Abscess after appendicitis cause. Possible early postoperative complications in appendicitis

Acute appendicitis is a very common surgical pathology. Such a disease requires urgent surgical intervention, otherwise serious and life-threatening complications may develop. One of these complications is considered to be an appendicular abscess - suppuration in the area of ​​\u200b\u200bthe inflamed appendix.

ICD-10 code

K35.1 Acute appendicitis with peritoneal abscess

Epidemiology

Appendicular abscess is diagnosed relatively rarely: in about 0.1-2% of patients with acute appendicitis.

As a rule, an appendicular abscess develops in the first three days from the onset of an acute inflammatory process in the appendix, or occurs as a complication of the infiltrate (a few days or a few weeks after its formation).

Causes of an appendicular abscess

The development of an appendicular abscess occurs only when there is no correct or timely treatment acute appendicitis. Unfortunately, it is impossible to predict acute inflammation in the appendix in advance. In addition, pathology is often mistaken for other types of inflammatory processes in the abdominal cavity. Time delay and incorrect diagnosis lead to the destruction of the inflamed tissues of the appendix, with the development of peritonitis or appendicular abscess. There are certain risk factors, the presence of which increases the risk of late detection of appendicitis, and, as a result, the formation of an appendicular abscess:

• Atypical localization of the appendix can lead to an initially incorrect diagnosis - inflammation of the kidneys, uterus, ovaries, enterocolitis, cholecystitis. As a result, the patient is offered treatment for other diseases, instead of urgent surgery. In this case, the diagnosis of appendicitis becomes clear only when an abscess is formed.
• Strong antibiotic treatment at the time of initial inflammation in the appendix, it can lead to a decrease in the inflammatory response and the formation of the so-called "cold" abscess - a sluggish process that can take place for several years without disturbing the patient.
• Delayed seeking medical attention for acute appendicitis often results in the development of an appendicular abscess.

Pathogenesis

There is a primary abscess, which occurs directly near the appendix, and a secondary one, which develops at some distance. The formation of an abscess is preceded by the appearance of an appendicular infiltrate - a kind of fencing of the inflamed appendix from the space of the abdominal cavity.

The formation of an infiltrate is a consequence of fibrin effusion and adhesions of the affected omentum, intestine, abdominal wall and appendix.

After the inflammation subsides in the appendix, the infiltrate is resorbed. But in the case when the purulent process diverges beyond the appendix, the infiltrate suppurates.

The location of an appendicular abscess depends on the location of the appendix. It is more favorable for the patient if an abscess is formed in the iliac zone against the background of the lateral location of the process: it is in this position that the maximum fencing of the inflamed area from the abdominal cavity is observed.

Secondary appendicular abscess is formed somewhat differently. The purulent process, spreading to healthy tissues, affects the region of the mesentery of the small intestine, the area near the liver, diaphragm and right kidney. According to a similar scheme, secondary appendicular abscesses are formed after resection of the appendix with destructive inflammation.

Symptoms of an appendicular abscess

The beginning of the development of an appendicular abscess by nature clinical course little different from acute appendicitis.

The first signs may look like this:

• the patient feels sick, vomiting may occur;
• appears great weakness;
• the pain in the abdomen is throbbing, it grows and becomes unbearable;
• there is bloating, increased gas formation;
• body temperature rises.

On palpation of the abdomen, the patient feels severe pain, but there are no symptoms of peritonitis. Body temperature is high (up to 40°C), accompanied by chills.

These symptoms may persist for 2-3 days.

Appendicular abscess in children

During the appendicular abscess in children, doctors distinguish several stages, by analogy with peritonitis:

1. Reactive stage - lasts about a day from the onset of inflammation. The stage is characterized by the appearance in the child of general signs of an inflammatory reaction. This may be a change in mood, vomiting, increased heart rate, febrile temperature. Increasing pain in the abdomen, abdominal muscles tense during palpation.
2. Toxic stage - lasts 1-3 days. There are symptoms of severe intoxication and dehydration: the child's skin is pale, his eyes shine, vomiting attacks become permanent.
3. The terminal stage - is detected on the 3rd day and is characterized by damage to the whole organism. First of all, the internal organs suffer, there are signs of respiratory and cardiovascular insufficiency.

After the reactive stage, the child's condition may mistakenly improve - the pain will become less pronounced. However, over time, the baby's well-being sharply becomes worse. At the same time, there is a trend: older child, the longer the period of false improvement may be.

Complications and consequences

With the development of an appendicular abscess, it is of great importance how fast the medical care was - it is on this fact that the severity of the consequences primarily depends.

If medical assistance was not provided at all, or provided, but too late, then the death of the patient may occur.

Timely and qualified medical intervention provides every chance for a complete recovery of the patient.

Most possible complications appendicular abscess can become:

• sepsis - systemic inflammatory reaction;
• gangrenous lesions of internal organs;
• adhesive process;
• peritonitis;
• liver failure.

For the most part, complications of appendicular abscess pose a serious danger not only to health, but also to the life of the patient. The reason for this is a purulent infection, which spreads throughout the body in a short time.

Diagnosis of an appendicular abscess

At the first sign of appendicitis, the patient must be immediately taken to medical institution. Doctor in without fail examine the patient, probe the abdomen and assess the patient's condition as a whole.

Diagnostic measures for suspected appendicular abscess always include blood and urine tests.

A blood test will indicate the presence of a pronounced inflammatory process: an increasing leukocytosis is detected with a shift of the leukocyte formula to the left, accelerated ESR.

Instrumental diagnostics can be represented by ultrasound examination of the abdominal cavity, x-ray examination, and in difficult cases- diagnostic puncture, laparocentesis (peritoneal puncture with fluid removal) and laparoscopy.

The sonographic sign of an appendicular abscess is the presence of an anechoic formation with irregular outlines, with the detection of detritus in its lumen. If the abscess is not large, then it is difficult to distinguish it from the loops of the intestines. To clarify the diagnosis, an ultrasound examination is performed in dynamics to determine the clear configuration of the intestine.

Differential Diagnosis

Differential diagnosis of appendicular abscess is difficult and is carried out with the following diseases:

• with food poisoning (especially with a lesion staphylococcal infection);
• with preperforative state peptic ulcer stomach and duodenum;
• with perforation of a stomach ulcer;
• With acute attack cholecystitis;
• with hepatic colic in cholelithiasis;
• with acute inflammation of the pancreas;
• with acute enterocolitis;
• with acute ileitis (nonspecific inflammation of the intestine);
• with diverticulitis and its perforation;
• with acute intestinal obstruction;
• with an acute inflammatory process in the uterus and / or appendages, with intrauterine pregnancy;
• with pelvioperitonitis;
• with right hand renal colic or right-sided pyelonephritis.

Treatment of appendicular abscess

There should be no delay in the treatment of an appendicular abscess, otherwise the abscess may break through, which will invariably lead to the development of peritonitis. It is strictly forbidden to drink laxatives, anti-inflammatory and painkillers with an appendicular abscess, as well as apply a warm heating pad to the stomach. At the prehospital stage, the patient should be provided with rest with mandatory bed rest. You can apply cold to the stomach.

The only true and adequate treatment appendicular abscess is an urgent surgical intervention, which consists of the removal of the abscess, followed by the setting of the drainage. During the operation, the surgeon removes dead tissue and cleans purulent cavity.

In the period after the operation, antibiotic therapy and washing of the wound with antiseptic solutions through the established drainages are prescribed.

Medicines for appendicular abscess

vitamins

After the operation, during the rehabilitation period, the doctor will prescribe vitamins to accelerate healing and restore the intestinal flora. To maintain the body, experts advise drinking dried fruit compotes, rosehip infusion, etc. Additionally, you can take B vitamins, ascorbic acid, vitamin A.

