Appendicitis – sharp, is more rare a chronic form of an inflammation of an appendage of a blind gut – an appendix or a worm-shaped shoot. Depending on a form appendicitis can proceed with pains in the right podvzdoshny area of various expressiveness, digestion violation (nausea, vomiting, a delay of a chair and gases) raised by body temperature. At recognition of appendicitis lean on positive diagnostic symptoms (Sitkovsky, Bartomye — Michelson, Blyumberg — Shchetkina), data of a manual research of a rectum and a vaginal research, the developed clinical blood test. At appendicitis surgical tactics (appendektomiya) is shown.
Appendicitis is one of the most widespread surgical pathologies of an abdominal cavity to which share 89,1% fall. Appendicitis occurs at persons of both sexes and any age; the peak of incidence is the share of age from 10 to 30 years. The inflammation of a worm-shaped shoot develops approximately at 5 people from 1000 a year. Treatment of appendicitis is engaged abdominal surgery (operational gastroenterology).
The appendix – the rudimentary appendage of a blind gut having the form of the narrow extended tube which distalny end terminates blindly, proximal - is reported with a cavity of a blind gut by means of an opening of a funneled form. The wall of a worm-shaped shoot is presented by four layers: mucous, submucous, muscular and serous. Length of a shoot makes from 5 to 15 cm, thickness – 7-10 mm. The appendix has own bryzheyka holding it and providing relative mobility of a shoot.
The functional purpose of a worm-shaped shoot is up to the end not clear, however is proved that the appendix performs sekretorny, endocrine, barrier functions, and also takes part in maintenance of intestinal microflora and formation of immune reactions.
Classification of appendicitis
Distinguish two main forms of appendicitis – sharp and chronic, each of which has several kliniko-morphological options. During an acute appendicitis allocate simple (catarrhal) and destructive forms (flegmonozny, flegmonozno-ulcer, apostematozny, gangrenous appendicitis). Catarrhal appendicitis is characterized by signs of disorder of blood circulation and a limfoobrashcheniye in a shoot, development of focuses of an ekssudativno-purulent inflammation in a mucous layer. The appendix bulks up, its serous cover becomes full-blooded.
Progressing of a catarrhal inflammation leads to acute purulent appendicitis. In 24 hours after the beginning of an inflammation leykotsitarny infiltration extends to all thickness of a wall of an appendix that is regarded as flegmonozny appendicitis. At this form the wall of a shoot is thickened, the bryzheyka is hyperemic and edematous, from a gleam of an appendix the purulent secret is allocated.
If at a diffusion inflammation multiple microabscesses are formed, apostematozny appendicitis develops; at ulcerations of mucous – flegmonozno-ulcer appendicitis. Further progressing of destructive processes leads to development of gangrenous appendicitis. Involvement in purulent process of the fabrics surrounding a worm-shaped shoot is followed by development of a periappenditsit; and its own bryzheyka – development of a mezenteriolit. The perforation of a shoot bringing to the poured or delimited peritonitis (appendicular abscess) belongs to complications sharp (is more often flegmonozno-ulcer) appendicitis.
Among forms of chronic appendicitis distinguish residual, primary and chronic and recidivous. The course of chronic appendicitis is characterized by atrophic and sclerous processes in a worm-shaped shoot, and also inflammatory and destructive changes with the subsequent growth of granulyatsionny fabric in a gleam and a wall of an appendix, formation of solderings between a serous cover and surrounding fabrics. At a congestion in a gleam of a shoot of serous liquid the cyst is formed.
The polymicrobic flora presented by colibacillus, stafilokokka, enterokokka, streptococci, anaerobe bacterias, as a rule, takes part in development of appendicitis. Activators get to an appendix wall in the enterogenny way, i.e. from its gleam.
Conditions for development of appendicitis arise at stagnation of intestinal contents in a worm-shaped shoot owing to its excess, existence in a gleam of foreign matters, kalovy stones, a giperplaziya of lymphoid fabric. Mechanical blockade of a gleam of a shoot leads to increase in vnutriprosvetny pressure, disorder of blood circulation in an appendix wall that is followed by decrease in local immunity, activization of gnoyerodny bacteria and their introduction in a mucous membrane.
The certain role contributing to development of appendicitis is played by character of food and feature of an arrangement of a shoot. It is known that at the plentiful use of meat food and tendency to locks in intestinal contents the excess quantity of products of disintegration of protein collects that creates a favorable environment for reproduction of pathogenic flora. Except the mechanical reasons, can lead infectious and parasitic diseases to development of appendicitis – , a typhoid, , intestines tuberculosis, etc.
Higher risk of development of appendicitis exists at pregnant women that is connected with increase in a uterus and shift of a blind gut and worm-shaped shoot. Besides, as the contributing factors to development of appendicitis in pregnant women locks, reorganization of immune system, change of blood supply of pelvic bodies can serve.
At typical clinic of an acute appendicitis are noted pain in podvzdoshny area on the right, the expressed local and general reaction. The painful attack at an acute appendicitis, as a rule, develops suddenly. At first pain has poured character or is mainly localized in an epigastriya, in okolopupochny area. Usually in several hours pain concentrates in the right podvzdoshny area; at an atypical arrangement of an appendix it can be felt in the right podreberye, in a waist, a basin, over a pubis. The pain syndrome at an acute appendicitis is expressed constantly, amplifies at a tussiculation or laughter; decreases in a prone position on the right side.
Signs of disorder of digestion belong to characteristic early displays of appendicitis: nausea, vomiting, delay of a chair and gases, diarrhea. It is noted subfebrilitt, tachycardia to 90-100 . in min. Intoxication is most expressed at destructive forms of appendicitis. The course of appendicitis can be complicated by formation of abscesses of an abdominal cavity – appendicular, poddiafragmalny, interintestinal, a duglasova of space. Sometimes thrombophlebitis of podvzdoshny or pelvic veins develops that can be the reason of TELA.
