Appendix. Appendix. Topography of the appendix. Position of the appendix. Atypical forms of acute appendicitis: pelvic acute appendicitis

HISTORICAL REFERENCE

Abscesses in the right iliac region were known in ancient Egypt, but work linking them with disease of the appendix appeared only in the second half of the 19th century. The first description of the appendix belongs to the Italian physician Da Carpi (1521). Images of the appendix are found in the anatomical drawings of Leonardo da Vinci, made in 1492, as well as in the work of A. Vesalius (1543).

The first reliably known appendectomy was performed in 1735 by the founder of St. George's Hospital in London, Claudius Amyand.

The term “appendicitis” was proposed by the American surgeon R. Fitz at the convention of the American Medical Association in 1886. Fitz emphasized that the main cause of ulcers in the right iliac fossa is the appendix and clearly described the clinical picture of the disease. In 1889 A.A. Bobrov removed part of the appendix from the appendicular infiltrate, and in 1890 A.A. Troyanov performed the first appendectomy at the Obukhov Hospital (St. Petersburg). Subsequently, several surgical approaches were proposed, of which the oblique variable incision McBarney (1894) turned out to be the most successful. Later, the same access was independently proposed by N.M. Volkovich and P.I. Dyakonov.

Initially, during appendectomy, the appendix was simply ligated at the base. In 1895, R. Dawbarn proposed the application of a purse-string suture. Currently, the ligature method of treating the stump of the appendix is ​​mainly used in children and during laparoscopic operations, but there are many of its supporters for conventional appendectomy.

In 1933, the All-Russian Conference on Acute Appendicitis was held, during which it was decided that patients with acute appendicitis should be hospitalized in the surgical department as early as possible and urgently operated on at any time from the onset of the disease. The only contraindication was the formed appendiceal infiltrate without signs of abscess formation. Decision III The All-Union Conference of Surgeons and Orthopedic Traumatologists (1967) stated the following: “When a diagnosis of acute appendicitis is made, urgent surgery is indicated, regardless of the form of acute appendicitis, the age of the patient and the time elapsed from the onset of the disease.”

Laparoscopy occupies a special place in the differential diagnosis of acute appendicitis. For the first time, an examination of the abdominal cavity through an incision in the posterior vaginal vault using mirrors and a head reflector was performed in 1901 by obstetrician-gynecologist D.O. Ott. Laparoscopic appendectomy was performed for the first time in 1982 by K.

Anatomy and physiology of the appendix

According to some data, the appendix has been evolving for at least 80 million years. The vermiform appendix arises from the posteromedial wall of the cecum at the convergence of the three tenaia, and is usually directed downward and medially. Most often it has a length of 7–12 cm and a diameter of 5–7 mm, is located intraperitoneally, has its own mesentery, in which there are vessels, nerves, and adipose tissue. The wall of the process is represented by serous, muscular, submucosal and mucous membranes. The muscular coat of the appendix consists of two layers - longitudinal and circular. In the submucosa there is a large number of lymphatic follicles and vessels. The mucous membrane is lined with columnar epithelium and forms deep crypts. The process communicates with the cecum by a narrow opening, the mucous membrane of which in some cases has semilunar folds - the valves of Gerlach. The cecum in a collapsed state lies in the depths of the right iliac region, covered with loops small intestine and a large seal. The swollen cecum is usually located at the anterior abdominal wall. The appendix can occupy different positions in relation to the cecum: medial, lateral (in the right lateral canal), ascending, descending. Sometimes it reaches the bladder, rectum, ovaries, fallopian tubes. In 5–7% of cases, the appendix is ​​located retrocecally, and in 2% – partially or completely retroperitoneally. In the latter case, the process may contact the right ureter or, much less frequently, the right kidney. With incomplete rotation of the intestine, depending on its degree, the cecum with the appendix is ​​located above the iliac fossa - in the mesogastrium, right hypochondrium, less often in the epigastrium. With the reverse arrangement of the organs, the cecum and the appendix are located in the left iliac fossa. In general, atypical location occurs in 10–17% of cases. It is extremely rare to have a duplication of the appendix or its intramural (intrawall) location.

The vermiform appendix is ​​supplied with blood by the a. appendicularis passing through its mesentery, which is a branch of the a. ileocolica, which branches off from the a. mesenterica superior. The outflow of blood from the appendix goes through the veins of the same name. In women, the Clado ligament, containing vessels, may run from the base of the process to the right broad ligament of the uterus.

Lymphatic drainage is carried out through intraorgan lymphatic vessels, forming a network in all layers of the process and flowing into the ileocolic lymph nodes along the a.ileocolica, and then into the lymph nodes along the superior and inferior mesenteric arteries and into the para-aortic lymph nodes.

The vermiform appendix has sympathetic innervation from the superior mesenteric and celiac plexuses and parasympathetic innervation from the vagus nerve fibers.

There is a lot of conflicting information about the significance of the appendix. A number of authors believe that it is important as a lymphoid, secretory and endocrine organ and is related to intestinal microflora and colon motility.

EPIDEMIOLOGY, PATHOGENESIS AND PATHOLOGICAL PICTURE OF ACUTE APPENDICITIS

Acute appendicitis is one of the most common surgical diseases. The incidence of acute appendicitis is 4–5 people per 1000 population. Acute appendicitis most often occurs between the ages of 20 and 40; women are affected 1.5–2 times more often than men. In emergency surgery, up to 30–40% of all operations are for acute appendicitis. On average, every fifth appendectomy is performed with an unchanged appendix. Postoperative complications with non-perforated appendicitis occur in 1–2%, with limited peritonitis in 5–9%, with widespread peritonitis they reach 20%. Postoperative mortality is 0.1–0.3%. For comparison, mortality in conservative treatment at the beginning of the 20th century it was 7–10%.

Several theories of the occurrence of acute appendicitis are known: Dieulafoy's theory (obturation), Grekov's theory (reflex), Riccard's theory (angiospasm), Aschoff's theory (infectious), Reindorff's theory (helminthic), Davydovsky's theory (lymphoid tissue of the appendix), Shamov-Elansky theory ( allergic), Vishnevsky-Rusanov theory (neuro-reflex). In the pathogenesis of appendicitis, obstruction of the lumen of the appendix is ​​of primary importance. Fecal stones, foreign bodies, swelling as a result of inflammation, hyperplasia of lymphoid follicles, adhesions leading to kinks, and tumors can contribute to obstruction. Blockage due to ongoing secretion of mucus leads to an increase in pressure in the lumen of the appendix, and contributes to disruption of intramural microcirculation. At the same time, conditions are created for the proliferation of microorganisms that secrete toxins, ulceration of the mucous membrane occurs and destructive processes progress. A serous effusion appears, which subsequently becomes infected. Ultimately, necrosis and perforation of the appendix develops, leading to a periappendiceal abscess or peritonitis. With a favorable course of the disease, fibrin, which falls out of the exudate, glues the intestinal loops and the greater omentum around the source of inflammation - an appendiceal infiltrate develops. In some cases, mainly in elderly patients, against the background of widespread atherosclerosis or impaired blood rheology, thromboembolism of the appendicularis occurs with the formation of primary gangrenous appendicitis.

There are simple (superficial), phlegmonous and gangrenous appendicitis. Simple appendicitis is also called catarrhal. This term is not entirely accurate, but it is generally accepted and widely used. Qatar is an inflammation of the mucous membrane, and with appendicitis the inflammation never begins with the mucous membrane. With simple appendicitis, the appendix is ​​somewhat tense, thickened, and the serous membrane is hyperemic. The mucous membrane is edematous, loose. Intramurally, a local focus of destruction can be detected in the wall of the process.

Acute appendicitis with typical

location of the process

The most consistent symptom of acute appendicitis is pain. The pain appears suddenly, is constant, sometimes intensifies in a cramping manner, is not intense, and irradiation is not typical. At the same time, with empyema of the appendix, pain can be pronounced. At the beginning of an attack of acute appendicitis, pain is felt in the epigastric or mesogastric region - in the projection solar plexus(visceral pain, appears when the vegetative endings of the appendix are irritated), and after a few hours (usually 2–4) they move to the right iliac region (somatic pain, appears when the effusion of the parietal peritoneum is irritated). This symptom of pain movement is called the Kocher-Volkovich symptom and is one of the most important symptoms of acute appendicitis. The localization of pain usually corresponds to the location of the inflamed process. Sometimes, from the very beginning of the disease, pain is localized in the right iliac region. As the inflammatory process progresses and peritonitis develops, the area of ​​pain increases. With the development of gangrene and death nerve endings the pain subsides. When the appendix is ​​perforated, a sudden increase in pain is observed.

Nausea may occur soon after the pain begins, one-time vomiting. Characterized by weakness, malaise, loss of appetite, low-grade body temperature, and stool retention. With the development of peritonitis, these signs progress, the temperature becomes hectic. However, it should be borne in mind that some patients have no other manifestations other than pain. Objectively, there may be moderate tachycardia. The tongue is wet and coated. The abdomen is not swollen and participates in breathing. With the development of peritonitis, the tongue becomes dry, during breathing the right half of the abdomen lags behind the left, and with perforated appendicitis it may not participate in breathing. Superficial palpation can reveal an area of ​​pain, skin hyperesthesia, and muscle tension.

The most significant symptoms for diagnosis are the following:

1. Sitkovsky’s symptom. When turning from the back to the left side, the pain in the right iliac region increases.

2. Barthomier-Mikhelson symptom. When palpated with the patient positioned on the left side, pain in the right iliac region increases.

3. Rovsing's symptom. Increased pain in the right iliac region with jerky palpation in the left iliac region. In this case, it is necessary to press the sigmoid colon with the other hand to the wing of the left ilium.

4. Razdolsky's symptom. Pain on percussion in the right iliac region. It is a peritoneal symptom.

5. Voskresensky's symptom ("shirt" symptom, sliding symptom). Increased pain when moving your hand from top to bottom from xiphoid process to the iliac regions on the left and right. It is a peritoneal symptom.

6. Shchetkin-Blumberg symptom. Increased pain when the hand is suddenly withdrawn after applying pressure. It is a peritoneal symptom.

Thus, with all the variety of symptoms, the cardinal signs of acute appendicitis are local pain and muscle tension in the right iliac region.

In many countries, the Alvarado scoring system (A. Alvarado, 1986), also known as the MANTRELS scale (an abbreviation for: migration of pain, anorexia, nausea, vomiting, pain in the right lower quadrant, pain when removing the arm, increased temperature, leukocytosis, shift to the left).

According to various data, the sensitivity of the Alvarado scale at 7 points and above averages 94% for adult men, 83% for women, 85% for children, and 82% for elderly patients.

A general blood test reveals leukocytosis, usually no higher than 13 - 15x10 9 / l, although in destructive forms and peritonitis it can reach 18 - 20x10 9 / l and a shift in the leukocyte formula to the left is observed. Of particular importance is the dynamic control of leukocytosis when monitoring a patient with an unclear diagnosis. IN biochemical analysis blood and general urine analysis usually show no changes.

