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12.72. ACUTE APPENDICITIS
The acute appendicitis — the most frequent reason for abdominal surgical intervention and along with an injury of internals, torsion of guts, commissural impassability of intestines and damage of ovaries is one of the few indications for urgentny surgical treatment of children 2 years are more senior. However it is difficult to make the diagnosis of appendicitis at children; in pediatric practice it is considerable more often than in adult, timely not recognizable appendicitis comes to an end with perforation. Cases of death of children from appendicitis meet and now.
Epidemiology. True frequency of an acute appendicitis is unknown; according to the available data, every year concerning this disease 4 of 1000 children till 14 flyings operate. The practicing doctor meets 2 — 3 cases of appendicitis every year, and 3 — 4 patients with appendicitis come every week to departments of acute management of pediatric services; among them boys prevail. Though appendicitis can develop at the baby and even at the newborn, but nevertheless at children more young than 2 years it is unusual and absolutely rare at children more young than 1 year. The peak of incidence is observed at teenagers and adults of young age. Appendicitis arises in autumn and summer months more often.
Etiology. Almost always the acute appendicitis is caused by obstruction of a gleam of a worm-shaped shoot, but the mechanism of obturation can be various. At histologic research of the inflamed shoot in the place of obstruction find dense particles or fecal stones. The proximal part of a worm-shaped shoot can be attached to a caecum by Jackson's team (anomaly of development) owing to what the shoot forms an acute excess and there is an impassability. The mesentery of a shoot can be so narrow that the distal part it together with a mesentery is overwound owing to what there is an acute ischemic necrosis. The hyperplasia of lymphoid elements in a submucosal layer, mainly as a result of an intercurrent infection is one more reason of obstruction. At morphological research normal and patholologically the changed shoots often find pinworms in them, however their role in an etiology of appendicitis is not found out. Shoot cavity fibrosis as an outcome taking place before inflammations and a carcinoid tumor (argentaffinoma) also contribute to development of an acute appendicitis.
Not obstructive appendicitis is rare; in some cases it is caused by fecal stones which then are expelled in an intestines gleam. Changes in fabrics and clinical manifestations at not obstructive appendicitis are less expressed, and sometimes it is allowed without perforation.
At bacteriological research reveal growth of the mixed intestinal microflora. Especially important role in development of intraeritonealny abscesses after perforation or surgical intervention is played by anaerobe bacterias.
The accompanying diseases can mask appendicitis owing to what it is diagnosed out of time and the risk of perforation increases; system infectious diseases hardly cause appendicitis or I contribute to it.
Pathogeny. At children of younger age the illness usually develops so quickly that the first of 3 stages of a pathogeny passes before the child comes into the view of the doctor. The first stage — sudden obstruction of a worm-shaped shoot, increase of pressure in its gleam because cells of a mucous membrane continue to produce slime. The prelum of vessels of a mucous membrane causes ischemia, death of cells and an ulceration. The second stage — after emergence of ulcers occurs fast infection of a mucous membrane. Inflammatory infiltrate takes all layers of a wall of a shoot; on a serous cover fibrinous exudate appears; even before perforation from a serous surface of the inflamed shoot it is possible to sow microorganisms. The third stage — perforation owing to a necrosis of a wall of a shoot and fecal pollution of an abdominal cavity. The perforative opening is localized in the field of a top or the basis of an appendix where the fecal stone passes through a shoot wall.
Children of advanced age have an epiploon and an adjacent ileal gut usually cover the inflamed appendix even before perforation that prevents development of diffuse fecal peritonitis. As a result limited abscess, mainly in the right ileal area forms, but sometimes it is localized in a cavity of a small pelvis. The multiple septic centers in an abdominal cavity and a pleura empyema as a result of generalized peritonitis are observed now seldom as the diagnosis is made, as a rule, at an early stage when treatment is most effective. Appendicitis can be complicated by paralytic or mechanical impassability of intestines, and also break of abscess in the adjacent soldered intestines loop, but not in a free abdominal cavity. Break of abscess in intestines sometimes leads to spontaneous recovery. At children of chest and early age appendicitis quickly is complicated by perforation and diffuse peritonitis as their epiploon has the small sizes and cannot localize an infection.
