Appendicular abscess – the delimited site of a purulent inflammation of a peritoneum which arose owing to destructive changes of a worm-shaped (blind person) shoot. Appendicular abscess is shown for 5-6 days after clinic of an acute appendicitis by a sharp exacerbation of fever and a pain syndrome, tachycardia, intoxication, the dispepsichesky phenomena. The diagnosis of appendicular abscess is established after studying of the anamnesis, performing the general blood test, ultrasonography and a X-ray analysis of abdominal organs. At appendicular abscess the emergency operation - opening and drainage of an abscess is shown, antibacterial and dezintoksikatsionny therapy is appointed; in the subsequent the appendektomiya is made.
Appendicular abscess is a serious and dangerous complication of a destructive acute appendicitis - its flegmonozny, apostematozny, flegmonozno-ulcer or gangrenous forms. Appendicular abscess can arise in the late period of a disease before operation at suppuration of appendicular infiltrate or in the postoperative period owing to an otgranicheniye of inflammatory process at peritonitis. Frequency of development of appendicular abscess at an acute appendicitis makes 1-3% of cases. The operational gastroenterology (the general surgery) is engaged in treatment of appendicular abscess.
Reasons of appendicular abscess
Appendicular abscess is usually caused by association of colibacillus, neklostridialny anaerobic microflora and cocci. Suppuration of appendicular infiltrate with development of abscess is promoted by the late request of the patient for medical care, untimely diagnosis of an acute appendicitis. After an appendektomiya decrease in immunological reactivity of an organism, high virulence of microorganisms and their resistance to the applied antibiotics, sometimes - defects of the operational equipment can lead to development of appendicular abscess.
Formation of appendicular infiltrate usually happens for 2-3 day after emergence of the first symptoms of an acute appendicitis. The inflammation of an appendix does not extend to all abdominal cavity thanks to protective physiological function of a peritoneum. Otgranicheny primary inflammatory center in a blind shoot from surrounding bodies happens due to formation of fibrinozny exudate, development of adhesive process and merging of the shoot to loops of a large intestine, the site of a blind gut, a big epiploon and a parietal peritoneum.
The created appendicular infiltrate at attenuation of an inflammation in a blind shoot (for example, after conservative therapy) can gradually resolve; at destruction of an appendix and spread of an infection out of its limits – to suppurate with formation of abscess. The arrangement of appendicular abscess in an abdominal cavity depends on localization of a blind shoot: to a thicket - in the right podvzdoshny pole, there can also be a retrotsekalny (retroperitoneal) or pelvic arrangement of an abscess.
Symptoms of appendicular abscess
The beginning of a disease is shown by clinic of an acute appendicitis with a typical pain syndrome and temperature increase of a body. In 2-3 days from the beginning of an attack as a result of an inflammation otgranicheniye in a blind shoot the sharp phenomena abate, pain gains the stupid, pulling character, temperature decreases, normalization of the general state is noted. At a palpation the belly wall is not strained, participates in the respiratory act, in the right podvzdoshny area insignificant morbidity and existence of inactive consolidation without accurate contours – appendicular infiltrate is defined.
Development of appendicular abscess for 5–6 days of a disease is shown by deterioration in the general condition of the patient, sharp rises in temperature (especially in the evening), a fever and perspiration, tachycardia, intoxication phenomena, small appetite, an intensive pain syndrome of the pulsing character in the right podvzdoshny area or in the bottom of a stomach, increase of pains at the movement, cough, walking.
At a palpation ill-defined signs of irritation of a peritoneum are noted: the belly wall is strained, sharply painful in the place of localization of appendicular abscess (a positive symptom of Shchetkin-Blyumberg), lags behind at breath, in the right lower quadrant painful tugoelastichny education, sometimes with a softening in the center and fluctuation is probed.
Language is laid over by a dense raid, the dispepsichesky phenomena are observed: violation of a chair, vomiting, abdominal distension; at an interintestinal arrangement of appendicular abscess - the phenomena of partial intestinal impassability, at pelvic - the speeded-up desires on an urination and depletion of intestines, pain at defecation, release of slime from an anus.
