Features of acute appendicitis in pregnant women, children, patients of elderly and senile age. Features of the course of acute appendicitis in children, in the elderly and during pregnancy features of the course of acute appendicitis in children

Assessment of the course of acute appendicitis Children makes it difficult to faster progression of inflammatory phenomena and lower symptoms.
In addition, the child does not know how to report them in time. A larger reaction of children for infection and less resistance to it is marked. The position of the worm-shaped process in the abdominal cavity and in relation to the ileocecular sector in children is less typical than adults.

More often in children a worm-shaped process Located in the right lumbar region and under the liver, especially in children under 3 years. The position of the process depends on the options for the location of the blind intestine and the relationship with the ascending department of the colon. The variety of the position of the process increases by the embodiments of the intestinal rotation, tipping, converting and turning along the axis of the ileocecal branch of the intestine (A. R. Shurinka).

In children under 5 years The initial part of the appendicular process in 80% of cases is located above the ultrasound line, while in 80% adults the base of the process is below this line.
Thus, pop Mac Burnea and Lance Do not have a large diagnostic value in acute appendicitis in children (V. E. Deineka).

Large gland that timely " signal"On the inflammatory process and tries to degrade it, in newborns and young children is poorly developed.
By 6 months his lower edge 3.5 cm above the navel, by 2 years - 2 cm above the navel, by 10 years - 1 cm below it. The rapid development of the gland comes during puberty (F. I. Valkher, S. R. Slutskaya).

To that Time blind gut It is lowered significantly lower in accordance with the growth of the ascending colon.
Diagnosis of acute appendicitis Presents special difficulties in children of chest and early children's age (A. P. Besin, S. D. Ternvsky, A. R. Shurinka, A. F. Dronov, Swenson, GROB).

Disease It is often recognized only after caming (GROSS, in 77-90% of cases).
It should be noted spontaneous Clinical symptoms, the relative frequency of diarrhea. A heavy overall condition with toxicosis accompanies running with subsequent spilled peritonitis, especially difficult to flow from a small child. The odds of the inflammatory process is difficult due to the insufficient development of the gland.

With side and retroty arrangement of the process Acute appendicitis often flows hidden with little pronounced symptoms. The pain is localized from behind and on the side and is detected by the palpation of the lower back. With an inflammatory process near the iliac-lumbar muscle, the forced bending of the lower limb in the right hip joint occurs.

Special reception palpation It is easier to reveal the infiltrate near the iliac-lumbar muscle. In the position of the child on a healthy side at the extension of the lower limb, the iliac-lumbar empty is strained. In order to identify the voltage of the iliac-lumbar muscle, the Trial of Yavorsky is used.
For the location of the inflamed process Vamal Tazus the very beginning is missing all the usual symptoms: vomiting, muscle protective tension, pain.

If a split Does not occur, the disease can pass under the guise of malaise, digestion disorders.
Development of inflammatory infiltrate Or an abscess around the process in the immediate vicinity of the rectum is manifested by painful urges to the act of defecation (tenesms), the temperature increases, the liquid mucosa stool moves, i.e. the picture of enterocolitis is marked. When the inflammatory infiltration is located near the bubble, pain in urination and leukocytes in the urine appear, i.e., a picture of cystitis is created.

Typical signs Acute appendicitis with vomiting, protective tension of muscles, soreness arise with the transition of inflammation from the cavity of the small pelvic to the abdominal cavity. Often, local symptoms appear on the left - the so-called left-sided appendicitis (GROB), which is explained by the anatomical features of the pelvis organs.
A rectal study in such cases is crucial.

Despite the weak development Big Salna, in children after the third year of life, there are no cases of covered acute appendicitis. It can proceed in two versions. At the first embodiment, with a process, covered with a gland, first there are no symptoms indicating the presence of an inflammatory process in the abdominal cavity. They appear later, with a breakthrough in the abdominal cavity. In the second embodiment, a two-phase current is noted: after vomiting and pain in the beginning of the disease, these symptoms are quickly subsided.
but soonIn a few days, they appear again after the spread of the inflammatory process into the abdominal cavity.

Acute appendicitis It often occurs against the background of some children's infectious diseases: measles, scarletins, as well as angina and influenza states. In this case, the vomiting of the abdominal pain is first taken for the symptoms of the first disease. Acute appendicitis is recognized after perforation, with the development of peritonitis.

Acute appendicitis is one of the most common acute surgical diseases of the abdominal organs. Appendectomy is 60-80% of all urgent operations in patients with this group of disease. Postoperative mortality during acute appendicitis decreases and recently co-exactly 0.2-0.3% (simple forms of inflammation practically do not give lethal outcomes). According to the issue of ambulance. N. V. Sklifosovsky, PRN destructive appendicitis mortality is 1%, moreover, more than 60 years of deceased face (B. A. Petrov, 1975).

The course of acute appendicitis is characterized by a number of features. Inside the beginning, a gradually increasing inflammatory process, which flows with the phenomena of local peritonitis, does not go beyond the limits of the Ileocecal region for 1-2 days. However, in recent times, cases occur when destructive changes in the worm-figurative process are developing in the first of the disease. Completely raises general peritonitis. With the high plastic properties of the peritoneum in the first 2-4 days in the ileocecal region, infiltrate may occur from the soldered among themselves around the zone of the oscillation, intestinal loops and parietal peritoneum. Appendicular infiltrate may resolve for 3-6 weeks or join (in different times), which, in turn, is fraught with a breakthrough of abscess and emptying it into the abdominal cavity (it is also possible to spontaneously open an abscess into the intestinal lumen, bladder). A severe complication of acute destructive appendicitis is pylephlegit.

