, gynecological pathology, cystitis , and, most often, food-borne disease are assumed. Difficulties in diagnosis are exacerbated by the much less pronounced and sometimes completely absent muscular protection of the anterior abdominal wall with pelvic appendicitis. In these cases, rectal is often the decisive factor, and in women it is also a vaginal examination that allows one to note the sharp tenderness of the pelvic peritoneum, which is not characteristic for the noted diseases, and in later stages to reveal infiltration around the inflamed appendix.

  Even more difficult is the recognition of retro-calcane appendicitis, in which often at first prevail common phenomena (fever, headache , vomiting), and the local symptoms are not very pronounced. In these cases, soreness is often marked significantly lateral to the right iliac region and is revealed in the bimanual (with two hands) abdominal-lumbar examination in the position of the patient on the left side. The special responsibility for the recognition of these forms of acute appendicitis lies with the medical worker, whom the patient addresses during the first hours of the illness, when, as a rule, a careful collection of an anamnesis and a thorough objective examination make it possible to recognize acute appendicitis with atypical localization of the appendage, or at least to suspect it . With the further development of the disease, when the pain often subsides, general phenomena prevail and complications arise, its recognition becomes more and more difficult.

  Complications - mesenteriolitis (inflammation of the mesentery of the appendix), infiltration (can develop on the 3rd-4th day of the disease when the inflammation is distinguished), abscess (manifested by an increase in infiltrate in size and the appearance of hectic fever), peritonitis (develops immediately after a pain attack or For 3 - 4 days due to gangrene or perforation of the process), sepsis .

  Differential diagnosis is performed with right-sided renal colic (it is characterized by irradiation of pain in the genitals, urethra, and dysuria); In women - with adnexitis and ectopic pregnancy; With acute cholecystitis (it is characterized by the irradiation of pain in the right shoulder or shoulder blade, frenicus syndrome); With acute pancreatitis, intestinal obstruction. Since appendicitis, accompanied by pain in the epigastrium, causes vomiting , and patients indicate a possibly poor quality of the food, the patient is often suspected of acute gastritis, food poisoning, rinsing the stomach, giving laxatives, putting an enema, that is, carrying out activities useless, and Sometimes contraindicated. Between attentive examination of the patient it is already possible in the first hours to reveal a limited strain of muscles and local soreness in palpation in the right iliac region.

  Treatment of all forms of acute appendicitis is only prompt. Patients with a diagnosis of acute appendicitis (or suspected of this disease) need immediate hospitalization in the surgical department, with maximum rest when transported in prone position. Strongly contra-indicated enemas and laxatives, enhancing peristalsis. Emergency care at the prehospital stage is reduced to the appointment of bed rest and the prohibition of water and food intake.

  With promptly conducted operative treatment. The prognosis is favorable, the work capacity of the patients is restored 3 to 4 weeks after the operation.