Appendicular infiltrate: acute, dense, loose

Differential diagnostics of the appendicular infiltrate and purulent tubo-ovarian formation of the right-sided localization presents considerable difficulties due to the longer process.

[1], [2], [3]

Causes of the appendicular infiltrate

Untimely surgical treatment of acute appendicitis leads to the fact that as a result of a purulent-infiltrative process (delimited peritonitis), a conglomerate of organs is formed in the ileal region, including the cecum, other sections of the large intestine, small intestinal loops, the omentum, and the parietal peritoneum.

So, according to R.Varela et al., Appendicular abscess was found in 15% of patients operated on for gynecological diseases.

Over the past 10 years, amounted to 2.1%, the secondary involvement of the process in the purulent-infiltrative process for gynecological pathology, according to our data, occurs much more often - 9.4%.

[4], [5], [6], [7]

Symptoms of the appendicular infiltrate

The lack of a characteristic relationship of the disease with provoking and genital risk factors for the development of inflammatory processes of the internal genital organs (IUD, intrauterine intervention, menstruation); the suddenness of the disease, the paroxysmal nature of pain, initially located in the area of the epigastrium or navel, still allow us to suspect surgical pathology when carefully collecting the history.

The appendicular infiltrate may be formed as early as 3-4 days after the onset of an acute attack, but usually this happens later, especially if antibacterial and anti-inflammatory drugs are used. By this time, the intensity of the pain decreases, but endogenous intoxication persists. Characterized by persistent fever - usually up to 37.5-37.8, moderate tachycardia and leukocytosis.

Palpation in the right iliac region is determined by the infiltration of a predominantly dense consistency with fairly clear boundaries. The infiltrate can "dissolve" after 4-6 weeks, but more often it suppurates, while the condition of patients worsens dramatically and all signs characteristic of suppuration appear: hectic temperature, chills, increased and severe infiltrate morbidity, uneven consistency and sometimes local fluctuation.

[8], [9]

Complications and consequences

• perforation of appendicular abscess in the cecum, small intestine with temporary improvement of the condition and subsequent formation of purulent fistulas;
• microperforation of the abscess with the formation of delimited forms of peritonitis - right subphrenic abscess or abscess Douglas pocket;
• perforation of the abscess in the "free" abdominal cavity with the subsequent development of diffuse purulent peritonitis (a more serious complication);
• perforation of the abscess in the bladder, followed by the development of ascending urinary tract infection and urosepsis;
• thrombophlebitis and pelvic venous thrombosis;
• sepsis.

[10], [11], [12]

Diagnostics of the appendicular infiltrate

Echography: in the right ileal area, infiltrates are determined, which are irregularly shaped echo-positive formations without a clear capsule, which have a reduced echogenicity with respect to the surrounding tissues; in the composition of infiltrates fixed intestinal loops are identified; during abscess formation, in the structure of infiltrates, one or many cystic formations with a clear capsule and heterogeneous liquid contents are determined, indicating the accumulation of purulent exudate.

[13], [14]

Treatment of the appendicular infiltrate

With the appendicular infiltrate formed, surgical treatment is advisable in the remission stage of the inflammatory process. The scope of the operation is the separation of extensive adhesions, appendectomy, sanitation and aspiration-drainage drainage of the abdominal cavity with subsequent intensive therapy.

Indications for emergency surgery are:

• perforation of the abscess in the abdominal cavity;
• perforation of the abscess in the bladder;
• septic shock.

Emergency surgery in the context of the activation of a purulent process presents significant technical difficulties and is fraught with the development of septic shock. The scope of operation is the same. In cases of a particularly serious condition of patients, palliative intervention is indicated - abscess drainage or removal of the cecum stoma with reconstructive surgery in remission.

As mentioned earlier, appendicular infiltrate or abscess is most often an unpleasant finding for a gynecologist at an operation.

Careful collection of anamnesis makes it possible to suspect the presence of a surgical disease prior to the operation, but in advanced cases it can be difficult to find out the root cause even with womb opening (right-sided tubo-ovarian formation with secondary appendicitis or vice versa). For tactics, this is of no fundamental importance, since an adequate volume of the operation in both cases is appendectomy and the corresponding gynecological amount of the surgical procedure, followed by drainage of the abdominal cavity.

Surgical technique

1. Restoration of anatomical relationships (separation of adhesions between intestinal loops, omentum, mobilization of the caecum dome) - all manipulations are performed only by an acute route - using dissecting scissors.
2. Mobilization of the appendix in infiltrated tissues. It is very complex and should be carried out only by an acute route. Errors: gross removal of the dome of the cecum, separation of seams of tupfer.
3. Cutting off the mesentery of the appendix and its ligation with flashing. Before cutting off the mesentery, it is recommended to pre-attach the clamps. It is not necessary to capture a large portion of the mesentery in the ligature, it is better to impose 2-3 ligatures. Suture material - catgut or vicryl number 00.
4. Careful allocation of the basis of a shoot.
5. Cutting off the appendix: the base of the appendix is “crushed” by the clamp, ligated, the appendix is cut off, its stump is smeared with iodine. Peritonization of the stump is carried out with a string of vicril (No. 00) suture, the latter should be supplemented with a Z-shaped vicryl suture.
6. Sanitation of the abdominal cavity, aspiration-leaching drainage.

Often, in conditions of purulent-infiltrative inflammation, significant destruction or even self-embedding of the appendix occurs. In this case, all necrotic non-viable tissues are removed, depending on the extent of its destruction, vicril sutures are superimposed on the dome of the cecum, further rehabilitation of the abdominal cavity is carried out, drainage is supplied to the area of operation.

[15], [16]

Prevention

Prevention of appendicular infiltrate is the timely recognition of acute appendicitis and its prompt treatment in the first two days.

[17], [18], [19], [20], [21]