The originality the clinic of appendicitis at children has, the elderly people, pregnant, at patients with atypical localization of a worm-shaped shoot. At children of early age at an acute appendicitis the general symptomatology inherent in many children's infections prevails: febrilny temperature, diarrhea, repeated vomiting. The child becomes low-active, whimsical, sluggish; at increase of a pain syndrome the uneasy behavior can be observed.
At elderly patients the clinic of appendicitis is usually erased. The disease quite often proceeds areaktivno, even at destructive forms of appendicitis. Body temperature can not increase, pains in a gipogastriya are expressed slightly, pulse within norm, symptoms of irritation of a peritoneum weak, small. At senior citizens, especially in the presence of the palpated infiltrate in podvzdoshny area, differential diagnosis of appendicitis with a tumor of a blind gut is necessary what requires carrying out a kolonoskopiya or irrigoskopiya.
At appendicitis at pregnant women of pain can be localized much above podvzdoshny area that is explained by a pushing off of a blind gut up the increased uterus. Tension of muscles of a stomach and other symptoms of appendicitis can be poorly expressed. The acute appendicitis at pregnant women should be distinguished from threat of spontaneous termination of pregnancy and premature birth.
Chronic appendicitis proceeds with the aching dull aches in the right podvzdoshny area which can periodically amplify, especially at a physical tension. Digestion violation symptoms (persistent locks or ponosa), feelings of discomfort and weight in epigastralny area are characteristic of clinic of appendicitis. Body temperature is normal, clinical analyses of urine and blood without the expressed changes. At a deep palpation morbidity in the right departments of a stomach is felt.
Diagnosis of appendicitis
At survey of the patient with an acute appendicitis the aspiration of the patient to reach the compelled position pays attention; strengthening of pains at any spontaneous tension of muscles – laughter, a tussiculation, and also in a prone position on the left side owing to the shift of a blind gut and its shoot to the left, tension of a peritoneum and a bryzheyka (Sitkovsky's symptom). Language during the first hours damp, covered with a white raid, then becomes dry. At survey of a stomach the lower departments of a belly wall lag behind at breath.
The stomach palpation at suspicion of appendicitis has to be carried out with care. Important diagnostic value at appendicitis has a symptom of Rovsinga (it is characterized by strengthening of pains on the right after tolchkoobrazny pressing on a stomach in the left podvzdoshny area) and Shchetkina-Blyumberg (strengthening of pains after easy pressing and bystry a hand otnyatiya from a belly wall).
At appendicitis the manual rectal research allowing to define morbidity and an overhang of a forward wall of a rectum at an exudate congestion is shown. At a gynecologic research at women morbidity and protrusion of the right arch of a vagina is defined. In blood at an acute appendicitis it is found moderately expressed 9-12Õ10*9/l with shift of a leykotsitarny formula to the left and a tendency to increase of changes within 3-4 hours. Ultrasonography of abdominal organs at an acute appendicitis reveals a congestion of a small amount of free liquid around the increased worm-shaped shoot.
The acute appendicitis should be differentiated from right-hand renal colic, sharp cholecystitis and pancreatitis, probodny stomach ulcer and a duodenum, a divertikulit, a food toksikoinfektion, intestinal impassability, right-hand pneumonia, a sharp myocardial infarction. Therefore in diagnostic not clear cases additional methods – biochemical tests of blood, a survey X-ray analysis of lungs and abdominal cavity, ECG, a diagnostic laparoscopy are used.
At women it is necessary to exclude gynecologic pathology – sharp adneksit, an ovary apopleksiya, extra-uterine pregnancy. Consultation of the gynecologist, survey on a chair, is for this purpose held by ultrasonography of bodies of a small pelvis. At children appendicitis is differentiated with a SARS, children's infections, koprostazy, diseases of an urinary system and GIT.
In diagnosis of chronic appendicitis contrast radiological researches - a barium passage X-ray analysis on a large intestine, an irrigoskopiya are used. For an exception of new growths the blind person of a gut can be required a kolonoskopiya.
Treatment of appendicitis
The standard tactics at an acute appendicitis is earlier surgical removal of the inflamed worm-shaped shoot. At a stage of the pre-hospital help at suspicion of an acute appendicitis the bed rest, an exception of reception of liquid and food, applying of cold to the right podvzdoshny area are shown. Reception of laxative medicines, use of a hot-water bottle, introduction of analgetics before final establishment of the diagnosis is categorically forbidden.
At an acute appendicitis the appendektomiya – removal of a worm-shaped shoot through an open section in the right podvzdoshny area or by a laparoscopy is carried out. At the appendicitis complicated by the poured peritonitis the median laparotomy is made for ensuring careful audit, sanitation and drainage of an abdominal cavity. In the post-operational period antibiotic treatment is carried out.
In a case the appendektomiya at chronic appendicitis is shown if the persistent pain syndrome depriving of the patient of normal activity is noted. At rather easy symptomatology the conservative tactics including elimination of locks, reception of spazmolitichesky medicines, physical therapy can be applied.
The forecast at appendicitis
At the timely and technically competently performed operation for appendicitis the forecast favorable. Working capacity is usually restored in 3-4 weeks.
Formation of postoperative inflammatory infiltrate, interintestinal abscess, abscess of a duglasov of space, development of adhesive impassability of intestines can be complications of an appendektomiya. All these states demand the emergency repeated hospitalization. As the reasons of complications and a lethal outcome at appendicitis serve overdue hospitalization and out of time executed surgery.