Symptoms and signs of appendicitis. The main symptoms and syndromes in surgical diseases Acute and chronic appendicitis Surgical symptoms of appendicitis by authors

appendicular symptoms

Shchetkin-Blumberg symptom

The examiner's left palm is placed on the right iliac region and exerts pressure on it, then the hand is quickly removed. The symptom is positive if, at the moment the hand is taken away from the abdominal wall, severe pain appears in the area under study. The symptom is positive in other inflammatory diseases abdominal cavity. Pain occurs over the focus of inflammation.

"fading soreness" symptom

Diagnostic symptom to differentiate chronic appendicitis from gastritis. In chronic appendicitis, patients can feel pain only in the epigastric region for a long time and even treat gastritis. The symptom is as follows: if with chronic appendicitis and (even acute) there is pain during palpation both in the epigastric and in the right iliac region, or only in the epigastric region, then with one hand they press on the painful area in the right iliac region and, at the same time, the epigastric region is palpated with the other hand. In the presence of appendicitis, pain in the epigastric region disappears. One has only to stop the pressure on the appendicular region, as pain in the epigastrium is restored.

Sitkovsky symptom

If a patient with acute appendicitis, lying on his back or on his right side, is turned to his left side, then the pain in the right iliac region increases or, if it was not there, appears. Pain occurs due to displacement of the caecum and inflamed process.

Rovsing symptom

Pressing the descending segment of the large intestine in the left iliac region causes pain in the right iliac region. Gases, moving through the large intestine, stretch the caecum and thus, in acute appendicitis, increase pain.

exemplary symptom

Pain on palpation of the right iliac region in acute appendicitis increases if the patient is forced to raise the right leg straightened at the knee joint.

Kocher symptom

Pain in the navel and in the epigastric region - early sign onset of acute appendicitis.

Resurrection symptom

The patient's shirt is pulled with the left hand, the fingertips of the right hand at the moment of exhalation slide along the shirt from the epigastric region to the right iliac region. The hand stops without leaving the abdominal wall. In the presence of acute appendicitis at the end of the slide, the patient notes increased pain in the right iliac region.

cough symptom

Increased pain when coughing with pressure on the fingers of the right iliac region.

Symptom of Bartomier-Michelson

Soreness during palpation of the caecum increases in the position of the patient on the left side.

Zatler's symptom

In patients in a sitting position, when raising the straightened right leg, pain occurs in the right iliac region.

Liver disease

Ortner symptom

Tapping on the right costal arch in diseases of the gallbladder causes a sharp pain in the liver.

Murphy symptom

With a deep depression of the fingers into the right hypochondrium with cholecystitis, the patient cannot take a deep breath.

exemplary symptom

Sharp pain when the hand is inserted into the region of the right hypochondrium when the patient inhales. The symptom is characteristic of liver and gallbladder disease.

Diseases of the pancreas

Mayo-Robson symptom

Soreness in the left costovertebral angle when feeling the posterior abdominal wall as a sign of acute pancreatitis. With a lesion only in the region of the head of the gland, this symptom is negative.

Shchetkin-Blumberg symptom

The examiner's left palm is placed on the right iliac region and exerts pressure on it, then the hand is quickly removed. The symptom is positive if, at the moment the hand is taken away from the abdominal wall, severe pain appears in the area under study. The symptom is positive in other inflammatory diseases of the abdominal cavity. Pain occurs over the focus of inflammation.

Acute appendicitis is an inflammation of the appendix of the caecum.

The incidence rate is 4-5 people per 1000 population, 40-50% of patients in surgical hospitals, women aged 20-40 years are most often ill.

According to the flow, they distinguish:

Chronic appendicitis. Forms of acute appendicitis:

catarrhal, phlegmonous,

Gangrenous,

Probodnaya.

There are the following complications of acute appendicitis:

1) appendicular infiltrate;

2) inflammation of the peritoneum;

3) local abscesses of the abdominal cavity - abscess of the Douglas space, subdiaphragmatic, inter-intestinal;

4) retroperitoneal phlegmon;

5) pylephlebitis.

REASONS AND MECHANISMS OF DEVELOPMENT

The nature of nutrition is of great importance in the occurrence of the disease. Meat food, causing putrefactive processes in the intestines, helminthic invasion. The microbial pathogen is nonspecific; coli, enterococcus are most often isolated, less often pyogenic microbes - staphylococcus aureus, streptococcus, with gangrenous forms - anaerobic microorganisms.

There is a genetic predisposition to appendicitis.

In acute appendicitis, pathological changes begin with a primary affect: functional disorders (spasm of the ileocecal angle, caecum, appendix), which are provoked by putrefactive processes, helminthic infections, fecal stones, foreign bodies.

Stagnation develops in the appendix and local circulatory disorders of the mucous membrane, the virulence of the microflora increases, easily penetrating the wall of the appendix, an inflammatory process begins with massive leukocyte infiltration of the initially mucous and submucosal layers, then all layers and the peritoneal cover. Infiltration is accompanied by hyperplasia of the lymphoid apparatus of the appendix.

Due to proteolysis (melting of proteins), destruction (destruction) of the appendix wall and its perforation develops, which is complicated by purulent peritonitis. In the catarrhal form, inflammation spreads to the mucous and submucosal layers, then to all layers, including the peritoneal, phlegmonous appendicitis, complete destruction develops - gangrenous appendicitis.

Morphologically, catarrhal appendicitis is characterized by some thickening of the process, the serous cover is dull, leukocytes infiltrate the submucosal layer, there are defects on the mucous membrane covered with fibrin and leukocytes. Immunochemical study in almost a third of observations reveals areas with an increased content of inflammation markers - cytokines.

With phlegmon, the process is significantly thickened, the serous membrane is covered with fibrin deposits, and purulent contents are in the lumen of the process. Leukocytes infiltrate all layers of the process, multiple erosions and superficial ulcers are visible on the mucous membrane.

The transition of inflammation to the serous membrane is accompanied by the detection of a cloudy effusion in the abdominal cavity, fibrin raids are found on the peritoneum of the caecum, loops of the small intestine and the parietal peritoneum. Leukocyte infiltrates are also determined in the mesentery of the process.

With an empyema of the process, the inflammation does not yet pass to its serous membrane, while the process is bulb-shaped thickened, in its lumen there is liquid pus. Leukocyte infiltration (impregnation) is found only in the mucous and submucosal layers. With gangrene of the appendix, necrotic changes are visible in its wall - thinned areas of a dirty green color.

In the abdominal cavity, a purulent effusion with a fecal odor is determined. Gangrenous changes in the process lead to perforation of the wall, the entry of pus into the abdominal cavity with the development of initially local and then general peritonitis. Microscopically, the perforation represents necrosis with vascular thrombosis and microabscesses in the mesentery of the appendix.

The catarrhal stage of acute appendicitis continues 6-12 hours from the onset of the disease, phlegmonous form 12-24 hours, gangrenous 24-48 hours, perforation occurs after 48 hours. If the symptoms of acute appendicitis disappear with active dynamic observation, then appendicular colic is suggested.

In relation to the caecum, the position of the appendix can be different: descending pelvic (40–50%), lateral (20–25%), medial (15–20%), anterior ascending (5–7%), posterior ascending (retrocecal, in 14% of cases). The appendix is ​​localized under the liver or in the small pelvis; with a mobile caecum - in the left iliac region. It is important to remember that in children the caecum is located higher than in adults, in women it is lower than in men.

SYMPTOMS AND DIAGNOSIS

Symptoms of catarrhal appendicitis are: there are constant pains in the abdomen, at night or in the early hours of the morning. They usually occur in the epigastric region or do not have a clear localization. At the beginning of the disease, the pain is dull in nature, sometimes it can be cramping. After 2-3 hours from the onset of the disease, the pains gradually increase, move to the right iliac region, to the place of localization of the appendix.

This displacement of pain is a characteristic symptom of acute Kocher-Volkovich appendicitis. It is due to the nature of the visceral innervation of the appendix and the connection with the nerve nodes of the root of the mesentery and the solar plexus, located in the projection of the epigastric region. In the first hours, almost half of the patients may experience reflex vomiting. It is rarely abundant and repeated.

More often worried about nausea, which has a wave-like character. There is no stool on the day of the disease, but with a pelvic or retrocecal location of the process, unstable loose stools are possible. Dysuric phenomena are observed quite rarely, associated with the localization of the process in a close projection to the right kidney, ureter, bladder.

An objective examination reveals the patient's condition as satisfactory, but the wet tongue during this period of the disease is already densely coated. Hemodynamic parameters are stable. not swollen, participates in respiration. With superficial palpation, in most patients it is possible to detect a zone of hypersensitivity in the right iliac region; with deep palpation in the same area, a clear and rather significant pain is determined.

This soreness occurs already in the first hours of the disease, when the patient complains only of pain in the epigastric region or throughout the abdomen. In the stage of catarrh, there are no symptoms of peritoneal irritation.

Symptoms of acute appendicitis:

- Rovsing's sign- with the left hand, through the abdominal wall, the sigmoid colon is pressed against the wing of the left ilium, completely blocking its lumen; at the same time, jerky movements are made with the right hand in the left iliac region; at the same time, as a result of vibrational shaking, pain occurs in the right iliac region;

- Sitkovsky's symptom: consists in the appearance or intensification of pain in the right iliac region when the patient is positioned on the left side, this symptom often occurs with adhesions in the abdominal cavity;

- Bartomier's symptom- Michelson: increased pain when feeling the right iliac region in the position of the patient on the left side, due to the fact that the loops of the small intestines and the greater omentum, which previously covered the appendix, move to the left, making it more accessible to the touch.

Body temperature is increased to 37-37.5 ºС, moderate leukocytosis - 10,000-20,000.

Most common. The pains are quite intense and constant, with a clear localization in the right iliac region, often have a pulsating character. Vomiting is not characteristic, but the feeling of nausea is constant. Moderate tachycardia 80-90 bpm. Coated tongue.

The abdomen lags behind when breathing in the right iliac region, on palpation here, in addition to increased sensitivity, the doctor determines the protective tension of the muscles of the anterior abdominal wall - a symptom of peritoneal irritation, suggesting that inflammation has spread to all layers of the appendix, including the peritoneal cover.

