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Appendicular infiltrate: acute, dense, friable
Last reviewed: 04.07.2025
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Differential diagnosis of appendicular infiltrate and purulent tubo-ovarian formation of right-sided localization presents significant difficulties due to the greater duration of the process.
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Causes appendicular infiltrate.
Untimely surgical treatment of acute appendicitis leads to the formation of a conglomerate of organs in the right iliac region as a result of the purulent-infiltrative process (limited peritonitis), including the cecum, other parts of the large intestine, loops of the small intestine, omentum and parietal peritoneum.
Thus, according to R. Varela et al., appendicular abscess was found in 15% of patients operated on for gynecological diseases.
Over the past 10 years, it has amounted to 2.1%; secondary involvement of the appendix in the purulent-infiltrative process in gynecological pathology, according to our data, occurs much more often - 9.4%.
Symptoms appendicular infiltrate.
The absence of a characteristic connection between the disease and provoking and genital risk factors for the development of inflammatory processes of the internal genital organs (IUD, intrauterine interventions, menstruation); the suddenness of the disease, the paroxysmal nature of the pain, initially localized in the epigastric or navel area, still allow, with careful collection of anamnesis, to initially suspect surgical pathology.
An appendicular infiltrate may form as early as 3-4 days after the onset of an acute attack, but this usually occurs later, especially if antibacterial and anti-inflammatory drugs are used. By this time, the intensity of pain decreases, but endogenous intoxication remains. Characteristic are persistent increases in temperature - often up to 37.5-37.8, moderate tachycardia and leukocytosis.
Palpation in the right iliac region reveals an infiltrate of predominantly dense consistency with fairly clear boundaries. The infiltrate may "resolve" in 4-6 weeks, but more often it suppurates, with the patient's condition sharply worsening and all the signs characteristic of suppuration appearing: hectic temperature, chills, enlargement and sharp pain of the infiltrate, uneven consistency and sometimes local fluctuation.
Where does it hurt?
What's bothering you?
Complications and consequences
- perforation of the appendicular abscess into the cecum, small intestine with temporary improvement of the condition and subsequent formation of purulent fistulas;
- microperforation of the abscess with the formation of limited forms of peritonitis - right-sided subphrenic abscess or abscess of the Douglas pouch;
- perforation of the abscess into the “free” abdominal cavity with subsequent development of diffuse purulent peritonitis (a more serious complication);
- perforation of the abscess into the bladder with subsequent development of ascending urinary tract infection and urosepsis;
- thrombophlebitis and thrombosis of the pelvic veins;
- sepsis.
Diagnostics appendicular infiltrate.
Echography: in the right iliac region, infiltrates are determined, which are irregularly shaped echo-positive formations without a clear capsule, having reduced echogenicity in relation to the surrounding tissues; fixed intestinal loops are identified in the infiltrates; in case of abscess formation, one or more cystic formations with a clear capsule and heterogeneous liquid contents are determined in the structure of the infiltrates, indicating the accumulation of purulent exudate.
What do need to examine?
What tests are needed?
Who to contact?
Treatment appendicular infiltrate.
In the case of an established appendicular infiltrate, surgical treatment is advisable at the stage of remission of the inflammatory process. The scope of the operation is separation of extensive adhesions, appendectomy, sanitation and aspiration-washing drainage of the abdominal cavity with subsequent intensive therapy.
Indications for emergency surgical treatment are:
- perforation of an abscess into the abdominal cavity;
- perforation of an abscess into the bladder;
- septic shock.
An emergency operation in conditions of activation of the purulent process presents significant technical difficulties and is fraught with the development of septic shock. The scope of the operation is the same. In cases of a particularly severe condition of patients, palliative intervention is indicated - drainage of the abscess or removal of the stoma of the cecum with the performance of a reconstructive operation in the period of remission.
As mentioned earlier, an appendicular infiltrate or abscess is most often an unpleasant discovery for a gynecologist during surgery.
A thorough anamnesis allows one to suspect the presence of a surgical disease before the operation, however, in advanced cases, even with laparotomy, it is difficult to determine the underlying cause (right-sided tubo-ovarian formation with secondary appendicitis or vice versa). This is not of fundamental importance for tactics, since the adequate volume of surgery in both cases is appendectomy and the corresponding gynecological volume of surgical intervention with subsequent drainage of the abdominal cavity.
Technique of surgical intervention
- Restoration of anatomical relationships (separation of adhesions between intestinal loops, omentum, mobilization of the dome of the cecum) - all manipulations are performed only by sharp means - using dissecting scissors.
- Mobilization of the appendix in infiltrated tissues. It is very difficult and should be performed only by an acute method. Mistakes: rough removal of the dome of the cecum, separation of adhesions with a swab.
- Cutting off the mesentery of the appendix and ligating it with suturing. Before cutting off the mesentery, it is recommended to first apply clamps to it. Do not ligate a large section of the mesentery; it is better to apply 2-3 ligatures. Suture material - catgut or vicryl No. 00.
- Careful selection of the base of the process.
- Severing the appendix: the base of the appendix is “crushed” with a clamp, ligated, the appendix is cut off, and its stump is lubricated with iodine. Peritonization of the stump is performed with a purse-string vicryl (No. 00) suture, which should be supplemented with a Z-shaped vicryl suture.
- Abdominal cavity sanitation, aspiration and irrigation drainage.
Often, in conditions of purulent-infiltrative inflammation, significant destruction or even self-amputation of the appendix occurs. In this case, all necrotic non-viable tissues are removed, vicryl sutures are applied to the dome of the cecum depending on the degree of its destruction, then the abdominal cavity is sanitized, and drainage is brought to the operation area.
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