Inflammation of appendicitis in the elderly. Acute appendicitis in elderly and senile patients
In older people, it occurs in 8-12% of those operated on for this pathology. abdominal cavity, 2-3 times less often than in young people. Its low prevalence in this group of patients is explained by age-related atrophic changes in the appendix, which are often completely replaced by scar tissue. In 30-50% of cases, along with typical variants of the course, erased ones are observed in older people, even with the development of severe destructive changes in the appendix. Symptoms in older people are mild pain syndrome, dyspeptic and dysuric disorders, normal or slightly elevated body temperature, absence of tachycardia and leukocytosis, increased ESR. Changes in white blood characteristic of acute appendicitis usually appear late, 2-3 days or more after the onset of the disease. During the examination, the protective tension of the abdominal muscles characteristic of acute appendicitis is not found. Often the abdominal wall is flabby.
The atypicality of the symptoms of acute appendicitis is the reason for the late presentation of patients for medical help. In practice, they are admitted to hospitals when complications of the disease develop: peritonitis, etc. abscess. The formation of the latter is often complicated by acute intestinal obstruction.
However, the presence of severe concomitant pathology- chronic pneumonia, emphysema, coronary heart disease, diabetes mellitus- aggravates the course of the postoperative period, often leading to death.
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Acute appendicitis in pregnant women happens in 0.7-1.2% of cases, i.e. significantly more often than among other groups of the population. This explains a number of factors contributing to the occurrence of the inflammatory process in the appendix: its displacement upward and outward along with the cecum by the gradually enlarging uterus, as a result of which kinks and stretching of the appendix occur; disruption of the evacuation of its contents, as well as deterioration of blood supply in conditions of changed anatomical relationships between organs. An important role is played by the tendency to constipation during pregnancy, which leads to stagnation of the contents and increased virulence of the intestinal flora. Finally, hormonal changes that lead to a decrease in immunity are of certain importance. These factors often lead to severe appendicitis, ending in a destructive process, especially in the second half of pregnancy. In turn, destructive appendicitis can lead to termination of pregnancy and fetal death. This complication occurs with appendicitis in pregnant women in 4-6% of cases.
Special consideration of appendicitis in pregnant women is due to the fact that a number of signs inherent in this disease (abdominal pain, vomiting, leukocytosis) may occur during the normal course of pregnancy, making its diagnosis difficult.
Clinical course Acute appendicitis in the first half of pregnancy is almost no different from that outside pregnancy. Significant differences arise only in the second half of pregnancy.
First of all, the rather weak severity of the pain syndrome is noteworthy, as a result of which patients do not pay attention to it, identifying it with the pain that often occurs in the second half of pregnancy due to stretching ligamentous apparatus uterus. Nevertheless, careful questioning allows us to establish the onset of pain in the epigastric region and its gradual displacement to the location of the appendix (Kocher-Volkovich symptom). Vomiting is not critical, since it often occurs during pregnancy in general.
When examining the abdomen, it is necessary to take into account the localization of the appendix, which moves upward as pregnancy progresses (see Fig. 43-13).
Rice. 43-13. The displacement of the cecum and appendix by the pregnant uterus necessitates a change in surgical approach.
Thus, local pain in acute appendicitis in the second half of pregnancy will not be in the right iliac region, but much higher. Due to the stretching of the abdominal wall by the enlarged uterus, local muscle tension is weakly expressed. In late pregnancy, when the cecum and its appendix are located behind the enlarged uterus, other symptoms of peritoneal irritation may be negative: Shchetkin-Blumberg, Voskresensky, etc. During this period, as a rule, Obraztsov’s symptom is well expressed. Palpation of the abdomen with the patient on the left side is extremely useful: in this case, due to some displacement of the uterus to the left, it is possible to palpate the area of the appendix and right kidney in more detail and identify the Barthomier-Michelson symptom.
The temperature reaction is less pronounced than outside pregnancy. The number of leukocytes increases moderately, but it must be taken into account that leukocytosis up to 12x10 9 / l in pregnant women is not uncommon.
