Gangrenous appendicitis: symptoms, consequences, surgery, postoperative period

The concept of “appendicitis” is known to everyone, but few people know about a diagnosis such as “gangrenous appendicitis”.

When talking about gangrenous appendicitis, they usually mean a complication of ordinary inflammation of the appendix, in which the processes of tissue necrosis of the appendix begin - as a rule, this occurs on the second or third day after the onset of acute appendicitis. This condition is considered critical and poses a significant threat to the patient.

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Epidemiology

Inflammatory processes in the appendix are registered in five people out of a thousand. Operations for acute appendicitis are approximately 70% of all emergency surgical interventions.

According to the latest statistics, gangrenous appendicitis is found in approximately 9% of all cases of acute appendicitis. Both men and women are equally susceptible to the disease.

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Causes gangrenous appendicitis

The main reason for the development of gangrenous appendicitis is insufficient blood supply to the appendix. Even a relatively small disorder of microcirculation can cause oxygen deficiency in tissues, metabolic disorders, ischemia and necrosis.

Gangrenous appendicitis can occur in patients of any age. In old and elderly people, the pathology occurs simultaneously with massive atherosclerotic vascular lesions. In children and young people, gangrenous appendicitis can be a consequence of congenital vascular defects. In addition, regardless of age, the pathology can develop as a result of increased thrombus formation in the appendicular vessels.

Disruption of the processes of cleansing the appendix from the contents of the intestine, additional penetration of microbial infection increase the degree of danger of developing gangrene of the appendix. Also, gangrenous appendicitis can be a consequence of untreated acute purulent inflammation.

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Risk factors

Among the main risk factors that are considered in gangrenous appendicitis, the following are distinguished:

• age from 50 years;
• tendency to thrombosis;
• atherosclerotic changes in blood vessels;
• unfavorable heredity (if close relatives had cases of gangrenous appendicitis).

Almost all factors are related to the disruption of microcirculation in patients. Disruption of blood circulation in the appendix leads to deterioration of the nutrition of the tissues of the vermiform appendix. With the simultaneous presence of infection or autoimmune processes, the development of gangrenous appendicitis is aggravated and accelerated.

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Pathogenesis

In gangrenous appendicitis, processes of tissue necrosis of the appendix occur.

Complete necrosis is relatively rare. In most patients, the necrotic area extends to a limited portion of the appendix.

The processes of necrosis are accelerated if there are deposits of fossilized feces or foreign objects inside the organ.

When examined macroscopically, the necrotic zone is dark green in color and has a loose structure: such tissues are easily damaged. The part of the appendix that is not affected by necrosis has the appearance of normal phlegmonous appendicitis.

The tissues adjacent to the appendix may contain fibrinous layers. The abdominal cavity may contain purulent fluid with a characteristic "fecal" odor and an accumulation of intestinal microflora, which is determined after sowing.

When conducting microscopy, the damaged layers of the appendix cannot be distinguished: they have all the signs characteristic of necrotic tissue. Other areas of the appendix are tissues involved in the phlegmonous inflammatory process.

Old people often develop a primary form of gangrenous appendicitis associated with the formation of an atherosclerotic thrombus in the appendicular artery. In fact, this pathology is a type of appendiceal infarction, the consequence of which is its gangrene. This course of the disease occurs without a preliminary catarrhal and phlegmonous stage.

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Symptoms gangrenous appendicitis

Gangrenous appendicitis occurs if acute inflammation is not treated within the first 24 hours. Starting from the second day of acute appendicitis, nerve sensitivity is lost and pain may cease to bother. Unfortunately, most patients think that their condition has returned to normal and they do not need to see a doctor. In such a situation, the risk of peritonitis is almost 100%.

The first signs of the onset of acute inflammation are repeated bouts of vomiting, after which there is no relief. General intoxication increases, body temperature often remains unchanged or even decreases.

The first stage of gangrenous appendicitis is called "toxic scissors": the patient's heart rate increases (about a hundred beats per minute), but there is still no increase in temperature. When examining the tongue, a typical yellow coating is found.

In senile primary gangrenous appendicitis, pain in the abdomen on the right side appears suddenly and disappears just as suddenly. When palpated, the abdomen is dense and painful. The patient feels grave.

If the patient does not receive the necessary medical care, then the gangrenous process is further complicated by perforation - a break in the wall of the appendix. At this point, the patient feels severe pain spreading throughout the entire abdominal cavity. The temperature rises, the heartbeat quickens, the surface of the tongue becomes dry, with a brownish coating. Exhaustive vomiting is observed.

Gangrenous appendicitis in children

In childhood, gangrenous appendicitis is usually the end of the acute appendicitis stage. With this type of disease, necrosis of the appendix walls occurs, and there is a risk of infection spreading to the peritoneum.