Rapid recovery after surgery is facilitated by taking vitamin and mineral complex preparations:

• Vitrum is a multivitamin complex tool, which is most suitable for improving the condition of the body in the postoperative period, as well as for intensive treatment with antibiotics and other strong drugs. Vitrum is taken immediately after meals, 1 tablet daily for several months.
• Alphabet is a multivitamin and polymineral remedy that perfectly fills the increased need for minerals and vitamins during a critical period for the body. Three tablets of different colors are taken per day, maintaining a time interval between doses of 4 hours. The alphabet is taken with meals, for at least one month.
• Supradin is a drug recommended by doctors during illness and rehabilitation. Supradin is perfectly absorbed in the body, thanks to its effervescent form - it is enough to take 1 effervescent tablet daily, after dissolving it in 100 ml of water.
• Perfectil is a vitamin and mineral complex preparation that accelerates cell regeneration, normalizes cellular metabolism, has wound healing, antioxidant and dermatoprotective properties. Perfectil is taken 1 capsule daily, after meals, preferably in the first half of the day.

Physiotherapy treatment

After surgery for appendicular abscess, a number of effective methods of physiotherapy are used, which helps to accelerate the rehabilitation of patients. At the same time, physical procedures that have a thermal effect are used extremely carefully.

First of all, physiotherapeutic procedures should be aimed at stimulating the healing process in the area of ​​surgical intervention:

• infrared laser treatment;
• ultrasound treatment;
• pelotherapy;
• low-frequency magnetotherapy;
• DMV treatment.

If the goal is to eliminate pain, then low-frequency electrotherapy, galvanization and drug electrophoresis are used.

Later it is shown Spa treatment, balneotherapy, hydrotherapy.

Alternative treatment

Folk recipes will come in handy during the postoperative recovery period. Means proven over the years will help to improve digestion, eliminate constipation and diarrhea, restore appetite, strengthen immunity, and also stimulate the rapid healing of the wound.

• Ginger root and fresh garlic cloves are effective foods for reducing the effects of inflammation and for normalizing digestive processes. If you add grated ginger and garlic in small amounts to food 1-2 times a day, you can quickly recover from serious illnesses and operations.
• A mixture based on lemon juice and fresh honey will bring great benefits to the body. This mixture will improve digestion, strengthen immune defenses. Every day it is enough to use 2-3 cups of warmly boiled water with the addition of 2 teaspoons of the medicinal mixture.
• If you drink burdock tea 3-4 times a day, you can prevent the development of the inflammatory process and improve overall well-being after the disease. Burdock can be combined with dandelion, but only if the patient does not take medications that lower blood pressure.

It is recommended to introduce freshly squeezed juices into the daily diet, especially from beets, carrots, spinach or cucumber, as well as drink enough warm clean water - this will help prevent constipation, which is highly undesirable during the rehabilitation period after an appendicular abscess.

Herbal treatment

In order to eliminate the consequences of the inflammatory process and relieve pain, treatment with medicinal plants can be applied. Herbal infusions and decoctions are a good and affordable remedy that will bring invaluable benefits to the body.

• Wormwood tincture can help at any stage of inflammation: in the morning before breakfast and at night, take 20 drops of tincture in 100 ml of water.
• Clover grass in the amount of 1 tbsp. l. pour 300 ml of boiling water and leave for 20 minutes. Drink three times a day, 100 ml after meals.
• Prepare a medicinal mixture from the same parts of the leaves of strawberries, raspberries and yarrow. Brew 2 tbsp. l. mixture in 1 liter of boiling water, insist for a quarter of an hour and drink throughout the day.

Teas based on mint, thyme, cumin, and chamomile also have an analgesic and calming effect. Such teas are brewed instead of regular black or green tea and are drunk little by little throughout the day. Similar treatment can be continued up to several weeks in a row.

Homeopathy

After surgery, homeopathic remedies can be connected to the treatment:

• Lachesis - 6-hundred dilution, 2 granules for 10 days;
• Bellis Perrenis - with severe postoperative pain, in low and medium dilutions, depending on the severity of the patient's condition;
• Hypericum - with sharp postoperative pain and paresthesia, 6 or 30 hundred dilution, depending on the severity of the patient's condition;
• Gepar Sulfur - for restriction purulent inflammation and improved evacuation of pus, 3 or 6 hundredth dilution, depending on the individual patient.

Of course, homeopathy cannot and should not replace traditional medicine, but it effectively complements it, contributing to the rapid recovery of the body, without excessive stress and side effects.

Surgical treatment

Features of surgical treatment of appendicular abscess are determined depending on its location.

Most often, a skin incision of approximately 10 cm is made over the right inguinal ligament near the iliac crest and superior anterior ilium. The skin is split subcutaneous tissue, fascia, and external oblique muscle of the abdomen. The internal oblique and transverse muscles are divided along the fibers.

With the help of a finger, the volume and localization of the abscess are examined. The appendix is ​​removed only when it is absolutely accessible, since there is a risk of pus getting inside the abdominal cavity.

The purulent cavity is cleaned and drained by placing a tube wrapped in a gauze swab to prevent the formation of a bedsore on the wall of the inflamed caecum. The tube is fixed to the skin, mainly in the lumbar region.

After surgery, treatment is aimed at preventing possible complications and activating defensive forces organism.

Opening of the appendicular abscess according to Pirogov

As a rule, an appendicular abscess is opened using extraperitoneal access according to Pirogov, or according to Volkovich-Dyakonov.

An autopsy according to Pirogov is used for an abscess located in the depths of the right iliac region. The surgeon performs a dissection of the anterior abdominal wall to the layer of the parietal peritoneum, from top to bottom and from right to left, approximately 10 mm medial to the upper horizontal iliac spine, or 20 mm lateral to the Volkovich-Dyakonov incision. After that, the parietal peritoneum is separated from inner region iliac bone, exposing the outer side of the abscess.

An autopsy according to Volkovich-Dyakonov is carried out with the appendicular abscess adjacent to the anterior abdominal wall.

After the abscess is opened and sanitized, if an appendix is ​​found in it, it is removed. A tampon and drainage are installed in the purulent cavity. The abdominal wall is sutured to the drainage tube.

Forecast

During the inflammatory purulent process, spontaneous opening (rupture) of the appendicular abscess can occur in the intestinal lumen, in the abdominal cavity or behind the peritoneum, less often - in the cavity of the bladder or vagina, even more rarely - outward. Therefore, the course of an acute illness can be complicated, and such complications are extremely unfavorable for the health and life of the patient.

Based on this, the prognosis of such a pathology as an appendicular abscess is considered very serious. Its consequences completely depend on how timely and competent the medical care was, how well and timely the operation was performed.

Complications of appendicitis are formed depending on the time of the course of the inflammatory process. The first day of the pathological process, as a rule, is characterized by the absence of complications, since the process does not go beyond the appendix. However, in the event of late delivery or improper treatment, after a few days, complications such as perforation of the process, peritonitis or thrombophlebitis of the mesenteric veins may form.

To prevent the development of complications of acute appendicitis, it is necessary to contact the medical institution. A timely diagnosed pathology and an operation to remove the inflamed appendix is ​​a prevention of the formation of life-threatening conditions.

Classification

Complications of appendicitis are formed under the influence of various factors. Many of the following consequences can develop in the human body both in the preoperative period and after surgery.

Preoperative complications are formed from the prolonged course of the disease without treatment. Occasionally pathological changes appendix can occur due to incorrectly chosen treatment tactics. On the basis of appendicitis in the patient's body, such dangerous pathologies can form - appendicular infiltrate, abscess, retroperitoneal phlegmon, pylephlebitis and peritonitis.

A postoperative complications characterized by clinical and anatomical features. They may appear several weeks after the surgical treatment. This group includes the consequences that are associated with postoperative injuries and pathologies of neighboring organs.

The consequences after the removal of appendicitis can develop according to different reasons. Most often, clinicians diagnose complications in such cases:

• late seeking medical attention;
• late diagnosis;
• errors in the operation;
• non-compliance with the recommendations of the doctor in the postoperative period;
• development of chronic or acute diseases of neighboring organs.

Complications in the postoperative period can be of several varieties depending on the localization:

• together operating wound;
• in the abdominal cavity;
• in neighboring organs and systems.

Many patients are interested in the question, what are the consequences after the surgical intervention. Clinicians have determined that complications after surgery are divided into:

• early - can form within two weeks after surgery. These include the divergence of the edges of the wound, peritonitis, bleeding and pathological changes from nearby organs;
• late - two weeks after surgical treatment, wound fistulas, suppuration, abscesses, infiltrates, keloid scars, intestinal obstruction, and adhesions in the abdominal cavity may form.