X-ray research methods in the diagnosis of acute appendicitis are uninformative and are used only for differential diagnosis.

Ultrasonography in some cases it can help in diagnosing acute appendicitis. It should be noted that the reliability of ultrasound in acute appendicitis does not exceed 50–60%. In some cases, it is possible to identify the following signs:

1. Increase in the size of the process.

2. Thickening of the wall of the process (with empyema, thinning is possible).

3. Impaired differentiation of the layers of the process (during destruction).

4. Rigidity of the appendix during dosed compression by the sensor.

5. The presence of effusion in the iliac fossa and pelvis.

6. The appearance of additional echo space between the uterus and the lateral surface of the parietal peritoneum (during pregnancy).

Laparoscopy has the greatest reliability in diagnosing acute appendicitis. The following signs may be detected:

1. Rigidity of the appendix.

2. Hyperemia of the serous membrane.

3. Fibrin deposits on the process or parietal peritoneum.

4. Infiltration of the mesentery of the process.

5. Infiltration of the dome of the cecum.

6. Effusion in the lateral canal and pelvis.

7. Swelling of the retroperitoneal tissue along the right lateral canal.

8. Hyperemia of the parietal peritoneum of the iliac fossa.

EMPYEMA OF THE WORMIC APPEAL

Empyema of the appendix occurs in 1–2% of cases of acute appendicitis. Clinically, this form has features different from phlegmonous appendicitis. Empyema is not characterized by the Kocher-Volkovich sign. Abdominal pain begins directly in the right iliac region and usually develops slowly. The general condition of the patient in the initial period suffers little. By the 3rd–5th day of the disease, the pain becomes severe, can take on a pulsating character, vomiting is observed once or twice, and body temperature rises to 38–39°C. Intoxication is pronounced. Symptoms of Sitkovsky, Bartomier-Mikhelson, Rovzing are usually positive. With deep palpation of the right iliac region, severe pain is determined. Characteristic feature is the absence of abdominal wall tension and peritoneal symptoms. In some cases, it is possible to palpate a sharply enlarged, painful vermiform appendix. Laboratory findings are characterized by high leukocytosis (17–20x10 9 /l) with a shift of the formula to the left.

ACUTE APPENDICITIS WITH RETROCEAL AND RETROPERITONEAL LOCATION OF THE APPENDIX

The location of the process behind the cecum occurs on average in 5–7% of patients, retroperitoneally – in 2%.

The onset of acute appendicitis is most often typical. Pain occurs in the epigastrium or throughout the abdomen, subsequently localizing in the area of ​​the right lateral canal or right lumbar region, although pain may be typical, in the right iliac region. Nausea and vomiting are observed less frequently, while fever is more common. There may be 2-3 mushy stools. If the vermiform appendix in the retroperitoneal space is in contact with the ureter or kidney, then dysuric phenomena may occur. In this case, red blood cells appear in a general urine analysis. With the retroperitoneal location of the appendix, its destruction occurs faster. In this case, retroperitoneal phlegmon develops, accompanied by severe intoxication, hectic temperature, and high leukocytosis. Pain may radiate to the right thigh; in some cases, painful contracture of the right hip joint (Arapov's contracture) develops. On palpation, pain is localized above the crest of the right iliac bone or in the area of ​​the right lateral canal. Palpation pain in the right lumbar region is possible. Tension of the abdominal wall muscles in the right iliac region and symptoms of peritoneal irritation are often mild or absent. Tension of the muscles of the posterolateral abdominal wall on the right may be noted.

Symptoms characteristic of the retroperitoneal location of the process:

1. Obraztsov’s symptom. In the supine position, the patient raises the extended right leg, and pain occurs in the lumbar or iliac region.

2. Ostrovsky's symptom. In the supine position, the patient raises the extended right leg upward. The doctor quickly lowers the patient's leg, causing pain in the lumbar or iliac region.

3. Yaure-Rozanov symptom. Pain on palpation in the area of ​​the right Petit triangle.

4. Gabay's symptom. The appearance or intensification of pain when removing the hand after pressing in the area of ​​the right Petit triangle.

5. Varlamov's symptom. Increased pain in the right iliac region when tapping the back of the XII rib.

ACUTE APPENDICITIS WITH PELVIC

LOCATION OF THE PROCESS

The pelvic location of the appendix occurs in women in 20–30%, in men in 10–15% of cases. The onset is most often typical, pain begins in the epigastrium or mesogastrium, and after a few hours is localized above the womb or in the right groin area. Nausea, vomiting, and fever are less common. Dysuric phenomena, tenesmus, and pasty stools with mucus are possible. Symptoms of Sitkovsky, Bartomier-Mikhelson, Rovzing are usually doubtful or negative. Palpation reveals an area of ​​pain above the pubis. Muscle tension is weak or absent. This is due to the fact that the parietal peritoneum of the pelvis does not have somatic innervation, and inflammatory processes in the pelvis are quickly limited. IN in some cases it is possible to identify Cope's symptom - the appearance of pain in the depths of the pelvis during outward rotation of the right lower limb bent at the knee joint (painful tension of the right obturator internus muscle). The value of this symptom is reduced due to the fact that it can be positive not only in acute appendicitis, but also in some gynecological diseases. Of primary importance in diagnosis are rectal and vaginal examinations, which reveal sharp pain in the area of ​​the Douglas pouch, and it is also possible to identify an inflammatory infiltrate. In laboratory tests, if the appendix is ​​located in the pelvis, changes in the urine are possible - the appearance of red blood cells, protein, leukocytes, and casts. Leukocytosis is usually moderately expressed, the shift of the formula to the left is less characteristic than with the typical location.

ACUTE APPENDICITIS IN SUBHEPATIC

LOCATION OF THE PROCESS

The incidence of subhepatic location of the process is less than 1%. Most often, this location is accompanied by incomplete intestinal rotation, i.e. The cecum also appears in the right hypochondrium. Less commonly, a subhepatic location occurs with caecum mobile. The main feature of this clinical form of acute appendicitis is pain in the right hypochondrium, but the area of ​​pain is determined laterally and below the projection of the gallbladder. The onset of the disease is typical, and a symptom of pain moving from the epigastrium or mesogastrium to the right hypochondrium can be identified. Nausea and single reflex vomiting, low-grade fever occur with the same frequency as with the typical location. Symptoms of Rovzing, Sitkovsky, Bartomier - Michelson may be positive. There are no symptoms of acute cholecystitis. Also, pain with subhepatic appendicitis is not accompanied by irradiation to the right shoulder and upper arm, which is possible for acute cholecystitis.

ACUTE APPENDICITIS WITH LEFT SIDE

LOCATION OF THE PROCESS

It is very rare in clinical practice. Causes: reverse position of internal organs, incomplete intestinal rotation, caecum mobile. With the reverse arrangement of the internal organs, the clinical picture is typical, except that pain is detected in the left iliac region. In the case of incomplete rotation of the intestine, pain can be detected in the left hypochondrium; in the case of caecum mobile, the localization of pain can vary along the entire left flank.

ACUTE APPENDICITIS AND PREGNANCY

The incidence of acute appendicitis in pregnant women ranges from 0.05–0.13% to 3–5%, according to various literature data. Most often during pregnancy it occurs in the first and second trimesters (19–36% and 27–60%, respectively), less often in the third trimester (15–33%). In this case, the mortality rate is 1.0–1.1%, while in non-pregnant women it usually does not exceed 0.1–0.3%. The longer the gestation period, the higher the mortality rate. This is due to the difficulty of diagnosis, and as a consequence – an increase in the frequency of complications and delayed surgical treatment. Mortality in late pregnancy with diffuse peritonitis is up to 20–50% for the mother and up to 40–90% for the fetus. The frequency of perforated forms in pregnant women is higher – 30–40% (in the general population 5–10%). The incidence of unnecessary appendectomies in pregnant women is also higher. There is evidence that unjustified appendectomy increases the risk of miscarriage by 2–2.5 times. The risk of fetal loss in the second half of pregnancy is 5 times higher than in the first.

The displacement of the cecum depends on the position of the patient, the timing of pregnancy, the tone of the anterior abdominal wall, and the shape of the abdomen. In the first half of pregnancy, the cecum is 5–7 cm below the level of the iliac crest, in the second half - at the level of the iliac crest or 3–5 cm below it, and also moves posteriorly. At the same time, there is evidence that pregnancy does not lead to displacement of the cecum with the appendix. This is explained by the fact that the frequency of atypical location of the appendix in women outside pregnancy does not differ from that during pregnancy.

During pregnancy, the intestine becomes tolerant to prostaglandins, serotonin, acetylcholine and other biologically active substances due to an increase in the sensitivity threshold of specific chemoreceptors. Intestinal hypotension is also supported by high levels of progesterone. A decrease in the tone of the smooth muscles of the intestine and compression by the uterus, kinks of the appendix lead to impaired evacuation from it and intramural ischemia, which contributes to the development of inflammation. Factors that complicate diagnosis also include relaxation of the abdominal muscles, physiological leukocytosis of pregnant women, the presence of various dyspeptic disorders, and a decrease in the systemic immune response. Due to the upward displacement of the greater omentum, the process is less likely to be limited, and during long periods of pregnancy, due to the uterus closing the entrance to the small pelvis, the effusion spreads predominantly upward, forming diffuse peritonitis and subdiaphragmatic abscesses. Also, diagnosis is complicated by the threat of miscarriage, pyelonephritis in pregnant women, and premature placental abruption, which often simulate acute appendicitis.

The course of appendicitis in the first half of pregnancy is almost no different from the course of acute appendicitis outside pregnancy. In the second half, the course of acute appendicitis is influenced by the above factors. In this case, the pain syndrome may not be expressed, as a result of which patients do not pay attention to it. Vomiting is common during pregnancy and has no diagnostic value. The temperature reaction is less pronounced than with appendicitis outside pregnancy. It should also be taken into account that leukocytosis up to 12x10 9 /l in pregnant women is a physiological phenomenon. In some cases, local pain will not be detected in the right iliac region, but somewhat higher and laterally. Due to stretching of the anterior abdominal wall, local muscle tension is weakly expressed, and in the later stages may be absent due to the fact that the cecum is covered by the uterus. For the same reason there may be negative symptoms peritoneal irritation. The main significance is a positive Michelson sign (increased pain in the position on the right side) and increased pain when the uterus is displaced from left to right.

The use of diagnostic laparoscopy during advanced pregnancy is limited high risk damage to the uterus and other organs, as well as the difficulty of visualizing all parts of the abdominal cavity. If necessary, the laparoscope is inserted using the “open” technique, and for better visualization of the right lateral canal, the patient is placed on her left side. In the first trimester, diagnostic laparoscopy is safer and does not cause any particular difficulties.

