Features of acute appendicitis in children are as follows. Symptoms of appendicitis in children

Features of the course of acute appendicitis directly depend on the stage of the disease. This violation manifests itself in the form of pain in the abdomen, nausea and a violation of the general condition. If you experience such symptoms, you should consult a doctor, since inflammation of the appendix requires urgent surgical intervention. If the operation is not carried out in time, the development of dangerous complications up to and even death is possible.

The appendix is ​​a lymphoid organ that contains many immune cells. Due to this, it protects the digestive organs. Sometimes this process becomes inflamed. There are many reasons for this state of affairs:

• blockage by dense pieces of food or feces;
• proliferation of appendix tissues;
• an increase in the size of the lymph nodes, which leads to blockage of the lumen of the process;
• infectious lesions of the intestine;
• irrational nutrition;
• allergic reactions;
• genetic predisposition;
• the presence of bad habits;
• stressful situations;
• spread of infection from other organs.

Classification

Depending on the stage of the pathological process, several types of appendicitis are distinguished:

1. Catarrhal stage - lasts for the first six hours.
2. Phlegmonous stage - lasts until the end of the first day.
3. Gangrenous stage - lasts about three days.
4. Perforation of the appendix - at this stage, the walls of the appendix rupture, which provokes the entry of its contents into the abdominal cavity and the development of peritonitis.

Symptoms

Features of the course of the disease directly depend on its duration. Each stage is characterized by certain symptoms. Pain first appears in the upper abdomen, and they occur suddenly. A pulling or stabbing sensation may also be present in the stomach or navel area. During laughter, coughing or movement, the pain syndrome increases.

Sometimes the appendix is ​​located atypically. In this case, pain can be present anywhere - in the right hypochondrium, above the pubis, or in the region of the ureters. Also, sometimes discomfort is felt in the left side of the abdomen or genitals.

In addition, acute appendicitis is characterized by nausea and vomiting. These symptoms usually accompany pain. It should be borne in mind that nausea occurs in 70% of cases of appendicitis. Vomiting usually has a single character and does not bring relief. This symptom is observed in 35% of patients. If the number of vomiting increases, this indicates the appearance of complications - in particular, peritonitis.

Another symptom of the disease is an increase in body temperature. Usually this figure does not exceed 38 degrees. Sometimes the temperature remains normal. If it becomes more than 38 degrees, this indicates an increase in inflammation.

Also a symptom of the acute form of appendicitis is a white coating on the tongue. As the disease progresses, dryness in the oral cavity appears. Also, inflammation of the appendix is ​​often accompanied by a deterioration in appetite, sleep disturbances, stool retention or diarrhea.

Features of acute appendicitis in children

This disease is often found in children and is associated with serious dangers. Firstly, it is much more difficult to make a correct diagnosis for a child than for an adult. This is due to the peculiarities of the course of acute appendicitis in children. Their inflammatory process is not so pronounced. In addition, it develops much faster, which is fraught with complications.

Appendicitis can be diagnosed in children of any age, but in the first two years it is quite rare. The peak incidence occurs at 8-12 years of age. In young children, the development of the disease begins with increased anxiety, sleep disturbances. After some time, the body temperature rises, vomiting, loose stools with mucous impurities may appear.

Pain on the right in children of this age, as a rule, does not occur. Most often, the baby has discomfort in the navel area, sleep disturbance, anxiety when changing body position. If these signs appear, you should immediately contact a pediatric surgeon.

Diagnostics

The following information will help diagnose inflammation of the appendix:

• patient complaints and symptoms of the disease;
• the results of the examination and the detection of special signs during palpation of the abdominal cavity;
• results of urine and blood tests;
• data of instrumental studies - radiography, ultrasound, laparoscopy.

If the appendix is ​​typically located, it is not difficult to make an accurate diagnosis. With abnormal localization of the organ, the symptoms of inflammation of the appendix must be distinguished from peptic ulcer, intestinal obstruction, pyelonephritis, cholecystitis, pancreatitis, diverticulitis, and renal colic. In women, similar symptoms occur with acute inflammation of the appendages or ovarian apoplexy.

Acute appendicitis is a rather dangerous condition that requires immediate surgical intervention. Any delay can cost the patient health and even life. In order to prevent the development of complications, it is important to make an accurate diagnosis in a timely manner and remove the appendix.

: from a year to 3 - 0.6 per 1000; from 4 to 7 - 2.6 per 1000; 13 years - 8 per 1000.

Anatomical and physiological features of the ileocecal region and appendix in children.

The high mobility of the caecum under the age of three years due to the long mesentery and disruption of the process of embryonic development has a significant impact on the clinical manifestations of the disease.

In children of the first year of life, the appendicular valve is absent or poorly developed, which causes the free discharge of intestinal contents from the appendix into the caecum, the absence of the possibility of the formation of fecal stones and stagnant processes in the process.

Variability in the location of the appendix: descending position (35%); medial and middle position (26%); retrocecal position (20%); lateral position (15%), which causes a variety of symptoms in children.

In children under three years of age, the appendix is ​​cone-shaped, which does not contribute to the occurrence of congestion, and the rarity of the disease at this age.

The thinness of the wall of the appendix and the weak development of the muscle layers cause the earlier development of acute appendicitis in children under 3 years of age.

Insufficient development of the follicular apparatus of the appendix, which plays an important role in the pathogenesis of appendicitis.

The presence of anastomoses between the lymphatic vessels of the ileocecal intestine with the lymphatic system of the internal organs of the abdominal cavity and retroperitoneal space, creating conditions for the generalization of the inflammatory process by the lymphatic route.

Morphofunctional immaturity of the nerve plexuses of the appendix, especially in young children, which explains the severity of acute appendicitis in children in the first years of life.

Underdevelopment of the omentum in children in the first years of life causes the generalization of the inflammatory process in complicated appendicitis.

Abundant blood supply to the peritoneum, its rapid involvement in the inflammatory process, with a low ability to delimit the inflammatory process and high suction capacity.

Pathogenesis of acute appendicitis in children

There are two theories explaining the mechanism of development of inflammation in the appendix: the neurovascular theory and the stagnation theory.

The neurovascular theory explains the occurrence of acute appendicitis through disorders of the gastrointestinal tract and viscero-visceral impulsation, which is reflected in the vascular trophism of the appendix. Spasm of smooth muscles and blood vessels leads to malnutrition of the process wall up to necrosis. The permeability of the mucous membrane for microflora changes with the subsequent development of inflammation.

The theory of stagnation explains the development of acute appendicitis by obstruction of the appendix by intestinal contents, followed by an increase in pressure in its lumen, deterioration of lymphatic outflow, leading to swelling of the appendix tissue. Violation of the venous outflow in conditions of high intraluminal pressure and edema leads to mucosal ischemia and microflora invasion.

Pathology.

In children, it is characterized by edematous and hyperemic serous membrane. Microscopically determined defects of the mucous membrane, covered with fibrin and leukocytes.

In children, it is manifested by purulent inflammation of all layers of the appendix. Macroscopically, the process is hyperemic, tense and thickened, covered with fibrin. Microcirculatory infiltration of all layers of the process is determined microscopically. Ulcerations, suppuration and partial rejection are noted in the mucous membrane.

In children, it is characterized by deep destructive changes in the entire wall of the appendix. Macroscopically, the process is thickened, dark gray in color, with purulent-fibrinous overlays. Microscopically - necrosis of the process walls.

Signs of acute appendicitis in children

In the abdomen of a constant nature, arising gradually, with localization in the epigastric region or the umbilical region, moving to the right iliac region, not disappearing during sleep.

Vomiting of a reflex nature, one or two times, not bringing relief.

Temperature response up to 38 °C.

The discrepancy between pulse and temperature: with an increase in body temperature by one degree, the pulse rate increases by 8-10 per minute.

Intestinal dysfunction manifests itself in the form of stool retention.

Tension of the muscles of the abdominal wall on palpation.

Symptom Filatov - increased pain on palpation in the right iliac region.

Pain in the right iliac region with deep palpation of the abdomen.

A positive symptom of Shchetkin-Blumberg is an increase in pain in the abdomen after gradual deep palpation, followed by withdrawal of the hand from the abdominal wall.