Perforation

Perforation is an early complication. It is formed a few days after the inflammation of the organ, especially in the destructive form. With this pathology, purulent fusion of the walls of the appendix and the outflow of pus into the abdominal cavity occur. Perforation is always accompanied by peritonitis.

Clinically pathological condition characterized by the following manifestations:

• progression of pain in the abdomen;
• high fever;
• nausea and vomiting;
• intoxication;
• positive symptoms of peritonitis.

In acute appendicitis, perforation of the organ is manifested in 2.7% of patients in whom therapy began in the early stages of the formation of the disease, and in the later stages of the formation of the disease, perforation develops in 6.3% of patients.

Appendicular infiltrate

This complication is typical for acute appendicitis in 1-3% of patients. It develops due to the late treatment of the patient for medical help. The clinical picture of the infiltrate appears 3–5 days after the development of the disease and is provoked by the spread of the inflammatory process from the appendix to nearby organs and tissues.

In the first days of the pathology, a clinical picture of destructive appendicitis is manifested - severe abdominal pain, signs of peritonitis, fever, intoxication. At a late stage of this consequence, the pain syndrome subsides, the patient's general well-being improves, but the temperature is kept above normal. On palpation of the appendix area, the doctor does not determine the muscular tension of the abdomen. However, in the right iliac zone, a dense, slightly painful and inactive mass can be determined.

In the case of diagnosing an appendicular infiltrate, the operation to remove (appendectomy) the inflamed appendix is ​​postponed and conservative therapy is prescribed, which is based on antibiotics.

As a result of therapy, the infiltrate can either resolve or abscess. If there is no suppuration in the inflamed area, then the formation may disappear after 3-5 weeks from the moment the pathology develops. In the case of an unfavorable course, the infiltrate begins to suppurate and leads to the formation of peritonitis.

Appendicular abscess

Complicated forms of acute appendicitis are formed at various stages of the progression of the pathology and are diagnosed in only 0.1–2% of patients.

Appendicular abscesses can form in the following anatomical regions:

• in the right iliac region;
• in the recess between bladder and rectum (Douglas pocket) - in men and between the rectum and uterus - in women;
• below the diaphragm
• between intestinal loops;
• retroperitoneal space.

The main signs that will help to establish a complication in a patient are the following manifestations:

• intoxication;
• hyperthermia;
• an increase in leukocytes and a high level of ESR in the general blood test;
• pronounced pain syndrome.

An abscess of the Douglas space, in addition to general symptoms, is characterized by dysuric manifestations, frequent urge to defecate, a feeling of pain in the rectum and perineum. It is possible to palpate a purulent formation of this localization through the rectum, or through the vagina - in women.

Subphrenic abscess manifests itself in the right subphrenic recess. In the case of the development of purulent formation, there are bright pronounced signs intoxication, shortness of breath, unproductive cough and chest pain. When examining the inflamed area, the doctor diagnoses a soft abdomen, a large liver volume and pain on palpation, light and barely perceptible breathing in the lower right lung.

Interintestinal purulent formation is characterized by a mild clinic on early stages pathological process. As the abscess grows, tension in the muscles of the abdominal wall, attacks of pain appear, the infiltrate is palpated, and a high body temperature is noted.

An appendicular abscess can be diagnosed with the help of an ultrasound of the abdominal cavity, and the disease is eliminated by opening a purulent formation. After washing the cavity, drainage is installed in it, and the wound is sutured up to the tube. The following days, the drainage is washed to remove the remnants of pus and introduce drugs into the cavity.

Pylephlebitis

Such a complication of acute appendicitis as pylephlebitis is characterized by severe purulent-septic inflammation portal vein of the liver with the formation of multiple abscesses. It is characterized by the rapid development of intoxication, fever, an increase in the volume of the liver and spleen, pallor of the skin, tachycardia and hypotension.

The lethal outcome in this pathology reaches 97% of cases. Therapy is based on the use of antibiotics and anticoagulants. If abscesses have formed in the patient's body, then they must be opened and washed.

Peritonitis

Peritonitis is an inflammation of the peritoneum, which is a consequence of acute appendicitis. The local delimited inflammatory process of the peritoneum is characterized by the following clinical picture:

• severe pain syndrome;
• hyperthermia;
• blanching of the skin;
• tachycardia.

The doctor can identify this complication by determining the symptom of Shchetkin-Blumberg - with pressure in the painful area, the pain does not increase, and with a sharp release, more pronounced pain appears.

Therapy consists in the use of conservative methods - antibacterial, detoxification, symptomatic; and surgical drainage of purulent foci.

Intestinal fistulas

One of the late complications that appear after the removal of appendicitis are intestinal fistulas. They appear when the walls of the nearest intestinal loops are damaged, followed by destruction. Also, the reasons for the formation of fistulas include such factors:

• broken process processing technology;
• squeezing the tissues of the abdominal cavity with too dense gauze napkins.

If the surgeon has not completely closed the wound, then intestinal contents will begin to flow through the wound, which leads to the formation of a fistula. With a sutured wound, the symptoms of the disease worsen.

In case of formation of fistulas, 4–6 days after the operation to eliminate the organ, the patient feels the first pain attacks in the right iliac zone, where a deep infiltrate is also revealed. In extreme cases, doctors diagnose symptoms of poor bowel function and peritonitis.

Therapy is prescribed by a doctor individually. Drug treatment is based on the use of antibacterial and anti-inflammatory drugs. Apart from drug treatment, surgical removal of fistulas is performed.

Voluntary fistula opening begins 10–25 days after surgery. In 10% of cases, this complication leads to the death of patients.

Based on the foregoing, we can conclude that it is possible to prevent the formation of complications of appendicitis by seeking medical help in a timely manner, since timely and correct appendectomy contributes to the fastest recovery of the patient.

Acute appendicitis (acute inflammation of the appendix of the caecum) is one of the most common causes.” acute abdomen” and the most common pathology of the abdominal organs requiring surgical treatment. The incidence of appendicitis is 0.4-0.5%, occurs at any age, more often from 10 to 30 years old, men and women get sick with approximately the same frequency.

Anatomical and physiological information. In most cases, the caecum is located in the right iliac fossa mesoperitoneally, the appendix departs from the posterior medial wall of the dome of the intestine at the confluence of the three ribbons of the longitudinal muscles (tenia liberae) and goes down and medially. Its average length is 7 - 8 cm, thickness 0.5 - 0.8 cm. The appendix is ​​covered with peritoneum on all sides and has a mesentery, due to which it has mobility. The blood supply of the appendix occurs along a. appendicularis, which is a branch of a. ileocolica. Venous blood flows through v. ileocolica v. mesenterica superior and v. portae. There are many options for the location of the appendix in relation to the caecum. The main ones are: 1) caudal (descending) - the most frequent; 2) pelvic (low); 3) medial (internal); 4) lateral (along the right lateral canal); 5) ventral (anterior); 6) retrocecal (posterior), which can be: a) intraperitoneal, when the process, which has its own serous cover and mesentery, is located behind the dome of the caecum and b) retroperitoneal, when the process is completely or partially located in the retroperitoneal retrocecal tissue.

Etiology and pathogenesis of acute appendicitis. The disease is considered as a non-specific inflammation caused by factors of various nature. Several theories have been proposed to explain it.

1. Obstructive (stagnation theory)

2. Infectious (Aschoff, 1908)

3. Angioedema (Rikker, 1927)

4. Allergic

5. Alimentary

The main reason for the development of acute appendicitis is the obstruction of the lumen of the appendix, associated with hyperplasia of the lymphoid tissue and the presence of fecal stones. Less often, a foreign body, a neoplasm, or helminths can become a cause of outflow disturbance. After obturation of the lumen of the appendix, a spasm of the smooth muscle fibers of its wall occurs, accompanied by vascular spasm. The first of them leads to a violation of evacuation, stagnation in the lumen of the process, the second - to a local malnutrition of the mucous membrane. Against the background of activation of the microbial flora penetrating into the appendix by the enterogenic, hematogenous and lymphogenous pathways, both processes cause inflammation, first of the mucosa, and then of all layers of the appendix.

Classification of acute appendicitis

Uncomplicated appendicitis.

1. Simple (catarrhal)

2. Destructive

• phlegmonous
• gangrenous
• perforative

Complicated appendicitis

Complications of acute appendicitis are divided into preoperative and postoperative.