When a diagnosis of acute appendicitis is made, emergency surgical treatment is indicated. At the same time, no form of appendicitis is an indication for termination of pregnancy, which is carried out as conservatively as possible. Tocolytic, antispasmodic, sedative drugs are used. In the first and second trimesters, the Volkovich-Dyakonov approach is used, less often Lennander; in the third trimester, the Volkovich-Dyakonov approach is used, but it is performed above the iliac crest, or a median laparotomy. If labor develops after an appendectomy in late pregnancy, delivery is carried out through natural birth canal. Caesarean section is performed only under strict indications.

In case of diffuse appendiceal peritonitis in pregnant women, under endotracheal anesthesia, a median laparotomy, appendectomy, sanitation and drainage of the abdominal cavity are performed, the abdominal wall wound is sutured tightly.

In case of a full-term pregnancy due to the upcoming birth, surgery against the background of peritonitis begins with a cesarean section, then after suturing and peritonization of the uterine wound, an appendectomy, sanitation and drainage of the abdominal cavity are performed. In modern conditions, with the presence of powerful antibacterial agents it is possible to avoid amputation of the uterus, which in the recent past was mandatory in similar situations. If acute appendicitis develops during normal labor, early delivery through natural routes is necessary, and then an appendectomy is performed. With the development of acute appendicitis in pathological labor, simultaneous C-section and appendectomy.

ACUTE APPENDICITIS IN CHILDREN

The overall incidence rate of acute appendicitis is 0.5–0.8 cases per 1000 children. The vast majority of cases are over 5 years of age. The incidence increases with age and reaches its greatest value by 9–10 years.

Acute appendicitis in children occurs more violently than in adults. This is due to insufficiently developed plastic properties and resistance of the peritoneum in childhood, insufficient development of the greater omentum, which is located high and cannot participate in limiting the inflammatory process. Immunity in children is imperfect; hyperergic reactions predominate. In children, the intestinal mucosa is more permeable to microorganisms, and the nervous system of the appendix and ileocecal region is immature, which together contributes to the rapid development of destructive changes.

The rarity of acute appendicitis in young children is explained by the small number of lymphoid follicles in the appendix, its funnel-shaped shape, which contributes to the absence of stagnation of intestinal contents, and the nature of nutrition at this age. The most difficult diagnosis of appendicitis is in children in the first years of life. The clinical picture is characterized by a predominance of general symptoms, which is explained by a generalized reaction child's body to the inflammatory process. The most common symptoms include pain, fever, vomiting, and in children of the first years of life, the presence of pain must be judged by indirect signs. The most important among them are changes in the child’s behavior, refusal to eat, and sleep disturbances. Children, as a rule, cannot accurately localize pain. Abdominal pain is usually constant, but can be cramping in nature. Vomiting occurs in 75%, and in the first years of life it is often repeated. Stool is delayed in 35%, and in young children it is more frequent and in 15% it can be liquid. The temperature from the onset of the disease is more pronounced than in adults and rises to 38°C. With the development of complicated forms, the temperature reaches 39°C and higher. At the same time, about 15% of children have a normal temperature. The child usually lies on the right side or back, bringing the hips towards the abdomen, placing a hand on the right iliac region. Palpation can reveal local soreness (Filatov's symptom) and muscle tension, and in some cases hyperesthesia. Of particular importance for identifying muscle tension is comparative palpation of the right and left iliac regions. Already in the first hours of the disease, symptoms of Shchetkin-Blumberg, Voskresensky, Razdolsky can be expressed. If the child exhibits restless behavior, a study is performed during medicated sleep. To do this, a 3% solution of chloral hydrate is administered rectally at a rate of 10 ml per year of life. Clinical manifestations in children after 7 years of age approach the typical clinical picture of the disease in adults. Leukocytosis in children usually does not exceed 15–17x10 9 /l, and is absent in 20–25%.

The treatment tactics for acute appendicitis in children do not differ from adults. Emergency surgical treatment is indicated. Appendiceal infiltration in children is also an indication for emergency surgical treatment. In case of unclear diagnosis, dynamic observation is carried out for 6 hours. The operation is performed under anesthesia. Appendectomy is performed using a ligature method, without immersing the stump of the appendix into purse-string and Z-shaped sutures, which reduces the risk of perforation of the cecum. This also eliminates deformation of the bauginian valve, which in children is located quite close to the base of the process.

The average mortality rate is 0.2–0.3%, but in children under 3 years of age it reaches 3–5%.

ACUTE APPENDICITIS IN THE ELDERLY

Elderly and old age constitute less than 10% of the total number of patients with acute appendicitis. At this age, destructive and complicated forms of appendicitis predominate. In elderly patients, in most cases there is atherosclerotic damage to the ileocolic and appendicular arteries, which contributes to the rapid development of gangrene of the appendix. Reduced reactivity of the body, involution of the lymphoid apparatus, physiological increase in the threshold of pain sensitivity, age-related psychology sick. Elderly patients, as a rule, do not pay attention to the epigastric phase of abdominal pain at the onset of the disease, confuse the medical history, and often begin self-medication, which contributes to late seeking medical help. The presence of concomitant diseases also complicates diagnosis. The pain is usually moderate and often vague. There is usually no temperature response. Nausea and vomiting are more common than in middle-aged people. There may be little or no tension in the abdominal wall muscles due to muscle atrophy. Shchetkin-Blumberg and Voskresensky symptoms are usually well expressed. Symptoms of Sitkovsky, Bartomier-Mikhelson, Rovzing are often positive. Appendiceal infiltration in elderly patients develops more often than in middle-aged people and is characterized by slow development. Leukocytosis may be low, in the range of 10–12x10 9 /l, or absent. The neutrophilic shift is usually not pronounced.

Due to thrombosis or embolism of the appendix artery, primary gangrenous appendicitis may develop in older patients. The clinic is characterized by sharp pain (ischemic origin) in the right iliac region. Due to the death of nerve endings, acute pain soon subsides, and the clinic of developing peritonitis comes to the fore.

Mortality in elderly and senile patients ranges from 3–5 to 15%, according to various sources.

TREATMENT OF ACUTE APPENDICITIS

An established diagnosis of acute appendicitis is an indication for emergency surgery within 2 hours from the patient’s admission to the hospital. The only contraindication for intervention is appendiceal infiltration. If the diagnosis is unclear, dynamic observation is carried out for no more than 6 hours. After the specified time, the diagnosis of acute appendicitis should either be confirmed or excluded. During the period of dynamic observation, repeated examinations, dynamic monitoring of leukocytosis are carried out, and, if necessary, instrumental methods diagnostics, including diagnostic laparoscopy. If it is impossible to exclude acute appendicitis during follow-up, emergency appendectomy is indicated.

If emergency surgery is not possible, conservative therapy with third or fourth generation cephalosporins or fluoroquinolones in combination with metronidazole or clindamycin is indicated. Glucocorticoids can also be used in treatment (they reduce hyperplasia of the lymphoid tissue of the appendix).

During appendectomy, endotracheal or intravenous anesthesia is used, and in some cases, spinal anesthesia. The main access is the Volkovich–Dyakonov skew-variable access. Lennander and Kolesov approaches are used less frequently. For diffuse peritonitis, lower-median laparotomy is used. Appendectomy is performed antegrade, from the apex to the base of the appendix, gradually mobilizing its mesentery. Retrograde appendectomy is used in some cases of retroperitoneal location when the apex of the appendix is ​​inaccessible. The base of the process is tied with catgut and immersed in purse-string and Z-shaped sutures. The abdominal cavity is sanitized. In case of peritonitis, drainage of the abdominal cavity is performed. Indications for placing a tampon in the abdominal cavity are the impossibility of complete removal of the appendix, diffuse bleeding of its bed, appendiceal abscess and detection of dense appendiceal infiltrate. In the postoperative period, non-narcotic analgesics and broad-spectrum antibiotics are indicated.

COMPLICATIONS OF ACUTE APPENDICITIS

Complications of acute appendicitis are appendiceal infiltrate and abscess, abdominal abscesses of various locations, diffuse peritonitis, retroperitoneal phlegmon, pylephlebitis.

Appendiceal infiltrate develops in 2–6% of patients with acute appendicitis and is an inflammatory conglomerate. Infiltration occurs around the destructively changed vermiform appendix in case of good reactivity of the body. The greater omentum, cecum, parietal peritoneum of the iliac fossa, and loops of the small intestine participate in its formation. A typical clinical picture develops 3–5 days after the onset of the disease. In this case, the pain in the right iliac region decreases or disappears, the condition and general health improves, but the low-grade temperature remains. An objective examination of the abdomen reveals a dense, slightly painful, inactive tumor-like formation in the right iliac region. There is no muscle tension. Symptoms of peritoneal irritation are negative. There are usually no symptoms of acute appendicitis. Leukocytosis is often insignificant, a shift in the leukocyte formula is not typical. The outcome of appendicular infiltrate can be either resorption or abscess formation. For differential diagnosis of infiltrate with cancer of the blind and ascending colon irrigoscopy is used. The treatment tactics for infiltrate without signs of abscess formation are conservative: in the first days, antibacterial therapy, local application of cold. After 4–5 days, as acute phenomena subside, physiotherapeutic treatment is used (ultrasound on the infiltrated area). The infiltrate can no longer be detected by palpation after 8–12 days, but complete resorption occurs 3–5 weeks after the onset of the disease. After a course of conservative therapy (7–14 days), the patient is discharged home. After 2 months, a planned appendectomy is indicated. There is evidence that after treatment, the normal structure of the appendix is ​​restored in 90% of cases. Recurrence of acute appendicitis after treated appendiceal infiltration is usually milder and occurs on average after 6–8 months in 5–10% of patients.

When the infiltrate abscesses (occurs in 1–2% of cases), pain in the right iliac region intensifies, symptoms of intoxication appear, hectic temperature is noted, and unexpressed symptoms of peritoneal irritation may appear. In some cases, softening in the center of the infiltrate can be determined. To do this, use bimanual palpation - through the abdominal wall and at the same time rectally or vaginally. High leukocytosis is detected in the blood with a shift in the leukocyte formula to the left. An appendicular abscess is an indication for emergency surgery. An extraperitoneal opening of the abscess is performed using the Pirogov approach (parallel and above the right inguinal fold). The abscess cavity is sanitized and drained with a glove swab. In case of spontaneous opening of an appendicular abscess into the free abdominal cavity, a median laparotomy, appendectomy, sanitation and drainage of the abdominal cavity are performed.

Other abscesses - pouches of Douglas, interintestinal, parietal, subdiaphragmatic - are also indications for emergency surgery. The abscesses are opened and drained according to their location.