As clinical experience shows, the best results of the surgical leverage of acute appendicitis are observed in patients operated on in the first 6-12 hours from the beginning of the disease. The later the operation was made, the fact of the emergence of complications and the onset of deaths. Therefore, all patients with acute appendicitis, regardless of the term of the disease, are subject to emergency surgical treatment. The exceptions are the persons who received in the later dates, which determine the well-filtered dense appendicular infiltrate without signs of suppuration (A. I. Krakowsky, A. N. ut-Kina, 1981; V. F. Egyazaryan with Sovat., 1984, and others .).

In the majority of patients entering the first 3 days. From the beginning of the disease, the clinical picture is typical, so the diagnosis does not appear to have difficulties. The remaining patients with diagnosis is extremely difficult. This is due to the fact that acute appendicitis has signs similar to other pathological processes and, moreover, can proceed atypically.

Often, acute appendicitis has to be differentiated with gynecological diseases-right-sided and acute inflammation of the appendages of the uterus, twisted with a cure ovary, apoplexy of the ovarian, ectopic pregnant women (F. Richkovsky, 1978; S. M. Lutsenko, N. S. Lutsenko, 1979; V.N. Busz Indo and et al., 1984, etc.). With normally proceeding pregnancy, the benefit of mixing the blind intestine and upstairs, in the event of an acute appendicitis, pain will be larched in the upper parts of the abdomen. It is possible to establish an erroneous diagnosis of acute cholecystitis or pancreas and conservative treatment prescribed instead of emergency operation.

Errors may occur with the differentiation of acute appendicitis with the same diseases of the digestive organs, like acute cholecystitis, acute pan-creatitis, aggravation of the ulcer of the stomach and duodenum, perforation of the ulcers, the inflammation of the ileum diverticule, terminal Ileit. With acute cholecystitis, accompanied by hepatitis, with a significant increase in liver, the inflamed gallbladder shifts into the right iliac region, where the greatest pain is felt. In addition, with acute cholecystitis, infected payments, descending along the right side channel, also accumulates in the right iliac region and determines the pronounced pain in this zone. Similarly, there may be a skap-loss of effusion in the right iliac region in acute pancreatitis. With perforative ulcers of the stomach or duodenal intestine, especially at-indoor, the contents of the hollow organs are also lowered by the right side channel of the book, causing pain, while in the upper parts, the pain is reduced due to the fact that the perforation hole was covered. The di-verticulation and the terminal department of the ileum are located in the zone of the lamination of a worm-like process and their inflammation can easily be accepted for acute appendicitis.

Often, the manifestation of acute appendicitis is reminiscent of the symptoms of urolo-hymical diseases - renal disease when the stone is located in the distal department of the right uretera, the wandering right kidney from the bib of the ureter.

In children under 4 years old, acute appendicitis can flow with a diff-fuzzy pain reaction and a high body temperature, as well as other general phenomena, characteristic of most diseases not only by the abdominal cavity organs, but also the chest, urogenital system, etc. In the first hours of the disease, the children of the capricious are restless. As inxication increases, they become adamic. In children, the destruction of the process and peritonitis develop faster. U 12. % Children are diarrhea, which creates additional diagnostic difficulties.

In individuals of elderly and senile age, there may be no characteristic symptoms of acute appendicitis, and the disease is detected only when a common peritonitis develops.

According to our data, the incidence of acute appendicitis in people of both sexes aged 15 to 19 years old is the largest-114.9, 10,000 people, in children from 1 year to 4 years-11.4, people aged 60-69 years-29 , 7, 70 years old and old-seed-15.8; In children under 1 year (the most "dangerous" in terms of diagnostic errors, a group of patients) The incidence is low - 3.48.

In patients of all ages, especially in children, right-sided lower-grade pneumonia can be accepted for the attack of a sharp appendi quota. In some patients with diabetes mellitus, there may be a clinic of "false abdomen" with uncertain symptoms.

Difficulties in the diagnosis of acute appendicitis may occur during the atypical arrangement of a worm-like process. In its mid-position in the process, the adjacent loops of the small intestine are quite quickly involved, and the clinical picture proceeds by the type of acute intestinal obstruction. Appendicitis is diagnosed during surgery.

With a retrocecal arrangement of the process, especially if it is located retroperitoneally or closed in spikes, there are no typical phenomenon of peritonean irritation phenomena in the right iliac region. Pain may radiate in the kidney region, dzuric phenomena may even develop, and therefore the attack of acute appendicitis can be regarded as renal colic. To clarify the diagnosis in such cases, excretory urography are produced.

There are extremely rare cases of the left-sided arrangement of the draft-shaped process. At the same time, the case of the usual arrangement of the process in a patient with dextricardia is described (S. N. Lukashov, 1981).

