Symptoms of acute abdomen in children. Acute abdomen syndrome in children with diseases of the abdominal cavity Lecture acute abdomen in children

Most often, abdominal pain is based on irritation of the peritoneum, the membrane lining the internal organs, or rather, its folds of the mesentery, on which it is suspended in humans. Any problems in or near the abdomen can put pressure on or irritate the mesentery and cause pain.

Pain in the abdomen in a child- a symptom of a wide variety of diseases. By the way, it is not at all necessary that the source of pain is in the abdomen.

Causes of abdominal pain:

• Diseases of the digestive system:

Esophagitis (inflammation of the esophagus);
- ;
- inflammation of the duodenum and stomach (duodenitis, gastroduodenitis);
- pancreatitis;
- gastric and duodenal ulcer;

Inflammation of the intestines (colitis, enteritis, enterocolitis);
- ;
- ;
- nonspecific ulcerative colitis.

• Diseases of the liver and biliary tract:

Cholecystitis (inflammation of the gallbladder);
- hepatitis (inflammation of the liver);
- biliary dyskinesia and other diseases.

Intestinal infection;
- the initial period of measles, chickenpox, SARS and other infections.

• Kidney diseases:

cystitis (inflammation of the bladder);
- and etc.
- pyelonephritis (inflammation of the kidneys);

• Respiratory diseases:

Pneumonia, when the process is in the lower parts of the lungs;
- pleurisy (inflammation of the pleura - the membrane that lines the lungs).

• Diseases of the genital organs in girls:

Premenstrual syndrome;
- adnexitis (inflammation of the ovary), etc.;
- salpingitis (inflammation of the fallopian tubes).

Lymphadenitis (inflammation of the lymph nodes in the abdominal cavity).

• Heart diseases:

Myocarditis;
- cardiac ischemia.

• Epilepsy (abdominal form).
• Poisoning with lead, mercury, thallium, colchicine.
• Neuropsychiatric disorders, hypochondria. The child is trying to attract attention or is too suspicious. In fact, no pathology is found with such pain.

Take a look at this long list again. You must think that you will not want to self-medicate after this. Of course, it is necessary to establish the reason why the stomach hurts, and for this it is necessary to consult a doctor. What? For starters - with a pediatrician. Depending on the accompanying symptoms, your pediatrician will determine what tests to take, what other examinations to undergo, and which specialist to refer the child to (gastroenterologist, nephrologist, surgeon, cardiologist, etc.) in order to establish an accurate diagnosis.

However, it is very important not to miss acute abdomen. This condition requires prompt medical and surgical care. Procrastination in the case of an acute abdomen is like death. Therefore, parents need to know well how this pathology manifests itself.

Acute abdomen- a severe syndrome, which is found mainly in injuries or acute diseases of the abdominal organs and retroperitoneal space, and often requires emergency surgical care. In this case, pain occurs in the peritoneal region and as a result, inflammation, peritonitis occurs.

The main causes of the development of an acute abdomen:

• Acute internal bleeding:

Traumatic rupture of an organ, for example: kidney, liver, spleen

• Acute inflammation:

• Acute circulatory disorders of the peritoneum.
• Acute diseases of the internal genital organs in girls:

Acute adnexitis (inflammation of the ovary);
- ovarian cyst rupture, etc.

Clinical picture of an acute abdomen

• Strong sudden stomach ache that increase with movement. The pain can be so intense that sometimes it leads to pain shock. However, in debilitated children, pain may be mild.
• Tension of the mouse anterior abdominal wall.
• Violation of the activity of the intestine, stool retention, less often - loose stools.
• Vomit.
• The general condition is usually severe. In acute appendicitis, acute cholecystitis - moderate.

The appearance of the patient may be different:

• With bleeding into the abdominal cavity and pronounced (diffuse) peritonitis, the position of the patient on his side, with the legs brought to the stomach, is characteristic, any movement causes pain.
• In acute pancreatitis, the patient rushes about, groans, screams.
• With perforation of the ulcer and severe internal bleeding, the patient turns pale sharply due to severe blood loss.
• In very severe cases, when the process is running (if help has not been provided for a long time), an indifferent facial expression, sunken cheeks, pale gray skin, sunken eyes, the skin is covered with droplets of cold sweat (called the “Hippocratic mask”) are characteristic.

Tactics of behavior in an acute abdomen

• In case of suspicion of an acute abdomen, it is imperative to call an ambulance and hospitalize the patient in the surgical department of the hospital.
• Before the arrival of the ambulance, it is strictly forbidden to use painkillers or narcotic drugs, laxatives, antibiotics, or to give an enema. The patient is forbidden to eat and drink.
• It is allowed to put cold on the stomach (ice pack).
• At acute abdomen urgent surgical intervention is needed. Without surgery, the patient will die.

The concept of "acute abdomen" syndrome combines a symptom complex that manifests various acute surgical diseases that require urgent surgical intervention. Most often, the "acute abdomen" syndrome develops in acute inflammatory diseases of the abdominal cavity - acute appendicitis, acute diverticulitis, acute peritonitis, necrotizing ulcerative enterocolitis and intestinal necrosis with late diagnosis of acute intestinal obstruction, perforation of the stomach or intestines.

Acute appendicitis - nonspecific inflammation of the appendix of the caecum.

In childhood, appendicitis develops faster, and destructive changes in the process, leading to appendicular peritonitis, are observed much more often than in adults. These patterns are most pronounced in children in the first years of life, which is due to the anatomical and physiological characteristics of the child's body that affect the nature of the clinical picture of the disease and in some cases require a special approach to solving tactical and therapeutic problems.

Clinical manifestations of acute appendicitis in children are variable and largely depend on the reactivity of the body, the anatomical position of the appendix and the age of the child. The general characteristic of the clinical picture is the predominance of general non-specific symptoms over local ones.

Clinical picture of acute appendicitis in older children.

The clinical picture of acute appendicitis in children of the older age group is more distinct and consists of the following main signs identified from the anamnesis: abdominal pain, fever, vomiting, and sometimes intestinal dysfunction.

The initial symptom of the disease is a sudden dull pain without a clear localization in the upper abdomen or navel. After 4-6 hours (with fluctuations from 1 to 12 hours), the pain moves to the right iliac region. Parents note that children become less active, refuse to eat. Appendicitis is characterized by continuous pain that does not disappear, but only subsides somewhat for a while.

The localization of pain depends on the location of the appendix: in a typical position, the patient feels pain in the right iliac region, in a high position - almost in the right hypochondrium, in the retrocecal position - on the lateral surface of the abdomen or in the lumbar region, in the pelvic position - above the pubis.

