– an acute nonspecific process of inflammation of the appendix - an adnexal formation of the cecum. The clinical picture of acute appendicitis manifests itself with the appearance of a dull pain in the epigastric region, which then shifts to the right iliac region; Nausea, vomiting, and low-grade fever are observed. Diagnosis of acute appendicitis is based on identifying characteristic symptoms during examination of the abdomen, changes in peripheral blood, and ultrasound; this excludes other diseases of the abdominal cavity and pelvis. In acute appendicitis, an appendectomy is performed - removal of the altered appendix.

ICD-10

K35

General information

Acute appendicitis is the most common surgical disease, accounting for more than 80% in surgical gastroenterology. Acute appendicitis most often occurs in people aged 20-40 years, although it can also occur in childhood or old age. Despite advances in diagnostics and improvements in surgical treatment methods, postoperative complications in acute appendicitis are 5-9%, and mortality is 0.1-0.3%.

Causes of acute appendicitis

To a certain extent, a nutritional factor can contribute to the development of acute appendicitis. It is known that eating predominantly meat foods contributes to disruption of intestinal motor-evacuation function and a tendency to constipation, which, in turn, predisposes to the development of acute appendicitis. Also, unfavorable background factors include intestinal dysbiosis, decreased body resistance, and some types of location of the appendix in relation to the cecum.

Acute appendicitis is caused by nonspecific microbial flora: anaerobic non-spore-forming microorganisms (bacteroides and anaerobic cocci - in 90% of cases), aerobic pathogens (Escherichia coli, enterococci, Klebsiella, etc. - 6-8%), less often - viruses, protozoa present in the appendix . The main mechanism of infection of the appendix is ​​enterogenous; lymphogenous and hematogenous routes of infection do not play a leading role in the pathogenesis of acute appendicitis.

Classification of acute appendicitis

Acute appendicitis can occur in a simple (catarrhal) or destructive form (phlegmonous, apostematous, phlegmonous-ulcerative, gangrenous).

The catarrhal form of acute appendicitis (catarrhal appendicitis) is characterized by disorders of lymph and blood circulation in the wall of the appendix, its swelling, and the development of cone-shaped foci of exudative inflammation (primary affects). Macroscopically, the appendix looks swollen and congested, the serous membrane is dull. Catarrhal changes may be reversible; otherwise, as they progress, simple acute appendicitis becomes destructive.

By the end of the first day from the onset of acute catarrhal inflammation, leukocyte infiltration spreads to all layers of the appendix wall, which corresponds to the phlegmonous stage of acute appendicitis. The walls of the appendix thicken, pus forms in its lumen, the mesentery becomes swollen and hyperemic, and a serous-fibrinous or serous-purulent effusion appears in the abdominal cavity. Diffuse purulent inflammation of the appendix with multiple microabscesses is regarded as apostematous acute appendicitis. With ulceration of the walls of the appendix, phlegmonous-ulcerative appendicitis develops, which, with an increase in purulent-destructive changes, turns into gangrenous.

Symptoms of acute appendicitis

The development of acute appendicitis is divided into an early stage (up to 12 hours), a stage of destructive changes (from 12 hours to 2 days) and a stage of complications (from 48 hours). Clinical manifestations of acute appendicitis manifest suddenly, without any precursors or prodromal signs. In some cases, several hours before the development of acute appendicitis, nonspecific phenomena may be observed - weakness, deterioration in health, loss of appetite. For the stage of advanced clinical manifestations of acute appendicitis, pain and dyspeptic disorders (nausea, vomiting, gas and stool retention) are typical.

Abdominal pain in acute appendicitis is the earliest and most persistent symptom. In the initial stage, the pain is localized in the epigastrium or peri-umbilical region, and is mild and dull in nature. When coughing or sudden changes in body position, the pain intensifies. A few hours after its onset, the pain shifts to the right iliac region and can be characterized by patients as tugging, stabbing, burning, cutting, sharp, dull. Depending on the location of the appendix, pain can radiate to the navel, lower back, groin, and epigastric region.