In patients with acute appendicitis arriving at the 3-4 days and later from the beginning of the disease, diagnostic difficulties are different. In the event that the patient has signs of spilled peritonitis, it undergoes emergency surgical treatment, and the source of peritonitis is detected during the operation. If the patient comes with appendicular infiltrate, the symptoms of peritonean irritation usually do not happen, the dense, well-degraded, painful, still education is palpable in the right iliac region. A characteristic history does not leave doubt in the diagnosis of appendicular infiltrate that requires stationary conservative treatment. When the appendicular infiltration is supposedly increasing, leukocytosis and leukocytic formula shift left, the body temperature acquires a hectician character, the infiltrate is sharply painful, increases in size, sometimes it is possible to reveal the symptoms of the unshame. Patients with ventilated appendicular infiltrate are subject to emergency operational treatment. Abscess is more often revealed from the right side extrearshitic access or use up to-stroke through the vagina or the rectum, depending on the fitting and nasya of the moods with the specified authorities.

The statistics of acute appendicitis are influenced by complications that arise after the presence of the presence, especially in elderly patients, various concomitant diseases, which can exacerbate or move to the decompensation stage. These include cardiovascular insufficiency, pneumonia, renal failure, thromboembolism and diabetes.

We consider it necessary to especially dwell on the question of the treatment of patients who have an east appendicitis occurs against the background of diabetes mellitus.

Performance of operational intervention in such patients is due to the need to use simple insulin, which is prescribed and patients who received oral saccharifying drugs to opera. The dose of insulin depends on the content of the glu-goat in the blood and the urine, which is determined at least 3 times a day.

Another feature is that patients with diabetes mellitus, even with an uncompliant appendicitis, antibiotics should be prescribed in the postoperative period, since they have increased the risk of purulent complications.

According to conjunctural reviews on the Ukrainian SSR for 1981, in the structure of complicated mortality, the share of peritonitis turned out to be the highest - 42%. This, apparently, is due to the fact that peritonitis develops at launched cases, with late operational interventions, as well as in the errors of operational equipment.

In second place after peritonitis, thromboembolic complications are facing (14.5%). Although the probability of the development of thromboembolism after late operations is also higher, nevertheless, to a large extent, these complications should be associated with the underestimation of the presence of terrible states in patients and, as a result, with the lack of relevant prevention.

In third place is a cardiovascular failure-9.2%. At the heart of the prevention of complications of acute appendicitis lies with the independent and unmistakable diagnosis of acute appendicitis and, which is no less important, concomitant diseases. To do this, all pre-foot diagnostic techniques must be used, which are reduced to the following.

1. Careful analysis of the history and clarification of the patient's complaints. The patient's survey begin with clarification of the disease. The time specified is fixed in medical documents.

For acute appendicitis, a acutely arising abdominal pain is characterized, at the beginning of the Nadium region, in the navel region or (less often) throughout the abdomen. Soon pain is localized in the right iliac region. Promotional symptoms are usually absent, sometimes the disease is preceded by general weakness. Often the attack of pain occurs at night. The pain is gradually growing, it is constant in nature, with coughing is strengthened. Be sure to figure out the presence of similar bouts of pain in the past, their duration. Specify whether the patient has a dull pain in the right iliac area with rapid walking or running (characteristic of a chronic recurrent appendicitis during the intergreacy period). Find out whether there is a nausea, whether vomiting was (with acute appendicitis, vomiting may not be), there is no latency of the chair and gases (usually it is, especially on the 2-3rd day and later). Diarrhea is extremely rare, once (in children it is celebrated quite often). It should be found in the patient, whether he had a recent influenza or angina (risk factors), as well as find out the presence of diseases that can simulate acute appan-dicyters (renal and bile sickness, ulcerative ulcer of the stomach and duodenum, diabetes, colitis, In women - gynecological per-roar). Specify whether there are no dysuric phenomena concomitant diseases.

Pain sneeze a few hours from the beginning of an intensive attack, especially in patients with senile age, possibly in the event of destructive changes.

2. Study of the condition of the respiratory organs and the cardiovascular system, determination of the pulse, blood pressure (if necessary, execution of the ECG). The presence of weak breathing or wheezing with auscultation of the lungs, other possible on-detectures detected during percussion and auscultation requires a permissive henth-geoscopy to exclude (or confirm) of pulmonary pathology. It is necessary to find out if the patient has a heart disease, arrhythmia. Check the presence of varicose veins, trophic changes, thrombophlebitis of the lower extremities (often in elderly). In patients of elderly and senile age with common atherosclerosis, pain in the abdomen, a simply linguing acute appendicitis, may be due to the spasm of the vessels of the abdominal cavity. Therefore, nitroglice-rin is given to differentiate pain pain. The latter reduces the pain associated with vessel spasms, and does not change the intensity of pain during acute surgical diseases, including in acute appendicitis.

3. Study of the abdomen. When inspection, the configuration of the abdomen is determined (it is usually not changed during appendicitis), the participation of the anterior abdominal wall in the act of breathing. With acute appendicitis, its right half, especially the iliac region, can restore or not to participate in the act of breathing. The stomach can be slightly. When palpation is determined by the muscle tension of the right iliac region, but with atypical arrangement of the process, it may have a different localization (with complication of acute appendicitis, the entire front abdominal wall is tense).