One of the most constant symptoms of acute appendicitis in children is vomiting, which develops in almost 75% of patients and is reflex in nature. In the following days of the disease, with the development of diffuse purulent peritonitis, vomiting becomes repeated, often an admixture of bile is detected in the vomit.

Quite often, stool retention is noted, sometimes loose stools appear no earlier than on the 2nd day from the onset of the disease. When the process is located near the cecum or rectum or among the loops of the small intestine, inflammation can spread to the intestinal wall, which leads to fluid accumulation in the intestinal lumen and diarrhea, with severe secondary proctitis, fecal masses may look like "spitting" mucus, sometimes even with an admixture a small amount of blood.

The tongue at the onset of the disease is moist, often lined with white scum. With the development of toxicosis and exsicosis, the tongue becomes dry, rough, and overlays appear on it.

Diagnostics

There are no pathognomonic symptoms of acute appendicitis, all symptoms are due to local peritonitis.

With the development of peritonitis, the forced position of the patient on the right side with the lower limbs pulled up to the stomach is noted.

When examining the abdomen, there may be a lag in the right lower quadrant of the abdominal wall during breathing. Palpation reveals muscle tension and sharp pain in the right iliac region. Positive symptoms of peritoneal irritation (Shchetkin-Blumberg, Razdolsky, Voskresensky symptom) can also be determined here. Pain, as a rule, intensifies when the patient is positioned on the left side (Sitkovsky's symptom), especially during palpation (Bartomier-Mikhelson's symptom). With the retrocecal location of the process, there may be a positive symptom of Obraztsov - increased pain when raising the straightened right leg. This symptom should be checked very carefully, since with rough pressure on the abdominal wall, perforation of the process is possible. The temperature is often elevated to subfebrile numbers.

In the blood - leukocytosis up to 5-17*10 9 /l with a shift of the formula to the left.

With a digital examination of the rectum, pain is noted on palpation of the right pelvic wall (especially in the pelvic position of the process).

The presence of erythrocytes and leukocytes in the urine does not exclude acute appendicitis.

Clinical picture and diagnosis of acute appendicitis in young children.

Due to the functional immaturity of the nervous system at this age, almost all acute inflammatory diseases have a similar clinical picture (high body temperature, repeated vomiting, impaired bowel function).

If in older children complaints of pain in the right iliac region are of leading importance, then in children of the first years of life there are no direct indications of pain, it is possible to judge the presence of this symptom only by indirect signs. The most important of these is changing the behavior of the child. In more than 75% of cases, parents note that the child becomes lethargic, capricious, with little contact. The restless behavior of the patient should be associated with an increase in pain. The continuity of pain leads to sleep disturbance, which is a characteristic feature of young children and occurs in almost a third of patients. The disease often develops at night, children wake up from pain.

An increase in body temperature in acute appendicitis in children of the first years of life is almost always. Often the body temperature reaches 38-39 0 C. A rather constant symptom is vomiting. For young children, repeated vomiting is characteristic (3-5 times).

In almost 15% of cases, loose stools are noted. Stool disorder is observed mainly in complicated forms of appendicitis and pelvic location of the appendix. Complaints of pain in the right iliac region in children of this age group are almost never found. Usually the pain is localized near the navel. Such localization is associated with anatomical and physiological features: the inability to accurately localize the place of greatest pain due to insufficient development of cortical processes and a tendency to irradiate nerve impulses, the close location of the solar plexus to the root of the mesentery. An important role is played by the rapid involvement of the mesenteric lymph nodes in the inflammatory process.

When diagnosing, they are also guided by the main symptoms, as in older children (passive muscle tension and local pain in the right iliac region). However, it is extremely difficult to detect these signs in children of the first years of life. This is due to the age-related characteristics of the psyche, primarily motor excitement and anxiety during examination. When conducting palpation of the abdomen, it is important to carefully monitor the behavior of the child. The appearance of motor anxiety, reactions of mimic muscles can help assess the pain of the examination. The method of examining children in a state of medical sleep is justified. At the same time, passive muscle tension of the anterior abdominal wall and local pain persist.

Rectal digital examination in younger children provides less diagnostic information and brings clarity only in the presence of infiltrate, which is relatively rare at this age. Nevertheless, digital rectal examination should be performed in all young children, since in many cases it helps to differentiate other diseases (intussusception, coprostasis, etc.)

In young children with acute appendicitis, an increase in the number of leukocytes in the peripheral blood up to 15-20 * 10 9 / l is most often noted. Often observed and hyperleukocytosis (25-30*10 9 /l).

Appendicitis in newborns

The disease develops mainly in premature babies weighing 1 to 2 kg at the age of 7-20 days. All children had a history of perinatal hypoxia, infection, cerebrovascular accident. The disease begins acutely, with an increase in symptoms of infectious toxicosis, vomiting with an admixture of bile, bloating, and stool retention appear. When examined in the first 12 hours from the onset of deterioration, it is possible to identify local symptoms: local pain in the right iliac region, passive muscle tension, Shchetkin-Blumberg symptom, and if the process tends to be limited, infiltrate can be palpated. As a rule, there is no temperature reaction, the number of leukocytes fluctuates over a wide range (from 7 to 18 * 10 9 / l) with a tendency to increase. Later, due to the rapid progression of the inflammatory process and the increase in toxicosis, symptoms of diffuse peritonitis are detected.

Diagnosis of acute appendicitis in premature infants at risk is difficult due to the complexity of differential diagnosis with necrotizing enterocolitis. Radiographically, with appendicitis in newborns, darkening is often determined in the right half of the abdomen against the background of paretically swollen loops of the intestine (especially the large intestine), the absence of thickening of the intestinal walls. With necrotizing enterocolitis, gas filling of the intestine is sharply reduced; due to significant hydroperitoneum, the outer contours of the intestinal loops lose their sharpness. However, the decisive factor in the diagnosis is the dynamics of these symptoms over the next 3-6 hours of intensive detoxification, rehydration and anti-inflammatory therapy. The absence of positive dynamics in the general condition of the child and the increase in local symptoms indicate an inflammatory process in the abdominal cavity and require emergency surgical care.

Differential diagnosis. In children of the older age group, acute appendicitis is differentiated from diseases of the gastrointestinal tract, biliary and urinary systems, diseases of the genital organs in girls, and hemorrhagic vasculitis. At a younger age (mainly in children of the first 3 years of life), differential diagnosis is often carried out with acute respiratory viral infections, coprostasis, urological diseases, otitis media, childhood infections.

