Retrocecal appendicitis. Atypical forms of acute appendicitis: pelvic acute appendicitis

Clinical features of acute appendicitis with atypical retrocecal location vermiform appendix.

Among the various forms of acute appendicitis, the greatest diagnostic difficulties are encountered with the retrocecal location of the appendix.

The clinical picture of retrocecal appendicitis, freely located in the abdominal cavity, is determined not only by the severity of the inflammatory process, but also by the anatomical position of the appendix. With the first and even the second variant of the retrocecal location of the appendix, the usual course of acute appendicitis occurs. In such cases, the retrocecal location of the process is detected only during surgery;

With the retroperitoneal location of the vermiform, a peculiar clinical course acute appendicitis. Retrocecal appendicitis begins with abdominal pain, which may be accompanied by nausea or vomiting. The latter is observed in approximately 1/3 of patients at the beginning of an attack. Sometimes the pain radiates to the genital area or right thigh. Often pain appears in the lower back or between the costal edge and the scallop ilium. The intensity of pain does not reach significant strength; Often a day or two after the onset of the attack, patients notice a decrease in pain. Such localization of pain is explained by inflammatory changes in the parietal layer of the peritoneum or the transition of the pathological process to the retroperitoneal space. During the examination, attention is drawn to the relatively slight soreness of the right iliac region. Local voltage abdominal muscles cannot be detected. The abdomen is soft and actively participates in the act of breathing. Palpation lumbar region You can establish pain, most pronounced according to Pettit's triangle. Sometimes there is moderate tension in the muscles of the lateral and posterior abdominal wall on the right. The Shchetkin-Blumberg symptom in the right iliac region, like other appendicular symptoms, is not expressed. When the appendix is located retroperitoneally or retroperitoneal tissue is involved in the pathological process, Pasternatsky's sign is positive. In 1/3 of patients, it is possible to detect fresh and leached red blood cells in the urine, which is caused by the transition of the inflammatory process to the ureter or renal pelvis. In these cases, sometimes even experienced doctors suspect independent disease kidney From the foregoing it is clear that in retrocecal acute appendicitis (with the appendix not freely positioned), symptoms of peritoneal irritation do not occur consistently. The most important signs of the disease are pain in the lumbar region, tension in the side wall of the abdomen, often a positive Pasternatsky sign and a small admixture of red blood cells in the urine.

Recognition of retroperitoneal appendicitis is difficult. However, with sufficient familiarity with clinical picture of this disease, a correct diagnosis is possible. It is only necessary to emphasize that delay in providing surgical care is dangerous due to the spread of the inflammatory process through the retroperitoneal tissue.

Acute appendicitis when the appendix is located in the pelvis.

Acute appendicitis when the appendix is located in the small pelvis occurs more often in women, which is apparently due to their weaker muscle development and a tendency to enteroptosis. Onset and course of the disease pelvic appendicitis does not have any characteristic features, except in cases where the spread of infection is created by contact from the inflammatory process to the pelvic organs ( bladder, rectum, uterus and its appendages). Depending on the location of the process in relation to these organs, certain symptoms may be observed. Thus, when the bladder wall is involved in the inflammatory process, dysuric phenomena sometimes develop, which may give rise to the mistaken interpretation of the disease as acute cystitis. Irritation of the lower colon or rectum is characterized by the appearance of loose stools mixed with mucus in the stool; Sometimes there is persistent diarrhea.

Acute appendicitis with the pelvic location of the appendix often gives complications in the form of infiltrates and abscesses in the pelvis. These complications are observed mainly in cases where the surgical intervention.

Acute appendicitis with a medial location of the appendix.

Even more rare forms of acute appendicitis include the so-called medial, or mesocoeliac, appendicitis. In these cases, the distal part and the apex of the process lie closer to midline towards the navel and are located between intestinal loops. With such localization of the altered process, the inflammatory process involves serosa adjacent intestinal loops, which determines the corresponding clinical picture of the disease. The onset of the disease in this form of acute appendicitis is characterized by a sharp manifestation clinical symptoms even with relatively minor inflammatory changes in the appendix. Most characteristic symptom There are severe, sudden onset abdominal pains. Within a few hours, the pain is accompanied by bloating and intestinal paresis, which is the result of irritation of the peritoneum. Noteworthy is the general serious condition sick. This circumstance, as well as severe pain in the abdomen and irritation of the peritoneum lead to thoughts of a perforated gastric ulcer or acute pancreatitis.

Palpation of the abdomen reveals significant muscle tension throughout the anterior abdominal wall. However, upon careful examination, it is possible to establish a more intense tension in the right half of the abdomen. The Shchetkin-Blumberg symptom is also most pronounced here. Thus, there are no pathognomonic symptoms of acute appendicitis with a medial location of the appendix; Therefore, diagnosing this type of disease is difficult. The typical medial position of the appendix is rare and only a few works are devoted to this issue. We also encountered few cases of acute appendicitis with this location of the appendix.

Acute appendicitis with a left-sided appendix.

The reason for the left-sided localization of the appendix may be an overly mobile and elongated cecum. The latter is located in these cases in the middle of the abdominal cavity, and the process (which is also mostly elongated) lies in the left iliac region. The process can be located freely or (which is more common) fixed with adhesions. In other cases, the left-sided location of the appendix is due to a developmental anomaly, the reverse arrangement of the internal organs. In such a patient, diagnosing acute appendicitis does not present much difficulty, because all the symptoms of acute appendicitis manifest themselves in the same way as with the usual localization of the appendix, but only on the left.

The second reason for left-sided location is the reverse arrangement of organs. In such cases, the diagnosis is guessed before surgery rather than recognized on the basis of clinical symptoms. Most patients are operated on for acute diseases other abdominal organs, and the left-sided location of the inflammatory process is an operational finding.

Differential diagnosis

According to I. I. Grekov, 26 diseases of the abdominal organs are differentiated from acute appendicitis.

Similar manifestations of the disease occur in 20-30% of patients.

The atypical clinical picture is explained by the variety of options for the location of the appendix in the abdomen, as well as age-related and physiological variations in the individual reactivity of the body, the presence or absence of signs of appendicitis, and the body’s systemic reaction to inflammation.

