APPENDICITIS

From Big Medical Encyclopedia

APPENDICITIS (appendicitis; lat. appendix, appendices] an appendage + - itis; synonym vermiculite) — inflammation of a worm-shaped shoot of a caecum.

History

Purulent inflammations in the right ileal area are known from an extreme antiquity what Tsels and Aretey's instructions confirm. Lannelong (O. of M.Lannelongue, 1902) reported that the trace of a section was found in one of the Egyptian mummies (an era of the XI dynasty of the Pharaohs) studied by Fouquet in the right ileal area, the Crimea was probably opened an abscess in ileal area. Similar observation forced Lannelonga to assume that Egyptians for several millennia made BC operations at peritonitis of an appendicular origin.

The first image of a worm-shaped shoot was executed by Leonardo da Vinci. In 16 century it was described also by the anatomist Berengario yes of G. Berengario da Carpi. In 1824 Mr. Luye-Villermey (J. Century of Louyer-Villermay) for the first time assumed that the inflammation of a shoot of a caecum is a special disease. It published results of two autopsies at which found the gangrene of a shoot which served in his opinion, a cause of death of patients. Melye (F. Myoneg, 1827) described a case of death of the patient from the peritonitis caused by perforation gangrenozno of the changed worm-shaped shoot. He resolutely spoke in favor of existence of an inflammation of a worm-shaped shoot as independent disease.

However these observations did not draw attention of contemporaries. At that time in clinic the ileal abscesses which were considered as an independent disease were known. In their explanation the greatest popularity was won by Dyupyuitren's theory (G. Dupuytren, 1834) who objected to Melye's look about causal dependence between an inflammation of an appendix and «an inflammatory tumor» in the right ileal area. The inflammation of a worm-shaped shoot, according to Dyupyuitren, met very seldom. The main representations of Dyupyuitren and his followers came down to the fact that in a caecum owing to an originality of its anatomic structure and function favorable conditions for accumulation and consolidation of fecal masses are created that can conduct to an inflammation, an ulceration and a perforation of a wall of a caecum, most likely back, deprived of a peritoneal cover. As a result of it phlegmon of retrocecal cellulose develops. Such abscesses were recommended to be opened at emergence of fluctuation. At that time there was still no thought of earlier operation. Due to the idea of ileal abscesses existing at that time Gold-bek and Albers (Goldbeck, 1830; Albers, 1838) offered classification of a disease standard afterwards: 1) typhlitis acuta; 2) typhlitis chronica; 3) paratyphlitis. Views of these authors formed the basis of all subsequent works about an inflammation of a caecum. Wrote about abscesses of an ileal pole also N. I. Pies (1852); he developed the classification, in a cut allocated five types of abscesses of this area. Quite indistinct characteristic of various forms of a disease concerned traumatic abscesses, purulent inflammations of a kidney, congestive abscesses at damages of a backbone, inguinal buboes and inflammations of ovaries. The insignificant place as an etiology was given to defeats of a back wall of a caecum. N. I. Pirogov did not mention a worm-shaped shoot as about a possible source of a disease. In the same years P. S. Platonov (1854) in detailed article spoke about a possible perforation of a worm-shaped shoot with «the most dangerous effects, more terrible, than abscesses in a back wall of a gut as outpouring of pus can directly happen in an abdominal cavity». Thus, P. S. Platonov the first in our country made the amendment of original positions of the theory of an origin of ileal abscesses dominating at that time. However, among a variety of reasons, ileal abscesses leading to education, P. S. Platonov allocated the small place to an inflammation of a worm-shaped shoot, but firmly pointed to it «indisputable influence». The possible inflammation and a perforation of walls of a worm-shaped shoot was considered by it only as result of jamming in its gleam of foreign bodys. The doctrine about an inflammation of actually worm-shaped shoot as to the main reason for ileal abscesses gained recognition only in the eighties of the last century and by the beginning of the 90th years won almost clear victory over the former theory about primary defeat of a wall of a caecum. Such bystry development of the new doctrine was promoted first of all by the growing number of section observations which showed that in most cases the perityphlitis is caused by an inflammation of a worm-shaped shoot. The operational treatment applied in various stages of a disease including in early stages, even more promoted recognition behind a worm-shaped shoot of the taking priority role in development of a perityphlitis. The name «appendicitis» was entered by Fitz (R. Fitz, 1886) who proved that ileal abscess is result of perforation of a worm-shaped shoot. He described a clinical picture and initial symptoms of a disease, and also recommended immediate operation, «if after the first 24 hours after the beginning of severe pains obvious peritonitis develops and the condition of the patient worsens». These years acute And. already begins to be considered preferential as a surgical disease. In 1884 J. Mikulicz-Radecki expressed opinion that in cases of a heavy perityphlitis operational treatment shall replace therapeutic. According to this council Krenleyn (R. U. Krönlein, 1884) the first made to the young man of 17 years for the 3rd day of a disease deliberate appendectomy through a median laparotomy. The wound was sewn up without drainage. The patient died in 3 days. The same year Mahomed also made appendectomy, but in the extra peritoneal way, through the section applied to bandaging and. iliacae externae. In 1886. Hall - removed a perforated worm-shaped shoot from a hernial bag. Honor of the first successful appendectomy belongs to Morton (T. G. Morton), which in 1887 made partial appendectomy to Z-e days of development of purulent infiltrate. Having opened a cavity of an abscess, it tied up - a worm-shaped shoot a silk ligature near the basis, places of perforation are lower and resected the struck part, having left a tip of an appendix on site. The cavity of an abscess is trained. The patient recovered. In Russia the first successful appendectomy was manufactured by

A. And. Trojans in the Obukhovsk hospital (1890). Having opened peritiflitichesky abscess with a pararectal section, it emptied an abscess and at the same time removed a worm-shaped shoot to the patient of 28 years in a month after the beginning of a disease. In 1904 E. Sonnenburg on the basis of the long-term experience (nearly 1500 observations) came to a conclusion that at acute And. in most cases it is necessary to adhere to waiting tactics and to operate in the cold period; at strict selection of cases operation is shown as well in an acute stage, at suspicion on perforation of a shoot. Early operation, in his opinion, is necessary when gangrene of an appendix or emergence of complications owing to its perforation is supposed. A lack of such formulation of indications is that pathoanatomical changes in a shoot which on clinical signs it is impossible to judge are their basis. However the provisions exposed by Zonnenburg thanks to his authority long time were dominating not only in Germany, but also in other countries. At the I congress of the Russian surgeons (1900) S. M. Rudnev reported on bacteriology acute And., and V. G. Tsege-Manteyfel — about his treatment. According to views of that time the last distinguished three forms acute And.: catarral, purulent and gangrenous.

In all cases of an acute appendicitis Tsege-Manteyfel considered operation shown only after the period of waiting, in the first free interval after an attack or at education extra peritoneal an abscess. At the same time he emphasized that «operation is forbidden during a bad attack, with the only exception for a gangrenous form where operation is represented permissible experience in view of a stalemate». In a debate most of surgeons agreed with it (A. A. Bobrov, P. I. Dyakonov, A. A. Kadyan, etc.). However F. I. Berezkin (Moscow) and I. Ya. Meerovich (Ekaterinodar) on the basis of the experience supported the earliest operation, in the first days after the beginning of an attack, «if appendicitis begins very sharply». Over time views of surgeons changed, and already at the IX congress of the Russian surgeons (1909) G. F. Tseydler,

B. M. Mintz and others firmly raised a question of need to operate patients acute And. in the first days from the beginning of a disease. However in broad surgical practice implementation of the principles of early diagnosis and early operation at acute And. it was carried out rather slowly in spite of the fact that a number of surgeons (I. I. Grekov, S. I. Spasokukotsky, V. A. Krasintsev, V. S. Levitte, etc.) persistently carried out the principle of the emergency operative measure. Early operation at acute And. became possible really only at the modern organization of the Soviet health care. Creation of stations and institutes of ambulance at first in Moscow (Ying t of Sklifosovsky, 1923), later in Leningrad (1932), and then and in other cities provided a possibility of departure of the doctor on the house at the first symptoms of an acute disease of abdominal organs and emergency (in the first 24 — 48 hours after the beginning of an attack) to hospitalization of the patient for performance of immediate operation.