Features of acute appendicitis in children of the first three years.

The clinical course is more severe, with a predominance of general symptoms due to the undifferentiated reactions of the child's nervous system to the inflammatory process.

The inability of a small child to accurately localize abdominal pain due to insufficient morphological and functional maturity of the cortical structures of the brain.

Earlier development of destructive forms of appendicitis with generalization of inflammation in the abdominal cavity due to a number of anatomical and physiological features.

The ability to involve other organs in the pathological process with the early development of metabolic, hemodynamic and microcirculatory disorders.

Changes in the child's behavior - sleep disturbance, anxiety, crying, refusal to eat.

Vomiting that is repeated.

An increase in body temperature up to 38-39 ° C.

Stool disorders - 12-70% of children have loose stools. In cases of stool retention, a cleansing enema is indicated, which facilitates diagnosis.

Examination of the abdomen during physiological or medication sleep allows you to determine the following symptoms: passive tension of the muscles of the abdominal wall, soreness in the right iliac region, the symptom of "pulling the right leg and pushing with the right hand" on palpation, Shchetkin-Blumberg's symptom.

Digital rectal examination in doubtful cases is indicated in all children, as it helps in the differential diagnosis with other diseases.

In the peripheral blood - hyperleukocytosis.

Diagnosis of acute appendicitis in children

Laboratory diagnostics I conclude in the study of a general blood test. An increase in the number of leukocytes in the peripheral blood up to 10000-12000 indicates the presence of an inflammatory process.

A digital rectal examination is performed in cases that are doubtful for diagnosis in order to identify signs of acute appendicitis of pelvic localization, exclude diseases of the pelvic organs in girls, and exclude the likelihood of tumor formations in the retroperitoneal space.

Ultrasound examination of the abdominal cavity, kidneys, genital organs in girls:

Direct signs of acute appendicitis:

In longitudinal section - a tubular structure with a blind end on one side:

In cross section - a symptom of the "target";

The value of the outer diameter is more than 6 mm;

The thickness of the wall of the process is more than 2 mm;

Heterogeneous structure of the process, incompressible under compression.

Indirect signs of acute appendicitis:

The presence of free fluid around the appendix;

The presence of free fluid in the pelvis;

Thickening of the wall of the caecum;

Paresis of the intestine.

Treatment of acute appendicitis in children

If it is impossible to confirm or remove the diagnosis of acute appendicitis after the initial examination, diagnostic observation is carried out in the conditions of the surgical department with repeated examinations every 2-3 hours. Observation is carried out for 12 hours, after which the diagnosis of acute appendicitis is excluded or a decision is made to conduct a diagnostic laparoscopy.

Stages of treatment:

All children are prescribed 30 minutes before surgery to prevent postoperative wound complications. During the operation, antibiotics are administered according to indications, depending on the degree of the inflammatory process:

Access to the abdominal cavity according to Volkovich-Dyakonov;

Detection of the appendix and assessment of inflammatory changes (catarrhal, phlegmonous, gangrenous, perforative);

Appendectomy:

Removal of inflammatory exudate from the abdominal cavity by electric suction;

Sewing of the surgical wound with the imposition of a cosmetic suture in uncomplicated forms of appendicitis.

If catarrhal appendicitis is detected, an additional examination of the abdominal cavity is indicated: examination of the mesentery of the small intestine for the presence of mesadenitis, revision of the ileum to check for the presence of Meckel's diverticulum, examination of the uterine appendages in girls.

Acute appendicitis after surgery

Early motor mode.

Early enteral feeding.

Antibiotics for acute appendicitis in children

With uncomplicated (phlegmonous) appendicitis is not indicated;

With gangrenous appendicitis, it is carried out within 24-48 hours;

With perforated appendicitis, it is carried out within 5 days.

Control of the abdominal cavity on the 3rd-4th day and before discharge from the surgical department.

The sutures are removed on the 7-8th day.

Acute appendicitis (K35)

Surgery for children

general information

Short description

Russian Association of Pediatric Surgeons

Acute appendicitis in children(Moscow 2013)

Acute appendicitis- acute inflammation of the appendix of the caecum (classified according to ICD-10 in K.35).

Acute appendicitis- one of the most frequent diseases of the abdominal cavity requiring surgical treatment.

In childhood, appendicitis develops faster, and destructive changes in the process, leading to appendicular peritonitis, occur much more often than in adults. These patterns are most pronounced in children of the first years of life, which is due to the anatomical and physiological characteristics of the child's body that affect the nature of the clinical picture of the disease and, in some cases, require a special approach to solving tactical and therapeutic problems.

Acute appendicitis can occur at any age, including newborns, but it is predominantly observed after the age of 7 years; in children under 3 years of age, the incidence does not exceed 8%. The peak incidence occurs at the age of 9-12 years. The overall incidence of appendicitis is 3 to 6 per 1000 children. Girls and boys get sick equally often. Acute appendicitis is the most common cause of peritonitis in children older than one year.

Classification

Classification
Acute appendicitis is classified according to morphological changes in the appendix. Attempts at preoperative diagnosis of the morphological form of acute appendicitis are extremely difficult and have no practical meaning.

In addition, there are uncomplicated and complicated appendicitis (periappendicular infiltrate and abscess, peritonitis).

Morphological classification of types of acute appendicitis

Non-destructive (simple, catarrhal);

Destructive:

phlegmonous,

Gangrenous.

Of particular difficulty for the clinician are non-destructive forms, the macroscopic evaluation of which does not exclude subjectivity.

Most often, this form hides other diseases that simulate acute appendicitis.

Etiology and pathogenesis

ANATO PECULIARITIES

The study of the features of the surgical anatomy of the right iliac region in children is of great practical importance, both for the diagnosis of acute appendicitis and for performing surgical intervention. Of greatest interest is the topography of the ileocecal intestine - the most complex formation of the digestive tract. This is explained by the fact that in childhood a number of diseases can be localized in this area: congenital malformations, invagination, tumors, and inflammatory processes.
Despite the diversity of the position of the appendix, the following types of localization are most common.
Most often (up to 45%) the appendix has a descending position. With this arrangement, the appendix descends to the area of ​​​​the entrance to the small pelvis. If the caecum is low and the appendix is ​​long enough, its apex may be adjacent to the bladder or rectal wall.

With this variant of the location of the appendix, dysuric disorders and increased stool may prevail in the clinical picture.
The anterior ascending position of the process is noted in 10% of patients. With this variant, the clinical picture is most pronounced and usually does not cause diagnostic difficulties.
The posterior ascending (retrocecal) position of the appendix is ​​observed in 20% of patients. In this variant, the appendix is ​​located behind the caecum and is directed dorsally upward. The retrocecal location of the appendix, especially if it is located retroperitoneally, creates the greatest diagnostic difficulties in appendicitis.
The lateral position of the process was noted in 10% of cases. Usually the appendix is ​​outside from a cecum, is directed a little upwards. Diagnosis of the disease in this location is usually not difficult.
The medial position of the appendix occurs in 15% of cases. The process is directed to the midline and its apex is turned to the root of the mesentery of the small intestine. In this case, the clinical picture is atypical. The inflammatory process easily spreads to the entire abdominal cavity, causing diffuse peritonitis or the formation of interloop abscesses.
Knowledge of the anatomy and topography of the greater omentum is of practical importance. Depending on the age of the child, the position and size of the omentum are different. It is especially underdeveloped in children of the first years of life (thin, short, poor in fatty tissue).