Other symptoms of peritoneal irritation include:

- Shchetkin's symptom- Blumberg: after pressing on the abdominal wall, the hand is sharply removed, at this moment the patient feels a sudden increase in pain as a result of shaking of the abdominal wall in the area of ​​​​inflammation;

- symptom of Resurrection(symptom of the "shirt"): through the patient's shirt, quickly slide the hand along the anterior abdominal wall from the costal arch to the pupart ligament and back; this movement is performed alternately, first on the left, then on the right; this causes a significant increase in pain in the right iliac region;

- Krymov's symptom: the appearance of significant pain when a finger is inserted into the right inguinal canal, which is associated with easy accessibility of the parietal peritoneum. Due to severe pain in the right iliac region, deep palpation is difficult.

- Symptoms of Rovsing, Sitkovsky, Bartomier- Michelson are still determined.

The patient's body temperature reaches 38–38.5ºС, the number of leukocytes in the peripheral blood is 12,000–20,000. The patient feels well.

Gangrenous appendicitis - a destructive form, which is characterized by extensive necrosis of the wall of the appendix with the development of putrefactive inflammation, while the nerve endings are destroyed, and complaints of pain may disappear.

Absorption from the intestines of toxic products leads to intoxication: euphoria, lethargy, tachycardia up to 100-120 beats / min, dry coated tongue, repeated vomiting appear. The tension of the muscles of the anterior abdominal wall becomes somewhat less than with the phlegmonous form, but with deep palpation, pain occurs immediately; symptom of Shchetkin-Blumberg, symptoms of peritoneal irritation - Voskresensky, Krymov positive. The symptoms of Rovsing, Sitkovsky, Bartomier - Michelson persist.

The temperature in the gangrenous form can be normal or even below normal, the number of leukocytes decreases to 10,000-12,000 or their content is normal. Significant tachycardia does not correspond to the level of temperature, this sign can be decisive in the diagnosis of the gangrenous form of acute appendicitis.

The elderly may develop primary gangrenous appendicitis (impaired blood flow through the appendicular artery with atherosclerosis, thrombosis or embolism), immediately, bypassing the catarrhal and phlegmonous stage, gangrene of the appendix occurs. The clinical picture has some features: the initial period of the primary gangrenous form of acute appendicitis is characterized by sharp pains that occur in the process, as the nerve endings die, the pain subsides. Symptoms of peritoneal irritation, fever, leukocytosis quickly appear.

Perforation of the process is manifested by sharp pains in the right iliac region against the background of apparent well-being during the period of gangrenous inflammation. Pain in the right iliac region becomes constant, its intensity increases. Against the background of increasing intoxication, repeated vomiting, tachycardia, dry, brown-coated tongue occur.

The abdominal wall, the elasticity of which decreases with the gangrenous form, again becomes tense; tension spreads to the rest of the abdominal wall as the purulent effusion spreads through the abdominal cavity. All symptoms of peritoneal irritation are sharply expressed. Body temperature becomes hectic. The perforation of the process ends with purulent inflammation of the peritoneum or the formation of a local abscess in the abdominal cavity.

Atypical forms of acute appendicitis. Empyema of the appendix complicates acute appendicitis in 1–2% of cases. At the same time, abdominal pains do not have a characteristic displacement, there is no Kocher-Volkovich symptom, the pains begin directly in the right iliac region, are dull in nature, slowly increase and reach their maximum manifestation by the 3rd-5th day, they can take on a pulsating character. Accompanied by occasional vomiting.

At the beginning of the disease, the general condition of the patient suffers little, the temperature is normal or slightly elevated; against the background of throbbing pain, chills occur with an increase in temperature to 38–39 ° C.

Even in advanced cases, the anterior abdominal wall is not tense, there are no symptoms of peritoneal irritation. Symptoms of Rovsing, Sitkovsky, Bartomier - Michelson are positive. With deep palpation in the right iliac region, significant pain is determined; in thin patients, a sharply thickened and painful appendix is ​​felt. In the first two days there is no leukocytosis, then the number of leukocytes rapidly increases to 20,000.

The retrocecal location of the appendix - behind the caecum - is observed in 6-25% of acute appendicitis. The process located behind the caecum is closely adjacent to the caecum, its mesentery is short, very rarely the process has no mesentery at all and is completely located retroperitoneally.

It is closely adjacent to the liver, right kidney, lumbar muscles. Retrocecal appendicitis most often begins with pain in the epigastric region or throughout the abdomen, then the pain is concentrated in the region of the right lateral canal or in the lumbar region.

Nausea and vomiting are rare, sometimes at the onset of the disease there may be an infrequent liquid stool with mucus, which is associated with irritation of the caecum by the inflamed appendix located on it. Dysuric phenomena are detected when the inflamed process is located in close proximity to the kidney or ureter.

Examination of the abdomen reveals pain in the region of the right lateral canal or slightly above the iliac crest. Symptoms of peritoneal irritation are not expressed, and muscle tension is found in the lumbar region, in the Petit triangle (the space bounded by the broad back muscle, lateral abdominal muscles and ilium) Shchetkin-Blumberg symptom is caused.

Obraztsov's psoasymptomatic is characteristic of retrocecal appendicitis - painful tension of the right iliopsoas muscle, while the patient lies on the couch, he is lifted up with his outstretched right leg, then asked to lower his leg on his own, the patient feels pain deep in the lumbar region. In retrocecal appendicitis, destruction often develops. Unexpressed symptoms from the abdominal cavity are accompanied by severe intoxication. The temperature and leukocytosis are higher than with typical localization of the process.

Pelvic acute appendicitis. The low, or pelvic, location of the appendix occurs in 11% of men and 21% of women. Pain also begins in the epigastric region or throughout the abdomen, after a few hours they are localized above the womb or above the pupart ligament on the right. Nausea and vomiting are not typical. There are frequent loose stools with mucus and dysuric disorders.

With the pelvic location of appendicitis, the inflammatory process is limited to the surrounding organs, therefore, when examining the abdomen, there is no tension in the muscles of the anterior abdominal wall, as well as other symptoms of peritoneal irritation. Symptoms of Rovsing, Sitkovsky, Barthomier - Michelson may also not be detected.

Sometimes a positive symptom of Cope is detected - a test for painful tension of the obturator internus muscle: in the position of the patient lying on his back, the right leg is bent at the knee and the thigh is turned outward; while the patient feels pain in the depths of the pelvis on the right; this symptom can be positive in other inflammatory diseases of the small pelvis. Vaginal and rectal examination reveals pain in the area of ​​the Douglas space, determine the presence of effusion in the abdominal cavity, inflammatory infiltrate.

Temperature and leukocytosis are slightly expressed.

The subhepatic location of the appendix is ​​difficult to recognize. Pain in the right hypochondrium, muscle tension, and other symptoms of peritoneal irritation suggest acute cholecystitis, but the history is typical of acute appendicitis. In acute cholecystitis, the doctor can feel the enlarged gallbladder; in acute appendicitis, it is only possible to detect an appendicular seal.

Very rarely, a left-sided location of the process occurs, which occurs either as a result of the reverse position of the internal organs, or in the case of a mobile caecum with a long mesentery.

Acute appendicitis is not recognized by doctors at the prehospital stage in 10-20% of cases, in a hospital - in 5-12%. Typical cases of acute appendicitis are no more than 50%. The complexity of diagnosis is associated with the absence of characteristic symptoms in the early period. The anamnesis indicates the onset of acute pain in the epigastric region or throughout the abdomen with a gradual shift to the right iliac region, which is typical for acute appendicitis and is rarely observed in other pathologies.

In acute appendicitis, vomiting is rare. The general condition of the patient suffers little, but with the gangrenous form, signs of intoxication are noticeable: pallor, immobility, tachycardia, moderate hypotension, dry coated tongue. With perforated appendicitis, the general condition of the patient suffers significantly: the position is immobile, the patient groans from pain in the abdomen, the knees are brought to the stomach, facial features are sharpened, tachycardia, blood pressure is low.

In the catarrhal phase of acute appendicitis, when examining the abdomen, no features are detected, with a phlegmonous form - a lag in the right iliac region during breathing. In the gangrenous form, the lag is clearly visible, and when perforated, the right lower abdomen does not participate in breathing.

The palpation of the abdomen begins with the left iliac region, then the examination is gradually moved to the right iliac region, where a zone of hypersensitivity and local muscle tension are found. With deep palpation, pain is found in the right iliac region. It may be impossible with destructive forms.

The symptom of Voskresensky, Krymov, Shchetkin - Blumberg, Rovsing, Sitkovsky, Bartomier - Michelson, Obraztsov is determined. Severe bloating and lack of peristalsis are determined in the later stages. Vaginal and rectal examination of the appendix is ​​necessary. The greatest number of errors is observed in the stage of catarrhal appendicitis.

It is necessary to differentiate acute appendicitis from almost all acute diseases of the abdominal cavity and retroperitoneal space. In the initial stage of the disease, when the pain does not yet have a clear localization in the right iliac region, but is localized mainly in the epigastrium, acute gastritis, acute pancreatitis, perforation of the stomach and duodenal ulcers can be suspected.

Pain in acute gastroenteritis is cramping, strong enough, localized in the upper and middle sections of the abdomen, associated with an error in the diet; accompanied by vomiting of food eaten, then bile; vomit may contain an admixture of blood, after a few hours frequent loose stools appear. On palpation of the abdomen, local pain, symptoms of peritoneal irritation and symptoms typical of acute appendicitis are absent; increased peristalsis; digital rectal examination determines liquid feces with an admixture of mucus. Body temperature is normal or subfebrile (37.5 °C), leukocytosis is insignificant.

Acute pancreatitis differs from acute appendicitis by the appearance of sharp pains of a girdle character in the upper abdomen, they radiate to the lower back and are accompanied by repeated vomiting of bile, which does not bring relief.

In the initial stage of the disease, patients are restless, as intoxication increases, they become lethargic, tachycardia, hypotension are noted; there is a noticeable discrepancy between the severity of the condition and the insignificance of local symptoms, there are no pains in the right iliac region, but when the effusion spreads from the omental sac and right hypochondrium along the lateral canal to the iliac region, pain appears in the right iliac region.

A perforated ulcer of the stomach or duodenum has characteristic clinical symptoms - gastric history, very severe pain in the epigastric region, widespread muscle tension, which almost immediately allow you to make the correct diagnosis.

With a perforated ulcer, vomiting almost never occurs, hepatic dullness disappears (radiologically - gas under the dome of the diaphragm) - a symptom characteristic of perforation of a hollow organ. But in cases of covered perforation, the gastric contents in the right iliac region leads to the fact that epigastric pain subsides and occurs in the right iliac region, a false symptom of Kocher-Volkovich, here it is determined muscle tension, symptoms of irritation of the peritoneum, x-ray during perforation, gas is determined under the right dome of the diaphragm.