Treatment

Treatment is operative. The operation is indicated not only in every case that is clear from a diagnostic point of view, but also with a reasonable suspicion of acute appendicitis, if it is impossible to exclude acute inflammation of the appendix on the basis of clinical signs and special research methods (including laparoscopy).

Anesthesia for children, especially young children, should only be general.

Treatment of appendicitis in newborns

Due to immaturity, the dome of the caecum is located high under the liver and deep in the lateral canal, therefore, a right-sided transmuscular or pararectal access 3-4 cm long is used. Appendectomy is performed using a ligature method with drainage left. Intraoperatively and in the next 3 days after the operation, a 1% solution of dioxidine is injected into the drainage. In the postoperative period, the started intensive therapy is continued.

Acute diverticulitis.

Gives a clinical picture of appendicitis: the patient develops vomiting, fever, stool retention, general anxiety are noted. When probing the abdomen, the pain is localized mainly closer to the navel or in the suprapubic region.

And also, in children, peptic ulceration of islands of ectopic gastric mucosa (the adjacent ileal mucosa) occurs, which is often the cause of massive intestinal bleeding. Bleeding can occur acutely and be profuse, but chronic bleeding in small portions is also observed. These bleedings occur in full health, recur at intervals of 3-4 months, which leads to anemia, pallor, tachycardia, and collapse. The first stools are usually dark in color, in the subsequent ones dark (scarlet) blood appears without clots and mucus. Unlike gastrointestinal bleeding of other origins, Meckel's diverticulum does not cause hematemesis.

Surgical treatment (wedge-shaped resection of a section of the intestine with a diverticulum) is carried out after appropriate preoperative preparation.

Peritonitis- an acute inflammatory complication (disease) of the peritoneum that occurs when the local protective functions of the peritoneum are impaired due to the pathological effects of exogenous or endogenous causative factors. The causes of peritonitis in children are varied. In most cases, it is the result of infection from the abdominal organs. There are also hematogenous and cryptogenic peritonitis, the causes of which are difficult to establish. Perforative peritonitis in children older than 1 year most often develops against the background of acute appendicitis. In children, peritonitis has a number of specific features. Depending on the origin of peritonitis, the duration of the disease and the age of the child, the course and prognosis change significantly. Especially quickly and malignant peritonitis occurs at an early age, when diffuse forms of inflammation of the peritoneum are mainly found. This is due to the anatomical and physiological features of the child's body, in particular, the short omentum, which reaches the lower abdominal cavity only by the age of 5-7 years and cannot contribute to the delimitation of the process. There is an infection of the reactive effusion, which appears very quickly and in significant quantities. The immaturity of the immune system and the peculiarities of the absorption capacity of the peritoneum also play a role (the younger the patient, the longer the resorption from the abdominal cavity occurs). The severity of the course of diffuse peritonitis is largely determined not only by the nature of the local process, but also by a violent and profound violation of homeostasis. Of the many causes of homeostasis disorders in peritonitis in children, water-salt imbalance and hyperthermic syndrome are of the greatest importance. Loss of water and salts in peritonitis in children, especially young children, is associated with vomiting, loose stools, accumulation of fluid and electrolytes in the free abdominal cavity and in the intestine as a result of its paresis. Of great importance is also an increase in imperceptible perspiration - the loss of fluid and salts through the lungs (rapid breathing) and skin, especially with a significant increase in body temperature. In the origin of hyperthermic syndrome, the direct effect on the center of thermoregulation of toxins and other products of inflammation, the decrease in heat transfer through the skin as a result of peripheral hemodynamic disorders, is important. It is worth noting the features of diagnosing peritonitis in young children: difficulties in verbal and psycho-emotional contact with the child; the need to use subjective, often insufficient anamnestic information; inability of young children to localize pain; inability to detect pain signs of abdominal syndrome; the need for examination with restless behavior of the child. The appendicular, cryptogenic Primary peritonitisand neonatal peritonitis. The disease most often occurs in girls aged 3 to 7 years. The infection enters the abdominal cavity through the vagina with the development of endosalpingitis. Clinically, two forms of primary peritonitis are distinguished - toxic and local. The toxic form occurs quite rarely: no more than 5% of cases. The toxic form is characterized by an acute and rapid onset of the disease. Severe abdominal pain is noted, usually in the lower sections. Body temperature rises to 38-39 C. Vomiting can be repeated. Loose stools are often inherent, which occurs with increased peristalsis due to a pronounced inflammatory process in the abdominal cavity. A significant severity of the general condition is noted with a short period from the onset of the disease (2-6 hours). The child is usually restless, the skin is pale, the eyes are shining. Tongue dry, covered with white coating. When examining the abdomen, all signs of severe peritonitis are found: sharp pain and a clear rigidity in all parts of the anterior abdominal wall, but somewhat more in the navel and on the right. Symptom Shchetkin - Blumberg positive. Moderate intestinal paresis is also noted. In the study of peripheral blood, high leukocytosis is noted. With a localized form, the clinical picture is erased, intoxication is not expressed, pain is often localized in the right iliac region. In this case, the body temperature reaches subfebrile figures. However, a more acute onset, the presence of ARVI at the time of examination or ARVI transferred the day before are important factors in the differential diagnosis of primary peritonitis with another pathology. Both localized and toxic forms of the disease are difficult to differentiate from appendicitis, therefore, with traditional tactics, patients undergo appendectomy. Diagnostic laparoscopy is often curative. Aspiration of pus is performed, a solution of antiseptics is injected. All patients are prescribed antibiotic therapy with penicillins or cephalosporins for 5-7 days. The prognosis is favorable. appendicular peritonitis Peritonitis is the most common complication of acute appendicitis in childhood, occurring in 8-10% of cases, and in children of the first 3 years of life 4-5 times more often than at an earlier age. Of the many classifications, the principle of dividing peritonitis according to the staging of the course of the process and the prevalence of peritoneal lesions, the severity of intestinal paresis, is most widely used. appendicular peritonitis -Local -General -Delimited -Unlimited The most widespread in peritonitis is the allocation of three phases of its course, reflecting the severity of the clinical course of the disease: Reactive phase: It is characterized by a violation of the motor-evacuation, digestive function of the gastrointestinal tract; hanging the functions of the respiratory and hemodynamic systems within their functional reserves. Toxic phase: Characterized by the exclusion of the gastrointestinal tract from life support processes; dysfunction of the liver, kidneys; compensated metabolic changes; violation of respiratory and hemodynamic systems in the absence of functional reserves; depression or excitation of the central nervous system. Terminal phase: generalized lesions of hemodynamics and hemostasiological disorders; ineffectiveness of spontaneous breathing; damage to the central nervous system; discrediting the metabolism and turning off the liver and kidneys from life support processes; oppression of the general and immune reactivity of an organism. In newborns and young children, by the end of the first day of the onset of peritonitis, it is possible to identify signs of the terminal phase. With postoperative peritonitis against the background of intensive therapy, the duration of the phases can be from several days to several weeks, which is confirmed by changes in central hemodynamics, microcirculation, and immunological reactivity. The pathogenesis of diffuse peritonitis is a complex chain of functional and morphological changes in systems and organs. Anatomical and physiological features of the child's body affect the course of appendicular peritonitis - intoxication and metabolic disorders increase faster, many protective reactions become pathological. The leading role in the pathogenesis of peritonitis belongs to the microbial factor and the immunoreactivity of the body. In most cases, peritonitis is a polymicrobial disease. The dominant role in its development belongs to E.Coli, enterococci, Klibsiella, etc., as well as anaerobes. One of the leading factors in the development of pathophysiological changes that occur with peritonitis is the resorption of toxic products of purulent exudate from the abdominal cavity by the peritoneum. It is the absorption of toxic products that causes a chain of various pathophysiological disorders, including dehydration, circulatory disorders, impaired immunological reactivity of the body, hyperthermia, acid-base disorders, metabolic disorders, and dysfunction of vital organs. In severe cases of the disease, these disorders can be considered as a manifestation of peritoneal shock. It should be borne in mind that in children under 3 years of age, protective mechanisms quickly turn into pathological ones, and general clinical symptoms prevail over local ones. Most of these disorders are manifested in clinical symptoms. In the clinical picture, abdominal, infectious-inflammatory, and adaptation syndromes can be distinguished. Abdominal Syndrome:

Visible signs of damage to the abdominal wall;

Change in skin color (hyperemia, Mondor's spots), pastosity, increased subcutaneous venous pattern of the anterior abdominal wall in newborns;

Non-localized pain in the abdomen with often detected local pain;

Passive protective muscle tension of the anterior abdominal wall;

Symptoms of peritoneal irritation;

Symptoms of mass formation, the presence of gas or liquid in the free abdominal cavity.

Infectious-inflammatory syndrome:

Sleep disturbance, child's behavior;

Hyperthermia.

Symptom of temperature-pulse "scissors";

Toxic-inflammatory changes in the hemogram, in urine tests;

Changes in the general and immune reactivity of the patient's body.

Adaptation syndrome: It consists of a combination of clinical signs of functional disorders of organs and systems. In the process of development of peritonitis are formed:

Gastroenteropathic (hypo- or anorexia; nausea; repeated vomiting of stagnant gastric contents; possible appearance of light stools with liquid, fetid contents; bloating; decrease in the intensity of peristaltic noises, up to their disappearance.),

Hepatorenal (hypo- or oliguria; pastosity of the subcutaneous tissue; increased urine density; violation of the filtration function of the kidneys (proteinuria, hematuria); icteric coloration of the sclera, skin; increased levels of bilirubin, aminotransferases in the blood plasma; decreased protein-forming function of the liver.),

Discirculatory-hypoxic (hypovolemia; hemoconcentration; dehydration; hypoxia; hypercapnia.),

Cerebral (Toxico-hypoxic encephalopathy (excitation, cerebral depression, convulsions, coma).),

Dysmetabolic syndromes.

Diagnosis is based on subjective and objective examination data: Subjective examination based on: duration of illness, suspected causative factor; complaints of recurrence or intensification of persistent abdominal pain; nausea, vomiting, decreased or lack of appetite; a change in the child's behavior, sleep disturbances, an increase in body temperature to subfebrile values ​​\u200b\u200band higher; when pointing to an injury to the abdomen, they find out: the traumatic factor and circumstances, the mechanism of injury; functional state of the gastrointestinal tract, bladder at the time of injury; specify: previous surgical interventions, the presence of concomitant diseases, treatment before seeking medical help). Objective examination based on: the presence of traces of traumatic injury to the abdominal wall; forced position of the child (change in gait, posture - Wolf's symptom, refusal of active movements); limitation of the participation of the anterior abdominal wall in the act of breathing (Winter's symptom); asymmetry in the groin; bloating, prolapse of the navel, hyperemia, pastosity; symptoms of Razdolsky and Sumner, Shchetkin-Blumberg, Gabay; disappearance of hepatic dullness; weakening of peristaltic noises; the presence of tenesmus, loose frequent stools in small portions, painful and frequent urination. Rectal examination can reveal a sharp soreness and overhanging of the rectal wall. Diagnosis is based on laboratory data:

Cellular composition of blood, Hb, Ht;

Proteinogram

Coagulogram

Biochemical blood tests6

Liver tests Total protein Blood glucose Plain radiography of the abdominal cavity reveals functional intestinal obstruction, the presence of gas, fluid in the free abdominal cavity. Differential diagnosis:

Pathology of the nervous system - meningitis, encephalitis, epilepsy, hysterical neuroses.

Diseases of the cardiovascular system - endocarditis, acute myocarditis, pericarditis, right ventricular failure, rheumatism, hemorrhagic vasculitis, mesenteric thrombosis, abdominal aortic aneurysm.

Pulmonary-pleural pathology - pneumonia, pleurisy, BDL, pyopneumothorax, tuberculosis.

Disease of the gastrointestinal tract, organs of the pancreato-biliary system - PTI, gastroenterocolitis, ileitis, hepatitis, cholecystitis and cholecystopathies, acute pancreatitis.

Pathology of the urinary system - purulent paranephritis, kidney carbuncle, glomerulonephritis.

Congenital extragenital pathology in pubertal girls, acute inflammatory diseases of the scrotum in boys.

Diseases of the blood system - leukemia.

Endocrinopathy - Diabetes mellitus.

Infectious diseases - measles, scarlet fever.

Acute intoxications.

Acute hematogenous osteomyelitis of the pelvic bones, sacroiliitis.