As operational access if the diagnosis is undoubted, the Volkovich-Dyakonov incision is used in the first half of pregnancy. In the second half of pregnancy, this access may be inadequate, so it is modified according to the principle: the longer the pregnancy, the higher the incision. Thus, in last weeks During pregnancy, the incision is made above the ilium due to a significant upward displacement of the cecum and appendix. It is advisable to expand the Volkovich-Dyakonov incision by dissecting the sheath of the rectus abdominis muscle.
Surgical tactics for any form of appendicitis in pregnant women do not differ from the generally accepted principles of its treatment. In other words, the features of the surgical technique and methods of drainage of the abdominal cavity, adopted for various forms ah acute appendicitis. It is only necessary to exercise maximum caution when manipulating near an enlarged uterus, since its injury can be a direct cause of miscarriage or premature birth.
For the same reasons, abdominal tamponade is carried out according to the strictest indications:
- if it is impossible to achieve reliable hemostasis in the abdominal cavity;
- when opening a periappendicular abscess.
In pregnant women, the most difficult task is the treatment of diffuse peritonitis. Mortality from this complication remains very high and, according to various authors, is 23-55% for the mother and 40-92% for the fetus, with the largest number of deaths observed in late dates pregnancy. Unfavorable results of treatment of diffuse purulent peritonitis in pregnant women gave rise to extreme radicalism surgical tactics. It was considered necessary to perform the following amount of surgical intervention: immediately after opening the abdominal cavity, perform C-section, then supravaginal amputation of the uterus, then appendectomy, toilet and drainage of the abdominal cavity.
Currently, thanks to the availability of powerful antibacterial drugs in the majority similar cases it is possible to avoid resorting to a caesarean section, much less subsequent amputation of the uterus. It must be emphasized that the question of the volume and nature of intervention in case of destructive appendicitis against the background of long periods of pregnancy should be resolved together with an obstetrician-gynecologist, with his direct participation in the surgical intervention. Briefly principle of modern surgical tactics can be formulated as follows: maximum activity against peritonitis, maximum conservatism against pregnancy.
IN modern conditions for diffuse appendiceal peritonitis in pregnant women, it is performed under general anesthesia median laparotomy, evacuation of pus, appendectomy, toilet of the abdominal cavity and drainage is installed. The surgical wound is sutured tightly. In case of full-term or almost full-term pregnancy (36-40 weeks), due to the inevitability of childbirth due to peritonitis, the operation begins with a cesarean section, then after suturing the uterus and peritonization of the sutures, an appendectomy and all further manipulations associated with the treatment of peritonitis are performed.
The urgent need for amputation of the uterus arises only when it is destructively damaged, which is rarely observed in conditions of diffuse purulent peritonitis. It should also be taken into account that with diffuse purulent peritonitis, the contractility of the uterus is significantly reduced. In this regard, sometimes after a cesarean section there is a danger of atonic bleeding, the only means of combating which is immediate amputation of the uterus.
Deserves special attention acute appendicitis during childbirth. Surgical tactics for appendicitis during childbirth depend both on the course of labor and on clinical form acute appendicitis. So, if labor proceeds normally with the clinical picture of catarrhal and phlegmonous appendicitis, then it is necessary to promote a speedy delivery and then perform an appendectomy. If, against the background of the normal course of labor, there is a clinical picture of gangrenous or perforated appendicitis, then it is necessary to temporarily stop the contractile activity of the uterus, perform an appendectomy and then stimulate it again. labor. In conditions of pathological childbirth, it is necessary to perform a simultaneous cesarean section and appendectomy for any clinical form of acute appendicitis.
Regardless of the timing of delivery, the patient for appendectomy and subsequent postoperative management must be transferred to surgery department, where she should be observed by both a surgeon and a gynecologist.