The most a common option atypical forms are retrocecal appendicitis (50-60%). In this case, the process may be close to the right kidney, ureter, and lumbar muscles. The disease usually begins with pain in the epigastrium or in the right half of the abdomen. If its migration occurs, it is localized in the right lateral or lumbar region.

The pain is constant, low-intensity, usually intensifies when walking and moving in the right hip joint. Developing contracture of the right iliopsoas muscle can lead to lameness in the right leg.

Nausea and vomiting are less common than with the typical location of the appendix, but irritation of the dome of the cecum causes the occurrence of 2-3 times liquid and pasty stool. Irritation of the kidney or ureteral wall leads to dysuria.

An objective examination notes the absence of the key symptom - increased tone of the muscles of the anterior abdominal wall, but reveals rigidity lumbar muscles on right. The area of maximum pain is localized near the iliac crest or in the right lateral region of the abdomen.

Shchetkin-Blumberg symptom on the anterior abdominal wall is doubtful; it can only be caused in the area of the right lumbar triangle (Petit).

Characteristics of retrocecal appendicitis are Obraztsov's symptom and pain on percussion and palpation of the lumbar region on the right. When examining laboratory data, you should pay attention to urine analysis, where leukocytes, fresh and leached red blood cells are detected.

The proximity of the retroperitoneal tissue, poor emptying of the appendix due to bends and deformations caused by a short mesentery, and therefore worse conditions blood supply, together with a poor atypical clinical picture, predetermine the tendency to develop complicated forms of appendicitis.

A low or pelvic location of the process occurs in 15-20% of atypical forms, and in women it is 2 times more common than in men. The process can be located either above the entrance to the small pelvis, or at the bottom of the rectovesical (uterine) cavity, directly in the pelvic cavity.

Under these conditions, the pain often begins throughout the abdomen, and then is localized in the first case - in the pubic region, less often - in the left groin; in the second - above the pubis or in the right iliac region, directly above the inguinal fold.

The proximity of the inflamed appendage to the rectum and bladder often causes imperative, frequent, loose stool with mucus (tenesmus), as well as frequent painful urination (dysuria).

Abdomen upon examination correct form, participates in the act of breathing. The difficulty of diagnosis is that abdominal muscle tension and the Shchetkin-Blumberg symptom may be absent. The diagnosis is clarified by rectal examination, since already in the first hours a sharp pain in the anterior and right walls of the rectum is detected (Kulenkampff's symptom). In children, swelling and infiltration of its walls may simultaneously appear.

Due to the frequent early delimitation of the inflammatory process, temperature and leukocyte reactions in pelvic appendicitis are less pronounced than in typical localization of the appendix.

That is why appendicitis with a midline location of the organ is characterized by the rapid development of clinical symptoms. Abdominal pain is initially diffuse, but then localized in the navel or right lower quadrant of the abdomen, accompanied by repeated vomiting and high fever.

Local pain, tension in the abdominal muscles and the Shchetkin-Blumberg symptom are most pronounced near the navel and to the right of it. Due to reflex irritation of the root of the mesentery, bloating occurs early and quickly increases due to intestinal paresis. Against the background of increasing dehydration, fever appears.

In the subhepatic variant of acute appendicitis (2-5% of atypical forms), the pain that initially appeared in the epigastric region then moves to right hypochondrium, usually localized lateral to the projection of the gallbladder - along the anterior axillary line. Palpation of this area makes it possible to establish tension in the broad abdominal muscles, symptoms of peritoneal irritation, and irradiation of pain to the epigastric region.

Symptoms of Sitkovsky, Razdolsky, Rovsing are positive. The high location of the dome of the cecum can be verified by plain fluoroscopy of the abdominal organs. Useful information can give an ultrasound.

Left-sided acute appendicitis

Left-sided acute appendicitis observed extremely rarely.

This form is due to the reverse position of the internal organs or excessive mobility of the right half colon. The clinical manifestations of the disease differ only in the localization of all local signs appendicitis in the left iliac region. Diagnosis of the disease is easier if the doctor detects dextrocardia and the location of the liver in the left hypochondrium.

Acute appendicitis in children has clinical features in the younger age group(up to 3 years). Unfinished ripening immune system and underdevelopment of the greater omentum (it does not reach the appendix) contribute to the rapid development of destructive changes in the appendix, reduce the possibility of delimiting the inflammatory process and create conditions for the more frequent development of complications of the disease.

A distinctive sign of the development of the disease is the predominance common symptoms over the locals. The clinical equivalent of pain in young children is a change in their behavior and refusal to eat. The first objective symptom is often fever (39-39.5°C) and repeated vomiting (in 4550%). 30% of children experience frequent loose stools, which, together with vomiting, leads to the development of early dehydration.

Examination during sleep reveals provoked pain, manifested by flexion of the right leg at the hip joint and an attempt to push away the surgeon’s hand (the “right arm and right leg” symptom). In addition, they find muscle tension, which during sleep can be differentiated from active muscle defense.

The same reaction as palpation of the abdomen is also caused by percussion of the anterior abdominal wall, carried out from left to right. In the blood of children under 3 years of age, pronounced leukocytosis (15-18x 109/l) with a neutrophilic shift is detected.

In elderly and old age(about 10% of all patients with acute appendicitis) reduced reactivity of the body, sclerosis of all layers of the wall of the appendix, as well as blood vessels supplying the appendix, predetermine, on the one hand, effacement clinical manifestations acute appendicitis, on the other - the predominance of destructive forms.

Physiological threshold elevation pain sensitivity leads to the fact that many patients overlook the occurrence of the epigastric phase of pain and associate the onset of the disease with pain in the right iliac region, the intensity of which varies from severe to slight.

Nausea and vomiting occur less frequently than in older people. Patients often explain the retention of stool, characteristic of appendicitis, as habitual constipation. During the examination, you should pay attention to severe general malaise, dryness of the mucous membranes of the oral cavity against the background of bloating caused by intestinal paresis.

