Appendicular and genital syndrome
Appendicular and genital syndrome — infectious and inflammatory defeat of pelvic bodies with involvement of an appendix and appendages of a uterus. It is shown by belly-ache, a hyperthermia, dispepsichesky frustration (nausea, vomiting, diarrhea) which can be combined with vaginal allocations. Apply vaginal or rectal survey, laboratory methods to diagnosis (a gemogramma, a microbiological research of dab from a vagina), ultrasonography of a small pelvis, a diagnostic laparoscopy. The treatment combined with surgical sanitation of the pathological center, purpose of antibacterial and antiadhesive means, physical therapy.
Appendicular and genital syndrome
For the first time an appendicular and genital inflammatory syndrome (AGS) as to separate nosological unit it was mentioned in 1951 during the International gynecologic congress passing in France. According to different authors, such pathology is revealed at 12-68% of patients with suspicion of an acute appendicitis. Most often teenage girls get sick that is connected with age anatomic features of an epiploon and the peritoneum raised by reactivity of lymphoid fabric and the beginning of puberty. In process of increase in age of the diseased the quantity of cases with primary defeat of appendages of a uterus or idiopathic process in a small basin increases, the frequency of pathological states with an initial inflammation of an appendix decreases. At adult women the disease comes to light extremely seldom.
Reasons of an appendicular and genital syndrome
The combined defeat of a worm-shaped shoot and appendages develops owing to sharp infectious process against the background of the reduced or changed immune responsiveness of an organism. It is important to distinguish causes of illness and the contributing factors promoting emergence of an appendicular and genital inflammation. Its direct activators are the nesporoobrazuyushchy nonspecific and specific microbic agents united in aerobic and anaerobic associations.
From a pathological peritonealny exudate in 40-42% of cases sow colibacillus that is characteristic of primary appendicular centers. At 24-25% of patients with primary inflammation of ovaries and pipes define hemolytic staphylococcus. At idiopathic forms of a syndrome with an arrangement of the infectious centers out of an abdominal cavity frustration is most often caused by epidermalny staphylococcus and klebsiyelly. Become the contributing factors of development of appendicular and genital pathology:
- Sharp and chronic infections. The probability of emergence of AGS increases in the presence of bacterial and viral diseases of ENT organs with involvement of lymphoid fabric — tonsillitis, a rinofaringit, an adenoidit, epidemic parotitis. Reliable more often the syndrome is diagnosed for the girls who just had chicken pox and having GIT diseases (chronic gastroduodenity and cholecystitis).
- Pathology of reproductive system. At every third patient the menstrual cycle with manifestations oligo-, opso-is broken, dismenore, the premenstrual syndrome is expressed. About 7-8% of girls report about the postponed earlier inflammatory gynecologic diseases. At 1 of 10 surveyed at a sonografiya or a laparoscopy reveal functional cysts.
- Anatomic features of children and teenagers. Bystry and rough distribution of an inflammation on belly and pelvic bodies is caused by high reactivity of a children's organism, immaturity of immune system, higher permeability of an intestinal wall for microorganisms and toxins. The situation is aggravated with an epiploon underdevelopment, imperfection of plastic function of a peritoneum.
- Features of placement of an appendicular shoot. Transition of inflammatory process from an appendix to uterus appendages is also in the opposite direction more probable with a big length of a shoot or its omission a small pelvis (pryamokishechno-uterine deepening). Practically in half of AGS cases the appendix settles down in the right podvzdoshny pole, at 37-39% of patients — in a cavity of a small pelvis, at 9-10% — retrotsekalno.
- Existence of communication between intestines and appendages. At 1/2-1/3 women the wide ligament of a uterus is connected to a root of a bryzheyka of an appendicular shoot by means of a team of Klado in which there pass blood and lymphatic vessels. Existence of this anatomic education creates prerequisites for direct limfogenny and hematogenic spread of an infection between the appendix and appendages of a uterus located on the right.
- Hyperaemia of bodies of a small pelvis. Changes of haemo dynamics which are observed in reproductive system in the second half of a menstrual cycle promote more bystry emergence and distribution of an inflammation. At 10-11% of girls the pain syndrome characteristic of appendicular and genital frustration appeared at an ovulation, within 1-2 days after it or in 1-2 days before monthly.
Primary zone of defeat at emergence of inflammatory process in an appendicular and genital zone can settle down in a worm-shaped shoot, appendages of a uterus or a pelvic peritoneum. Under the influence of microbic agents the local center of alteration with the subsequent development of the catarrhal ekssudativny phenomena, and in more hard cases — with suppuration and fusion of fabrics is formed. Early emergence of a pain syndrome is observed primary damage of an appendix – at the expense of a giperplaziya of lymphoid fabric the gleam of a shoot okklyuzirutsya, and formation of an exudate leads to bystry increase of intracavitary pressure and ischemia of a wall. Increase in permeability mucous promotes involvement in an inflammation of all layers of an appendix, a peritoneum and nearby bodies.
