Acute appendicitis

In acute appendicitis in the first 2-3 days pathological process is usually limited to the boundaries of the process (catarrhal inflammation, abscess, empyema), and inflammatory changes in the adjacent section of abdominal cavity are missing, are insignificant or are mainly reactive. Such an attack of appendicitis can sometimes spontaneously safely to end. But usually with a third day, develops General peritonitis (see); with perforation or gangrene process he may appear before (even in the first hours of the disease). Developed peritonitis or takes spilled nature, creating a grave danger to the patient or quickly (in the same or the following day) comes delimitation with the formation of infiltration into the abdominal cavity. Formed infiltration may gradually disappear, but can acceleromete to go to appendiceal" iliac or pelvic abscess (limited purulent peritonitis). The latter, in turn, threatens to break free of the abdominal cavity and the General peritonitis, which in such cases is developing most rapidly and is hard.
It must be borne in mind, first, that before the surgery, clinical picture can only assume some degree of morphological changes in the process; secondly, that at the commencement of the attack of acute appendicitis is no possibility of any reliably predict how will flow disease in the future. The attack, even the most easy at the beginning, can very quickly and unexpectedly move in deadly peritonitis. All of this implies major principled position; when the diagnosis of acute appendicitis shown an immediate operation to avoid the risk of deadly complications.
In most cases, an attack of acute appendicitis starts suddenly, among the total well-being. First of all, pain in the abdomen. They are often located not in the right iliac depression, and in the navel or above, under the spoon, and only later to concentrate in the area of a blind gut. Usually the pain will not give, but worse with coughing. There is nausea, and sometimes vomiting, although the absence of both does not exclude appendicitis. The temperature usually rises (37,8-of 38.5 degrees), but does not reach too high figures, sometimes initially normal. Always celebrated moderate leukocytosis (9000-12 000, sometimes more). ROE is accelerated, although not as markedly as in inflammation of the uterine appendages, but with the development of the disease more accelerated. The pulse is always fast, first to 90-100 beats per 1 min. tongue coated and dry.
Critical study of the abdomen. The patient is lying flat on his back, with straightened legs and stretched along the body hands. He offered to open your mouth and breathe calmly.
The patient is breathing a few easy on the stomach, abdominal wall in the lower half of the less mobile. With the feeling of stomach needs to observe the well-known system, so as not to cause pain: begin cautiously and gradually to touch the left iliac region, then the left and right upper quadrant and only after verifying that there are no special protective voltage and the sharp pain, move to the right iliac region. Here in acute appendicitis almost always find a symptom muscle protection and acute pain, especially with deep palpation. The process, as it is known, may take a different position, and therefore changes the place of the greatest sensitivity. In doubtful cases a light tapping her fingers along the abdominal wall help to establish the most painful part. The feeling of stomach should be "flat hand", because they seek not painful point, and the painful area. So in the diagnosis of acute appendicitis lose the value of estrus MC-Barnea, Lanza, Nummela, which once was attributed to the specific importance of early diagnosis A. At the same time retain value symptom Sudkovskogo (increased pain in the right iliac region at the turn of the patient on the left side) and a symptom of Rusinga (strengthening the pain in the cecum jerky when the pressure in the left iliac region). Of very great importance, as with any inflammation in the abdomen, is a symptom Blomberg-Shchetkina; after a soft pressure on the abdominal wall palm quickly tear; arise at this point, sharp pain, stronger than when pressed, speaks of peritoneal irritation in the study area. This is a very important symptom is captured in the right iliac region in the first day of the attack. You should check no symptom of Pasternatskogo, for which the patient is seated and gently tap his hand on the back. - Tap and listen to the chest and necessarily produce digital examination of the rectum, and women bimanual, and you can find a painful place in the lowest section of the pelvic peritoneum.
In the most favorable cases, the attack of acute appendicitis is permitted. Pain subside, the temperature falls, the heart rate slows, the independent chair, and in 1-2 days the patient recovers. But this is relatively rare and expect such an outcome is not necessary.