In acute appendicitis, as a rule, there are symptoms of digestive disorders: nausea, single vomiting, flatulence, constipation, and sometimes loose stools. Body temperature usually rises to low-grade levels.

In the stage of destructive changes, the pain syndrome intensifies, which significantly affects the condition of the patients. Body temperature increases to 38.5-390C, intoxication increases, tachycardia is noted up to 130-140 beats. per minute In some cases, a paradoxical reaction may be observed when pain, on the contrary, decreases or disappears. This is a rather ominous sign, indicating gangrene of the appendix.

Destructive forms of acute appendicitis are often accompanied by complications - the development of appendiceal abscess, periappendicitis, mesentericitis, abdominal abscess, perforation of the appendix wall and peritonitis, sepsis.

Diagnosis of acute appendicitis

In the diagnostic process, acute appendicitis must be differentiated from gastritis, gastric or duodenal ulcer, acute cholecystitis, pancreatitis, urolithiasis, cholelithiasis, ectopic pregnancy, adnexitis, acute orchiepididymitis, acute cystitis and other diseases that occur with abdominal pain.

Acute appendicitis is characterized by a number of abdominal symptoms: lag of the right abdomen during breathing (Ivanov's symptom), muscle tension of the anterior abdominal wall, symptom of peritoneal irritation (Shchetkin-Blumberg), pain in the right iliac region during percussion (Razdolsky's symptom), increased pain in position on the left side (Sitkovsky, Bartomier-Mikhelson symptom), etc. Changes in the leukocyte blood count increase in accordance with the stages of acute appendicitis - from 10-12x10 9 /l with catarrhal inflammation to 14-18x10 9 /l and higher - with purulent destructive forms.

For the purpose of differential diagnosis, a rectal or vaginal examination is performed. To exclude other acute pathologies of the abdomen, an ultrasound of the abdominal organs is performed, which also detects an enlargement and thickening of the appendix, and the presence of effusion in the abdominal cavity. If the clinical and laboratory picture is unclear, they resort to diagnostic laparoscopy.

Treatment of acute appendicitis

In acute appendicitis, the earliest possible removal of the inflamed appendix is ​​indicated - appendectomy. In typical cases of acute appendicitis, the Volkovich-Dyakonov approach to the appendix is ​​used - an oblique incision in the right iliac fossa.

In diagnostically unclear situations, the pararectal Lenander approach is used, in which the surgical incision runs parallel to the outer edge of the right rectus muscle above and below the navel. Mid-middle or lower-middle laparotomy is resorted to in cases where the course of acute appendicitis is complicated by peritonitis.

, adhesive intestinal obstruction, etc.) the prognosis is serious.

Etiology. Acute appendicitis is an inflammation of the appendix of the cecum, caused by the introduction of pathogenic microbial flora into its wall. The main route of infection of the appendix wall is enterogenic. Hematogenous and lymphogenous variants of infection are extremely rare and do not play a decisive role in the pathogenesis of the disease.

The direct cause of inflammation is a variety of microorganisms (bacteria, viruses, protozoa) located in the appendix. Among bacteria, anaerobic non-spore-forming flora (bacteroides and anaerobic cocci) are most often found (90%). Aerobic flora is less common (6-8%) and is represented primarily by Escherichia coli, Klebsiella, enterococci, etc. (the numbers reflect the ratio of the content of anaerobes and aerobes in the chyme of the colon).

Risk factors for acute appendicitis include a deficiency of dietary fiber in a standard diet, which promotes the formation of dense pieces of chyme content - fecoliths (fecal stones).

The secretion of mucus that continues under these conditions leads to the development and sharp increase of intracavitary pressure in a limited volume of the cavity of the appendix (0.1-0.2 ml). An increase in pressure in the appendix cavity due to its stretching with secretions, exudate and gas leads to disruption of first venous and then arterial blood flow.