Treatment of the disease in children is a difficult task and consists of three main stages: preoperative preparation, surgery, and postoperative period. Treatment of peritonitis should be timely, etiotropic, pathogenetically substantiated, complex. The purpose of preoperative preparation is to reduce hemodynamic disturbance, acid-base status and water-electrolyte metabolism. The whole complex of preoperative measures should be performed in a fairly short time (no more than 2-3 hours). Antibiotic therapy is carried out with broad-spectrum drugs - intravenous administration of a 3rd generation cephalosparin (cefotaxime, ceftriaxone) or an inhibitor of protected penicillin (amoxicillin + clavulonic acid) is recommended. In the postoperative period, the introduction of antibiotics in the form of combination therapy is continued, which makes it possible to cover the entire spectrum of potential causative agents of peritonitis. Probing and gastric lavage helps to reduce intoxication, improve breathing, and prevent aspiration. An important role is played by the fight against hyperemia, pneumonia, pulmonary edema, convulsions. Surgical intervention is started when hemodynamic processes, acid-base state, water-electrolyte metabolism, body temperature are compensated and stabilized. Surgical intervention for peritonitis is carried out in order to eliminate the primary focus, sanitation and drainage of the abdominal cavity. The impact on the primary focus is appendectomy. In children, access depends on the stage of peritonitis and age. In the reactive stage, especially in children under 3 years old, Volkovich-Dyakonov access is used. This access, with a relatively small abdominal cavity in children, does not interfere with the implementation of the main task - sanitation of the abdominal cavity. With peritonitis older than 3 days, a median laparotomy is indicated. Successive stages of the operation: evacuation of exudate, elimination of the source of peritonitis, toilet and suturing of the abdominal cavity. The exudate is removed using an electric suction. Appendectomy is performed with the obligatory immersion of the stump into the purse-string and z-shaped sutures. After that, the toilet of the abdominal cavity is produced by washing. The basis of the washing medium is isotonic or slightly hypertonic saline solutions, a solution of furacilin (1: 5000), to which most surgeons add antibiotics at a rate of 1 g / l (aminoglycoside group). The total volume of flushing liquid is 2-3 liters. The final stage of the surgical intervention is the drainage of the abdominal cavity with tubular drains. The postoperative period is

It develops more often in children aged 5-10 years and adolescents.

Symptoms and signs of acute appendicitis in children

In school-age children, the disease begins gradually. The first sign is constant (aching) pain, first in the epigastric region, then covering the entire abdomen and after a few hours it is determined in the right iliac region. Vomiting at the beginning of the disease is single, with an increase in intoxication it becomes multiple. Refusal to eat. Possible stool retention. Body temperature is normal or subfebrile. Often there is a discrepancy between the rapid pulse and subfebrile body temperature. The child takes a forced position on the right side, with bent legs pulled up to the stomach. Positive symptoms of Rovsing, Sitkovsky, Shchetkin-Blumberg are revealed.

In young children, the picture of acute appendicitis develops rapidly. There are general anxiety, repeated vomiting, frequent loose stools with an admixture of mucus, streaks of blood. Urination becomes frequent. Body temperature rises to 38-40 °C. It is difficult to establish the localization of pain, although at the end of the first day of the disease it is possible to determine the local tension of the muscles of the anterior abdominal wall. Symptoms of "acute abdomen" in acute appendicitis in young children are often negative, and before the development of "catastrophe" in the abdominal cavity, an acute intestinal infection (AII) is often diagnosed. Acute appendicitis is diagnosed based on the history of the disease, discrepancy between the pulse rate and body temperature, local tenderness, muscle tension, symptoms of peritoneal irritation, tenderness and infiltration of the right rectal wall during rectal examination. Leukocytosis is detected (15.0-16.0 109/l and more).

Ultrasound of the abdomen reveals an enlarged appendix, periappendicular edema, conglomerates of intestinal loops.

With gangrenous appendicitis, the pain in the abdomen subsides, a period of imaginary well-being sets in - before the onset of symptoms of acute diffuse peritonitis. Only tachycardia and external signs of intoxication and dehydration of the body remain.

Significant difficulties arise with the abnormal location of the appendix. When it is located in the pelvic cavity, pain is localized in the right inguinal region, above the pubis. Dysuric disorders are expressed. With the retrocecal location of the process, acute pain radiates to the lower back. The left-hand arrangement of a shoot meets seldom.

Acute appendicitis is differentiated from acute nonspecific mesadenitis, acute pneumonia, renal colic, coprostasis, acute cholecystitis, in infants and young children with intestinal infections.

Difficulties in differential diagnosis also arise in adolescent girls with rupture or torsion of ovarian cysts. Ultrasound of the abdomen and other studies can clarify the diagnosis.

Treatment of acute appendicitis in children

Treatment is surgical, and the sooner it is started, the better the results. Rehydration therapy before surgery consists in the intravenous administration of a 5% glucose solution in an isotonic sodium chloride solution at the rate of 20 ml/kg of body weight. Fluid therapy should be continued during and after surgery to replace lost water and electrolytes. With intestinal perforation, signs of peritonitis, antibiotics are prescribed - ampicillin, gentamicin, clindamycin.

Conservative therapy of appendicular infiltrate, abscess drainage is carried out under ultrasonographic control, which allows preparing the child for a planned appendectomy. Preoperative conservative treatment of acute appendicitis dramatically reduces the incidence of complications.

Inflamed Meckel's diverticulum (acute diverticulitis) in children

Inflammation of the diverticulum of the ileum in clinical manifestations is very similar to acute appendicitis, but the symptoms are more pronounced.

Symptoms and signs of an inflamed Meckel's diverticulum in children

The disease begins with severe pain in the navel or slightly to the right or below it. Tension of the muscles of the anterior abdominal wall, a symptom of Shchetkin-Blumberg, are clearly identified. Abdominal CT can confirm the diagnosis.

Treatment of an inflamed Meckel's diverticulum in children

Emergency surgery.

Intestinal volvulus in children

Intestinal volvulus is one of the forms of obstruction, in which part of the loops of the small or large intestine, together with the mesentery, rotates around the longitudinal axis. The cause of volvulus is malformations of the small or large intestine (incomplete turn, dolichosigma, megadolichocolon, Hirschsprung disease). Necrosis of intestinal loops and peritonitis develop rapidly.

Symptoms and signs of volvulus in children

The disease begins suddenly. Severe cramping pain is localized near the navel or in the epigastric region. Feces and gases do not depart. Soon there is frequent vomiting with an admixture of bile. The abdomen is evenly swollen, with palpation, muscle tension is felt. Violent peristalsis of the intestine (with auscultation of the abdomen) quickly fades away. The pulse is frequent, weak filling, the discrepancy between the indicators of the pulse and body temperature is determined. X-ray examination of the abdominal cavity reveals Kloiber's cups, typical for obstruction. Differentiate with other forms of intestinal obstruction.

Treatment- operational.

Intussusception in children

Intussusception - the introduction of one part of the intestine into the lumen of another.