Clinical picture in the growing phenomena of peritonitis is characterized by deterioration of the patient, coming suddenly, sometimes more slowly, but still quickly - within a few hours. Fairly constant and very terrible symptom is the resumption of suspended or appearance before absent vomiting. Pain grow, pulse quickens disproportionately to the increase of temperature, increases leukocytosis, changes WBC, accelerated ROHE. Peritoneal symptoms (pain, muscle protection, symptom Blomberg - Shchetkina) are defined more sharply and more over, reflecting the spread of inflammatory changes in the peritoneum, usually in the direction of ileo-zakalnoe area from top to bottom, then left and up to the left-hand quadrant. In an unfavorable course of the phenomenon progress, and soon develops a picture of diffuse peritonitis. The upcoming delimitation appears, on the contrary, stop the recent proliferation of peritoneal symptoms, pain, termination vomiting, if the latter appeared. Improves General condition of the patient, but hematologic changes often remain significant, and sometimes even continue to grow for some time, and then stabilized at a fairly high level.
In the process of infiltration in the soft and painless abdominal wall and in the absence of peritoneal events in ileo-zakalnoe region is painful seal. It is formed sleepsonic loops guts and gland, enveloping inflamed Appendix, sometimes surrounded by effusion. The body temperature is raised, the pulse Ochsen respectively temperature, leukocytosis high. Infiltration or obsederunt, or self-absorbed within 2 to 6 weeks when political temperature drop, the gradual normalization of hematological parameters. Started abstsedirovanie is manifested by the persistent rise of the temperature curve, hectic nature of the temperature, significant growth leukocytosis, increased pain. Abdomen is soft, but infiltration increases, changing the form, and sometimes the position (for example, falls to papatowai conjunction or pubis).
Sometimes infiltrate spaevaet with the anterior abdominal wall, and then in the thick of it may appear zublena. In other cases of purulent accumulation moved to the pelvis and is well palpated through the rectum. Often infiltrate from the very beginning is localized in the pelvis and abscess formation is formed not iliac abscess, and ulcer red space available palpation through the abdominal wall. About this possibility, it is imperative to remember, if the patient has acute appendicitis after remitting peritoneal events persistently increasing temperature and leukocytosis, and infiltration to probe fails. In the study per rectum found dense, and sometimes already fluktuiruyushchimi painful education, vypyachivalis front wall of the rectum.
Formed appendiceal abscess can spontaneously opened in a hollow organ in the intestinal loop, sometimes in the bladder, but more often in the rectum, women have the opportunity to break through into the vagina. But equally likely and a breakthrough in the free abdominal cavity, which is manifested sudden the most rapid peritoneal symptoms and picture the hardest General peritonitis, developing for hours and even faster and almost inevitably leads to death.
Depending on the anatomical location of the vermiform process the clinical picture of acute appendicitis may change. The greatest danger is retroatelie, retroperitonealny appendicitis. It is difficult to recognize, that often leads to delayed the operation. It can be suspected by the positive symptom of Pasternatskogo, especially if there's psoas-symptom and leg bent and given to the stomach. When in doubt, you must operate in order to avoid very dangerous retroperitoneal phlegmon.
Differential diagnosis of acute appendicitis difficult for elderly patients; from the very beginning they may leak areactive even in severe degradation process. Pain in the abdomen cramping in nature simulate intestinal obstruction (see bowel Obstruction). Appendiceal infiltrate resolved very slowly, which gives grounds for suspecting a malignant tumor. You also have to remember right renal colic (positive symptom of Pasternatskogo, the giving of pain in the testicle, dysuric disorders, hematuria), acute attack of cholecystitis (see), perforated duodenal ulcer (see peptic Ulcer disease), inflammation of the uterus in women (see Adnexitis), rupture of the pipe when an ectopic pregnancy (see), ovarian apoplexy (see), ileia, even lobar pneumonia (see Pseudorandomly syndrome).
Complications. In addition peritonitis, sometimes developing very rapidly, and iliac boil, it is also possible thrombosis various veins - mesenteric, iliac, femoral. Especially dangerous pylephlebitis (see) - rising mesenteric thrombosis with the formation of abscesses in the liver. They are accompanied by jaundice, chills, hectic fever.
The patient suffered an attack of acute appendicitis, the past can never be repeated. However, much more probable recurrence of attacks, with more severe than the first. But such recurrent appendicitis possible and the patient, whose first attack was very heavy, for example, was accompanied by the formation of large infiltrate. Even transferred appendiceal abscess, i.e. appendicitis with the apparent destruction process does not prevent repeated attack. The duration of intervals between attacks ("cold periods") are the most uncertain, sometimes for several months, even weeks, sometimes years. "The cold period" in some cases is a state of complete well-being, in some other painful symptoms occur in between bouts of acute appendicitis.