At break of appendicular abscess in intestines improvement of health, reduction of pains, decrease in temperature, emergence of a liquid chair with a large amount of fetid pus is noted. Opening of appendicular abscess in an abdominal cavity leads to development of peritonitis, is followed by a septikopiyemiya – emergence of the secondary purulent centers of various localization, increase of symptoms of intoxication, tachycardia, fever.
Diagnosis of appendicular abscess
In recognition of appendicular abscess data of the anamnesis, the general survey and results of special methods of diagnostics are important. At a vaginal or rectal manual research sometimes it is possible to propalpirovat the lower pole of abscess as painful protrusion of the arch of a vagina or a forward wall of a rectum. Results of the general blood test at appendicular abscess show increase of a leykotsitoz with shift of a leykotsitarny formula to the left, significant increase in SOE.
Ultrasonography of an abdominal cavity is carried out for specification of localization and the size of appendicular abscess, identification of a congestion of liquid in the field of an inflammation. At a survey X-ray analysis of abdominal organs homogeneous blackout in podvzdoshny area on the right and the small shift of loops of intestines towards the median line is defined; in a zone of appendicular abscess the level of liquid and a congestion of gases in intestines comes to light (). Appendicular abscess it is necessary to differentiate with reabrupt ovary cysts, the poured purulent peritonitis, a tumor of a blind gut.
Treatment of an appendicular abtsess
At a stage of appendicular infiltrate the emergency operation for an acute appendicitis is contraindicated, he is treated conservatively in the conditions of a hospital: the high bed rest, in the first 2-3 days cold is appointed to a stomach, then – heat, the sparing diet, antibiotic treatment. Laxative and narcotic medicines are excluded. Sometimes for the purpose of a rassasyvaniye of infiltrate paranefralny novokainovy blockade are appointed. At a full rassasyvaniye of appendicular infiltrate in 1-2 months carry out a planned appendektomiya as repeated attacks of an acute appendicitis, development of infiltrate, abscess and heavy complications are possible.
Treatment of the created appendicular abscess – quick: the abscess is opened and drained, access depends on localization of an abscess. In certain cases at appendicular abscess its chreskozhny drainage under control of ultrasonography with use of local anesthesia can be carried out.
Expeditious opening and depletion of an abscess is carried out under the general anesthesia right-hand side vnebryushinny access. At pelvic appendicular abscess it is opened at men through a rectum, women – through the back arch have vaginas with a preliminary trial puncture. Purulent contents of appendicular abscess are aspirirut or deleted with tampons, the cavity is washed out antiseptics and drained, using dvukhprosvetny tubes. Removal of a blind shoot is preferable, but if there is no such opportunity, it is not deleted because of danger of distribution of pus to a free abdominal cavity, by traumatizing the inflamed intestinal wall forming a wall of appendicular abscess.
In the postoperative period careful leaving for drenazhy, washing and aspiration of contents of a cavity, antibiotic treatment (a combination of aminoglycosides to metronidazole), the dezintoksikatsionny and all-strengthening therapy is carried out. The drainage remains until from a wound purulent contents separate. After removal of a drainage tube the wound heals a secondary tension. If the appendektomiya was not made, it is carried out according to plan in 1-2 months after subsiding of an inflammation.
Forecast and prevention of appendicular abscess
Appendicular abscess can spontaneously be opened in a gut gleam, an abdominal cavity or zabryushinny space, sometimes in a bladder or a vagina, is very rare through a belly wall outside. The poured purulent peritonitis, zabryushinny or pelvic phlegmons, purulent paracolitis and paranephrite, liver abscess, poddiafragmalny abscess, purulent thrombophlebitis of a vorotny vein, adhesive intestinal impassability, infections of uric ways, fistulas of a belly wall occur among complications of appendicular abscess.
Forecast of appendicular abscess serious; the outcome of a disease is defined by timeliness and adequacy of surgery. Prevention of appendicular abscess consists in early recognition of an acute appendicitis and carrying out an appendektomiya in the first 2 days.