An attack of acute cholecystitis begins with very severe pain in the right hypochondrium, which radiates to the right shoulder and shoulder blade and is accompanied by repeated vomiting of food and bile. Pain occurs repeatedly, sometimes accompanied by jaundice, associated with the intake of fatty foods, alcohol. The subhepatic location of the appendix, like acute cholecystitis, is manifested by pain in the right hypochondrium, here the tension of the muscles of the anterior abdominal wall is determined.

When palpated, an enlarged, painful gallbladder is determined. Fever in acute cholecystitis is more pronounced than in all forms of acute appendicitis, it develops more slowly.

Sometimes the doctor has to differentiate acute appendicitis with phlegmon of the terminal ileum (Crohn's disease), the symptoms of which are pain, high fever, sometimes diarrhea, leukocytosis up to 30,000, a painful tumor is palpated in the right iliac region. These patients are often operated on with a diagnosis of acute appendicitis.

The clinical picture of acute mesenteric tuberculous mesadenitis is very similar to acute appendicitis, differentiated during appendectomy.

Right-sided renal colic begins with severe pain in the right lumbar or right iliac region, vomiting occurs against the background of pain, in typical cases, pain spreads to the right thigh, perineum, genitals, accompanied by frequent urination.

Dysuric disorders may be in acute appendicitis, if the process is located near the kidney, ureter or bladder. With renal colic, there is no intense pain in the abdomen, there are no symptoms of peritoneal irritation. Urinalysis, data of chromocystoscopy or excretory urography in these cases is necessary.

Clinical manifestations of acute appendicitis differ in variety, course options, dependence on the form of inflammation, the position of the appendix. It is not easy for a practitioner to make a correct diagnosis. Therefore, the error rate ranges from 12 to 31%.

Many prominent surgeons and scientists devoted their research to the study of the symptoms of appendicitis and left a mark in the history of medicine, as well as in the practice of surgeons, with the nominal names of the signs of the disease. The rapid development of complications further confuses the manifestation of appendicitis.

Classic symptoms of appendicitis

A reasonable person will think about appendicitis if he feels pain in his stomach or close people complain to him. Do not try to diagnose, it is better to call an ambulance as soon as possible. For those who are interested in how appendicitis manifests itself, we will describe the most typical signs.

The main symptom of acute inflammation of the appendix is ​​pain. It has a permanent character, but different localization:

• the most typical beginning is from the right iliac region (in the lower part of the abdomen on the right above the inguinal fold), while it does not have typical irradiation;
• in half of the cases - according to the symptom of Volkovich-Kocher, it begins in the epigastrium (substratum) or around the navel (according to Kümmel), only after 1-3 hours it passes into the right iliac fossa;
• less often, the pain is immediately diffuse and spreads throughout the abdomen, this indicates a sign of rapid inflammation in appendicitis.

Atypical pain syndrome is more often associated with the features of the topography of the appendix:

• when lowered into the small pelvis - the pain is localized above the pubic joint or in the depths of the pelvic organs, the inflamed appendix in adults forms many adhesions with the intestines, bladder, in women - with the uterus and appendages, such symptoms are very similar to gynecological diseases;
• with a retroperitoneal position (retrocecal) - it should be expected in the right iliac region, lower back, irradiation to the right thigh is possible, painful urination, there is no Shchetkin-Blumberg symptom and tension in the abdominal muscles;
• for the ascending position, pain in the hypochondrium on the right is typical;
• in the retroileal (medial) position, they occupy the entire right half of the abdomen, spread in the direction of the right ureter, similar to renal colic, in men they give into the testicle, in women - into the labia.

If the pain attack subsides, then one should think about necrosis of the appendix wall, death of nerve endings, which is a symptom of gangrenous inflammation of the appendix. A sudden sharp increase in intensity can be a sign of perforation of the process (if the wall has "burst"), the threat of peritonitis and other complications.

Sometimes surgeons find an appendix in the left side of the abdomen. This is possible if the mesentery of the caecum is too long or the mirror arrangement of the organs. Then it is difficult to predict in advance which side and localization of the pain syndrome is considered a symptom of inflammation.

The second most important symptom in the diagnosis of suspected appendicitis is vomiting and persistent nausea. It is present in 75% of patients. Metaphorically, vomiting is called the "shadow of pain." In adult patients occurs 1-2 times. It is caused by a reflex reaction during inflammation of a limited area of ​​\u200b\u200bthe peritoneum.

Minor symptoms of appendicitis in adults are not typical for lesions of the appendix, but reflect general disorders of bowel function. These include:

• loss of appetite;
• bloating;
• stool disorders (diarrhea or constipation).

What can be judged when examining a patient?

The first symptoms of appendicitis that can be detected when examining a patient are moderately pronounced signs of general malaise:

• the position of the patient cannot be attributed to a forced position, the patients lie quietly on their back or on their right side, there is no excitation;


• body temperature in the range of 37–38 degrees, the appearance of chills indicates the development of purulent inflammation;
• a slight tachycardia appears, the increase in heart rate increases with an increase in temperature, this is due to destructive processes, the growth of intoxication and local peritoneal phenomena, their mismatch (tachycardia against the background of normal temperature or bradycardia with its increase) - this is a symptom of the patient's serious condition;
• the color of the skin does not change, pallor is observed in cases of complications with peritonitis;
• examination of the tongue pays attention to white coating, dryness indicates intoxication processes, local or diffuse peritonitis;
• examination of the abdomen shows sparing of the right sections during breathing due to limited mobility of the abdominal wall, more often occurs with phlegmonous or gangrenous form of appendicitis.

Diagnosis by symptoms

The symptoms of appendicitis according to the authors who discovered them and proposed to take them into account for the detection of appendicitis and its differential diagnosis with other diseases remain valid to this day. They are checked by surgeons even with the availability of ultrasound and laboratory tests. In such cases, a conservative approach, taking into account the practice accumulated over the years, is justified.

The methods only emphasize that once doctors could only rely on themselves, their knowledge and observations. Here are a few symptoms indicating, according to the authors, acute appendicitis.

1. Shchetkina-Blumberg - it is necessary to lightly and gradually press on the abdominal wall, then sharply withdraw the hand, peritoneal inflammation is characterized by the manifestation of pain at the time of pressure release, and not during palpation.
2. Voskresensky - being to the right of the patient, the doctor should pull the shirt over the lower edge with his left hand, and with his right hand make a sharp sliding movement along the tissue above the abdomen from top to bottom, stop in the iliac fossa. A positive symptom is manifested by an increase in pain at the moment the sliding stops.
3. Rovsinga - when pressing with one hand on the left side of the descending intestine with the other - a short push is produced, while in patients with appendicitis, pain appears on the right.
4. Razdolsky - the author used percussion of the abdomen, the method gave a positive result in increasing pain over the projection of the process.
5. Ortner-Sitkovsky - the patient is offered to turn on his left side, while he has pulling pains in his right side.
6. Obraztsova - increased pain on palpation in the right lateral region against the background of a raised leg straightened at the knee.
7. Michelson - helps in diagnosing inflammation of the appendix in pregnant women, the author noticed an increase in pain when the woman is positioned on the right side, due to the pressure of the enlarged uterus on the inflammatory focus.
8. Pasternatsky - tapping in the lumbar region causes pain in the abdomen, is used not only in the diagnosis of kidney diseases, but also to identify the retroperitoneal position of the inflamed appendix.


9. Volkovich - the author pointed out that in patients with chronic appendicitis, the abdomen looks sunken in the right lateral and hypochondrium due to the softer abdominal wall.
10. Lanza - a painful point characteristic of the disease is determined, mentally it is necessary to connect the protruding upper ends of the iliac bones with a line, the point lies at the junction of the outer and middle thirds on the right.

Symptoms of an atypical course of appendicitis

The main reason for the absence of the classical course of appendicitis is the variations in the position of the appendix relative to nearby organs and the peritoneum. Pelvic and retrocecal forms are accompanied by the most severe course, gangrenous and perforative types of inflammation occur more often. It depends on erroneous and belated diagnosis. Let us dwell on the recognition of these forms.

Pelvic position of an inflamed appendix

Instead of the most clear symptoms, the patient has dysuric disorders:

• frequent urination;
• cuts and pains above the pubis.

Signs of intestinal damage:

• liquid frequent stools;
• sometimes false urge to defecate (tenesmus).

The tension of the abdominal muscles is weakly expressed. In diagnosis, it is important to conduct a rectal examination to detect infiltration around the appendix. Women should consult with a gynecologist.

Retrocecal appendicitis

It differs by pronounced symptoms of general intoxication (fever, vomiting, nausea, headache) with minor local signs. It is recommended to palpate the patient in the position on the left side with both hands, pressing from the side of the lower back and the right half of the abdomen.

If the doctor is unsure of the absence of appendicitis, an operation should be performed and the issue of diagnosis should be resolved during the intervention. Prolongation of observation is life-threatening for the patient.

Modern diagnostic methods

The first signs of appendicitis make themselves felt according to the results of laboratory tests. In the blood test, leukocytosis is observed with a shift of the formula to the left, the changes allow us to judge the nature of the severity of the inflammatory process:

• with simple forms - the growth of leukocytes is moderate (from 8 x 10 9 to 10 x 10 9 / l);
• with destructive and complicated - from 14 x 10 9 to 20 x 10 9 /l.

However, it should be remembered that in 4% of cases of acute appendicitis, the blood test remains normal, and also that a slight leukocytosis with a significant shift indicates a severe process in the peritoneum.

Deviations in the composition of the urine sediment in the form of a small pyuria, the appearance of protein, erythrocytes occurs with the pelvic and retrocecal position of the inflamed process. Caused by involvement of the urinary system. For the purpose of specification urgent additional researches of a condition of kidneys, a bladder are necessary.

Carrying out an ultrasound examination according to emergency indications helps to solve the problem of diagnosis. The sensor of the ultrasound machine is placed in the epicenter of pain, if it is unclear, then the examination begins from the right iliac region. It is necessary to press it more tightly against the abdominal wall and try to expel gases from the intestines.

Signs of appendicitis on ultrasound are:

• an increase in the diameter of the process up to 7 mm or more;
• identification of a rounded diameter without changing shape under pressure;
• the presence of a reactive effusion around the process;
• absence of gas in the appendix;
• increased blood flow on a color Dopplerogram;
• an increase in regional lymph nodes;
• determination of a fecal stone in the lumen of the process.

The most reliable method of diagnosis is laparoscopy. Inspection of the intestinal loops and appendix and the surrounding peritoneum allows for a confident diagnosis and then removal of the appendix.