With increasing ischemia of the wall of the appendix, conditions are created for the rapid proliferation of microorganisms. Their production of exo- and endotoxins leads to damage to the barrier function of the epithelium and is accompanied by local ulceration of the mucous membrane (primary Aschoff affect). In response to bacterial aggression, macrophages, leukocytes, lymphocytes and other immunocompetent cells begin to simultaneously secrete anti-inflammatory and anti-inflammatory interleukins, platelet activating factor, adhesive molecules and other inflammatory mediators, which, when interacting with each other and with epithelial cells, are able to limit the development of inflammation without allow the generalization of the process, the emergence of a systemic reaction of the body to inflammation.

After inflammation covers the entire thickness of the organ wall and reaches its serous membrane, the parietal peritoneum and surrounding organs begin to be involved in the pathological process. This leads to the appearance of a serous effusion, which becomes purulent as the disease progresses. Over time, the infiltrate may resolve or turn into an abscess.

Classification of appendicitis.

Acute uncomplicated appendicitis:

a) catarrhal (simple, superficial),

b) destructive (phlegmonous, gangrenous).

Acute complicated appendicitis: perforation of the appendix, appendicular infiltrate, abscesses (pelvic, subphrenic, interintestinal), peritonitis, retroperitoneal phlegmon, sepsis, pylephlebitis.

Chronic appendicitis (primary chronic, residual, recurrent).

Clinical picture and diagnosis.

Complaints. In acute uncomplicated appendicitis, abdominal discomfort suddenly appears at the onset of the disease: a feeling of bloating, distension of the abdomen, colic or vague pain in the epigastrium or in the umbilical region. Passing stool or gas relieves the patient's condition for a short period. Over time (1-3 hours), the intensity of the pain increases and its character changes. Instead of paroxysmal, aching, stabbing pain, a constant, burning, bursting, pressing pain appears. As a rule, this corresponds to the phase of migration of pain from the epigastrium to the right lower quadrant of the abdomen (Kocher-Wolkovich symptom). During this period, sudden movements, deep breathing, coughing, shaking, walking increase local pain, which can force the patient to take a forced position (on the right side with the legs brought to the stomach).

The localization of abdominal pain often indicates the location of the inflammatory focus in the abdominal cavity. Thus, pain concentrated in the pubic region, in the lower abdomen on the right, may indicate the pelvic localization of the appendage. With a medial location of the appendix, pain is projected to the umbilical region, closer to the middle of the abdomen. The presence of pain in the lumbar region, possible irradiation to the right leg, perineum, external genitalia in the absence of pathological changes in the kidney and ureter may indicate the location of the inflamed process behind the cecum. Pain in the right hypochondrium is characteristic of the subhepatic localization of the appendix. Pain in the left lower quadrant of the abdomen is very rare and can occur when the cecum and appendix are located on the left side.

Abdominal pain in acute appendicitis is usually moderate and tolerable. When the appendix is ​​stretched by pus (empyema), it reaches great intensity, becomes unbearable, pulsating, twitching. Gangrene of the appendix is ​​accompanied by the death of its nerve endings, which explains the short period of apparent improvement in the condition due to the disappearance of independent abdominal pain. Perforation of the appendix is ​​characterized by a sudden sharp increase in pain with its gradual spread to other parts of the abdomen.

A few hours after the onset of “abdominal discomfort,” the majority of patients (80%) experience nausea, accompanied by one or two vomitings (observed in 60% of patients, more often in children). Nausea and vomiting in patients with appendicitis occur against the background of abdominal pain. The appearance of vomiting before the development of pain makes the diagnosis of acute appendicitis unlikely.

As a rule, the majority of patients (90%) experience anorexia. If appetite persists, the diagnosis of inflammation of the appendix is ​​problematic.

An important and constant sign of acute appendicitis is stool retention (30-40%), caused by intestinal paresis due to the spread of the inflammatory process throughout the peritoneum. In rare cases (12-15%), patients report loose, single or double stools or tenesmus

Objective research

Particularly characteristic is the appearance or intensification of pain in the right lower quadrant of the abdomen when turning on the left side (Sitkovsky’s symptom). In the position on the right side, the pain decreases, so some patients take this position with their legs brought to the stomach.