The onset of the disease is often quite typical, but may be similar to right-sided renal colic. However, unlike her, the patient does not rush around in search of a position that reduces pain. In cases of pain radiating to the lower back, to the right groin area, the pain is much less pronounced than with colic, there is no visible blood in the urine, only microhematuria is possible when the inflamed appendix is close to the ureter. In the immediate proximity of the appendage to the cecum, irritation of the latter may explain the appearance of loose stools with mucus, which, given the paucity of objective examination data from the abdomen, may be an erroneous reason for hospitalization of the patient in infectious diseases department regarding the alleged intestinal infection. Most valuable diagnostic signs This form of appendicitis is a shift in the area of localized pain to the lateral abdomen or to the lumbar region on the right, possible muscle tension in this particular area and the appearance of Obraztsov’s symptom (psoas symptom), which is caused by in the following way: the doctor’s hand gently presses the cecum to the back wall of the abdomen, while the patient is asked to raise his straight right leg. When abdominal pain appears or intensifies, this symptom can be considered positive. Contraction of the iliopsoas muscle causes the cecum to shift along with the inflamed appendix, which causes pain. Shchetkin's symptom may not be clearly expressed or may be completely absent, but if present, it is localized in the projection of the area of pain.

With a pelvic location of the appendix the inflammatory process is limited to the pelvic bones and adjacent internal organs. In this regard, when examining the abdomen, as a rule, there is no muscle tension and other typical symptoms of acute appendicitis. It is especially difficult to diagnose pelvic appendicitis in women, when it is necessary to differentiate this disease and inflammatory processes in the uterine appendages, which are characterized by a combination of pain in the pelvic area with radiation to the rectum and the occurrence of fever. Vaginal discharge may occur. Detection of acute appendicitis can be facilitated by positive Cope's symptoms (pain in the depth of the pelvis on the right, appearing when the right hip is rotated outward with the patient in the supine position while bent in knee joint limbs) and Obraztsov’s symptom. The identification of this atypical form of appendicitis can largely be facilitated by a rectal examination, which should not be forgotten even at prehospital stage. With a digital examination of the rectum, you can obtain such valuable information for staging correct diagnosis, such as the presence of a painful infiltrate or simply pain on palpation of the right wall of the rectum. If the inflamed appendix is in close proximity to the uterine appendages, Promptov's symptom, characteristic of inflammatory diseases of the uterus and appendages, may also be positive (pain when moving the cervix when moving it anteriorly during finger examination rectum), which, without taking into account anemnesis and other clinical data, can serve as a reason for incorrectly referring the patient to a gynecological hospital. In cases of doubt in the diagnosis between acute appendicitis (with a pelvic location) and inflammation of the uterine appendages, emergency and emergency physicians should put acute appendicitis in the first place when writing a diagnosis in the referral and deliver patients to surgical hospitals. Vaginal examination, useful for differential diagnosis, should be carried out only in hospitals.

Rarely seen subhepatic location of the appendix in the presence of pain and symptoms of peritoneal irritation in the right hypochondrium, it can simulate acute cholecystitis, however, the difference in anamnestic data and the absence of the gallbladder, which is often palpable in acute cholecystitis, help to correctly make the diagnosis.

In the right lateral canal.

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WITH AN ATYPICAL LOCATION OF THE VERMIFORMAL APPRESS

Retrocecal location of the appendix occurs in 5–12% of cases. The location of the appendix behind the cecum is accompanied by less severe symptoms of acute appendicitis and their slower increase. At the onset of the disease, vomiting is almost always absent, but predominant pain symptom. Pain stupid character localized in the right iliac or lumbar region, often radiating to right thigh. Palpation of the cecum is painful. Shchetkin-Blumberg symptoms and defense muscles are not expressed and appear much later than with the usual localization of the vermiform appendix. Positive symptoms of Obraztsov, Ostrovsky, Rovzing, Bartomier-Mikhelson, Sitkovsky, often Yaure-Rozanov, Gabay, “effleurage” are identified.

Retroperitoneal location of the appendix is observed in 1–2% of cases. This clinical form Acute appendicitis is very difficult to diagnose due to the location of the appendix in the retroperitoneal space and the absence of symptoms of peritoneal irritation. Characterized by pain in the right half of the abdomen and lower back. Painful urination is sometimes noted. When retroperitoneal tissue is involved in the inflammatory process (retroperitoneal phlegmon, abscess), a myogenic flexion-adduction contracture of the right hip joint appears. A greater degree of its severity is observed with a low location of the abscess and accumulation of pus under the fascia of the iliopsoas muscle. Tension of the abdominal wall muscles in the right iliac region, the Shchetkin-Blumberg symptom and other symptoms characteristic of the intraperitoneal location of the appendix are rarely detected. Positive symptoms of Yaure-Rozanov, Gabay, Pasternatsky, Obraztsov, Ostrovsky are determined. There are red blood cells in the urine. Ultrasound and computed tomography are useful in diagnosis.

The pelvic location of the appendix is diagnosed in 9–18% of cases, more often in women. With this variant of the location of the inflammatory altered appendix, the pain is localized in the lower abdomen, above the pubis, and often radiates to the navel and epigastrium. Due to the proximity of the appendix to the rectum, frequent loose stools with mucus and blood appear, and to the bladder - painful urination with micro- or macro-hematuria, leukocyturia. There is pain during digital vaginal or rectal examination. Diagnostic laparoscopy and ultrasound help in making the correct diagnosis.

The subhepatic location of the appendix is observed in 0.4–1% of patients. This clinical form of acute appendicitis manifests itself as aching, dull, but more often intense pain in the right hypochondrium. The pain radiates to the epigastric and right iliac regions. Sometimes patients experience nausea and vomiting. Body temperature may remain normal or rise slightly.

Localization of the vermiform appendix in the left iliac region occurs in 3 cases - with a complete reverse arrangement of the internal organs ( situs viscerum inversus), when the cecum is located in the left iliac region; with an overly mobile cecum ( cecum mobile); with a long appendix, when the tip of the appendix reaches the left iliac region. Displacement of the appendix to the left iliac region is accompanied by the appearance of local symptoms characteristic of acute appendicitis.

The medial location of the appendix is manifested various pains and significant muscle tension in the meso- and hypogastrium, mainly in the right sections, more pronounced general symptoms of intoxication, which is associated with the good resorption capacity of the peritoneum of these sections of the abdominal cavity.

You should always remember the onset of the disease, when dull pain in acute appendicitis first appears in epigastric region even with an atypical location of the process!