Widespread peritonitis develops as a result of the lack of delimitation of the inflammatory process or the opening of the periappendiceal abscess into the free abdominal cavity. The clinical picture of appendiceal peritonitis is nonspecific and is similar to the manifestations of peritonitis of other origins. At the same time, the condition of the patients deteriorates sharply. Increased abdominal pain, repeated vomiting, severe tachycardia, and dry tongue are observed. The abdomen is symmetrically swollen, does not participate in the act of breathing, is tense and sharply painful in all parts. There is no peristalsis. Positive symptoms of Shchetkin - Blumberg, Voskresensky, Mendel are determined. It should be remembered that in the terminal phase of peritonitis there is no muscle tension. In a general blood test, high leukocytosis is observed with a pronounced shift in the leukocyte formula to the left.

Retroperitoneal phlegmon occurs mainly in the case of a retroperitoneal location of the appendix, although it can also develop with a typical location. In this case, the entrance gate of infection into the retroperitoneal tissue is the mesentery of the appendix. The clinic develops gradually with an increase in temperature, increased pain in the lumbar region, and an increase in leukocytosis. In some cases, flexion contracture of the right hip is possible. When a diagnosis of retroperitoneal phlegmon is made, emergency surgical treatment is indicated. An appendectomy, opening and drainage of the phlegmon are performed, for which both standard access and Pirogov access and lumbotomy are used.

Pylephlebitis is purulent thrombophlebitis of the portal vein and its branches. Often leads to liver abscesses and sepsis, and therefore has a high mortality rate. It occurs quite rarely, in 1–2% of cases of perforated appendicitis. In the clinic of pylephlebitis, severe intoxication, hectic temperature, jaundice, and hepatomegaly prevail. Possible ascites. Treatment is complex, including appendectomy, detoxification therapy, including extracorporeal methods, and massive antibiotic therapy. In some cases, antibiotics are administered intraportally through the recanalized umbilical vein. When liver abscesses develop, they are opened and drained.

Complications after appendectomy

The most common wound complications after appendectomy occur (according to various sources, their frequency ranges from 1 to 10%). These include infiltrate, abscess, seroma, hematoma, ligature fistula of a postoperative wound. The wound infiltrate is treated conservatively, the abscess must be opened and drained by removing several skin sutures. Seroma and hematoma can be treated with both puncture and standard drainage. For ligature fistulas, if there is no effect from dressings, their excision is indicated.

A severe wound complication is eventration. Usually occurs in weakened patients with advanced peritonitis. In this case, a divergence of all layers of the abdominal wall occurs with the exit of strands of the omentum or intestinal loops outside the abdominal cavity. In some cases, subcutaneous eventration develops, which is diagnosed by abundant soaking of the dressings with serous-hemorrhagic exudate. Eventration is subject to emergency surgical treatment - suturing, most often using tread sutures.

A rare but life-threatening wound complication is epifascial cellulitis. It also occurs in weakened patients with high virulence of the microflora. Moreover, against the background of abscess formation, the process goes beyond the postoperative wound, quickly spreading throughout subcutaneous tissue. Epifascial phlegmon can spread to the entire abdominal wall, chest, lower back, right thigh. IN short time sepsis develops. Patients are indicated for emergency surgical treatment with wide opening and drainage of all leaks, and advanced incisions are also used. Comprehensive antibacterial and detoxification treatment is carried out.

Intra-abdominal complications include infiltrates and abscesses of the abdominal cavity, bleeding into the abdominal cavity, failure of the sutures of the stump of the appendix with peritonitis, intestinal obstruction, and intestinal fistulas.

General somatic complications are also possible - thrombophlebitis, thromboembolism, pneumonia, respiratory and heart failure, stress ulcers, etc.

Infiltrates and abscesses of the abdominal cavity occur more often due to widespread peritonitis. Abscess of the pelvic cavity (Douglas abscess) after appendectomy occurs in 0.1–0.5% of patients. In some cases, these abscesses resolve spontaneously, opening into the intestinal lumen, but they can also open into the bladder or free abdominal cavity. Of particular importance in diagnosis is digital rectal and vaginal examination, in which infiltration, overhang and tenderness of the anterior wall of the rectum and posterior vaginal fornix are determined. IN diagnostic purposes It is possible to perform a puncture of the anterior wall of the rectum or posterior fornix. Treatment involves opening and drainage through the anterior wall of the rectum in men and children or posterior colpotomy in women.

Doctors diagnose atypical forms of appendicitis and their manifestations in 20 to 30% of patients: adults and children. Atypia is explained by the fact that the vermiform appendix can be located differently in the abdomen. Negative consequences depend on the state of health, age, and the patient. The course of the disease depends on the general reaction of the whole organism to local inflammation.

Symptoms of atypical appendicitis

The inflamed process is located near the bladder and rectum. With constant irritation, frequent, medium-consistent or very loose stools may occur. If with mucus, this is tenesmus. In such cases, urination is painful (dysuria) and quite frequent.

When a doctor examines the abdomen of adults and children, he sees that it is of normal shape and moves in rhythm with breathing. Shchetkin-Blumberg symptoms, when obvious tension in the peritoneal walls may be absent. Additionally, rectal diagnostics are performed, since very quickly, within a few hours, the patient will already have pain in the right and anterior wall of the rectum. This is a Kulenkampff symptom.

In children, infiltration and swelling of the walls of the rectum are often observed. The course of the disease is complex. Leukocyte reaction and temperature at pelvic appendicitis may be slightly elevated. When the location of appendicitis is typical, tests will show noticeable pathology.

The process is placed medially in 8 to 10% of patients. Here the process moves towards the middle and grows next to the small intestine, its mesenteric root. If this is the middle location of appendicitis in an adult or child, the symptoms of the disease will manifest themselves violently.

Retrocecal appendicitis

Occurs in 50 to 60% of patients. The process in this case is presented very closely right kidney. Here is the ureter and muscles of the lumbar region. A person feels a sharp pain on the right in the abdomen or epigastrium. The pain is not severe, but constant. When a person walks, it gets worse and especially hurts in the hip joint on the right.

Sometimes the person on the right has a noticeable limp. Vomiting with nausea, as symptoms, appears less frequently than with the typical location of the appendix. The cecum, its dome, becomes irritated and mushy or very loose stools appear (2-3 times). Dysuria occurs when there is irritation in the wall of your ureter or kidney. When a doctor examines adults or children, he notices that there is no typical symptom - the anterior wall of the peritoneum does not have increased tone. The most strong pain felt on the right in the abdomen or at the iliac crest.

The well-known Shchetkin-Blumberg symptom in the anterior part of the peritoneal wall is unlikely. It may appear on the right side of the lumbar triangle (Petit). With appendicitis, retrocecal palpation reveals pain on the right side of the lower back and the well-known Obraztsov symptom. They do a urine test and pay attention to the level of leached and fresh red blood cells and how many white blood cells?

The appendage does not empty well enough, as it is deformed and bent. The location of the appendix is ​​too close to the retroperitoneal tissue. The mesentery is short, the blood supply is impaired. All this contributes to the development of complications in appendicitis.

Medial placement of the process

This type of location of appendicitis occurs in 8 to 10% of patients. The process is located close to the middle and is located next to the root of the mesentery (small intestine). Here the symptoms manifest themselves violently.
First, a person feels pain spreading throughout the stomach. It hurts everywhere and nowhere in particular. Then, most often, pain is felt at the navel or on the right in the very bottom of the abdomen. The patient has a fever and is vomiting a lot.
The muscles in the abdomen are tense, acute pain is felt. To the right of the navel and directly next to it, there is pronounced pain. So with the Shchetkin-Blumberg symptom. The root of the mesentery is often involuntarily irritated and the abdomen quickly swells - this is paresis in the intestines. Dehydration increases and fever occurs.

The process is located in the pelvis

In 15 to 20% of patients, the process is located near the pelvis, quite low. This is observed several times more often in women, and less often in men. It happens that the process is located at the bottom of the uterine cavity, in the small pelvis (in the cavity) or above the entrance to the pelvis. Then the pain is felt throughout the abdomen. Pain will be felt in one case on the right in the iliac region, or above the pubis, or inguinal fold. In case 2 - in the area of ​​the womb, in the groin on the left, less often.

The appendix is ​​located quite close to the rectum. This provokes a disorder (tenesmus). The stool is loose and mucus is visible. Frequent urges occur. Urination is also frequent and painful.
Such loose and frequent stools are due to severe intoxication from the inflamed appendix. There is pus and mucus there.

When the doctor examines the abdomen, it is normal. Tension of the peritoneal muscles and Shchetkin-Blumberg symptoms are not observed, which makes correct diagnosis difficult. An accurate rectal examination is carried out and the correct diagnosis is established. Already in the first few hours there is a Kulenkampff symptom, when a sharp pain is felt in the right and anterior wall of the rectum. In children, infiltration with swelling of the walls is observed. The temperature and leukocyte reaction with this appendicitis are less pronounced than with typical appendicitis.

Acute subhepatic appendicitis

This type of inflammation occurs in 2 to 5% of patients. Doctors suspect cholecystitis or colic in the liver. The pain first occurs in the epigastric region, then moves to the hypochondrium (right). It also hurts in the area of ​​the gallbladder.

The doctor performs palpation and discovers that the abdomen (lati muscles) hurts. Due to irritation of the permanent peritoneum, the pain goes to the epigastric region of the body. Complex course of the disease.
Symptoms are observed: Razdolsky with Sitkovsky and Rovsing.

You can see that the dome of the cecum is highly located through fluoroscopy. An ultrasound will provide additional information. Diagnosing subhepatic location of appendicitis is difficult, since cases of such placement are rare. Because of this, there are severe complications; more patients (25 times) die from this appendicitis than from other types.

Left-handed

This type of appendicitis occurs extremely rarely in humans. This form occurs when the patient’s internal organs are located not in a typical manner, but in the opposite direction. Or the colon on the right is too mobile. The patient experiences pain on the left in the iliac region. Diagnosis of such atypical acute appendicitis is easier if the doctor quickly feels the liver on the left.

Acute with hyperthermia

When a person develops acute appendicitis, the temperature most often rises to 38°C. Later it will be higher. This means that complications have arisen:

• perforation in the process;
• periappendicular abscess;
• Peritonitis is common.

There are times when the temperature is immediately below 40°C or higher and a person has chills. Sometimes purulent intoxication occurs. Its signs:

• tachycardia;
• tongue dry and coated.

Doctors think that these are symptoms of pneumonia or pyelitis and continue to monitor the patient, conduct examinations, and take tests. The diagnosis of acute appendicitis in this case cannot be excluded.

In children

Appendicitis in children under 3 years of age has its own characteristics. The large omentum has not yet grown to the appendix, the immune system has not yet fully formed. Children often experience complications.

Complications

Let's look at some complications of acute appendicitis:

1. Appendicular infiltrate;
2. Peritonitis;
3. Thrombophlebitis of the portal vein with branches;
4. Abscesses or pus in the peritoneum (subphrenic, pelvic with interintestinal);
5. Septic pylephlebitis.