I. Preoperative complications of acute appendicitis:

1. Appendicular infiltrate

2. Appendicular abscess

3. Peritonitis

4. Phlegmon of retroperitoneal tissue

5. Pylephlebitis

II. Postoperative complications of acute appendicitis:

Early(appeared within the first two weeks after surgery)

1. Complications from the surgical wound:

• wound bleeding, hematoma
• infiltrate
• suppuration (abscess, phlegmon of the abdominal wall)

2. Complications from the abdominal cavity:

• infiltrates or abscesses of the ileocecal region
  • Douglas pouch abscess, subdiaphragmatic, subhepatic, interintestinal abscesses
• retroperitoneal phlegmon
• peritonitis
• pylephlebitis, liver abscesses
• intestinal fistulas
• early adhesive intestinal obstruction
• intra-abdominal bleeding

3. Complications of a general nature:

• pneumonia
• thrombophlebitis, pulmonary embolism
• cardiovascular insufficiency, etc.

Late

1. Postoperative hernia

2. Adhesive intestinal obstruction (adhesive disease)

3. Ligature fistulas

The causes of complications of acute appendicitis are:

1. 1. Untimely appeal of patients for medical care
2. 2. Late diagnosis of acute appendicitis (due to atypical course of the disease, diagnostic errors, etc.)
3. 3. Tactical mistakes of doctors (neglect of dynamic monitoring of patients with a dubious diagnosis, underestimation of the prevalence of the inflammatory process in the abdominal cavity, incorrect determination of indications for drainage of the abdominal cavity, etc.)
4. 4. Technical errors of the operation (tissue injury, unreliable ligation of vessels, incomplete removal of the appendix, poor drainage of the abdominal cavity, etc.)
5. 5. Chronic progression or occurrence acute diseases other organs.

Clinic and diagnosis of acute appendicitis

In the classic clinical picture of acute appendicitis, the main complaint of the patient is abdominal pain. Often, pain occurs first in the epigastric (Kocher's symptom) or paraumbilical (Kümmel's symptom) region, followed by a gradual movement after 3-12 hours to the right iliac region. In cases of atypical location of the appendix, the nature of the occurrence and spread of pain may differ significantly from that described above. With pelvic localization, pain is noted above the womb and in the depths of the pelvis, with retrocecal pain - in the lumbar region, often with irradiation along the ureter, with a high (subhepatic) location of the process - in the right hypochondrium.

Another important symptom that occurs in patients with acute appendicitis is nausea and vomiting, which is more often single, stool retention is possible. General symptoms of intoxication in initial stage diseases are mild and manifested by malaise, weakness, subfebrile temperature. It is important to assess the sequence of occurrence of symptoms. The classic sequence is the initial occurrence of abdominal pain and then vomiting. Vomiting prior to the onset of pain calls into question the diagnosis of acute appendicitis.

The clinical picture in acute appendicitis depends on the stage of the disease and the location of the appendix. On early stage noted slight increase temperature and increased heart rate. Significant hyperthermia and tachycardia indicate the occurrence of complications (perforation of the appendix, the formation of an abscess). At usual location of a shoot at a palpation of a stomach there is a local morbidity in McBurney's point (McBurney). With pelvic localization, pain is detected in the suprapubic region, dysuric symptoms are possible (frequent painful urination). Palpation of the anterior abdominal wall is uninformative, it is necessary to perform a digital rectal or vaginal examination to determine the sensitivity of the pelvic peritoneum (“Douglas cry”) and assess the condition of other organs of the small pelvis, especially in women. With a retrocecal location, the pain is shifted to the right flank and the right lumbar region.

The presence of protective tension in the muscles of the anterior abdominal wall and symptoms of peritoneal irritation (Shchetkin-Blumberg) indicates the progression of the disease and the involvement of the parietal peritoneum in the inflammatory process.

Establishing a diagnosis makes it easier to identify characteristic symptoms acute appendicitis:

• Razdolsky - soreness on percussion over the focus of inflammation
• Rovsinga - the appearance of pain in the right iliac region when pushing in the left iliac region in the projection of the descending colon
• Sitkovsky - when the patient turns to the left side, there is an increase in pain in the ileocecal region due to the movement of the appendix and the tension of its mesentery
• Voskresensky - with a quick slide of the hand over a stretched shirt from the xiphoid process to the right iliac region, a significant increase in pain is noted in the latter at the end of the movement of the hand
• Bartomier - Michelson - palpation of the right iliac region in the position of the patient on the left side causes a more pronounced pain reaction than on the back
• Obraztsova - on palpation of the right iliac region in the position of the patient on the back, the pain intensifies when raising the right straightened leg
• Coupe - hyperextension of the patient's right leg when he is positioned on his left side is accompanied by a sharp pain

Laboratory data. A blood test usually reveals moderate leukocytosis (10 -16 x 10 9 /l) with a predominance of neutrophils. However, a normal peripheral blood leukocyte count does not rule out acute appendicitis. In the urine, there may be single erythrocytes in the field of view.

Special research methods usually carried out in cases where there is doubt about the diagnosis. With inconclusive clinical manifestations diseases in the case of an organized specialized surgical service, it is advisable to start additional examination with a non-invasive ultrasound(ultrasound), during which attention is paid not only to the right iliac region, but also to the organs of other parts of the abdomen and retroperitoneal space. An unambiguous conclusion about the destructive process in the organ allows us to correct the operative approach and the option of anesthesia with an atypical location of the process.

In the case of inconclusive ultrasound data, laparoscopy is used. This approach helps to reduce the number of unnecessary surgical interventions, and in the presence of special equipment, it makes it possible to transfer the diagnostic stage to the therapeutic one and perform endoscopic appendectomy.

Development acute appendicitis in elderly and senile patients has a number of features. This is due to a decrease in physiological reserves, a decrease in the reactivity of the body and the presence of concomitant diseases. The clinical picture is characterized by a less acute onset, mild severity and diffuse nature of abdominal pain with a relatively rapid development of destructive forms of appendicitis. Often there is bloating, non-excretion of stools and gases. Tension of the muscles of the anterior abdominal wall, pain symptoms, characteristic of acute appendicitis, may be weakly expressed, and sometimes not determined. General reaction on the inflammatory process is weakened. The rise in temperature to 38 0 and above is observed in a small number of patients. In the blood, moderate leukocytosis is noted with a frequent shift of the formula to the left. Careful observation and examination wide application special methods (ultrasound, laparoscopy) are the key to timely surgical intervention.

Acute appendicitis in pregnant women. In the first 4-5 months of pregnancy, the clinical picture of acute appendicitis may not have any features, however, in the future, the enlarged uterus displaces the caecum and appendix upwards. In this regard, abdominal pain can be determined not so much in the right iliac region, but along the right flank of the abdomen and in the right hypochondrium, irradiation of pain to the right lumbar region is possible, which can be erroneously interpreted as a pathology from the biliary tract and right kidney. Muscle tension, symptoms of peritoneal irritation are often mild, especially in the last third of pregnancy. To identify them, it is necessary to examine the patient in the position on the left side. For the purpose of timely diagnosis, all patients are shown the control of laboratory parameters, ultrasound of the abdominal cavity, joint dynamic observation of the surgeon and obstetrician-gynecologist laparoscopy may be performed if indicated. When the diagnosis is made, emergency surgery is indicated in all cases.

Differential Diagnosis for pain in the right lower sections abdomen is carried out with the following diseases:

1. 1. Acute gastroenteritis, mesenteric lymphadenitis, food poisoning
2. 2. Exacerbation of peptic ulcer of the stomach and duodenum, perforation of ulcers of these localizations
3. 3. Crohn's disease (terminal ileitis)
4. 4. Inflammation of Meckel's diverticulum
5. 5. Cholelithiasis, acute cholecystitis
6. 6. Acute pancreatitis
7. 7. Inflammatory diseases of the pelvic organs
8. 8. Rupture of an ovarian cyst, ectopic pregnancy
9. 9. Right-sided renal and ureteral colic, inflammatory diseases of the urinary tract

10. Right-sided lower lobe pleuropneumonia

Treatment of acute appendicitis

A generally accepted active surgical position in relation to acute appendicitis. The absence of doubt in the diagnosis requires emergency appendectomy in all cases. The only exception is patients with well-demarcated dense appendicular infiltrate requiring conservative treatment.