Features of symptoms in childhood

Acute appendicitis affects children of all ages. In the neonatal period and up to two years, it is very rare. Prevalence peaks at 9–12 years of age.

The peculiarity of the clinical course is due to:

• reduced resistance of the peritoneum to any infection;
• a small omentum;
• more active reactivity of the body.

The pain syndrome is difficult to localize according to complaints. The child has:

• heat;
• frequent vomiting;
• diarrhea.

Growing up:

• signs of intoxication (anxiety or lethargy, symptoms of meningism);
• violations of water and electrolyte balance towards dehydration (dry mucous membranes, aggravation of facial features).

Palpation of the abdomen is hampered by the violent reaction of the child. In older children, it is possible to determine the positive symptoms of appendicitis, the tension of the abdominal muscles in the right side.

Features of signs in the elderly and senile age

In older people, the characteristics of the course of appendicitis depend on:

• from a decrease in the reserve capacity of immunity to protect against infection;
• the presence of concomitant damage to the vessels by the atherosclerotic process;
• chronic diseases.

The onset of the disease is less pronounced than in young people, the pain is moderate even in destructive forms. In patients:

• there is nausea, vomiting, constipation with difficult passage of gases;
• the temperature rarely rises;
• tension of the abdominal muscles is weak or absent;
• in the blood test, moderate leukocytosis without a shift in the formula.

What disease is appendicitis distinguished from?

Differential diagnosis of acute appendicitis needs careful comparison with the clinic of diseases hiding under the guise of "acute abdomen", taking into account the atypical course, unclear and mild symptoms.

The most common pathology from which it is necessary to distinguish appendicitis includes:

• peptic ulcer of the stomach and duodenum in the stage of perforation - "dagger" pains, a picture of shock, a previous ulcer history;
• acute cholecystitis - maximum pain in the right hypochondrium, bitterness in the mouth, phrenicus symptom, high fever;
• intestinal obstruction - intestinal atony, lack of gases;
• Crohn's disease - connection with heredity;
• acute pancreatitis - "girdle" pain;
• enterocolitis of various etiologies - connection with low-quality products, frequent diarrhea, vomiting;
• ectopic pregnancy, adnexitis on the right, rupture of an ovarian cyst in women - menstrual irregularity, painful formation during manual examination;
• right-sided renal colic with urolithiasis - irradiation in the groin, external genitalia, lower back, blood in the urine;
• right-sided croupous pneumonia - lack of breathing in the lower parts of the lungs, shortness of breath, unilateral lagging of the chest;
• acute myocardial infarction - retrosternal localization of pain, connection with physical activity or stress, decrease from Nitroglycerin, pressure drop.

No more than 3-5 hours are allotted for observation, consultations of specialists and emergency examination. If symptoms persist or worsen, surgery is indicated. The doctor is responsible for the timely diagnosis of appendicitis.

Often patients in the hospital are examined by several surgeons in order to develop a common opinion. Modern requirements set the task of training physicians in primary ultrasound diagnostics and independent application of this technique when examining a patient. This feature is designed to reduce the number of diagnostic errors and improve treatment prognosis.

jktguru.ru

Symptoms characteristic of acute appendicitis

• Abrazhanov's point is painful, located in the middle of the McBurney point.
• Pain adaptation symptom. Normally, the sensation of pain irritation (pricks) is usually dulled symmetrically on both halves of the body after 3-7 seconds. In acute simple appendicitis in the most sensitive areas in the right iliac region, the feeling of pain is significantly lengthened (sometimes 8-15 times compared to the norm and the left iliac region in patients). With phlegmonous-purulent appendicitis, the time of adaptation to pain in the right iliac region slows down by 4-5 times, with gangrenous-perforative form, by 15-20 times.
• Symptom of Asaturyan. The fist of the right hand presses on the left iliac region. In this case, the right iliac region protrudes. The caecum is palpated with the left hand and a painful point is found, which corresponds to acute and chronic appendicitis.
• Symptom of Bartomier-Michelson - soreness during palpation of the caecum increases in the position of the patient on the left side.
• Bassler's symptom is pain on pressure in the middle, between the navel and the anterior superior iliac spine towards the iliac spine.
• Ben Asher's symptom - the appearance of pain in the right iliac region as a result of pressure with the tips of two fingers in the left hypochondrium during deep breathing or coughing of the patient.
• Symptom Brando - pain on the right when pressing on the left rib of the pregnant uterus. Occurs with appendicitis during pregnancy.
• Britten's symptom - during palpation of the abdominal wall in the place of maximum pain, contraction of the abdominal muscles and pulling of the right testicle to the upper part of the scrotum are observed. With the cessation of palpation, the tightening of the testicle stops. The symptom is characteristic of destructive appendicitis.
• Bulynin's symptom is pain when pressed at points located 3-4 cm to the right of the spinous processes of the 1st and 2nd lumbar vertebrae.
• Varlamov's symptom - pain in the right iliac region when tapping in the region of the XII rib on the right.
• The Hubergrits point is pain that occurs when pressure is applied under the pupart ligament in the Skarn triangle. Determined with the pelvic location of the inflamed appendix.
• Donnelly's symptom is the appearance of pain on palpation, above and below the McBurney point, while simultaneously extending the patient's right leg, which is typical for retrocecal appendicitis.
• Dieulafoy's triad - pain, muscle tension and hyperesthesia of the skin in the right iliac region.
• Zhendrinsky's symptom - the patient is in the supine position, the doctor presses the abdominal wall at the Kümmel point (2 cm to the right and below the navel) with a finger and, without removing it, offers to stand up. An increase in pain indicates appendicitis, a decrease indicates acute salpingo-oophoritis.
• Zatler's symptom - in patients in a sitting position, when raising the straightened right leg, pain occurs in the right iliac region.
• Symptom Ikramov - increased pain in the right iliac region when pressing the poison of the femoral artery.
• Symptom of Iliescu - soreness with pressure at the cervical point of the right phrenic nerve.
• Symptom Kaden. Frequent urination and loose stools in adults speak against appendicitis. This symptom is used for the differential diagnosis of appendicitis and intestinal intussusception.
• Symptom Klemm - accumulation of gas in the ileocecal region, determined by X-ray examination.
• Symptom of Koten-Meyer and Ko Tui - displacement of the white line of the abdomen and navel to the affected side. Observed in acute appendicitis, perforated gastroduodenal ulcer. The place of maximum contraction of the diseased side corresponds to the localization of the pathological process.
• Cope's symptom - increased pain in the right iliac region during rotation of the right hip.
• Krymov's symptom is the appearance or intensification of pain in the right iliac region when examining the palm of the external opening of the right inguinal canal.
• Lanz's symptom is the weakening or disappearance of the cremaster reflex on the right.
• Lanz's point is a painful point on the line connecting both upper anterior iliac spines, 5 cm from the right spine.
• Laroque's symptom is a tightened position of the right or both testicles, which occurs spontaneously or during palpation of the anterior abdominal wall.
• Lenander's symptom - the difference between the axillary and rectal temperatures is more than 1 degree. It is observed in acute destructive appendicitis.
• Lockwood's symptom is a rumbling or noise of iridescent fluid, determined by palpation of the right iliac region in a patient lying on his back with his legs slightly bent at the knee joints. Determined with appendicitis and adhesions of the abdominal cavity.
• Mac Burney's point is a painful point on the border of the middle and outer third of the line connecting the right anteriosuperior iliac spine with the navel.
• Maro's point is a painful point at the intersection of the line connecting the navel with the right upper anterior iliac spine, with the outer “paradise of the right rectus abdominis muscle.
• Michelson's symptom - increased pain in the right side of the abdomen in the position of the patient on the right side, when the uterus presses on the inflamed appendix. Characteristic for destructive forms of acute appendicitis in pregnant women.
• The symptom of "muscular protection" is the tension of the abdominal muscles in the right iliac region.
• Murphy's symptom - when percussion of the right iliac region with four fingers in a row (as when playing the piano), the usual tympanic sound is absent.
• Symptom Obraztsov - pain on palpation of the right iliac region increases if the patient is forced to raise the right leg straightened at the knee joint.
• Ostrovsky's symptom. The patient is offered to lift up (up to an angle of 130-140 degrees) the straightened leg and hold it in this position. The doctor quickly unbends it, laying it horizontally. There is pain in the right iliac region, caused by muscle tension.
• Payr's symptom is hyperesthesia of the sphincter with tenesmus and spastic stools. It is observed with the pelvic location of the inflamed appendix.
• Symptom Pasqualis. A discrepancy between rectal and axillary temperatures of less than 1 degree at a temperature of 38 degrees or more corresponds to retrocecal appendicitis or latent appendicitis of any other localization. A recto-axillary temperature discrepancy of more than 1 degree indicates inflammation of the process, which lies freely in the abdominal cavity.
• Symptom Razdolsky - pain in the right iliac region during percussion with a hammer or finger.
• Rovsing's sign. With the left hand, they press on the abdominal wall in the left iliac region, according to the location of the descending part of the colon, without taking away the pressing hand, with the right hand, a short push is made through the anterior abdominal wall to the overlying segment of the colon. With appendicitis, pain occurs in the right iliac region. According to the author, the gases of the colon move with a push proximally, reaching the wall of the caecum.
• Rotter's point - during rectal examination, having reached the Douglas space with a finger, against the anterior wall of the rectum, from above and on the right, it is possible to get a reaction from the peritoneum, which did not respond during the study of the abdomen, in the form of hyperesthesia, severe pain. This pain point indicates the presence of destructive appendicitis.
• Rutkevich's symptom - increased pain when the caecum is retracted inward.
• Sitkovsky's symptom is the occurrence or intensification of pain in the right iliac region when the patient is lying on his left side.
• Symptom Sorezi - pain in the right iliac region, which occurs when coughing and simultaneous palpation of the right hypochondrium in a patient lying on his back with bent legs.
• Symptom Supolt-Seye - pain behind the bladder with a deep breath is observed with inflammation of the process located in the pelvis.
• Tressder's symptom is a decrease in pain in the supine position.
• Filatov's symptom is an increase in local pain and a certain area in the right iliac region during palpation of the abdomen in children.
• Chase's symptom - pain that occurs in the right iliac region during rapid and deep palpation along the transverse colon - from left to right, while pressing the descending colon with the other hand.
• The symptom of Sherren's triangle is hyperesthesia, determined in the right iliac region within the boundaries of a triangle formed by lines connecting the right anterior-superior iliac spine, the navel and the right pubic tubercle.
• Shilovtsev's symptom. In the supine position, a pain point is identified in the right iliac region and, without taking away the hand, the patient is asked to turn on his left side. If there is no adhesive process and the caecum is displaced, then the pain at the found point decreases and shifts lower and to the left.
• Shchetkin-Blumberg symptom. After gentle pressure on the abdominal wall, the fingers are sharply torn off. With inflammation of the peritoneum, pain is greater when the doctor's hand is released from the abdominal wall than when pressing on it.
• Symptom of Yavorsky-Meltzer. The patient, lying on his back, tries to raise the outstretched right leg, while the doctor holds it, pressing on the knee. With appendicitis, pain occurs in the region of the caecum, depending on the tension of the iliopsoas muscle and the inflammatory process in the appendix.
• Symptom Yaure-Rozanov - soreness when pressed with a finger in the area of ​​the petite triangle. Seen in retrocecal appendicitis.