Abscesses occur around the vermiform appendix, but not only. They occur in different places of the peritoneum, due to hematomas, when suppuration occurs on the sutured stump. Therefore, abscesses can be pelvic, subdiaphragmatic or interintestinal. To detect and remove foci of suppuration in a timely manner, ultrasound is used. An abscess in the pelvis is determined by doing a vaginal examination.

Treatment

The main method that promotes complete cure for an abscess - this means drainage, and then proper antibiotic therapy. Drainage is done surgical intervention or minimally invasive method under ultrasound control. The operation is performed under general anesthesia. The patient does not feel pain.

To get to the abscess, the anus is dilated. Dotted lines are made with a needle on the anterior wall of the rectum in a soft place, then opened. The hole is specially widened using a forceps. A drainage tube is inserted where the abscess is. Antibiotic therapy uses broad-spectrum drugs. Microflora: aerobic, anaerobic are successfully suppressed.

Atypical forms of acute appendicitis do not occur often in patients. The main thing is to seek medical help in time. In the hospital, it is very important that the doctor correctly diagnoses such atypical appendicitis and removes it. It’s very bad when a patient doesn’t call an ambulance on time and is brought in with peritonitis and other complications - abscesses, etc. Don’t joke about it, with peritonitis there is a threat to life. If you have severe abdominal pain, see your doctor immediately. family doctor or call an ambulance.

Appendicitis is an inflammation of the appendix, which is also called the vermiform appendix of the cecum in the form of an anatomical formation with a length of 4 to 10 cm and a diameter of 4-6 mm. The appendix originates from the end of the cecum. The appendix has a tubular structure, and its end ends blindly. Most often there is acute appendicitis and much less often - chronic.

Signs (symptoms) of appendicitis.

• Pain in the abdominal area is cramping or aching in nature and becomes stronger over time. In the beginning, the pain often begins with upper area abdomen (epigastric - 1, 2, 3 areas in Fig. 1). Sometimes the pain can radiate to the lumbar region or genitals. A little later, the pain drops lower and to the right (area 7 in Fig. 1) or spreads to the entire abdominal area. Even later, the pain begins to subside and a period of false well-being sets in. The pain subsides due to tissue necrosis.
• An increase in body temperature to 37-38 degrees, often with chills and sweating. This symptom is not a characteristic sign indicating appendicitis.
• Rectal temperature is more than one degree higher than body temperature (Lenander's sign).
• Vomiting is usually one-time, which does not bring relief. According to statistics, vomiting occurs in 2-4 patients out of 10. It occurs at the beginning of the disease after the onset of pain.
• Weakness and malaise.
• As the disease progresses, a coated tongue appears, then the tongue becomes more coated and dry. At the onset of the disease, the tongue is often normal.
• The pulse can be rapid up to 90 or more beats per minute.
• In some cases, urination problems may occur.
• Constipation may develop, which is accompanied by bloating.
• There may be a single loose stool, after which there may be a painful false urge to defecate with an almost complete absence of feces. This symptom is more typical for children.
• Rectal examination reveals tenderness of the anterior wall of the rectum.
• Blood analysis. Leukocytes increase due to an increase in the number of neutrophils, a shift in the leukocyte formula to the left, and the appearance of juvenile forms. The ESR (erythrocyte sedimentation rate) indicator increases.

Symptoms of appendicitis in medical diagnosis.

What does a doctor pay attention to when examining a patient?

• The doctor asks the patient to lie on his left side, with pain in right iliac region (Fig.1) intensifies (Sitkovsky's symptom).
• If the patient sticks out his stomach and then sharply draws it in, the pain intensifies.
• In a lying position, the patient raises his right leg without bending it at the knee (leg straight), while the pain in the right iliac region intensifies (Obraztsov’s symptom).
• The doctor asks the patient to cough, and the pain intensifies (cough symptom).
• When you lightly tap the edge of your palm on the abdomen, the pain intensifies (Razdolsky's symptom).
• The doctor gently and not deeply presses the right iliac region with his fingers (the pain becomes less), and after 3 seconds he sharply removes his hand. After this, the pain intensifies (Shchetkin-Blumberg symptom).
• The doctor palpates the descending part of the large intestine (corresponding to the 6th and 9th areas of the abdomen), while the pain in the right iliac region intensifies (Rovsing's symptom).

If all the symptoms or most of them coincide during diagnosis, then the doctor can diagnose acute appendicitis. Such symptoms of appendicitis are most typical for adults. But the signs of appendicitis may not always be typical. And this is also largely due to the fact that the appendix can be located differently in different people. Moreover, the symptoms of appendicitis in children, pregnant women, and the elderly have their own specifics.

Location of the appendix.

Descending (pelvic) position. The appendix descends down into the pelvic cavity. When inflamed, it forms multiple adhesions, which involve the rectum. The bladder and, in women, the internal genitalia may also be involved. This position of the appendix is ​​the most typical. Shown in Fig. 2.
Medial position. The appendix is ​​located along the medial wall of the cecum. When it is inflamed, pain can occur almost anywhere in the right half of the abdomen.
Forward position. The appendix is ​​located in front of the cecum.
Retrocecal position. The process is located behind the cecum, along its posterior surface. This arrangement is often combined with a short and fixed cecum. There is pain in the right iliac region, no muscle tension, no pain when coughing, no Shchetkin-Blumberg sign. Dysuric phenomena may occur.

Retroperitoneal (retroperitoneal, lateral) position. The vermiform appendix is ​​directed to the lateral outer side of the body. It is located on the side of the intestines, without touching the abdominal organs. With this location of the appendix, the onset of the disease often begins acutely, but the pain is localized not in the abdomen, but in the right lumbar region, reminiscent of renal colic. The abdomen is soft, there is slight tenderness in the right iliac region.
Ascending (subhepatic, high) position. The vermiform appendix is ​​directed upward with its apex, and if it is long enough it can be located under the liver. When inflamed, it can fuse with its capsule. With this position of the appendix, pain and muscle tension appear in the right hypochondrium, resembling acute cholecystitis.
The location of the appendix is ​​on the left. There is a location of the appendix in the left half of the abdomen. This is possible if the organs are located in reverse or if the cecum has a long mesentery.
Very rarely there are anomalies of the appendix, which can be in the form of two separately located parts or possibly the presence of two appendices.

Important!
Until your doctor rules out appendicitis, you should not apply warm heating pads to your stomach. Heat accelerates the development of appendicitis and its transition to more severe stages, at which the patient’s life is threatened!
You should also not take laxatives to stimulate intestinal motility.

Treatment of acute appendicitis.
What are the treatment methods for acute appendicitis? Unfortunately, traditional medicine still has only one reliable way to treat appendicitis - appendectomy (removal of the appendix).
Are there any alternative methods treatment of acute appendicitis to avoid removal of the appendix. Yes, I have.
While appendicitis is at the initial (catarrhal) stage, it can be successfully treated with su-jok therapy, acupuncture (acupuncture). Therefore, if you know a doctor who practices one of these treatment methods and you trust him, you can call him and discuss the possibility of solving your problem.
But this issue must be resolved very quickly, since acute appendicitis quickly progresses to other stages, and this can pose a threat to the patient’s life! After treatment, the patient should remain under medical supervision for some time.

- an unpleasant symptom, which, moreover, can be very dangerous. One of the most dangerous conditions is appendicitis, which often leads to life-threatening complications. On which side is the appendix located, and what are the symptoms of appendicitis?

Appendix and its functions

The appendix is ​​an appendage of the cecum, extending from its posterolateral wall, having a cylindrical shape and a length of 2 to 13 cm with a diameter of 5-8 mm.

The functions of the appendix, or ventricular appendix, are:

1. participation in many processes of the immune system, which is possible due to the presence of many lymphatic vessels in it. It is in these vessels that cells are present that provide the body with protection from the effects of viruses and bacteria;
2. preservation of beneficial microflora necessary for normal function digestive system. The appendix stores a large number of bacteria that are able to restore lost beneficial microflora during intestinal dysbiosis (for example, after long-term use antibiotics).

Where is the appendix located?

The celiac appendix is ​​usually located slightly in the lower abdomen to the right of the line navel This point has its own medical name - McBurney's point. It happens that the appendix is ​​found at some distance from its usual place, and also on the left side of the navel.

The left-sided arrangement is usually observed in people with transposition, that is, with a mirror arrangement of all internal organs.

The appendix is ​​a descending organ that descends into the pelvic cavity. This location is typical for almost half of the planet's population.

An atypical location of the appendix is:

• ascending, in which the appendix is ​​attached to the peritoneum (occurs in 13-14% of cases);
• medial, with the cortical appendix located near the white line of the abdomen (almost 20% of cases);
• lateral, in which the process is located at the lateral wall of the peritoneum (15%)

There are rare cases of the celiac appendix being located under the liver and in the left iliac region.

Appendicitis

Inflammation of the appendix is ​​a surgical pathology called appendicitis.Both men and women under the age of 65 are susceptible to inflammation.

Interesting: appendicitis is rarely observed in preschool children due to anatomical features and in persons over 65 years of age due to involution of lymphoid tissue.

Video - Appendicitis in children

Classification of appendicitis

Appendicitis occurs in acute and chronic forms. Chronic is rare condition and does not require surgical treatment, while the acute form requires emergency surgery.

Depending on the complexity and depth of the inflammatory process There are 4 types of acute appendicitis:

1. Catarrhal. The first stage, which is characterized by inflammation of the mucous membrane of the appendix and mild symptoms;
2. Surface. This type of appendicitis is characterized by inflammation not only of the mucous membrane, but also of the tissues underneath it, and impaired blood and lymph circulation. Symptoms become brighter, signs of intoxication appear.
3. Phlegmous. A severe form of pathology, characterized by diffuse inflammation of all layers of tissue of the appendix, which is filled with pus, its walls become ulcerated. The symptoms are pronounced.
4. Gangrenous. The most severe form of the disease that develops in the absence of timely treatment is phlegmous appendicitis. It is characterized by the death of all cells of the appendix, as a result of which the pain disappears, which gives reason to mistakenly believe about a favorable outcome. In fact, the inflammatory process continues, spreading to the entire abdominal cavity. The patient's general condition deteriorates sharply. Gangrenous appendicitis is the initial stage of peritonitis, which often leads to death.

Causes of inflammation of the appendix

The main reason for the development of pathology is blockage of the lumen of the appendix due to its bending or mechanical obturation when foreign bodies and fecal stones enter the lumen.

The development of the disease is also caused by ulcers on the mucous membrane of the appendix after viral infections previously suffered.

Signs of acute appendicitis

Signs acute form pathologies appear suddenly, but the background general health person. Symptoms of acute appendicitis include:

• sharp, diffuse pain in the abdomen, especially in the side (right or left, depending on where the appendix is ​​located), around the navel and epigastrium, which can last from 2 to 4 hours, after which it is localized at the point where the appendix is ​​located;
• increased pain as inflammation progresses;
• increased pain when coughing, sneezing, movements;
• stool disorder, usually difficulty passing stool, less often diarrhea;
• reflex muscle tension in the abdomen due to irritation of nerve receptors;
• decreased appetite;
• feeling of nausea with single (sometimes double) vomiting;
• temperature rise to 38C.