Statistics

Acute And. is among the most frequent acute diseases of abdominal organs. Since the beginning of the current century a certain increase in frequency of a disease of acute A. V the countries of a temperate climate acute is everywhere noted And. is a mass disease; the number of the emergency appendectomies in the USSR approaches one million a year (1970).

In Moscow for the same year 31 320 operations were performed that made 81% of all made emergency interventions at acute diseases of abdominal organs. Acute And. people of all age are ill, and at persons 60 years are more senior destructive forms meet more often — in 72,5% of cases. More often acute And. it is observed at women.

With growth of number of early immediate surgeries at acute And. for the last decades the group of patients at whom at a clear clinical picture acute began to increase And. pathologists do not find in a worm-shaped shoot of visible morphological changes; these cases carry to simple (catarral) A. V to this group of patients also women (68%) prevail. Most often lack of morphological changes in a remote shoot is noted at girls of 12 — 15 years and young women. At male patients of the same age lack of morphological changes is noted 1,5 — 2 times less often [L. N. Leonova, Harding (H. E. Harding)].

On pathoanatomical this P.F. Kaliteevsky (Ying t of Sklifosovsky), at microscopic examination of 2000 shoots removed at acute And., total number of not changed shoots made 31% (for women of 47%, for men of 26%). In his opinion, dominance in this group of women is connected by hl. obr. with diagnostic mistakes. Indirectly it is confirmed by less satisfactory long-term results after appendectomies at women in comparison with men of the same group [Sh. of X. Murlaga, J. C. Moir, O'Rourke]. Obviously, regarding cases the pain syndrome simulating an attack acute And., it is connected with a disease of internal generative organs. However such interpretation does not exclude the fact of existence of considerable group of clinically reliable forms acute at all And. without visible morphological changes in a remote shoot. It is confirmed by the fact that most of patients of this group completely recovers after operation.

In group of destructive forms acute And. distinguish: phlegmonous And., which makes 90,1% of cases, gangrenous and perforative And. — 7,6%, an empyema of a shoot — 0,5%, appendicular infiltrate and periappendikulyarny abscess — 1,8%.

Depending on age of the patient the frequency of destructive forms acute A. Tak changes, gangrene of a shoot and its perforation aged up to 20 years are observed in 8,1 — 8,5%, and after 60 years — in 29 — 33% of cases. Phlegmonous And. aged up to 20 years meets in 17,9% of cases, and after 60 years in 9% of cases.

In the USSR the progressing decrease in a postoperative lethality is noted at acute And.: for the last decade it makes only 0,1 — 0,2%. However, so low lethality after appendectomy at acute And. is calculated on huge number of operations which are made in the first two days and in a large number at simple forms of an inflammation of a shoot. At destructive forms A. it is higher. So, in Ying-those of Sklifosovsky in 1965 — 1969 on 3050 appendectomies at destructive forms acute And. the lethality made 1%, and more than a half of the dead after operation were aged more senior than 60 years.

Etiology and pathogeny

Fig. 1. Balanthidiasis of a worm-shaped shoot. Among purulent exudate balantidiya are visible (are specified by an arrow).

Since acute And. it was allocated in a special nosological form, the inflammation of an appendix was always considered as the damage caused by a bacterial flora, vegetans in intestines. The etiological moment in development And. balantidiya (fig. 1), pathogenic amoebas, trichomonads can serve.

Defeat of an appendix meets at an actinomycosis, histoplasmosis. The specific inflammation of a shoot can arise at tuberculosis, bacillar dysentery, a typhoid, at collagenoses and some other diseases both infectious, and noninfectious. However multi-infection (colibacillus, staphylococcus, streptococci, pneumococci, diplococcuses, anaerobe bacterias) participates in the prevailing number of cases in pathological process where into the forefront Escherichia coli acts. Sudden manifestation of pathogenic properties of this microflora, edge, residing in intestines, not only does not exert an adverse effect, but is necessary for normal digestion, was explained by formation of the closed cavity in a shoot. Under such circumstances harmless saprophytes show the pathogenic action because they find the favorable environment for growth and reproduction in the closed cavity. In 1896. A. A. Bobrov paid attention to anatomic feature of a worm-shaped shoot (excesses or narrowings of its gleam) and to the processes causing stagnation in a caecum and at the same time in an appendix. At the same time microbes are implemented into walls of a shoot directly from its gleam — an enterogenous way. A part of researchers insisted on a hematogenous, metastatic way of an origin acute And., believing that the disease comes owing to a drift of microorganisms in a wall of an appendix from the remote center. So sometimes explained communication of acute Ampere-second with the previous quinsy [L. Kretz] especially as in a wall of a worm-shaped shoot the adenoid tissue is strongly developed that can promote defeat by its microbes circulating in blood. The anatomic premises (richness of a worm-shaped shoot an adenoid tissue) do it by the constant participant of all processes in an organism which are followed by a little expressed immune response. Activation of the lymphatic device of a shoot can lead to swelling it, to disturbance of emptying and development in it nonspecific inflammatory changes.

Further researches with attempts of sowing of microorganisms from blood at acute And. (that never gave positive takes), as well as experiments on rabbits with intravenous administration of bacteria, substantially shook a hypothesis of a hematogenous origin acute And. Some authors attached special significance to an influenzal infection, seeing in it even true responsible for emergence acute And. [H. Faisans]. However in 1918 — 1921 during one of the strongest pandemics of flu in Europe incidence acute And. it was considerably reduced. As well in recent years at flu epidemics number of the diseased acute And. remained at the previous level. Thus, according to most of authors, the enterogenous way of implementation of microorganisms is the most frequent reason of acute A. Odnako similar views could not offer an exhaustive explanation of an etiology of acute A. Uzhe at the I congress of the Russian surgeons (1900) F. I. Sinitsyn dropped a hint of doubt in existence of excesses or narrowings of a shoot in all cases acute And. He fairly specified that he remains absolutely unclear why «the lowest organisms in one case do not make anything, in another only Qatar, in the third — an inflammation purulent, and in the fourth — even gangrene». In 1907 the pathologist L. Aschoff submitted the theory of emergence acute And. In his opinion, process in a shoot begins in one of crypts of his mucous membrane with development of primary affect, a shaped wedge with the basis turned towards a serous cover. At top of a wedge, on a mucous membrane, the insignificant erosion covered with fibrinous exudate with impurity of cells is found. Within the wedge-shaped center fabric is penetrated by leukocytes, sometimes with impurity of erythrocytes. From it suppurative process extends in the parties, there is phlegmon of a shoot with an ulceration of a mucous membrane and development of a phlegmonous and ulcer stage of a disease and diffusion is purulent - ulcer And. Further the necrosis and gangrenous disintegration is formed that can lead to perforation of a shoot. L. Aschoff considered acute And. result of the infection caused mainly by gram-positive diplococcuses and colibacilli. However he never managed to see with primary affect bacteria in the thickness of fabrics of a shoot, in its muscular and serous covers, despite leukocytic infiltration. Therefore he explained emergence of the wedge-shaped center with absorption of the toxicants spreading on lymphatic cracks. The contributing reason acute And. relative rest of a worm-shaped shoot, the assumed lack of its vermicular movement was considered that, according to L. Aschoff, leads to stagnation in a gleam of a shoot of intestinal contents. Same also its physiological bends promote. Further many authors continued studying of a pathogeny acute And. in the same direction, so far Bryunn (Brünn) did not state the new view which radically changed former representations. During the studying of drugs of the inflamed worm-shaped shoots he found out that initial process is localized on vascular segments. On this basis in 1926 G. Ricker offered the neurovascular theory of emergence acute And., developed by A. V. Rusakov (1951). By this time by means of a radiological method it was confirmed (S. Grigoriev, etc.) that the worm-shaped shoot has clearly the expressed peristaltics, regions it allows it to be freed from contents systematically. Bends of a shoot are also result of its changing muscle performance [S. Grigoriev, Kohn (M. of Cohn)]. At the same time it turned out that primary affect in the form of a wedge at acute And. find not always. Developing the theory, G. Ricker proved that the necrosis and gangrene of a shoot are result not of the secondary, but primary fabric changes having the previous stage. Most the prematurity of a necrosis is observed sometimes in the first 6 — 8 hours of a disease, and it is impossible to present that this process could be result of primary affect with gradual development of the progressing stages of defeat, since an erosion, transition to the ultserozno-phlegmonous form which further is coming to the end with gangrene of a shoot. Necroses of a wall of a shoot which lead to his gangrene are the sekvestratsionny necroses caused by a long staz of blood in intraparietal vessels and a heart attack of a wall owing to emigration of erythrocytes. This process takes one or several segments of a shoot, often vascular segment in the field of a top. In some cases changes are limited to a mucous membrane where occurs staz blood and escaping of vessels of red and white blood cells. All process first of all develops in vascular system, and the circulatory disturbance depending on irritation of the nervous system regulating a normal blood stream is the cornerstone of it. G. Ricker came to a conclusion that there is a certain stage of functional changes in a shoot until there occur obvious micro and a makroskopicha sky changes. Thus, it is about purely functional disturbances which till the known period do not change structure of a shoot. At its amputation in this period no visible changes in it are found. It is known that at the beginning of an attack of pain begin in a navel or in an anticardium that forced G. Ricker to think of initial functional changes in the centers of a sympathetic innervation of a stomach — in ganglia coeliaca therefore there is the subsequent process p in a shoot. G. Ricker and A. V. Rusakov's neurogenic theory, certainly, helps to understand emergence of some forms of acute A. V it its obvious advantage. However for the majority of forms destructive And., especially developing quickly, this theory is of little use. If in some cases really takes place neurogenic staz in vessels of a shoot which is in such cases a releaser for development acute And., for other forms of change proceed upside-down when blood supply of a shoot is broken owing to increase in pressure in it. It is known that the worm-shaped shoot is supplied with exclusively powerful nervous device (M. F. Quiricus, 1938). But numerous neurohistologic researches of the intramural device of a shoot showed that the greatest changes in it are observed not at acute, and at chronic And.