Acute appendicitis in children occurs much less frequently than in adults. The vast majority of cases occur over the age of 5 years. The rarity of acute appendicitis before 5 years of age explains the fact that the appendix has a funnel-shaped shape, which facilitates good emptying of the appendix, as well as the fact that the lymphoid apparatus of the appendix is still poorly developed during this period of life.
Acute appendicitis in children occurs more violently than in adults. This is due to insufficient resistance child's body to infection, weak plastic properties of the children's peritoneum, insufficient development of the omentum, which does not reach the appendix and, thus, does not participate in the creation of a delimiting barrier.
The pain that arises in the abdomen is often cramping in nature and does not have the clear dynamics that are characteristic of acute appendicitis in adults. It should be noted that children under 10 years of age, as a rule, cannot accurately localize pain, which makes it difficult to recognize the disease. Vomiting in children is most often repeated, stool does not tend to be retained, and in children younger age even quickened. The pose of a sick child is typical. He lies on his right side or on his back, bringing his legs to his stomach and placing his hand on the right iliac region, protecting it from examination by a doctor. With careful palpation, it is often possible to identify hyperesthesia, muscle tension and the area of greatest pain. Even in the first hours of the disease, symptoms of Shchetkin-Blumberg, Voskresensky, and Bartomier-Mikhelson can be expressed.
The temperature from the very beginning of the disease is significantly higher than in adults, often reaching and exceeding 38 °C. The number of leukocytes is also increased, but it rarely exceeds 20x10 9 /l along with the existing neutrophil shift.
In the differential diagnosis of acute appendicitis in children, the following diseases deserve attention: pleuropneumonia, acute gastroenteritis, dysentery, hemorrhagic vasculitis (Henoch-Schönlein disease).
When differentiating from pleuropneumonia, it must be taken into account that this disease is characterized not only by pain spreading towards the abdomen, but also by cough, sometimes with transient cyanosis of the lips, wings of the nose and shortness of breath. It should be recalled that in children normal ratio breathing and pulse is 1:4, and if the ratio becomes 1:3 or 1:2, then this is rather in favor acute pneumonia. With pleuropneumonia, you can also listen to rales and pleural friction sounds on the corresponding side of the chest.
When differentiating from gastroenteritis, it must be taken into account that this disease begins, as a rule, not with abdominal pain, but with vomiting and the appearance of characteristic repeated watery stools; Unlike acute appendicitis, pain occurs later. In addition, with gastroenteritis they have a pronounced cramp-like character, which is often followed by the urge to stool. Temperature at the specified disease increased, as with appendicitis, but the number of leukocytes is normal or even slightly reduced, the neutrophil shift is not pronounced.
The need to differentiate acute appendicitis from dysentery occurs most often in the younger age group. Here, first of all, the anamnesis plays a role, in particular, indications that similar disease appeared in several children at once, especially in children's groups. Pain in dysentery is clearly cramping in nature and is localized mainly in the left half of the abdomen, repeated loose stool, often mixed with blood. Maximum palpation pain is determined in lower sections abdomen on the left, symptoms of peritoneal irritation, with rare exceptions, are not detected. Body temperature during dysentery is often high (38.0-39.0 ° C), the number of leukocytes can be increased without a significant neutrophil shift.
When differentiating with hemorrhagic vasculitis take into account that abdominal pain in this disease is caused by multiple small subserous hemorrhages and does not have a clear localization. In addition, a careful examination of the skin can reveal the presence or residual effects hemorrhagic exanthema on symmetrical areas of the trunk, limbs, buttock areas. You should also pay attention to the mucous membrane of the cheeks, sublingual space, where it is possible even before the appearance of a rash on skin detect the presence of minor hemorrhages. The abdominal wall is not tense during the examination, but the Shchetkin-Blumberg symptom is most often pronounced, the abdomen is distended and uniformly painful. At rectal examination bloody intestinal contents can be detected. Body temperature sometimes reaches 38 °C and higher, the number of leukocytes is also often increased without a significant neutrophil shift.