At primary reaction in ovaries and fallopian pipes the activator gets to a worm-shaped shoot gematogenno or limfogenno. Feature of appendicular and genital pathological frustration is deep damage of tissues of ovaries at a part of patients. Microcirculator violations, hypostasis, ischemia, mono - and polynuclear cellular infiltration, occurring at AGS in ovarialny fabric, activate maturing of follicles. At the same time the risk of autoimmune reactions with a blasttransformation of lymphocytes and transformation of macrophages in response to formation of an autologichny ovarialny anti-gene increases. So-called pauperization of gonads because of a multiple obturatsionny and cystous atresia of germinativny elements is as a result possible.
Final systematization of forms of an appendicular and genital syndrome is not developed yet. Experts in the sphere of gynecology suggest to consider when determining option of frustration several factors — its etiology and pathogenesis, including specifics of the infectious agent, duration and existence of complications. The clinically fullest is classification on the basis of primary arrangement of the pathological center according to which the following forms are allocated:
- Appendicular. The first inflammatory changes arise in a worm-shaped shoot, and only after that reaction extends to uterine appendages. The syndrome develops against the background of an acute appendicitis or in the remote period at the patient who was operated about it earlier.
- Genital. Primary inflammation is localized in ovaries or uterine tubes. Respectively distinguish AGS options which arose at the sharp or aggravated ooforit, a salpingita, an adneksita. Defeat of an appendix again, the first is involved in an inflammation a periappendikulyarny peritoneum.
- Idiopathic (cryptogene). The option of defeat of bodies of a basin at which at first develops pelvioperitonit. Genital and ekstragenitalny pathology becomes a basis of an inflammation. In such cases the most possibly limfogenny or hematogenic spread of an infection.
For the choice of the correct medical tactics it is important to consider what activator caused a disease — nonspecific or specific. At AGS the inflammation usually nonspecific, however is not excluded an obsemeneniye of fabrics by a mycoplasma, hlamidiya and other causative agents of sexually transmitted infections. Taking into account features of a current distinguish a sharp and chronic appendicular and genital inflammatory syndrome. Separately allocate pathology options with complications of appendicular and genital genesis.
Symptoms of an appendicular and genital syndrome
Key feature of a disease — not specificity of a clinical picture. At an appendicular form the pathological state has symptoms of an acute appendicitis. Patients complain of severe pain in a stomach and nausea. Almost in 40% of cases there is vomiting. Body temperature rises to subfebrilny figures (37,3-37,6 °C). At a half of teenagers with an appendicular and genital inflammatory syndrome pain at first is felt in epigastralny area or about a navel, and then gradually moves to the right podvzdoshny area. More rare it is localized over a pubis or in the left podvzdoshny area. Pain is continuous, can only abate for some time.
For a genital form of a syndrome of the leader there is a symptomatology of a sharp adneksit. Morbidity is concentrated in the lower departments of a stomach, over a pubis, at the left in podvzdoshny area (at an inflammation of the left appendages). Dispepsichesky frustration brighter, are shown by nausea attacks, vomiting, frustration of a chair. The patient quite often tests a fever, and temperature of her body increases to 38 °C and more. Sharply expressed intoxication is noted. Feature of secondary appendicular and genital frustration at a pelvioperitonita — the sudden beginning and heavier current of a syndrome. Pain is felt as intensive, the constant poured on all stomach. Repeated vomiting, rumbling of a stomach and a liquid chair is observed. Temperature reaches 39-40 °C. The oglushennost, block or confusion of consciousness is quite often noted.
In the early postoperative period the disease is complicated by formation of solderings in a small basin, emergence of morbidity in the period of monthly (algodismenorey). At untimely diagnostics and wrong tactics of maintaining formation of appendicular infiltrate, tubovarialny abscess or development of sharp peritonitis is possible. The remote consequences of AGS are primary infertility observed at 23-25% of women who at teenage age had appendicitis, a spontaneous abortion and right-hand extra-uterine pregnancy. Almost at a third of patients violations of an ovarialno-menstrual cycle are noted. Due to post-inflammatory changes of connecting fabric of gonads the probability of emergence of an apopleksiya of an ovary increases, is more often than right.