Thus, neither Ashoff's theory, nor the neurogenic theory can be accepted without reservations, and most of researchers pays attention mainly to the stagnation of contents in a shoot caused by various reasons (an excess of a shoot, dense contents, sometimes fecal stones, a lymphatic hyperplasia, swelling of follicles, delay of a vermicular movement, staz in a caecum) that leads to build-up of pressure in it, to a staz in intraparietal vessels, to the strengthened reproduction of microbes.

It was stated above that in 20 — 30% of cases acute And. the shoot is a little changed, despite all clinical symptoms indicating its inflammation (a characteristic onset of the illness, a muscle tension of a stomach in the right ileal area, a leukocytosis). If to exclude chances of wrong diagnosis at early operation, nevertheless there is a large number of cases where there is a discrepancy between clearly the expressed clinical symptoms acute And. and lack of changes at a histologic research of the shoot removed at operation.

It is impossible to disprove existence of such frequent forms acute And. only because they do not find rather convincing explanation. Firm situation r indications to operation at acute And. on the basis of clinical displays of a disease remains in force.

From the reasons contributing to emergence acute And., significance was long since attached to an alimentary factor.

Luke-Shampionnyer (J. The m of M. of Lucas-Championniere, 1901) for the first time paid attention to sharp increase in incidence acute And. at plentiful meat food. Further this observation was confirmed. So, the Soviet surgeons noted sharp reduction of number of patients acute And. during civil war of 1918 — 1921, during hunger in the Volga region 1921 — 1922, and also in days of the Great Patriotic War in Moscow and especially in Leningrad. Some researchers assume that plentiful proteinaceous food changes character of an intestinal chyme; perhaps, in it the excess quantity of the end products of an albuminolysis which are the favorable environment for growth of microbes accumulates. Also changes in a metabolism, disturbances of acid-base equilibrium and increase in excitability of a nervous system are possible.

Pathological anatomy

Morphologically all forms of an inflammation of a worm-shaped shoot can be divided on nonspecific, inherent actually And. as to nosological unit, and specific. The last meet seldom.

In the shoots removed concerning acute And., irrespective of starting date of a disease all options of an acute inflammation from focal to diffusion are found. In this regard distinguish the following forms acute destructive And.: focal purulent, phlegmonous, phlegmonous and ulcer, apostematous (with formation of small intraparietal abscesses), gangrenous. All these options do not bear any peculiar features (see. Inflammation ). Inflammatory infiltrate consists hl. obr. from polymorphonuclear leukocytes, sometimes with a large number eosinophilic that some researchers consider a sign of subsiding of inflammatory process. The phlegmonous inflammation is always followed by diffusion and sharp hypostasis of a wall of a shoot, frequent the centers of necroses of a mucous membrane. The gangrenous and necrotic options connected with thrombosis of vessels can be both primary, and secondary, complicating originally easier forms of an acute appendicitis.

Fig. 2. Phlegmonous and ulcer appendicitis. Sharply reinforced worm-shaped shoot with filmy imposings on a serous cover and a wide perforation opening at the basis.

Macroscopically the shoot can look not changed (at easy forms acute And.) or sharply reinforced, dirty it is red go, sometimes (at severe necrotic forms) black-green color (as a result of an imbibition of a wall hemoglobin and its derivatives). On a surface of a shoot often already with the naked eye it is possible to find fibrinopurulent imposings (fig. 2), the gentle fibrinous film is visible also at microscopic examination. Existence of such film indicates an exit of inflammatory process out of limits of a wall of a shoot, i.e. a periappendicitis, and a possibility of distribution of inflammatory process on other departments of a peritoneum.

Fig. 3. The large fecal stone is restrained at the basis of a shoot.

In some cases at a research of remote shoots in their gleam soft and firm fecal stones — coprolites (fig. 3) are found, various foreign bodys, occlusive a gleam of a shoot are more rare. In such cases the severe form of destructive appendicitis is often had.

Sometimes distalny obturation in an expanded gleam accumulation of pus — an empyema of a worm-shaped shoot is formed. At all forms acute destructive And. the perforation of body from microscopic, dot to extensive, sometimes with self-amputation of a part of a shoot is possible. Most often perforation is observed in the presence of an obstacle to emptying of a shoot, and also at development in it false diverticulums (see. Diverticulum ). At a careful research of shoots with destructive changes false diverticulums are found approximately in 5% of cases while in shoots without destruction they meet extremely seldom. It indicates their undoubted role in genesis destructive And. Inflammatory changes can be limited to a diverticulum or extend to adjacent sites of a shoot, or to all shoot. In view of absence in an outside wall of a diverticulum of continuous muscular layers the last is the «weak» place, and the frequency of perforation at an inflammation of a shoot against the background of a divertuculosis reaches 38%.

At all options of destruction distribution of inflammatory process on a mesenteriolum of a shoot, developing of phlebitis, development of metastatic suppurative focuses in a liver and sepsis is possible.

In large part cases, according to various data in 25% and more, in the shoots removed concerning assumed acute And., at microscopic examination no inflammatory changes are found or the observed changes are indistinguishable from artifacts or the disturbances of structure caused by an operative measure. A part of these cases is connected with errors of diagnosis.

In other cases there comes the permanent cure after appendectomy. This circumstance forced to enter into the classification scheme acute And. a heading «simple» (superficial, catarral) A. V such cases the methods of a morphological research which are usually applied in pathoanatomical prozektura do not allow to catch the changes explaining a clinical picture acute A. Boley difficult methods of a research — ultramicroscopy, histochemical methods, etc. — also did not yield convincing results yet. The existing theoretical situation denying a possibility of existence of purely functional forms of pathology forces to continue searches of morphological changes at this form acute And.

Fig. 4. Appendicism. A sharp atrophy and a sclerosis of all layers of a wall of a shoot with an obliteration of a gleam.

Approximately in the fourth part of remote shoots at a research dystrophic changes are found various degree of manifestation, is more often in the form of an atrophy of various layers of the wall of a shoot which is followed by a sclerosis is more rare a hypertrophy than them. The atrophy and a sclerosis can be sharply expressed and be followed by a full obliteration of a gleam of a shoot (fig. 4) with disappearance of a mucous membrane. In parallel there comes also the atrophy of the lymphatic device of a shoot. Slightly more often these changes are localized in its distal departments. As a rule, at these forms, contrary to acute destructive processes, the expressed changes of the intramural nervous device — both ganglionic cells, and nerve fibrils are observed. Quite often (is more often at hypertrophic options) changes of intramural vessels in the form of a hypertrophy of their walls and reorganization with formation of a numerous anastomosis, arteries of the closing type are observed.