In case of significant difficulties in differential diagnosis, if there are no symptoms of peritoneal irritation, dynamic observation of the child for 6-12 hours is acceptable.
At the same time, it should be remembered that appendicitis in children occurs more rapidly than in adults, and often during the first day of the disease destruction of the appendix develops. Based on this, surgical tactics in children should generally be more active than in adults.
All this fully applies to appendicular infiltrate, which in children often begins to be determined already on the second day of the disease. Since in children the appendix is relatively long, and the omentum, on the contrary, is short, and the peritoneum does not have sufficient plastic properties, the resulting infiltrate cannot be a reliable obstacle to the spread of infection throughout the abdominal cavity. In this regard, surgery is indicated even with a palpable infiltrate, especially since isolating the appendix from loosely fused organs is not particularly difficult.
Appendectomy in children is always performed under general anesthesia. The Volkovich-Dyakonov incision is used as an operative access, with the exception of cases of diffuse purulent peritonitis, when a lower-median laparotomy is indicated.
In most cases, appendectomy in children is technically uncomplicated due to the lack of adhesive process and fusion of the appendix with surrounding organs. The procedure for surgical manipulations is the same as for adults, with the exception of treatment of the stump of the appendix, which in children under 10 years of age is not immersed due to the danger of a through puncture of the small intestinal wall when applying a purse-string suture. In this regard, in children of the first years of life, the so-called ligature (amputation) method of appendectomy is used, in which the stump of the appendix is bandaged not with catgut, but with silk or other non-absorbable thread, the mucous membrane is cauterized with an electrocoagulator and left in this form in the abdominal cavity.
Numerous clinical observations have proven the safety of this method of treating the stump of the appendix, although in older children it is still better, as in adults, to immerse the stump in order to avoid strong adhesion of intestinal loops to it, which may subsequently serve as a cause intestinal obstruction. The operation is completed by suturing the surgical wound tightly and, if necessary, draining the abdominal cavity. Due to the fact that in children the appendix is located in the abdominal cavity more freely, in childhood There are reasons for performing laparoscopic appendectomy. In many clinics, the vast majority of surgical interventions for acute appendicitis are currently performed laparoscopically.
Acute appendicitis in the elderly and senile age happens somewhat less frequently than in young and middle-aged people. The number of elderly and senile patients is about 10% of the total number of patients with acute appendicitis.
In elderly and senile age, destructive forms of appendicitis predominate. This is due, on the one hand, to the reduced reactivity of the body, and on the other - atherosclerotic lesions its vessels, which is the direct cause of rapid disruption of blood supply with the development of necrosis and gangrene of the appendix. It is in old people that the so-called primary gangrenous appendicitis occurs, which develops bypassing the catarrhal and phlegmonous phases of inflammation.
The symptom complex of acute appendicitis in patients in this group often has a blurred picture. Due to physiological increase threshold of pain sensitivity in old age, patients often do not pay attention to the epigastric phase of abdominal pain at the onset of the disease.
Nausea and vomiting occur more often than in middle-aged people, which is associated with rapid development destructive process. Stool retention is not of decisive importance, since in old age there is a physiological tendency to slow bowel movements.
When examining the abdomen, only moderate pain is detected in the right iliac region, even with destructive forms of appendicitis. Due to age-related relaxation of the muscles of the abdominal wall, muscle tension in the lesion is insignificant, but the Shchetkin-Blumberg symptom is usually determined. Voskresensky and Sitkovsky symptoms are often positive.
In some cases, especially with destructive forms of the disease, there is severe flatulence due to intestinal paresis. Body temperature, even with destructive appendicitis, increases moderately or remains normal. The number of leukocytes is normal or slightly increased: within 10-12x10 9 /l, the neutrophil shift is slight.
In elderly and senile people, much more often than in middle-aged people, appendiceal infiltration occurs, which is characterized by slow development. Patients often notice a tumor-like formation in the right iliac region several days after an attack of mild pain, which forces them to pay special attention to the differential diagnosis of appendiceal infiltrate with a tumor of the cecum.
