Gangrenous appendicitis

Gangrenous appendicitis is named according to the nature of the inflammation in the wall of the appendix. In form refers to destructive. This means the inevitable destruction of the integrity of the wall.

In the abdominal cavity, surgeons find a serous or purulent fluid( effusion) with the smell of rot. The disease almost always occurs with severe complications. The final diagnosis can only be done with a visual examination of the process.

The older the patient, the more likely the rapid development of gangrene. If in children and adolescents it is found in 8% of the operated cases, in the elderly after 60 years - the frequency reaches 33%.

Pathanatomy of the inflamed process

The inflammatory process begins with the catarrhal stage, the expansion of the capillaries, the influx of lymphocytes trying to stop and localize the disease. There are edema and infiltration of the wall. Possible small purulent foci. Conditionally, this stage occurs up to 6 hours after the onset of an attack in a patient.

If during this period does not remove the process, then on the walls appear foci of necrosis, and in the abdominal cavity the effusion takes a purulent character. All layers undergo melting. The appendix looks dirty-green in color, enlarged, the wall flabby with areas of hemorrhage and necrosis. The development of necrosis takes up to three days.

Intermediate picture of appendicitis in the patient is caused by phlegmonous gangrenous changes. In the gangrenous stage, adjacent tissues and organs join the inflammation of the appendage. The intestinal loops, the omentum, the peritoneal sheets suffer. They are found to be affected by fibrin, hemorrhage. In the blind and ileum there is hyperemia and infiltration.

The combination of abscess and necrosis is more often found in the end zone of the appendix

. The outcome is self-amputation of the appendix( detachment from the cecum) or perforation of the wall( perforation) due to rupture. Surgeons know that any manipulations against the background of a gangrenous appendix in the patient always lead to a breakthrough of purulent contents.

There is an opinion that the rate of anatomical changes does not depend on the timing of the onset of pain. Therefore, the relationship to the above references is relatively arbitrary.

What causes gangrenous disorders?

Important risk factors for the transition of inflammation to the gangrene stage are:

• impaired blood circulation in the elderly patient due to widespread atherosclerosis;
• bowel ischemia due to obstructed patency of the mesentery arteries( thrombosis);
• congenital maldevelopment of feeding arteries( in children of child age).

These changes in the patient's body lead to the development of the main cause - impaired microcirculation in the wall of the appendage. In the future,

• is infected with pathogenic microbes;
• infringement of passableness for contents of an appendix( the expanded lymphoid follicles at young, intestinal parasites and foreign bodies - at the child, fecal stones - in an old age);
• is an autoimmune reaction of the body.

They aggravate the course of the disease. It is possible to gradually change the forms of inflammation from catarrhal to phlegmonous, untimely rendering specialized care, transition to destruction and purulent fusion.

Manifestations of

Symptoms of gangrenous appendicitis begin according to the classical canons with catarrhal inflammation. The patient has epigastric pain, nausea, vomiting, fever. For 2 hours, the pains "descend" into the right iliac region at the normal position of the process. They can irradiate in the hypochondrium to the right, into the coccyx, into the central zone of the abdomen.

Acute gangrenous appendicitis developing from phlegmonous causes first pulling or pulsating pain, then stagnation due to complete destruction of sensitive nerve endings in the wall. Phlegmonous appendicitis can be considered as gangrenous, which, with timely surgical intervention, has no practical significance.

Vomiting becomes repeated, multiple. The temperature rises to high figures, which is accompanied by chills. The patient pales, becomes covered with a cold sweat. Upon examination, the doctor discovers dryness of the tongue.

Local soreness and denser density of the abdominal muscles of the patient is a sign of irritation of the peritoneum, the stomach does not participate in the act of breathing.

In the blood test, leukocytosis does not always increase sharply, but draws attention to a significant shift of the leukocyte formula to the left. Differential diagnosis is particularly difficult in female patients. It is necessary to exclude right-side adnexitis, rupture and torsion of ovarian cysts, ectopic pregnancy, apoplexy of appendages.

With atypical location of the process, the disease gives the mask:

• of the large intestine diverticulitis;
• right-sided pyelonephritis;
• of renal colic;
• of acute cholecystitis;
• gastritis or duodenitis;
• perforated stomach ulcer;
• acute pancreatitis.

What helps in diagnosis?

The doctor has to rely on his practical experience and laboratory indicators, since ultrasound of the abdominal cavity is not enough informative study with appendicitis. But the hardware methods allow to exclude gynecological pathology in women, pancreatitis, ectopic pregnancy, urolithiasis, pyelonephritis. The gynecologist is being consulted, rectal examination is performed in men.

What is the difference in gangrenous-perforated form?

Gangrenous-perforated is called the form of inflammation of the process with a mandatory violation of the integrity of the wall. Its isolation emphasizes the severity of the course, justifies complications and the risk of surgical intervention.

The danger is the presence of penetration of purulent contents into the abdominal cavity. Local or diffuse peritonitis occurs. The patient has pronounced signs of irritation of the peritoneum, there is no intestinal peristalsis. Disturbs palpitation, dizziness, weakness.

Treatment of

If catarrhal appendicitis still has opinions about the possibility of conservative treatment, then gangrenous and gangrenous-perforated form can be cured only surgically. To stop the spread of the inflammatory process to the peritoneum, a source of pus must be removed.

The operation is performed most often for emergency indications in 2-4 hours from the onset of an

attack. A planned approach is possible at a later date, but rather it should be called "delayed".Time is spent on stabilizing the patient's condition with a drop in pressure, heart failure caused by intoxication, decompensation of diabetes mellitus.

In preparation for surgery, patients are given detoxification, drip fluids, antibiotics, funds to support cardiac activity. Through the probe, the contents of the stomach are taken out. Doctors must find out the patient's inclination to allergic reactions.