A large number of pain symptoms characteristic of acute appendicitis are described. The greatest recognition in the clinic was obtained by a symptom of roving (with a push, with the left hand in the left iliac region, the arrangement of the descending segment of the colon, the right hand, is pressed on the overlying segment of the colon; the symptom is considered to be enhanced if the pain in the right iliac region); Sytkovsky's symptom (strengthening pain in the right iliac region with a patient's pollen on the left side), as well as a symptom of Slosset's slip (rapid movement of spacelock down to the blind intestine through a stretched shirt-ku II-IV finger-hand of the surgeon causes an increase in pain in the right sub-seam area). An exceptional value is a symptom of Brush-Blum-Berg (indicates as the symptom of Voskresensky, on inflammation of the peritoneum). It is caused by slow pressed fingers on the front abdominal wall, and then rapidly excluding his hands. The symptom is considered positive if the pain occurs when the hand appears. When determining this symptom, the doctor must indicate the degree of propagation of pain and its severity. It should be remembered that this symptom may be absent or being weakly pronounced with a retro-centened arrangement of a worm-like process, even with destructive changes in it. However, with such acute abdominal diseases, as inflammation of the appendages of the uterus, Crohn's disease, inflammation of the ileal diverticula, acute cholecystitis (with a bubble lowered), per-phratic ulcer, may be a positive symptom of Brush-Blumberg in the right iliac Areas.

In patients with suspicion of acute appendicitis, the definition of the symptom of Pasternatsky on both sides is determined (the appearance of pain when painting by hand on the lower back in the area of \u200b\u200bthe kidneys. In case of suspected for the presence of urological diseases that simulate a clinic of acute appendicitis, the patient should perform a chloroethyl sample on Borisov (the disappearance of pain in the renal colic after irrigating the lumbar chlorhethy-leaving) or blockade of Lorin Epstein (with an introduction of 40-60 ml 0.25 % Ras-Calor Novocaine to the area of \u200b\u200bthe seed rope in men and a round bunch of uterus in women, pain decreases with renal colic and remains unchanged with acute appendicitis). If necessary, urgently performs urography and other studies to determine the diagnosis.

A rectal study must be carried out (the presence of local diseases on the right with acute appendicitis, the hovering wall of the rectum in the presence of effusion), and in women vaginal research.

When fulfilling all these studies, it is necessary to pay attention to the general condition and behavior of the patient, at the beginning of the disease with a sharp appendicitis, the general state remains quite satisfactory (the exception of the children of the first years of life), then can progressively deteriorate as peritonitis develops when the patients are trying to move less Since the movement enhances pain. The language is at first wet, on the 2-3rd day, it becomes dry dry or dry, covered with a white hoist. It is possible to hyperemia, because acute appendicitis, especially in children, is often combined with An-Gina,

Communicable laboratory studies include blood test. The content of leukocytes, the leukocyte formula, ESO (for the acute appendicitis, is initially characterized by moderate leukocytosis, the leukocytic formula shift, aneozinophyla or eosinopenia, normal ESO). The urine analysis is also made (for the differential diagnosis of right-hand renal colic, pyelitis, pyelcistics, etc.). When evaluating the analysis obtained, it should be remembered that with an acute appendicitis of changes in the urine usually no, but with a retrocecal arrangement of a worm-like process, when it is adjacent to the ureter, there may be changes that are not associated with renal pa-tolog.

Many authors recommend measuring the skin (for acute appendicitis is characterized by a higher temperature in the right iliac region compared with the left) and rectal temperature (gradient between skin and rectal temperatures with acute appendicitis more than 1 ° C), in order to diagnose acute appendicitis. A thermal imager, liquid crystal thermography (A. A. Lobenko et al., 1982, etc. is also used.

According to modern views, all patients with the signs of acute surgery-hymic pathology of the abdominal bodies need to be subjected to x-ray research (see p. 17). According to V. G. Polezhaev and co-authors (1984), if he suspected acute appendicitis, a radiological study was shown 12 hours from the beginning of the disease.

As indicated by M. K. Shcherbatenko and E. A. Beresneva (1977, 1981), with an acute catarial appendicitis, reveal radiographic changes.

With an appendicular infiltrate on radiographs produced in the vertical position of the patient, or on a laaterogram can be found a horizontal fluid level, located outside the lumen of the kiss-nickname, more often in the right side channel of the duck from a blind intestine or on an x-ray-gene. Completed in the horizontal position of the patient, the accumulation of small bubbles of gas is determined against the background of a limited darkening, the locale-sowing in the projection of a worm-shaped process.

In difficult diagnostic cases, along with radiological studies, laparoscopy (V.N. Chetwerikova, E. P. Phadichko, 1982, and others) can be provided.

A significant percentage of complications in acute appendicitis are associated with error allowed during surgery, as well as with the errors of patients in the postoperative period.

I. Mattyshin, Yu. V. Baltaitis (1977) analyzed 1146 cases of fatal outcomes in acute appendicitis, which had a place in the medical institutions of the USSR for a number of years. They noted that the majority of patients (70%) were operated on in the first 4 hours from the moment of hospitalization, and the non-decoded outcomes are mainly due to technical and tactical errors during the operation. One of the widespread errors was the wrong choice of anesthetic method. Most patients with uncomplicated acute appendicitis can be operated on under local anesthesia. If you have peritonitis, you need to use overall anesthesia. Previously, it is also shown to patients who assume difficulties in performing the operation due to constitutional features or severity of the pathological process.