The peculiarity of the course of acute appendicitis in old people is that accurate recognition of one or another clinical form of acute appendicitis before surgery is difficult. This indicates the need for active surgical tactics, especially since the risk of appendectomy in old age is often exaggerated. When choosing a method of pain relief, preference is given to local anesthesia, especially in patients with concomitant diseases of the respiratory and cardiovascular systems. Management of the postoperative period in elderly patients is no less important than the operation itself. Dynamic control is required functional state critical systems body. The main activities should be aimed at the prevention and treatment of respiratory disorders, circulatory disorders, renal failure and metabolic changes. Particular attention should be paid to the prevention of pulmonary embolism.
Forecast
With timely diagnosis and adequate treatment the prognosis is quite favorable. Mortality is 0.1-0.3%. It is associated with the development of severe abdominal sepsis due to late presentation of patients for medical care and severe concomitant diseases. Postoperative complications occur in 5-9% of cases, most often wound infection. No adverse effects were noted after appendectomy.B.C. Savelyev, V.A. Petukhov
Appendicitis represents greatest danger in old age, when the body’s reactivity is reduced and it is not always possible to detect the onset of the disease in time. At first, the disease may occur with almost no symptoms, but develops quickly and leads to peritonitis. In the postoperative period, there is a high risk of bedsores and other complications.
Features of appendicitis in old age
Appendicitis is most dangerous in old age for two reasons: inflammation occurs rapidly, and the symptoms are blurred and appear with a delay. At the beginning of the disease, the temperature does not rise to critical values - it is low-grade, 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 abdominal wall are weakened, there is practically no tension in the abdominal muscles. In general, clinical manifestations do not correspond to the true picture of the disease. Therefore, appendicitis in the elderly is often diagnosed late and often leads to postoperative mortality.
In old age, 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 older people is usually complicated by other concomitant diseases. Many people by this age experience atherosclerosis, cardiovascular pathologies, respiratory systems, calculous cholecystitis and other ailments. All this complicates diagnosis, affects the manifestations of the disease and causes complications during and after surgery.
Symptoms
The elderly are characterized by a delayed and inconsistent onset of symptoms. This is explained by the body’s slow response to the pathological focus. Therefore, it is important to seek medical help at the first suspicion of illness.
Acute pain and fever, which are pronounced in young people, are moderate in old age. Thus, 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 is equally dangerous. The source of pain may be subtle, displaced, radiating to the lumbar region.
The temperature is high only in 10% of cases, low-grade 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, muscle protection is usually pronounced - the muscles of the anterior abdominal wall are tense during appendicitis. In older people, on the contrary, the stomach can be easily felt.
Appendicitis in old age is almost always accompanied by stool retention, dry tongue and general malaise. The manifestation of these symptoms becomes more pronounced with age. Due to the blurred picture, appendicitis is easily confused with neoplasms of the cecum. 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 older people is quite difficult: the symptoms are weakened and do not appear immediately; due to age-related dulling of tactile, temperature and pain sensitivity, the patient can tell the doctor little. 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 survey of complaints do not provide grounds for diagnosis, urgent hospitalization and diagnosis using modern medical equipment are necessary. Ultrasounds are performed lab tests, additional symptoms are taken into account (nausea, vomiting, dry tongue, stool retention). In case of acute appendicitis, urgent surgery is necessary, since there is a high risk of developing peritonitis.
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 and gentle treatment of tissues. The patient is given local anesthesia as gentle as possible. In case of peritonitis and a number of complications, the operation is performed under mask or intubation anesthesia.
Rehabilitation
After surgery, elderly people are at high risk of intestinal paresis, which is extremely difficult to tolerate. Bloating of the intestinal loops raises the diaphragm and leads to dysfunction of the lungs and heart. This, in turn, can cause pneumonia, convergence and compression of the lung walls (atelectasis), and acute cardiovascular failure. To avoid this situation, constant aspiration of the stomach contents is carried out.
