Chronic appendicitis

The existence of such a form of inflammation of the appendix as chronic appendicitis in both adults and children is questioned by many surgeons.

Preoperative diagnosis of this pathology is usually made on the basis of repeated abdominal pain localized in the right iliac region.

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Epidemiology

In recent years, interest in this complex and extremely important problem in abdominal surgery has increased again. Having studied in detail the clinical and morphological parallels in various forms of inflammation.

Using modern research methods (ultrasound scanning, endoscopic and morphological methods), the authors came to the conclusion that chronic appendicitis as a nosological form exists and accounts for up to 5% of patients with abdominal pain syndrome.

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Causes chronic appendicitis

It is usually impossible to determine what causes chronic appendicitis. The leading role in the development of the chronic process is played by the obstruction of the lumen of the appendix by dense fecal masses. As in the case of acute appendicitis, infectious, neurovascular, and neuroimmune theories of the development of chronic inflammation are considered. They indicate a frequent combination of this pathology and parasitic diseases of the gastrointestinal tract (for example, enterobiasis).

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Pathogenesis

Chronic appendicitis manifests itself most often in the form of an intermediate form of productive inflammation with hyperplasia of the lymphoid apparatus of the appendix with a predominance of lymphohistiocytic infiltration, as well as an increase in the amount of connective tissue, characterizing the processes of fibrosis or sclerosis in all layers of the appendix up to their complete atrophy.

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Symptoms chronic appendicitis

Symptoms of chronic appendicitis are characterized by paroxysmal course of the disease with local abdominal pain lasting from 6 months to 4 years. Most often, suspicion of the presence of sluggish pathology from the vermiform appendix arises 6-12 months after the onset of the disease. Periodic pain attacks in the right iliac region, occurring mainly after physical exertion, active games, with errors in diet, reduce the child's quality of life. In most cases, after another such attack, the child is hospitalized with a diagnosis of "acute appendicitis". But in the future, data on acute pathology of the abdominal organs cannot be identified.

In most patients, pain is localized in the right iliac region, less often in the lower abdomen, periumbilical region and right abdomen. In some patients, attacks of abdominal pain are accompanied by nausea, vomiting, constipation or diarrhea.

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Forms

The following classification is proposed:

• Primary chronic appendicitis. There is no objective data in the anamnesis about the previous acute inflammatory process in the appendix.
• Secondary chronic appendicitis. Changes in the appendix are caused by an acute inflammatory process in the form of an appendicular infiltrate or appendicular abscess.

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Diagnostics chronic appendicitis

During objective examination, moderate pain in the right iliac region is determined by palpation. Some patients experience weakly positive symptoms of peritoneal irritation.

Laboratory and instrumental studies

A thorough examination of patients with periodic abdominal pain, including laboratory and instrumental methods, is of fundamental importance. The most informative diagnostic method is ultrasound scanning of the abdominal organs. FEGDS is also justified, except for inflammatory diseases of the upper gastrointestinal tract - the most likely cause of pain syndrome.

Only after excluding any pathology from the abdominal cavity and pelvic organs can abdominal pain syndrome be associated with pathology of the appendix.

The following are considered ultrasound criteria for chronic appendicitis:

• enlargement of regional mesenteric lymph nodes, visualized as structures of low echogenicity, in the absence of enlargement of other groups of mesenteric lymph nodes:
• presence of 3-5 ml of fluid in the right iliac fossa:
• mild hypoechogenicity of the muscular layer of the appendix, diameter within 4-6 mm, but uneven along its length, with alternating areas of narrowing up to 3 mm and widening up to 6 mm;
• absence of peristalsis, local pain when pressing in the projection of the appendix:
• the presence of a fecal stone in the lumen of the appendix.

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Differential diagnosis

It is necessary to take into account that in childhood the spectrum of diseases with similar symptoms is extremely wide. This is directly the pathology of the ileocecal angle: inflammatory (mesadenitis, terminal ileitis, Crohn's disease of the cecum), developmental defects (caecum mobile, membrane, Lein's ligament, embryonic cords in the area of the vermiform appendix), functional pathology (Bauhinia spasm or insufficiency of the Bauhinia membrane), benign, and sometimes malignant neoplasms. In turn, many diseases of the gastrointestinal tract, biliary system, urinary tract and gynecological pathology in girls have a clinical picture similar to chronic appendicitis. In addition, it is known that this form of inflammation of the vermiform appendix is the most difficult not only for clinicians, but also for morphologists due to the lack of convincing macroscopic and microscopic data.

Treatment chronic appendicitis

Patients diagnosed with chronic appendicitis are recommended to undergo diagnostic laparoscopy with a thorough examination of the abdominal organs and appendectomy.

Forecast

Patients operated on for such pathology as chronic appendicitis are subject to observation for 6 months after the operation. It is necessary to always remember that only a thorough study of the remote results of treatment of children can possibly provide clarity in solving this complex problem.