In children, the clinical picture of gangrenous appendicitis is similar to those in adults:

• diffuse abdominal pain;
• vomiting, after which the child does not feel better;
• normal or even low temperature;
• thirst, dry mouth.

It is worth noting that in children, due to the continued growth of the body, an atypical location of the intestinal appendix is often diagnosed - this point must be taken into account during diagnostic measures. An elevated location of the appendix is relatively common - approximately under the liver. In such a situation, the disease can be confused with cholecystitis. If the appendix is located behind the cecum, then there may be no tension in the anterior abdominal wall, and the pain will be localized in the lumbar region.

Forms

• Acute gangrenous appendicitis is an acute inflammation with symptoms that are not typical for ordinary appendicitis. Among these symptoms is a weak, diffuse pain without a clear localization that cannot be felt. The pain weakens as the destructive processes increase, and sometimes even disappears completely for a period of time. Vomiting and nausea are present.
• Gangrenous-perforative appendicitis occurs if timely assistance is not provided to a patient with acute gangrenous appendicitis. The complication is characterized by perforation of the walls and the outpouring of the contents of the appendix into the abdominal cavity, after which purulent peritonitis inevitably develops. In turn, purulent peritonitis can develop into a limited abscess, or into extensive widespread peritonitis.
• Purulent-gangrenous appendicitis is a combination of a purulent inflammatory process in the intestinal appendix with destructive necrotic processes in it. This type of appendicitis is the most insidious and requires the most urgent surgical intervention.

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Complications and consequences

If a patient with gangrenous appendicitis is operated on before the organ perforates, the probability of adverse effects is practically reduced to zero. In such a situation, only a postoperative complication may arise - for example, suppuration or wound infection.

If the patient did not undergo timely surgery, the consequences could be much more serious:

• perforation of the appendix with subsequent release of pus and fecal matter into the abdominal cavity;
• autoamputation of the appendix (separation of the necrotic appendix from the intestine);
• purulent peritonitis, fecal peritonitis;
• multiple abscesses;
• septic complications;
• the spread of purulent infection through the circulatory system.

All of the listed complications appear and increase rapidly. The patient experiences severe intoxication and dysfunction of vital organs, which together can lead to death.

• Elevated temperature after gangrenous appendicitis can normally persist for three days. If the condition does not normalize on the fourth day, then it is necessary to look for the cause and prescribe treatment. Why can the temperature rise? Firstly, the wound can become infected. Postoperative traumatic inflammatory process can develop. In some patients, an increase in temperature is the body's response to stress - usually this condition develops in people with weakened immunity. In order to accurately determine the cause of such a complication, the doctor usually prescribes diagnostics: a general blood test, ultrasound. In addition, antibiotic therapy will be mandatory.
• Purulent peritonitis is a complicated course of appendicitis, in which the peritoneum, the thinnest sheet that covers the internal organs, becomes inflamed. Purulent peritonitis occurs after a rupture of the appendix, when pus gets directly into the abdominal cavity. When a rupture occurs, the patient immediately feels much worse: the pain changes from localized to diffuse and becomes unbearable. The patient cannot rise, he lies on his side, bent over. The condition may be accompanied by vomiting, a sharp drop in blood pressure, tachycardia, and an increase in temperature.

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Diagnostics gangrenous appendicitis

Diagnosis of the disease is sometimes difficult. This is due to frequent cases of "smoothed" symptoms and atypical forms of appendicitis. However, doctors follow a generally accepted diagnostic scheme:

1. Collecting anamnesis, or more simply – questioning the patient about the signs, location, duration of pain syndrome, the presence of other symptoms and diseases.
2. Examination of the patient: external examination of the skin, palpation of the abdomen, assessment of the signs of Shchetkin-Blumberg, Rovsing, Sitkovsky.
3. Tests: general blood test (leukocytosis or leukopenia, accelerated ESR are noted), general urine test (needed to differentiate from urological pathology).
4. Instrumental diagnostics (ultrasound, computed tomography, radiography, laparoscopy, both diagnostic and therapeutic).

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Differential diagnosis

Differential diagnostics are carried out with the following pathological conditions:

• closed abdominal injuries with damage to hollow or parenchymal organs;
• acute intestinal obstruction;
• acute mesadenitis;
• acute inflammation of the pancreas, gallbladder;
• pneumococcal peritonitis;
• perforation of gastric ulcer and duodenal ulcer;
• dissection of abdominal aortic aneurysm;
• mesenteric thromboembolism.

In women, gangrenous appendicitis should be distinguished from ectopic pregnancy (ruptured tube or tubal abortion), from ovarian apoplexy, from acute inflammation of the uterine appendages, from pelvic peritonitis and necrosis of the myomatous node.

Treatment gangrenous appendicitis

The only possible treatment option for gangrenous appendicitis is considered to be surgical intervention – removal of the appendix.