Sometimes it happens that a perfectly healthy child suddenly begins to feel ill. He is nauseated, and bouts of pain force him to pull his legs up to his stomach. At times, the picture of the disease is dominated by vomiting, and sometimes pain. Vomiting is more profuse and frequent than normal regurgitation in an infant. Spasms come on suddenly and are usually very severe. Sometimes only a few minutes pass between them.

In between, the child may feel quite normal and even sleep. After a few hours (during which the child may have normal or slightly loose stools), bloody mucus appears in the child's stool. They resemble the consistency and color of currant jelly or plum juice.

This condition is caused by intestinal obstruction, which occurs due to the fact that a small piece of intestine is embedded in the lumen formed by another intestine. This disease occurs in children aged 4 months to 6 years. If treatment is started on time, then this disease can be dealt with quite easily, but if the intestines are damaged during the course of the disease, then surgery may be required.

Other forms of intestinal obstruction are just as rare, but that does not make them any less dangerous. Some segment of the intestine may be, for example, pinched in an inguinal hernia. In this case, vomiting and severe painful spasms in the intestines are usually observed.

Symptoms and signs of intussusception in children

Vomiting first food masses, and then bile, feces. With complete obstruction, feces and gases do not depart, stools may consist of mucus and blood. Cramping diffuse pain in the abdomen. In young children, toxicosis and exsicosis (dehydration of the body) develop very quickly.

The diagnosis of invagination is established by irrigoscopy. Conduct differential diagnosis with acute dysentery.

Treatment of intussusception in children

In the first 12-18 hours after the presacral blockade, a conservative straightening of the intussusceptum with air is possible. Signs of peritonitis and intestinal obstruction (on X-rays of the Kloiber cup) serve as an absolute contraindication to conservative straightening of the intussusceptum. With late diagnosis (after 12-18 hours), surgical treatment is necessary. Before and after surgery, parenteral rehydration therapy is performed. After the operation, parenteral and then fractional enteral nutrition are prescribed. If intestinal intussusception is suspected, the child is urgently hospitalized in the surgical department.

Obstructive or dynamic intestinal obstruction (ileus) with helminthiases in children

Obstructive or dynamic intestinal obstruction (ileus) in helminthiases occurs due to blockage of the intestinal lumen by a ball of roundworms or other helminths.

Symptoms and signs of obstructive or dynamic intestinal obstruction in helminthiasis in children

Complete or partial intestinal obstruction begins with a sharp pain in the abdomen, vomiting and a violation of the excretion of bowel movements, gases. Ascaris is often found in vomit or feces. The general serious condition of the child is due to intoxication caused by intestinal obstruction and helminthic invasion.

Treatment of obstructive or dynamic intestinal obstruction in helminthiases in children

For diagnostic and therapeutic purposes, a siphon enema is prescribed, a presacral blockade is performed with a 0.25% solution of novocaine, a 0.1% solution of atropine is injected subcutaneously at a dose of 0.1 mg / year of life with a 1% solution of promedol (children over 2 years old) at a dose of 0.003 -0.0075 g. With the help of these measures, the spasm of the intestinal loop is relieved. If the diagnosis is made in the next 2-3 hours, 2-4 high cleansing enemas with hypertonic sodium chloride solution should be done to remove ascaris.

Assign levamisole orally at a dose of 5 mg / (kg-day). Vermox is the drug of choice. For children older than 1 year, it is prescribed for. 100 mg 2 times a day (morning and evening) for 3 days. If conservative measures fail, surgery is indicated.

Acute pancreatitis in children

Causes: viral infections (mumps, viral hepatitis, Coxsackie B enterovirus infection, infectious mononucleosis, rubella, chickenpox, etc.) or bacterial infections (salmonellosis, shigellosis, etc.), blunt trauma to the pancreas, increased pressure in the pancreatic ducts ( with anatomical anomalies - annular or lobular pancreas, cysts of the bile duct, changes in the common bile duct, nipple of Vater, with pathology of the duodenum, helminthiases, chronic cholecystitis, hypercalcemia, toxic and drug-induced lesions, etc.).

Symptoms and signs of acute pancreatitis in children

Suddenly there is cramping or constant pain in the epigastrium, radiating to the left hypochondrium, back, left shoulder, with nausea and vomiting. The pain is sometimes girdle, accompanied by a feeling of heaviness, fullness in the upper abdomen. The position of the child is often forced: he lies on his left side. Body temperature is normal or subfebrile. Some patients develop vascular collapse, respiratory failure. Perhaps tension in the muscles of the abdominal wall in the epigastric region.

In the initial period of the disease in the blood and urine, amylase activity is increased, and subsequently it decreases. High activity of immunoreactive trypsin in the blood (trypsinogen) is more stable. Mild hyperglycemia and glucosuria are noted. Ultrasound of the abdominal organs reveals an enlarged pancreas, a decrease in its density. With doubtful ultrasound data, a CT scan of the abdomen is performed.

Treatment of acute pancreatitis in children

In the first 1-3 days of illness, hunger is prescribed. A permanent cazogastric tube is installed to administer fluid and suction gastric contents. In the future, limit the fat content in food.

It is recommended to introduce a 0.1% solution of atropine 0.1-0.2 ml subcutaneously 2 times a day, dalargin 1 mg 2 times a day intramuscularly. Antacids - Almagel, Maalox give 1 tablespoon 3 times a day. In severe forms, blockers of histamine H 2 receptors are indicated, for example, ranitidine at a dose of 2-4 mg / (kg per day) in 2 doses. To suppress the functions of the pancreas, octreotide (sandostatin) is used at a dose of 25-100 mcg, depending on age, subcutaneously or intravenously for 5-7 days, you can use contrical - 500-1000 IU / (kg day) or Gordox (aprotinin) - 2500-5000 IU / (kg day) intravenously slowly in isotonic sodium chloride solution. To prevent purulent complications in severe forms of pancreatitis, broad-spectrum antibiotics (cephalosporins, aminoglycosides) are prescribed. With the development of purulent pancreatitis and the appearance of cysts, surgical intervention is indicated.

Peritonitis in children

Peritonitis develops primarily or becomes a consequence of perforation of the intestinal wall with its obstruction of various origins.

Symptoms and signs of peritonitis in children

Pain throughout the abdomen, aggravated by trying to breathe deeply or cough; general hyperesthesia of the abdominal skin. The wall of the abdomen is not involved in respiration. The abdomen gradually swells due to flatulence from paresis of peristalsis, the passage of gases and feces stops. An important symptom is persistent vomiting with an admixture of bile. The pulse is rapid, thready.

Treatment- operational.