Currently, surgical clinics use various options open and laparoscopic appendectomy, usually under general anesthesia. In some cases, it is possible to use local infiltration anesthesia with potentiation.

To perform a typical open appendectomy, the Volkovich-Dyakonov oblique variable ("rocker") access through the McBurney point is traditionally used, which, if necessary, can be expanded by dissecting the wound down the outer edge of the sheath of the right rectus abdominis muscle (according to Boguslavsky) or in the medial direction without crossing the rectus muscle (according to Bogoyavlensky) or with its intersection (according to Kolesov). Sometimes Lenander's longitudinal approach is used (along the outer edge of the right rectus abdominis muscle) and the Sprengel's transverse one (used more often in pediatric surgery). In case of complications of acute appendicitis with widespread peritonitis, with severe technical difficulties during appendectomy, as well as erroneous diagnosis, median laparotomy is indicated.

The appendix is ​​mobilized in an antegrade (from the apex to the base) or retrograde (first, the appendix is ​​cut off from the caecum, the stump is treated, then it is isolated from the base to the apex) method. The appendix stump is treated with a ligature (in pediatric practice, in endosurgery), invagination or ligature-invagination method. As a rule, the stump is tied with a ligature of absorbable material and immersed in the dome of the caecum with purse-string, Z-shaped or interrupted sutures. Often, additional peritonization of the suture line is performed by suturing the stump of the mesentery of the appendix or fatty suspension, fixing the dome of the caecum to the parietal peritoneum of the right iliac fossa. Then the exudate is carefully evacuated from the abdominal cavity and, in the case of uncomplicated appendicitis, the operation is completed by suturing the abdominal wall tightly in layers. It is possible to install a micro-irrigator to the process bed for summing up antibiotics in the postoperative period. The presence of purulent exudate and diffuse peritonitis is an indication for sanitation of the abdominal cavity with its subsequent drainage. If a dense inseparable infiltrate is detected, when it is impossible to perform an appendectomy, and also in case of unreliable hemostasis, after removal of the process, tamponing and drainage of the abdominal cavity are performed.

In the postoperative period with uncomplicated appendicitis, antibiotic therapy is not carried out or limited to the use of broad-spectrum antibiotics in the next day. In the presence of purulent complications and diffuse peritonitis, combinations of antibacterial drugs are used using various ways their introduction (intramuscular, intravenous, intra-aortic, into the abdominal cavity) with a preliminary assessment of the sensitivity of the microflora.

Appendicular infiltrate

Appendicular infiltrate - this is a conglomerate of loops of the small and large intestines, the greater omentum, the uterus with appendages, the bladder, the parietal peritoneum, welded together around the destructively altered appendix, reliably delimiting the penetration of infection into the free abdominal cavity. Occurs in 0.2 - 3% of cases. Appears on 3-4 days from the onset of acute appendicitis. In its development, two stages are distinguished - early (formation of a loose infiltrate) and late (dense infiltrate).

In the early stage, an inflammatory tumor is formed. Patients have a clinic close to the symptoms of acute destructive appendicitis. In the stage of formation of a dense infiltrate of the phenomenon acute inflammation subside. General state patients are improving.

A decisive role in the diagnosis is given to the clinic of acute appendicitis in history or on examination in combination with a palpable painful tumor-like formation in the right iliac region. At the stage of formation, the infiltrate is soft, painful, has no clear boundaries, and is easily destroyed when the adhesions are separated during the operation. In the stage of delimitation, it becomes dense, less painful, clear. The infiltrate is easily determined with typical localization and large sizes. To clarify the diagnosis, rectal and vaginal examination, abdominal ultrasound, and irrigography (scopy) are used. Differential diagnosis is carried out with tumors of the caecum and ascending intestine, uterine appendages, hydropyosalpix.

Tactics for appendicular infiltrate is conservative and expectant. A comprehensive conservative treatment is carried out, including bed rest, a sparing diet, in the early phase - cold on the infiltrate area, and after normalization of temperature, physiotherapy (UHF). They prescribe antibacterial, anti-inflammatory therapy, perform pararenal novocaine blockade according to A.V. Vishnevsky, blockade according to Shkolnikov, use therapeutic enemas, immunostimulants, etc.

In the case of a favorable course, the appendicular infiltrate resolves within 2 to 4 weeks. After complete subsidence of the inflammatory process in the abdominal cavity, not earlier than 6 months later, a planned appendectomy is indicated. If conservative measures are ineffective, the infiltrate suppurates with the formation of an appendicular abscess.

Appendicular abscess

Appendicular abscess occurs in 0.1 - 2% of cases. It can form in early dates(1 - 3 days) since the development of acute appendicitis or complicates the course of the existing appendicular infiltrate.

Signs of abscess formation are symptoms of intoxication, hyperthermia, an increase in leukocytosis with a shift in the white blood formula to the left, an increase in ESR, increased pain in the projection of a previously determined inflammatory tumor, a change in consistency and the appearance of softening in the center of the infiltrate. An abdominal ultrasound is performed to confirm the diagnosis.

The classic option for the treatment of appendicular abscess is the opening of the abscess by extraperitoneal access according to N.I. Pirogov with a deep, including retrocecal and retroperitoneal location. In the case of a tight fit of the abscess to the anterior abdominal wall, the Volkovich-Dyakonov access can be used. Extraperitoneal opening of the abscess avoids the entry of pus into the free abdominal cavity. After sanitizing the abscess, a tampon and drainage are brought into its cavity, the wound is sutured to the drainage.

Currently, a number of clinics use extraperitoneal puncture sanitation and drainage of the appendicular abscess under ultrasound control, followed by washing the abscess cavity with antiseptic and enzyme preparations and prescribing antibiotics, taking into account the sensitivity of the microflora. With large abscess sizes, it is proposed to install two drains at the upper and lower points for the purpose of flow-through washing. Given the low traumatic nature of puncture intervention, it can be considered the method of choice in patients with severe concomitant pathology and weakened by intoxication against the background of a purulent process.

Pylephlebitis

Pylephlebitis - purulent thrombophlebitis of the portal vein branches, complicated by multiple liver abscesses and pyemia. It develops as a result of the spread of the inflammatory process from the veins of the appendix to the iliac-colic, superior mesenteric, and then to the portal vein. More often occurs with retrocecal and retroperitoneal location of the process, as well as in patients with intraperitoneal destructive forms of appendicitis. The disease usually begins acutely and can be observed both in the preoperative and postoperative periods. The course of pylephlebitis is unfavorable, it is often complicated by sepsis. Mortality is over 85%.

The pylephlebitis clinic consists of hectic temperature with chills, pouring sweat, icteric staining of the sclera and skin. Patients are concerned about pain in the right hypochondrium, often radiating to the back, lower chest and right collarbone. Objectively find an increase in the liver and spleen, ascites. An x-ray examination determined the high standing of the right dome of the diaphragm, an increase in the shadow of the liver, and a reactive effusion in the right pleural cavity. Ultrasound reveals areas of altered echogenicity of the enlarged liver, signs of portal vein thrombosis and portal hypertension. In the blood - leukocytosis with a shift to the left, toxic granularity of neutrophils, increased ESR, anemia, hyperfibrinemia.

Treatment consists in performing an appendectomy followed by complex detoxification intensive therapy, including intra-aortic administration of broad-spectrum antibacterial drugs, the use of extracorporeal detoxification (plasmapheresis, hemo- and plasma absorption, etc.). A long-term intraportal administration of drugs is carried out through a cannulated umbilical vein. Liver abscesses are opened and drained or punctured under ultrasound guidance.

pelvic abscess

Pelvic localization of abscesses (abscesses Douglasova space) in patients undergoing appendectomy is most common (0.03 - 1.5% of cases). They are localized in the lowest part of the abdominal cavity: in men, excavatio retrovesicalis, and in women, in excavatio retrouterina. The occurrence of abscesses is associated with poor sanitation of the abdominal cavity, inadequate drainage of the pelvic cavity, the presence of abscessing infiltrate in this area with the pelvic location of the process.