As mentioned above, the establishment of the diagnosis of acute appendicitis is an absolute indication to emergency operation, regardless of the form of the disease, the age of the patient, the time spent from the beginning of the disease. Exception can be only patients with the presence of a dense, fixed, well-bound infiltrate.

In patients with accompanying diseases (myocardial infarction, stroke, decompensation of blood circulation, pneumonia, etc.), in which the operation may be more dangerous of the disease itself, the issue of operational intervention is solved by the Consilium of Doctors, individually. With a small period of illness, a qualified medical and laboratory control, permissible to change cold, antihistamines, antibi-ticks. Patients with destructive appendicitis, accompanied by peritonitis, are subject to unconditional operating, although the risk of operation is very large.

Pregnancy, not excluding the first half of her half, when the clinical picture of acute appendicitis is erased, does not serve as a contraindication to operating under the diagnosed diagnosis. Since changes in the Cell-shaped process may not correspond to the external manifestations of the disease, the expectancy is especially dangerous.

Classic operational access is a section on Volkovich-Dyaconov. The length of the cut must be at least 8 cm, while the incision of the skin increases in proportion to the thickness of the subcutaneous fatty fiber. The use of small operational cuts during appendectomy is a gross error of operational equipment.

It should, as a rule, perform an appendectomy in an affected way. At the same time, the worm-like culture is tied with a ketgut and immersed in a brine seam superimposed with silk or a chip. The mesentery of a black-shaped process is tied with a non-reprehensive material, if necessary, it is randed.

An important point of operation is thorough hemostasis. The surgeon does not have the right to close the abdominal cavity if he does not have absolute confidence in a reliable stopping of bleeding (hemostasis control is carried out by introducing gauze tampons, including a small pelvic cavity). The success of treatment often depends on the rational drainage of the abdominal cavity. Under the Ost-ROM appendicitis, drainage is shown in case of peritonitis detection (according to the general rules, taking into account the prevalence of the process); With destructive changes in a worm-like process with the presence of inflammatory effusion (see chapter 2).

Removal of a worm-like process must always be justified. Unacceptable so-called passing appendectomy during other interventions. Appendectomy with an uncontrolled intervention is dangerous, as it is often accompanied by heavy OS-fans associated with the opening of the intestinal lumen and the formation of adhesions.

If there are no macroscopic changes in a worm-like process, then a revision of the terminal division of the small intestine is necessary at a distance of at least 1-1.5 m from the blind intestine to eliminate the inflammation of the diverticule of the ileum or terminal ileet.

With terminal Ilert (Crown's disease) due to non-specific inflammation, the terminal mining department of the ileum is thickened, edema, hyperemic, on the serous shell there are small hemorrhages, it is possible to release fibrinous exudate. The inflamed teaching of the intestine carefully examines, a solution of antibiotics is introduced into the mesentery. The unlucky surgeons sew the operating wound tightly, the majority leave the microderry gator to bring antibiotics after the operation, which is more appropriate.

With inflammation of the ileal diverticulum at a distance of about 60 cm from the ileocecal angle (fluctuations are possible from 20 cm to 1.5 m) on the ileum, the protrusion is completely 4-6 cm long and a diameter of 1 GM (and less) to the width of the iliac Guts (occasionally there are diverticulus of considerable length). May not marvel: catarrhal, phlegmonous, gangrenous changes in the walls of the diverticulus or its per feed. The inflamed diverticulus of the iliac is deleted. With a base diameter, less than 1 cm applies a technique similar to appendectomy. With a wider-room basis, the diverticulactomy is performed by the type of cutting or cone-shaped rectification of the intestine. If the base diameter exceeds half the inch diameter, then it is recommended to a circular resection of the intestine with an anastomosis by the end to the end. When ka-taral!; 6m inflammation of the diverticulus, when serous effusion is absent or the scarce amount is determined, the drainage of the abdominal cavity is not produced, in other cases (phlegmonous inflammation, abundant serous-purulent effusion, etc.) drainage abdominal cavity rules.

You should pay attention to the state of the appendages of the uterus, the colon. During the diffe-renocial diagnosis during the operation, the nature of the exudate (greenish-gray, often sticky, with pieces of food, shine, when adding a drop of iodine - with perforative ulcers; with admixture of bile - with the pathology of the gallbladder; hemorrhagic - with pancreatitis, intestinal obstruction, rebounding the intestines in hernia, ischemia and intestinal in-prank). In doubtful cases, exudate is sent for an urgent laboratory study. In all cases, when antibiotics are assumed, the co-holding abdominal strips is supposed and sent to the bacteriological laboratory to determine the character of microflora and the selection of the antibiotic. Therefore, the operating should always be sterile test tubes.

Purulent peritonitis discovered during surgery discovered during the operation requires appropriate treatment.

The postoperative wound is sewn tightly with acute catarial appne dicitis. In the presence of purulent payments, a pronounced subcutaneous fatty Chatka, when there is a real risk of suppuration, the skin edges of the wound and the life of the fiber do not sneak (primary delayed or secondary seams). With a significantly developed subcutaneous fatty tissue, many authors recommend that the wound is drained to drain it from the corners with a beam of silk yarns for 1-2 days. After the operation, or use water-soluble ointment for the prevention of suppuration.