The listed symptoms of acute appendicitis occur unequally often and are different in their significance. The most striking symptoms of appendicitis are the symptoms of Shchetkin-Blumberg, Sitkovsky, Rovsing, Voskresensky, Obraztsov, Razdolsky, Lenander and Bartomier-Mikhelson. All other symptoms are additional information and often help in clarifying the diagnosis.

E.Kapashyrov et al.

"Symptoms of acute appendicitis" and other articles from the section Research in Surgery

lor.inventech.ru

Acute appendicitis is a nonspecific inflammation of the appendix caused by suppuration microbes. This is the most common abdominal disease requiring surgery. Acute appendicitis is more common in young people aged 10-30 years, but you can get sick at any age.

By classification Distinguish between catarrhal, phlegmonous, gangrenous and perforated appendicitis. Destructive forms include phlegmonous, gangrenous and perforated appendicitis.

Etiology and pathogenesis. The main reason for the development of acute appendicitis is the obstruction of the lumen of the appendix with fecal stones, or (less often) foreign bodies, helminths, hyperplastic lymphoid tissue. It is believed that the obturation of the lumen of the appendix leads to spasm of its muscles and blood vessels, which is accompanied by local malnutrition of the mucous membrane of the appendix, impaired evacuation and stagnation of its contents. As a result, inflammation of the mucous membrane of the appendix occurs, which then spreads to all its layers.

Complaints. The main complaint of a patient with acute appendicitis is abdominal pain. The disease usually begins among full health, without precursors, more often in the afternoon or at night. There are cutting or pressing pains in the epigastric region, then spreading throughout the abdomen, and after a few hours “moving” to the right iliac region (Kocher's symptom). Sometimes the pain from the very beginning is localized in the right iliac region. Often the pain is aggravated by walking, because. the tensing lumboiliac muscle displaces the caecum with the process and increases pain. The shaking of the viscera when walking also contributes to increased pain in destructive forms of the disease. A frequent symptom of acute appendicitis is nausea, maybe 1 - 2 - multiple vomiting, which does not bring relief. There is no appetite. Signs of intestinal disorders are rare, usually the stool in patients is normal. Body temperature is often subfebrile, but with destructive and complicated appendicitis, it can rise to 38-39 degrees. Occasionally, dysuric phenomena (frequent, painful urination) can be observed.

Anamnesis. As a rule, acute appendicitis is characterized by a brief history of the disease - no more than 2-3 days, and most often - a few hours. In most patients, the classic sequence of onset of symptoms of the disease is observed - first anorexia, then abdominal pain, and then vomiting.

Examination of the patient. In the first hours of the disease, the general condition of the patient suffers little. The skin is of normal color, the pulse is slightly quickened. The tongue is moist but often furred. The abdomen is not swollen and participates well in the act of breathing. With the progression of the inflammatory process in the iliocecal region, the general condition of the patient worsens, the temperature rises to 38-39 degrees, tachycardia increases, the tongue becomes dry, the stomach participates in the act of breathing to a limited extent.

Percussion of the abdomen often reveals pain in the right iliac region. (symptom of Razdolsky).

With superficial palpation of the abdomen, it is possible to determine the tension of the muscles of the abdominal wall in the right iliac region and here to identify the zone of hyperesthesia. With deep palpation in the first hours of acute appendicitis in the right iliac region, it is possible to determine a clear, sometimes quite significant pain. When conducting a study, it must be remembered that deep palpation can be done only after performing superficial; palpation is carried out carefully, gradually penetrating into the depth of the abdominal cavity. Auscultatory in the case of a typical attack of acute appendicitis in the initial stage of the disease, ordinary intestinal noises are heard; with destructive forms, intestinal noises decrease.

In the diagnosis of acute appendicitis, the identification of some special symptoms characteristic of acute appendicitis is of great importance. However, it should be clarified that these symptoms are not strictly specific only to acute appendicitis. They indicate the presence of an acute inflammatory process in the right iliac region with involvement of the peritoneum. And in the vast majority of cases, such an acute inflammatory disease is acute appendicitis.

Symptom of Shchetkin - Blumberg lies in the fact that with the rapid removal of the fingertips, pressing down on the abdominal wall, pain arises. This symptom must be checked very carefully and first in the left iliac region. With the fingertips of the right hand, they press on the abdominal wall, then not very sharply, but quickly take the hand away from the stomach. If there is no soreness on careful withdrawal of the hand, then the symptom check is repeated and the hand is withdrawn more vigorously. Shchetkin-Blumberg's symptom will be positive with inflammation of the peritoneum, that is, it is a sign of peritonitis. The presence of a positive Shchetkin-Blumberg symptom in the right iliac region is highly likely to indicate inflammation of the appendix.

Resurrection symptom (symptom of “slip” or “shirt”) check as follows. The patient's shirt is pulled with the left hand and fixed on the pubis. With the fingertips of the right hand, they lightly press on the abdominal wall in the area of ​​the xiphoid process and, during exhalation, carry out a quick sliding movement towards the right iliac region, where the hand is held without tearing it away from the abdominal wall (so as not to get the Shchetkin-Blumberg symptom).

Obraztsov's symptom associated with increased pain during palpation of the caecum with contraction of the lumboiliac muscle. In the position of the patient on the back, the most painful place is felt in the right iliac region and the fingertips are fixed in this place. The patient is asked to raise the straightened right leg to an angle of 30 degrees - while the pain intensifies. Lowering the leg is accompanied by a decrease in soreness due to relaxation of the lumboiliac muscle and the cessation of pressure on the caecum with the appendix.

Symptom Sitkovsky is considered positive when, in the position of the patient on the left side, pain appears or intensifies in the right iliac region. The mechanism of this symptom is associated with the movement of the appendix and its mesentery, as well as the tension of the inflamed peritoneum of the mesentery.

Bartomier-Michelson sign- increased pain on palpation of the right iliac region in the position of the patient lying on his left side. In this case, the mobile organs of the abdominal cavity are displaced to the left and expose the fixed caecum with its process for palpation.

Rovsing's sign associated with the appearance of pain in the right iliac region with jerky tremors of the abdominal wall in the left iliac region. During the pushes produced by the right hand, the sigmoid colon is pressed against the back wall of the abdomen with the fingertips of the left hand. Some believe that the mechanism of pain is associated with a simple concussion of the abdominal wall, others believe that there is a movement of the contents of the colon in the opposite direction.

With the retrocecal and retroperitoneal location of the appendix, the following symptoms may be positive: Gabai's symptom(on palpation in the area petit triangle pain on the right side) Yaure-Rozanova symptom(pressure in Petit's triangle and then a quick withdrawal of the hand causes increased pain).

Diagnostics. Of the laboratory research methods, it is mandatory to carry out a general blood test (leukocyte count and leukocyte formula) and a general urine test (it is of great importance for differential diagnosis).

Objective signs of acute appendicitis are an increase in body temperature up to 37-37.5 degrees, leukocytosis in the range of 10-12 thousand, as well as a shift of the leukocyte formula to the left, expressed in an increase in the percentage of stab neutrophils in the blood of more than 5-6%. With destructive forms of appendicitis, these indicators increase.

When diagnosing acute appendicitis in doubtful cases, it is necessary to carry out:

digital examination of the rectum. With this manipulation, it is possible to determine the soreness of the anterior wall of the rectum on the right, compaction (with infiltration) or overhanging of the anterior wall of the intestine and fluctuations with the accumulation of pus.

in women, a vaginal examination can be performed, in which it is possible to determine the soreness of the posterior fornix of the vagina in the presence of pus in Douglas space.

Ultrasound of the abdominal cavity in the right iliac region with examination of the appendix. A sign of its inflammation will be its increase in size, thickening of its walls, the presence of fluid in its circumference.

laparoscopy, revealing in acute appendicitis hyperemia, thickening, inflammatory infiltration of the process, fibrinous plaque on its surface, the presence of exudate in the abdominal cavity.

Treatment. If the diagnosis is "Acute appendicitis", an emergency operation is necessary, regardless of the time elapsed since the onset of the disease, the age and sex of the patient. An exception is a dense appendicular infiltrate, where surgery is contraindicated. If the diagnosis is not accurate, there are doubts, observation with an entry in the medical history is necessary. If the condition does not improve, let alone worsens, laparoscopy or urgent surgical intervention is necessary. When the patient's condition improves, it is necessary to conduct the necessary studies to exclude acute appendicitis and clarify the diagnosis.

The method of surgical treatment of acute appendicitis is the operation of appendectomy, which can be performed in two versions:

1) The usual, classical appendectomy involves laparotomy through an oblique variable incision (McBurney) in the right iliac region, removal of the dome of the caecum along with the appendix into the wound, ligation and cutting off from the process of its mesentery with vessels passing through it, applying a ligature to the base of the process and cutting it off. The stump of the appendix is ​​usually immersed in the dome of the cecum with a purse-string suture. But more and more surgeons consider this manipulation unnecessary. If it is impossible to remove the dome of the caecum into the wound, with a strong fixation of the tip of the process in the depths of the abdominal cavity with adhesions, the so-called "retrograde" appendectomy is possible. In this case, first, in the depth of the wound, the place of attachment of the appendix to the caecum is found, its mesentery is pierced at the base of the process, and a ligature is applied to it, followed by cutting off the base of the appendix from the caecum. And then gradually, in the direction from the base of the process to its top, the appendix is ​​separated from its mesentery and adhesions.

2) Laparoscopic appendectomy is performed from 3 punctures of the abdominal wall. The mesentery of the appendix is ​​either coagulated with a power tool, or clips are applied to the vessels of the mesentery. The process itself, after applying a ligature to its base, is cut off. The stump of the appendix during laparoscopic appendectomy is not immersed in the dome of the caecum.