One researchers refer these changes to effects of the postponed or recurrent inflammation, others to flowing hron, to an inflammation, the third — to manifestation of involute processes. Similar morphological pictures are most often observed in the shoots removed concerning chronic And. All these changes can be combined with any options of the acute destruction described above with the corresponding clinical picture.

Fig. 5. The opened cyst (mucocele) of a worm-shaped shoot; in a gleam on site of a gap the large fecal stone is visible.

Occasionally at hron, obliterations of proximal department of a shoot, most often cicatricial character, in its distal department the secret as a result of the proceeding products its glands of a mucous membrane collects. The kolbovidny swelling filled with mucous contents is formed. Such retentsionny cyst (fig. 5) of a worm-shaped shoot carries the name mucocele (see). Very seldom mucous contents can gather in balls — myxoglobulosis (see). At break of a cyst in an abdominal cavity implantation of muciparous cells on a peritoneum with development of a limited or diffuse pseudomyxoma of a peritoneum is possible (see. Pseudomyxoma ).

Sometimes reason of development acute And. other pathological processes in a shoot can be, quite often these changes are found accidentally during operation or at a histologic research of a remote worm-shaped shoot.

Sometimes in remote shoots find various parasites. Most often pinworms (both adult individuals, and their eggs) meet. However their role in development And. it is not clear as well as other helminths, behind an exception shistosy (see. Shistosomatoza ).

A clinical picture

In clinic distinguish two forms of an inflammation of a worm-shaped shoot: acute and chronic And.

Unlike acute And., having a bright clinical picture, hron. And. it is shown by so uncertain signs that the nek-eye to authors in general grants the right to deny this form of a disease, certainly, if the available complaints are not a direct consequence of the bad clear attack postponed in the past And.

Acute appendicitis

Wide experience of operational treatment acute And. allows to come to a conclusion that on a clinical picture, it is as if bright and typical it it was expressed, it is impossible to judge morphological changes in a worm-shaped shoot.

Various degree of manifestation of its pathoanatomical changes, various forms of an inflammation can cause an identical clinical picture. It means that at clinical diagnosis there are no bases to take as a basis alleged changes of an appendix (perforative And., empyema of a shoot, catarral And.). It is possible to speak about it only with the known share of probability. Tactics of the surgeon in all cases is identical: early operation is obligatory. It is also impossible to divide acute And. on easy, moderately severe and severe forms. From the clinical point of view division into the early and late periods acute is correct And. depending on a number of hours (days) which passed from an onset of the illness. Thus, distinguish: 1) acute And. in the first 2 — 3 days of a disease (can be followed by the phenomena of local peritonitis); 2) the acute Ampere-second the phenomena of the general peritonitis which in most cases develops, since third day of a disease, but at perforation of a shoot arises earlier; 3) acute And., complicated by formation of appendicular infiltrate, can gradually pass into ileal abscess.

An acute appendicitis in the first 2 — 3 days of a disease. Attack acute And. in most cases begins suddenly, more or less sharply. A precursory symptom, as a rule, is pain. At the beginning of an attack it is quite often localized in a navel, is more often above it or on all stomach, and only a few concentrates in the field of a caecum later. Pains do not irradiate anywhere, but amplify at a tussiculation. There are nausea and vomiting though lack of the last is not excluded acute by A. Stul and a passage of flatus usually are late. The diarrhea is observed seldom, abdominal pains in the presence of a liquid chair, especially in summertime, in most cases testify against acute And. Body temperature increases to 37,8 — 38,5 °, more rare remains normal. At a blood analysis the moderate leukocytosis — to 9000 — 12 000 is found. In doubtful cases the blood analysis on a leukocytosis is necessary repeated (in 3 — 4 hours). At the beginning of an attack of ROE remains normal, in the next days can be accelerated. As at any acute disease of abdominal organs, at acute And. the triad of symptoms is of great importance: condition of pulse, language and stomach. Pulse at acute And. in the first days about 90 — 100 blows in 1 min. become frequent. Language is laid slightly over and wet in the beginning, but becomes dry soon. Crucial importance has a research of a stomach. At first carefully and gradually palpate the left ileal area, then the left hypochondrium, an upper part of a stomach and, at last, the right ileal area where at acute And. always (with rare exception) sharp morbidity is defined. The place of the greatest morbidity and its expressiveness to a certain extent depend on localization of a shoot. At most of patients easy percussion with fingers in various sites of an abdominal wall helps to establish the place of the greatest morbidity quickly. It is better to make palpation of a stomach not fingers and not finger-tips, but «a flat hand» because at acute And. look for not a painful point, but painful area without accurately expressed borders. Therefore at acute And. definition of morbidity in Mac-Berney, Lants, Kyummell's points lost value, a cut it was offered in quality differentsialno - a diagnostic character of the early periods of a disease. Morbidity in these points can be taken to a certain extent into account only at diagnosis chronic A. Simpt Sitkovskogo (strengthening of pains in the right ileal area at position of the patient on the left side) in some cases acute And. keeps the value, just as a symptom of Rovsinga (strengthening of pains in the field of a caecum at tolchkoobrazny pressing in the left ileal area). If to take skin pleated, then on the right, in the field of a caecum, the region of a hyperesthesia is defined. Sharp morbidity at palpation of the right ileal area at acute And. it is usually combined with a protective muscle tension on the limited site, a cut it is shown here especially considerably at a soft abdominal wall in other parts of a stomach. Extremely important value in diagnosis acute And. has Shchetkin's symptom — Blyumberg (see. Shchetkina-Blyumberg symptom ), which appears in the right ileal area in initial stages acute And., and in process of a course of a disease it is found and at the left, and in an upper half of a stomach. It characterizes prevalence of inflammatory reaction in an abdominal cavity. At diagnosis acute And. it is impossible to be limited only to a research of a stomach, its morbidity, tension of an abdominal wall and Shchetkin-Blyumberg's symptom. It is necessary to check a sign of Pasternatsky which at acute And. happens negative, to inspect bodies of a breast not to miss changes in lungs. Surely make a manual research of a rectum, and at women — and bimanual, at the same time it is possible to grope болезненно© the place in the lowest site of an abdominal cavity.

At establishment of the diagnosis acute And. the patient is immediately sent to surgical department and make urgent operation. In doubtful cases at women and girls survey by the gynecologist is necessary. When for various reasons the doctor for the first time observes the patient on 3 — the 4th days from the beginning of a disease, he meets various picture or rapid development of a disease and diffusion peritonitis, or, on the contrary, subsiding of symptoms. In optimum cases the attack comes to an end on 2 — the 3rd days from its beginning: temperature decreases to norm, pulse urezhatsya, abdominal pains disappear, there is a moderate morbidity at a deep palpation in the right ileal area and insignificant muscle tension. Gases begin to depart, appetite appears. In 1 — 2 day the attack finally passes, and it is possible to consider that the patient recovered.

At obviously abating attack acute And. overseeing by the patient in a hospital is admissible. At clear improvement of the general state, decrease in temperature and a leukocytosis operation is not necessary.

However in doubtful cases in order to avoid complications especially as pathoanatomical changes in a shoot, in broad practice quite often are unknown prefer to operate patients and at the abating attack acute And.

An acute appendicitis with the phenomena of the general peritonitis. Spread of peritonitis on a considerable part of a peritoneum at once after the beginning of an attack or on 3 — results the 4th days from gangrene of a shoot or its perforation. The morbidity in the beginning localized in the right ileal area begins to extend quickly on all stomach. During this period the protective muscle tension of an abdominal wall, how many abdominal distention is found already not so much that distinguishes initial stages of peritonitis of an appendicular origin from a perforation of the ulcer of a stomach or a duodenum at which the abdominal wall from the very beginning strains «as a board». Shchetkin's symptom — Blyumberg is sharply expressed on all stomach; in the next days it weakens. At auscultation of a stomach intestinal noise are not listened. There is no chair, gases do not depart. The patient becomes uneasy. His face expresses concern, eyes sink down, lines are pointed, coloring of skin becomes gray and earthy color (facies Hippocratica), extremities grow cold, on a forehead sweat acts. Temperature usually increases to 39 — 40 °, pulse sharply becomes frequent and reaches 120 and more blows in 1 min. Arterial pressure at first remains within norm; at further development of peritonitis systolic pressure gradually decreases, and diastolic increases; thus, the pulse pressure (amplitude of pulse fluctuations) sharply decreases.

