Acute phlegmonous appendicitis: purulent, ulcerative, gangrenous

Phlegmonous appendicitis is an acute form of inflammation of the appendix, characterized by the deposition of fibrin on its surface, a large concentration of pus and a clearly marked edema.

[1], [2], [3],

Epidemiology

1. Women more often suffer from an ailment at the age of 15-40, men - 12-20;
2. Men suffer from the disease much less often, but women have a much better prognosis and less risk of complications.
3. The least phlegmonous appendicitis is diagnosed in infants up to a year and people of advanced age.
4. After fifty years, the risk of developing an inflammation of the appendix is reduced to 2 percent;
5. Removal of the appendix makes up 80% of all simple operations performed.

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

Causes of the phlegmonous appendicitis

The etiology of the disease has not been fully established.

There are few reasons for the appearance of phlegmonous appendicitis:

1. The thrombosis of the vessels of the appendage, and as a consequence the ischemia of its tissues. Because of this, such a function of lymphoid tissue decreases as a protective one, inflammation occurs and the activity of conditionally pathogenic flora within the intestine increases.
2. Also, the cause of phlegmonous appendicitis may be the occurrence of a complication of the catarrhal form of the disease.
3. Mechanical obturation of the appendix.

[8], [9], [10], [11], [12], [13]

Risk factors

The greatest danger for the development of phlegmonous appendicitis is the age from twenty to thirty years. Although the disease can also occur at any age.

Most often, risk factors are:

• endocrine - the presence in the appendix of the cecum (its mucous membrane) of a number of cells that produce the hormone serotonin.
• casuistic - the presence of foreign bodies (for example, grape seeds, peel of sunflower seeds, fish scales) in the human intestine.
• food - when a person eats mainly meat products or food, rich in animal proteins.

[14], [15], [16], [17], [18]

Pathogenesis

The enterogenic route of infection is most often the cause of the disease. At the same time, in a crucial role in the pathogenesis of the disease, the hematogenous and lyphogenic pathway practically does not play.

Various microorganisms that are in the process (protozoa, viruses and bacteria) are the cause of inflammation. Basically, this is an anaerobic form of flora (anaerobic cocci), less often - aerobic (enterococci, E. Coli).

[19], [20], [21]

Symptoms of the phlegmonous appendicitis

The manifestation of phlegmonous appendicitis is quite pronounced:

• The first sign will be acute pain with, most likely, fuzzy localization, amplified by movement. Further morbidity will increase and take a more precise location.

Other symptoms are:

1. general intoxication of the body and lethargy,
2. grayish or white coating on the tongue,
3. lack of appetite,
4. nausea, vomiting is possible,
5. bloating, diarrhea or vice versa constipation,
6. headache and a slight increase in temperature.

When the patient is examined by a medical worker, the following signs will be revealed:

• in the place of painful sensations the intensity of the muscular tissues of the abdomen will be noted;
• affirmative symptoms of "slipping" and irritation of the peritoneum.

Forms

There are few varieties of appendicitis of the phlegmonous form:

1. acute phlegmonous appendicitis - occurs in a very short period of time (several hours). Characterized by an acute onset of inflammation, with changes not of a destructive, but purulent nature.
2. Phlegmonous - ulcerative appendicitis - against the background of the development of mucosal lining of the appendix with ulcerative processes, a purulent inflammation occurs.
3. Purulent stage of phlegmonous appendicitis - "growth" of body temperature, further development of intoxication processes, intensification of pain - all this indicates the occurrence of localized purulent foci on the walls of the appendage. The reason is the continued development of microorganisms.
4. Phlegmonous appendicitis in a child is manifested by an inflammation of the purulent nature of the entire appendix. When a macroscopic examination is visible, it is thickened, all covered with fibrin, intensely red. Microscopically visible infiltration of all layers of the appendix, there are signs of suppuration and a slight rejection in the mucosa.

[22], [23], [24], [25], [26]

Complications and consequences

Phlegmonous appendicitis can have very unfavorable consequences when untimely seeking medical help. It:

• intestinal obstruction;
• Append appendicular compaction or abscess;
• inflammation of the venous wall of the iliac or pelvic veins;
• thrombosis;
• peritonitis, as a result of rupture of the appendix;
• inflammation of the veins of the liver purulent;
• sepsis;
• multiple organ failure;
• death.

[27], [28], [29], [30], [31]

Diagnostics of the phlegmonous appendicitis

The study of the abdominal organs and radiography will not be able to detect inflammation in the appendage of the cecum.

Radiography only helps to clarify the differentiation of appendicitis from a perforated ulcer of the stomach or duodenum.

Ultrasound diagnosis of the gastrointestinal tract in this case can be used to distinguish phlegmonous appendicitis from inflammation in the bile or urinoznom bladder.

[32], [33], [34], [35], [36], [37]

Differential diagnosis

This type of research is carried out for correct diagnosis with a whole group of diseases.

