Appendicitis: symptoms in adults, the elderly, pregnant women and children. Appendicitis in children, pregnant women and the elderly
Recently, the diagnosis and treatment of appendicitis in the elderly has improved significantly, there has been significant progress. Gerontology and geriatrics have always been of great interest in healthcare and surgery. Although the treatment of elderly patients differs sharply in quality improvement, especially in last years, mortality remains high. And this happens regardless of the fact that diagnosis and treatment have moved forward. IN modern medicine the characteristics of the organism, the age category are taken into account, but this does not protect against fatal outcomes.
Among some of the most dangerous diseases is appendicitis. What are the features of appendicitis in the elderly?
Previously, it was believed that the elderly do not get sick, appendicitis is a problem for the young, but recently, this opinion has been rejected.
In older people, diseases of the cardiovascular system, respiratory organs are often observed, kidney and liver function insufficiency is manifested, and constant weakness in organism. With such symptoms, it is difficult even for an experienced therapist or surgeon to establish the correct diagnosis. If the patient suffers from nephrolithiasis, intestinal obstruction, acute cholecystitis He has mild symptoms. In such cases, it is most difficult to diagnose the patient. Atypicality is a problem in old age, which can cause delayed delivery of the patient to the hospital, as well as be the cause of a diagnostic error.
Features of appendicitis in old age have a reduced reactivity of the body and a fairly rapid development of inflammation. At the onset of the disease, no high temperature and the pain is weak. Pain is felt throughout abdominal cavity. Impaired bowel movements and dry mouth may be monitored. There may be a delay in stool. The muscles of the anterior wall of the abdominal cavity partially atrophy, especially in older women, this is due to increased deposition of fat, naturally, there is practically no tension in the abdominal muscle. It is worth carefully conducting an anamnesis, a correct assessment of the results of the patient's research will make it possible to diagnose appendicitis in people in old age.
It is worth noting that in the elderly, the destructive form of appendicitis is much more common than in young people. Here, metabolic disorders, changes in the walls of the process, which appear with age, as well as a reduced resistance of the body, play a role. In old age, an inflammatory infiltrate may form, it is difficult to catch it, and sometimes it can be detected late. In the elderly, the inflammatory process takes place gradually, which means that the disease can be overlooked, it is insidious and slow. Patients in the elderly should be treated with increased attention, even if the severity clinical symptoms does not seem sharp at first glance. If the patient suffers long enough, there may be catarrh process. These patients require increased attention to postoperative period. Do not forget that there may be vascular complications with thrombosis, embolism. There may be a problem with metabolism, this should also be monitored.
Mortality in elderly people is 20-30 times higher than in younger patients. If the diagnosis is not made in time, then the patient is at risk of peritonitis, however death can overtake not because of peritonitis, but occur against the background of diseases of the cardiovascular system.
It is advisable to visit a doctor more often and not delay if you feel the symptoms described above. It is important to accurately establish the diagnosis, unfortunately, the features of appendicitis can not always be recognized immediately, this leads to diagnostic errors. If the diagnosis is established, do not postpone the operation, finding out the clinical picture. Procrastination can lead to complications in the future.
Often in older people there is a bright clinical picture chronic appendicitis. Feeling in the right side of the abdomen dull pain. Features are such that a person is disturbed frequent constipation changing to diarrhea. to install chronic form using contrast x-rays.
It is worth remembering that the ability to work in older people is restored for a long period, usually after 6-8 weeks. Treat with understanding a person who is no longer young.
A 65-year-old woman was brought to our clinic. She had acute abdomen, complaints of a different nature. When palpation was performed, she could not clearly say exactly where it hurts more. Naturally, her weight exceeded the norm. Due to her fullness, it was difficult to determine what exactly was troubling her. She was prescribed a series of tests, but it still took quite a long time. The therapist did not determine in time that the woman had acute appendicitis. She had to wait for the results of the tests, undergo an ultrasound diagnosis, which took about 2 hours. The woman did not lose consciousness, her temperature did not rise, she calmly waited for the results. While the nurse carried the tests to the emergency department, the patient sat quietly on the bench and did not particularly worry about her condition. However, these 2 hours of waiting had a negative effect on the body. elderly woman because she needed urgent surgery. As a result, after the diagnosis was established, on the operating table, surgeons fought not with appendicitis, but with peritonitis.
Acute appendicitis in older people is much more difficult to determine than in the younger generation. The symptoms are very different. But you need to understand that after 60, the likelihood of appendicitis is as high as in younger years.