The leukocytosis is observed, ROE accelerates, the noticeable deviation to the left with increase in number of young and band leukocytes appears. At a X-ray analysis of a stomach find accumulation of liquid and gases in a caecum and in various departments of a small bowel (Kloyber's bowl). All this speaks about development of diffuse peritonitis (see. Peritonitis ). In such cases immediate operation is required.

The acute appendicitis which was complicated by formation of appendicular infiltrate. Infiltrate can be formed already on 3 — the 4th days of a disease. It is manifestation of restriction of inflammatory process, at the same time the barrier is formed of the sticking together loops of guts, an epiploon and a parietal peritoneum. In the right ileal area consolidation with quite well outlined borders, painful is probed the big or smaller sizes at palpation. In other parts the stomach is blown moderately up, but an abdominal wall soft and painless. Temperature is increased, pulse is speeded up, there is a leukocytosis. Appendicular infiltrate can resolve during 4 — 6 weeks. In case of transformation of infiltrate into an abscess the general condition of the patient worsens; temperature gains gektichesky character, with big daily fluctuations, the leukocytosis sharply increases. Infiltrate increases in sizes and becomes very painful. Through an abdominal wall sometimes it is possible to feel a zybleniye. Ileal abscess as a result of an acute inflammation of a worm-shaped shoot which was not removed in 1 — the 2nd days of a disease is so formed. In cases of formation of abscess it is dangerous to adhere to waiting tactics. It is necessary to open timely an abscess, otherwise it can break in an abdominal cavity. Sometimes pus finds an independent way out and is emptied through a caecum, melting its wall; at the same time at the patient the liquid, fetid chair then temperature sharply decreases is noted. Cases of break of an abscess in one of the soldered loops of a small bowel or in a bladder are known.

Between these most typical pictures acute And. there can be various transitional forms.

Complications

From complications at acute And., except peritonitis (see), developing sometimes very violently, and abscesses of various localization — subphrenic abscess (see), Douglas abscess (see), interloopback abscesses, thrombophlebitises of various localization, coming from veins of the inflamed mesenteriolum of a shoot take place (mesenteriolitis). The thrombosis arising in small veins can extend to larger branches of system of a portal vein, leading to very terrible complication — a mezenterialny pyemia and to a pylephlebitis (see). Also thrombophlebitises ileal, pelvic, etc. veins are possible. At early operation similar complications are rare. They proceed always very hard, with tremendous oznoba, pouring sweats, gektichesky fever, icteric coloring of scleras, increase in a liver. The sharp deviation to the left is noted.

The appendicism

the Appendicism is characterized by complaints to the pain which is periodically amplifying in the right half of a stomach, is preferential in the field of a caecum. Often patients complain of the locks which sometimes are replaced by ponosa. Locks happen persistent, demanding use of laxatives and enemas, cause morbidity in the field of a caecum. The feeding schedule, a diet, heat, rest, a belladonna and other means do not give relief. If the patient is to the doctor soon after the postponed bad attack And., in the field of a caecum it is possible to probe the remains of infiltrate. In more remote terms it is possible to note only local morbidity at palpation of area of a caecum. It should be noted that direct palpation of a shoot, according to most of surgeons, works well very seldom both in a normality, and at hron. A. For diagnosis hron. And. a number of more or less characteristic symptoms is described. Pressing in Mac-Berney's point — the border of an outside and average third of the line which is mentally carried out from the right anterosuperior awn to a navel — gives sensation of pain. If to connect the right and left anterosuperior awns and to divide them into three parts, then pressing on border of the right third with average (Lants's point) gives sensation of pain. Morbidity can be defined as well in Kyummell's point: it is 1 — 2 cm below and to the right from a navel.

It must be kept in mind that the called points called on surnames of the authors who offered them cannot be considered an exact projection to an abdominal wall of the most frequent arrangement of a worm-shaped shoot or the place of its otkhozhdeniye from a caecum as thought of it earlier. A large number of observations confirms only that for chronic And. the localized morbidity in the specified points is characteristic; therefore these symptoms deserve nek-ry attention. In addition to others, it is necessary to mention still a symptom of a petitov of a triangle, or a «back» symptom (G. G. Yaure): pressing now over a comb of an ileal bone causes morbidity that does not happen usually neither at a paranephritis, nor at a stone of a kidney or an ureter.

The diagnosis

Despite a well-known picture of a disease, acute And. always was considered as a «artful» disease. Cases meet. difficult for diagnosis that is often caused by anatomic features. In case of a median arrangement of a shoot process quickly passes to surrounding loops of guts and leads them to paresis owing to what symptoms of acute intestinal impassability appear.

Presents special difficulty for diagnosis acute And. at a retrocecal arrangement of a shoot when pains are localized not in a stomach, and in the right lumbar area, the stomach remains soft, low-painful at a palpation. In these cases it is sometimes difficult to define the nature of a disease. In this regard quite often the diagnosis is made out of time, and the patient with delay is brought in a hospital. The analysis of lethal outcomes shows that is more often than others remains not distinguished acute And. at a retrocecal arrangement of a shoot. In Ying-those of Sklifosovsky among the dead at acute And. at 44,7% of patients the retrocecal arrangement of a shoot was revealed.

For recognition retrocecal acute And. there are no pathognomonic signs. It can be suspected in the presence of a positive symptom of Pasternatsky, especially if there is a contracture of m. ileo-psoas and the right leg of the patient is bent and brought to a stomach (Larash's symptom). In these cases it is necessary to investigate repeatedly blood on a leukocytosis and to check a gemogramma.

It must be kept in mind an opportunity left-side And. at an arrangement of a shoot together with a caecum in the left ileal area (situs viscerum inversus).

Meets difficulty diagnosis acute And. at patients at advanced age (60 years are more senior). From the very beginning And. at them can proceed areaktivno, even in the presence of the expressed destruction of a shoot. Pain at a deep palpation is insignificant, the muscle tension is expressed poorly, temperature subfebrile or remains normal, pulse keeps within 90 blows in 1 min., even the leukocytosis happens small, but in a leukocytic formula the sharp shift is noted to the left. Abdominal distention, colicy pains and a hyperperistalsis sometimes are a reason for the wrong diagnosis of acute intestinal impassability. At development of infiltrate in elderly people it can sometimes not resolve within 2 — 3 months that gives the grounds to suspect a tumor of a caecum. In these cases between a tumor and inflammatory infiltrate it is necessary to make a X-ray analysis of a large intestine with administration of barium by an enema for differential diagnosis.

At differential diagnosis acute And. it is necessary to remember renal colic, edges at infringement of a stone in the right ureter can give strong painful attacks with localization in the right ileal area and abdominal distention. In these cases the symptom of Pasternatsky which is absent at acute matters And. (except for retrocecal And.). Pay attention to dysuric frustration, make retest of urine, do a x-ray film of a kidney and an ureter, in doubtful cases the hromotsistoskopiya or novocainic blockade of a seed cord is shown (or a round ligament of a uterus). The last method leads to bystry disappearance of pains at renal colic and does not render essential effect at acute And. Acute cholecystitis is mixed sometimes with acute And., especially at elderly women at whom sharply increased gall bladder can fall to the level of a navel and even below. In these cases all right half of a front abdominal wall is strained, difficult happens to distinguish the place of the greatest morbidity. At the same time the inflammation of the worm-shaped shoot located under a liver can simulate an attack of acute cholecystitis. Carefully collected anamnesis, tension in right the hypochondrium and return of pains in the right shoulder or a shovel at acute cholecystitis help to make the correct diagnosis. Sometimes happens it is necessary to distinguish acute And. from acute pancreatitis; at the last the leading symptom are the pains in epigastriß area arising suddenly. They often are the surrounding character, give to a breast and a back. Almost always there is vomiting. Temperature often does not increase. The general serious condition, decreases arterial pressure, the stomach is blown moderately up, a little intense, at a palpation morbidity in epigastriß area with the expressed Shchetkin's symptom — Blyumberg is noted. For acute pancreatitis increase in content of amylase in urine higher than 128 units on Volgemuta is pathognomonic. Sometimes acute And. causes symptoms of acute intestinal impassability, especially in elderly people at whom the disease can be followed by a hyperperistalsis of guts as a result of the nek-ry obstacle created by the arising infiltrate in the field of a caecum. Though perforation of a worm-shaped shoot is also the most frequent reason of acute peritonitis, it is worth to remember also about perforation of stomach ulcers and a duodenum, a perforation of a gut at a typhoid, especially at its so-called out-patient form. Also known vigilance at the phenomena of food intoxication since acute is necessary And. can proceed it is similar to this disease.