Perforated ulcer of the stomach and duodenum in children

A perforated ulcer of the stomach and duodenum is a breakthrough (perforation) of the organ wall with the entry of gastroduodenal contents into the abdominal cavity. Causes: peptic ulcer of the stomach and duodenum.

The perforation of the ulcer is preceded by the progression of a chronic destructive-inflammatory process in the ulcer. Provoking moments: overeating, physical stress, leading to increased intra-abdominal pressure, neuropsychic trauma, etc. Perforations are more common in autumn and spring, which is associated with an exacerbation of peptic ulcer during these periods, vitamin deficiencies and other factors.

Symptoms and signs of perforated gastric and duodenal ulcers in children

In the clinical course, periods of sudden sharp pain or shock (lasting 6-7 hours), imaginary well-being (duration 7-12 hours) and progressive peritonitis (12 hours after perforation) are distinguished.

Treatment of perforated gastric and duodenal ulcers in children

Urgent hospitalization for surgical treatment. Transportation on a stretcher. Avoid prescribing narcotic analgesics until an accurate diagnosis is established.

Toxic megacolon in children

Toxic megacolon is an acquired (unlike congenital Hirschsprung disease) expansion of a segment of the large intestine, more often the transverse colon. It develops with chronic nonspecific inflammatory changes - chronic ulcerative colitis, Crohn's disease, as well as after long courses of antibiotic therapy, treatment with corticosteroids of these or other diseases.

Symptoms and signs of toxic megacolon in children

Pain in the abdomen, tension in the muscles of the abdominal wall, fever, tachycardia, intoxication. High risk of intestinal bleeding, intestinal perforation.

The diagnosis is established on the basis of anamnesis data, X-ray contrast examination of the colon, and the presence of blood in the feces.

Treatment of toxic megacolon in children

Vancomycin is used at 40 mg/(kg-day) in 4 divided doses or cephalexin as a suspension orally up to 100 mg/(kg-day). Corticosteroids are shown - dexamethasone at the rate of 0.1-0.5 mg / kg of body weight (intramuscularly). Inside - enterosorbents: microsorb-P (0.5-1 g/kg), smecta, etc. Detoxification therapy is carried out by intravenous drip of plasma and glucose-salt solutions.

Closed abdominal trauma in children

A closed abdominal injury is one of the most severe types of injuries, often threatening the life of a child. Reasons: fall from a great height, car accident, compression of the abdomen, limbs and other parts of the body, strong blows.

Symptoms and signs of closed abdominal trauma in children

Injuries to the abdominal organs are accompanied by acute abdominal pain, internal bleeding, and peritonitis. Acute abdominal pain occurs due to rupture of the spleen, damage to the pancreas and other abdominal organs. Pain throughout the abdomen or in its lower part, aggravated by breathing, is characteristic of damage to the spleen, and in the epigastric region with irradiation to the left, it is characteristic of damage to the pancreas. Pain in the upper abdomen, to the right of the navel, may indicate a rupture of the retroperitoneal part of the duodenum. Severe pain in the abdomen is accompanied by traumatic shock with a drop in blood pressure, tachycardia.

Treatment of closed abdominal trauma in children

Immediate hospitalization of the child in the surgical department with transportation on the shield in the supine position. The diagnosis is clarified with the help of ultrasound, CT of the abdominal organs, radionuclide scanning.

Cholecystitis and cholecystocholangitis acute in children

Cholecystitis and acute cholecystocholangitis are more often of an infectious nature (E. coli, strepto- and staphylococci, anaerobes).

Symptoms and signs of cholecystitis and cholecystocholangitis in children

The disease begins with an increase in body temperature to febrile and the appearance of cramping pain in the right side of the abdomen, which radiates to the right shoulder, collarbone, shoulder blade. Nausea and vomiting are observed. The pain is aggravated in the position on the right side. Possible jaundice. The abdomen is swollen, its upper sections lag behind when breathing. Palpation reveals rigidity of the muscles of the anterior abdominal wall on the right, more in the upper sections and hypochondrium. Positive symptoms of Mendel, Ortner, Murphy and Ker are determined. Leukocytosis with stab shift, elevated ESR. The disease is differentiated with acute appendicitis, renal colic.

Treatment of cholecystitis and cholecystocholangitis in children

Bed rest, hunger, heavy drinking, later - table number 5, rest, antibiotics intramuscularly - ampioks 100 mg / (kg day), cefuroxime, claforan at a dose of 100 mg / (kg day), etc., antispasmodic (platifillin, atropine, no-shpa, metacin, buscopan in suppositories) and analgesics, infusion therapy. If purulent, phlegmonous or gangrenous cholecystitis is suspected, as well as if the gallbladder wall breaks through, surgery is indicated.

Etiotropic antibiotic therapy;

Regulation and correction of microcirculation disorders and central hemodynamics;

Correction of hydroionic disorders and regulation of hydroionic balance;

Correction of decompensated metabolic disorders;

Prevention and treatment of intestinal paresis;

Intensive monitoring and appropriate care are also required, the presence of rehabilitation measures (exercise therapy methods, physiotherapy, mandatory medical examination at the place of residence with subsequent observation). Neonatal peritonitis Neonatal peritonitis is a polyetiological disease, caused in 84% of cases by perforation of the gastrointestinal tract wall (mainly the large intestine) with necrotizing enterocolitis or intestinal malformations, much less often by hematogenous, lymphogenous or contact infection of the peritoneum. Among inflammatory diseases of the abdominal organs, complicated by peritonitis, acute appendicitis occupies the first place in frequency, much less often its occurrence can be associated with perforation of Meckel's diverticulum during its inflammation, iatrogenic perforation of hollow organs. Classification In generally accepted classifications, peritonitis in newborns is divided as follows:

Etiologically:

necrotizing enterocolitis (posthypoxic, septic);

malformations of the gastrointestinal tract (segmental defect of the muscular layer of the wall of a hollow organ, complications with atresia, intestinal volvulus, meconium ileus, Hirschsprung disease);

destructive cholecystitis and cholangitis;

iatrogenic perforations of hollow organs.

hematogenous, lymphogenous infection of the peritoneum;

contact infection of the peritoneum.