An abscess of the Douglas space is formed 1-3 weeks after surgery and is characterized by the presence of general symptoms of intoxication, accompanied by pain in the lower abdomen, behind the womb, dysfunction of the pelvic organs (dysuric disorders, tenesmus, mucus discharge from the rectum). Per rectum, soreness of the anterior wall of the rectum is found, its overhang, a painful infiltrate can be palpated along the anterior wall of the intestine with softening foci. Per vaginam, there is pain in the posterior fornix, intense pain when the cervix is ​​displaced.

To clarify the diagnosis, ultrasound and diagnostic puncture are used in men through the anterior wall of the rectum, in women - through the posterior fornix of the vagina. After receiving pus, an abscess is opened along the needle. A drainage tube is inserted into the cavity of the abscess for 2-3 days.

A pelvic abscess that is not diagnosed in time can be complicated by a breakthrough into the free abdominal cavity with the development of peritonitis or into neighboring hollow organs (bladder, rectum and caecum, etc.)

Subdiaphragmatic abscess

Subdiaphragmatic abscesses develop in 0.4 - 0.5% of cases, they are single and multiple. By localization, right- and left-sided, anterior and posterior, intra- and retroperitoneal are distinguished. The reasons for their occurrence are poor sanitation of the abdominal cavity, infection by the lymph or hematogenous route. They can complicate the course of pylephlebitis. The clinic develops 1-2 weeks after surgery and is manifested by pain in the upper abdominal cavity and lower chest (sometimes with irradiation to the shoulder blade and shoulder), hyperthermia, dry cough, symptoms of intoxication. Patients can take a forced semi-sitting position or on their side with their legs adducted. Rib cage on the side of the lesion lags behind when breathing. The intercostal spaces at the level of 9-11 ribs swell above the abscess area (symptom of V.F. Voyno-Yasenetsky), palpation of the ribs is sharply painful, percussion - dullness due to reactive pleurisy, or tympanitis over the gas bubble area with gas-containing abscesses. On the survey radiograph - a high standing of the dome of the diaphragm, a picture of pleurisy, a gas bubble with a liquid level above it can be determined. With ultrasound, a delimited accumulation of fluid under the dome of the diaphragm is determined. The diagnosis is specified after a diagnostic puncture of the subdiaphragmatic formation under ultrasound control.

Treatment consists in opening, emptying and draining the abscess by extrapleural, extraperitoneal access, less often through the abdominal or pleural cavity. In connection with the improvement of ultrasound diagnostic methods, abscesses can be drained by passing single- or double-lumen tubes into their cavity through a trocar under ultrasound control.

Interintestinal abscess

Interintestinal abscesses occur in 0.04 - 0.5% of cases. They occur mainly in patients with destructive forms of appendicitis with insufficient sanitation of the abdominal cavity. In the initial stage, the symptoms are poor. Patients are concerned about abdominal pain without a clear localization. The temperature rises, the phenomena of intoxication increase. In the future, there may be a painful infiltrate in the abdominal cavity and stool disorders. On the survey radiograph, foci of blackout are found, in some cases - with a horizontal level of liquid and gas. To clarify the diagnosis, latheroscopy and ultrasound are used.

Interintestinal abscesses adjacent to the anterior abdominal wall and soldered to the parietal peritoneum are opened extraperitoneally or drained under ultrasound control. The presence of multiple abscesses and their deep location is an indication for laparotomy, emptying and drainage of abscesses after preliminary delimitation with tampons from the free abdominal cavity.

Intra-abdominal bleeding

The causes of bleeding into the free abdominal cavity are poor hemostasis of the appendix bed, slippage of the ligature from its mesentery, damage to the vessels of the anterior abdominal wall, and insufficient hemostasis when suturing the surgical wound. Violation of the blood coagulation system plays a certain role. Bleeding can be profuse and capillary.

With significant intra-abdominal bleeding, the condition of patients is severe. There are signs acute anemia, the abdomen is somewhat swollen, tense and painful on palpation, especially in the lower sections, symptoms of peritoneal irritation may be detected. Percussion find dullness in sloping places of the abdominal cavity. Per rectum is determined by the overhang of the anterior wall of the rectum. To confirm the diagnosis, ultrasound is performed, in difficult cases - laparocentesis and laparoscopy.

Sick with intra-abdominal bleeding after appendectomy, an urgent relaparotomy is indicated, during which an audit of the ileocecal region, ligation of a bleeding vessel, sanitation and drainage of the abdominal cavity are performed. At capillary bleeding additionally perform tight tamponing of the bleeding area.

Limited intraperitoneal hematomas give a poorer clinical picture and may manifest with infection and abscess formation.

Abdominal wall infiltrates and wound suppuration

Infiltrates of the abdominal wall (6 - 15% of cases) and suppuration of wounds (2 - 10%) develop as a result of infection, which is facilitated by poor hemostasis and tissue injury. These complications often appear on the 4th - 6th day after surgery, sometimes at a later date.

Infiltrates and abscesses are located above or below the aponeurosis. Palpation in the area postoperative wound find a painful seal with fuzzy contours. The skin above it is hyperemic, its temperature is elevated. With suppuration, a symptom of fluctuation can be determined.

Treatment of the infiltrate is conservative. Broad-spectrum antibiotics, physiotherapy are prescribed. Perform short novocaine blockade of the wound with antibiotics. Festering wounds are widely opened and drained, and further treated taking into account the phases of the wound process. Wounds heal secondary tension. With large sizes of granulating wounds, the imposition of secondary early (8-15) days or delayed sutures is indicated.

Ligature fistulas

Ligature fistulas observed in 0.3 - 0.5% of patients who underwent appendectomy. Most often they occur at 3-6 weeks of the postoperative period due to infection of the suture material, suppuration of the wound and its healing by secondary intention. There is a clinic of recurrent ligature abscess in the area of ​​the postoperative scar. After repeated opening and drainage of the abscess cavity, a fistulous tract is formed, at the base of which there is a ligature. In case of spontaneous rejection of the ligature, the fistulous tract closes on its own. Treatment is to remove the ligature when instrumental revision fistulous course. In some cases, the entire old postoperative scar is excised.

Other complications after appendectomy (peritonitis, intestinal obstruction, intestinal fistulas, postoperative ventral hernias, etc.) are discussed in the relevant sections of private surgery.

Control questions

1. 1. Early symptoms of acute appendicitis
2. 2. Features of the clinic of acute appendicitis with atypical location of the appendix
3. 3. Clinical features of acute appendicitis in the elderly and pregnant women
4. 4. Tactics of the surgeon with a dubious picture of acute appendicitis
5. 5. Differential diagnosis of acute appendicitis
6. 6. Complications of acute appendicitis
7. 7. Early and late complications after appendectomy
8. 8. Tactics of the surgeon with appendicular infiltrate
9. 9. Modern approaches to the diagnosis and treatment of appendicular abscess

10. Diagnosis and treatment of pelvic abscesses

11. Tactics of the surgeon when detecting Meckel's diverticulum

12. Pylephlebitis (diagnosis and treatment)

13. Diagnosis of subphrenic and interintestinal abscesses. Medical tactics

14. Indications for relaparotomy in patients operated on for acute appendicitis

15. Examination of working capacity after appendectomy

Situational tasks

1. A 45-year-old man has been ill for 4 days. Disturbed by pain in the right iliac region, temperature 37.2. On examination: the tongue is wet. The abdomen is not swollen, participates in the act of breathing, soft, painful in the right iliac region. Peritoneal symptoms are inconclusive. In the right iliac region, a tumor-like formation 10 x 12 cm, painful, inactive, is palpated. The chair is regular. Leukocytosis - 12 thousand.

What is your diagnosis? Etiology and pathogenesis of this disease? What pathology should be treated with differential pathology? Additional Methods surveys? Tactics of treatment of this disease? Treatment of the patient at this stage of the disease? Possible complications of the disease? Indications for surgical treatment, the nature and extent of the operation?

2. Patient K., 18 years old, was operated on for acute gangrenous-perforated appendicitis, complicated by diffuse serous-purulent peritonitis. Performed appendectomy, drainage of the abdominal cavity. The early postoperative period proceeded with the phenomena of moderately expressed intestinal paresis, which were effectively stopped by the use of drug stimulation. However, by the end of the 4th day after the operation, the patient's condition worsened, increasing bloating appeared, cramping pains throughout the abdomen, gases stopped leaving, nausea and vomiting, common signs of endogenous intoxication.

