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Retrocecal appendicitis - Surgical diseases of an abdominal cavity behind a mask of food toxicoinfection

Table of contents
Surgical diseases of an abdominal cavity behind a mask of food toxicoinfection
Introduction
Acute food toxicoinfection - a salmonellosis
Acute food toxicoinfection - paratyphoid appendicitis
Acute food toxicoinfection - salmonellezny appendicitis
Acute food toxicoinfection - infectious pancreatitis
Comparison of symptoms at acute surgical diseases and food toxicoinfection
Comparison of pains at acute surgical diseases and food toxicoinfection
Vomiting at acute surgical diseases and food toxicoinfection
Diarrhea at acute surgical diseases and food toxicoinfection
Protective tension of an abdominal wall
Symptom of an immovability of a stomach, Shchetkin-Blyumberg
Rectal manual research
Blood changes
Acute appendicitis and acute food toxicoinfection
Pelvic appendicitis
Retrocecal appendicitis
Acute appendicitis at pregnancy
Combination of an acute appendicitis to an acute respiratory infection or to quinsy
Pelviperitonitis of a genital origin
Acute cholecystitis and acute food toxicoinfection
The broken pipe pregnancy masked by acute food toxicoinfection
The restrained hernia
Strangulyatsionny impassability
Obturatsionny impassability
Thrombosis of mezenterialny vessels
Intestinal invagination
Torsion of guts
Acute pancreatitis
Perforated stomach ulcer and duodenum and acute food toxicoinfection
The acute gastrointestinal bleeding masked by food toxicoinfection
Diseases of bodies of uric system
The course of acute diseases of an abdominal cavity at elderly people
Diagnostic mistakes
Literature

THE RETROCECAL APPENDICITIS MASKED BY ACUTE FOOD TOXICOINFECTION
Clinical symptoms of appendicitis often do not correspond to extent of anatomic defeat of a worm-shaped shoot. Banal clinical symptoms of appendicitis so familiar to the doctor can be scarcely noticeable, and sometimes even absolutely be absent, at the same time the worm-shaped shoot can be completely destroyed pathological process. It is possible to meet such phenomenon also at a usual arrangement of appendicitis, but to a thicket face it when the worm-shaped shoot is located abnormally.
In fig. 16 it is shown that the worm-shaped shoot can be located in any place from a navel to a duglasov of space, from one spina ossis ilei to another, can lie in or out of an abdominal cavity.
That scheme which we provided in fig. 16 far does not settle all possible variations of abnormal provision of a worm-shaped shoot. Among the acute appenditsit subjected by us to studying were such when the top of a worm-shaped shoot reached bottom edge of a liver when vnebryushinno the located shoot was found under a horizontal branch of a duodenum etc.
Unfortunately, cases when the most persistent searches of the center which are firmly prompted by initial symptoms of a disease do not lead to the purpose meet. When the expected center is abnormally located worm-shaped shoot, it is possible to face such versions of the provision of a shoot which are not provided by any schemes. The caecum, as well as a worm-shaped shoot, has a full peritoneal cover. Owing to this fact it differs in big mobility. Cases when the caecum is found under the lower surface of a liver, at the bottom of a basin, in left-side femoral hernia and when it managed to be displaced even to the trochanter major level are given in literature (Corning).

положения червеобразного отростка
Fig. 16. Various provisions of a worm-shaped shoot.