It is advisable immediately after the operation to impose a cargo on the wound. The next day, after the operation, they definitely change the bandage.

Above, we indicated the need to drain the ventilated appendicular infiltrate. If the abscess cannot be achieved through the right extra-abrained lateral access (at the wing of the iliac bone), through the rectum (National Assembly, the National Assembly of the National Assembly with it) or through the vagina, then an autopsy is made through a typical intraperous oblique cut. For the prevention of infectiousness of the abdominal cavity, before opening the abscess, the location of the alleged intervention should be carefully combed.

Operation in a patient with acute appendicitis is only the beginning of treatment. Some patients with complicated acute appendicitis after the operation are sent to the ward of intensive therapy.

Events that contribute to the timely diagnosis and profilatus of postoperative complications include daily physical, if necessary, X-ray control of the state of the chest organs, con-treatment of the therapist. The best measures to prevent the development of pneumatic-research institute are early rise (from 1-2 days), respiratory gymnastics, chest mass.

Patients with varicose scanning superficial veins in order to prevent thromboembolic complications are necessary even before surgery to break the limbs with elastic bandages (in individuals of elderly and senile age, the binting of the limbs contributes to the stabilization of hemodynamic obstacles). When the operation of the coagulation system of the blood coagulation is discovered before operation, it should be administered intramuscular administration of heparin after operation (5000 meal every 6 hours).

A decrease in the number of postoperative complications by the wound method is to change the dressing in the 1st day on the 3rd day after the operation. In the presence of edema of the edges of the wound, redness, increasing the body temperature Already on the 3rd day after the operation, the removal of one to two seams is shown, breeding on this part of the edges of the wound, assignment of 2-3 UHF sessions. Mandatory is emptying of a geometry or so-called gray. When the infiltration is detected in the depth of the wound, physiotherapeutic treatment methods are shown. In the case of detection in the wound, the purulent discharge is removed all the seams, the edges of the wound are bred. And the painful isolate in specially dedicated chambers or separation for patients with purulent complications.

In the majority of patients with a smooth postoperative course of seams, it takes to shoot on the 5th day. Only in elderly, weakened or obese patients, they are removed on the 7-8 days.

Early seam removal (on the 3-4th day) and early discharge helps to reduce the number of purulent complications. With the uncomplicated course of acute appan-dicitis, patients of young and middle-aged may be discharged on the 3-4th day after the operation (the seams are removed in the clinic). Before discharge, it is necessary to repeat the clinical tests of blood and urine. If there is even a mining increase in body temperature, rectal rectal study is required (to eliminate abscesses or infiltrate in a small pelvis). The increase in ESP may also indicate a developing complication. After extracting from the hospital, the patient must appear in the Polycloth Nick no later than the third day. The frequency of subsequent inspections of the patient in the clinic should not exceed 5 days. The presence of even minor infiltrate requires the appointment of physiotherapeutic treatment methods, in the event of the appearance of ligature fistulas, late suppuration, with which it is not possible to cope within 5-7 days, it is necessary to repeatedly send a patient to the hospital.

Acute appendicitis is the most insidious disease among all the urgent pathology. With it, it makes mistakes not only young, but also kva-licked specialists. Therefore, if the patient complains of pain in Libe, the doctor must first of all eliminate acute appendicitis.

Appendicitis is a disease of the Cell-shaped outflow of a blind intestine (Appendix), which is based on its inflammation. Children are sick less often than adults. However, the picture of the disease in the child differs from that. Consider the features of the flow and symptoms of appendicitis in children in more detail.

Classical development of inflammation in appendicitis

Appendicitis is inflammation of a heart-shaped process. First wears a catarrhal, in the absence of timely operational intervention progresses in a gangrenous form.

In acute appendicitis, the inflammation of the process develops in stages, moving from one stage to another:

• Catarial appendicitis. At this stage, only the mucous membrane of the heart-shaped process is inflamed.
• Surface. Due to the progression of the inflammatory process, primary damage to the appendix mucosa is formed. In his lumen, you can detect leukocytes, blood.
• Phlegmonous. Inflammation captures all layers, up to the outer shell. In the lumen of the pus and blood, on the outer shell - fibrin.
• Phlegmosno-ulceal. On the surface of the mucous membrane, the process is formed ulcers.
• Apostleatous. At this stage, necrosis of fabrics begins.
• Gangrenous. The samples of the wall of the draft-like process, often - breakthrough the contents of the abdominal cavity and the development of subsequent peritonitis. At this stage, the most high mortality from this disease is the highest.

If adults from the moment of the beginning of the inflammation before the gangrenoz appendicitis takes about 2 days, then in children due to the characteristics of the structure of the emerging organism, all processes proceed much faster, so at the slightest suspicion of appendicitis, it is necessary to act very quickly.

Features of the flow of appendicitis in children

From about from the seven age, the signs of appendicitis coincide with those in adults. A distinctive feature is just that the child is more scared, can cry, capricious. Some children because of fear of operational intervention can say that they do not hurt anything and everything is fine.

The kids have inflammation of appendix begins with common symptoms:

• they sleep badly, capricious, restless, refuse food. Against this background, multiple vomiting, nausea, high temperature may be observed.
• The kids show on their stomach and say that they have it all hurts.
• In each eighth or tenth child, a chair becomes liquid, there may be impurities of mucus.
• Sometimes there is a latency of the chair or along with pain in the abdomen, nausea, vomiting and common concern can be an ordinary runny nose.