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Causes of acute appendicitis

• direct infection from the blood due to the presence of infectious diseases of the intestine or the presence of chronic inflammatory diseases (in women, this is more often a disease of the pelvic organs, such as adnexitis or inflammation of the ovaries),
• appearance of a tumor
• swollen lymph nodes
• helminthic formations
• malnutrition of small peripheral vessels due to a tendency to thrombosis,
• mechanical damage resulting from trauma.

Therefore, the prevention of the disease includes:

• Proper nutrition
• Timely treatment of inflammatory diseases (especially if they have become chronic)
• Antihelminthic therapy

Classification of acute appendicitis

Typically, appendicitis is subdivided by location and by the degree of development of the pathology.

According to its location, it is divided into typical and atypical (ascending retrocecal, subhepatic, medial, descending pelvic)

According to the stage of development of the disease, the classification of appendicitis is as follows:

At the beginning of an attack, the first 12 hours of appendicitis are called simple or catarrhal, and then it goes into a destructive stage (it can be phlegmonous, phlegmonous ulcerative, purulent, perforative - from 12 to 48 hours and gangrenous after 48 hours).

The phlegmonous stage is the stage when the inflammatory process passes into all the tissues of the appendix. The mesentery becomes edematous, and the inflammation passes to the peritoneum.

The gangrenous form is the most dangerous, as it leads to peritonitis (the nerve endings die, gangrene begins, the process perforates and purulent discharge passes into the abdominal cavity).

The photo below shows what a perforated appendicitis looks like.

In most cases, appendicitis develops in two to three days (in children, even less in about 36 hours).

The acute form of the disease differs from the sluggish chronic inflammation of the appendix, when a person for more than one year may be disturbed by recurrent pain in the right iliac region and other typical symptoms that accompany an exacerbation of the disease. In the second case, special treatment and planned removal of the process in the surgery department are necessary.

Possible Complications

If appendicitis is not urgently removed, it leads to complications that pose a danger to the life of the patient, among them can be listed:

• Diffuse peritonitis, when, due to gangrene, the walls of the appendix rupture and purulent or serous discharge (effusion) enters the abdominal cavity and affects part of the intestine and other organs.
• Localized abdominal abscesses (interintestinal, pelvic, Douglas pouch)
• Intestinal fistula or ulcer
• Appendicular infiltrate - dense formation around the appendix, which leads to the development of chronic appendicitis and the appearance of appendicular abscesses
• Pylephlebitis is a lesion of the liver vessels, almost always leading to death, it is often too late to treat a patient in this condition.
• Sepsis or general blood poisoning

Symptoms of acute appendicitis

The earliest sign of appendicitis is abdominal pain. Then other clinical manifestations of the disease appear. At different ages, in men and women, they manifest themselves in different ways. Below is a table that shows how the disease manifests itself in different groups of people.

Diagnosis of acute appendicitis

In order to make an accurate diagnosis, first of all, it is necessary that the patient be examined by a doctor. Therefore, the appearance of a pronounced pain syndrome, it is urgent to call ambulance and until the doctor arrives, provide the patient with complete rest and adhere to a number of contraindications. This means: in no case do not give him painkillers, do not put a heating pad on his stomach and do not try to treat yourself, otherwise the clinical picture of the disease will be blurred and the doctor may make a mistake in making a diagnosis. This will complicate the situation and may lead to the death of the patient.

If the doctor from the ambulance insists on hospitalization in a medical institution, you should not refuse it. Attempting to treat appendicitis without being hospitalized in a hospital ward is life-threatening for the patient. Therefore, it will be necessary to stay in the clinic under the supervision of medical specialists for as long as necessary. main feature pathology lies in the fact that the only method of treatment is an urgent operation to remove the appendix.

When the patient enters the surgical department, the surgeon examines him again, and also conducts all the necessary laboratory and instrumental studies.

Medical checkup

If appendicitis is suspected, the doctor first listens to the patient's complaints, finds out if he has any chronic diseases, whether he has undergone any operations, the presence or absence of pregnancy (in women), etc. All this contributes to an accurate diagnosis.

After this, the patient is examined by a surgeon. During the examination, he uses the classical diagnostic method for determining the features of the pathology, based on a positive reaction for a number of appendicular symptoms.

Symptoms of an atypical location of appendicitis:

Appendicular symptoms during pregnancy:

Laboratory research

Blood analysis

The first thing they do in the hospital is to take blood for analysis. In the presence of an inflammatory process, the level of leukocytes in the blood (leukocytosis) should be elevated. This sign does not allow to accurately determine appendicitis in pregnant women, since at this time the leukocytes themselves are overestimated. The norm of leukocytes is 9, and if this indicator is from 11 to 17, then an inflammatory process is diagnosed, if it is above 20, then the risk is very high that diffuse peritonitis will be found. In older people, on the contrary, the level of leukocytes, even with inflammation, remains normal.

With appendicitis, neutrophilic leukocytes predominate in the leukocyte formula (75% of neutrophils are found in two-thirds of cases).

An increase in C-reactive protein may also indicate the presence of inflammation. If this indicator does not increase, appendicitis is ruled out.

For women, they also do an analysis of the level of the hormone hCG (human chorionic gonadotropin), which is produced during pregnancy. This is done to rule out an ectopic pregnancy.

Analysis of urine

Urinalysis is a mandatory component of diagnostic measures. It is taken to rule out kidney problems.

With retrocecal and pelvic appendicitis in the urine, the number of leukocytes and erythrocytes changes, this is due to the fact that inflammation affects the ureters or bladder, occurs in 25% of cases.

In the early stages of classic appendicitis, there are no changes in the composition of urine. The presence of an inflammatory process is also indicated by an increase in the level of sialic acids (normal value is from 100 to 250). This indicator also determines the stage of appendicitis. At the first, catarrhal stage, this indicator is 290 units, and at destructive (phlegmonous, phlegmonous-ulcerative and gangrenous) - 335.

Instrumental Research

In combination with a medical examination and laboratory tests of blood and urine tests, the following types of instrumental examinations are used:

• X-ray,
• X-ray,
• Laparoscopy
• Irrigoscopy.

One of the most accessible methods for diagnosing appendicitis is an ultrasound (ultrasound examination) of the abdominal cavity. That examination is more often done in young women, children and the elderly, since their clinical picture may be implicit.

If the examination is carried out by an experienced doctor, in 90% of cases, according to ultrasound, inflammation of the appendix can be identified. An obstacle to obtaining useful data can be obesity, late pregnancy, intensive formation of gases in the intestines.

The main sign is an increase in the appendix in diameter (the norm is up to 4-6 mm, and with appendicitis it increases to 8-10 mm.), And in addition, the walls of the appendix become thick (normal wall - 2 mm., inflamed - 4-6 mm.)

The following indirect signs may indicate inflammation of appendicitis:

• Changing the shape of the appendix
• Mesenteric infiltration
• Accumulation of fluid in the abdominal cavity

How is the examination carried out?

For ultrasound with appendicitis, the patient does not need additional preparation (enemas or bowel movements).

1. The patient lies on his back
2. The sensor of the device is set to maximum pain, the doctor gently presses on this point, reducing the distance to the appendix to 3 cm, after which its structure is visible on the screen. Examination of women is also carried out transvaginally (when additional examination is needed).

Fluoroscopy

In 80% of cases, fluoroscopy of the abdominal cavity helps to identify the following signs of acute appendicitis:

• Increased fluid level in the caecum (guardian loop)
• Pneumatosis of the right part of the colon and ileum
• Change in the medial contour of the caecum
• The presence of gas in the abdominal cavity may indicate that a process perforation has occurred.

Laparoscopy

Most effective method detection of pathologies inside the abdominal cavity - laparoscopic examination. The effectiveness of the method - 95% - 98% It allows you to see both direct and indirect signs of inflammation.

Direct signs include:

1. Rigidity or loss of ability to contract the walls of the appendix
2. Tension and thickening of the process, as well as fibrin plaque
3. A very strongly enlarged process of a greenish-black color with multiple hemorrhages indicates the gangrenous stage of the disease.
4. Hyperemia (blood congestion) of the visceral peritoneum and serosa
5. Hemorrhage on the serosa of the appendix
6. Mesenteric infiltration

Indirect signs include:

1. Cloudy serous-fibrinous effusion in the abdominal cavity, concentrating in the pelvic region and in the right iliac fossa
2. Infiltration of the rectal wall

Irrigoscopy

Irrigoscopy is one of the types of X-ray examination. This type of examination is used only when it is appropriate and there are difficulties with the diagnosis. Before the procedure, a barium mixture is injected into the patient's intestines, which the doctor sees during the examination. The filling of the process indicates that there is no appendicitis.

Treatment of acute appendicitis

The only treatment is an operation to remove the appendix, called an appendectomy. It can be done by the classical method through an open incision or through three incisions (less than 1 cm) by the laparoscopic method. The decision about which tactics of the operation is better depends on the stage of appendicitis.

Preparing for the operation

Often, surgery for the removal of appendicitis is performed on an emergency basis, so it can be done as early as two hours after admission to the surgical department of the hospital, so there is no time for special preparation. The appendectomy itself can take 40 minutes, or it can take several hours. It depends on whether there are complications.

Mandatory patient preparation includes:

• Examination of the state of the cardiovascular system
• Determination of which anesthesia is suitable for the patient (perform a check for the absence of an allergic reaction to painkillers)
• An isotonic solution is administered intravenously to the patient to eliminate the symptoms of intoxication and to prevent dehydration.
• Cleanse the stomach (as a rule, the patient does not eat or drink anything, so this is often not necessary)
• Hair removal in the area of ​​the operation
• Skin disinfection

Tactics of classical appendectomy

1. Anesthesia. Most often, the operation to remove the appendix is ​​done under general anesthesia. Sometimes local anesthesia is used by injecting a solution of novocaine.
2. Incision. Before operating, the surgeon marks the site of the incision, mainly according to the method of McBrunei Volkovich Dyakonov, but other operational methods of access are also possible. For clarity, below is a table where the incision is located and what is its length for each access.

   The surgeon makes the incision itself in layers, moving apart and fixing the edges of the wound along the way. Damaged vessels are cauterized. Muscle tissue is not cut, but pushed apart with blunt instruments.