Clinical manifestations. Pain reaction is noted at all patients. At first, when process is limited to mucous and muscular covers of a worm-shaped shoot, pains have skhvatkoobrazny character and are localized in paraumbilical area, they are caused by the hyperperistalsis of an appendix directed to exile of an occluding body. When in process it is involved
the parietal and visceral peritoneum, pain is felt directly under an appendix. Thus, pain is localized in the right ileal pole, but can be felt in hypogastriums and even in a small basin or a waist (depending on localization of a shoot". At body concussions (jumps, driving in the car) pain amplifies. In this stage the expressed muscle tension of a front abdominal wall over an appendix, temperature increase, tachycardia and a leukocytosis are noted. Though at many children of advanced age of pain develop on classical type, in many cases pain is localized in the right ileal area during all disease. Small children often lay a hand to a navel when they are asked to show where hurts. At babies irritability, desire to lie not movably with the bent legs can be the only symptom of pain. Attacks of pains at obstructive appendicitis seldom happen strong. It is possible to tell that if the child of advanced age cries with an abdominal pain, then it is not appendicitis. The inflammation of a peritoneum is followed by pain at each movement (cough, sharp turn of a trunk).
After emergence of pain there is almost always rare not plentiful vomiting; the child is more senior, the it is more rare. Anorexia is observed practically at all children.
At children usually perforation comes so quickly that the lock does not manage to develop. Diarrhea is, as a rule, caused by an acute gastroenteritis, however the liquid chair can appear also at appendicitis when the large intestine is angry the inflamed shoot adjoining to it. At an inflammation of the worm-shaped shoot located in a small basin the speeded-up urination owing to irritation of a bladder is observed.
Sometimes localization of the inflamed shoot in retrocecal or retroilealny space strengthens a lumbar lordosis and forces the child to bend a hip owing to a spasm of the right lumbar muscle. Collecting the anamnesis, in many cases of an acute appendicitis it is possible to establish that in the past similar, but easier attacks took place.
At survey of the child it is important to pay attention to color of integuments (pallor, face reddening), the general physical activity, the movement of a front abdominal wall, pulse rate and rectal temperature. If slightly to shake a bed or the child, having put a hand on his hip, then the pain which arose at the same time in the right lower quadrant of a stomach will testify in appendicitis. During conversation and survey of the patient it is important to create a quiet situation, to entertain the child a joke, it is impossible to hurry or do the sharp frightening movements.
Inspection is begun with an abdominal cavity at once, having postponed other methodical receptions for later term. First. it is necessary to pay attention to whether the stomach is blown up and whether the abdominal wall is mobile. Is more senior than the child ask to cough, involve and stick out a stomach; at the same time in a zone of irritation of a peritoneum there is pain reaction. Children of younger age at first it is possible to palpate by means of a stethoscope; stethoscope pressure upon an abdominal wall is constantly strengthened, and then passed to a manual palpation. It is important to estimate muscular resistance, slightly pressing on an abdominal wall in each quadrant. The palpation has to be gentle, otherwise muscular reaction to pain will not give the chance to estimate a true tone. Localization of the revealed muscular tension has essential value; at children of advanced age it often corresponds to Mac-Berney's point (border of a lateral and average third of the line connecting a front upper awn right ileal (a bone with a navel). At children of younger age tension is usually localized in the right ileal pole. A valuable symptom, especially at the uneasy child, pain in an appendix zone in response to a palpation of other departments of an abdominal cavity is. The diagnostic receptions based on provocation of muscular protection are inexpedient as they cause pain and break psychological contact between the patient and the doctor. Besides these receptions often yield false positive and false-negative results. Peristaltic noise at an acute appendicitis are usually weakened or are not listened at all.
The atypical arrangement of a shoot causes diagnostic difficulties. If it lies in a fillet lateralny a caecum, then tension can be defined in the right lateral area of a stomach. It is possible to Propalpirovat the shoot which is in a small basin only through a rectum. Retroilealny appendicitis is shown by pains of uncertain localization so the diagnosis, as a rule, manages to be made only after perforation. The inflammation of the shoot located on m. psoas forces the patient to lie on the left side with the right leg attracted to a stomach. Attempt to passively unbend a leg causes pain (psoas symptome). The only most informative diagnostic character — constant considerable local muscular tension. It does not change from research to research, different doctors reveal it in the same place. The inflamed, but not become torn shoot does not cause unilateral and the more so the bilateral muscular tension therefore existence of an extensive zone of muscular tension calls into question the diagnosis of uncomplicated appendicitis.