ACUTE APPENDICITIS IN CHILDREN

Acute appendicitis in children is more severe than in adults. Characterized by a predominance of symptoms general intoxication above local manifestations. It is characterized by rapid (within 6-12 hours) progression of destructive changes in the appendix and the occurrence of diffuse peritonitis. This is due to the low plastic properties of the peritoneum, poor development of the omentum, and reduced reactivity of the body, which together does not allow limiting the inflammatory process in the abdominal cavity. The most atypical disease occurs in the chest and early childhood. Clinical manifestations resemble dysentery or gastroenteritis. The leading symptoms are cramping pain in the navel or in lower section abdomen on the right; repeated vomiting, first with food and then with bile; diarrhea; heat body, reaching 39–40 °C; discrepancy between pulse rate and temperature: the pulse is increased to a greater extent than the temperature is increased. An increase in tachycardia with a simultaneous decrease in body temperature can be considered a sign of peritonitis in children.

Tension of the abdominal wall muscles with gangrene of the appendix and diffuse peritonitis is often absent. However, the abdominal type of breathing is always preserved.

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Similar manifestations of the disease occur in 10% of patients. The atypical clinical picture is explained by the variety of options for the location of the appendix in the abdomen, as well as age-related and physiological variations in the individual reactivity of the body, the presence or absence of signs of a systemic reaction of the body to inflammation.

The most common variant of atypical forms is retrocecal appendicitis (50-60%). In this case, the process may be close to the right kidney, ureter, and lumbar muscles. The disease usually begins with pain in the epigastrium or in the right half of the abdomen. If its migration occurs, it is localized in the right lateral or lumbar region. The pain is constant, low-intensity, usually intensifies when walking and moving in the right hip joint. Developing contracture of the right iliopsoas muscle can lead to lameness in the right leg. Nausea and vomiting are less common than with the typical location of the appendix, but irritation of the dome of the cecum causes the occurrence of 2-3 times liquid and pasty stool. Irritation of the kidney or ureteral wall leads to dysuria. An objective examination notes the absence of the key symptom - increased tone of the muscles of the anterior abdominal wall, but reveals rigidity of the lumbar muscles on the right. The area of maximum pain is localized near the iliac crest or in the right lateral region of the abdomen. The Shchetkin-Blumberg sign on the anterior abdominal wall is questionable; it can only be caused in the area of the right lumbar triangle (Petit). Characteristics of retrocecal appendicitis are Obraztsov's symptom and pain on percussion and palpation of the lumbar region on the right. When examining laboratory data, you should pay attention to urine analysis, where leukocytes, fresh and leached red blood cells are detected.

The proximity of the retroperitoneal tissue, poor emptying of the appendix due to bends and deformations caused by a short mesentery, and therefore worse blood supply conditions, together with a poor atypical clinical picture, predetermine the tendency to develop complicated forms of appendicitis.

A low or pelvic location of the process occurs in% of atypical forms, and in women it is 2 times more likely than in men. The process can be located either above the entrance to the small pelvis, or at the bottom of the rectovesical (uterine) cavity, directly in the pelvic cavity. Under these conditions, the pain often begins throughout the abdomen, and then is localized in the first case - in the pubic region, less often - in the left groin; in the second - above the pubis or in the right iliac region, directly above the inguinal fold.

The proximity of the inflamed appendage to the rectum and bladder often causes urgent, frequent, loose stools with mucus (tenesmus), as well as frequent painful urination (dysuria). The abdomen, when examined, is of correct shape and participates in the act of breathing. The difficulty of diagnosis is that abdominal muscle tension and the Shchetkin-Blumberg symptom may be absent. The diagnosis is clarified by rectal examination, since already in the first hours a sharp pain in the anterior and right walls of the rectum is detected (Kulenkampff's symptom). In children, swelling and infiltration of its walls may simultaneously appear.

Due to the frequent early delimitation of the inflammatory process, temperature and leukocyte reactions in pelvic appendicitis are less pronounced than in typical localization of the appendix.

The medial location of the appendix occurs in 8-10% of patients with atypical forms of appendicitis. In this case, the process is shifted to the midline and is located close to the root of the mesentery of the small intestine. That is why appendicitis with a midline location of the organ is characterized by the rapid development of clinical symptoms.

Abdominal pain is initially diffuse, but then localized in the navel or right lower quadrant of the abdomen, accompanied by repeated vomiting and high fever. Local pain, tension in the abdominal muscles and the Shchetkin-Blumberg symptom are most pronounced near the navel and to the right of it. Due to reflex irritation of the root of the mesentery, bloating occurs early and quickly increases due to intestinal paresis. Against the background of increasing dehydration, fever appears.

In the subhepatic version of acute appendicitis (2-5% of atypical forms), the pain, which initially appeared in the epigastric region, then moves to the right hypochondrium, usually localized lateral to the projection of the gallbladder - along the anterior axillary line. Palpation of this area makes it possible to establish tension in the broad abdominal muscles, symptoms of peritoneal irritation, and irradiation of pain to the epigastric region. Symptoms of Sitkovsky, Razdolsky, Rovsing are positive. The high location of the dome of the cecum can be verified by plain fluoroscopy of the abdominal organs. Ultrasound can provide useful information.

Left-sided acute appendicitis is observed extremely rarely. This form is caused by the reverse position of the internal organs or excessive mobility of the right half of the colon. The clinical manifestations of the disease differ only in the localization of all local signs of appendicitis in the left iliac region. Diagnosis of the disease is easier if the doctor detects dextrocardia and the location of the liver in the left hypochondrium.

Acute appendicitis in children has clinical features in the younger age group (up to 3 years). Incomplete maturation of the immune system and underdevelopment of the greater omentum (it does not reach the appendix) contribute to the rapid development of destructive changes in the appendix, reduce the possibility of delimiting the inflammatory process and create conditions for the more frequent development of complications of the disease.

A distinctive sign of the development of the disease is the predominance of general symptoms over local ones. The clinical equivalent of pain in young children is a change in their behavior and refusal to eat. The first objective symptom is often fever (39-39.5°C) and repeated vomiting (in 4550%). 30% of children experience frequent loose stools, which, together with vomiting, leads to the development of early dehydration.