In uncomplicated forms of appendicitis, the tongue is moist and covered with a white coating. Dry mucous membranes of the inner surface of the cheek and tongue indicate severe dehydration, observed as peritonitis develops. A large number of signs of acute appendicitis have been described. Not all of them have the same diagnostic significance; the main ones are given below.

When examining the abdomen, it is found that its configuration, as a rule, is not changed, but sometimes some swelling is noted in the lower sections, caused by moderate paresis of the cecum and ileum. Less commonly observed is abdominal asymmetry caused by protective muscle tension in the right lower quadrant.

With percussion of the abdomen, in many patients it is possible to determine moderate tympanitis over the right iliac region, often spreading to the entire hypogastrium. In 60% of patients, shaking of the inflamed peritoneum during percussion in the right lower quadrant of the abdomen causes severe pain (Razdolsky's symptom), in most cases corresponding to the localization of the source of inflammation.

Palpation of the abdomen reveals the two most important symptoms of acute appendicitis - local pain and tension in the abdominal wall muscles in the right iliac region. Superficial palpation should begin in the left iliac region, sequentially moving through all sections (counterclockwise), and end in the right iliac region.

The “key” to the diagnosis of acute appendicitis, “a symptom that has saved the lives of millions of patients,” is the protective tension of the abdominal wall muscles. It is necessary to distinguish the degree of tension in the muscles of the abdominal wall: from slight resistance to pronounced tension and, finally, a “board belly”.

Sliding your hand along the abdominal wall through the shirt in the direction from the epigastrium to the pubic region allows you to detect (in 60-70%) an area of ​​skin hypertension (pain) in the right iliac region ( Voskresensky's symptom).

To determine pain symptoms, deep palpation of the abdomen is performed. It begins, just like the superficial one, on the left side away from the place of projected pain. One of the most informative signs is the Shchetkin-Blumberg symptom (slow deep pressure on the abdominal wall with all fingers folded together does not affect the patient’s well-being, whereas at the moment of quickly removing the hand, the patient notes the appearance or sharp increase in pain). In acute appendicitis, the Shchetkin-Blumberg sign is positive in the part of the abdominal wall that is closest to the appendix. The symptom is caused by shaking of the inflamed peritoneum and is not specific. Often (40%) the appearance or intensification of pain in the right iliac region is detected with a sharp, hacking cough (Kushnirenko’s symptom).

Concussion of internal organs also occurs with the symptom Rovsinga: pressing with the left hand on the abdominal wall in the left iliac region, according to the location of the descending part of the colon, and with the right hand on its overlying part (push-like), causes the appearance or intensification of pain in the right iliac region.

When the patient turns on the left side, the appendix becomes more accessible for palpation due to the displacement of the greater omentum and loops of the small intestine to the left. When palpating in this position in the right iliac region, the appearance or intensification of pain is noted (positive Barthomier's sign).

If, with the patient lying on the left side, the right hand slowly moves the intestinal loops from bottom to top and from left to right, and then sharply removes the hand during exhalation, the internal organs shift to their original position under the influence of gravity. This leads not only to concussion of the internal organs and inflamed peritoneum, but also to tension in the mesentery of the appendix, which provokes sharp pain in the right iliac region in acute appendicitis.

If the inflamed process is located in the right iliopsoas muscle (m. ileopsoas), then palpation of the right iliac region when the patient lifts the right leg straightened at the knee joint will cause sharp pain ( Obraztsov's symptom).

With careful examination of the patient, in a typical case, the most painful point can be determined. It is usually located on the border between the middle and outer thirds of the line connecting the umbilicus and the right anterosuperior spine (McBurney's point) or on the border between the middle and right third of the line connecting the 2 anterosuperior iliac spines (Lanz's point).