Clinical picture

Symptoms, course

TOLINIC PAINTING ACUTE APPENDICITIS
A variety of clinical manifestations of acute appendicitis depends on the location of the appendix, the severity of the inflammatory process, the reactivity of the body and the age of the patient. The greatest difficulties arise in the group of children under 3 years of age.
In children older than 3 years, acute appendicitis begins gradually. The main symptom is pain that occurs in the epigastric region or near the navel, then captures the entire abdomen and only after a few hours is localized in the right iliac region. Usually the pain is constant aching.
Vomiting is usually observed in the first hours of the disease and, as a rule, is single. The tongue is slightly coated with white. Some children have stool retention. Liquid, frequent stools with an admixture of mucus are often noted with the pelvic location of the process.
Body temperature in the first hours is normal or subfebrile. High numbers of fever are not typical for uncomplicated forms of acute appendicitis. A characteristic symptom is tachycardia, not corresponding to the height of the fever.
The general condition in acute appendicitis suffers slightly, but may worsen with the spread of inflammation to the peritoneum. Patients are usually in a forced position, lie on their right side with the lower limbs bent and pulled up to the stomach.
As a rule, in patients with acute appendicitis, sleep is disturbed, children sleep very restlessly, wake up in a dream, or do not sleep at all. Appetite in a child with acute appendicitis is reduced or absent.
On examination, the shape of the abdomen is usually not changed. At the beginning of the disease, the anterior abdominal wall is involved in the act of breathing, as the inflammatory process spreads, a lag in breathing of its right half becomes noticeable.
The greatest information for the doctor is palpation of the abdomen. Palpation of the abdomen is carried out according to generally accepted rules. It usually starts from the left iliac region in a counterclockwise direction. Superficial palpation reveals local pain, tension in the muscles of the anterior abdominal wall. To make sure that there is no or presence of rigidity of the muscles of the anterior abdominal wall, it is important to keep your hand on the stomach every time you change the point of palpation, waiting for the patient to inhale. This allows you to differentiate active voltage from passive.

Among the numerous symptoms of acute appendicitis, local pain in the right iliac region (94-95%), passive tension of the muscles of the anterior abdominal wall (86-87%) and symptoms of peritoneal irritation, primarily the Shchetkin-Blumberg symptom, are of the greatest importance. However, the symptoms of peritoneal irritation acquire diagnostic value only in children older than 6-7 years and are not permanent (55-58%). Percussion of the anterior abdominal wall is usually painful.
A valuable diagnostic method is palpation of the abdomen during sleep, which makes it possible to detect local passive tension in the muscles of the anterior abdominal wall, especially in restless children, which are difficult to examine while awake.
With prolonged absence of stool (more than 24 hours), a cleansing enema is indicated. If the cause of abdominal pain was stool retention, then after performing an enema, the pain syndrome stops.
In some cases, with difficulties in diagnosis, it is useful to conduct a rectal digital examination, especially in cases of the pelvic location of the appendix or the presence of an infiltrate, which reveals pain in the anterior wall of the rectum. If the diagnosis of acute appendicitis is beyond doubt, a rectal digital examination is not a mandatory diagnostic manipulation.

Features of the clinical picture in young children
In newborns, inflammation of the appendix develops extremely rarely and is diagnosed, as a rule, only with the development of peritonitis. The use of modern imaging tools, primarily ultrasound, makes it possible to establish the diagnosis of acute appendicitis in newborns before the development of complications.

The clinical picture of acute appendicitis in toddlers most often develops rapidly, against the background of complete health. The child becomes restless, capricious, refuses to eat, body temperature rises to 38-39°C. There is repeated vomiting. Multiple loose stools often develop. In the feces, pathological impurities (streaks of blood, mucus) can be determined.

Examining the abdomen of a young child is often difficult. The child is worried, resists inspection. Palpation of the abdomen in such patients should be carried out with warm hands, after calming the child.

In young children, there is a lag in the right half of the abdomen in the act of breathing, its moderate swelling. A constant symptom is the passive tension of the muscles of the anterior abdominal wall, which is sometimes difficult to detect when the child is anxious.

The general rule in diagnosing acute appendicitis in children is the following: the younger the child, the more often the symptoms of intoxication prevail over the local clinical picture, reaching their peak in newborns who may have no local manifestations at the onset of the disease.

Diagnostics

DIAGNOSIS

The diagnosis of acute appendicitis is established on the basis of a combination of anamnesis data, examination and a number of laboratory and instrumental diagnostic methods. In most cases, the diagnosis can be established only on the basis of the clinical picture without the use of additional research methods. Despite this, it is mandatory to conduct a series of diagnostic studies.

It is mandatory to perform a clinical blood test, which reveals nonspecific changes characteristic of the inflammatory process: leukocytosis (usually up to 15 - 10 x 109 / ml) with a shift of the formula to the left and an acceleration of ESR.

At the present stage, patients with acute abdominal pain are shown to undergo an ultrasound examination, which allows both to identify changes characteristic of acute appendicitis and to visualize changes in the abdominal cavity and small pelvis organs, which can give a clinical picture similar to acute appendicitis. To obtain reliable information, the study should be carried out by a specialist who knows the anatomical features of the abdominal organs in children in normal and pathological conditions.

Ultrasound examination reveals the appendix, which, with the development of inflammation in it, is defined as a non-peristaltic tubular structure with thickened, hypoechoic walls, the lumen of which is filled with heterogeneous liquid contents or fecal stone. Around the process, fluid accumulation is determined, an edematous omentum adjacent to the appendix, enlarged mesenteric lymph nodes with a hypoechoic structure can be visualized.

Ultrasonography can also detect complicated forms of appendicitis, primarily periappendicular infiltrate and abscess.

Diagnostic laparoscopy is the only way to preoperative visual assessment of the condition of the appendix. The use of diagnostic laparoscopy in doubtful cases allows not only to establish the presence or absence of inflammation in the appendix, but also, if the diagnosis of acute appendicitis is excluded, to conduct a sparing revision of the abdominal organs and in more than 1/3 of patients to identify the true cause of abdominal pain.
In case of doubts about the diagnosis, hospitalization of the child and dynamic monitoring should be carried out, which should not exceed 12 hours. Inspection is carried out every 2 hours, which is recorded in the medical history indicating the date and time of the examination. If after 12 hours of observation the diagnosis cannot be ruled out, surgical intervention is indicated.

Differential Diagnosis

Differential Diagnosis

Differential diagnosis is carried out with a number of diseases in which acute abdominal pain can be observed.

Pleuropneumonia, especially in young children, may be accompanied by abdominal pain. Clinical and radiological signs of pneumonia are quite typical and difficulties in diagnosis usually arise only at the very beginning of the disease. In case of doubts about the diagnosis, dynamic observation allows to exclude the diagnosis of acute appendicitis.

Intestinal infections accompanied by abdominal pain, however, in the vast majority of cases, they are characterized by nausea, repeated vomiting, loose stools, cramping abdominal pain, severe fever. In this case, the abdomen, as a rule, remains soft, there are no symptoms of peritoneal irritation.

Dynamic observation also makes it possible to exclude the presence of acute surgical pathology.

Viral respiratory diseases often accompanied by abdominal pain. Careful history taking, clinical examination, ultrasonography and dynamic observation allow to exclude the diagnosis of acute appendicitis.

Abdominal syndrome of Henoch-Schonlein disease accompanied by severe pain in the abdomen, nausea, vomiting, fever. The skin of the child should be examined very carefully, since in Henoch-Schonlein disease there are usually hemorrhagic petechial rashes, especially in the joints.

Renal colic, especially when the right kidney is affected, it can give a picture very similar to acute appendicitis. Urinalysis, ultrasound examination of the kidneys and urinary tract makes it possible to establish the correct diagnosis.

Acute surgical diseases of the abdominal organs(pelvioperitonitis, ovarian cyst torsion, diverticulitis) can be quite difficult to differentiate from acute appendicitis.

Ultrasound examination in some cases reveals such conditions. If the diagnosis cannot be ruled out, an emergency operation is indicated, and, if appropriate, diagnostic laparoscopy is performed.

It should be noted that even an accurate diagnosis of a disease that mimics acute appendicitis does not allow us to exclude acute appendicitis itself, since their combination is possible, which should always be remembered.

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Treatment

TREATMENT OF CHILDREN WITH ACUTE APPENDICITIS

Treatment of acute appendicitis is only surgical.

Indications for emergency surgical treatment

Emergency surgery immediately after hospitalization in a surgical hospital, or after a short preoperative preparation (depending on the severity of the patient's condition) is indicated:

When establishing the diagnosis of acute appendicitis;

The impossibility of its exclusion after the entire complex of diagnostic measures and dynamic observation for more than 12 hours.