During examination, pay attention to the dryness of the mucous membranes of the oral cavity and tachycardia over 100 beats per minute. It is advisable to examine the abdomen in a state of medicated sleep. For this purpose, a 2% solution of hydrochloride is administered rectally at the rate of 10 ml/year of the patient’s life. Examination during sleep reveals provoked pain, manifested by flexion of the right leg at the hip joint and an attempt to push away the surgeon’s hand (the “right arm and right leg” symptom). In addition, muscle tension is detected, which during sleep can be differentiated from active muscle defense. The same reaction as palpation of the abdomen is also caused by percussion of the anterior abdominal wall, carried out from left to right. In the blood of children under 3 years of age, pronounced leukocytosis (15-18 x 10 9 / l) with a neutrophilic shift is detected.

In elderly and senile patients (about 10% of all patients with acute appendicitis), reduced reactivity of the body, sclerosis of all layers of the wall of the appendix, as well as blood vessels feeding the appendix, predetermine, on the one hand, the erasure of the clinical manifestations of acute appendicitis, on the other hand, the predominance destructive forms.

The physiological increase in the threshold of pain sensitivity leads to the fact that many patients overlook the occurrence of the epigastric phase of pain and associate the onset of the disease with pain in the right iliac region, the intensity of which varies from strong to slight. Nausea and vomiting occur less frequently than in older people. Patients often explain the retention of stool, characteristic of appendicitis, as habitual constipation.

During the examination, you should pay attention to severe general malaise, dryness of the mucous membranes of the oral cavity against the background of bloating caused by intestinal paresis.

Although, due to age-related relaxation of the abdominal wall, muscle tension over the lesion is expressed insignificantly, the cardinal symptom - local pain on palpation and percussion over the location of the appendix - is usually detected. Often the symptoms of Shchetkin-Blumberg, Voskresensky, Sitkovsky, Rovsing are not clearly expressed and have an erased form. Body temperature, even with destructive appendicitis, remains normal or rises to subfebrile values. The number of leukocytes is also normal or increased to 8-12x9l, the neutrophil shift is not pronounced. In old people, more often than in middle-aged people, appendiceal infiltration occurs, characterized by a slow, sluggish course. The absence of indications of an acute attack of abdominal pain, the first visit to the doctor in the phase of dense infiltration in the right iliac region forces the doctor to carry out differential diagnosis between appendiceal infiltrate and cecal cancer.

Atypical location of the appendix

Considering that this is a fairly common pathology among all segments of the population, and sometimes quite complex clinical differential diagnosis, we will dwell on this issue separately.

Historical reference

In 1982, for the first time in our practice (A. Penu), an attempt was made to study the diagnostic capabilities of echography in determining the pathological condition of the appendix. (At that time there were no reports of this kind in available sources). The reason was the controversial issue of diagnosis and treatment tactics for a person close to the author after clinical exclusion by a surgeon acute pathology appendicular process, although we previously described some echographic signs of possible acute appendicitis. When the patient was refused surgical intervention, it was decided to undergo ultrasound monitoring of the abdominal cavity every 2 hours using an SSD 202 D device from Aloka (Japan), operating in real time (at that time it was the only one in the Republic of Moldova) using sensors in 3.5 and 5 MHz. The last, fourth, study revealed the following echographic picture:

Local reaction of the peritoneum in the form of echogenic fine-grained thickening.

The cecum is somewhat deformed, the wall is unevenly thickened, varying degrees echogenicity, and there was no content in the cavity (later in the literature this phenomenon was described as a “symptom of an empty cecum”).

In the ileocecal angle, a small amount of fluid was detected, against which a modified appendicular process was located, located medially, with the apex deepening into the small pelvis - thickened, with uneven erased contours, different echogenicity, in two places with echo-positive inclusions (coprolites), the apex is spherically enlarged with echo-negative, poorly contoured area - retention cyst (perforation site).

After this conclusion, they insisted on surgical intervention (albeit, giving a receipt for responsibility). At laparotomy, our conclusion was completely confirmed; all the signs of gangrenous perforated appendicitis that we described were identified.

This incident gave us inspiration and forced us to study and evaluate diagnostic capability real-time echography to detect pathology of the appendiceal process. For 23 years, we examined more than 4800 patients with sharp or dull pain in the right iliac region and abdomen or with classic clinical signs of acute appendicitis. For the purpose of retrospective comparison of the echographic report with the data of the surgical intervention, a video recording of the echographic picture of the pathology of the appendicular process was performed. Of this large group, only patients referred for examination with clinical signs of acute appendicitis were of direct echographic interest. In 98.7%, our data was confirmed on the operating table. It should be noted that the remaining individuals from this group (women) had secondary changes in the appendicular process associated with acute gynecological diseases. The remaining patients underwent a comprehensive differential diagnosis and were eliminated without errors from the group of patients with possible pathology of the appendiceal process.

I cannot help but note that my life became very complicated when I began this research. I often had to take on enormous responsibility, deciding whether emergency surgery was necessary, and waiting in fear for the surgeon’s verdict. But confirmation of the diagnosis on the operating table, along with the satisfaction gained from providing complex diagnostic assistance to surgeons, gave me vitality for new, more complex searches.

Indications:

Any sharp or dull pain in the epigastric (especially in children) and in the right iliac regions,

Clinical signs of acute appendicitis,

Vomiting combined with increased body temperature.

Anatomy

The vermiform appendix extends from the posteromedial wall of the cecum 2-5 cm below the ileocecal angle. It is a narrow tube with a diameter of 3-4 mm, a length of 2 cm, has its own mesentery, its lumen communicates with the lumen of the cecum. Typically, the vermiform appendix lies in the right iliac fossa, the free end is directed downwards and to the medial side, sometimes descending into the small pelvis. Its location can be very atypical, which sometimes makes diagnosis difficult. Connection lymphatic vessels cecum and appendix with vessels right kidney, gallbladder and stomach leads to the spread of the inflammatory process from one organ to another.

Research methodology

To study the appendix, ultrasound equipment is used, operating in real time, using linear and convex sensors of 3.5-5 and 7.0 MHz. Using 3.5 and 5 MHz, adults are examined, and children are examined with 5.0 and 7.0 MHz. The examination is carried out with the patient lying on his back, and in some cases turning on his left side. In this case, the ileum moves slightly to the left, freeing up the cecum and ileocecal angle to search for straight or indirect signs pathology of the appendix. Basically, classical scanning methods are used - longitudinal along the cecum and oblique in the right groin and pelvis.