The physical examination should be completed with a rectal examination. When the inflamed process is located at the bottom of the vesico-rectal (uterorectal) cavity, sharp pain in the right and anterior walls of the intestine can be established, which often allows a final diagnosis to be made.

Laboratory and instrumental diagnostics.

Most often (90%) a leukocytosis of more than 10 x 109/L is detected; in 75% of patients, leukocytosis reaches a value of 12 x 109/L or more. In addition, in 90% of patients, leukocytosis is accompanied by a shift in the leukocyte count to the left, while in 2/3 of patients more than 75% of neutrophils are detected.

In urinalysis, in 25% of patients, a small number of red blood cells and leukocytes is detected, which is due to the spread of inflammation to the wall of the ureter (with a retrocecal retroperitoneal location of the appendix) or bladder (with pelvic appendicitis).

In some cases, it is advisable to resort to radiation diagnostic methods (survey fluoroscopy of the chest and abdominal organs, ultrasound, computed tomography).

A survey fluoroscopy of the abdominal organs in 80% of patients can reveal one or more indirect signs of acute appendicitis: fluid level in the cecum and terminal ileum (the “guarding loop” symptom), pneumatosis of the ileum and right half of the colon, deformation of the medial contour of the cecum intestines, blurred contour of m. ileopsoas. Much less frequently, an X-ray-positive shadow of a fecal stone is detected in the projection of the appendix. When the appendix is ​​perforated, gas is sometimes found in the free abdominal cavity.

In acute appendicitis, the inflamed appendix is ​​identified by ultrasound in more than 90% of patients. Its direct distinguishing features are an increase in the diameter of the appendix to 8-10 mm or more (normally 4-6 mm), thickening of the walls to 4-6 mm or more (normally 2 mm), which in cross section gives a characteristic symptom of the “target” " ("cockades"). Indirect signs of acute appendicitis include rigidity of the appendix, changes in its shape (hook-shaped, S-shaped), the presence of stones in its cavity, disruption of the layering of its wall, infiltration of the mesentery, detection of fluid accumulation in the abdominal cavity. The accuracy of the method in the hands of an experienced specialist reaches 95%.

Laparoscopic signs of acute appendicitis can also be divided into direct and indirect. Direct signs include visible changes in the appendix, rigidity of the walls, hyperemia of the visceral peritoneum, pinpoint hemorrhages on the serous cover of the appendix, fibrin deposits, and infiltration of the mesentery. Indirect signs are the presence of cloudy effusion in the abdominal cavity (most often in the right iliac fossa and small pelvis), hyperemia of the parietal peritoneum in the right iliac region, hyperemia and infiltration of the wall of the cecum.

Treatment: appendectomy

Nonspecific inflammation of the appendix. The vermiform appendix is ​​part of the gastrointestinal tract, formed from the wall of the cecum; in most cases, it arises from the posteromedial wall of the cecum at the junction of three ribbons of longitudinal muscles and is directed from the cecum downward and medially. The shape of the process is cylindrical. Length 7-8cm, thickness 0.5-0.8cm. It is covered with peritoneum on all sides and has a mesentery, thanks to which it has mobility. Blood supply through a.appendicularis, a branch of a.ileocolica. The venous flows through v.ileocolica into v.mesenterica superior and v.porte. Sympathetic innervation is from the superior mesenteric and celiac plexus, and parasympathetic innervation is from the fibers of the vagus nerves.

During the prehospital period, it is prohibited to apply local heat, heating pads to the abdominal area, administer narcotics and other painkillers, give laxatives, and use enemas.

In the absence of diffuse peritonitis, surgery is performed using the McBurney (Volkovich-Dyakonov) approach.

The subcutaneous fatty tissue is dissected, then the aponeurosis of the external oblique muscle is dissected along the fibers, then the external oblique itself.