Ppreoperative Preparation And anesthesia.
Children with uncomplicated forms of acute appendicitis, as a rule, do not need special preoperative preparation. Preoperative preparation is indicated for patients with repeated vomiting, high fever (above 38ºC) and other symptoms of severe intoxication. Water and electrolyte disturbances are corrected, body temperature is lowered (NSAIDs, physical methods). The duration of preoperative preparation should not exceed 2 hours.
Surgery is performed under general anesthesia using muscle relaxants and mechanical ventilation.
Before surgery, as part of premedication, or more preferably, during the induction of anesthesia, an antibacterial drug is administered. Use cephalosporins I - II generation: cefazolin 20 - 30 mg / kg, cefuroxime 20 - 30 mg / kg; semi-synthetic penicillins: co-amoxiclav 25 mg/kg.

Surgical treatment

The operation for acute appendicitis is performed by a qualified doctor of the department, and on duty the senior surgeon of the team with the obligatory presence of an assistant.

Currently, preference is given to laparoscopic appendectomy, which allows for a complete revision of the abdominal organs, is associated with a lower risk of adhesive complications and wound infection, is less traumatic and leads to an excellent cosmetic effect. Despite this, the traditional intervention has not completely lost its significance.

Appendectomy is performed according to vital indications, the only contraindication to its implementation is the agonal state of the patient.

Ttraditional appendectomy
An incision is made in the right iliac region according to McBurney-Volkovich-Dyakonov. The caecum with the appendix is ​​brought out into the wound. In the mesentery of the appendix at its base, a "window" is made with a clamp, through which a ligature is passed from a synthetic non-absorbable material 2-0 - 3-0, the mesentery is tied up and cut off. Appendectomy can be performed both by ligature and by submersible method. When performing an appendectomy by the submersible method, a purse-string suture with absorbable synthetic material 3-0 - 4-0 is first applied around the base of the appendix separated from the mesentery. A Kocher clamp is applied to the base of the appendix, the clamp is removed, and in this place the appendix is ​​tied with a ligature of absorbable material. Above the ligature, a Kocher clamp is applied and the process is crossed between the clamp and the ligature. The stump of the appendix is ​​treated with a solution of iodine and, if necessary, immersed with a purse-string suture into the wall of the caecum.
In cases where the appendix cannot be brought into the wound, a retrograde appendectomy is performed. The cecum is brought out into the wound as much as possible. Then the base of the process is clamped with a Kocher clamp and tied up in this place with a ligature. The process is crossed between the clamp and the ligature. The stump is treated with iodine and immersed with a purse-string suture. After that, the caecum becomes more mobile. The selected process is removed into the wound, its mesentery is bandaged.
The surgical wound is sutured tightly in layers.

Laparoscopic appendectomy
To perform a laparoscopic appendectomy, a number of conditions must be met.
- The presence of a specialist who owns the technique of laparoscopic interventions and has the appropriate certificate;
- Availability of the necessary equipment: monitor, digital video camera, insufflator, coagulator, carbon dioxide supply system (central wiring or cylinder) and special tools;
- The presence of an anesthesiologist who knows the technique of conducting anesthesia during interventions accompanied by the imposition of carboxyperitoneum.
Laparoscopic interventions are contraindicated in severe concomitant pathology of the cardiovascular and respiratory systems. A relative contraindication is the presence of a pronounced adhesive process in the abdominal cavity. In each case, the possibility of performing a laparoscopic intervention is decided with the participation of the operating surgeon, an anesthesiologist and a specialized specialist.
For intervention, three-millimeter instruments are used in children up to three or four years old and five- and ten-millimeter instruments in older children.
Trocars are installed at three points: through the navel, at the Mac-Burney point on the left and above the bosom. After the introduction of trocars and the imposition of pneumoperitoneum, an examination of the abdominal cavity is carried out. The examination begins with the right iliac region, then the pelvic cavity, the left sections of the abdomen, the upper floor of the abdominal cavity are examined.
In the typical location of the appendix, it is grasped with a clamp and gently pulled. Standard bipolar forceps produce coagulation of the mesentery of the process from the apex to the base, followed by its intersection with scissors.
With an atypical location of the process (retrocecal, retroperitoneal), a retroanterograde appendectomy is performed. A window is formed in the mesentery in the place where it is accessible for manipulation. After that, the mesentery is coagulated and crossed first retrograde to the apex, and then anterograde to the base.
Next, 2 Raeder's loops are applied to the base of the skeletonized appendix. To do this, the process is placed in a loop with a clamp, grasped and slightly pulled. In this position, the loop is tightened at its base. The ligature is crossed.
At a distance of 5 - 6 mm from the ligature, bipolar coagulation of the process is performed, after which it is crossed along the lower border of the coagulation zone and removed from the abdominal cavity. The abdominal cavity is sanitized and the trocars are removed. Interrupted sutures are applied to the wounds.

POpostoperative treatment
Antibacterial therapy is carried out in the postoperative period. As a rule, a combination of I-II generation cephalosporins or semi-synthetic penicillins with aminoglycosides is used. Only 3rd generation cephalosporins can be used. Mandatory in the scheme antibiotic therapy add metronidazole. Antibacterial therapy is carried out for 4-5 days.

Information

Sources and literature

1. Clinical guidelines of the Russian Association of Pediatric Surgeons
   1. 1. Isakov Yu. F., Stepanov E. A., Dronov A. F. Acute appendicitis in childhood. - M.: Medicine, 1980. 2. Stepanov E. A., Dronov A. F. Acute appendicitis in young children. - M.: Medicine, 1974. 3. Bairov G. A. Urgent surgery for children. – A guide for physicians. - St. Petersburg, 1997. - 323 p. 4. Bairov G. A., Roshal L. M. Purulent surgeons of children: A guide for doctors. - L .: Medicine, 1991. - 272 p. 5. Operative surgery with topographic anatomy of childhood / Under the editorship of Yu. F. Isakov, Yu. M. Lopukhin. – M.: Medicine, 1989. – 592 p. 6. Practical guidance on the use of the WHO Surgical Safety Checklist, 2009. Printed by the WHO Document Production Services, Geneva, Switzerland. 20 s. 7. Dronov A.F., Poddubny I.V., Kotlobovsky V.I. Endoscopic surgery in children / ed. Yu. F. Isakova, A. F. Dronova. - M.: GEOTAR-MED, 2002, - 440 p. 8. Acute appendicitis / In the book. Pediatric surgery: national guidelines / under. Ed. Yu. F. Isakova, A. F. Dronova. - M., GEOTAR-Media, 2009. - 690 p. 1. Al-Ajerami Y. Sensitivity and specificity of ultrasound in the diagnosis of acute appendicitis. East Mediterr Health J. 2012 Jan; 18 (1): 66–9. 2. Blanc B, Pocard M. Surgical techniques of appendectomy for acute appendicitis. J Chir 2009 Oct; 146 Spec No 1:22–31. 3. Bravetti M, Cirocchi R, Giuliani D, De Sol A, Locci E, Spizzirri A, Lamura F, Giustozzi G, Sciannameo F. Laparoscopic appendectomy. Minerva Chir. Dec 2007; 62 (6): 489–96. 4. Drăghici I, Drăghici L, Popescu M, Liţescu M. Laparoscopic exploration in pediatric surgery emergencies. J Med Life. 2010 Jan Mar; 3 (1): 90–5. 5. Doria AS. Optimizing the role of imaging in appendicitis. Pediatric Radiol. 2009 Apr; 39 Suppl 2: S 144–8. 6. Kamphuis SJ, Tan EC, Kleizen K, Aronson DC, de Blaauw I. Acute appendicitis in very young children. Ned Tijdschr Geneeskd. 2010;154 7. Kapischke M, Pries A, Caliebe A. Short term and long term results after open vs. laparoscopic appendectomy in childhood and adolescence: a subgroup analysis. BMC Pediatr. 2013 Oct 1; 13:154. 8. Lee SL, Islam S, Cassidy LD, Abdullah F, Arca MJ. Antibiotics and appendicitis in the pediatric population: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review., 2010 American Pediatric Surgical Association Outcomes and Clinical Trials Committee. J Pediatric Surg. Nov 2010; 45 (11): 2181–5. 9. Müller AM, Kaucevic M, Coerdt W, Turial S. Appendicitis in childhood: correlation of clinical data with histopathological findings. Klin Padiatr. Dec 2010; 222 (7): 449 – 54. 10. Quigley AJ, Stafrace S. Ultrasound assessment of acute appendicitis in pediatric patients: methodology and pictorial overview of findings seen. Insight Imaging. 2013 Aug 31. 22 11.Sinha S, Salter MC. Atypical acute appendicitis. Emerge Med J. 2009 Dec; 26 (12): 856. 12. Vainrib M, Buklan G, Gutermacher M, Lazar L, Werner M, Rathaus V, Erez I. The impact of early sonographic evaluation on hospital admissions of children with suspected acute appendicitis. Pediatric Surg Int. Sep 2011 27 (9): 981-4.