3. Examination and assessment of the condition of the internal organs of the abdominal cavity. The intestines, located on both sides of the appendix, the doctor examines with great care. If the appendicitis bursts, and pus enters the abdominal cavity, the doctor assesses its condition, thinks over the scheme of subsequent treatment. After surgery, in such cases, a drain is installed. It is necessary so that the resulting infiltrate can come out from the inside.
4. Removal of the process and suturing the edges of the caecum. The appendix is ​​cut off after it is completely removed into the surgical wound and isolated from other organs. This minimizes the spread of infection to internal organs. The edges of the process are sutured so that the edges of the wound are inside the stump, which also eliminates the possibility of infection.
5. The wound is sutured with self-absorbable threads in the internal tissues, and on the skin with strong synthetic threads.

Laparoscopic Appendectomy

Laparoscopic appendectomy is performed under general anesthesia through three small incisions less than one centimeter in diameter. Through one surgeon introduces a laparoscope, the video from which can be seen on the monitor screen. With this tool, the doctor can carefully examine the appendix and its surrounding tissues. After the operation, there is no long scar.

Laparoscopy avoids errors in diagnosis. In particular, this modern method reduces the number of erroneous operations for appendicitis by 30%. As a rule, the procedure is first done to clarify the diagnosis, and if it is confirmed, they proceed to the direct removal of the appendix.

Since laparoscopy is the most minimally invasive method of appendectomy, it is prescribed for obesity of 2-3 degrees and for diabetes mellitus.

Contraindications for laparoscopy

• Late pregnancy
• Allergic reaction to anesthesia components
• Heart attack or pre-infarction condition

Important! With peritonitis, only strip operation is indicated.

Stages of laparoscopy

1. The work area is disinfected
2. An incision is made in the umbilical region for the introduction of a tube forcing carbon dioxide (it is inserted in order to expand the internal space)
3. The laparoscope is then inserted through the same incision using a hollow tube.
4. The doctor examines the appendix and abdominal cavity, assessing the degree of inflammation. Based on this examination, he makes decisions regarding the further course of the operation. If appendicitis is uncomplicated, and it can be done with the help of laparoscopy, then do the following:
5. The doctor makes two more incisions: one above the pubis, and the second in the right hypochondrium for the introduction of manipulator instruments.
6. The appendix is ​​removed and removed through a hollow tube or trocar. At the same time, they adhere to the basic principle: to prevent the contents of the appendix from passing to other organs.
7. The surgeon examines the abdominal cavity again, sanitizes it and installs a drainage tube, if necessary.

Postoperative period

The duration of the rehabilitation period depends on how advanced the appendicitis was, on the age and health of the patient, and on the method of appendectomy. Children under the age of ten take longer to recover, as do obese people.

After surgery, the patient needs from two weeks to a month to fully recover. The stitches are removed on the 7th - 10th day.

If drainage has been installed, then it is removed on the third day. As a rule, there is such a need when the patient has been diagnosed with gangrenous appendicitis.

Within 5-7 days after the operation, the patient may experience hyperthermia. At this time, antibiotic therapy is often performed. To speed up healing and avoid complications these days, you need to strictly adhere to the diet until the intestines work normally. In addition, it is important to take seriously the restrictions on physical activity, and doctor's recommendations regarding medication, sauna visits, alcohol consumption and smoking cessation.

A sick leave in connection with an operation for appendicitis is issued for a maximum of 1 month. But even after returning to work, it is important to remember that within four months you can not lift weights more than 10 kg.

Early postoperative complications

• Even during the operation, the surgeon may encounter internal bleeding from the stump of the mesentery, this complication may occur due to insufficiently strong ligation of the vessel that feeds the appendix. Re-ligation of the vessel solves the problem. Blood that has entered the abdominal cavity must be removed.
• Early complications include the formation of an infiltrate in the thickness of the abdominal wall. This may lead to the fact that it is necessary to remove the accumulated fluid between the edges of the wound by puncture. The presence of temperature and pain in the wound area indicates that there is a risk of the occurrence and development of suppuration. To solve the problem on the second day after the operation, two or three stitches are removed to open the wound and the resulting pus comes out. In difficult cases, the wound is completely opened and drained.

Late Complications

• Intestinal fistula. Often a consequence of peritonitis. To eliminate the complication, a second surgical intervention is necessary.
• Douglas abscess. For elimination, an abscess is opened through the vagina in women or through the rectum in men.
• Pylephlebitis. A life-threatening condition, which is manifested by an increase in temperature up to 40 - 41 C˚, excessive sweating, vomiting and jaundice. In this case, first of all, the sources of inflammation are eliminated and they proceed to intensive treatment with antibiotics.
• Intestinal obstruction. The problem may appear both immediately after the operation, and after some time, when it seems that the wound has healed. Adhesions of the intestines provoke sharp pains in the abdomen and vomiting. If traditional methods of treatment do not help and the condition worsens, a second operation is necessary to eliminate the complication.

Differential Diagnosis

In terms of its symptoms, acute appendicitis is similar to the following pathologies:

• Pancreatitis
• Cholecystitis
• Ulcer in the stomach or duodenum
• Crohn's disease
• Gastritis
• Colitis
• Intestinal obstruction
• Meckel's diverticulitis
• Renal colic
• food infection
• Cystitis
• Abdominal form of myocardial infarction

In women, the symptoms of diseases of the genital organs are similar, such as:

• Right-sided ovarian apoplexy
• Torsion of an ovarian cyst
• Ectopic pregnancy
• Acute adnexitis

Statistics:

• frequency 1/150-200 people
• over the past 10 years, the frequency has increased. 2-3 times.
• more often people who eat meat.
• mostly city dwellers.
• more often in 20-40 years.
• more often women (1: 1.5 times).
• accounts for 25-30% of all surgical patients.
• 50-60% of all emergency surgical patients.
• more recently severe forms.
• in recent years, mortality has not decreased (0.1-0.6%).
• Belarus - 0.15-0.20%.

Development: 2-3 months intrauterine development, from the primary intestinal loop, with counterclockwise rotation.

Location:

1. mezacecal;
2. retrocaecal;
3. ahead of the caecum;
4. retroperitoneally;
5. in the mesentery of the colon;
6. in the pelvic cavity;
7. under the liver;
8. left.

Slime layer:

• 9 stagnation in the crypts of intestinal contents -> stagnation of blood, lymph.
• in the submucosal layer from 300 to 1000 limf. follicles.

Muscular:

• longitudinal + circular + longitudinal.
• outside covered by the peritoneum, with inflammation of the cat. peritoneal syndrome occurs.
• forms a fold of Herlag.
• Robinson's sphincter at the border of the intestine and appendix -> violation of the outflow of contents.

Blood supply:

br. aorta -> a. mesehterica superior -> a. ileocolica -> a. appendicularis (passes in the free edge of the mesentery of the appendix). Segmental branches depart from the appendicular artery -> segmental lesion.

Venous return:

v.appendicularis -> v.colica -> v.messuperior -> v.port (liver abscesses) -> right heart (myocarditis) -> lung (abscess).

Lymph drainage:

1. lymph nodes of the mesentery;
2. l / in the retroperitoneal space;
3. iliac l / y, inguinal l / y.

Innervation:

due to plexus mesentericus superior (sympathetic twigs + n.vagi branches). Innervation is 40 times more intense than in other parts of the gastrointestinal tract.

Functions:

1. rudiment;
2. tonsil of the intestine (barrier);
3. production of lymphocytes;
4. affects the growth of the body through the pituitary gland;
5. affects peristalsis;
6. affects the formation of the skeleton;
7. affects the function of the autonomic nervous system;
8. "pupil" of the abdominal cavity;
9. has a powerful innervation.

Ways of spread of infection:

1. venous (pylephlebitis) -> liver abscess -> endocarditis -> lung abscess.
2. lymphatic;
3. along the peritoneum;
4. on retroperitoneal tissue;
5. mixed path.

2. - lymphadenitis of the mesentery (mesodenitis);

• retroperitoneal phlegmon;
• subphrenic abscess of retroperitoneal localization;
• lymphadenitis of the iliac, inguinal region.

3. - abscesses, ulcers of the right lateral canal;

• subhepatic, subphrenic abscesses small pelvis:
• ulcers of the left channel up to the left subdiaph. pr-va
• interintestinal abscess in the left mesenteric sinus.

4. - retroperitoneal tissue -> phlegmon

• - subphrenic ulcers of the retroperitoneal space behind the coronary ligament of the liver.

Theories of pathogenesis:

Aschoff - infectious (primary affect).

Reindorf - worms, foreign bodies, fecal stones.

Dielofoy - stagnation, kinks -\u003e violation of the outflow.

Ricker - angioedema (disturbances in the vessels).

Davydovsky - the role of the lymphatic system (inflammation).

Grekov - Ch.O. and Bauhin's valve - the pyloric part of the stomach is well innervated, interconnected (appendicitis on the background of ulcers, gastritis).

Shamov, Rusakov, Elansky - allurgical theory (special protein food -> sensitization -> resolving dose -> immune response).

Nervous reflex:

1. violation of trophism -> chronic forms;

2. vascular innervation -> destructive forms;

3. motor innervation -> no change.

Various factors of the external and internal environment send impulses to the central nervous system. If the impulses are pathological, then the reverse impulses are also pathological. All impulses go to the internal organs, as well as the appendix has increased innervation -> appendicitis occurs.

At some stage, an infection joins, i.e. the role of infection is secondary.

All theories are true, but all are limited, except for the neuro-reflex. The disease is polyetiological, but the pathogenesis is the same - neuro-reflex. The role of infection is secondary.

Pathological changes:

Karatal: thickening, hyperemia, swelling, defects of the mucous wall, tissues are infiltrated, the muscle layer is unchanged, normal intestinal contents are in the lumen.

Phlegmonous: C.O. significantly thickened, bluish-purple in color, dense tissue, fibrin deposition on the peritoneum, purulent-hemorrhagic contents in the lumen, cell-purulent infiltration of the walls.

With empyema C.O. - a bag filled with pus.

Gangrenous: black in color, putrid odor, fibrio overlays, the wall is thickened, thin in places, liquid hemorrhagic contents in the lumen, the area of ​​inflammation is limited from healthy tissues by a demarcation line.

Classification:

clinical pathoanatomically

1. sharp simple

phlegmonous | destructive forms.

gangrenous |

infiltrate (limited peritonitis).

2. chronic tissue sclerosis;

1) primary muscle atrophy;

2) recurrent adhesions;

3) residual (after deformation;

acute attack pain obliteration;

remains permanently). dropsy;

myxoglobulosis - changes in cells
slime. obol. -> work out. slime -> mic
catfish br. cavities (false) - ac.
character evil. tumors.