The following stage — an assessment of the general condition of the patient which comes to the end with obligatory rectal research. To facilitate inspection of especially excited patient, sometimes it is given light sleeping pill, for example a barbiturate, but in general purpose of hypnotic drugs or sedatives should be avoided. The patience and delicate persistence allow to perform full inspection of the child who is in fear. In hard cases it is useful to inspect repeatedly the child in 4 — 6 h as appendicitis at children develops quickly enough and this term is sufficient to reveal change of a clinical picture and to make the correct diagnosis. However even in ideal circumstances
in 15% of cases of expected appendicitis delete an uninflammed shoot.
Datas of laboratory. Increase of number of leukocytes in blood indicates acute purulent process. The neutrophilia with shift of a formula to the left and an aneosinophilia is noted. At teenagers the leukocytosis in the first stage of a disease usually does not exceed 15000, but at children of younger age it can reach 20000 and more, even without perforation. In some cases the quantity of leukocytes falls below norm. The pyuria is a sign to an infection of uric ways, especially if it is followed by presence of bacteria in fresh urine, however similar changes in urine can be observed also at an acute appendicitis when the inflamed shoot prilezhit to an ureter or a bladder. Other biochemical hematologic indicators of a maloinformativna at diagnosis of appendicitis, but help to estimate the general condition of the patient.
Radiological it is possible to find impassability of intestines, a calcific stone in a worm-shaped shoot, and also pneumonia. Appendicitis sometimes causes right-hand scoliosis. Define paralytic impassability of intestines by a radiological method. Nevertheless almost in all cases of the indication to operation have to be based on clinical, but not on radiological signs.
Differential diagnosis. Attacks of diffusion colicy abdominal pains and diarrhea usually distinguish enteritis from appendicitis, however the last can develop against the acute gastroenteritis which is already existing several days. The enteritis caused by Yersinia enterocolitica, the acute outbreak of an illness Krone or a regional ileitis, and even invagination of intestines can be followed by the symptoms which are very reminding an acute appendicitis. In particular, the illness Krone quite often begins behind a mask of appendicitis. Seldom found inflammation of a diverticulum of a podyzdoshny gut clinically is indistinguishable from appendicitis. At many children with pains and muscular protection in the right ileal area mezenterialny lymphadenitis takes place. The ileocecal lymphadenopathy causing appendicitis symptoms meets seldom. Many generalized viral infections are followed by abdominal pains which are usually localized in a mesogaster, amplify after food and are followed by a neutropenia. The system infection, as a rule, is shown in the beginning by fever, a headache and oznoba, and abdominal pains appear later. The irritation of a diaphragm at right-hand nizhnedolevy pneumonia causes the expressed rigidity of the right half of a front abdominal wall and synalgias reminding appendicitis. The abdominal pain sometimes accompanies acute streptococcal tonsillitis or pharyngitis; at the same time the clinical picture is very similar to appendicitis, besides, appendicitis really can accompany these diseases. Acute rheumatic attack also sometimes begins with abdominal pains. The infection of uric ways is in certain cases shown by an appenditsitopodobny syndrome therefore careful urological research has to precede appendectomy always. Not diagnosed diabetes can be confused with appendicitis as diabetic to etoatsidoz causes abdominal pains and vomiting. Therefore before urgent surgical intervention it is necessary to make the analysis of urine which allows to establish correct the diagnosis. Bleeding from the right ovary, counts the follicle or a persistent yellow body can simulate appendicitis. Primary peritonitis is considered in section 12.105.
Abdominal pain — a frequent symptom of many hematologic diseases. It is observed at leukoses, especially during the periods of aggravations. It is necessary to remember, however, that at a leukosis there can be true appendicitis which clinical signs can be erased by immunodepressive drugs. It is necessary to think of appendicitis at abdominal pains at the patient with hemophilia though is more often the basic disease is their reason. Heavy painful attacks often accompany anaphylactic purpura (Shenleyn's illness — Genokh) and a sickemia.