Information

DEVELOPERS EDITIONS

Chief Editor ROZINOV Vladimir Mikhailovich, Doctor of Medical Sciences, Professor, Deputy Director of the Moscow Research Institute of Pediatrics and Pediatric Surgery of the Ministry of Health of Russia


METHODOLOGY WITHBUILDINGS AND PROGRAM SECURITIESQUALITIES CLINICAL RECOMMENDATIONS

ANDinformational resources, used For development clinical recommendations:
· Electronic databases (MEDLINE, PUBMED);
· Consolidated clinical experience of the leading pediatric clinics in Moscow;
· Thematic monographs published in the period 1952 - 2012.

methods, used For estimates quality And credibility clinical recommendations:
Consensus of experts (the composition of the profile commission of the Ministry of Health of Russia in the specialty "pediatric surgery");
· Assessment of significance in accordance with the rating scheme (table).

working group:
The final version and quality control of the recommendation were re-analyzed by the members of the working group, who came to the conclusion that all the comments and comments of the experts were taken into account, the risk of systematic errors in the development of recommendations was minimized.

WITHOholding
The recommendations include a detailed description of the sequential actions of the surgeon in certain clinical situations. In-depth information about the epidemiology, etiopathogenesis of the processes under consideration is presented in special guidelines.

Guarantees
The relevance of clinical recommendations, their reliability, generalization based on modern knowledge and world experience, applicability in practice, clinical effectiveness are guaranteed.

ABOUTbinnovation
As new knowledge about the essence of the disease arises, appropriate changes and additions will be made to the recommendations. These clinical guidelines are based on the results of studies published in 2000-2013.

WITHAfashion sufficiency
The format of clinical recommendations includes the definition of the disease, epidemiology, classification, including, in accordance with ICD-10, clinical manifestations, diagnosis, and various types of treatment. The choice of the topic of clinical recommendations is motivated by the high frequency of occurrence of the considered pathological condition, its clinical and social significance.

Aatditoria
Clinical recommendations are intended for pediatric surgeons, general surgeons providing medical care to children, students of higher education and postgraduate education.

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Boys are more often ill (ratio 3:2), and aged 12 to 20 years. Due to the fact that younger children are suspected less often, complications of appendicitis are more common in them.

Embryology and anatomy.

The appendix develops as a continuation of the caecum at its lower pole. In a newborn, the appendix looks like an inverted pyramid. At an early age, the lateral walls of the caecum grow sac-like, but the appendix does not assume its adult position (on the posterior-medial wall of the caecum, 2.5 cm below the ileocecal valve) until adolescence, when the phase of rapid growth of the anterior and right wall of the caecum begins. intestines. Suppression of the growth of the caecum leads to appendix hypoplasia or agenesis. There are cases of doubling of the appendix.

The base of the appendix is ​​located at the convergence of the three shadows of the colon. Its colonic epithelium, circular and longitudinal muscle layers pass to the same layers of the wall of the caecum. The appendix is ​​located intraperitoneally in 95% of cases, but its exact position varies widely. In 30%, the end of the appendix is ​​located in the pelvis, in 65% - retrocecally, in 5% - truly retroperitoneally. In cases of incomplete bowel rotation or situs inversus, the incorrectly located appendix shows signs of inflammation of unusual localization.

The length of the appendix is ​​on average 10 cm. The blood supply is a. appendicularis, a branch of a. ileocolica, which runs behind the terminal ileum. At birth, there are only a few submucosal lymph nodes. Their number at the age of 12-20 years increases to 200, and then sharply decreases after 30 years, and only traces of lymphoid tissue remain after 61 years of age.

Pathophysiology.

Appendicitis develops due to obstruction of its lumen and subsequent infection of its wall. This was experimentally confirmed by Wangensteen in 1939. He showed that the appendix continued to secrete mucus even when the intraluminal pressure increased above 93 mm Hg. Stretching of the appendix leads to strong irritation of the visceral pain nerves, so at first the pain is indistinctly localized, dull, in the navel.

The obturated appendix is ​​an excellent environment for the growth of bacteria that are normally present in it. As intraluminal pressure increases, lymphatic drainage decreases, leading to more edema. An increase in pressure leads to venous obstruction, which in turn leads to tissue ischemia, infarction and gangrene. Bacterial invasion of the appendix wall occurs. Inflammatory mediators are released from the ischemic tissue of the appendix, destroyed leukocytes and bacteria, which lead to such important three clinical signs of appendix destruction as fever, tachycardia and leukocytosis.

Due to the contact of the inflamed visceral peritoneum of the appendix with the parietal peritoneum, its somatic pain receptors are irritated and the pain is now localized not in the navel, but above the location of the appendix, usually in the right lower quadrant. Further destruction of the appendix wall leads to perforation with the release of infected contents with the further formation of local or general peritonitis. This process depends on the rate of development of perforation and the ability of the body to limit the appendicular contents in the abdominal cavity.

Cause of obstruction appendix in children with acute appendicitis in 20% are coprolites, and in children with perforated appendicitis, fecal stones are the cause of the disease in 30-40%. The presence of coprolites can be confirmed by ultrasound or radiographic examination. Hyperplasia of lymphoid follicles often leads to obstruction of the lumen, and the incidence of appendicitis coincides with the amount of lymphoid tissue in it. The cause of a local or generalized reaction of the lymphoid tissue is yersinia, salmonella, shigella, as well as amoebiasis, strongyloidiasis, enterobiasis, schistosomiasis, ascariasis. Intestinal and systemic viral diseases such as measles, chickenpox, and cytomegalovirus infection can also lead to appendicitis. In patients with cystic fibrosis, appendicitis is more common, which can be explained by changes in the glands that secrete mucus. Carcinoid tumors can lead to obstruction of the appendix, especially if they are located in the proximal third of the appendix. Foreign bodies such as needles, vegetable seeds, and cherry pits have been described as the cause of appendicitis over 200 years ago. Causes such as trauma, psychological stress, and heredity have also been described.

Traditionally, appendicitis is thought to progress from simple inflammation to perforation and subsequent abscess formation over a period of 2–3 days, with perforation occurring 24–36 hours after the onset of symptoms of appendicitis. Signs of perforated appendicitis include a temperature above 38.6, leukocytosis above 14,000, and generalized peritoneal symptoms. Such risk factors as male gender, young children, old people, such an anatomical feature as the retrocecal location of the appendix are indicated. However, perforated and non-perforated appendicitis can occur independently of each other. Spontaneous recovery has also been described. Asymptomatic course up to perforation can take place; symptoms may persist for more than 48 hours, but perforation does not occur. Although in general cases, the longer the symptoms are observed, the higher the risk of perforation. Perforation may also occur for other reasons, such as in neonates with Hirschsprung's disease.

The existence of chronic or recurrent appendicitis has been debated for decades. Recent literature data indicate their existence, and they should be considered in the differential diagnosis of recurrent abdominal pain.

Clinic of appendicitis.

The main and first symptom is abdominal pain. The pain is at first constant, aching, without a specific localization. Reflex, unrelieved vomiting. Subfebrile temperature, tachycardia.

Then the pain is localized above the location of the appendix: at the usual location - in the right iliac region, and there will be symptoms of irritation of the parietal peritoneum; when located in the pelvis - pain gives to the testicle, urination becomes more frequent, liquefied stools; with a retrocecal location, the pain radiates to the back, there may be no symptoms of irritation of the peritoneum of the anterior abdominal wall in the last two cases. An important symptom of appendicitis is anorexia. After perforation, the degree of spread of the process can be assessed by the tension of the muscles of the anterior abdominal wall - first local, and then generalized (a complication of acute appendicitis develops - peritonitis).