 Appendicitis at the retrocecal provision of a shoot is the main thing
source of mistakes, overdue diagnoses, late operations, and sometimes and catastrophic outcomes. These forms of appendicitis are especially easily taken for acute food poisoning and with this diagnosis of patients send to hospital. Not only the patient's relatives, but it is frequent and the doctor directing the patient willingly stop on this diagnosis. Always it is possible to attract some food stuff as a cause of illness; repeated vomiting is so usual for food poisoning, for "diarrhea", without going into detail, with the known stretch it is possible to accept three - or quadruple ease even if it is a usual kashitseobrazny chair.
The major physical symptoms as, for example, reduction of belly muscles to which on diagnostic value concede all symptoms not always draw attention of the doctor not of the surgeon. He is more inclined to be guided by the analysis of white blood and the quantity of leukocytes puts forward as diagnostic test on the first place.
From all abnormally located appendixes we most often should meet with retrocecal and pelvic. The heaviest appenditsita — the gangrenous, close to perforation, even perforated, for the time being protected caecum covering them or inflammatory infiltrate, can "hide" and be shown by suddenly developing picture of rough peritonitis. At retrocecal and retroperitoneal appendicitis the worm-shaped shoot more often than at other forms, is surprised a sphacelism, proceeds with the phenomena of the general intoxication at very scanty symptomatology from an abdominal cavity. This form of retrocecal appendicitis therefore is known under the name toxic.
Quickly developing picture of a necrosis of a worm-shaped shoot in these cases is connected, perhaps, with unfavorable anatomic conditions (the short fixed mesentery, shoot excesses).
Some authors (K. T. Nazyrov, 1967) consider that as retrocecal appendicitis it is possible to consider an inflammation of such worm-shaped shoot which not just hides behind a caecum, and is there in the fixed condition of a pla is located in retroperitoneal space. In these cases inflammatory process long remains closed, isolated from an abdominal cavity that considerably changes a clinical picture.
From among the patients who came to Hospital of S. P. Botkin with the diagnosis of an acute food toksnkoinfektion and further operated concerning an acute appendicitis 16% had a retrocecal and retroperitoneal arrangement of shoots.
31/X 1882 g the famous figure of the French revolution Gambetta died from retrocecal gangrenous appendicitis with two perforation. Only of all famous Parisian surgeons of Lannelong insisted on operation, having firmly stopped on the diagnosis of retrocecal appendicitis and retrocecal purulent accumulation. But other surgeons did not agree with its diagnosis. "My assumptions were rejected — wrote Lannelong — the persons surrounding Gambetta ceased to put in me trust".
We give below some case histories in which all of us reminded the surgeons treating Gambetta a little.
 The patient of 29 years came to hospital with the diagnosis of acute food toxicoinfection in June, 1961 in 4 hours after some error in food. It had moderate force colicy pains in a stomach, mainly in epigastric and paraumbilical area, several times it was torn, was shivering, temperature increased to 37,6 °, the diarrhea was not. The patient has a 34-week pregnancy. Without having shown great attention to pregnancy of the patient when appendicitis demands special vigilance, the duty infectiologist of a reception undertook a number of risky medical actions — a gastric lavage and a cleansing enema. Without having called the surgeon on consultation, it hospitalized the patient. Only after 58 hours for the first time called the surgeon who, having examined the patient, wrote down: "Morbidity in the right ileal area, a soft stomach, a chair after an enema. The diagnosis is not clear". The surgeon was far from thought of a retrocecal shoot. Only in 6 hours after this survey other more experienced surgeon stated: "Pain in right lumbar and in the right ileal area. Possibly, acute appendicitis of retrocecal localization". On operation in an abdominal cavity the muddy exudate is found. The shoot is gangrenous, it is located retrotsekalno in infiltrate, highly spread on a back parietal peritoneum. With great technical difficulties of appendectomia in situ. From an onset of the illness there passed 66 hours, from the moment of hospitalization — 62 hours. The patient recovered.
The infectiologist of 38 years arrived to Moscow for improvement. She worked hard and did not leave visit of lectures even then when ached: began to complain of the general weakness, nausea, abdominal pains and subfebrile temperature. The feeling sick increased, the pain which was defined in the first days in an anticardium extended on all stomach, without having strictly certain localization. Temperature increased to 38,6 °. Only for the 6th day the patient came to hospital. The day before she addressed the therapist who investigated her stomach, found it blown up and could note only sensitivity on the right in space between the XII edge and a comb of an ileal bone, without having attached it any significance. Obviously, in this case it is difficult to blame someone for an illness failure as the