Cholecystitis. Tense hypochondria on the right side, "giving" pains to the scapula or shoulder, the existence in the patient's history of the signs of cholelithiasis earlier, as well as the results of ultrasound examination, will indicate acute inflammation of the gallbladder and help to correctly differentiate it with appendicitis. Often the gallbladder, increasing in size, falls very low (sometimes even below the navel), and pain sensations are determined throughout the right side of the abdomen. Or the appendix, inflamed and being under the liver, can stimulate the development of acute cholecystitis. Therefore, it is very difficult to diagnose without additional studies.

Pleuropneumonia or pneumonia of the right lower lobe. To distinguish this pathology from appendicitis, you need to audition the lungs. At the same time, you will hear a slight breathing and wheezing. And with pleuropneumonia, it is also like rubbing the pleura with breathing. If in the right cavity there is a congestion of fluid from the blood vessels - dullness of the percussion tone will be heard, a decrease in respiratory noise. Also, with this disease, there may be cough, fever and pain with irradiation in the right half of the belly.

Mesadenite. Because of localization of pain from the right iliac side, it is possible to disorient the medical specialist. But the presence in the anamnesis of the recently transferred disease of the upper respiratory tract, and a combination with an increase in lymph nodes, and in six percent also with iersiniosis, leave no doubt in the diagnosis.

Inflammation of the diverticulum of Meckel ( diverticulitis ). As well as phlegmonous appendicitis, it requires urgent hospitalization and surgical intervention. The disease is rarely established before surgery and laparoscopy, which is done for the purpose of diagnosing. To make a diagnosis, an intraoperative revision of 100 cm of the ileum of the intestine should be done.

Acute pancreatitis. Similar to appendicitis symptom of Shchetkin-Blumberg. Very often there is multiple vomiting. The abdomen is slightly swollen in the upper parts. The patient's state of health is poor, but the temperature is almost not increased. The analysis shows an increased level of the digestive enzyme in the urine.

Acute intestinal obstruction. The diagnosis can be difficult, especially with neoplasm on the large intestine. This will help to make the presence of cramping pain, increased noise of peristalsis, constipation and flatulence. On the x-ray, Clauber's "cups" are clearly visible.

Crohn's disease. Characterized by severe pain in the lower abdomen. It is rare to have diarrhea, leukocytosis. On the right side, the formation is clearly palpable, which hurts. Basically, the diagnosis is made during appendectomy, because of mistaken admission of the disease for acute appendicitis. To make the diagnosis correctly, laparoscopy will help medical workers. Also, before revision in the abdominal cavity, you must pay attention to changes in the appendix. If it is not the same as it was before the surgery, you should pay attention to the ileum in the intestine.

Acute gastroenterocolitis. It is characterized by a pain of spastic, diffuse nature. The patient complains of nausea, vomiting, diarrhea and false urge to defecate. Often there is swelling and rumbling of the abdomen. Appendicular symptoms will not be characteristic here.

Renal colic on the right side. Characterized by frequent urination. When taking urine tests, a macro or microhematuria is detected. There may also be bloating. The main symptom is Pasternatsky's symptom, since it is not necessary for appendicitis (if you do not take into account the cases of the appendix retrocestically). If there is any doubt about the diagnosis, a radiographic examination of the urinary tract should be performed. Most likely there will be a presence of "stones" in the right ureter and signs of pyeloakzation. And "pokalachivaniya" in the lumbar region, will help to accurately diagnose. Still it is possible to spend novocaine blockade in the right seminal cord or uterus. With renal colic, the pain will quickly subside, and with appendicitis it will remain.

[38], [39], [40], [41], [42], [43]

Treatment of the phlegmonous appendicitis

When making a diagnosis - phlegmonous appendicitis, surgical treatment should be performed immediately.

Intervention is performed under general anesthesia. If there are no contraindications, it passes with the help of endotracheal anesthesia. This kind of anesthesia does not limit the movement of the surgeon, and makes it possible, if necessary, to perform a wide resection of the abdominal cavity. If the patient has an individual intolerance, it is possible to use local anesthesia.

The most commonly used is traditional appendectomy or laparoscopy.

Laparoscopy

Used when:

• there is no inflammatory process on the cecum;
• I have no adhesions on the intestine;
• no complications in the form of peritonitis, inflammatory infiltrate or retroperitoneal phlegmon.

Contraindications for its implementation will be: pregnancy in the third trimester, obesity, increased bleeding, and also if the appendix is located atypically.

Appendectomy is performed under general anesthesia.

Stages of the operation:

1. It is necessary to make three punctures on the abdominal wall (length from 5 to 10 cm), so that one of them was on the navel.
2. Introduce a video camera and special tools to remove the process.
3. Intervention.

This type of surgery can reduce the patient's stay in the hospital, reduce the pain in the postoperative period, there is a faster recovery of the intestine, the scar has a cosmetic appearance.