Important: in case of inflammation of the appendix in a child or an elderly person, a change in the nature of the pain is noted. Dyspepsia disorders come to the fore in terms of symptoms.

Symptoms of chronic appendicitis

• dull aching pain in the iliac region from the side of the appendix, aggravated by physical activity;
• irradiation of pain to the rectal area in men and to the appendages and vagina in women;
• frequent urination, causing discomfort;
• feeling of heaviness in the stomach, increased gas formation, heartburn, feeling of nausea;
• increase in temperature in the evening;
• periodic appearance of symptoms of acute appendicitis.

Diagnostics

Most often, appendicitis does not cause difficulties in diagnosis, which is carried out on the basis of signs characteristic of the condition. You can find out about inflammation using the following tests:

• increased abdominal pain upon palpation;
• increased pain in the iliac region with tapping;
• increased intensity of pain when the hand is suddenly removed after pressing on the anterior wall of the peritoneum;
• sharp pain in a person lying on his left side;
• increased pain when raising a straight leg (from the side of the appendix) while lying on your back;
• the occurrence of pain in the iliac region from the side of the celiac process when pushing the fingers in the opposite direction.

In case of an atypical location, diagnosis is carried out using ultrasound.

Appendix treatment

Treatment is exclusively surgical. If a pathology is suspected, the patient must be kept at rest until emergency assistance arrives. The patient can only be transported in a prone position.

A person with appendicitis is strictly prohibited from giving cleansing enemas, taking painkillers, food and water, as these actions may subsequently interfere with the diagnosis.

The operation is carried out on an emergency basis to avoid rupture of the appendix and the development of peritonitis.

Before surgical intervention The patient is given antibiotics, which reduces the risk of infection during the appendectomy. Antibacterials are prescribed for use after surgery for a course of at least 3 days.

An appendectomy is performed under general anesthesia, but in some cases local anesthesia is acceptable.

Catarrhal appendicitis is excised laparoscopically, while in more serious forms it is performed abdominal surgery.

Consequences of lack of treatment

Lack of treatment, as well as untimely surgery, entails serious consequences , such as:

• acute, which leads to the cessation of muscular work of the intestines;
• perforation of the appendix, in which the abdominal cavity rapidly becomes infected and peritonitis develops;
• sepsis, which in most cases leads to the death of the patient.

Appendicitis - dangerous pathology, often leading to the death of a person. If signs of inflammation appear, emergency hospitalization is necessary.

Timely contact with specialists will help not only to avoid negative complications, but also to save human life.

Video - Appendicitis: what are the symptoms of appendicitis?

Low or pelvic location of the process occurs in 15-20%

atypical forms, and in women 2 times more often than in men. Process

may be located either above the entrance to the small pelvis, or at the bottom of the rectum

cystic (uterine) cavity, directly in the cavity of the small

pelvis In these conditions, the pain often begins throughout the abdomen and then

localized in the first case - in the pubic region, less often - in the left inguinal;

in the second - above the womb or in the right iliac region, directly

above the inguinal fold.

Pelvic and retrocecal appendicitis have the most severe course; gangrenous and perforated forms are much more common, and they are characterized by significantly higher mortality. This is not happening because anomalous location vermiform appendix predisposes to a more severe course of the inflammatory process, but only because pelvic and retrocecal appendicitis are often recognized late - already when severe complications appear (peritonitis, retroperitoneal phlegmon).

A characteristic feature of pelvic appendicitis is the appearance of dysuric disorders (frequent, painful urination), frequent loose stools, sometimes with tenesmus. These symptoms are caused by the transition of the inflammatory process from the appendix hanging down into the small pelvis to the wall of the bladder or rectum. They are the cause of frequent diagnostic errors when, instead of acute appendicitis, gynecological pathology, cystitis, and, most often, foodborne toxic infection are assumed. Difficulties in diagnosis are aggravated by the much less pronounced and sometimes completely absent muscular protection of the anterior abdominal wall in pelvic appendicitis. In these cases, a rectal and, in women, a vaginal examination often plays a decisive role, making it possible to note severe pain. pelvic peritoneum, which is not typical for the noted diseases, and in later stages, an infiltrate around the inflamed appendix can also be detected.

The proximity of the inflamed appendix to the rectum and bladder often

causes imperative, frequent, loose stools with mucus (tenesmus),

as well as increased painful urination(dysuria). Abdomen with wasp

motre of correct shape, participates in the act of breathing. Difficulty of diagnosis

is that abdominal muscle tension and the Shchetkin-Blumberg symptom

may be missing. In some cases it turns out positive symptom Cope - painful tension of the obturator internus muscle. It is called as follows: with the patient lying on her back, bend the right leg at the knee and rotate the thigh outward. In this case, the patient feels pain in the depths of the pelvis on the right. The diagnosis is clarified during a rectal examination, since already in the first hours a sharp pain in the anterior

and the right walls of the rectum (Kulenkampff's symptom). Children may

swelling and infiltration of its walls appear simultaneously.

Due to the frequent early delimitation of the inflammatory process, temperature and leukocyte reactions in pelvic appendicitis are pronounced

weaker than with typical localization of the process.

Complications - mesenteriolitis (inflammation of the mesentery of the appendix), infiltrate (can develop on the 3-4th day of the disease when the inflammatory process is limited), abscess (manifested by an increase in the infiltrate in size and the appearance of hectic fever), peritonitis (develops immediately after a painful attack or on the 3rd - 4th day due to gangrene or perforation of the appendix), sepsis.

Pulmonary hemorrhage.

Release through the respiratory tract of clots and liquid blood flowing from the vessels of the lung tissue, trachea and bronchi. Hemoptysis, hemophthisis - secretion of sputum streaked with blood. Bleeding is a life-threatening complication of various diseases and injuries that occur with destruction of the pulmonary parenchyma, damage to the vessels of the pulmonary or systemic circulation, and disintegration of tumor tissue. Pulmonary bleeding is observed in 3-5% of patients with acute purulent abscess and in 20% with gangrenous destruction. Long-term course of chronic abscess, bronchiectasis, chronic deforming bronchitis, metapneumonic fibrosis, single bronchogenic cysts and polycystic disease, complicated by suppuration, is accompanied by aneurysmal dilatations of the bronchial arteries, prone to rupture with heavy bleeding

Pulmonary hemorrhage may develop due to closed and open injury lung, trachea and bronchi, aspirated foreign body, as well as purulent-necrotic postoperative complications in the bronchial stump.

According to the clinic hospital surgery SSMU, the structure of causes of pulmonary hemorrhage is as follows: acute infectious destruction - 45.5%, chronic nonspecific diseases - 24.5%, tuberculosis

12.0%, cancer - 8.5%, lung damage - 7.0%, other diseases - 2.5%. Bleeding II and III degree.

[According to the classification of V.I. Struchkova and L.M. Nedvetskaya (1982), distinguish three steps no pulmonary hemorrhages.

I degree- coughing up to 100 ml of blood simultaneously or over several hours.

IIstep n, - the volume of blood loss from respiratory tract exceeds 100 ml and
can reach 500 ml.

Sh degree- leakage of more than 500 ml of blood; profuse bleeding often leads to death from blood asphyxia Yu. 1

/Kr Hemorrhage occurs suddenly, usually during a cough, and may be preceded by hemoptysis. First, liquid scarlet blood with air bubbles is coughed up. The sudden cessation of bleeding occurs as a result of blood coagulation and the formation of an occlusive clot. Symptoms of acute blood loss: adynamia of the patient due to dizziness, tinnitus, diplopia, severe pallor of the skin, cold cyanotic hands and feet. Tachycardia, low blood pressure, shortness of breath.

Existing bleeding adversely affects the course of the destructive process. Blood clots in the cavity serve as a stimulator for increasing the destruction zone. Pneumonia develops in the lobe of the lung that is shut off by an obstructive blood clot.

0 pulmonary hemorrhage is indicated by a pulmonary history: discomfort, pain, feeling of heat and gurgling sounds in the chest on the bleeding side. Blood is released during an attack in foamy spittle or flows out of the mouth.

In first-degree bleeding, blood mixes with sputum. Vomiting "coffee grounds" is observed very rarely after pulmonary hemorrhage in a patient who has swallowed blood and sputum.

Percussion and auscultation are not very informative when diagnosing the source of pulmonary hemorrhage. Plain radiography of the chest in most cases allows one to obtain more accurate data1 The X-ray picture depends on the nosological form: obstructive atelectasis and non-structural root of the lung with central cancer, destruction against the background of inflammatory infiltration in acute abscess, gangrene and infiltrative tuberculosis with decay, cavity irregular shape with fibrous walls in chronic abscess and fibrous-cavernous tuberculosis. In the case of leakage, aspiration of blood into healthy bronchi and the development of pneumonia, radiographs taken several days after pulmonary hemorrhage reveal large-focal confluent and polysegmental infiltration.

Diagnostic bronchoscopy is performed at the height of bleeding and after it has stopped. In case of light bleeding, the lobar, zonal or segmental bronchus from which the blood flows is determined. If by the time of bronchoscopy the bleeding has stopped, a loose red or dense blood clot is detected, obstructing the bronchus or bronchi. Sometimes bleeding is observed from under a loose clot. In the case of heavy bleeding, in which the bronchoscope tube instantly fills with blood, it is difficult to determine only the side of the bleeding - the release of blood from the right or left main bronchus. En Prescopic examination at the height of bleeding and after bleeding of II, III degrees should be performed with a rigid Friedel bronchoscope. under general anesthesia, since during bronchoscopy it is necessary to resort to bronchial occlusion for the purpose of hemostasis.

When studying angiograms of bronchus. Arteries: direct signs - extravasation, leakage of blood outside the lumen of the vessel and thrombosis of the branches of the bronchial artery. An indirect sign is a symptom of periarterial diffusion.

Treatment of pulmonary hemorrhage is challenging. To stop or reduce the intensity of bleeding and prevent its negative Consequences, it is necessary to reduce the pressure in the vessels of the pulmonary circulation and blood pressure to a safe level, increase the coagulant properties of blood, restore the patency of the lower respiratory tract, and implement therapeutic measures to prevent recurrence of bleeding and I.

In the absence of hemorrhagic shock, the optimal position is for the patient to sit half-sitting, tilted towards the lung from which bleeding is expected, with legs down. In order to reduce venous return to the right side of the heart, the application of venous tourniquets to the middle third of the thighs for 30-50 minutes is indicated.