patient till 6th day did not see a doctor. It is necessary to express, however, regrets that the therapist, noting at research of the patient sensitivity in the right belly and lumbar area, did not attach to this symptom due significance. At the described clinical picture the knowledge of this symptom would allow to come to the correct diagnosis. The first survey of the patient in hospital showed that the maximum morbidity and tension of muscles keep in lateral part of the right half of a stomach, over a comb of an ileal bone. In blood there were 18 000 leukocytes with neutrophylic shift to 23%. The patient was urgently transferred to department of an urgent surgery with the diagnosis of acute retrocecal appendicitis. On operation the muddy serous exudate in an abdominal cavity is found. The caecum is fixed, behind it infiltrate. With great technical difficulties from infiltrate, after a section of a back leaf of a peritoneum, the phlegmonous shoot is allocated. Purulent infection of pozadibryushinny cellulose.
In the postoperative period the progressing phlegmon of this cellulose. Repeated operation did not rescue the patient: at the phenomena of a heavy septicaemia she died.
The patient of 25 years with the diagnosis: acute appendicitis (?), acute food toxicoinfection (?) came to Hospital of S. P. Botkin in 1963. The duty surgeon, having examined the patient the first, rejected the diagnosis of an acute appendicitis and surely replaced it with the diagnosis of acute food toxicoinfection though in the history of an illness wrote down: "A back pain and a stomach on the right with return down a stomach — in a bladder". In 2 hours the same surgeon, examined the patient repeatedly and noted in the history of an illness: "The stomach soft is also absolutely painless at a deep palpation. There are no data for an acute appendicitis now. Consultation of the infectiologist". The infectiologist, though did not see any symptoms of food toxicoinfection, under pressure of the surgeon transferred the patient to infectious department. The patient continues to complain of small abdominal pains. The chair is still absent. The patient lies quietly, does not disturb the doctor, and the last is busy with entering into a case history of numerous home details. From a case history we learn heredity of the patient, the postponed children's diseases, including measles, whooping cough, dysentery, we learn that the family lives in the apartment from two rooms that it consists of 3 people, including the 6-month-old child. Unfortunately, there is no word about the made rectal research, about a palpation of belly and lumbar area. The surgeon, "having given" painful to the infectiologist, watches her repeatedly only 32 hours later after the first survey. Record it says: "A stomach at research soft, lekalny morbidity in the right ileal area. Shchetkin's symptom — Blyumberg indistinct. Symptom of Rovzinga positive". Again words about purposeful research of belly and lumbar area.
From the given supervision it is obvious, as the infectiologist, and the young surgeon had no due idea of those receptions to which it is necessary to resort for the diagnosis of such forms. Symptoms accrued and in 36 hours from the moment of arrival of the patient operation is made; there is no exudate, the shoot is located retrotsekalno is, zabryushinno, immured, removed with great technical difficulties. Gangrenozno the changed top of a shoot is highly located at the lower bound of a liver. The patient recovered.
The patient of 30 years in May, 1964 came to hospital with the diagnosis of food toxicoinfection. The illness began one day before receipt pristupoobrazny pains in an anticardium, nausea and the general weakness. Several times tore it, once was a kashitseobrazny chair, strongly was shivering, temperature increased        to 37,8 °. Within the last year the patient had 4 similar attacks which were always regarded as food poisoning. It is necessary to do justice to the duty infectiologist: he tverdo rejected the diagnosis of food toxicoinfection and caused on consultation of the surgeon. From this point the patient repeatedly looks round surgeons who steadily write down in the history of an illness: "The stomach is not blown up, in breath participates, in the right ileal area morbidity only at a deep palpation, not clear symptom of Shchetkin — Blyumberg". However in the history of an illness there are no instructions on the fact that someone from the doctors examining the patient thought of a possibility of abnormally located shoot and made in this direction necessary research. Only in 46 hours from the moment of receipt and in 3 days from the beginning of a disease of the patient it is operated; the gangrenous shoot which was located retrotsekalno in dense infiltrate is hardly allocated and removed retrogradno. Fortunately, the integrity of infiltrate was not broken anywhere, in an abdominal cavity there was only a pure serous exudate.
Along with numerous examples when did not even think of a possibility of retrocecal appendicitis, to pertinently give a case history of the patient in which the diagnosis was timely made at a symptomatology which could cause to a certain extent suspicion on the most acute food toxicoinfection. Involvement of more experienced companion for the solution of not clear question is the rule which is not allowing an exception.
