Acute appendicitis – sharp nonspecific process of an inflammation of a worm-shaped shoot - additional formation of a blind gut. The clinic of an acute appendicitis demonstrates from emergence of dull ache in nadchrevny area which then is displaced to the right podvzdoshny area; nausea, vomiting are noted, subfebrilitt. Diagnosis of an acute appendicitis is based on identification of characteristic symptoms at a research of a stomach, changes in peripheral blood, ultrasonography; at the same time other diseases of an abdominal cavity and small pelvis are excluded. At an acute appendicitis the appendektomiya – removal of the changed worm-shaped shoot is carried out.
The acute appendicitis is the most frequent surgical disease to which share in operational gastroenterology more than 80% fall. The acute appendicitis meets at persons at the age of 20-40 years more often though can also arise at children's or advanced age. Despite achievements in the field of diagnostics and improvement of surgical methods of treatment, postoperative complications at an acute appendicitis make 5-9%, and a lethality – 0,1-0,3%.
Reasons of an acute appendicitis
In a question of the reasons of development of an acute appendicitis still there is no consensus. Among etiologichesky theories of an acute appendicitis are discussed mechanical, infectious, angioneurotic, allergic, immunological, etc. It is considered that the mechanical blockade of a gleam of a worm-shaped shoot caused by a kalovy stone, a foreign matter, parasites, giperplaziy lymphoid fabric acts as the leading factor of an inflammation of an appendix (appendicitis). It leads to a congestion in a shoot of slime, activization of bacterial flora, to an inflammation of walls of an appendix, vascular thrombosis.
According to the infectious theory, various infectious diseases – , parasitic infections, tuberculosis, , a typhoid, etc. can initiate development of an acute appendicitis. Supporters of the angioneurotic theory hold the opinion on primacy of the trophic violations in a wall of a worm-shaped shoot connected with violation of its innervation.
To some extent the alimentary factor can promote development of an acute appendicitis. It is known that the use of mainly meat food promotes violation motor functions of intestines, tendencies to locks that, in turn, contributes to development of an acute appendicitis. Also carry an intestinal dysbiosis, decrease in resistance of an organism, some types of an arrangement of an appendix in relation to a blind gut to adverse background factors.
The acute appendicitis is caused by nonspecific microbic flora: anaerobic nesporoobrazuyushchy microorganisms (bakteroida and anaerobic cocci – in 90% of cases), aerobyony activators (colibacillus, enterokokka, klebsiyelly, etc. - 6-8%), is more rare – viruses, the protozoa who are present at a shoot. The main mechanism of infection of a worm-shaped shoot – enterogenny; limfogenny and hematogenic ways of penetration of an infection do not play the leading role in pathogenesis of an acute appendicitis.
Classification of an acute appendicitis
The acute appendicitis can proceed in a simple (catarrhal) or destructive form (flegmonozny, apostematozny, flegmonozno-ulcer, gangrenous).
The catarrhal form of an acute appendicitis (catarrhal appendicitis) is characterized by frustration lympho-and blood circulations in a shoot wall, its hypostasis, development of cone-shaped focuses of an ekssudativny inflammation (primary affects). Macroscopically the appendix looks bulked up and full-blooded, a serous cover – dim. Catarrhal changes can have reversible character; otherwise, at their progressing, the simple acute appendicitis passes into destructive.
By the end of the first days from the beginning of an acute catarrhal inflammation leykotsitarny infiltration extends to all layers of a wall of an appendix that corresponds to a flegmonozny stage of an acute appendicitis. Walls of a shoot are thickened, in its gleam pus is formed, the bryzheyka becomes edematous and hyperemic, in an abdominal cavity appears serous or a serous and purulent exudate. The diffusion purulent inflammation of an appendix with multiple microabscesses is regarded as an apostematozny acute appendicitis. At ulcerations of walls of a worm-shaped shoot flegmonozno-ulcer appendicitis which at increase it is purulent develops - destructive changes passes into gangrenous.