Diagnostics.

Based on clinical examination by the same surgeon over time. Comparative dosed percussion according to A.R. Shurink (light percussion with a brush, starting from the left thigh through the epigastric region towards the right iliac region) helps to localize the appendix. The Shchetkin-Blumberg symptom in children is not reliable, since it requires the active participation of the patient. Leukocytosis, tachycardia and fever are auxiliary indirect signs of inflammation.

If pelvic appendicitis is suspected, a rectal examination can be used to detect local tenderness and wall overhang (infiltrate, abscess). However, the study in children is used last, since 50% of children will have a rather sharp pain even in the absence of pelvic appendicitis. Ultrasound diagnosis of appendicitis is also possible, when its anterior-posterior size is at least 7 mm, and the diameter does not change with pressure; a fecal stone can be found in the process.

Features of the clinic and diagnosis of acute appendicitis

in young children. "

First, at this age, almost all acute inflammatory diseases have a similar clinical picture (high temperature, repeated vomiting, impaired bowel function).

Secondly, the inflammatory process in the appendix in children proceeds extremely rapidly. At the same time, the mechanisms of its delimitation are poorly expressed.

Thirdly, there are specific difficulties in examining young children. Anxiety, crying, resistance to examination make it difficult to identify the main local symptoms of acute appendicitis. In order to make a timely diagnosis of acute appendicitis, it is necessary to know the features of the clinic and diagnosis of this disease in young children. The reason for the more frequent complications of appendicitis in children under 3 years of age, including mortality at this age, is the low alertness of the doctor. During the initial examination of patients, district pediatricians, doctors of polyclinics, ambulances and emergency care should show increased alertness to children's complaints of abdominal pain.

"If in older children complaints of pain in the right" iliac region are of primary importance, then in children of the first years of life there are no direct indications of pain and it is possible to judge the presence of this symptom only by a number of indirect signs. The most important of these is change in the child's behavior. In more than 75% of cases, parents note that the child becomes lethargic, capricious, with little contact. The restless behavior of the patient should be associated with an increase in pain. The continuity of pain leads to sleep disturbance, which is a characteristic feature of the disease in young children and occurs in almost 1/3 of patients.

"An increase in temperature in acute appendicitis in children of the first years of life is almost always observed (95%). Often the temperature reaches 38 - 39 ° C. A rather constant symptom is vomit(85%). For young children, repeated (3-5 times) vomiting is characteristic, which refers to the peculiarities of the course of the disease at this age. The peculiarity of these symptoms in young children at the onset of the disease is explained by the non-differentiation of the reaction of the central nervous system of the child to the localization and degree of the inflammatory process.

"In almost 15% of cases, there is liquid stool. Stool disorder is observed mainly in complicated forms of appendicitis and the pelvic location of the appendix. Complaints of pain in the right iliac region in children at this age are almost never found. Usually the pain is localized around the navel, as in any intercurrent disease that occurs with abdominal syndrome. Such localization is associated with a number of anatomical and physiological features: the inability to accurately localize the place of greatest pain due to insufficient development of cortical processes and the tendency to irradiate nerve impulses, the close location of the solar plexus to the root of the mesentery. An important role is played by the rapid involvement of the mesenteric lymph nodes in the inflammatory process. "When diagnosing, they are guided by the same main symptoms as in older children (passive muscle tension and local pain in the right iliac region). However, it is extremely difficult to detect these signs in children of the first years of life. They are due to age-related mental characteristics and, first of all, motor excitation and restlessness during examination Under these conditions, it is almost impossible to determine local pain and differentiate active muscle tension from passive.

"Since these symptoms are the most important, and in young children often the only ones indicating the localization of the pathological process, special importance should be attached to their identification. The ability to find contact with a small child plays a certain role. This applies to children who are already starting to speak. Examination of the child preceded by conversations that are accessible to his understanding, as a result of which the child calms down and it becomes possible to examine him.It must be emphasized that the method of palpation of the anterior abdominal wall itself is important.The abdomen should be examined slowly, with soft movements of a warm hand, at first barely touching the anterior abdominal wall , and then gradually increasing the pressure.In this case, palpation should be started from a known healthy place, i.e. from the left thigh, left iliac region along the colon.When performing palpation of the abdomen, it is important to carefully monitor the behavior of the child.The appearance of motor restlessness, mimic reactions musculature can help assess the pain of the examination. "To detect local signs in acute appendicitis in children, special examination methods have been proposed (simultaneous comparative palpation in both iliac regions, deep palpation while inhaling, etc.)." examination of the child during sleep. Sometimes during palpation of the right iliac region, a symptom of "repulsion" can be noted: in a dream, the child pushes away the hand of the examiner with his own hand. At the same time, passive muscle tension of the anterior abdominal wall and local pain remain, the symptoms are easily detected, since motor excitation disappears, the psycho-emotional reaction and active tension are removed.

Differential diagnosis.

Pain appears first with appendicitis, and then symptoms of a gastrointestinal disorder appear. If the disorder appears first, and then the pain, then the diagnosis of acute appendicitis fades into the background. Vomiting can be, but frequent, especially indomitable vomiting will suggest food poisoning. Loose stools can be observed with irritation by the process of the rectum, however, diarrhea with pathological impurities will also suggest an infectious nature of the disease. In a newborn, the presence of acute appendicitis should suggest Hirschsprung's disease. The differential diagnosis of acute appendicitis in even older children has fundamental differences from that in adults. This is due to the fact that acute appendicitis in childhood in its clinical manifestation (especially with atypical variants of the location of the appendix) is similar to a large number of diseases that do not require surgical intervention. Even more diseases, both somatic and surgical with localization in the abdominal cavity and outside it, are "disguised" as acute appendicitis.

In children, one should never count on limiting the inflammatory process in the appendix. It is important to carry out all the necessary clinical studies as soon as possible, involving, if necessary, doctors of related specialties (pediatrician, infectious disease specialist, otolaryngologist) in consultations. Usually, 2-6 hours of active observation is sufficient for a definitive diagnosis. In some cases, these dates may be changed.

"The complexity of diagnosis in children is also explained by the fact that, depending on age, the range of diseases from which acute appendicitis has to be differentiated also changes. In children of the older age group, the clinical picture of acute appendicitis is most often simulated by diseases of the gastrointestinal tract, biliary and urinary systems, coprostasis, acute respiratory viral diseases, pneumonia, diseases of the genital organs in girls, congenital and acquired diseases of the ileocecal angle, childhood infections, hemorrhagic vasculitis (Schonlein-Genoch disease).

"At a younger age (mainly in children of the first 3 years of life), differential diagnosis is more often carried out with acute respiratory viral infections, coprostasis, urological diseases, pneumonia, gastrointestinal diseases, otitis media, childhood infections. "Mistakes are due to both insufficient awareness of clinical options the course of acute appendicitis, and the difficulties of recognizing this disease in children, especially at an early age. "The use of objective research methods in the preoperative diagnosis of clinically questionable acute appendicitis allows minimizing the percentage of hypo- and overdiagnostic errors and, accordingly, sharply reducing the number of unnecessary appendectomy. With this tactic, the likelihood of postoperative complications decreases and the diagnosis of diseases that cause abdominal pain syndrome improves.

Treatment. Only surgical. There are a number of features in the surgical treatment of various forms of acute appendicitis, which are most pronounced in the first years of a child's life.

"Pain relief in children, especially young children, should be only general. An important point prior to anesthesia is the psychological preparation of the patient. It is necessary to drain the abdominal cavity only as a last resort, since the frequency of adhesive obstruction doubles with the setting of drainage.

In young children, attention is drawn to the rapid generalization of the process due to the small size of the omentum, which is not able to delimit the infected effusion in the abdominal cavity. That's why with appendicular infiltrate in children under 3 years of age surgical treatment is recommended after 3 years- conservative, consisting in strict bed rest, intravenous antibiotics and intravenous intensive care. When abscessing the infiltrate, it is only recommended to drain it, and the appendix itself to be removed in the cold period after 2 months.