After spreading the edges of the wound, the internal oblique muscle is revealed. In the center of the wound, the perimysium of the oblique muscle is dissected, then with two anatomical tweezers, the internal oblique and transverse abdominal muscles are bluntly pulled apart along the fibers. The hooks are moved deeper to hold the spread muscles. Bluntly push the preperitoneal tissue to the edges of the wound. The peritoneum is lifted with two anatomical tweezers in the form of a cone and cut with a scalpel or scissors over a length of 1 cm.

The edges of the dissected peritoneum are grasped with Mikulicz-type clamps and its incision is expanded upward and downward by 1.5-2 cm. Now all layers of the wound, including the peritoneum, are pulled apart with blunt hooks. As a result, access is created that is quite sufficient for removing the cecum and vermiform appendix.

Then an appendectomy. After removing the appendage, the mesentery is crossed between hemostatic clamps and tied with thread; in this case, you need to make sure that the first (closest to the base of the process) branch a is included in the ligature. appendicularis to avoid bleeding. The so-called ligature method, in which the stump is not immersed in a pouch, is too risky; It should not be used in adults. A purse-string suture is placed (without tightening) around the base of the appendix on the cecum. The base of the appendage is tied with a ligature, the appendage is cut off, its stump is immersed in the intestinal lumen, after which the purse-string suture is tightened.
Having finished removing the appendix, checking hemostasis and lowering the intestine into the abdominal cavity, gauze pads are removed.

Nowadays, laparoscopic appendectomy—removal of the appendix through a small puncture of the appendix—has become widespread. 3 punctures: one 1 cm above the navel, another 4 cm below the navel and the third depending on the location of the process.

Appendicitis is inflammation of the appendix of the intestine. Incidence of appendicitis: every year, 1 in 200 residents, regardless of age, develops acute appendicitis.

Etiology

There is no single cause of acute appendicitis, just as there is no specific microbial pathogen: Foreign bodies in the lumen of the appendix damage the mucous membrane and create a path for infection. Increased pressure in the lumen of the appendix (clogging with fecal stones, worms, scar, etc.) Stagnation of feces in the appendix (impaired intestinal motility) Malnutrition of the wall of the appendix Proliferation of lymphoid tissue Immune status disorders Features of the diet (more often occurs in people consuming large amounts of meat). As a result of exposure to one of the above reasons, spasm of the appendix occurs, which leads to impaired evacuation and stagnation of the contents and is accompanied by vasospasm. Vascular spasms lead to malnutrition of the mucous membrane of the appendix. Both processes cause inflammation, first of the mucous membrane, and then of other layers of the organ.

Clinic

There are no specific signs of acute appendicitis. Most often characterized by Rapid onset Abdominal pain (sometimes a feeling of heaviness, nausea, and only then pain appear first) - in the sub-umbilical or peri-umbilical areas, gradually moving to the lower right part of the abdomen. Pain decreases when bending the right leg at the hip joint Lack of appetite Nausea Single vomiting Stool is usually normal, but loose stools are also possible (once), as a result of inflammation transferring to the cecum Slight increase in body temperature Pain decreases in the position on the right side Children: rapid increase in manifestations appendicitis.

Body temperature is often high. Vomiting and diarrhea are more pronounced.

Early return to a regime of full physical activity Elderly: the blurred manifestations of appendicitis can be the reason for untimely diagnosis and hospitalization. Pregnancy: diagnosis is difficult, because

The vermiform appendix is ​​displaced upward by the pregnant uterus, which leads to a change in the typical location of pain, and its location behind the uterus leads to a decrease in the severity of signs of peritoneal irritation.

Intrauterine fetal death occurs in 2-8.5% of cases. Complications of appendicitis Appendicular infiltrate Limited or diffuse peritonitis Pylephlebitis Fecal fistula Adhesive intestinal obstruction.

Diagnostics

Usually, in patients with acute appendicitis, changes in the general blood test are detected. Rectal (or vaginal) examination reveals pain in the wall of the rectum in front and on the right, sometimes - overhang of the fornix on the right. X-ray examination. In some cases, diagnostic and tactical difficulties can be resolved with the help of laparoscopy - an inflamed area is detected vermiform appendix or indirect signs of inflammation (effusion, hyperemia of the serous membranes) Ultrasound can reveal a thickened and swollen appendix

Treatment

If acute appendicitis is suspected, urgent hospitalization in a surgical hospital is necessary. Treatment is surgical. Appendiceal infiltrate without signs of abscess formation and peritonitis is considered a contraindication to surgery.