The success of rehabilitation also depends on prevention vascular diseases and cardiopulmonary failure. Patients are prescribed cupping, mustard plasters, oxygen therapy, elevated body positions, early rising, breathing exercises, and heart medications. To prevent bedsores, it is necessary to carefully monitor the condition of the skin and observe hygiene measures.
Recently, the number of elderly patients with acute appendicitis, who, as a rule, suffer from concomitant diseases, has increased significantly.
Features of the symptoms of acute appendicitis in old age, due to reduced reactivity of the body, inconsistency clinical manifestations and laboratory parameters lead to delayed diagnosis and high postoperative mortality. Improving diagnostic capabilities in this group of patients is an urgent task of our time.
The problem of acute appendicitis in elderly and senile patients occupies one of the important places in gerontology and geriatrics. Elderly and senile patients are usually burdened with concomitant diseases: atherosclerosis, cardiovascular diseases, pulmonary emphysema, pneumosclerosis, calculous cholecystitis etc. These diseases can significantly affect the symptoms and outcome of acute appendicitis, and are sometimes the main source of postoperative complications and the cause of death.
Symptoms of acute appendicitis in old age
With acute appendicitis, the majority of elderly patients fail to note the onset of the disease, and their main symptoms are less constant than in young patients. One of the leading - sharp pain is less intense and is often localized outside the right iliac region. In 41% of cases, elderly patients have a normal temperature, in 14.7% of cases there is a normal number of leukocytes in the blood. In old people with acute appendicitis, changes in the white blood usually appear late (after 2-3 days or more).
If in elderly patients the main acute symptoms appendicitis, then they almost always experience stool retention, dry tongue and general malaise. The older the patient, the more pronounced these phenomena are.
With an atypical location of the inflammation in patients in this group, not only low intensity is noted, but also uncertainty in the localization of abdominal pain, but more often it occurs in the lower abdomen, lumbar region or is of a spilled nature. Quite often this is accompanied by dysuric disorders.
It is observed much more often in old age. It was noted in 4.1% of cases, i.e. 4 times more often than in young and middle-aged people. Appendiceal infiltrates in elderly patients have their own characteristics: they often appear without a characteristic previous acute attack, their course is usually sluggish, which often makes differential diagnosis with a neoplasm of the cecum difficult. In elderly people, pelvic appendiceal ulcers or infiltrates located in the pelvic area, which proceed sluggishly and atypically, are often not recognized in a timely manner.
In order to reduce such diagnostic errors in old age, it is necessary to conduct a digital examination of the rectum (and vaginal examination in women).
A slow response of the body to a pathological focus, blurred symptoms in elderly and senile ages lead to delayed surgery, which results in high mortality after appendectomy. According to some data, it is 30 times higher than the overall mortality rate for this disease, and postoperative complications observed in almost 1/3 of patients.
Diagnosis of appendicitis in elderly patients
It is known that old people often experience “silence of symptoms” against the background of general adynamia. Flabbiness of the abdominal wall and obesity mask the tension of the muscles of the anterior abdominal wall. With age, tactile, temperature, and pain sensitivity dulls, which reduces diagnostic value many symptoms.
Diagnostic errors in recognizing acute appendicitis in elderly and senile people are more common than in young people. This is explained not only by the blurred clinical picture of the disease and the pronounced unresponsiveness of patients, but also by the morphological changes that occur in the appendix at this age.
Scientists have shown that with increasing age, atrophy appears both of the entire appendix and its individual layers; the number of follicles and vessels in the appendix decreases; obliteration of its lumen occurs. These changes are a prerequisite for the occurrence of destructive appendicitis. Early development of necrotic processes, tendency to thrombus formation - the most important features course of acute appendicitis in old age.