At women often it is necessary to distinguish acute And. from an inflammation of appendages of a uterus, from an extrauterine pregnancy, an apoplexy of ovaries, an acute pyelocystitis. At an inflammation of appendages of pain arise often soon after periods, are localized in the bottom of a stomach, give to a sacrum; at a pyelocystitis gripes at an urination are noted; temperature reaches 40 °, ROE is sharply accelerated.

At vaginal examonation are defined morbidity during the pressing on a neck of uterus and infiltrate in the field of the right or left appendages. However in certain cases the exact diagnosis is difficult, and if it is impossible to exclude acute And., the surgeon is obliged to make laparotomies). To rather rare diseases which can be mixed with acute And., phlegmon of terminal department of an ileal gut (belongs at a terminal ileitis — diseases Krone), symptoms a cut are pains, high temperature, sometimes diarrhea, a leukocytosis to 30 000, the probed painful tumor. Also other departments of a small bowel can be surprised. These patients operate sometimes with the diagnosis acute And. Audit of an ileal gut during operation if changes of a shoot do not correspond to a clinical picture, helps with many cases to establish the true diagnosis. For a long time the prolonged, slowly resolving infiltrates in the field of a caecum force to think sometimes of defeat by its actinomycosis. In such cases it is required to make the corresponding researches for specification of the diagnosis. The clinical picture of an acute mezenterialny tubercular mesadenitis is so similar with acute And., that most of patients is operated with the diagnosis And. Cases of appreciable diagnostic mistakes when the right-hand lung fever was accepted for acute are known And. also unnecessary operation was made.

Diagnosis hron. The ampere-second is put by the greatest reliability when in the anamnesis of the patient there are instructions on the postponed attack of acute Ampere-second development of infiltrates. Meets initially chronic less often And., when there is no instructions on an exacerbation of a disease in the past.

In many cases the diagnosis hron. And. it is put by process of elimination: it is necessary to subject the patient to careful inspection for an exception of diseases of a stomach and a duodenum, a gall bladder and bilious channels, a large intestine, a right kidney and an ureter, internal generative organs at women since many diseases of each of these bodies can be accepted for chronic And.

At suspicion on hron. And. surely make X-ray inspection of ileocecal area with filling by barium of a large intestine through a rectum to exclude a new growth of a caecum. It must be kept in mind that to be guided by each of the given clinical symptoms separately for exact establishment of the diagnosis it is impossible; only the general symptom complex of the phenomena and the careful analysis all clinical yielded and results of special researches allows to make the correct diagnosis and to offer surgical treatment.

Radiodiagnosis of appendicitis

Radiodiagnosis And. it is carried out in cases when establishment of the exact diagnosis is accompanied by serious difficulties owing to the atypical course of the disease caused by an unusual arrangement of a worm-shaped shoot and a caecum, its excess mobility, and also existence of the pathological processes in or out of an abdominal cavity able to simulate a clinical picture A., to accompany a disease or to complicate its current.

At acute And. make roentgenoscopy of bodies of chest and belly cavities in vertical position of the patient and a survey X-ray analysis of an abdominal cavity in vertical and horizontal (on spin and in lateroposition on the left side) provisions with obligatory inclusion in a zone of a research of area of a basin.

Fig. 6. Acute appendicitis. Horizontal fluid levels in a caecum (roentgenogram).

The main radiological signs indicating existence of inflammatory process in a worm-shaped shoot are: a) accumulation of liquid and gas in a caecum and a terminal loop ileal owing to their paresis that is followed by emergence of horizontal levels — Kloyber's (fig. 6) bowls; b) sometimes the left-side scoliosis of lumbar department of a backbone caused by a reflex spasm of the right lumbar muscle; c) an illegibility of an outside contour of a lumbar muscle owing to hypostasis of fabrics of a back abdominal wall; d) lack of contents in the right half of a large intestine (early tiflospazm); e) accumulation of gas in an appendix (infrequent, but very valuable sign); e) existence of small vials of free gas in an abdominal cavity or retroperitoneal space (at perforative And.).

For diagnosis chronic And. apply contrast X-ray inspection of a worm-shaped shoot, a caecum and a terminal loop ileal. The baric suspension is accepted inside (usually twice, to 14 hours and 6 hours prior to a research) or is entered by means of an enema. Sometimes it is necessary to apply both of these methods. Main radiological signs chronic And. consider: a) not filling or partial filling with the baric mass of an appendix caused by an obliteration of its gleam; b) the expressed deformation of a shoot; c) the unusual provision of a shoot which is combined with fixing by its commissures; d) long (to 2 — 3 days) delay of baric weight in a shoot — appendikostaz; e) the morbidity which is strictly localized in a projection of a worm-shaped shoot combined with appendiko-or ileostazy, deformation of a caecum, restriction of a smeshchayemost of a shoot; e) obyzvestvivshiyesya fecal stones (coprolites) in a shoot.

These radiological signs are not absolutely reliable, however in combination with clinical and datas of laboratory promote recognition And. and its complications.

Treatment and the forecast

At establishment of the diagnosis acute And. immediate operation irrespective of the term of a disease, except for cases with availability of sharply delimited, dense infiltrates is required. The best term for operation are the first 12 hours from the beginning of an attack; at the operation made in this period, deaths meet as a rare exception. At the same time in doubtful cases, at not clear symptoms of a disease, in initial stages, especially at young women and girls, waiting and observation is admissible a nek-swarm, it is obligatory in the conditions of a hospital, for identification of dynamics of a disease. At such thoughtful and careful studying of clinical disease it is possible to reduce number of operations at «the shoot which is not changed», keeping at the same time huge saving value and expediency of immediate operations at the established diagnosis acute And.

Purpose of laxative patient acute And. is extremely dangerous action, a cut can lead to development of peritonitis. Therefore any laxative (especially castor oil and salt laxative) is categorically contraindicated at the slightest suspicion on acute to A. Nedopustimo also use of a hot-water bottle and drugs at severe pains in a stomach until the issue of operation finally is not resolved.

Operation at acute And. in most cases comes down to appendectomies (see).

Sick acute Ampere-second availability of the delimited dense infiltrate in the right ileal area appoint a high bed rest, a sparing diet, antibiotics, cleansing enemas. In the first days appoint cold to area of infiltrate, and further for acceleration of a rassasyvaniye of infiltrate pass to thermal procedures. Treatment by a quartz lamp or radiation therapy has useful effect. The autohemotherapy gives good effect. If infiltrate under the influence of the carried-out treatment does not resolve, and, on the contrary, increases in sizes, it speaks about development of abscess. In these cases specification of the diagnosis requires manual inspection of a rectum.

If find protrusion of front its wall and suspect that the abscess went down in a cavity of a small pelvis, make at first a puncture and right there if find pus, opening of abscess through a wall of a rectum. If the abscess occupies the right ileal area, it is emptied the right side extra peritoneal section. The typical slanting section because of danger of infection of an abdominal cavity is made less often, only at unattainability of an abscess extra peritoneal access or through a rectum (or a vagina). After emptying of an abscess enter a thick drainage tube and tampons into it. During the opening of ileal abscess it is not obligatory to delete a shoot.

At timely operation the forecast is favorable.

Working capacity after postponed acute And. in the absence of complications it is recovered usually later 3 — 4 weeks after operation. Persons of physical work should extend the term of disability. At complicated acute And., especially in the presence of peritonitis, this term is considerably extended and considerably varies depending on weight of complications and existence of the residual phenomena (intestinal fistula, alloyed fistula, infiltrate, etc.).

Appendicitis at pregnant women

And. at pregnant women meets in the first half of pregnancy more often, is more rare — in the second and at the time of delivery; more often pervoberemenny get sick. Since 5th month of pregnancy the worm-shaped shoot together with a caecum changes the usual arrangement owing to shift up and kzad a pregnant uterus.

Shift and a prelum of a caecum, excesses at a tension of commissures lead to disturbance of blood circulation, a delay of emptying of a worm-shaped shoot that favors to development of an infection.