Controlled decrease in systolic blood pressure to 110-100 mm Hg. Art. It is especially indicated for persons with pneumofibrotic processes and aneurysmal diseases of the bronchial arteries. Reduction of pulmonary hypertension achieved by intravenous administration aminophylline a, nitroglycerin (nitroject, perlinganct). I prescribe as hemostatic agents T ascorbic acid acid(500 mg), dicinone (250-500 mg), P inhibitors rotea z ( kontrikal 1 0 000, g ordox 100,000 units each) and fibrinolysis (5% solution of aminocaproic acid), calcium chloride under the control of thromboelastogram and coagulogram. From blood products: fresh frozen plasma with all coagulation factors. Intense cough - opium alkaloids and other antitussives. Bronchospasm – 0.1% atropine 1 ml, inhalation of beta adrenergic agonists (solbutamol, Berotec).

Transportation over short distances is carried out on a stretcher. By transport. During transportation, the patient should lie on sick side, before transportation over a significant distance by any type of transport, it is necessary to perform therapeutic and diagnostic bronchoscopy, temporary occlusion of the bleeding bronchus with a sterile foam sponge or an occluder balloon (a Fogarty probe can be used) (Fig. 111). This curative measure prevents life-threatening bleeding along the way.

In case of asphyxia with blood, emergency tracheal intubation and aspiration of tracheal contents are indicated bronchial tree and artificial ventilation. If pulmonary hemorrhage continues, separate intubation of the main bronchi with a double-lumen tube or temporary bronchial occlusion is necessary. The issue of continuing mechanical ventilation after bronchial occlusion is decided depending on the specific clinical situation. IN specialized department possible: balloon occlusion and irrigation of the mucous membrane of the occluded bronchus through a catheter passing in a balloon with an adrenaline solution: embolization kro here- common bronchial arteries, endobronchial laser photocoagulation of inoperable bronchial cancer. For pulmonary hemorrhage caused by purulent inflammatory process, use embolization of bronchial arteries with albumin macroaggregates; bleeding recurs in 26.5%; the tip of the catheter cannot be securely fixed at the mouth of the bronchial artery and embolization is performed; 5-10 ml of a 10% solution are injected calcium chlo read The drug causes spasm and has an irritating effect on the intima of the bronchial artery with subsequent thrombosis. However, recurrent bleeding occurs in 40.7% of patients. More reliable way hemostasis - occlusion of bronchial arteries with polyurethane emboli. For combined sources of pulmonary hemorrhage, synchronous occlusion of the bronchial arteries and branches is performed pulmonary artery Gianturco spirals! An immediate positive effect is achieved in 90.4% of patients. Method of choice in operable patients

is a radical operation: lobectomy, bilobectomy and pneumonectomy. Pneumoperitoneum, artificial pneumothorax and thoracoplasty have limited use ka.

070. Indications for surgical treatment JABZH and DPC. Complications.

Indications for surgical treatment are divided into absolute and relative. Absolute indications include perforation of the ulcer, profuse

new or recurrent gastroduodenal bleeding, pyloroduodenal

nal stenosis and severe cicatricial deformities of the stomach, accompanied by

violations of its evacuation function.

A relative indication for surgery is the failure of full-scale

conservative treatment:

1) often recurrent ulcers that do not respond well to repeated courses

conservative therapy;

2) not healing for a long time despite conservative treatment (resistant)

ulcers accompanied by severe clinical symptoms

(pain, vomiting, hidden bleeding);

3) a history of repeated bleeding, despite adequate treatment;

4) callous and penetrating gastric ulcers that do not scar with adequate

conservative treatment for 4-6 months;

5) recurrence of an ulcer after previously performed suturing of a perforated

6) multiple ulcers with high acidity gastric juice;

7) social indications (there are no funds for regular full-fledged drug treatment) or the patient’s desire to get rid of peptic ulcer

surgically;

8) intolerance to the components of drug therapy.

Classification of complications of peptic ulcer

Ulcerative-destructive nature:

Bleeding

Perforation

Penetration

Ulcerative-scarring nature:

Narrowing of the entrance or exit of the stomach

Stomach deformity

Narrowing of the duodenum

Inflammatory in nature:

Duodenitis

Perigastritis

Periduodenitis

Malignancy

Combined complications.

071. Chronic lung abscess.

Chronic abscesses include pulmonary abscesses, in which the pathological

the process is not completed within 2 months, which with modern

complex treatment is relatively rare.

Etiology and pathogenesis. Reasons for the transition of acute abscess to chronic

can be divided into two groups.

1. Due to the characteristics of the flow pathological process:

a) the diameter of the cavity in the lung is more than 6 cm;

b) the presence of sequesters in the cavity;

V) bad conditions for drainage (narrow, convoluted drainage

d) localization of the abscess in the lower lobe;

d) sluggish response of the body to the inflammatory process.

2. Caused by errors in the treatment of the patient:

a) late started and inadequate antibacterial therapy;

b) insufficient drainage of the abscess;

c) insufficient use of restorative medications.

Chronic course characteristic of abscesses with slow formation

abscess, especially in old and elderly people, in patients with diabetes

diabetes.

Pathological picture. Chronic abscess is a continuation

acute purulent-destructive process. Periodically occurring

exacerbations lead to involvement in the inflammatory process

new areas of the lung, proliferation connective tissue around the abscess

and along the bronchi, vascular thrombosis. Conditions for development arise

new abscesses, widespread bronchitis. So the chain

pathological changes in chronic abscesses (single

or multiple) excludes the possibility full recovery

sick.

Clinical picture and diagnosis. There are two main forms (or

type) course of chronic abscesses.

In the first type, the acute stage ends with clinical recovery

or significant improvement. The patient is discharged from the hospital

with normal body temperature. Changes in the lung are interpreted as limited

pneumosclerosis, sometimes with a “dry” cavity. Condition after discharge

the patient remains satisfactory for some time and he often

starts work. However, after some time it rises again

body temperature, cough intensifies. After 7-12 days, emptying occurs

abscess, body temperature returns to normal. Subsequent exacerbations

become longer and more frequent. Phenomena develop

purulent bronchitis, intoxication and associated dystrophic

changes in internal organs.

In the second type, the acute period of the disease without pronounced remission passes

into the chronic stage. The disease occurs with hectic temperature

bodies. Patients excrete up to 500 ml per day (and sometimes more)

purulent sputum, which when standing is divided into three layers. Fast

Severe intoxication, exhaustion, and degeneration of parenchymal organs develop and increase. More often, this type of course is observed with multiple lung abscesses. The patients have a characteristic appearance: they

pale, sallow skin, mucous membranes cyanotic. At the beginning

puffiness of the face is noted, then swelling appears on the feet and

lower back, which is associated with protein starvation and impaired renal function. Decompensation of the pulmonary heart is rapidly increasing, from which patients

With a chronic abscess, the same complications may develop as

in the acute period.

Diagnosis of chronic abscess is based on medical history, and

also the results of x-ray examination, which allows

identify infiltration of the lung tissue surrounding the abscess cavity, the presence

contents in it.

Treatment. Conservative treatment of chronic lung abscesses is ineffective.

Use of antibiotics, improvement of drainage conditions

contribute to the subsidence of the inflammatory process, but the remaining

morphological changes prevent complete cure. Therefore, in the absence

contraindications due to concomitant diseases

or advanced age of patients, casting doubt on the possibility

successful surgical treatment, surgical treatment is indicated.

Absolute indication before surgery there are repeated pulmonary hemorrhages,

rapidly increasing intoxication.

For chronic abscesses, only radical surgery is effective -

removal of a lobe or the entire lung (Fig. 6.9). Pneumotomy is not justified

since the dense capsule of a chronic abscess and inflammatory infiltration

the lung tissue around it will prevent elimination

Preparation for surgery should be carried out according to the same scheme as for

acute lung abscesses. It is necessary to achieve subsidence before surgery

inflammatory phenomena, reducing the amount of sputum, correcting

eliminate protein metabolism disorders, hydroion disorders, improve

cardiac activity, increase the functionality of the system

Postoperative mortality reaches 4-5%. In most patients,

who have undergone a lobectomy, their ability to work is restored after

3-4 months after surgery. After pneumonectomy during the first half of the year

it is necessary to transfer patients to disability, then use

at light work, in a warm room without harmful production factors.

072. Bleeding from varicose veins of the esophagus.

Varicose veins of the esophagus - pathological change veins of the esophagus, characterized by an uneven increase in their lumen with protrusion of the wall, the development of nodular tortuosity of the vessels.

Epidemiology

The disease is relatively common, but the true frequency is unknown.

Etiology and pathogenesis

Esophageal varicose veins occur due to:

a) increased flow of blood into them through anastomoses in the area of ​​the cardia with v. v. gastricae at portal hypertension in patients with cirrhosis of the liver, its tumors, with thrombophlebitis of the hepatic veins (Chiari syndrome), anomalies and compression of the portal vein, etc.;

b) compression of the superior vena cava;

V) general increase pressure in the systemic circulation in heart failure.

A pathological examination reveals dilated convoluted veins of the esophagus and often the cardiac part of the stomach. The mucous membrane over the veins is often thinned and may be inflamed or eroded. After severe bleeding, the veins collapse, as a result of which the perforation from which the bleeding occurred is invisible.

Clinical picture, preliminary diagnosis

Usually, varicose veins of the esophagus, before bleeding occurs, are asymptomatic or with minor symptoms (mild dysphagia, heartburn, etc.), which recede into the background before the signs of the underlying disease (cirrhosis of the liver, cancer, heart failure, etc.). Varicose veins of the esophagus can be detected during X-ray examination: characteristic scalloped jagged contours of the esophagus, rough convoluted folds of the mucous membrane, small round or longitudinal filling defects, serpentine-like areas of reduced shadow density. However, more reliable data are obtained with esophagoscopy, which should be performed carefully due to the risk of bleeding if the vein wall is injured. Indirectly, a conclusion about the possibility of varicose veins of the esophagus can be made if the patient has other signs of portal hypertension.

Complications: chronic esophagitis, esophageal bleeding. The latter is often sudden and profuse, in 25-50% of cases it is the cause of death of the patient. Esophageal bleeding is manifested by vomiting dark unchanged blood, with less heavy bleeding and accumulation of blood in the stomach - “coffee grounds”. Then melena joins.

When formulating a diagnosis, first indicate the underlying disease that caused this syndrome, then - varicose veins of the esophagus and complications (if any).

Differential diagnosis, diagnosis verification

An X-ray examination may lead to differential diagnostic difficulties with esophagitis and a tumor of the esophagus. Esophageal bleeding, even in the presence of varicose veins, can be caused by a peptic ulcer of the esophagus, a disintegrating tumor, Mallory-Weiss syndrome (which is characterized by a sudden rupture of the mucous membrane in the cardia area, usually accompanied by vomiting) and other reasons. The final diagnosis of varicose veins of the esophagus is established on the basis of data from contrast fluoroscopy (or radiography) and esophagoscopy.