Objectively: state medium degree severity, pulse 92 per minute, A / D 130/80 mm Hg. Art., the tongue is wet, lined, the abdomen is evenly swollen, diffuse soreness in all departments, peristalsis is increased, peritoneal symptoms are not detected, when examining per rectum - the ampoule of the rectum is empty

What complication of the early postoperative period occurred in this patient? What methods of additional examination will help determine the diagnosis? The role and scope of X-ray examination, data interpretation. What are possible reasons development of this complication in the early postoperative period? Etiology and pathogenesis of disorders developing in this pathology. The volume of conservative measures and the purpose of their implementation in the development of this complication? Indications for surgery, the amount of operational benefits? Intra- and postoperative measures aimed at preventing the development of this complication?

3. A 30-year-old patient is in the surgical department for acute appendicitis at the stage of appendicular infiltrate. On the 3rd day after hospitalization and on the 7th day from the onset of the disease, the pain in the lower abdomen and especially in the right iliac region increased, the temperature became hectic.

Objectively: Pulse is 96 per minute. Breathing is not difficult. The abdomen is of the correct form, sharply painful on palpation in the right iliac region, where a positive symptom of Shchetkin-Blumberg is determined. The infiltrate in the right iliac region slightly increased in size. Leukocytosis increased compared to the previous analysis.

Formulate clinical diagnosis in this case? Patient treatment strategy? The nature, volume and features of surgical aid in this pathology? Features of the postoperative period?

4. A 45-year-old man underwent an appendectomy with drainage of the abdominal cavity due to gangrenous appendicitis. On the 9th day after the operation, the entry of small intestine contents from the drainage canal was noted.

Objectively: the patient's condition is moderate. Temperature 37.2 - 37.5 0 C. The tongue is wet. The abdomen is soft, slightly painful in the wound area. There are no peritoneal symptoms. Chair independent 1 time per day. In the area of ​​drainage there is a channel approximately 12 cm deep, lined with granulating tissue, through which intestinal contents are poured. The skin around the canal is macerated.

What is your diagnosis? Etiology and pathogenesis of the disease? Disease classification? Additional research methods? Possible complications of this disease? Principles of conservative therapy? Indications for surgical treatment? The nature and extent of possible surgical interventions?

5. By the end of the first day after appendectomy, the patient has a sharp weakness, pale skin, tachycardia, falling blood pressure, free fluid is determined in sloping places of the abdominal cavity. Diagnosis? surgeon tactics?

Sample answers

1. The patient developed an appendicular infiltrate, confirmed by ultrasound data. Tactics conservative-expectant, in case of abscessing, surgical treatment is indicated.

2. The patient has a clinic of postoperative early adhesive intestinal obstruction, in the absence of the effect of conservative measures and negative X-ray dynamics, an emergency operation is indicated.

3. Abscess formation of the appendicular infiltrate has set in. Shown surgical treatment. Preferably extraperitoneal opening and drainage of the abscess.

4. The postoperative period was complicated by the development of an external small bowel fistula. An X-ray examination of the patient is necessary. In the presence of a formed tubular low enteric fistula with a small amount of discharge, measures for its conservative closure are possible; in other cases, surgical treatment is indicated.

5. The patient has a clinic of bleeding into the abdominal cavity, probably due to slipping of the ligature from the stump of the mesentery of the appendix. An emergency relaparotomy was indicated.

LITERATURE

1. Batvinkov N.I., Leonovich S.I., Ioskevich N.N. Clinical surgery. - Minsk, 1998. - 558 p.
2. Bogdanov A. V. Fistulas of the digestive tract in the practice of a general surgeon. - M., 2001. - 197 p.
3. Volkov V. E., Volkov S. V. Acute appendicitis - Cheboksary, 2001. - 232 p.
4. Gostishchev V.K., Shalchkova L.P. Purulent pelvic surgery - M., 2000. - 288 p.
5. Grinberg A. A., Mikhailusov S. V., Tronin R. Yu., Drozdov G. E. Diagnostics difficult cases acute appendicitis. - M., 1998. - 127 p.
6. Clinical surgery. Ed. R. Conden and L. Nyhus. Per. from English. - M., Practice, 1998. - 716 p.
7. Kolesov V. I. Clinic and treatment of acute appendicitis. - L., 1972.
8. Krieger A. G. Acute appendicitis. - M., 2002. - 204 p.
9. Rotkov I. L. Diagnostic and tactical errors in acute appendicitis. - M., Medicine, 1988. - 203 p.
10. Savelyev V.S., Abakumov M.M., Bakuleva L.P. and other Guidelines for emergency surgery of the abdominal organs (under the editorship of V.S. Savelyev). - M.: Medicine. - 1986. - 608 p.

The inflammatory process in the process of the appendix leads to a common disease of the abdominal cavity - appendicitis. Its symptoms are soreness in the abdominal region, fever and disorders of the digestive function.

the only the right treatment in the case of an attack of acute appendicitis, an appendectomy is the removal of the appendix surgically. If this is not done, severe complications can develop, leading to death. What threatens untreated appendicitis - our article is just about that.

Preoperative consequences

The inflammatory process develops at different speeds and symptoms.

In some cases, it goes into and may not manifest itself for a long time.

Sometimes between the first signs of the disease before the onset critical condition it takes 6 - 8 hours, so you can not hesitate in any case.

For any pain of unknown origin, especially against the background of fever, nausea and vomiting, you should definitely seek medical advice. medical assistance Otherwise, the consequences can be the most unpredictable.

Common complications of appendicitis:

• Perforation of the walls of the appendix. Most frequent complication. In this case, ruptures of the walls of the appendix are observed, and its contents enter the abdominal cavity and lead to the development of sepsis of the internal organs. Depending on the duration of the course and the type of pathology, severe infection can occur, even death. Such conditions account for approximately 8-10% of the total number of patients diagnosed with appendicitis. With purulent peritonitis, the risk of death increases, as well as exacerbation accompanying symptoms. Purulent peritonitis, according to statistics, occurs in approximately 1% of patients.
• appendicular infiltrate. Occurs when adhesions of the walls of nearby organs. The frequency of occurrence is approximately 3 - 5% of cases of clinical practice. It develops approximately on the third - fifth day after the onset of the disease. Start acute period characterized pain syndrome fuzzy localization. Over time, the intensity of pain decreases, the contours of the inflamed area are felt in the abdominal cavity. The inflamed infiltrate acquires more pronounced boundaries and a dense structure, the tone of the muscles located near it slightly increases. After about 1.5 - 2 weeks, the tumor resolves, abdominal pain subsides, general inflammatory symptoms(high temperature and biochemical parameters of the blood return to normal). In some cases, the inflammatory area can cause the development of an abscess.
• . It develops against the background of suppuration of the appendicular infiltrate or after surgery with previously diagnosed peritonitis. Usually the development of the disease occurs on the 8th - 12th day. All abscesses must be opened and sanitized. Drainage is performed to improve the outflow of pus from the wound. Antibacterial therapy is widely used in the treatment of abscess.

The presence of such complications is an indication for urgent surgery. The rehabilitation period also takes a lot of time and an additional course of drug treatment.

Complications after removal of appendicitis

Surgery, even if performed before the onset of severe symptoms, can also lead to complications. Most of them are the cause of death in patients, so any alarming symptoms should alert.

Common complications after surgery:

• . Very often occur after the removal of the appendix. Characterized by the appearance of pulling pains and tangible discomfort. Adhesions are very difficult to diagnose, because they are not seen by modern ultrasound and X-ray devices. Treatment usually consists of absorbable drugs and laparoscopic removal.
• . Quite often appears after surgery. Manifested as a prolapse of a fragment of the intestine into the lumen between muscle fibers. It usually appears when the recommendations of the attending physician are not followed, or after physical exertion. Visually manifests itself as swelling in the area surgical suture, which over time can increase significantly in size. Treatment is usually surgical, consisting of suturing, truncation, or complete removal part of the intestine and omentum.