The patient of 22 years in July, 1964 arrived with the diagnosis of acute food toxicoinfection. There passed 20 hours from an onset of the illness. Exclusively serious, semiconscious condition, the patient it is sluggish, adynamic, extremely weak, complains of pains in a navel, the face is covered cold then, pernicious vomiting. About function intestines, unfortunately, in the history of an illness are not present instructions. The infectiologist called the surgeon who wrote down: "The acute appendicitis cannot be excluded" and appointed digestive tract roentgenoscopy (??) In an hour of the patient it is examined by other, more experienced surgeon who noted that pains are defined as much as possible when pressing on lateral part of an abdominal wall, is slightly higher than a comb of an ileal bone, and concluded: "Clinical picture of an acute appendicitis, apparently, retronekalny localization". On the operation made in 25 hours from the moment of receipt it is established that the gangrenous shoot is located retroperitonealno under the lower horizontal branch of a duodenum, deeply goes to retroperitoneal space between an inner edge of m. ileo-psoatis and a backbone. The patient recovered.
The given examples could be increased several times, but also they are enough to draw those conclusions which arise by itself. The unexperienced doctor quite often forgets that nondetection of usual symptoms of appendicitis does not guarantee that the patient has no appendicitis, and does not exempt the doctor from absolutely necessary bimanual belly and lumbar research, it is preferable in position of the patient on the left side. Lack of symptoms of an acute appendicitis, so usual for the doctor, calms him, and he surely rejects this diagnosis. Calmed by results of the as a matter of fact defective research, the surgeon reports painful to the infectiologist. The last if it is young and is confident in itself(himself) insufficiently, comes under influence of the surgeon and transfers the patient to infectious department. It it never has to do if it has no absolute confidence in correctness of the surgeon because here that chain of wrong actions and appointments which are quite convincingly provided in the given case histories begins. Time goes, operation is removed, the situation eventually accepts drama character. Most of patients with appendicitis who perish without operation or are operated too late, are patients with retrocecal appendicitis. It they, without causing big alarm in the doctor owing to false protection of the ominous center "cover" for the time being, are capable to be shown at some point by pozadibryushinny phlegmon, the purulent progressing phlebitis, peritonitis, and sometimes and a deadly septicaemia.
Dense infiltrate in which the destructive center is immured, temporarily reducing sharpness of symptoms, gives the deceptive chance to regard a disease as the systemic intestinal infection (a tifo-paratyphoid disease) or to justify primary diagnosis of acute food toxicoinfection with which the patient came to medical institution.
At the come calm after the first days of abdominal pains and repeated vomiting, despite a soft stomach and lack of muscular protection from an abdominal wall, it is necessary to estimate with exclusive attention some indirect symptoms as increase of pulse to 110 — 120 beats per minute, chilling, small temperature increase and shifts of white blood. Initial, very acute symptoms of an illness can almost disappear. In 4 — 5 days temperature increase is almost not noted, the patient quietly lies, without showing special complaints, but then temperature begins to increase progressively. It can say that the formed infiltrate is abscessed. The third and most terrible moment when the integrity of the infiltrate delimiting the destructive center is broken and abscess is opened or in pozadibryushinny cellulose, having caused septic phlegmon of the last, or in an abdominal cavity, having caused the rough diffusion peritonitis which sometimes is quickly coming to an end with death of the patient.
The death of the brother who died from not recognizable pozadibryushinny phlegmon of an appendicular origin is memorable to us.
Whatever strong and harmless infiltrate seemed, it is never impossible to be charged that it is rather reliable.
Experiences which got to us many years ago, in days of early profession of a physician are remembered. A family of one famous poet, going for a while to Kiev, charged to watch their grandmother 70 years "recovering" from appendicitis with infiltrate, proceeding very favorably. The health of the patient was good, temperature almost normal, pains any were not, the chair is settled. The infiltrate palpated on the usual place, appear, every day decreased in sizes; it was authorized to patient to go for the dacha under Moscow. In 5 days the softened infiltrate suddenly was opened in an abdominal cavity, and the patient within 2 days died from septic peritonitis.
The terms which went from the moment of a disease and from the moment of receipt to hospital before operation at patients with a retrocecal arrangement of a worm-shaped shoot are shown in tab. 4. It is impossible to tell that these figures give the grounds to big optimism and self-calmness.
TABLE 4
Acute appenditsita of retrocecal and retroperitoneal localization


