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Appendicitis at children

Table of contents
Appendicitis at children
The historical background about an inflammation of a worm-shaped shoot
Anatomy of a caecum and worm-shaped shoot
Physiology of a worm-shaped shoot
Etiology and pathogeny
Sensitivity of anaerobic flora to antibiotics
Pathological anatomy
Clinic of appendicitis at children of advanced age
Clinic of appendicitis at children of advanced age - survey
Clinic of appendicitis at early children's age
Acute appendicitis at newborns
Retrocecal appendicitis
The deep, toxic, masked appendicitis
Laboratory researches
Current of an acute appendicitis
Surgical diseases of abdominal organs
Surgical diseases of paraabdominal bodies
Urological diseases
Diseases of the gynecologic sphere
Internal diseases
Infectious diseases
Neurologic diseases
Indications to operation
Surgical treatment
Treatment of acute perforative appendicitis with the progressing diffusion peritonitis
Elimination of the center of an infection at acute perforative appendicitis with the progressing diffusion peritonitis
Fight against an infection at acute perforative appendicitis with the progressing diffusion peritonitis
Recovery of a homeostasis
Periappendikulyarny infiltrate and abscess
Subphrenic abscess
Postoperative intestinal impassability
Paralytic intestinal impassability
Mechanical intestinal impassability
Late mechanical intestinal impassability
The intestinal impassability caused by intraperitoneal infiltrate and abscess
Chronic recurrent appendicitis
Abnormal mobility of a caecum
Own results
The short overview of the past and perspective on the future

Аппендицит у детей

Prof. MU Dr.
Vaclav Tolovsky, DrSc., spolupracovnici
Avlcenum/zdravotnicke nakladatelstvi, Praha

V. Toshovsky
Transfer from the Czech V. D. Sukharev
Moscow "Medicine" of 1988
Toshovsky V.

In the monograph questions of a current of an acute appendicitis at children of various age groups are taken up. The short overview of anatomy and physiology of an appendix is provided, data on an etiology and a pathogeny of an acute appendicitis are provided. Clinical displays of a disease and feature of a clinical picture at various forms of an acute appendicitis at children of younger and senior age are described. Questions of differential diagnosis and surgical treatment are considered. Possible postoperative complications and the related morbid conditions are provided.
For surgeons, pediatricians, gastroenterologists, therapists.