Photo of a hernia after appendicitis

• postoperative abscess. Most often manifested after peritonitis, can lead to infection of the whole organism. Antibiotics are used in the treatment, as well as physiotherapy procedures.
• . Fortunately, these are quite rare consequences of an appendectomy operation. The inflammatory process extends to the region of the portal vein, the mesenteric process and the mesenteric vein. Accompanied high temperature, sharp pains in the abdominal cavity and severe liver damage. After acute stage arises, and, as a result, death. Treatment of this ailment is very difficult and usually involves the introduction of antibacterial agents directly into the portal vein system.
• . In rare cases (in about 0.2 - 0.8% of patients), the removal of the appendix provokes the appearance of intestinal fistulas. They form a kind of "tunnel" between the intestinal cavity and the surface of the skin, in other cases - the walls of internal organs. The causes of fistulas are poor sanitation of purulent appendicitis, gross mistakes doctor during the operation, as well as inflammation of the surrounding tissues during drainage of internal wounds and abscess foci. Intestinal fistulas are very difficult to treat, sometimes resection of the affected area or removal of the upper layer of the epithelium is required.

The occurrence of this or that complication is also facilitated by ignoring the recommendations of the doctor, non-compliance with the rules of hygiene after surgery and violation of the regimen. If the deterioration occurred on the fifth or sixth day after the removal of the appendix, most likely, we are talking about pathological processes in the internal organs.

In addition, in the postoperative period, other conditions may occur that require a doctor's consultation. They can be evidence of various ailments, and also not related to the operation at all, but serve as a sign of a completely different disease.

Temperature

An increase in body temperature after surgery can be an indicator of various complications. The inflammatory process, the source of which was in the appendix, can easily spread to other organs, which causes additional problems.

Most often, inflammation of the appendages is observed, which can make it difficult to determine exact reason. Often the symptoms of acute appendicitis can be confused with such ailments, therefore, before the operation (if it is not urgent), an examination by a gynecologist and ultrasound examination pelvic organs.

An elevated temperature can also be a symptom of an abscess or other diseases of the internal organs. If the temperature has risen after an appendectomy, it is necessary additional examination and delivery of laboratory tests.

Diarrhea and constipation

Digestive disorders can be considered as the main symptoms and as consequences of appendicitis. Often the functions of the gastrointestinal intestinal tract broken after surgery.

During this period, constipation is the worst tolerated, because the patient is forbidden to push and strain. This can lead to divergence of the seams, protrusion of the hernia and other consequences. For the prevention of digestive disorders, it is necessary to adhere to strict and prevent stool fixation.

Stomach ache

This symptom can also have a different origin. Usually, pain sensations appear for some time after the operation, but completely disappear for three to four weeks. Usually, this is how much the tissues will need for regeneration.

In some cases, abdominal pain may indicate the formation of adhesions, hernia, and other consequences of appendicitis. In any case, the best solution would be to see a doctor, and not try to get rid of discomfort with the help of painkillers.

Appendicitis is a common pathology requiring surgical intervention. The inflammatory process that occurs in the process of the caecum can easily spread to other organs, lead to the formation of adhesions and abscesses, and also give many more serious consequences.

To prevent this from happening, it is important to seek help from the hospital in a timely manner, and also not to ignore the alarm signals that may indicate the development of the disease. What is dangerous appendicitis, and what complications it can lead to, is described in this article.

An appendicular abscess is an abscess in the abdominal cavity, a complication of acute appendicitis. It occurs before surgery as a result of suppuration of the appendicular infiltrate, and can also form in the postoperative period. The frequency of development is 1-3%. Initially, an appendicular infiltrate is formed, which, under the influence of treatment, resolves or abscesses.

Causes of an abscess

An abscess is caused jointly by cocci, non-clostridial anaerobic flora and Escherichia coli.

Untimely diagnosis of an acute process, late seeking help contribute to the development of the disease.

Causes in the postoperative period:

• defects surgical technique,
• decrease in the immune defense of the body,
• insensitivity of microorganisms to the antibiotics used.

The infiltrate is formed on the 2-3rd day due to fibrinous effusion and the formation of adhesions between the greater omentum, appendix, intestinal loops. After conservative treatment, the inflammatory process in the appendix fades. If the process is destroyed, then the infection goes beyond its limits and an abscess is formed. Abscess formation occurs after 5-6 days.

Depending on the location of the process, the appendicular abscess can be located in the iliac fossa on the right or in the pelvic region.

Secondary ulcers in the postoperative period are associated with the spread of pyogenic infection through the lymphatic tract.

Symptoms

1. Deterioration of the general condition: chills, malaise, fatigue, sweating, loss of appetite.
2. The phenomena of intoxication,.
3. Dyspeptic phenomena: vomiting, stool disorder, bloating.
4. The tongue is coated.
5. High temperature: especially high performance in evening time.
6. Constant pain in the abdomen (right iliac region) of a pulsating nature. Aggravated by shaky driving, walking, coughing.
7. The abdominal wall is tense, painful at the location of the abscess, lagging behind when breathing. The Shchetkin-Blumberg symptom is determined. An immovable infiltrate is palpated (tumor-like formation, immobile, painful), sometimes fluctuation.
8. When the pathological focus is located among the intestinal loops, manifestations of intestinal obstruction (vomiting, cramping pains, bloating) are possible.
9. With pelvic localization: pain and bloating is noted in the lower abdomen, increased urge to urinate, mucus from the rectum, pain during defecation.
10. With the proximity of the abscess to the abdominal wall: local reddening of the skin and swelling.
11. Breakthrough of an abscess into the intestines: improvement, reduction of pain, drop in temperature, loose stools with a huge amount of fetid pus.
12. Opening of an abscess into the peritoneal cavity: the development of peritonitis, the formation of secondary purulent foci, fever, tachycardia, an increase in the phenomena of intoxication.

Special diagnostic methods

1. Rectal examination allows you to determine the painful protrusion, often fluctuation. If the abscess is located high, then characteristic features may not be detected.
2. In some cases, a vaginal examination is also carried out, revealing soreness, and sometimes the formation itself.
3. In the leukocyte formula, leukocytosis and a shift to the left. Increase in ESR.
4. X-ray examination: does not reveal absolute signs infiltrate or abscess. In the vertical position, it is possible to detect homogeneous darkening in the iliac region with a slight shift to the midline of the intestinal loops. In advanced situations, a fluid level is visible in the abscess area. With intestinal obstruction - fluid in the intestinal loops.
5. With the help of ultrasound, you can determine the exact localization of the abscess and its size.

Complications of an appendicular abscess

• thrombosis, thrombophlebitis of the veins of the pelvis,
• sepsis,
• perforation into the small and caecum, followed by the formation of fistulas,
• diffuse purulent peritonitis,
• delimited forms of peritonitis due to microperforation of the abscess,
• perforation into the bladder, leading to ascending urinary tract infection, as well as urosepsis,
• intestinal obstruction.

Treatment

Stage of appendicular infiltrate

Treatment is conservative. The operation is contraindicated.

• Bed rest.
• Cold on the stomach for the first 3 days.
• Sparing diet.
• Antibiotic therapy.
• Drugs and laxatives are not prescribed.
• Sometimes pararenal novocaine blockade for resorption of the infiltrate.

After complete resorption, an appendectomy is performed in a planned manner after 1-2 months.

Formed appendicular abscess

Necessarily surgery: opening the abscess, washing and draining it. In some cases, under ultrasound guidance, percutaneous drainage is performed under local anesthesia.

The classical approach is the right-sided extraperitoneal one. With a pelvic location, the abscess is opened through the rectum; in women, the posterior fornix of the vagina serves as access. Pus is removed, the cavity is washed with antiseptics, and then drainage tubes are installed. It is preferable to remove the blind process, however, if there is a risk of damage to the inflamed intestinal wall and the spread of pus into the peritoneal cavity, then it is left.

Postoperative period:

• Careful care of drains: washing, removal of contents.
• Antibiotic therapy: with aminoglycosides.
• Detoxification therapy.
• Fortifying agents.

Drainages are left as long as there is purulent discharge. After that, the drainage tube is removed, and the wound heals. If an appendectomy was not performed, then a planned operation is indicated after 2 months.

Forecast and prevention

The prognosis for an appendicular abscess is serious. The result depends on the adequacy and timeliness of the start of therapy.

Abscess prevention is timely diagnosis acute appendicitis and surgery in the first 2 days.