Time which passed from an onset of the illness before operation (in days)

Number of patients

Time which passed from the receipt moment before operation

Number of patients

To 1

1

Till 6 o'clock

5

1 — 2

15

6 — 12"

5

2-3

9

12 — 18"

3

3 — 4

1

19 — 24 hours

6

4 — 10

5

1 — 2 days

8

10 and more

4

2 — 4"

6

 

 

7 — 9"

2

In with e of the lake.

35

In with e of the lake.

35

The lethality at retrocecal appendicitis remains high. On our material it is expressed by figure of 54,5% from total number of the patients who died of an acute appendicitis. V. N. Meshkova (1958) gives lethality figures on Institute of N. V. Sklifosovsky for 10 flyings (1945 — 1955): from 21388 patients with an acute appendicitis died 90, from them 9 patients were not operated. On opening all 9 patients had a retrocecal appendicitis. From operated died 81, at 54 of them there were retrocecal appenditsita.
D. A. Arapov, noting that results of treatment at a retrocecal arrangement of a worm-shaped shoot are more sad, than at usual anatomic ratios, concludes that if to remember this form and not to be limited to a palpation of a front wall of a stomach, then he of diagnostic mistakes will be much less. This symptom is very important; it is recommended persistently and patiently to find it. To pertinently remember witty expression of Mondor: "Pain and tension at an acute appendicitis not always appoint to the surgeon meeting in the right ileal area".


Fig. 17. A temperature curve at gangrenous retrocecal appendicitis.
and — receipt in hospital at the end of the days from an onset of the illness; — imaginary improvement within 5 — 6 days owing to formation of the extensive dense infiltrate which covered the center of destructions; in — increase of painful symptoms; — operation (phlegmonous and ulcer appendicitis: pernappendikulyarny abscess); d — recovery.
Three temperature curves given on fig. 17, 18 and 19 concern to patients from whom one recovered after long stay in hospital, another died for the 27th day of an illness from pozadibryushinny phlegmon, and the third immediately died from septic peritonitis owing to break of an abscess in an abdominal cavity. All three came to different terms from the beginning of a disease with the same diagnosis: "Acute food toxicoinfection".
Температурная кривая при ретроперитонеальном гангренозном аппендиците
Fig. 18. A temperature curve at retroperitoneal gangrenous appendicitis.
and — receipt for the 6th day of an illness; operation in 4 hours after receipt; 6 — "improvement" within 3 days after operation; in — the accruing deterioration owing to formation of pozadibryushinny phlegmon; — drainage of pozadibryushinny phlegmon; d — death for the 27th day of an illness.
Температурная кривая при ретроцекальном флегмонозно-язвенном аппендиците
Fig. 19. A temperature curve at retrocecal phlegmonous and ulcer appendicitis.
and — receipt in hospital for the 5th day of an illness; — imaginary improvement owing to formation of the friable infiltrate which covered the destructive center; in — break of the abscess formed in the center of infiltrate in a free abdominal cavity; — death from septic peritonitis.



 
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