This acute inflammation appendix of the caecum (appendix). The disease belongs to urgent surgery and requires urgent surgical intervention. In the elderly, acute appendicitis occurs in 1-6% of cases. A feature of the disease in old age is necrotic changes in the appendix and an erased clinical picture. This complicates the diagnosis of pathology and leads to the development of complications - peritonitis, V severe cases lethal outcome.
Features of the clinical picture
In old age, the general reactivity is reduced, as a result of which severe local inflammatory response against the backdrop of a weak response immune system and the whole organism as a whole. This leads to necrosis of the appendix and purulent inflammation of the surrounding tissues, while Clinical signs pathologies are poorly expressed (erased symptoms).
Features of the clinical picture of appendicitis.
- Normal or subfebrile temperature(37-37.3 degrees).
- Pain syndrome without a clear localization. Pain is rarely localized in the right iliac region. It often occurs throughout the abdomen or in the lower back.
- Mild irritation of the peritoneum. characteristic symptom Shchetkin-Blumberg is doubtful or negative.
- More common than in patients young age, there is nausea and vomiting, dryness of the tongue.
- Paresis of the intestine, which is complicated by dynamic intestinal obstruction.
- Muscle tension in the anterior abdominal wall absent or slightly expressed due to age-related atrophy and decreased muscle tone.
- In blood tests, in most cases, there is no inflammation reaction (leukocytosis, shift leukocyte formula to the left, an increase in ESR) even in the case of the formation of a purulent infiltrate or peritonitis.
Features of diagnosis and therapy
In elderly patients, due to the peculiarities of the course of appendicitis, the diagnosis of the disease is difficult. To detect pathology, the clinical picture and objective examination are often not enough, as in young patients. For staging accurate diagnosis resort to additional methods research.
apparent easy current disease against the background of an erased clinical picture does not exclude urgent appendectomy- surgery to remove the appendix. Expectant tactics and methods of monitoring the patient in old age are not used. On the contrary, the earlier surgery is scheduled, the lower the risk of complications.
Appendectomy is performed under local anesthesia. Local anesthesia in old age reduces the likelihood of exacerbation of concomitant chronic diseases from the respiratory, cardiovascular, digestive, nervous system. General anesthesia is prescribed in case of impossibility of local anesthesia.
During the operation Special attention give hemostasis to prevent the development of hematoma in the area surgical intervention. The formation of an infiltrate in the suture area impairs tissue healing against the background of a low ability to regenerate in old age.
In the postoperative period, pressure ulcer prevention , congestive pneumonia, limb muscle atrophy. Schedule a massage therapeutic gymnastics, antibacterial and restorative therapy. Rehabilitation in the postoperative period prevents exacerbation of concomitant chronic diseases and deterioration of the general condition.
Acute appendicitis in the elderly is a more severe disease than in other age groups. Fortunately, its frequency in the elderly is relatively low. In the elderly, high mortality rates from acute appendicitis are usually associated with concomitant severe cardiac pathology and late diagnosis. Due to bad memory older people sometimes it is not easy to find out many details of the anamnesis of the disease. Often, patients attribute their symptoms to a chronic disease. Physical examination findings can be highly vague or masked by other illnesses or complications, as these patients often arrive late at the hospital. advanced stage diseases. In some cases, the only symptom of the disease may be bloating.
By different reasons in the elderly, the body's reaction to the purulent-inflammatory process may be poorly expressed, as a result of which they often do not have fever and leukocytosis. On radiographs, signs of dynamic or mechanical intestinal obstruction. A surgeon who encounters mild and atypical symptoms in patients with multiple comorbidities is sometimes hesitant to perform surgery. In such situations great help staged correct diagnosis can provide irrigoscopy and ultrasound scan belly.
Acute appendicitis in the elderly. People over 60 years of age get sick with acute appendicitis 2-3 times less often than younger people. In the elderly and senile age, destructive forms of acute appendicitis predominate, which is associated with vascular sclerosis and rapid circulatory disorders, leading to the development of necrosis and gangrene.
Symptoms of appendicitis in the elderly weakly expressed. Complaints are moderate, the temperature rises slightly or remains normal, the pulse quickens. Nausea, vomiting. Delayed stool is not critical, sometimes there are phenomena of dynamic intestinal obstruction. The number of leukocytes rarely reaches 10-109-12-109 / l, however, there is a shift to the left in the blood formula and toxic granularity may appear.
Acute appendicitis in children the most common surgical disease of the abdominal organs in children, requiring urgent surgical intervention. In development inflammatory process in the appendix the leading role belongs to the autoflora. Anaerobes play a major role. The anatomical and physiological features of the process, the infectious and somatic diseases, neurovascular factors.