Finally the diagnosis of an appendicular and genital syndrome can be confirmed only intraoperatsionno. The existing fizikalny, laboratory and tool researches in most cases allow to suspect this pathology only. At identification of characteristic clinic and specific symptoms of irritation of a periappendikulyarny peritoneum (Shchetkina-Blyumberg, Rovzinga, Sitkovsky, Voskresensky), the comprehensive plan of inspection includes such methods of diagnostics as:
- General blood test. These gemogramma are characteristic of sharp inflammatory process. It is usually observed moderated with shift of a blood count to the left, acceleration of SOE. Emergence of toxic granularity of neutrophils is possible.
- Survey of the gynecologist. The vaginal research is conducted at the patients who began sex life. At a palpation appendages (usually right) are condensed, painful. The back arch of a vagina is condensed. To virgins instead of vaginal rectal survey is appointed.
- Ultrasonography of pelvic bodies. When involving appendages the wall of pipes is thickened, the shape of an ovary changes, in ovarialny Strom cystous inclusions are defined. In an abdominal cavity there is an exudate. Diameter of an appendix is increased, its wall rigidny.
- Research of vaginal dab. At inflammatory diseases of a reproductive system in dab from a vagina it is possible to reveal the activator. Crops on flora from antibiotikogrammy allow to specify sensitivity of a microorganism.
- Diagnostic laparoscopy. The endoscopic research is considered the gold standard of diagnostics. With its help without carrying out a laparotomy it is possible to estimate objectively a condition of an appendix, ovaries, fallopian pipes, peritoneums.
Inflammatory appendicular and genital frustration differentiate with an acute appendicitis without damage of reproductive organs, a sharp ooforit, salpingity, salpingoofority, tuboovarialny abscess, appendicular infiltrate, a rupture of a cyst of an ovary or reabrupt her legs, ektopichesky pregnancy, other diseases in a basin cavity. At detection at girls of symptoms of appendicitis the increased vigilance concerning defeat of appendages is necessary. Such patients are examined without fail by the children's surgeon and the children's gynecologist, if necessary — the urologist.
Treatment of an appendicular and genital syndrome
At the choice of medical tactics it is necessary to consider specifics of maintaining both appendicitis, and an inflammation in the field of appendages. The medical laparoscopy allowing to sanify the inflammatory center with the minimum travmatization of fabrics is considered operation of the choice. In difficult cases with a destructive current of a syndrome and massive defeat of pelvic bodies the laparotomy is carried out. Treatment at appendicular and genital inflammatory processes always is combined and is directed to the solution of such tasks as:
- Surgical sanitation of the center. At identification of visible changes even if they seem secondary, the appendix is deleted. Intervention volume on a pipe and an ovary depends on extent of their damage and assumes the maximum preservation of reproductive organs. Removal of appendages is allowed only at their dense union with an appendix excluding a possibility of its allocation. Reconstructive plastic surgeries at an acute inflammation are usually inefficient.
- Fight against the infectious agent. For prevention of purulent complications antibacterial therapy at AGS begins at a stage of preoperative preparation. Before definition of sensitivity of the activator the antibiotic of a broad spectrum of activity is intravenously entered, further appointments korrigirutsya. An important stage of treatment is sufficient processing of an abdominal cavity during operation with exudate aspiration, application of anti-septic tanks and antibacterial means.
- Antiadhesive prevention. Due to the high risk of formation of solderings between pelvic bodies introduction of corticosteroids, the medicines influencing coagulation of blood, fermental complexes, hormones, creation of artificial ascites is recommended. Antiadhesive barriers — the gels preventing adhesion and merging of a peritoneum in a pelvic cavity are effective. In the late postoperative period physiotherapeutic procedures are shown (electropulse, magnitnolazerny and an ultratonterapiya).
Considering weight of a state and the accompanying frustration, appoint infusional therapy, enter dezintoksikatsionny means, analgetics, immunoproofreaders, eubiotik, vitamin medicines. For achievement of the best results after operation for AGS recommend rehabilitation actions in the form of sanatorium treatment from balneoprotsedura.
Forecast and prevention
At timely diagnostics and adequate treatment forecast of appendicular and genital inflammations favorable. Sanitation of the pathological center, sufficient on volume and the equipment, with the subsequent complex rehabilitation allows to keep reproductive function of the patient and to reduce risk of emergence of other complications. With the preventive purpose adequate therapy of chronic infectious diseases, hygiene of genitals, immunity strengthening, the balanced diet corresponding to age and the state of health of the girl is recommended. An important role is played by prevention of early sex life, work with teenagers from risk groups for the prevention of undesirable pregnancy and genital infections. For the first postoperative year quarterly professional surveys are shown to the operated girls, in the subsequent before transfer to adult policlinic examine the patient 1 time in half a year.