At children, as well as at adults, the acute inflammation of a worm-shaped shoot of a caecum is the most frequent disease demanding operational treatment. So, for example, until recently in one decade Czechoslovak surgeons made more than half a million appendectomies [Pavrovsky, 1968]. This disease arises suddenly, is not predicted, and features of its current create great difficulties for diagnosis. So far artful and changeable character of a disease constantly conceals in itself a possibility of dangerous complications. Practically at one other surgical disease wrong diagnoses, as so often do not meet at an acute appendicitis.
It formed a basis of my commitment to this problem. The big role in forming of the direction of my research interests was played also by the academician Arnold Irasek who during a time of our study at university prepared the book "Acute Abdominal Pathology" unsurpassed for those times for issue and which lectures on this subject we, future physicians, listened with the held breath, taken so by their contents, as both great skills and fascinating form of presentation of material.
To distinguish an acute inflammation of a worm-shaped shoot happens sometimes extremely simply. Even nonprofessionals can make quite often correct diagnosis. In other cases this task can be difficult even for the experienced surgeon who daily faces acute pathology of abdominal organs and always remembers a possibility of appendicitis. In some cases, unfortunately, quick start and the atypical course of a disease lead to overdue statement of the correct diagnosis already in a stage of perforation of a worm-shaped shoot when inflammatory process extends to a peritoneum and the peritonitis symptomatology appears.
Further changes in a condition of the patient depend on timely diagnosis. At a simple inflammation of a worm-shaped shoot and the uncomplicated course of a disease, and also timely surgical intervention during the postoperative period of the patient practically does not show complaints, pointing out only insignificant sensitivity in area: operational wound. The sleep at the patient is not interrupted, body temperature normal, pulse meets standard, breath equal and quiet. Nausea and desires on vomiting are absent, with the first passage of flatus and fecal masses the intestines peristaltics appears. The wound heals first intention. Not later than in a week after operation of the patient it is discharged from hospital.
At late recognition of a disease there is a so-called postoperative storm. Limited inflammatory process with formation of infiltrates and abscesses (superficial and deep) which then diffuzno extends to a peritoneum develops. On this background there can be phenomena of intestinal impassability of the paralytic, mechanical or mixed type with threat of endotoxic shock: fistulas, superficial and deep, sometimes fecal, burdening a condition of already exhausted patient are formed. There is a need of repeated operations, painful sufferings of sick do not have the end, his life constantly is in danger. Only thanks to modern methods of treatment in most cases it is possible to rescue the patient. However many patients are not among this "majority". Means, and today children die of appendicitis, a disease which our predecessors absolutely fairly called "artful".
The uncomplicated option of a course of process described in the first case comes to an end with an absolute recovery of the patient, bringing joy and simplification to it and his relatives, and also deep satisfaction to the doctor. The second, complicated, the option is a source of alarms and fears, concerns, sufferings, sleepless nights and, besides, testing of professional ability and human qualities of doctors and nurses. It and bitter reproaches from parents and other professionally ignorant persons. Such reproaches to doctors can be understood, however only in rare instances they are justified, reasonable, fair. Reproaches of this sort are followed sometimes even by judicial proceedings.
Our first monograph "Treatment of Peritonitis at Children" published in Prague in 1944 was devoted to this problem. Later 40 flyings we return to an appendicitis subject. With diagnostic mistakes, especially in cases of an acute abdomen at children, we will probably meet constantly. Yet there are practically no changes what also works of the last years testify to. However we have to aim at that there were as little as possible similar mistakes, and over time — to exclude also those from them which, apparently, are today inevitable. The first-priority and main goal of our work — to show the modern level of diagnostic and therapeutic opportunities and to protect, thus, the patient from medical errors in respect of identification and treatment of an acute appendicitis. It is especially important, if it is about the child — a small, defenseless being, unexpectedly sick and lost serene pleasure of life. At the same time we set before ourselves the purpose to protect and the doctor (certainly, only conscientious and professionally competent) who after carrying out all necessary actions, available modern medicine, could not diagnose timely and precisely a disease.
"Acute abdominal pathology" A. Irasek finishes a forward to the book with words: "I will not hide that acute abdominal pathology was for me the most interesting aspect; work on this subject brought me as to the researcher and the surgeon big satisfaction, and failures always served as a lesson in practical work, helping to cultivate with themselves the best professional and purely human qualities, first of all modesty — a trait of character, necessary for the surgeon. I would like that the reader felt it and drew for himself the corresponding conclusions."
Perhaps, it is difficult to find more right and deep words for the preface to this monograph. The subsequent its pages are devoted to our predecessors, their persistent work, courage and experience laid the foundation for our common cause which we only continue on the basis of done by them works. We consider a duty with gratitude to mention names at least of some of our colleagues and teachers, such as R. Yedlichka, A. Irasek, O. Kukula, K. Maydl, I. Pavrovsky, I. Pelparzh, Yu. Petrzhivalsky, I. Podlaga, I. Znoyemsky. Among children's surgeons we will mark out W. Kafka Sr. and B. Kafka Jr., V. Mazal, M. Mikula, to I. Zhukh. Without exaggeration it is possible to tell that concerning them
Tulp's words are quite fair: "Aliis serviendo consumor" that means: "Serving others, I spend myself".
Looking in the future, it would be desirable to express a wish that the surgeon pe faced so often gangrenous, perforative forms of appendicitis that such complications as peritonitis were less often observed, and at operations such forms of pathology of ovaries as a pyosalpinx and a hydrosalpinx which can cause further infertility did not occur at girls. At the same time there is a wish to wish that the number of unreasonably remote worm-shaped shoots decreased to a minimum. The opinion is represented to me a little convincing that the appendix as if is excess body; we know today very few about its function (immune, and it is possible, and endocrine).
(For example, concerning drainage) some surgeons, perhaps, will not agree with our separate conclusions. I think that in it there is a certain sense. We are not supporters of doctrines and dogmas, especially in medicine. I address to the surgeons adhering to other opinions to which I nevertheless am respectful the following lines from the ancient book:
"Non cuique lectori, auditorique placebo.
Lector et auditor nec mihi quisque placet."
Vaclav V. Toshovsky, September, 1983.
Took part in preparation of work for the publication:
X. Gaykova, edging. medical sciences,
I. Yodel, associate professor, edging. medical sciences,
I. Trnkova,
M. Zavadova, edging. medical sciences.
M. Yanets, professor, dokt. medical sciences,
I. Kopetsky, associate professor, edging. medical sciences.

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