A transverse scan is used to clarify the details of the pathology. It should be immediately noted that modern echography technology does not allow visualizing an unchanged or catarrhally changed vermiform appendix, except in rare cases (if there is large quantity ascitic fluid in the abdominal cavity, its visualization is possible).

Pathology

Acute catarrhal appendicitis

As already noted, echography is not very informative in identifying this condition, since in 92% of cases there are no direct signs - visualization of the altered appendicular process, and only in 27% are there secondary signs- Availability small quantity fluid in the ileocecal angle and some swelling (thickening) of the cecum in the projection anatomical location base of the appendicular process. Ultrasound diagnosis in these cases is based only on a large clinical experience a researcher who is able to formulate a clinical and echographic conclusion. In rare (7-8%) cases, in the right ilioinguinal region in the ileocecal angle, less often in the small pelvis, a somewhat thickened, more in the apex, rigid vermiform appendix can be found, around which a narrow anechoic strip (a small amount of serous fluid) can be located ). Also rarely, a local reaction of the peritoneum can be detected - a more echogenic zone.

Phlegmonous appendicitis

All cases of the pathology of the appendix that we diagnosed belonged to its destructive forms, the nosological differentiation of which is very difficult, since the transition from one form to another occurs quickly and leads to complications when the inflammatory process covers the entire thickness of the wall of the appendix, and the surrounding tissues are involved in the process .

The main landmark of a destructive lesion of the appendix is the location in the right iliac region or around the appendix of free fluid, which can change its position, sometimes flow into the pelvis or be fixed when the ileocecal angle is involved in the inflammatory process, the presence of adhesions of the apex of the appendix to the peritoneum of the posterior wall of the abdominal cavity , omentum and intestinal loops.

On the echogram, the affected appendicular process is unevenly thickened, of varying echogenicity, with uneven contours, surrounded by fluid, the apex is spherically thickened, swollen (weak echogenicity), may be fused with the blind, ileum, with omentum or peritoneum.

Gangrenous appendicitis

With the gangrenous development of the process, the appendix becomes significantly thicker and deformed. Sometimes, when the outflow completely stops, pus (empyema) accumulates in its cavity, and the process takes on the shape of a flask, the contours are uneven, the structure of the walls is of varying degrees of hypoechogenicity, foci of necrosis are located - anechoic (black) spots. At the apex of the process, an oval echo-negative bulge can be located - a retention cyst. A large amount of fluid with echogenic floating signals (pus) is located around the appendix. The peritoneum is finely compacted (high echogenicity) – signs of peritonitis. The wall of the cecum is unevenly thickened, of varying echogenicity, and the “symptom of an empty cecum” described above is present.

Perforated appendicitis

Purulent melting of sections of the appendix wall in phlegmonous appendicitis or necrosis in gangrenous appendicitis leads to its perforation. In this case, the echogram shows a significantly altered appendicular process and the site of perforation in the form of an anechoic spot, from which, when pressed with a probe, the contents of the appendix flow out into the surrounding fluid in the form of echogenic particles (pus).

Atypical forms of location of the appendicular process

With the retrocecal location of the appendix, when it is adjacent to the posterior wall of the abdomen, behind the cecum, echography is uninformative, but its use is justified in order to exclude the presence of pathology of the kidney and retroperitoneal space (prolapse, wandering kidney, acute pyelonephritis, carbuncle, abscess, ureter blocked by stones or tumor, infected cyst right kidney, decay of a kidney or retroperitoneal tumor, festering hematoma, etc.). With perforation of the posterior parietal peritoneum and breakthrough of the abscess into the retroperitoneal tissue in the lumbar region on the right, retroperitoneal phlegmon can be detected in the form of a weakly echogenic formation with uneven contours and a progressive clinical picture.

When the appendage is located in the pelvis, the echogram may reveal fluid (pus) or a dense echogenic infiltrate in the pouch of Douglas and secondary changes (thickening) of the bladder wall adjacent to the pathological process. The difficulty of diagnosis lies in the fact that the same echographic signs can be detected in men with the disintegration of a rectal tumor, abscess and disintegration of a prostate tumor, the presence of post-traumatic hematomas, etc., in women they should be differentiated from painful menstruation(a small amount of fluid is always present in the pouch of Douglas before and during menstruation), parametritis, pyosalpinx, impaired ectopic pregnancy and etc.

If the appendix is located subhepatically, the examination is carried out through the abdomen or right side. On the echogram, the appendicular process is long and tortuous. The echo picture depends on the degree of involvement in the inflammatory process. More often it can be detected under the right lobe. On a transverse scan, it sometimes appears as a “hollow organ sign,” which makes it difficult to distinguish from other focal liver lesions.

It should be noted that using echography in in rare cases it is possible to identify a variant of the location of the process, which, of course, can play a certain positive role in the surgeon’s tactics. It is also difficult to differentiate destructive forms of pathology of the appendiceal process (phlegmonous, gangrenous, perforated or abscessed), since the echographic picture is almost identical, although this is large clinical significance for surgical intervention does not have.

Acute appendicitis in children

A special feature is the rapid, sometimes within 24 hours, development of destructive changes in the appendicular process and frequent development diffuse peritonitis. Of the echographic signs, indirect ones are most often present, such as:

Pain in the epigastric, right iliac regions, but more often throughout the abdomen, when pressed with a probe;

The presence of a small amount of fluid in the ileocecal angle or in the pelvis;

Reaction of the peritoneum of the anterior abdominal wall in the form of a fine-grained compaction;

With the development of diffuse peritonitis, the presence of fluid and abscesses between the intestinal loops, under the diaphragm and under the liver.

Acute appendicitis in elderly and senile people

Due to the blurred clinical picture, in most cases, patients are examined with complications of destructive forms of appendicitis, such as:

The presence of appendiceal infiltrate in the form of a rounded formation with unclear contours, but differentiated with increased echogenicity (density);

The presence of limited small accumulations of fluid in the ileocecal angle, pelvis or between intestinal loops.

Chronic appendicitis

At chronic appendicitis echography is not very informative, since the altered process can rarely be detected; secondary echographic signs are more often present, such as:

Changes in the cecum in the form of uneven thickening of the wall of high echogenicity, its deformation;

The presence of echogenic cords (adhesions) between the cecum and the peritoneum of the anterior or posterior abdominal wall, etc.