Depending on the technical capabilities (equipment), open or laparoscopic removal of the appendix is ​​performed. Open removal of the appendix is ​​the method of choice for destructive forms of acute appendicitis. Laparoscopic removal of the appendix is ​​preferable in obese patients, as well as in cases of unclear diagnosis

Attention! The described treatment does not guarantee a positive result. For more reliable information, ALWAYS consult a specialist.

Forecast

Mortality in acute appendicitis ranges from 0.15-0.30%. Old age, the presence of severe concomitant diseases (diabetes mellitus, pulmonary heart failure), and generalized peritonitis significantly worsen the prognosis.

Acute appendicitis- the most common surgical disease. Every year one out of every 200-250 people suffers from acute appendicitis. Women get sick 2-3 times more often than men. In Russia, more than 1 million appendectomies are performed annually. Postoperative mortality is 0.2-0.3%, and its cause is most often complications that developed in patients operated on late from the onset of the disease. In this regard, constant sanitary and educational work with the population is necessary, the purpose of which is to promote among the population the need to early seek medical help for abdominal pain and avoid self-medication.

Etiology and pathogenesis of acute appendicitis

As a result of dysfunction of the neuro-regulatory apparatus of the appendix, circulatory disturbance occurs in it, which leads to trophic changes in the appendix.

Dysfunction of the neuroregulatory apparatus can be caused by three groups of factors.

1. Sensitization (allergic component - food allergy, helminthic infestation).

2. Reflex path (diseases of the stomach, intestines, gall bladder).

3. Direct irritation (foreign bodies in the appendix, fecal stones, kinks).

In approximately 1/3 of cases, acute appendicitis is caused by obstruction of the lumen of the appendix with fecal stones (fecalitis), foreign bodies, worms, etc. Fecalitis is found in almost 40% of patients with simple appendicitis, in 65% of patients with destructive appendicitis and in 99% of patients with perforated appendicitis. tive appendicitis. With obstruction of the proximal part of the appendix, mucus secretion continues in its distal part, which leads to a significant increase in intraluminal pressure and impaired circulation in the wall of the appendix.

Dysfunction of the neuroregulatory apparatus leads to spasm of the muscles and blood vessels of the appendix. As a result of circulatory disorders in the appendix, swelling of its wall occurs. The swollen mucous membrane closes the mouth of the appendix, the contents accumulating in it stretches it, puts pressure on the wall of the appendix, further disrupting its trophism. As a result, the mucous membrane loses its resistance to microbes that are always present in its lumen (Escherichia coli, staphylococci, streptococci, enterococci and other microbes). They penetrate the wall of the appendix, and inflammation occurs. Acute appendicitis is therefore a nonspecific inflammatory process.

When the inflammatory process involves the entire thickness of the wall of the appendix, surrounding tissues are involved in the process. A serous effusion appears, which then becomes purulent. Spreading throughout the peritoneum, the process takes on the character of diffuse purulent peritonitis. With a favorable course of the disease, fibrin falls out of the exudate, which glues the intestinal loops and omentum, delimiting the source of inflammation. A similar demarcation around the appendix is ​​called appendicular infiltrate.

The appendicular infiltrate may resolve or fester. When the appendiceal infiltrate suppurates, a periappendicular abscess is formed, which can break into the free abdominal cavity (leading to diffuse peritonitis), into the intestine, into the retroperitoneal space, and can encyst and lead to septicopyemia. Very rarely, such an abscess can break out through the anterior abdominal wall. When an abscess breaks into the retroperitoneal space, phlegmon of the retroperitoneal tissue occurs.