Early diagnosis has extremely important value And. at pregnant women. The arrangement of a zone of morbidity, atypical owing to shift of a caecum, poorly expressed pain syndrome, difficulty of identification of muscular tension at the stretched abdominal wall complicate diagnosis acute And. at pregnant women. The reflex tension of an abdominal wall can be absent since often inflammatory center at the shift of a caecum does not adjoin to a front parietal peritoneum.

At acute And. pregnant women can have a pain in the right half of a stomach during the pressing on the left edge of a uterus. Temperature increase, increase of pulse, a leukocytosis with neutrophylic shift to the left and the careful accounting of anamnestic data, especially at instructions on attacks And. in the past, help establishment of the diagnosis of acute A. Neredko at acute And. at pregnant women from objective symptoms it is possible to establish only increase of pulse and a leukocytosis.

It is extremely difficult to distinguish acute And. at the time of delivery, since labor pains shade a clinical picture of a disease, and tension of an abdominal wall is poorly expressed. Recognition is helped by the expressed local morbidity with the right half of a stomach at a palpation in situation on the left side, morbidity in the same area at the movement by the right leg, a leukocytosis and a neutrocytosis with shift to the left.

Clinical picture acute And. during pregnancy often does not correspond to morphological changes in a shoot; quite often at destructive And. symptoms of a disease happen erased.

At diagnosis of an acute appendicitis at pregnant women it is necessary to exclude diseases went. - kish. path, kidneys and ureters, inflammation of appendages of a uterus, twisting of a leg of a tumor of an ovary, and also right-hand pneumonia. In the course of differential diagnosis observation and an additional research of patients during 1 — 2 hour, and also holding actions for prevention of premature abortion is admissible.

Simple forms acute And. occur at pregnant women on average in 63%, destructive — in 37% of cases. Repeated attacks acute And. happen at pregnant women in 30 — 50% of cases.

At the sacculated periappendikulyarny abscess at the time of delivery or abortion of commissure can be broken that leads to hit of pus in an abdominal cavity and to development of peritonitis. Peritonitis of an appendicular origin at pregnant women proceeds very adversely since the worm-shaped shoot is highly located and displaced as well as because the pregnant uterus interferes with accumulation and encystment of pus in rectal and uterine space.

At perforation of a worm-shaped shoot in the second half of pregnancy of encystment of a periappendikulyarny exudate does not occur, and diffuse peritonitis quickly develops. If there is encystment due to formation of commissures to a uterus, then exudate, irritating a serous cover of a uterus, causes its reductions leading to an abortion or premature births.

By the only method of treatment acute And. at pregnant women operation is.

At bystry disappearance of all signs acute And., improvement of the general state tactics of the surgeon shall be strictly individual, it depends on a condition of the patient, on durations of gestation, features of its current, etc. So, at pregnancy to 20 weeks and disappearance of signs acute And., but in the presence of the raised tone of a uterus and threat of premature abortion it is necessary to carry out treatment, the warning premature abortion then it is better to make appendectomy. At pregnancy over 20 weeks (and especially after 30 weeks) at bystry disappearance of the phenomena acute And. and improvement of the general state it is necessary to carry out conservative treatment (a bed rest, an antibioticotherapia, a sparing diet), and also the therapy warning misbirth (see). At repeated emergence of symptoms acute And. or at suspicion on it the immediate surgery is shown.

At hron, recurrent And. at pregnant women operation is shown. At pregnancy over 30 weeks conservative therapy and observation of the surgeon and obstetrician-gynecologist is more reasonable.

At uncomplicated acute And. make appendectomy, sew up a belly wound tightly and take measures to preservation of pregnancy.

In the presence of limited peritonitis after removal of a worm-shaped shoot in an abdominal cavity leave a rubber catheter for the subsequent introduction of antibiotics.

During operation care with fabrics, bodies and especially pregnant uterus since rough traumatic operation, excessively big section, rough manipulations at search of a shoot increase the frequency of abortions and premature births is necessary. If the shoot is covered with a pregnant uterus, the patient should be laid on the left side that the uterus was displaced to the left and there was more available a caecum. If childbirth occurs in 1 — 2 day after operation, then is shown in the second period of childbirth to resort to operation of imposing of obstetric nippers.

At a favorable current of the postoperative period and lack of symptoms of abortion it is possible to allow the woman to rise on 4 — the 5th day.

At phlegmonous perforative and gangrenous And. pregnancy most often is interrupted.

The developed patrimonial activity, change of situation and volume of a uterus after its emptying break process of encystment of exudate and generalizations of peritonitis promote.

At initial symptoms of peritonitis or if operation at perforative And. it is made in the first days from the beginning diseases it is possible to refrain from abortion, and an abdominal cavity, to drain a rubber catheter.

At the remained pregnancy after appendectomy the long bed rest is shown.

At diffuse purulent peritonitis and delivery Caesarian section make supravaginal amputation or is more rare a hysterectomy. Then delete a shoot at an abdominal cavity drain. Reasonablly additional drainage of an abdominal cavity through, a back vault of the vagina.

In the presence at pregnant women of appendicular infiltrate conservative treatment in the conditions of a hospital is applied (see above). After a rassasyvaniye of infiltrate (usually in 4 — 6 weeks) make appendectomy.

In need of abortion at the woman who transferred appendectomy, abortion should be made not earlier than in 2 — 3 weeks after operation on condition of a smooth current of the postoperative period.

Appendicitis at children

Acute And. meets at children's age quite often and proceeds much heavier, than at adults. At babies the disease is observed seldom, but further its frequency increases, reaching the largest frequency at the age of 9 — 12 years. Girls and boys are ill equally often. Acute And. at children it is characterized by the following features: small specificity of a clinical picture, bystry development of destruction in a worm-shaped shoot, early approach of complications (is more often than diffusion and diffuse peritonitis).

Small specificity of a clinical picture is connected with the inferiority coordinating roles of c. N of page at early children's age, tendency, to irradiation of nervous impulses, extensiveness of viscerovisceral bonds, bystry approach of intoxication owing to the increased resorptive ability of a peritoneum.

Clinical displays of an acute appendicitis at the senior children, unlike patients to 3 — 4-year age, are similar to those at adults. In a younger age group acute And. begins with the general phenomena. The instructions of parents on change of behavior of children who in 76% of cases from the very beginning of a disease become uneasy, whimsical are important. Existence of pain causes a sleep disorder. Vomiting meets often (75%), and its recurrence is possible. Temperature usually increases, sometimes reaching high figures. At 12% of patients the liquid chair, sometimes with slime is noted. The hyperleukocytosis is possible (over 15 000). Complaints to pain in the right ileal area at this age almost do not meet. Usually the child points to area around a navel, as well as at any intercurrent disease at children proceeding with an abdominal syndrome. Such localization of pain, in addition to the moments mentioned above, is connected with a close arrangement of a number of the interested neuroplexes to a root of a mesentery and bystry development of a mesadenitis. If there are no direct instructions on an abdominal pain, then are guided by its equivalents: a sleep disorder, reduction of hips to a stomach (especially in a prone position on the right side), «sucheniye» legs, concern at a postural change of a body, careless touch to a stomach during disguise.

Inspection of the small child presents considerable difficulties owing to his negativism, concern and an active muscle tension of an abdominal wall. Are guided by objective symptoms: the place of the greatest morbidity, a passive muscle tension in the bottom of a stomach on the right, a positive symptom of Shchetkin — Blyumberg or signs equivalent to it. The first two symptoms are most valuable. Detection of these data demands considerable expense of time from the uneasy child. It is important to contact with the little patient. Pay attention to that the palpation was gradual, comparative and repeated. Carefully put a hand on the left half of a stomach, on its lower parts, and wait for a breath, at height to-rogo the active muscle tension disappears. Manipulation is repeated several times. The same is reproduced on the right. At the same time becomes noticeable that in comparison with the left half the abdominal wall relaxes on a breath less. It should be noted that the doskoobrazny or expressed muscular tension at acute And. at this age almost does not meet therefore are guided only by moderate, but constant rigidity.

Along with search of passive tension determine the place of the greatest morbidity by reaction of the patient. At a careful palpation more expressed reaction of the child in the form of concern is noted on the right, than at a research at the left.