Symptoms of an acute appendicitis
In development of an acute appendicitis allocate an early stage (till 12 o'clock), a stage of destructive changes (from 12 hours to 2 days) and a stage of complications (of 48 o'clock). Clinical displays of an acute appendicitis demonstrate suddenly, without any harbingers or prodromalny signs. In some cases several hours prior to development of clinic of an acute appendicitis the nonspecific phenomena – weakness, deterioration in health, appetite loss can be noted. The pain syndrome and dispepsichesky violations (nausea, vomiting, a delay of gases and a chair) are typical for a stage of the developed clinical displays of an acute appendicitis.
Belly-ache at an acute appendicitis – the earliest and enduring symptom. In an initial stage pain is localized in an epigastriya or okolopupochny area, has not intensive, stupid character. At cough, sharp change of position of a trunk pain amplifies. In several hours from emergence pain is displaced to the right podvzdoshny area and can be characterized by patients as pulling, pricking, burning down, cutting, sharp, stupid. Depending on an arrangement of a worm-shaped shoot of pain can irradiate in a navel, a waist, a groin, subspoon area.
At an acute appendicitis digestion violation symptoms are, as a rule, noted: nausea, single vomiting, a meteorizm, a lock, sometimes – a liquid chair. Body temperature usually increases to subfebrilny values.
In a stage of destructive changes the pain syndrome amplifies that considerably is reflected in a condition of patients. Body temperature increases to 38,5-390C, increases intoxications, tachycardia to 130-140 is noted. in min. In certain cases paradoxical reaction when pains, on the contrary, decrease can be observed or disappear. It is quite terrible sign testifying to shoot gangrene.
Destructive forms of an acute appendicitis often are followed by complications – development of appendicular abscess, a periappenditsit, mezenteriolit, abscess of an abdominal cavity, perforation of a wall of a shoot and peritonitis, sepsis.
Diagnosis of an acute appendicitis
In the course of diagnostics the acute appendicitis needs to be differentiated from gastritis, stomach ulcer of a stomach or 12 perstny guts, sharp cholecystitis, pancreatitis, an urolithic disease, ZhKB, extra-uterine pregnancy, an adneksit, a sharp orkhoepididimit, sharp cystitis, etc. the diseases proceeding with abdominal pains.
A number of abdominal symptoms is characteristic of an acute appendicitis: lag of the right departments of a stomach at breath (Ivanov's symptom), tension of muscles of a forward belly wall, a symptom of irritation of a peritoneum (Shchetkin-Blyumberg), morbidity in the right podvzdoshny area at percussion (Razdolsky's symptom), strengthening of pain in situation on the left side (Sitkovsky's symptom, Bartomye-Michelson), etc. Changes in a leykotsitarny blood count accrue according to stages of an acute appendicitis – from 10-12Õ109/l at a catarrhal inflammation to 14-18Õ109/l above – at is purulent - destructive forms.
For the purpose of differential diagnostics the rectal or vaginal research is conducted. For an exception of other sharp pathology of a stomach ultrasonography of abdominal organs which also finds increase and a thickening of a shoot, existence of an exudate in an abdominal cavity is carried out. At not clear clinical laboratory picture resort to carrying out a diagnostic laparoscopy.
Treatment of an acute appendicitis
At an acute appendicitis earlier removal of the inflamed worm-shaped shoot – an appendektomiya is shown. In typical cases of an acute appendicitis access to a worm-shaped shoot according to Volkovichu-Dyakonov – a slanting section in the right podvzdoshny pole is used.
In diagnostic not clear situations pararectal access on Lenandera at which the operational section passes parallel to the outer edge of the right direct muscle above and below a navel is used. Resort to an average and median or lower median laparotomy in those cases if the course of an acute appendicitis was complicated by peritonitis.
The forecast at an acute appendicitis
The timely request for medical care and early surgical intervention are the key to a favorable outcome of an acute appendicitis. Return to usual physical and labor activity is usually allowed in 3 weeks after an appendektomiya.
In case of development of complications of an acute appendicitis (an appendicular inyofiltrat, local abscesses in an abdominal cavity - the tazoyovy, interintestinal, poddiafragmaljny, poured peritonitis, a pileflebit, adhesive intestinal impassability, etc.) the forecast serious.