1. Cold, hunger, peace.

2. Intravenously: calcium chloride, EACC, Vicasol, fibrinogen, plasma (preferably fresh frozen), glucose with vitamins.

3. Pituitrin (vasopressin) causes spasm of the gastrointestinal arteries.

20 units per 200 ml of 5% glucose solution are administered intravenously over 20 minutes. 40-60 minutes after administration, a repeated intravenous injection of 5-10 units is acceptable. The drug can be administered 2 times a day. Efficiency is approximately 75%. Intraoperative administration is possible (pharmacological portal decompression).

Contraindications: hypertension, general atherosclerosis, thyrotoxicosis, bronchial asthma, allergic reaction to the drug. M.D. Patsiora \"74).

4. Blackmore-Sentstaken probe.

5. Gastrotomy operation with suturing of the veins of the stomach and esophagus (M.D. Patsiora \"74).

After laparotomy, the stomach is opened for 10-12 cm from the bottom to the lesser curvature and emptied of liquid blood and clots.

A mirror is inserted into the stomach, lifting its front wall; with the fingers of the left hand, the straightened gastric mucosa is brought out into the wound, which makes it possible to detect the expansion of the veins of the lesser curvature in the form of sharply thickened folds of the mucosa that do not change their shape, sometimes with bleeding defects;

Thickened folds of the mucous membrane on the lesser curvature, where the dilated coronary veins mainly pass, are stitched with separate interrupted sutures in a checkerboard pattern; by tightening the ligatures and squeezing the mucous membrane of the lesser curvature, the bulging stems of the veins of the lower part of the esophagus are sutured;

After suturing the veins and stopping the bleeding, the gastric wound is sutured in two rows; if the patient’s condition allows, the left gastric and splenic arteries are ligated before gastrotomy.

6. Tanner-Petrov operation (in classic version- transthoracic access on the left) and the operation of Phemister and Humphrey (1947) - resection of the abdominal esophagus and cardia of the stomach with gastroesophageal anastomosis.

7. In case of bleeding from the confluence of short vessels of the stomach (according to greater curvature in the area of ​​the fundus and body) - splenectomy with additional suturing of vessels in the wall of the stomach.

073. Zenker's diverticulum

Esophageal diverticulum– limited protrusion of the esophageal wall. There are pulsion and traction diverticula. Pulsion diverticula are formed due to protrusion of the esophageal wall under the influence of high intraesophageal pressure that occurs during its contraction. The development of traction diverticula is associated with an inflammatory process in the surrounding tissues and the formation of scars that pull the wall of the esophagus towards the affected organ (mediastinal lymphadenitis, chronic mediastinitis, pleurisy). Diverticula are divided depending on their location into pharyngeal-esophageal (Zenker's), epibronchial (bifurcation, mid-esophageal), epiphrenal (supradiaphragmatic). There are true diverticula, the wall of which contains all layers of the esophageal wall, and false diverticula, in the wall of which there is no muscle layer. The vast majority of diverticula are acquired. Congenital diverticula are extremely rare. Diverticula are observed rarely before the age of 30 years and often after 50 years; Among the patients, men predominate. Most often diverticula occur in thoracic region esophagus.

The main role in the formation of Zenker's diverticula is achalasia of the cricopharyngeal muscles (impaired opening of the upper esophageal sphincter in response to swallowing). Diverticula descend down between the posterior wall of the esophagus and the spine and can be displaced under the lateral muscles of the neck. Their size varies, they have a wide mouth. The wall of the diverticulum does not contain muscle fibers, is usually not fused with the surrounding tissues, its inner surface is covered with the mucous membrane of the pharynx, and there may be superficial erosions or scars.

Clinic and diagnostics: a small pharyngoesophageal diverticulum is manifested by a feeling of soreness, scratching in the throat, dry cough, sensation of a foreign body in the throat, increased salivation, sometimes spastic dysphagia. As the diverticulum enlarges, filling it with food may be accompanied by a gurgling noise when swallowing, leading to the development of dysphagia of varying severity, and the appearance of a protrusion in the neck when the head is pulled back. The protrusion has a soft consistency, decreases with pressure; after drinking water, a splashing noise can be detected by percussion over it. Possible spontaneous regurgitation (reflux) of undigested food from the lumen of the diverticulum in a certain position of the patient, difficulty breathing due to compression of the trachea, and the appearance of hoarseness due to compression of the recurrent nerve. When eating, patients may develop a “blockade phenomenon”, manifested by redness of the face, a feeling of lack of air, dizziness, fainting, which disappears after vomiting. When food is retained for a long time in the diverticulum, a putrid odor appears from the mouth. Most patients have malnutrition, which leads them to exhaustion. The course of the disease is slow, without significant progression.

Zenker's diverticula can be complicated by the development of diverticulitis, which in turn can cause phlegmon of the neck, mediastinitis, the development of an esophageal fistula, and sepsis. Regurgitation and aspiration of diverticulum contents lead to chronic bronchitis, repeated pneumonia, lung abscesses. Bleeding from the eroded mucous membrane of the diverticulum, the development of polyps in it, and malignancy (malignancy) of its wall are possible.

Chronic diverticulitis predisposes to cancer. Pharyngeal-esophageal diverticula can sometimes be detected by inspection and palpation of the neck. The main method for diagnosing diverticula of the esophagus is a contrast X-ray examination, which establishes the presence of a diverticulum, the width of the neck, the duration of barium retention in it, the degree of obstruction of the esophagus, signs of the development of a polyp and cancer in the diverticulum, the formation of esophageal-bronchial and esophageal-mediastinal fistulas. Endoscopic examination makes it possible to establish the presence of a diverticulum, detect ulceration of its mucous membrane, the presence of bleeding, and diagnose a polyp or cancer in the diverticulum.

It is possible to eliminate a diverticulum only surgically. Indications for surgical treatment of esophageal diverticula: complications (perforation, penetration, bleeding, stenosis of the esophagus, cancer, development of fistulas), large diverticula complicated by at least short-term retention of food masses in them, long-term retention of food in the diverticulum regardless on its size. The essence of surgical treatment is the complete removal of the diverticulum - diverticulectomy: the diverticulum is isolated from the surrounding tissues up to the neck, a myotomy is performed, it is excised and the hole in the wall of the esophagus is sutured. With small diverticula, no complications, absolute contraindications undergo surgical treatment conservative therapy, aimed at preventing the retention of food masses in the diverticulum and reducing the possibility of developing diverticulitis.

074. Causes and methods of preoperative diagnosis of subhepatic, obstructive jaundice

075. Classification of ulcerative bleeding Forrest

The intensity of bleeding almost all over the world is designated according to the criteria proposed by J. Forrest.

Classification of the intensity of ulcer bleeding (J. Forrest, 1985-1995)

according to endoscopic signs.

Continued bleeding

Forrest Ia - Arterial bleeding

Forrest Ib - Venous, parenchymal bleeding

Existing bleeding

Forrest IIa - No active bleeding; visible thrombosed vessel at the bottom of the ulcer

Forrest IIb - No active bleeding; tightly fixed blood clot at the bottom of the ulcer

Forrest IIc - No active bleeding; hydrochloric acid hematin at the bottom of the ulcer

No signs of bleeding were detected

Forrest III - Ulcer with clear white bottom

076. Septic lung abscess

LUNG ABSCESS is a limited purulent-necrotic lesion of the lung tissue with the presence of one or more cavities. A lung abscess can sometimes develop into gangrene. In turn, gangrene, with a favorable course, can result in the formation of one or multiple abscesses.

In etiology lung abscess Of primary importance are pathogenic pathogens, impaired bronchial obstruction, circulatory and lymph circulation disorders, and innervation in the affected area. However the main role belongs to the reactivity of the body, because only with a decrease in immunity can these factors cause an inflammatory-destructive process in the lung.

There is no specific pathogen for lung abscess.

Bacterial flora is often polymorphic. In the lesion, white and golden hemolytic staphylococcus, viridans and hemolytic streptococcus, fusospirochetous flora, coli, anaerobic microbes, Friedlander's bacillus. Viruses, in particular influenza, also play a significant role. Thus, the bacterial flora can be characterized as microbial-viral.

Lung abscess most often has a post-pneumonic or aspiration, less often hematogenous-embolic, traumatic, lymphogenous origin. The role of influenza pneumonia is very significant, in which destructive changes in the walls of the bronchi quickly develop, their drainage function is disrupted, and thrombosis of small pulmonary vessels occurs.

Absence of pneumonia usually occurs in one of three ways. In the first option, 12-20 days after the onset of pneumonia, after the acute symptoms subside and apparent recovery, a significant deterioration occurs: the temperature rises, pain in the side reappears, and copious purulent sputum begins to be released with a cough.

The second option: pneumonia takes on a protracted character and, 20-30 days after the onset of the disease, against the background of a rise in temperature, the amount of purulent sputum increases, and radiographically a cavity appears in the area of ​​the inflammatory focus. In the third option, against the background of 1-2 weeks of illness, low-grade fever, chest pain, the temperature rises to high numbers, and after 2-3 days the patient begins to cough up sputum. In such cases, they sometimes talk about a primary lung abscess.

Significant role in the pathogenesis of lung abscess after acute pneumonia plays an ever-increasing number of patients with microbial flora resistant to antibiotics.

The aspirated path of development of a lung abscess is associated with an outbreak of infection in a lobe or segment of the lung due to the entry of a foreign body, vomit, blood, or gastric contents into the corresponding bronchus. This path often occurs due to alcohol intoxication, diabetic coma, epilepsy, various wounds and surgical operations, especially on the head and neck.

A much rarer way of developing a lung abscess is hematogenous-embolic. In this case, a septic embolus, entering one of the branches of the pulmonary artery with the bloodstream, leads to the development of an infected pulmonary infarction. In this zone, purulent melting occurs quite quickly. Embolic processes develop with thrombophlebitis of the deep veins of the legs and pelvis, septic endocarditis, osteomyelitis, postpartum sepsis. The detachment of a blood clot and its introduction into the vessels of the lungs can be facilitated by surgery on infected tissues.

There are acute purulent, gangrenous and chronic lung abscess. The disease occurs more often in men 30-50 years old, i.e. in people who smoke more often, drink alcoholic beverages, and are exposed to hypothermia.

Acute purulent lung abscess in 75-80% of cases is single and localized in segments of the right lung. Large abscesses involve several segments of one lobe or different lobes of the lung.

During a lung abscess, two phases are distinguished. The first phase is characterized by acute purulent inflammation and destruction of lung tissue without breakthrough of purulent-necrotic masses into the lumen of the bronchial tree. Patients complain of chest pain, cough, general weakness, sweating, chills, lack of appetite, thirst. The temperature reaches high numbers. Availability pleural effusion. The ESR increases, the level of hemoglobin in the blood decreases, leukocytosis with a shift in the leukocyte formula to the left is typical. X-ray reveals gross infiltrative changes.

The second phase of the course of an acute lung abscess begins after its contents break through into the lumen of the bronchus (at 2-3 weeks from the onset of the disease). Temperature and other symptoms of intoxication decrease, leukocytosis decreases, and ESR slows down. Starting