The clinical picture of acute appendicitis in children has specific features, depending on the anatomical position of the vermiform appendix.
sprout, age of the child, features of his immunity. The most typical is the localization of the process in the right iliac region. Along with this, it can be in front of the caecum and be directed upwards into the subhepatic space. Often, the appendix is located retrocecally, intimately adjoining the right ureter and kidney, involving them in the inflammatory process. It sometimes occurs with a given localization of its retroperitoneal location. In some cases, a pelvic location of the process is observed. With a long mesentery of the caecum, it may shift to the left with the position of the process in the area middle line abdomen or left iliac region, the so-called medial position.
For each localization of the appendix in inflammation, a specific clinical picture is characteristic. Its features also depend on pathoanatomical changes in the appendix. Based on the pathoanatomical picture, four forms of acute appendicitis are distinguished: catarrhal, phlegmonous, gangrenous and perforative.
In case of catarrhal appendicitis, the serous membrane of the process is hyperemic, the process is tense, and fecal stones can be found in its lumen.
Phlegmonous appendicitis is characterized by purulent inflammation all layers of the appendix. Its wall is hyperemic, often covered with fibrinous-purulent plaque. Often, the process is club-shaped thickened due to the presence of pus in its lumen. This is an empyema of the appendix. The mesentery of the process phlegmonous appendicitis thickened, swollen. In the abdominal cavity, almost half of the patients have serous purulent exudate.
With gangrenous appendicitis, destructive changes occur in the entire thickness of the appendix wall. It thickens, acquires an earthy color, is covered with purulent overlays. The wall of the process becomes flabby and easily torn. The inflammatory process, as a rule, passes to the parietal peritoneum, blind and ileum. Serous-purulent or purulent exudate accumulates in the abdominal cavity. The altered appendix is wrapped in an omentum, which is the beginning of the formation of the appendicular infiltrate.
Perforated appendicitis develops when purulent fusion of the appendix wall occurs and its contents enter the abdominal cavity. This form of appendicitis occurs in older children with untimely (late) treatment for medical care or untimely diagnosis this disease. In older children with perforated appendicitis, an appendicular infiltrate is formed, and in the younger age group(children under 3 years old) - generalized peritonitis.
Clinical picture of acute appendicitis in older children characterized by the appearance of non-localized abdominal pain that occurs gradually. Initially, pain may appear in the epigastric region with irradiation to the navel. In the future, the pain is localized in the right under the iliac region, has a aching character. The highest intensity of pain is observed at the beginning of the disease, then it decreases due to the death of the nervous apparatus of the appendix, a period of "imaginary bliss" begins.
good fortune." When the process is perforated, the pain intensifies again, signs of peritoneal irritation appear.
In the first hours of the disease, older children with inflammation of the appendix have nausea and single vomiting. Body temperature may be normal or subfebrile. Most children refuse to eat, some of them have stool retention, others have diarrhea.
General state children with acute appendicitis satisfactory at the onset of the disease. With the development of the inflammatory process, it may worsen. The position of the patient is characteristic: more often he lies on his right side, legs slightly bent, avoiding any movements. Sometimes the child lies on his back, but not on his left side.
Objective examination the patient begins with the determination of the pulse rate. In the presence of an inflammatory process in the abdominal cavity, a discrepancy between the pulse rate and the height of body temperature can be detected: severe tachycardia with subfebrile condition.
The tongue at the beginning of the disease is wet, clean. Then comes dry mouth, dry, furred gray coating language.
During the external examination of the abdomen in the first hours of the disease, no pathology is determined. The abdomen is not swollen, participates in the act of breathing. With the involvement of the peritoneum in the inflammatory process - protective sparing of the right iliac region in the form of lagging behind it during the act of breathing. Very valuable informative data are obtained by palpation of the anterior abdominal wall. It must start on the healthy side. At superficial palpation the presence of tension of the anterior abdominal wall in the area of the location of the inflamed appendix is determined. Deep palpation reveals local pain in the right iliac region. To clarify the diagnosis, it is necessary to check a number of other symptoms characteristic of acute appendicitis. These should include:
Symptom coughing shock"- increased pain in the right iliac region when coughing;
Symptom Sitkovsky - increased pain in the iliac region on the right when the child is positioned on the left side;
Rovsing's symptom - squeezing the lumen with the right hand sigmoid colon in the left half of the patient's abdomen, after which jerky movements are made with the left hand above this place, under the influence of which the gas in the colon is displaced retrograde. If there is inflammation of the appendix and the dome of the caecum, then there is an increase in pain in this area;
Resurrection symptom - determined by sliding the II-IV fingers right hand the doctor along the patient's shirt stretched on the anterior abdominal wall from the epigastric region to the outer third of the left and right inguinal folds. With increased pain in the right iliac region, the symptom should be considered positive;
Symptom Filatov - increased pain in the right iliac region with deep palpation;
Symptom of Shchetkin-Blumberg - determined by deep gradual pressure with two or three fingers right hand on the abdominal wall with their rapid abduction. Increased pain in the abdomen when the arm is abducted indicates involvement in the inflammatory process of the peritoneum (positive symptom).
