Академический Документы
Профессиональный Документы
Культура Документы
Latin - appendicitis acuta- this is an acute inflammatory disease of appendix, the causal organism of this disease, as a rule, is unspecific purulent infection. Patients with AA make 20-50% of all sick persons in surgical departments Appendectomy makes 70-80% of all surgical interventions at patients with urgent pathology. The disease is more frequent met in the age of 10-40 years. Level of postoperative lethality is 0,2-0,3% Reasons of death at AA: -late resort for medical aid - doctors errors in diagnostics of AA (primary care physician make 55%, doctors of first-aid - 35%, surgeons 10% )
Physiology of appendix
- secretory - a mucus layer produces juice, which contains mucus, tracks of such enzymes as amylase, lipase; - retractive - the poorly expressed peristalsis provides evacuation of contents; - hemopoietic, limphopoetic, - immune, thanks to accumulation of lymphoid tissue;
Etiology, pathogeny of AA
The microbes of purulent infection : - aerobes, that inhabit a thick intestine (intestinal bacillus, staphylococcus, streptococcus, protey and other entetrobacterias); - nonclostridial anaerobes, that inhabit the colon (peptococcus, peptostreptococcus, fousobacterias, bacteroids and others). - mixed aerobic-anaerobic infection; - specific infection: tuberculosis, actinomicosis, abdominal typhus, salmonella, sometimes Crowns illness, tumors of appendix.
Theories of pathogeny of AA
1. Infectious. Leading role in the development of disease the supporters of this theory give to the infection of appendix, its amount, virulence, which can be activated at favorable terms (stagnation, excrement stones, helminths, foreign body).
2. Neuroreflex (nervous-trophic). The reason of all is necrosis of mucus layer of appendix which is the result of its durable ischemia. The ischemia is caused by the long-standing spasms (appendicobauginiospasm), or spasms of vessels of this region. 3. Allergic (immunological). The supporters of this theory consider that the reason of beginning of inflammation and of defeat of mucus layer is allergic reaction antigen-antibody. Allergization is caused by penetration of alimentary and microbic antigens into the immune components of mucus layer (lymphatic follicles).
Classification of AA by V.I.Colesov
I. Acute appendicitis 1. Acute simple (superficial) appendicitis. 2. Acute destructive appendicitis: ) phlegmonous, b) gangrenous, c) perforative, d) empyema of appendix. 4. Complicated acute appendicitis: )appendicular infiltrate; b)appendicular abscess; c)peritonitis of appendiculars origin; d)other complications (pilephlebitis, sepsis and others). II. Chronic appendicitis 1. Primary-chronic appendicitis. 2. Residual chronic appendicitis. 3. Recurrent chronic appendicitis.
Clinic of AA
General symptomatology. The attack of acute appendicitis begins, as a rule, from a stomach-ache. In 20-40% of cases the pain arises up at first in epigastric region, then it moves to right iliac region (s-m of Volcovich-Coher), but can be localized from the beginning in right iliac region. For AA are characteristic gradual growth of pain and its permanent character, absence of irradiation, moderate intensity. In 2-3 hours from the beginning of disease at 50% of patients nausea appears, vomit is more frequent single, Delay of defecation, gases is expressed. In children at toxic forms of AA diarrhea can appear. Temperature of body subfebrile is marked. At objective examination of patients tachycardia is determined. In clinical blood test moderate leukocytosis is marked (up to 1012*10/l), neutrophilia, shift of neutrophils to the left are marked, too.
Clinic of AA
Local symptomatology. The most informing from them are:
1. D'elofouas triad (classic triad of AA) - spontaneous pain in the right iliac fosse; - tension of muscles of right iliac region at the palpation of abdomen; - hyperesthesia of skins of right iliac region. 2. Rovzings Symptom - pain in right iliac fosse at impulse motion in the projection of descending department of thick intestine with fixing of sigmoid intestine. 3. Obraztsovs symptom - it is strengthening of pain at pressure in right iliac fosse during the bending of right leg in coxofemoral joint. 4. Voscresenskiys symptom 1 - it is strengthening of pain in right iliac fosse during the sliding palpation through the strained shirt from the epigastrium to the right iliac region (symptom of shirt). 5. Sitcovskits symptom - it is appearance of dragging pain in the right iliac fosse, if a patient lies on the left side. 6. Bartom'e-Mihelsons symptom - pain at the palpation in the right iliac fosse is more expressed, if a patient lies on the left side than on the back. 7. Yaoure-Rozanovs symptom - it is appearance of pain at the palpation in the region of Petits triangle from the right side (at retrotcecal AA). 8. Coups symptom 1 it is appearance of pain the in right iliac fosse at passive overextension of right leg in the coxofemoral joint.
Diagnostics of AA.
Diagnostics of AA is based on the revealing of characteristic complaints about permanent pain in the right iliac fosse, or Volcovich-Cohers symptom, nausea, increase of temperature of body, at objective examination positive Rovzings, Voscresenskiys, Obraztsovs, Sitcovskiys, Bartom'e-Mihelsons symptoms. For the confirmation of diagnosis clinical blood test and analysis of urine are done. In the analysis of blood leucocytosis, neutrophilia, neutrophil shift to the left are determined.
Additional examinations
- laparoscopy
-diagnostic laparotomy
Abdominal ultrasound
CT scan
Pregnancy of the first three months has not influence on clinic of AA, but with 4- 5 month the increased uterus displaces upwards the cecum and appendix. For AA at pregnant the acute beginning of disease with the pain in lower part of right half of abdomen is characteristic. Tension of muscles of abdomen and also ShotcinBltombergs, Rovzings symptoms are rarely determined at objective examination. Appearance of pain, or the strengthening of pain in the right iliac fosse at pressure on the left rib of pregnant uterus (Brendos symptom); Strengthening of pain in the right half of abdomen, when the patient lies on the right side (Mihelsons symptom, or Sitcovskiys reverse symptom). In the blood test the amount of leucocytes can be normal, and more constant sign of AA is the neutrophil shift to the left. Early operation is the single method of treatment. Anesthesia mainly local infiltration anesthesia, narcosis is used only in case of peritonitis. In the second half of pregnancy Volcovich-D'yaconovs operational access is used, but it is displaced upwards the more, than the term of pregnancy is greater. Carefulness of manipulations in the area of uterus and appendages, prescribing of sufficient anaesthetic and spasmolitic therapy in postoperative period are necessary for saving of pregnancy. At acute peritonitis of appendicular nature medical tactic does not differ from tactic in other case. Artificial breaking of pregnancy in such cases is the rough tactical error.
AA at pregnant
Appendectomy