Differential diagnosis

The value of echography lies in the fact that, being in the hands experienced specialist, it allows you to make a differential diagnosis with other pathological conditions, which in most cases have a similar clinical picture (perforation of a gastric ulcer and duodenum, acute cholecystitis, pancreatitis, Crohn's disease, acute intestinal obstruction, acute adnexitis, pyosalpinx, apoplexy, rupture of an ovarian cyst) and other echographic signs, which are described in detail in the relevant sections.

Complications of acute appendicitis

Appendiceal infiltrate

At the initial stage, appendiceal infiltrate can occur with a significant reaction of the peritoneum of the anterior abdominal wall in the form of a fine-grained highly echogenic compaction in the right iliac region, through which visualization of the abdominal cavity is impossible, or in the form of an echogenic conglomerate oval shape with outlined contours, consisting of inflammatory loops of intestines and areas of the omentum.

The appendicular infiltrate can resolve, and then the dynamics of reverse development are detected in the form of its reduction until complete disappearance; or suppurate, while the pus can be limited to the area of the appendicular process, forming a peri-appendiceal abscess in the form of a weakly echogenic strip of different widths around the appendicular process, or spread to other places in the abdominal cavity, forming interintestinal, subhepatic, subdiaphragmatic or pelvic abscesses in the form of anechoic or weakly echogenic formations of various shapes .

Diffuse purulent peritonitis

This peritonitis occurs due to the lack of restriction of the inflammatory process around the appendix or the rupture of a periappendiceal abscess in the abdominal cavity. At the initial stage, when manipulating the probe, there is pain throughout the entire abdomen, and the peritoneum of the anterior abdominal wall is finely compacted. In more late dates the intestines are swollen, contain a large amount of gas and liquid, peristalsis is sluggish or absent.

Free fluid with echogenic signals is detected between the intestinal loops and in the pelvis.

Pylephlebitis

This is purulent thrombophlebitis of the branches portal vein. On the echogram, the walls of the veins are unevenly thickened; echo-positive inclusions (purulent blood clots) can be located in their cavities. The liver is enlarged; single or multiple low-echoic oval formations (abscesses) of varying sizes may be located in the parenchyma, which can sometimes be confused with cancer metastases.

The acute onset of the disease helps in differentiation.

Tumors of the vermiform appendix

Benign (fibroids, fibromas, lipomas, angiomas, polyps) and malignant (cancers, carcinoids and cysts) tumors are extremely rare; their echographic diagnosis due to the lack of specific differential features impossible. Nosological diagnosis is carried out only by histological examination of the appendix. Sonographically, secondary signs of acute or chronic appendicitis are more often detected.

Thus, echographic diagnosis of acute appendicitis and its complications is based on direct and indirect signs.

Direct signs (identified only in 20% of cases):

Detection of an altered appendicular process (described above) in combination (or without) with a limited peritoneal reaction in the right iliac region in the form of a fine-grained echogenic consolidation with (or without) a small amount of free fluid in the form of an anechoic strip or rim periappendicularly.

Indirect signs (an experienced specialist can be detected and correctly interpreted as a consequence of damage to the appendicular process in% of cases):

Reaction of the right flank of the iliac region to manipulation of the ultrasound probe during the study;

The presence of fixed anechoic (serous) or with echogenic point inclusions (pus) fluid in different quantities in the ileocecal angle, between the loops of the small intestine in the pelvis or in the right part of the retroperitoneum below the right kidney;

The presence of a reaction of the bladder wall (thickening with a double contour) adjacent to the infected fluid (transudate or pus);

Limited thickening (edema) of the wall of the cecum, which has low echogenicity in acute appendicitis and echogenicity (scars) in chronic;

Deformation of the cecum with absence of contents (symptom of an empty cecum).

From the above it follows that the widespread use of echography in the diagnosis of acute pathology of the appendiceal process is ineffective, and sometimes even dangerous due to the large number of false positive or false negative conclusions.

Echography can be highly informative only in the hands of an experienced specialist who knows the clinic well, differential diagnosis, and has some surgical experience (like the author), which will allow a clinical and echographic conclusion to be made about the presence of acute pathology of the abdominal cavity related to the appendiceal process. At the same time, one cannot help but appreciate the simplicity of the method in quickly differentiating many acute pathological conditions of the abdominal organs, pelvis and right retroperitoneal space, which sometimes have much in common with the clinical picture of acute pathology of the appendiceal process.

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As soon as a person, or especially a child, experiences severe abdominal pain, many begin to assume inflammation of the appendix or a special appendage of the cecum, which, according to many experts, is unnecessary for the normal functioning of the body. In such cases, it is important to contact a doctor immediately. But, since not everyone knows which side the appendicitis is on, and most people hope that everything will go away on its own, patients sometimes get to specialists with a delay.

Where is the appendix located?

Sharp, severe pain in the side of the average person is usually associated with appendicitis. As you know, this by no means rare disease is characterized by pain spread throughout the abdomen, without precise localization. Then it gradually moves to the side and the victim can more or less accurately say where exactly it hurts. But where is appendicitis located: on the right or on the left?

The appendix is a worm-shaped extension of the cecum. For this it was called a vermiform appendix. Until recently, it was generally accepted that it does not carry any functions, therefore it is a kind of rudiment, and, therefore, can be removed surgically even without evidence for it. However, some modern scientists have discovered that this process performs functions such as:

barrier;
protective;
secretory, etc.

Attention! Now you can increasingly hear that the appendix is directly involved in the creation and maintenance of immunity, but this does not mean that if it is inflamed, surgery should be avoided. Such an attitude can cost the patient his life.

Traditionally, the appendix is located in the right iliac fossa. But different people it may be shifted slightly above or, conversely, below it. In the first case, it is closer to the liver, and in the second, to the bladder or internal genital organs (in women).

The specific location of the appendix depends on the position of the cecum, therefore, just as it is impossible to find two people who are completely identical in appearance, it is impossible to find an identical location of the appendix. However, in most cases, appendicitis manifests itself as pain in the right lower abdomen.