Treatment of appendicitis in the elderly
The main principle of treating acute appendicitis in elderly patients is early surgery. This group of patients requires more time both to clarify the diagnosis in the hospital and to prepare the patient for surgery. However, targeted preparation for surgery should not delay it. The use of cardiac and detoxification agents, hormone therapy is a mandatory minimum complex of preoperative preparation.
Most operations in elderly patients are performed under local anesthesia, which makes it possible to successfully perform surgery. In some cases - with an atypical location of the appendix, phenomena, perforation of the appendix - it is more advisable to immediately perform a median laparotomy under mask or intubation anesthesia.
Along with the right choice method of pain relief, the technique of performing surgical intervention and sparing treatment of tissues are of no small importance. Such patients should be operated on by more experienced surgeons.
The current point of view on packing and drainage of the abdominal cavity in patients with acute appendicitis young requires some adjustments towards expanding the indications in elderly patients due to the reduced plastic properties of the peritoneum in this group of patients. According to some data, in 1/3 of elderly and senile patients with destructive acute appendicitis, packing was performed, and in ½, drainage of the abdominal cavity was performed.
Due to the characteristics of the senile body, this group of patients has a much more severe course. Intestinal paresis, pneumonia, cardiopulmonary failure, and thromboembolic complications are more often observed. Special attention it is necessary to pay attention to the postoperative management of patients with destructive forms of acute appendicitis, accompanied by peritoneal phenomena. Targeted antibiotic therapy taking into account the sensitivity of the abdominal flora, intravenous transfusions of glucose with saline solution, plasma, blood - necessary measures combating the symptoms of existing peritonitis.
Postoperative period
One of critical issues postoperative period is the fight against postoperative intestinal paresis, which is observed in older people much more often and is difficult for them to tolerate. Constant bloating intestinal loops, overflowing with their contents and gas - all this leads to a high standing of the diaphragm, disruption of pulmonary ventilation and cardiac activity, resulting in the development of pneumonia, pulmonary atelectasis, and acute cardiovascular failure. The fight against intestinal paresis should begin from the first hours after surgery. One of the most effective measures in the fight against it is constant aspiration of stomach contents.
Prevention of vascular diseases, in particular thrombosis and embolism, is of great importance. Considering the cardiopulmonary failure often observed in elderly patients, it is necessary to widely use breathing exercises and a complex of cardiac drugs in the postoperative period. Such generally accepted measures as cupping, mustard plasters, oxygen therapy, elevated body positions, and getting up early are reliable prevention. It is necessary to constantly monitor the neatness of patients and the condition of their skin in order to prevent the development of bedsores, which can sometimes even lead to the death of the patient.
Acute appendicitis in older people is a more severe disease than in other age groups. Fortunately, its incidence in older people is relatively low. In older people, high mortality rates from acute appendicitis are usually associated with concomitant severe cardiac pathology and late diagnosis. Due to bad memory For older people, it is sometimes difficult to find out many details of the medical history. Patients often attribute their symptoms to some chronic disease. Findings obtained during physical examination may be extremely vague or masked by other diseases or complications, since such patients often arrive at the hospital late, advanced stage diseases. In some cases, the only symptom of the disease may be bloating.
By various reasons in older people, the body’s reaction to purulent inflammatory process, as a result of which they often lack fever and leukocytosis. Radiographs often show signs of dynamic or mechanical intestinal obstruction. The surgeon who encounters mild and atypical symptoms in patients with multiple concomitant diseases, sometimes one hesitates to perform surgery. In such situations great help staged correct diagnosis irrigoscopy and ultrasound scanning belly.
Acute appendicitis in the elderly. People over 60 years of age develop 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 impairment, leading to the development of necrosis and gangrene.
Symptoms of appendicitis in the elderly weakly expressed. The complaints are moderate, the temperature rises slightly or remains normal, the pulse quickens. Nausea, vomiting. Stool retention is not of decisive importance; sometimes dynamic intestinal obstruction is observed. 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 emergency surgical intervention. In the development of the inflammatory process in the appendix, the leading role belongs to autoflora. Anaerobes play a major role. The anatomical and physiological characteristics of the appendix, infectious and infectious diseases suffered by the child are of certain importance. somatic diseases, neurovascular factors.