In the case of an atypical arrangement of a worm-like process, pain is given to the lower back, irradiate into external genitals, in the right hypochondrium.

Aged 0 to 3 years, appendicitis develops very rapidly. It is often observed an increase in temperature even up to 40 degrees, a liquid frequent chair, pain in urination (the kid crying when trying to urinate). Any touching to the abdomen causes an increase in pain, so the children resist inspection, shout, strain the muscles of the abdominal wall. With a careful observation of the child, you can see how he pulls the right leg to the stomach. During the game or movement, kids can suddenly squat and cry.

Due to the difficulty of diagnosis at this age, with any pain in the abdomen or increasing the temperature, it is necessary to show the victim's fellow child.

The beginning of appendicitis in children of this age is gradual and manifested by an ordinary disorder in behavior. At night, the baby can just wake up from crying, sleeping his disturbing. There is an increase in temperature from 37 to higher digits. If the baby is on breastfeeding, the temperature can remain low until the development of the phlegmonous form of appendicitis, so normal numbers on the thermometer are not at all a reason for complacency.

In general, appendicitis under the age of 2 years is practically not found, which is associated with the peculiarities of the intestinal structure.

Other diseases of children with similar symptoms

This picture very often resembles a conventional intestinal infection, as well as a number of other diseases:

• diseases of the stomach and intestines,
• pneumococcal peritonitis,
• diseases of the kidneys and urinary organs,
• right-sided bronchopneumonia
• coprostase
• correct, rubella, chickenpox, scarletina (may be accompanied by pain in the stomach),
• hepatitis.

The difficulties of diagnosis and the abundance of other diseases that are accompanied by similar symptoms, dictate the need to provide a timely as qualified to the surgeon in any abdominal pain in the child.

Otherwise, the probability of developing formidable complications increases sharply, among which not only intestinal obstruction, but also perforation of a worm-like process, the development of peritonitis, blood infection (sepsis) and, ultimately, the death of a child.

To which doctor to turn

If you suspect the child's appendicitis, it is necessary to urgently deliver to a counseling for the surgeon.

With the appearance of appendicitis symptoms, it is necessary to call "ambulance", which delivers the child to a surgical hospital. Additionally, it examines the pediatrician to eliminate other pathology.

Usually acute appendicitis over the age of 3-4 years, more often in 8-13 years. Leather is heavier, more violently, due to the wealth of the process, the lymphoid fabric and the underdevelopment of the large gland and the less pronounced plastic properties of the peritoneum, and therefore the process is not inclined to deliberate. Children predominate destructive forms, after 24 hours 50% occurs perforation - spilled peritonitis + severe intoxication. Diagnostics is difficult because children are poorly localized pain, it is difficult to identify specific symptoms, children are aggressive, the pose on the right side. Frequent vomiting, tachycardia. Local tension of the muscles of the abdominal wall.

In pregnant women.

In the first trimester the current is normal. Distribution in the diagnosis in the second trimester, the fact that the increased uterus displays the process into the upper floors of the side canal. Typical symptoms are not. Pain in the right hypochondrium, simulating the attack of acute cholecystitis or hepatic colic. If the process behind the uterus is pain in the lumbar region. The symptom of Voskresensky (holding a palm on the PBS from the right edge edge down - pain), Mendel, Brush-Blumyberg, Michelson (strengthening pain in the right half of the abdomen in the right side of the right side, due to the pressure of the uterus on the inflammatory hearth during destructive appendicitis.) Leukocytes are normal.

In the elderly.

Low prevalence is due to age atrophic changes in the process, often fully replaced by a scar cloth. Often with a lubricated clinic. The pain is less pronounced, spilled, bloating, the Voltage of the PBS is little expressed. Raising temperature, leukocytosis. Very often later appeal - the occurrence of infiltrates, abscesses.

Acute appendicitis in children, as in adults, the most frequent disease that requires emergency surgical treatment. In the first two years of life, acute appendicitis in children is rarely found, which is explained by a number of reasons:

1) the cone-shaped shape of a blind intestine and a heart-shaped process determines the best evacuation of the contents,
2) the lymphoid device of the process is not developed or poorly developed,
3) Features of nutrition (children at this age feed in gentle, unprazing food).

However, acute appendicitis can be in children of any age .. There are cases of acute appendicitis in children on the first day after birth, in two months and even in the period of intrauterine development.

The emergence and course of acute appendicitis in children has its own characteristics caused by the tendency of the children's body to turbulent, hypergic, spastic and atonic, reactions; In young children, the Symptom of Brush - Blumyberg may be absent, and such important symptoms, as vomiting, the inconsistency of the pulse and temperature, leukocytosis and dehydration, may be in non-surgical diseases; On the 3rd - 5th day of peritonitis, the general condition of the child is often qualified as "satisfactory", and a lot of silent pus is found in the abdominal cavity; With complicated acute appendicitis, metabolic acidosis is rapidly developing, exacerbating renal failure and dehydration, which requires preoperative preparation: the introduction of a 10-15% glucose solution with insulin, vitamins C, B6, C) 2, Cocarboxylase, cardiovascular, antihistamine drugs and especially careful conduct of the postoperative period with ensuring the prevention of respiratory failure, decompression of the stomach and intestines, normal homeostasis, antimicrobial therapy (S. Ya. Doletsky, Yu. F, Isakov, A. 3. Manevich, 1969).