Appendicitis Presents greatest danger in old age, when the reactivity of the body is reduced and it is not always possible to mark the onset of the disease in time. Initially, the disease may be almost asymptomatic, but develops rapidly and leads to peritonitis. In the postoperative period, the risk of pressure sores and other complications is high.
Features of appendicitis in the elderly
Appendicitis is most dangerous in the elderly for two reasons: the inflammation proceeds rapidly, and the symptoms are lubricated and manifest with a delay. At the beginning of the disease, the temperature does not rise to critical values - it is subfebrile, which is typical for many chronic diseases.
The pain is mild and is combined with impaired intestinal motility and dry mouth. Due to the fact that the muscles of the anterior wall of the abdominal cavity are weakened, there is practically no tension in the abdominal muscles. Generally clinical manifestations do not correspond to the true picture of the disease. Therefore, appendicitis in the elderly is often diagnosed with a delay and often leads to postoperative mortality.
In the elderly, in 4% of cases, appendicitis is complicated by appendicular infiltrate surrounding the appendix. In such a situation, an antibiotic is administered until the infiltrate resolves. Sometimes complete atrophy and necrotic changes of the entire appendix occur, which is accompanied by extensive inflammation.
Acute appendicitis in the elderly is usually complicated by other comorbidities. Many by this age have atherosclerosis, pathologies of the cardiovascular, respiratory systems, calculous cholecystitis and other ailments. All this complicates the diagnosis, affects the manifestations of the disease and causes complications during and after surgery.
Symptoms
The elderly are characterized by delayed and inconsistent onset of symptoms. This is due to the slow reaction of the body to the pathological focus. Therefore, it is important to seek medical help at the first suspicion of an ailment.
Acute pain, temperature, which are clearly manifested in young people, are moderately expressed in old age. So, pain impulses are not intense and are often localized outside the right iliac region, although the development of the inflammatory process is not slow and just as dangerous. The focus of pain may be implicit, displaced, extending to the lumbar region.
The temperature is high only in 10% of cases, subfebrile in 50% and normal in 40%. As for blood tests, in 15% of cases the number of leukocytes in the blood is normal, and changes appear only 2-3 days after the onset of the disease. In young patients, muscular protection is usually pronounced - the muscles of the anterior abdominal wall are tense with appendicitis. In older people, on the contrary, the abdomen is easily palpable.
Appendicitis in old age is almost always accompanied by stool retention, dry tongue and general malaise. These symptoms become more pronounced with age. Due to the blurred picture, appendicitis is easily confused with neoplasms of the caecum. Therefore, to clarify the clinical picture, it is recommended to do a digital examination of the rectum and vaginal examination in women.
Diagnostics
Diagnosing appendicitis in the elderly is quite difficult: the symptoms are weakened, they do not appear immediately, due to age-related blunting of tactile, temperature and pain sensitivity the patient has little to tell the doctor. In addition, with age, the appendix atrophies, its lumen becomes overgrown, contributing to the development of a destructive form of appendicitis.
Since a superficial examination and a survey of complaints do not give grounds for making a diagnosis, urgent hospitalization and diagnosis with the help of modern medical equipment. Ultrasounds are performed lab tests, are taken into account additional symptoms(nausea, vomiting, dry tongue, stool retention). In acute appendicitis, an urgent operation is necessary, since the risk of developing peritonitis is high.
Treatment
Acute appendicitis in the elderly requires urgent surgical intervention. The operation should be performed by an experienced surgeon, since success depends on the technique of execution and sparing attitude to the tissues. The patient is given local anesthesia as gentle as possible. With peritonitis and a number of complications, the operation is performed under mask or intubation anesthesia.
Rehabilitation
After surgery, the elderly are at high risk of intestinal paresis, which is extremely difficult to tolerate. The swelling of the bowel loops raises the diaphragm and leads to dysfunction of the lungs and heart. This, in turn, can cause pneumonia, convergence and compression of the walls of the lung (atelectasis), acute cardiovascular failure. To avoid this situation, a constant aspiration of the contents of the stomach is performed.
The success of rehabilitation also depends on prevention. vascular diseases And cardiopulmonary insufficiency. Patients are prescribed banks, mustard plasters, oxygen therapy, elevated body position, early rising, breathing exercises, cardiac drugs. To prevent bedsores, it is necessary to carefully monitor the condition of the skin and observe hygiene measures.