Syndromes:

1. painful;

2. peritoneal;

3. inflammatory;

4. dyspeptic.

appendicular symptoms:

1. Voskresensky - the appearance of pain in the right iliac region when quickly holding the palm through a shirt stretched over the abdomen.
2. Rovsinga - with jerks on the left, pain appears on the right.
3. Sitkovsky - lying on the left side, the pain appears on the right (cough s-m)
4. Bartholier-Michelson - position on the left side; pain on palpation of the right iliac region.
5. Obraztsova - pain in rights. iliac region at the moment of raising the right straightened leg.
6. Razdolsky - tapping with fingers.
7. Kocher - the pain begins in the epigastric, then passes into the pr. iliac. region
8. Brando - pain in pr. iliac. region when pressing on the lion. rib (at take.)

+ peritoneal symptoms:

• Shchetkin-Blumberg
• Mendel (beating on the br. wall)
• Krymov (w/w inguinal ring - acute pain on the right)
• Lennander - the difference in t in the armpit and rectum (in N< 1 C)
• Cremasterica - right testicle tightening
• a symptom of intestinal paresis - the diameter of the abdomen increases.

Clinic. Diagnostics. Treatment

1. Pain syndrome. It does not always occur, predominantly. in ave. podvzd. region, may irradiate.

The pain is mild, tolerable, does not reflect changes. By har-ru constant, rarely periodic; aggravated by movement, combined with a slight disturbance of appetite, chills.

Biphasic changes over time:

2. Peritoneal: - intoxication;

• the face of Hippocrates;
• coated tongue.

the abdomen is swollen, does not participate in breathing (Winter's syndrome).

• tense muscles;
• palpation pain;
• dullness in sloping places;
• weakening of peristatics ("deathly silence").

Symptoms of Shchetkin-Blumberg, Mendel, Krymov.

3. Inflammatory:

• temperature (39 , 38 , 37)
• lecocytosis, neurophilia, shift to the left, stole. ESR.

4. Dyspeptic: - nausea, vomiting; - violation of the chair.

CCC - increased heart rate, smart. BP, then increased., muffled heart sounds.

DS - rapid breathing, superficial, mobility of the pulmonary edge

limited, crepitating rales.

NS - insomnia, internal anxiety, lethargy.

MVS - protein, erythrocytes, cylinders.

The liver is enlarged, painful, bilirubin is gone.

Signs of damage to the pancreas - stole. diastasis.

Finger examination of the rectum.

The diagnosis is made on the basis of 4 main syndromes: appendicular symptoms, observation and exclusion of other diseases.

Clinic of acute appendicitis:

Depends on:

1. Ch.O. location: right - left;

top - bottom;

retroperitoneally.

2. the duration of the disease: at first, not all symptoms, later - peritonitis, other complications.

3. from the course: stable with remission, progressive, complicated.

4. from the clinical form of o. appendicitis:

1) light with resolution; 5) with festering infiltrate;

2) light, protracted; 6) septic;

3) rapidly progressive; 7) atypical;

4) with infiltrate; 8) with peritonitis.

In children: - rarely up to 2 years;

• weak plastic properties of the peritoneum;
• small omentum;
• difficult to examine;
• general symptoms predominate;
• often toxic forms;
• difficult to differentiate from pneumonia;
• choice of anesthesia.

In pregnant women: - the position of Ch.O. changes;

• it is difficult to determine muscle tension;
• there are conditions for peritonitis;
• difficult diagnosis in childbirth;
• you can remove the fallopian tube instead of Ch.O.;
• miscarriage is possible after the operation.

In old people: - sagging muscles;

• all symptoms are lubricated;
• more often destruction;
• difficult to distinguish app. infiltrate from cancer of the caecum;
• after surgery, complications in the lungs, heart, and blood vessels are more common.

Diagnosis of difficult cases:

• history taking;
• detailed inspection;
• pay attention to pain and inflammation syndromes;
• differentiate well;
• conduct dynamic monitoring.

differentiate from:

1. Diseases of the chest cavity (pneumonia, pleurisy, myocardial infarction).

2. Diseases of the stomach: (gastritis, food intoxication, samples.

ulcer zhel., perforation of the tumor, phlegmon of the wall).

3. Diseases of the liver, f. ways, 12 p. to-ki, podzhel. glands

(abscess, liver, cholecystitis, cholelithiasis, ulcer perforation, pancreatitis).

4. Diseases of the intestines (mesadenitis-flare l / y, inflammation

keleva divertula, intestinal obstruction, Crohn's disease - inflammation

nie terminal sections of the ileum.

5. Diseases of the uterus and appendages:

• adnexitis;
• bleeding from the ovary;
• ectopic pregnancy.

6. Diseases of the genitourinary system:

• renal colic;
• mobile kidney;
• pyelitis
• cystitis;
• pochenno-stone b-n;
• orchiepidimitis;
• hydropionephrosis;

7. Diseases of the caecum: tuberculosis, cancer, amoebiasis, volvulus.

8. Peritonitis:

• pneumococcal;
• traumatic;
• tuberculosis;
• cryptogenic.
• streptococcal;

9. Infectious and other diseases:

• typhoid fever;
• tinea versicolor;
• iliac vein thrombosis;
• radiculitis.

PLAN OF DIFFERENTIAL DIAGNOSIS about. appendicitis:

common symptoms different symptoms

pocheno- | according to subjective symptoms

stone | with the flow

disease | according to general survey

| according to laboratory data

| according to special research methods

| (laparosk)

CAUSES OF DIAGNOSTIC ERRORS:

Incomplete examination;

all data is not taken into account;

no differential diagnosis;

no dynamic observation;

doctor's self-confidence;

not guided by tactics;

the apathy of the flow.

Appendicular infiltrate: limited peritonitis (1st stage delimitation, 2nd stage - resorption).

TREATMENT OF ACUTE APPENDICITIS:

Urgent operation, except for appendicular infiltrate.

Why: - there are no other methods;

• the clinic does not correspond to anatomical changes;
• waiting is dangerous;
• difficult to treat complications.

During the operation, we dissect:

2. subcutaneous tissue; 1. oblique (t. Lanz);

3. superficial fascia; 2. pararectal (t. McBur-

4. aponeurosis of the external oblique muscle; not me)

5. internal oblique muscle; 3. additional-median

6. transverse abdominal muscle; laparotomy.

7. transverse fascia;

8. preperitoneal fatty tissue;

9. parietal peritoneum.

Area innervation: n.iliogipogasfricus, n.ilioinginalis.

Blood supply: vasa circumflexa ilium superficialis.

epigasfrica superficialis

pudenda exferna.

vasa epigasfrica inferior

vasa circumflexa ilium profunda.

1. Can cancer be prevented?
The occurrence of a disease such as cancer depends on many factors. No one can be completely safe. But everyone can significantly reduce the chances of a malignant tumor.

2. How does smoking affect the development of cancer?
Absolutely, categorically ban yourself from smoking. This truth is already tired of everyone. But quitting smoking reduces the risk of developing all types of cancer. Smoking is associated with 30% of cancer deaths. In Russia, lung tumors kill more people than tumors of all other organs.
Eliminating tobacco from your life is the best prevention. Even if you smoke not a pack a day, but only half, the risk of lung cancer is already reduced by 27%, as the American Medical Association found.

3. Does excess weight affect the development of cancer?
Keep your eyes on the scales! Extra pounds will affect not only the waist. The American Institute for Cancer Research has found that obesity contributes to the development of tumors in the esophagus, kidneys, and gallbladder. The fact is that adipose tissue serves not only to store energy reserves, it also has a secretory function: fat produces proteins that affect the development of a chronic inflammatory process in the body. And oncological diseases just appear against the background of inflammation. In Russia, 26% of all cancer cases are associated with obesity.

4. Does exercise help reduce the risk of cancer?
Set aside at least half an hour a week for exercise. Sports are on the same level as proper nutrition when it comes to cancer prevention. In the US, a third of all deaths are attributed to the fact that patients did not follow any diet and did not pay attention to physical education. The American Cancer Society recommends exercising 150 minutes a week at a moderate pace or half as much but more vigorously. However, a study published in the journal Nutrition and Cancer in 2010 proves that even 30 minutes is enough to reduce the risk of breast cancer (which affects one in eight women in the world) by 35%.

5.How does alcohol affect cancer cells?
Less alcohol! Alcohol is blamed for causing tumors in the mouth, larynx, liver, rectum, and mammary glands. Ethyl alcohol breaks down in the body to acetaldehyde, which then, under the action of enzymes, turns into acetic acid. Acetaldehyde is the strongest carcinogen. Alcohol is especially harmful to women, as it stimulates the production of estrogen - hormones that affect the growth of breast tissue. Excess estrogen leads to the formation of breast tumors, which means that every extra sip of alcohol increases the risk of getting sick.

6. Which cabbage helps fight cancer?
Love broccoli. Vegetables are not only part of a healthy diet, they also help fight cancer. This is also why recommendations for healthy eating contain the rule: half of the daily diet should be vegetables and fruits. Especially useful are cruciferous vegetables, which contain glucosinolates - substances that, when processed, acquire anti-cancer properties. These vegetables include cabbage: ordinary white cabbage, Brussels sprouts and broccoli.

7. Which organ cancer is affected by red meat?
The more vegetables you eat, the less red meat you put on your plate. Studies have confirmed that people who eat more than 500 grams of red meat per week have a higher risk of developing colon cancer.

8. Which of the proposed remedies protect against skin cancer?
Stock up on sunscreen! Women aged 18-36 are particularly susceptible to melanoma, the deadliest form of skin cancer. In Russia, in just 10 years, the incidence of melanoma has increased by 26%, world statistics show an even greater increase. This is blamed on the equipment for artificial tanning, and Sun rays. The danger can be minimized with a simple tube of sunscreen. A study published in the Journal of Clinical Oncology in 2010 confirmed that people who regularly apply a special cream get melanoma half as often as those who neglect such cosmetics.
The cream should be chosen with a protection factor SPF 15, apply it even in winter and even in cloudy weather (the procedure should turn into the same habit as brushing your teeth), and also do not expose yourself to the sun's rays from 10 to 16 hours.

9. Do you think stress affects the development of cancer?
By itself, stress does not cause cancer, but it weakens the entire body and creates conditions for the development of this disease. Research has shown that constant worry alters the activity of the immune cells responsible for turning on the fight-and-flight mechanism. As a result, a large amount of cortisol, monocytes and neutrophils, which are responsible for inflammatory processes, constantly circulate in the blood. And as already mentioned, chronic inflammatory processes can lead to the formation of cancer cells.

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