Preoperative and postoperative management of patients is based on knowledge of the principles of infusion therapy, the ability in each case to determine the volume and quality of infusion therapy, depending on the age, weight and general condition of the child. The volume of liquid for intravenous administration is equal to the physiological need in ml per 1 kg of the child's body weight:

2 days from birth - 25

3 days - 40

4 days - 60

5 days - 90

6 days - 115

7-14 days - 150-140

up to 1 year of life - 150

up to 5 years of life - 100

up to 10 years of life - 70

14-15 years of life - 40

The volume for pathological losses is added to the volume of physiological need (based on 1 kg of mass):

hyperthermia 1C above 37 (more than 6 hours) - 10 ml,

shortness of breath - (for every 10 breaths above normal) - 10 ml,

vomiting - 20 ml

paresis of the intestines - 20-40 ml

excretion from the intestinal stoma - 20 ml

To combat paresis of the intestines in the postoperative period, it is necessary to apply:

gastric lavage,

the introduction of prozerin, cerucal in age doses with an interval of 10-15 minutes,

cleansing enema with hypertonic solution, (15-20 minutes after the injection of prozerin or cerucal),

epidural anesthesia,

correction of the level of potassium in the blood plasma,

pararenal or presacral novocaine blockade.

28350 0

Acute appendicitis in pregnancy happens in 0.7-1.2% of cases, i.e. much more frequently than in other populations. This explains a number of factors that contribute to the occurrence of an inflammatory process in the appendix: its displacement upward and outward, along with the caecum, by a gradually increasing uterus, resulting in kinks and stretching of the appendix; violation of the evacuation of its contents, as well as the deterioration of blood supply in conditions of changed anatomical relationships between organs. An important role is played by the tendency to constipation during pregnancy, which leads to stagnation of the contents and an increase in the virulence of the intestinal flora. Finally, hormonal changes that lead to a decrease in immunity are of some importance. These factors often lead to a severe course of appendicitis, ending in a destructive process, especially in the second half of pregnancy. In turn, destructive appendicitis can lead to abortion and fetal death. This complication occurs with appendicitis of pregnant women in 4-6% of cases.

Special consideration of appendicitis in pregnant women is due to the fact that a number of signs inherent in this disease (abdominal pain, vomiting, leukocytosis) may occur during the normal course of pregnancy, making it difficult to diagnose.

The clinical course of acute appendicitis in the first half of pregnancy almost does not differ from that outside of pregnancy. Significant differences occur only in the second half of pregnancy.

First of all, the rather weak severity of the pain syndrome draws attention, as a result of which patients do not fix attention on it, identifying it with pain that often occurs in the second half of pregnancy due to stretching of the ligamentous apparatus of the uterus. Nevertheless, careful questioning allows you to establish the onset of pain in the epigastric region and their gradual shift to the location of the appendix (Kocher-Volkovich symptom). Vomiting is not critical, as it often occurs during pregnancy in general.

When examining the abdomen, it is necessary to take into account the localization of the appendix, which shifts upward as the duration of pregnancy increases (see Fig. 43-13).

Rice. 43-13. The displacement of the caecum and appendix by the pregnant uterus makes it necessary to change the surgical approach.

Thus, local pain in acute appendicitis in the second half of pregnancy will not be in the right iliac region, but much higher. Due to stretching of the abdominal wall by the enlarged uterus, local muscle tension is weakly expressed. In late pregnancy, when the caecum and its process are behind the enlarged uterus, other symptoms of peritoneal irritation may also be negative: Shchetkin-Blumberg, Voskresensky, etc. During this period, as a rule, Obraztsov's symptom is well expressed. Extremely useful is palpation of the abdomen in the position of the patient on the left side: in this case, due to some displacement of the uterus to the left, it is possible to probe the region of the appendix and the right kidney in more detail, to identify the symptom of Bartomier-Michelson.

The temperature reaction is less pronounced than outside pregnancy. The number of leukocytes moderately increases, but it must be borne in mind that leukocytosis up to 12x10 9 / l in pregnant women is not uncommon.

The Volkovich-Dyakonov incision is used as an operative access for an undoubted diagnosis in the first half of pregnancy. In the second half of pregnancy, this access may be inadequate, so it is modified according to the principle: the longer the gestation period, the higher the incision. Thus, in the last weeks of pregnancy, the incision is made above the ilium due to a significant displacement of the caecum and appendix upwards. It is advisable to expand the Volkovich-Dyakonov incision by dissecting the sheath of the rectus abdominis muscle.

Operative tactics for any form of appendicitis in pregnant women does not differ from the generally accepted principles of its treatment. In other words, the features of the surgical technique and methods of drainage of the abdominal cavity, adopted in various forms of acute appendicitis, fully retain their significance here. It is only necessary to be extremely careful when manipulating near the enlarged uterus, since its injury can serve as a direct cause of miscarriage or premature birth.
For the same reasons, tamponade of the abdominal cavity is carried out according to the most stringent indications:

• if it is impossible to carry out reliable hemostasis in the abdominal cavity;
• opening of a periappendicular abscess.

In pregnant women, the most difficult task is the treatment of diffuse peritonitis. Mortality in this complication remains very high and, according to various authors, is 23-55% for the mother and 40-92% for the fetus, with the greatest number of deaths observed in late pregnancy. Unfavorable results of treatment of diffuse purulent peritonitis in pregnant women gave rise to extreme radicalism of surgical tactics. It was considered necessary to perform the following volume of surgical intervention: immediately after opening the abdominal cavity, perform a caesarean section, then supravaginal amputation of the uterus, then appendectomy, toilet and drainage of the abdominal cavity.

Currently, due to the availability of powerful antibacterial drugs, in most of these cases it is possible not to resort to a caesarean section, and even more so to the subsequent amputation of the uterus. It must be emphasized that the issue of the volume and nature of the intervention in destructive appendicitis against the background of long gestation periods should be decided together with the obstetrician-gynecologist, with his direct participation in the surgical intervention. Briefly principle of modern surgical tactics can be formulated as follows: maximum activity in relation to peritonitis, maximum conservatism in relation to pregnancy.

In modern conditions, with diffuse appendicular peritonitis in pregnant women, a median laparotomy, evacuation of pus, appendectomy, and a toilet of the abdominal cavity are performed under general anesthesia and drains are installed. The surgical wound is sutured tightly. At full-term or almost full-term pregnancy (36-40 weeks), due to the inevitability of childbirth against the background of peritonitis, the operation begins with a caesarean section, then, after suturing the uterus and peritonization of the sutures, an appendectomy is performed and all further manipulations associated with the treatment of peritonitis.

The urgent need for amputation of the uterus arises only with its destructive defeat, which is occasionally observed in conditions of diffuse purulent peritonitis. It should also be borne in mind that with diffuse purulent peritonitis, the contractility of the uterus is significantly reduced. In this regard, sometimes after a caesarean section there is a danger of atonic bleeding, the only remedy for which is the immediate amputation of the uterus.

Deserves special attention acute appendicitis in childbirth. Surgical tactics for appendicitis in labor depends both on the course of labor and on the clinical form of acute appendicitis. So, if the birth proceeds normally with a clinical picture of catarrhal and phlegmonous appendicitis, then it is necessary to facilitate the speedy delivery and then perform an appendectomy. If, against the background of the normal course of labor, there is a clinical picture of gangrenous or perforated appendicitis, then it is necessary to temporarily stop the contractile activity of the uterus, perform an appendectomy and then stimulate labor activity again. In conditions of pathological childbirth, it is necessary to perform a simultaneous caesarean section and appendectomy for any clinical form of acute appendicitis.

Regardless of the timing of delivery, the patient for appendectomy and subsequent postoperative management must be transferred to the surgical department, where she should be observed by both the surgeon and the gynecologist.

Acute appendicitis in children much less common than in adults. The vast majority of cases occur in people over 5 years of age. The rarity of acute appendicitis before the age of 5 explains the fact that the appendix has a funnel-shaped form, which contributes to a good emptying of the appendix, and also that the lymphoid apparatus of the appendix is ​​still poorly developed during this period of life.

Acute appendicitis in children is more severe than in adults. This is due to the insufficient resistance of the child's body to infection, the weak plastic properties of the child's peritoneum, the insufficient development of the omentum, which does not reach the appendix and, thus, does not participate in the creation of a delimiting barrier.