Removal of gangrenous appendicitis can be performed in several ways:

• The standard method of appendectomy: the surgeon makes an oblique incision of 10 to 12 cm in length. The appendix is released and removed through it, after which the doctor sutures the cecum. The operation is always accompanied by a revision of the cavity and the installation of drainage devices.
• The transluminal appendectomy method involves making a transvaginal (in the vaginal wall) or transgastric (in the stomach wall) puncture, after which the surgeon uses special elastic instruments.
• Laparoscopy is currently the most popular method, which involves three punctures in the abdominal wall - near the navel, between the pubis and the navel, in the right iliac region. Laparoscopic access allows you to assess the condition of all internal organs, remove gangrenous appendicitis, and remove adhesions. This method is less traumatic for the patient, and healing occurs in the shortest possible time.

The doctor decides which method to use to perform the operation – this depends, first of all, on the availability of the necessary equipment and instruments in the hospital.

Recovery from gangrenous appendicitis

During the recovery period, the patient is prescribed drug therapy, physiotherapy, exercise therapy, and manual therapy.

The following medications are typically prescribed:

• Antibiotics:
  • cephalosporin series (Ceftriaxone, Cefixime);
  • fluoroquinolone series (Levofloxacin, Ofloxacin).
• Analgesics:
  • narcotic analgesics (Promedol);
  • non-narcotic analgesics (Baralgin, Ibuprofen).
• Infusion solutions:
  • glucose solution;
  • isotonic sodium chloride solution;
  • reosorbilact.
• Drugs that prevent thrombus formation (heparin).

Nutrition after gangrenous appendicitis

Gangrenous appendicitis almost always leads to a disorder of the intestinal motor function. If complications arise, such as peritonitis, then the difficulties with peristalsis only worsen. As a result, the processes of digestion of food and the processes of excretion of feces slow down.

The diet after surgery for gangrenous appendicitis is as follows:

• The first day after surgery is actually the most "hungry" day. Most often, postoperative patients have no appetite. However, it is allowed to drink a small amount of pure still water, weakly brewed sweetened tea, compote, low-fat kefir. In some cases, the doctor may allow you to eat a couple of spoons of weak chicken broth.
• If there are no complications, then on the second day after surgery, you can add mashed potatoes, strained cottage cheese, liquid porridges and soups to your diet. If peristalsis is weak and the wound is not healing well, the doctor may recommend dietary restrictions, as on the first day.
• On the third day, most postoperative patients resume bowel function. If the patient has had a bowel movement, he may be recommended dietary treatment table No. 5, the essence of which is the exclusion of fatty, fried, smoked and pickled dishes, as well as fractional and frequent meals. The patient should adhere to this dietary principle for as long as possible - weeks and months after the operation, depending on the severity of the condition.

Postoperative period

The period after surgical treatment of gangrenous appendicitis has significant differences from the treatment of ordinary inflammation of the appendix.

• After surgery, antibiotic therapy with strong antimicrobial drugs is mandatory.
• The postoperative period may be accompanied by severe pain, so adequate painkillers are prescribed, both non-narcotic and narcotic.
• Since gangrenous appendicitis usually causes severe intoxication, after surgery, infusions of saline solutions, albumin, glucose solution, xylate, etc. are prescribed.
• To avoid the formation of blood clots in the vessels, as well as to prevent post-drug diseases of the digestive system, anticoagulants and drugs to regulate the secretory activity of the stomach (omeprazole, quamatel, etc.) are prescribed.
• For several days after the operation, a general blood test is performed daily.
• Every day, the wound is bandaged and the drainage system is washed.
• After the patient's health has returned to normal, massage, therapeutic exercise and breathing exercises are prescribed.

Prevention

Preventive measures should first of all be aimed at preventing infection from entering the circulatory and digestive systems, as well as preventing the development of diseases of the digestive tract.

It is important to establish regular bowel movements, as constipation contributes to stagnation of feces in the intestines, which can trigger the development of gangrenous appendicitis.

In addition, it is necessary to observe the rules of intimate and personal hygiene, eat properly and nutritiously:

• observe the meal schedule;
• do not overeat;
• consume sufficient amounts of fiber, which is found in vegetables, fruits, dried fruits, and cereals;
• prevent the development of dysbacteriosis (avoid prolonged and chaotic use of antibiotics, consume fermented milk products).

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Forecast

If a patient with gangrenous appendicitis was operated on in a timely and competent manner, the prognosis of the disease can be considered positive. The working capacity of most patients is fully restored within a month.

If complications develop – for example, with peritonitis, with the development of adhesive disease and intestinal obstruction – treatment may be more difficult and longer.

An unfavorable outcome is observed when a doctor is consulted late - in such a situation, gangrenous appendicitis can even end in death.

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