It is important to know for choosing the method of processing the operating field, anesthesia. The patient necessarily signs his consent to the surgical intervention, for the children - this is done by the parents or guardians.

For complete anesthesia, one of the following methods is used:

• creation of an anesthetic infiltrate;
• conductor block of the nearest nerve plexuses;
• general anesthesia.

Chooses his anesthesiologist, depending on the patient's age, excitability, tolerability of drugs. Sufficient anesthesia helps to reduce the time of surgery, the risks of postoperative complications, complete healing.

Local anesthesia is not used in children, fear and excitement do not allow them to completely relax the abdominal wall and examine the cavity. Adults suffer quite enough local anesthesia in the catarrhal form of appendicitis, but the likely peritonitis and the need for an expansion of the operation with gangrene require general anesthesia. Because it suppresses the gag reflex, it relaxes the muscles when you inject muscle relaxants.

After the treatment of the operating field and anesthesia, the surgeon conducts a layer-by-layer dissection of the peritoneal wall. The method allows you to suture bleeding vessels, less to injure the muscles. The length of the incision should be sufficient to ensure that the doctor examines the cavity. The muscles and their aponeuroses are separated by hand in the course of the fibers.

In the open abdominal cavity, the omentum and intestine are removed. For inspection, a check of 50 cm length on each side of the appendix is ​​necessary. An inflamed process is identified by the beginning of the ribbons of the large intestine.

The process is isolated very carefully, so as not to cause a spontaneous rupture of the

. The appendix is ​​removed, and the remaining stump is sutured with a special sealed sachet. It consists in immersion inward and the possibility of combining the serous membranes. When an exudate is found in the peritoneum, it is washed with sterile solutions, an antibiotic is administered. Suturing the abdominal wall of the patient is done with dense strands that dissolve after a while.

7-10 stitches are applied to the skin. The need to combat peritoneal phenomena requires leaving a drainage tube. After stabilization of the patient's condition, drainage is removed. The operation usually lasts up to three hours. Special regulations are not provided. Time is determined by the severity of the condition, age, complicating factors( adhesions in the abdominal cavity, abnormal arrangement of the process).

How does the patient have a postoperative period?

The first day is called an early postoperative period. The patient continues the introduction of detoxification drugs, antibiotics. The doctor controls temperature, urine output and diuresis daily, hears intestinal noises.

In the days that follow, a gradual recovery of the patient's condition is observed: appetite and defecation appear, and the temperature normalizes. With daily dressings, inspect the surgical suture, wash the wound through the drainage. Anxiety causes pain in the seam area, discrepancy, prolonged absence of stool.

Unlike the simple form of appendicitis, the patient needs:

• stronger antibacterial agents( from the group of cephalosporins, antibiotics Levofloxacin, Ornidazole, Amikacin);
• analgesics;
• introduction for the removal of intoxication albumin, fresh frozen plasma, rheosorbilact, refortan;
• prevents the development of thromboembolism and stressful stomach ulcers.

Infusion therapy - the basis for the recovery of

Consequences of surgical delay

With timely surgical intervention, if the process does not explode, patients quickly recover. It is noticed that they have more often than in other forms possible suppuration of the wound. Severe consequences threatened by the refusal of the operation.

Delayed removal of the appendix provokes:

• perforation( perforation) of the wall, the pus flows into the abdominal cavity;
• detachment( self-amputation) of the caecum due to tissue melt;
• development of purulent and purulent-fecal peritonitis, with the patient's condition getting heavy on the eyes, the temperature is rarely significant, there is no usual dependence on the pulse rate, conducting an overview radiography of the abdominal cavity confirms peritonitis by the presence of a level of fluid in the intestine;
• multiple abscesses in the organs of the abdominal cavity and pelvis;
• abdominal sepsis;
• pylephlebitis - purulent inflammation of the portal vein of the liver.

Diet after operation

A special approach to nutrition with gangrenous appendicitis is associated with a longer disruption of intestinal motility. The organs of the abdominal cavity are more severely injured, which slows down the digestion of the patient. In the first 24 hours allowed to drink only boiled water, low-fat kefir, decoction of dried fruits. From six to seven times a day give a small portion of liquid broth, soup with croup.

It is allowed to drink mineral water without gas, slightly sweet weak tea, broth of dogrose

For the second day, in the absence of signs of complications, grated boiled meat, mashed potatoes, sausages, cottage cheese, liquid cereals with butter are added. This diet is reserved for patients until a pronounced peristalsis appears.

From the third day with full bowel movements and defecation it is allowed to expand the diet to table number 5.To observe it is necessary to exclude fatty and sharp dishes, smoking, marinades, fat, spices, to eat often and little by little.

What regimen is needed for patients?

In uncomplicated course, the patient can and even needs to get up 5-6 hours after the operation. Early active movements, therapeutic exercises, deep breathing exercises prevent inflammation of the lungs.

Against the backdrop of complications, walking is delayed for 2 days. The first ascent from bed is best done in the presence of relatives or medical personnel. Expansion of the regime is allowed by the doctor individually. It is recommended for less painful to wear a bandage or tightly wrapped with a towel.

Usually, the patient is discharged on the tenth day. Within a month, a gentle exercise regime is necessary. Elevation of severity is contraindicated within three months. Possible exercises for strengthening the muscles of the legs, hands, slow walking.

Sutures are removed in the treatment room with a good wound condition.

. Sports( running, weightlifting, football, volleyball) will have to be postponed for at least 3 months. The decision to allow training should be taken with a doctor. A clear dependence of the complications and the results of the operation on the patient from neglect of the disease requires own control over abdominal pains, timely calling of the "First Aid", supervision by specialists.