Clinical picture acute appendicitis in children has specific features, depending on the anatomical position of the worm-shaped
sprout, age of the child, characteristics of his immunity. The most typical location of the process is in the right iliac region. Along with this, it can be located in front of the cecum and be directed upward into the subhepatic space. Often the appendix is located retrocecally, in intimate contact with the right ureter and kidney, involving them in the inflammatory process. Its retroperitoneal location is sometimes found in this localization. In some cases, a pelvic location of the process is observed. If the mesentery of the cecum is long, it may shift to the left with the position of the process in the area midline abdomen or left iliac region, the so-called medial position.
Each location of the appendix with inflammation is characterized by a specific clinical picture. Its features also depend on pathological-anatomical changes in the appendix. Based on the pathological picture, four forms of acute appendicitis are distinguished: catarrhal, phlegmonous, gangrenous and perforated.
With catarrhal appendicitis, the serous membrane of the appendix is hyperemic, the appendix is tense, and there may be fecal stones 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. 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, and becomes covered with purulent deposits. The wall of the process becomes flabby and easily ruptures. The inflammatory process, as a rule, spreads to the parietal peritoneum, cecum and ileum. Serous-purulent or purulent exudate accumulates in the abdominal cavity. The modified appendix is enveloped in omentum, which is the beginning of the formation of an appendicular infiltrate.
Perforated appendicitis develops in cases where purulent melting of the wall of the appendix occurs and its contents exit into the abdominal cavity. This form of appendicitis occurs in older children with untimely (late) seeking medical help or delayed diagnosis of this disease. In older children with perforated appendicitis, an appendicular infiltrate is formed, and in younger children 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 area. Subsequently, the pain is localized in the right subiliac region, has 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, the period of “imaginary pain” begins.
good luck." When the appendix is perforated, the pain intensifies again, and signs of peritoneal irritation appear.
In the first hours of the disease, older children with inflammation of the appendix experience nausea and single vomiting. Body temperature may be normal or low-grade. Most children refuse to eat, some of them have stool retention, while others have diarrhea.
General state children with acute appendicitis at the onset of the disease are satisfactory. As the inflammatory process develops, it may worsen. The patient's position is typical: most often he lies on his right side, with his legs slightly bent, avoiding any movements. Sometimes the child lies on his back, but not on his left side.
An objective examination of the patient begins with determining 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 may be detected: pronounced tachycardia with low-grade fever.
At the beginning of the disease, the tongue is moist and clean. Then there is a dry mouth, dry, coated gray coating language.
An external examination of the abdomen in the first hours of the disease does not detect any pathology. The abdomen is not swollen and 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 its lag during the act of breathing. Very valuable informative data is obtained by palpation of the anterior abdominal wall. It must start from the healthy side. At superficial palpation is determined by the presence of tension in the anterior abdominal wall in the area where the inflamed appendix is located. 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 include:
Symptom " cough impulse» - increased pain in the right iliac region when coughing;
Sitkovsky's symptom - increased pain in the iliac region on the right when the child is positioned on the left side;
Rovsing's sign - the lumen is compressed with the right hand sigmoid colon in the left half of the patient’s abdomen, after which jerking movements are made with the left hand above this place, under the influence of which the gas in the large intestine shifts retrogradely. If there is inflammation of the appendix and the dome of the cecum, then increased pain in this area appears;
Voskresensky's symptom is determined by sliding the II-IV fingers of the doctor's right hand 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. If pain in the right iliac region increases, the symptom should be considered positive;
Filatov's symptom - increased pain in the right iliac region with deep palpation;
Shchetkin-Blumberg symptom - determined by deep, gradual pressure with two or three fingers right hand on abdominal wall with their rapid removal. Increased pain in the abdomen when the arm is abducted indicates involvement of the peritoneum in the inflammatory process (a positive symptom).