Treatment. Method of treatment of an acute appendicitis in an early stage is urgent appendectomy. Only at force majeure it can be postponed for several hours. Recovery comes quickly, in 3 — 4 days the child is physically active. Most of surgeons recommend to apply at limited appendicular abscess an outside drainage after the corresponding correction of water and electrolytic balance.
At the diffuse peritonitis which arose owing to a rupture of an appendix it is required to enter intravenously saline solutions before operation as the inflammation of a peritoneum is followed by big loss of liquid. The amount of the entered liquid directly depends on dehydration degree. If symptoms of dehydration are absent, then enter Ringer's solution with lactose in the quantity making 5% of body weight. Before operation pour in a half of necessary amount of liquid, and other quantity — in time and after intervention. In the presence of symptoms of dehydration the volume of the entered liquid has to be equal to 7% of body weight; a half of shortage is filled in the preoperative period. At sharp dehydration the volume of the entered liquid can reach 10 — 15% of body weight. Before operation it is also necessary to provide adequate diuresis.
At perforation antibiotics enter before operation in such doses which provide necessary concentration of medicine in blood and fabrics. Method of the choice is intravenous administration of mix from 3 antibiotics — aminoglycoside, ampicillin and clindamycin or one of new aptibiotok of group tsefalo-
Sparinums. Appendectomy is necessary to stop fecal pollution of an abdominal cavity. After operation it is important to support water-salt balance, and also to regulate vnutrizheludechnoye \and intra intestinal pressure by means of the probe entered through a nose before recovery of a vermicular movement.
Forecast. The forecast is very good if appendectomy is carried out before perforation, but even after a rupture of a shoot the forecast remains favorable. According to Children's hospital Toronto, from 550 children with diffuse peritonitis owing to perforation of an appendix died 3 (0,5%).
Complications. The most frequent complication in the postoperative period — an infection, usually in the field of a wound. If the shoot was gangrenous or perforation took place, then formation of pelvic, subphrenic or other intra belly abscesses is possible. During this period the useful information can be obtained by means of ultrasonic scanning. Development of an abscess in an abdominal cavity does not demand urgent repeated operation as almost all pelvic abscesses are opened in an adjacent loop of intestines and are spontaneously resolved. They practically should never be drained through a rectum; however subphrenic suppuration demands creation of a surgical drainage.
After diffuse peritonitis long paralytic impassability is often observed; it amplifies if the patient begins to be fed before term.
Impassability of intestines can arise as postoperative complication. If it appears within a month after appendectomy, then nonsurgical treatment is desirable. The impassability which appeared in later terms can try to be liquidated by a decompression by means of a gastric tube (in the absence of symptoms of ischemia of intestines). If during 48 h it is not possible to recover passability, then it is necessary to resort to a laparotomy. Commissures in the right lower quadrant can lead to torsion and even to gut gangrene. Such complication can arise in many years after appendectomy. Pelvic peritonitis after a rupture of an appendix can cause impassability of uterine tubes and the subsequent sterility.
Worm-shaped shoot and chronic abdominal pains. Crossclamping of a worm-shaped shoot fibrous commissure, and also or a fecal stone is considered to be its obstruction of helminthomas as the important reasons of recurrent or chronic abdominal pains, and many children, proceeding from these reasons, subject to planned appendectomy. The positive effect is in certain cases reached, but at most of children of pain after operation remain. Further diagnose pathology of uric ways, dysfunctions of digestive organs which are not connected with appendicitis or mental disturbances for them. Recurrent obstruction of a worm-shaped shoot — the rare reason of chronic abdominal pains; the issue of operation needs to be resolved only after careful search of other reasons of pain. Existence of an appendicism is doubtful.
Acute mezenterialny lymphadenitis. This low-studied state often accompanies acute upper respiratory tract infections and can simulate an acute appendicitis. Both the acute, and chronic inflammation of lymph nodes of a mesentery sometimes accompanies infectious process in a worm-shaped shoot or intestines.