The pains that have arisen in the abdomen are often cramping in nature and do not have the clear dynamics that are characteristic of acute appendicitis in adults. It should be noted that children under 10 years of age, as a rule, cannot accurately localize pain, which makes it difficult to recognize the disease. Vomiting in children is most often repeated, the stool does not tend to be delayed, and in young children it is even faster. Characteristic posture of a sick child. He lies on his right side or on his back, bringing his legs to his stomach and putting his hand on the right iliac region, protects it from being examined by a doctor. With careful palpation, it is often possible to identify hyperesthesia, muscle tension and the zone of greatest pain. Even in the first hours of the disease, the symptoms of Shchetkin-Blumberg, Voskresensky, Bartomier-Michelson are expressed.

The temperature from the very beginning of the disease is much higher than in adults, it often reaches and exceeds 38 ° C. The number of leukocytes is also increased, but it rarely exceeds 20x10 9 /l along with the existing neutrophilic shift.

In the differential diagnosis of acute appendicitis in children, the following diseases deserve attention: pleuropneumonia, acute gastroenteritis, dysentery, hemorrhagic vasculitis (Schonlein-Genoch disease).

When differentiating from pleuropneumonia, it should be borne in mind that this disease is characterized not only by pain spreading towards the abdomen, but also by cough, sometimes with transient cyanosis of the lips, wings of the nose and shortness of breath. It should be recalled that in children the normal ratio of respiration and pulse is 1:4, and if the ratio becomes 1:3 or 1:2, then this rather speaks in favor of acute pneumonia. With pleuropneumonia, wheezing and pleural friction rubs can also be heard on the corresponding side of the chest.

When differentiating from gastroenteritis, it must be taken into account that this disease usually begins not with abdominal pain, but with vomiting and the appearance of a characteristic repeated watery stool; in contrast to acute appendicitis, pains join later. In addition, with gastroenteritis, they are of a pronounced cramping character, followed by an urge to stool often. The temperature in this disease is increased, as in appendicitis, but the number of leukocytes is normal or even slightly reduced, the neutrophilic shift is not pronounced.

The need to differentiate acute appendicitis with dysentery occurs most often in the younger age group. Here, first of all, the anamnesis plays a role, in particular, indications that a similar disease appeared in several children at once, especially in children's groups. Pain in dysentery is clearly cramping in nature and is localized mainly in the left side of the abdomen, multiple loose stools are noted, often with an admixture of blood. The maximum palpation pain is determined in the lower abdomen on the left, the symptoms of peritoneal irritation, with rare exceptions, are not detected. Body temperature in dysentery is often high (38.0-39.0 ° C), the number of leukocytes can be elevated without a significant neutrophilic shift.

When differentiating with hemorrhagic vasculitis, it is taken into account that abdominal pain in this disease is caused by multiple small subserous hemorrhages and does not have a clear localization. In addition, a careful examination of the skin allows you to identify the presence or residual effects of hemorrhagic exanthema in symmetrical areas of the trunk, limbs, buttocks. You should also pay attention to the mucous membrane of the cheeks, the sublingual space, where it is possible to detect the presence of small hemorrhages even before the appearance of a rash on the skin. The abdominal wall during the study is not tense, however, the Shchetkin-Blumberg symptom is most often pronounced, the abdomen is swollen and evenly painful. Rectal examination may reveal bloody bowel contents. Body temperature sometimes reaches 38 ° C and above, the number of leukocytes is also more often increased without a significant neutrophilic shift.

In case of significant difficulties in differential diagnosis, if there are no symptoms of peritoneal irritation, it is permissible to dynamically monitor the child for 6-12 hours.

At the same time, it should be remembered that appendicitis in children proceeds more rapidly than in adults, and often, during the first day of the disease, destruction of the process develops. Based on this, in children, surgical tactics in general should be more active than in adults.

All of this also applies to appendicular infiltrate, which in children often begins to be determined already on the second day of the disease. Since the appendix is ​​relatively long in children, and the omentum, on the contrary, is short, and the peritoneum does not have sufficient plastic properties, the resulting infiltrate cannot be a reliable obstacle to the spread of infection in the abdominal cavity. In this regard, the operation is indicated even with a palpable infiltrate, especially since the isolation of the appendix from loosely soldered organs is not particularly difficult.

Appendectomy in children is always performed under general anesthesia. As an operative access, the Volkovich-Dyakonov incision is used, with the exception of cases of diffuse purulent peritonitis, when a lower median laparotomy is indicated.

In most cases, appendectomy in children is technically simple due to the absence of adhesions and fusion of the appendix with surrounding organs. The order of surgical manipulations is the same as in adults, with the exception of the treatment of the appendix stump, which is not immersed in children under 10 years of age due to the danger of a through puncture of the thin intestinal wall when applying a purse-string suture. In this regard, in children of the first years of life, the so-called ligature (amputation) method of appendectomy is used, in which the stump of the appendix is ​​bandaged not with catgut, but with silk or another non-absorbable thread, the mucous membrane is cauterized with an electrocoagulator and left in this form in the abdominal cavity.

Numerous clinical observations have proven the safety of this method of processing the stump of the appendix, although in older children it is still better, as in adults, to immerse the stump in order to avoid strong adhesion of intestinal loops with it, which may subsequently cause intestinal obstruction. The operation is completed by suturing the surgical wound tightly and, if necessary, draining the abdominal cavity. Due to the fact that in children the appendix is ​​located more freely in the abdominal cavity, in childhood there are reasons for performing laparoscopic appendectomy. In many clinics, the vast majority of surgical interventions for acute appendicitis are currently performed laparoscopically.

Acute appendicitis in the elderly and senile age happens a little less often than at persons of young and middle age. The number of elderly and senile patients is about 10% of the total number of patients with acute appendicitis.

In the elderly and senile age, destructive forms of appendicitis predominate. This is due, on the one hand, to a reduced reactivity of the body, and on the other hand, to atherosclerotic lesions of its vessels, which is the direct cause of a rapid disruption of blood supply with the development of necrosis and gangrene of the appendix. It is in the elderly that the so-called primary gangrenous appendicitis occurs, which develops, bypassing the catarrhal and phlegmonous phases of inflammation.

The symptom complex of acute appendicitis in patients of this group often has an obscure picture. Due to the physiological increase in the threshold of pain sensitivity in old age, patients often do not fix attention on the epigastric phase of abdominal pain at the onset of the disease.

Nausea and vomiting are more common than in middle-aged people, which is associated with the rapid development of the destructive process. Stool retention is not critical, since in old age there is a physiological tendency to slow bowel movements.

Examination of the abdomen reveals only moderate pain in the right iliac region, even with destructive forms of appendicitis. Due to age-related relaxation of the muscles of the abdominal wall, muscle tension in the lesion is insignificant, but the Shchetkin-Blumberg symptom is usually determined. Often the symptoms of Voskresensky, Sitkovsky are positive.

In some cases, especially in destructive forms of the disease, there is pronounced flatulence due to intestinal paresis. Body temperature even with destructive appendicitis rises moderately or remains normal. The number of leukocytes is normal or slightly increased: within 10-12x10 9 /l, the neutrophilic shift is small.

In elderly and senile people, appendicular infiltrate occurs much more often than in middle-aged people, which is characterized by slow development. Patients often notice a tumor-like formation in the right iliac region a few days after an attack of non-intense pain, which makes it necessary to pay special attention to the differential diagnosis of appendicular infiltrate with a tumor of the caecum.

The peculiarity of the course of acute appendicitis in the elderly is that it is difficult to accurately recognize one or another clinical form of acute appendicitis before surgery. This indicates the need for active surgical tactics, especially since the risk of appendectomy in old age is often exaggerated. When choosing a method of anesthesia, local anesthesia is preferred, especially in patients with concomitant diseases of the respiratory and cardiovascular systems. Management of the postoperative period in elderly patients is no less important than the operation itself. It is necessary to carry out dynamic control of the functional state of the most important systems of the body. The main activities should be aimed at the prevention and treatment of respiratory disorders, circulatory disorders, renal failure and metabolic changes. Particular attention should be paid to the prevention of pulmonary embolism.

Forecast

B.C. Saveliev, V.A. Petukhov