A rare complication is pylephlebitis (thrombophlebitis of the portal vein) with the subsequent development of abscesses in the liver tissue. Pylephlebitis is detected in 0.05% of patients with acute appendicitis.

Classification of acute appendicitis (according to V.I. Kolesov)

1. Appendicular colic.

2. Simple (superficial, catarrhal) appendicitis.

3. Destructive appendicitis: phlegmonous, gangrenous, perforated.

4. Complicated appendicitis: appendiceal infiltrate, appendiceal abscess, diffuse purulent peritonitis, other complications of acute appendicitis (pylephlebitis, sepsis, etc.)

Pathological anatomy of acute appendicitis

For appendicular colic no changes in the appendix can be detected.

Simple (catarrhal) appendicitis. When opening the abdominal cavity, a transparent, odorless serous effusion (exudate) is sometimes visible. The vermiform appendix is ​​somewhat thickened, slightly tense, its serous membrane is hyperemic. The mucous membrane is thickened, swollen, loose, hyperemic, sometimes small ulcerations are visible on it - foci of epithelial destruction. These changes are most pronounced at the apex of the appendix. As a result of catarrhal inflammation, mucus accumulates in the lumen of the appendix. Histological examination reveals small areas of epithelial destruction on the mucous membrane, around which the tissues are infiltrated with leukocytes, and there is a fibrinous plaque on their surface.

From this focus of destruction of the epithelium of the mucous membrane, the process quickly spreads both into the thickness of the appendix to all its layers, and throughout - from the apex of the appendix to its base. The inflammation becomes purulent in nature, i.e. it develops phlegmonous appendicitis. In this case, the exudate in the abdominal cavity can be serous or purulent, the peritoneum of the iliac fossa becomes dull and cloudy, i.e. the process extends beyond the limits of the appendage. The vermiform appendix is ​​sharply thickened and tense, hyperemic and covered with fibrinous plaque. In the lumen of the appendix with phlegmonous inflammation there is pus. If the outflow from the appendix is ​​completely blocked, then pus accumulates in its closed cavity - an empyema of the appendix is ​​formed, in which it has a flask-shaped shape and is sharply tense.

Histological examination of the phlegmonically altered vermiform appendix clearly shows thickening of its wall, poor differentiation of the layers, with their pronounced leukocyte infiltration. Ulcerations are visible on the mucous membrane.

The next stage of the process is gangrenous appendicitis, in which necrosis of sections of the wall or the entire appendix occurs. Gangrenous appendicitis is a consequence of thrombosis of the vessels of the mesentery of the appendix. In the abdominal cavity there is a serous or purulent effusion, often with a strong unpleasant odor. The process has a dirty green color, but more often than not, gangrenous changes are not visible on the outside. There is necrosis of the mucous membrane, which can be affected throughout or in certain areas, more often in the distal sections.

Histological examination reveals necrosis of the layers of the process wall and hemorrhages in its wall. With gangrenous appendicitis, the organs and tissues surrounding the appendix are involved in the inflammatory process. Hemorrhages appear on the peritoneum, it is covered with fibrinous plaque. The intestinal loops and the omentum are soldered together.

For the development of gangrenous appendicitis, the occurrence of a phlegmonous form of inflammation, leading to thrombosis of the vessels of the appendix wall (secondary gangrene), is not necessary. In case of thrombosis or pronounced spasm of the vessels of the appendix, its necrosis (primary gangrene) may immediately occur, sometimes accompanied by self-amputation of the appendix.

Purulent melting of sections of the wall of the appendix in phlegmonous appendicitis or necrosis in gangrenous appendicitis leads to its perforation, i.e. to the development perforated appendicitis, in which the contents of the appendix spill into the abdominal cavity, which leads to the development of limited or diffuse peritonitis. Thus, a distinctive feature of perforated appendicitis is the presence of a through defect in the wall of the appendix. In this case, histological changes in the appendix correspond to phlegmonous or gangrenous appendicitis.

Surgical diseases. Kuzin M.I., Shkrob O.S. et al., 1986