Existence of a symptom of Shchetkin — Blyumberg is also judged on comparative reaction of the child during a palpation of a stomach: the bigger concern of the child at an otnyatiya of a hand is noted, than at a palpation. It is better to use, however, less traumatic equivalents it — percussion of an abdominal wall through a finger or direct.

Especially valuable method helping with the most difficult cases — inspection of the sick child during sleep when negative psychogenic reaction and the related active muscle tension of a front abdominal wall are absent. However the research during a physiological dream is quite often connected with undesirable loss of time. In recent years the research of the child is implemented into practice during medication sleep.

In the conditions of a hospital do to the child a small hypertensive enema. After a chair enter a catheter on distance of 10 — 15 cm into a rectum. On a catheter install warm 3% aqueous solution of Chlorali hydras in the following dosages: to children till 1 year — to 10 ml, from a year to 2 years — 15 — 20 ml, from 2 to 3 years — 20 — 25 ml. In 15 — 20 min. after administration of Chlorali hydras there comes the superficial dream, in time to-rogo it is possible to reveal easier the passive muscular tension, local morbidity and Shchetkin's symptom — Blyumberg.

The differential diagnosis

In the senior age group acute And. most often it is necessary to differentiate with a coprostasis, food toxicoinfections, renal colic, inflammatory process in appendages of a uterus, a rupture of an oothecoma, a helminthic invasion, rheumatism, a diverticulitis. Differential diagnosis at children of early age is most difficult. First of all it shall be carried out with infectious diseases, nonspecific mezenterialny lymphadenitis, with a coprostasis, diseases went. - kish. a path, and also the otitis and pneumonia proceeding, as a rule, with abdominal pains. In these cases there are signs of a basic disease, there is no constant muscular protection.

Considering complexity of diagnosis, at the child with abdominal pains or their equivalents it is always necessary to suspect acute A. Rebenka with abdominal pains it is necessary to consult with the surgeon; at impossibility to exclude acute And. it is necessary to hospitalize the child for dynamic observation. Prescription of antibiotics since they stushevyvat sharpness of clinical manifestations is contraindicated. At small children in doubtful cases active surgical tactics is preferable.

Existence acute And. at the child at any age, as well as at the adult, is the absolute indication to operation — appendectomy (see. Appendectomy ).

Appendicism at children — rather rare disease (about 6% of all appendectomies) which meets usually later 7 — 8-year age. Clinical manifestations are similar to those at adults. The diagnosis is quite difficult and can be put only after careful clinical inspection with an exception first of all of diseases of kidneys and urinary tract, a nonspecific mesadenitis, helminthoses, and at girls — and pathologies from genitalias.

Bibliography

Baradulin G. I. Appenditsit, M., 1903, bibliogr.; Velikoretsky A. N. Alimentary theory of an origin of appendicitis, Vestn. hir., t. 4, book 10-11, page 151, 1924; In about lx about in and the p H. M. Appenditsit, Cholelithiasis, Tubercular peritonitis, Kiev, 1926, bibliogr.; Strong E. D. Klinika and morphology of an acute appendicitis, Kiev, 1964, bibliogr.; Kolesov V. I. Clinic and treatment of an acute appendicitis, JI., 1972, bibliogr.; Rose trees V. N. Appenditsit, Zhurn. sovr. hir., t. 2, No. 4, page 675, 1927; Rostovtsev M. I. The doctrine about a perityphlitis, SPb., 1909, bibliogr.; I at r e G. G. The clinical value of painful symptoms at an appendicism, the Russian wedge., t. 1, No. 4, page 578, 1924; As with ho ff L. Die Wurmfortsatzentzündung, Jena, 1908; about N of e, Pathogenese und Ätiologie der Appendicitis, Ergebn. inn. Med. Kinderheilk., Bd 9, S. 1, 1912; Ciminata A. Pato-logica chirurgica, p. 527, Milano, 1955; Fitz H.H. Perforating inflammation of the vermiform appendix, Amer. J. med. Sei., n. s., v. 92, p. 321, 1886; G about 1 d-hahn R. u. Jorns G. Lehrbuch der speziellen Chirurgie, Bd 2, S. 172, Lpz., 1956; G u with with i G. L’addome acuto nel quar-do diagnostico della appendicite acuta, Firenze, 1955, bibliogr.; Karn H. History of acute appendicitis, N. Z. med. J., v. 49, p. 400, 1950; McB urneyC. Experience with early operative interference in cases of disease of the vermiform appendix, N. Y. med. J., v. 1, p. 676, 1889; Nouveau traitä de technique chirurgicale, publ. sous la dir. de J. Patel et L. Leger, t. 11, P., 1969; Sonneburg E. Pathologie und Therapie der Perityphlitis (Appendicitis), Lpz., 1913; Sprenge IO. Appendicitis, Stuttgart, 1906.

Pathological anatomy of A.

Apricots of A. I. Inflammations of intestines, Mnogotomn. the management on a stalemate. annate., under the editorship of A. I. Strukov, t. 4, book 2, page 77, M., 1957; Davydovsky I. V. and Yudin V. S. K to a question of normal worm-shaped shoots in surgical practice, Klin, medical, t. 42, No. 6, page 8, 1964; Kaliteevsky P. F. Diseases of a worm-shaped shoot, M., 1970; Collins D. Page 71000 human appendix specimens, Amer. J. Proctol., v. 14, p. 365, 1963, bibliogr.; Moreliead R. P. Human pathology, p. 1051, N. Y. and. lake, 1965.

Radiodiagnosis And.

3edgenidze G. A. and Lindenbraten L. D. Urgent radiodiagnosis, page 290, L., 1957; N.G. and Lazarev K. N. pine forests. Radiodiagnosis of an appendicism and the long-term results of operational treatment of patients, It is new. hir. arkh., No. 12, page 59, 1961, bibliogr.; Zhukov S. G Shchyokotovg.M. Clinicoradiological parallels at an appendicism, Surgery, No. 10, page 79, 1970, bibliogr.; Shcherbatenko M. K., Beresnyo-v and E. A. and E in d about to and m about in V. N. X-ray inspection in diagnosis of an acute appendicitis, Vestn. rentgenol, and radio-gramophones., No. 1, page 18, 1970, bibliogr.; Brooks D. W.a.K il lenD.A. Roentgeno-graphic findings in acute appendicitis, Surgery, v. 57, p. 377, 1965, bibliogr.; Casper R.B. Fluid in the right flank as a roentgenographic sign of acute appendicitis, Amer. J. Roentgenol., v. 110, 1970.

And. at pregnant women

Braude I. L. L. S's ipersianin. Acute management at obstetric and gynecologic pathology, page 171, M., 1962; Dekhtyar E. G. An acute appendicitis at women, page 81, M., 1971, bibliogr.; Ivanov G. I. of Appenditsit at pregnant women, M., 1968, bibliogr.; Persianinov L. S. Obstetric seminar, t. 2, page 106, Tashkent, 1973.

And. at children

Drones A. T. both Burkov of I. V. Klinik and diagnosis of an acute appendicitis at children of early age, Pediatrics, No. 8, page 33, 1969; Isakov Yu. F. and d river. Appendicular peritonitis at children, in book: Materials dokl. 2nd Vseros. konf. children's surgeons, page 17, Kaliningrad, 1966; Lyonyushkin A. I., Vorokhobov L. A. and Slutskaya S. R. An acute appendicitis at children, M., 1964; Moskvin V. I. A helminthic invasion at appendicitis at children, Surgery, No. 4, page 84, 1971; Ovchinni

of A. A. Iburkov's k of I. V. Razlitoy purulent peritonitis at children, M., 1972; Stepanova M. N. and Stakhov-s to and I am S. N. Prichiny of a lethality at an acute appendicitis at children, Surgery, No. 7, page 26, 1970, bibliogr.; Shchitinin V. E. Differential diagnosis of an acute appendicitis and dysentery at children, a tamzha, page 31, bibliogr.; G of about s s R. E. The surgery of infancy and childhood, Philadelphia, 1953; Lilly J.R.a. Randolph J. G. Total inversion of the appendix, experience with incidental appendectomy in children, J. pediat. Surg, v. 3, p. 357, 1968, bibliogr.

B. A. Petrov; Yu. F. Isakov (ped.), P.F. Kaliteevsky (stalemate. An.), A. N. Kishkovsky (rents.), L. S. Persianinov (academician).

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