Acute appendicitis in children develops most often rapidly, with a sharp increase in temperature accompanied by hyperemia of the face of the face. Often in children acute appendicitis precede the catarrhal phenomena of the upper respiratory tract and angina. In 50% of the children of the first months of life, after 24 hours, the perforation of the process (Schiitze et al., 1972) occurs.

Kids are restless, cry, try to lie down in bed. Children of the first years of life can not explain their feelings. They refuse food, fall on the right side, pull up the legs to the stomach and keep behind the priest half of the abdomen. Older children complain of pain in the right iliac region, nausea.

The diagnosis of acute appendicitis in children is much more complicated. This is due, on the one hand, with the difficulties or impossibility of studying complaints and anamnesis, and on the other hand, the negative attitude of almost all of the children to doctors.

By the way, this is a negative attitude towards doctors, to unauthorized people indicates a child's unhealthy. A big connoisseur of suddenly emerging diseases of the abdomen Mongdor wrote: The more aggressive, the child behaves restlessly, what he persistently repels the doctors from himself and the more he screams, the more persistent to be a doctor, collect all his doctoral and human abilities to find out the reason for such restless behavior Little patient. For no reason, children cry and repel adults very rarely.

In the study of the child, all stages of the study should be especially careful. It is very important to pay attention to the reaction of the child to percussion, palpation, the severity of the muscles tension (right and left). It is necessary to perform auscultation and other research methods, which are significantly more difficult to appreciate the child than an adult. It helps the diagnosis of the finger study of the rectum, temperature measurement in the axillary depression and in the rectum (with peritonitis in the rectum temperature above Pa 1 ° -1.5 °), blood test. To perform differential diagnosis with pneumonia and infectious diseases, it is necessary to attract pediatricians. Thai, Wuttke (1963) noted the difficulties of differential diagnosis in children between acute appendicitis and pneumonia. The diagnosis of acute appendicitis determines the need for surgery, which is performed under anesthesia.

In the elderly, acute appendicitis is less common, which is explained by atrophic and sclerotic changes in a worm-like process. It decreases in size, loses the lymphoid apparatus, sometimes partially or completely refrred. At the old age, the vessels suffer significantly, protective reactions decrease. From here, it can be concluded that acute appendicitis in old people with a smaller severity of clinical manifestations is often accompanied by large pathoanatomic changes, giving perforations and gangrenes. According to E.R. Baiteyakova (1969), the typical beginning of acute appendicitis in the elderly was only in 30% of patients. In this difficulty diagnosis, and therefore the treatment of acute appendicitis in old people. Even with the weakest symptoms of acute appendicitis in the elderly, it is necessary to raise the question of immediate surgical intervention and consider the operation quite justified even in cases where minor changes are found in from-sprout.

I had to operate at different times of two elderly people in the family of doctors. Woman 67-68 appealed to me with complaints PA. Weak abdominal pain and malaise. Its condition was quite satisfactory, pulse p. Temperature is normal, the language is clean. In the study of the belly, a minor pain in the right iliac region was found and barely expressed by the symptom of Voskresensky. On the same day, this patient was operated on, and at the time of the operation was found only a small hyperemia of the top of a thin worm-like process, the lumen of which was almost completely refused.

The postoperative period was dripped smoothly, and the patient was discharged from the clinic in good condition. After 2 years, her 70-year-old spouse fell ill. I was called home to him when the patient felt already bad. He fell ill four days ago.

Moderate abdominal pain appeared, stool delay and weakness. No one paid attention to these pains, and the patient continued to do homemade affairs and grandson. The state gradually worsened, after three days he became difficult to walk, and he was forced to lie down in bed. Inspection by a daughter doctor did not find any disturbing. Another day invited me.

The patient was lying in bed, the face was loyed, but a look alive. Language is wet, pulse within 90, subfebrile temperature. In the detached stomach places, dulling, weakly pronounced Symptom of Brush - Blumberg, all over.

The greatest, but very moderate, soreness in the right iliac area. The patient immediately on the stretchers, and then on the car were taken to the hospital emergency care, where I operated it. A total peritonitis with a huge amount of silent pus is discovered. After a day, the patient died.

Features of the course of acute appendicitis in pregnant women are mainly connected with two circumstances:

1) by changing the position of the blind intestine and a worm-like process,
2) the appearance of some symptoms in a pregnant woman without communication with appendicitis.

The displacement of the blind intestine, especially in recent months of pregnancy, changes localization and irradiation of pain.

It makes it difficult for the diagnosis and the fact that the appearance of nausea, vomiting, stool delays and gases, and sometimes pain can be explained by pregnancies. Acute appendicitis is found at various times of pregnancy. But this should not have influence on the doctor's tactics. In the presence of acute appendicitis, it is necessary to operate, even "ate to childbirth remained for several days.

There are cases when women safely gave birth a few hours after appendectomy. The expectant tactic is dangerous to the occurrence of peritonitis, to treat which in pregnant women is much more difficult. During the operation, it is necessary to take into account the position of the blind intestine and make a cut accordingly above.