Atypical locations of the appendix

In isolated cases, the vermiform appendix may be located:

Behind the cecum. In such situations, appendicitis can masquerade as diseases of the right kidney and ureter. Therefore, pain on the right side in the lumbar region may also indicate the development of appendicitis.
Behind the bladder, which is accompanied by the appearance of signs, in particular, excessive frequent urges to urination, pain and pain directly during urine excretion. However, the results of a urine test do not indicate the presence of an acute inflammatory process in the urinary organs.
Under the stomach. IN similar cases one may suspect the presence, etc., since the source of pain is localized approximately in the center of the abdomen or slightly shifted to the right.

Important: very rarely, but still there are people with mirror arrangement organs. In such individuals, the appendix may be located on the left, as well as the liver. But the heart of such people is on the right side of the body.

Diagnostic features

Usually, diagnosing an attack of acute appendicitis is not difficult for a doctor, especially if the appendix is located in its typical location. But with other localization options for the appendix, its inflammation can be confused with:

cholecystitis;
pancreatitis;
gynecological pathologies;
cystitis;
stomach or duodenal ulcer;
pyelonephritis;
intestinal obstruction, etc.

Therefore, to put accurate diagnosis Typically, ambulance doctors recommend hospitalizing the patient and conducting a series of examinations, including:

radiography;
laparoscopy (in especially difficult cases).

These measures will help to accurately determine the cause of abdominal pain and find out where appendicitis is located.

Attention! You should not try to palpate the inflamed appendix yourself, since inept palpation can lead to rupture of the intestinal appendix and leakage of all its infected contents into the abdominal cavity. The consequence of this can be peritonitis, sepsis and even death.

In the practice of surgeons, inflammation of the appendix is one of the most common diseases of the abdominal organs. Appendicitis is a dysfunction of the appendix of the cecum, accompanied by severe symptoms. The disease may end fatal, because it progresses quickly and can only be treated with surgery. Therefore, it is extremely important to know where a person’s appendicitis is located and to receive prompt medical attention.

In children, the pathology is rare due to the specific anatomical structure organs during this period. Elderly people also rarely encounter such a disease, since they experience a reverse development due to age-related processes. lymphoid tissue. The percentage of pathology diagnosed by gender is approximately the same.

Location of the appendix

Where is the appendix located? The vermiform appendix of the cecum is located in the right iliac region. It is attached to the intestinal loops using the mesentery. In medicine, the localization of the organ is called McBurney's point. Dimensions usually vary between 7-10 cm. The structure of the appendix includes a base, body and apex attached to the cecum. There are three forms of the organ:

stem-shaped - has a uniform diameter along the entire length;
embryonic - thickness as a continuation of the cecum;
cone-shaped - narrower at the base.

The organ participates in the production intestinal juice, produces lymphoid cells that strengthen the immune system, accelerates intestinal recovery after infectious diseases. But these functions have very little effect on general state organism, the process is considered a rudiment.

The mesentery can have different lengths, as a result of which the appendix is sometimes located at some distance from its natural location.

There are several types of atypically located cecal appendix. All of them are considered variants of the norm. The pathological process can develop on the right or left. IN the latter case it occurs in people born with transposition - a mirror arrangement of internal organs or who have a very long mesentery.

In women, the pelvic position of the appendix is very often diagnosed when it bothers painful sensations in the groin. Inflammatory process in this case, it can affect the bladder and internal genital organs. Symptoms of the disease will differ from the classic signs of appendicitis. Differential diagnosis will help distinguish the pathological process from gynecological problems, muscle rupture abdominals or gastrointestinal ailments.

In the subhepatic position, the appendix is located closer to the right hypochondrium. The stomach may not hurt, but discomfort in the side and back will bother you. Manifestations of pathology are often mistaken for an attack of cholecystitis.

With a retrocecal location of the appendix discomfort appear in the epigastric area, resembling gastritis and sometimes accompanied by nausea and vomiting.

In old age, an attack of appendicitis usually does not lead to an increase in body temperature. Nausea and stomach pain are common.

In children, the pathological process is accompanied by discomfort on the right side, low-grade fever, loss of appetite, nausea, vomiting, drowsiness, and rarely, cough and runny nose. Qualified specialist will always be able to understand where appendicitis is located.

Diagnosis and treatment

The disease usually begins suddenly and progresses quickly. The main signs of appendicitis are:

pain in the right iliac region, aggravated by coughing, movement, sneezing;
nausea, vomiting;
general weakness;
pale and dry skin;
increase in body temperature to subfebrile values;
dyspnea;
stool disorder;
tachycardia;
chills;
the appearance of a yellowish or white coating on the tongue.

During the examination, the specialist performs special moves, allowing to recognize appendicitis. These are changes in the position of the body or limbs during which pain worsens (symptoms of Obraztsov, Taranenko, Brando, Michelson).

Diagnostic procedures help in this case to definitively clarify the diagnosis. Ultrasound of the abdominal cavity, CT, MRI, X-ray diagnostics reveal pathology, differentiate the disease, excluding other ailments and helping to understand where the appendix is located. Laboratory tests of urine and blood show the presence of an inflammatory process.

After the diagnosis is made, an appendectomy is performed - cutting out the appendix. This is the only treatment option for appendicitis, no matter where it is located. The operation can be performed classically or laparoscopically. In the first case, under general anesthesia, the patient's appendix is removed through an incision on the right side of the abdomen. After the operation, a scar approximately 10 cm long remains. Patients are under the supervision of a specialist for 10 to 40 days. With laparoscopic removal of the appendix, the rehabilitation period is shorter (up to 7 days, provided there are no complications), and there is no scar left. Treatment is performed under general or local anesthesia.

With late diagnosis, complications may occur. The most common pathological conditions are: sepsis, peritonitis, intestinal obstruction. Without emergency surgery, death occurs.

After removal of appendicitis, a person recovers fairly quickly, but he must adhere to dietary and physical activity restrictions for the next 4-8 weeks.

A sick leave certificate is issued in the absence of complications for an average of 14 days.

Complete recovery of the body occurs in 2-3 months.

Where is appendicitis located? Basically it is localized and begins to bother with right side belly. Due to the individual characteristics of the body, appendicitis may be located in atypical places. This often complicates diagnosis and provokes complications due to late surgery. Therefore, an appeal for medical care should occur when any discomfort in the abdomen, back, pelvis or hypochondrium.