Normal appendectomy

Stages of intervention:

• The operating field is processed and it is covered with sterile gauze napkins.
• The surgeon makes a dermal incision (10-12 cm long) in the right ileal region.
• After dissection of subcutaneous fat, the doctor, with a scalpel and special surgical scissors, cuts the tendon of the oblique abdominal muscle. After this, in the upper corner of the wound surface, the muscle is cut and the peritoneum is opened with the help of blunt hooks.
• The wound is drained with a napkin. To identify the bacterial flora, it is necessary to take an analysis.
• Then the doctor finds the cecum and extracts it to the wound deepening. Spikes, if any, are cut. To carefully consider the lateral canal and ileal fossa, if they interfere, withdraw the loops of the small intestine. This is easy to do, since the outgrowth will most likely be on the dome of the blind section of the digestive system. The surgeon, taking into account that he needs to fix the distal appendix, holds a ligature under it and drops the apex into the abdominal cavity.
• The ligation is applied to the mesentery of the appendage, so that the artery of the vermiform appendage is bandaged. To avoid slipping the thread, if the mesentery is loose, ligature is stitched.
• Then the fold of the peritoneum must be cut off. Clamp the appendix at the base and tie it.
• With the help of an atraumatic needle, the doctor, after retreating 1.5 cm, performs a circular seam.
• After 0.5 cm from the seam, the clamp is again applied, and the appendix is cut off.
• The assistant of the operating doctor, treats the stump with a solution of iodine, and grasps it with a special tweezers, inserts into the circular seam. The surgeon does the tightening.
• Before fixing the dome, you must again make a Z-shaped seam, and return the top of the cecum to the peritoneal cavity.
• The surgeon needs to stop the bleeding, by drying the cavity of the cavity from the formed exudate.
• The wound is washed with physiological saline to exclude the possibility of complications due to tissue debris, blood or infected effusion.
• Making 2-3 seams, the doctor sows muscles. Next, with the help of an intricate thread, sutures the outer aponeurosis of the oblique muscle.

This operation is characterized by a long postoperative rehabilitation period.

Retrograde appendectomy

Carry out in the event that there is no possibility of isolating the process into the wound cavity. Its difference from the usual appendectomy is that in this case the mesenteric gland is not cut off immediately and, preserving its blood supply, cultivating the stump, and after removing the appendix.

Features of the surgical operation with phlegmonous appendicitis:

1. Because of inflammation of the mucosa of the appendix, there is a possibility of appearance of effusion in the right aerial region. Therefore, the doctor should dry the fossa, the lateral canal to the right and the cavity of the small pelvis, necessarily taking the exudate for analysis. If it is turbid, it is required to introduce antibiotics in parallel.
2. When the surgeon has doubts about the absolute removal of the inflamed - phlegmonous process, it will be necessary to install drainage for three or four days.
3. In the case of complications in the form of perforation, the apendectomy is performed with absolute access, thereby facilitating the sanation and removal of pathological tissues.

Postoperative period

To reduce the risk of postoperative complications, the patient should be sparing. So, getting out of bed after surgery can be no earlier than six to eight hours, but only if consciousness and breathing are fully restored.

Perhaps, for patients at risk of the emergence of a postoperative hernia, it is necessary to wear a special postoperative bandage.

The patient needs to do dressings every day, necessarily evaluating the stage of wound healing and applying antiseptics. Depending on the pain intensely used painkillers.

In the case when there was a need to use drainage to prevent complications of a purulent nature, in the postoperative period, the introduction of such antibacterial drugs from the class of cephalosporins or macrolides is required.

The sutures are removed seven to eight days after the operation, if the wound healing is not complicated.

After surgery on phlegmonous appendicitis, heavy physical exertion is not recommended for about three months. The doctor can prescribe only exercise therapy or respiratory gymnastics.

Diet after operation with abscess appendicitis

For two to four weeks after the operation and discharge from the hospital, to prevent the occurrence of constipation, you must follow a diet. You can eat only foods that are grown by a doctor.

The first two days you need to eat exclusively cereals in liquid form and vegetable puree. It is also worth adding to the diet of jelly or low-fat kefir. Then gradually introduce black bread with a small amount of butter. The transition to the usual, familiar to the patient food can only be with excellent health and a normal stool. But do not forget that the food should not be spicy, pickled, smoked, fatty, fried or hard. Also in the diet should be excluded coffee and strong tea, soda, baked pastry. All food is prepared by baking or cooking.

You need to eat small portions, about five to six times a day.

[44], [45], [46], [47], [48], [49]

Prevention

There are no special preventive measures to prevent phlegmonous appendicitis. The most important thing is timely access to medical workers for the provision of qualified assistance.

[50], [51], [52], [53], [54], [55]

Forecast

If treatment is started on time, the prognosis is favorable. Mortality is not more than 0.03%, and the risk of complications, most often peritonitis in impaired people, is no more than 9%. Inflammation of the peritoneum often occurs, but it is quickly limited by the omentum or walls of neighboring internal organs.

Rarely can form an infiltrate, after which, after a while, spikes will form .

[56], [57], [58], [59], [60]