By time of occurrence:

According to the degree of distribution in the abdominal cavity:

By the nature of the effusion in the abdominal cavity:

Intrauterine intestinal perforations with malformations lead to aseptic adhesive peritonitis, postnatal - to diffuse fibrinous-purulent, fecal peritonitis. With necrotizing enterocolitis against the background of intensive therapy, the development of delimited peritonitis is possible. Non-perforative fibrinous-purulent peritonitis, which develops in utero with hematogenous, lymphogenous and transplacental infection, is now rarely observed. In the postnatal period, infection of the peritoneum occurs by contact with purulent periarteritis and periphlebitis of the umbilical vessels, liver abscesses, purulent diseases of the retroperitoneal space, phlegmon of the anterior abdominal wall. These forms also rarely occur now. Clinical picture The clinical picture of postnatal perforative peritonitis in newborns with intestinal wall defects is manifested by acute symptoms of peritoneal shock on the 2nd-3rd day of life. The child is lethargic, groans. The skin is pale gray, acrocyanosis. Breathing is frequent, superficial due to the high standing of the dome of the diaphragm. Heart sounds are muffled. Attention is drawn to a sharp swelling, tension and soreness of the abdomen, expansion of the subcutaneous venous network. With peritonitis in newborns, hyperemia of the skin in the lower abdomen and on the genitals is often observed. Intestinal peristalsis is not heard. Percussion above the liver reveals a box sound - a symptom of the disappearance of hepatic dullness (Spizharny's symptom). They note constant vomiting of intestinal contents, stools and gases do not go away. Diagnosis The diagnosis is confirmed by a plain radiograph of the abdominal organs. Under the dome of the diaphragm reveal a significant pneumoperitoneum. Treatment Treatment is surgical only. After a puncture of the abdominal cavity and a decrease in intra-abdominal pressure for 2-3 hours, a comprehensive preoperative preparation is carried out, aimed at eliminating the symptoms of centralization of blood circulation. Preference is given to upper-transverse laparotomy, which allows for a full revision of the abdominal organs. An intestinal loop with a perforated area is sutured to the abdominal wall in the form of an intestinal fistula. After that, the abdominal cavity is washed with antiseptic solutions and sutured leaving drainage. Conclusion Treatment of peritonitis in children, especially young children, is a task that requires an individual approach, taking into account many factors. Currently, special attention is paid to the prevention of peritonitis in children. Early diagnosis of malformations and diseases leading to peritonitis can significantly reduce its incidence and improve treatment outcomes.

Necrotizing enterocolitis of the newborn - a non-specific inflammatory disease caused by infectious agents against the background of immaturity of local defense mechanisms and / or hypoxic-ischemic damage to the intestinal mucosa, prone to generalization with the development of a systemic inflammatory response. According to D. Cloherty (2002), NEC is an acute necrotic intestinal syndrome of unclear etiology.

Symptoms of Ulcerative necrotic enterocolitis:

Clinical signs of NEC can be divided into systemic, abdominal and generalized. Systemic include: respiratory distress, apnea, bradycardia, lethargy, thermolability, excitability, poor nutrition, hypotension (shock), decreased peripheral perfusion, acidosis, oliguria, bleeding. To abdominal - bloating and hyperesthesia of the abdomen, aspirates of the stomach (food debris), vomiting (bile, blood), intestinal obstruction (weakening or disappearance of intestinal noise), erythema or swelling of the abdominal wall, constant localized mass in the abdomen, ascites, bloody stools. The fulminant course of NEC is typical for full-term newborns who have had asphyxia, trauma of the brain and / or spinal cord, hemolytic disease and gastrointestinal tract defects during childbirth. Apnea and the need for respiratory support are typical, and tissue perfusion disorders or acute cardiovascular failure are possible. There is regurgitation or a large residual volume in the stomach before feeding. Gregersen's reaction is positive. Sometimes a significant admixture of blood in the stool. The acute course of NEC is typical for premature newborns with a birth weight of less than 1500 g. The disease begins at 2-4 weeks of life with pronounced symptoms from the abdominal cavity: regurgitation and vomiting, refusal to eat, bloating, impaired passage through the intestines . Soon, general somatic symptoms are added, indicating intoxication and dysfunction of vital organs and systems. Subacute NEC is common in extremely low birth weight preterm infants. Symptoms develop gradually from the 3rd week of life. Early symptoms are the appearance of intolerance to enteral nutrition and a change in the nature of the stool. Flatulence is common, but the abdomen is often soft on palpation, abdominal wall muscle rigidity may be absent, and peristaltic murmurs may be detected on auscultation. Such patients require the immediate initiation of therapy and examination (frequent radiographs and examination of the stool for occult blood). If left untreated, this form of NEC presents with severe systemic and radiographic symptoms, usually within 24 to 36 hours. Among the above diagnostic tests, the most constant and informative are changes in the hemogram (leukocytosis / leukopenia, shift of the leukoformula to the left, thrombocytopenia), increased C-reactive protein, acidosis, electrolyte imbalance, interstitial pneumatosis and gas in the portal venous system according to ultrasound and X-ray studies of organs abdominal cavity. To determine the stages of NEC, in addition to the criteria described above, the Bell criteria modified by Walsh and Kleigman are used. Generalized symptoms resemble a septic process and are characterized by lethargy, hypotension, pallor, respiratory distress, oliguria, persistent cyanosis, and bleeding. The more pronounced the listed generalized signs, the greater the severity of the disease. Early symptoms of the disease are nonspecific and variable - from signs of intolerance to enteral nutrition to a catastrophic course with a clinical picture of sepsis, shock and peritonitis. CNS depression syndrome, apnea and signs of impaired tissue perfusion dominate - a positive white spot symptom, peripheral cyanosis, acidosis, hyperglycemia, and temperature instability. Flatulence, delayed evacuation of gastric contents, diarrhea, and bloody stools are common. The progressive process is manifested by erythema and swelling of the abdominal wall, growing tension of the abdominal muscles. Identification of dense masses during deep palpation of the abdomen indicates covered perforation of the intestine or widespread peritonitis. There are no peristaltic sounds on auscultation, but physical data are very scarce.

Causes of Ulcerative necrotic enterocolitis:

NEC is multifactorial. It is believed that NEC is a heterogeneous disease and its main components are ischemia suffered in the perinatal period, abnormal colonization of the intestine of the newborn and inadequate nutritional patterns of the child in the early postnatal period. Risk factors for the development of NEC: perinatal asphyxia, umbilical artery catheterization, polycythemia, arterial hypotension (reduced blood flow in the intestine), immaturity of the immune system, nutrient mixtures.

Treatment of Ulcerative necrotic enterocolitis:

First of all, in case of violation of the respiratory function, additional oxygen supply or artificial ventilation of the lungs is provided. In case of violation of hemodynamics, blood circulation is supported - replenishment of the BCC. For this purpose, fresh frozen plasma is used at the rate of 10 ml/kg of body weight, since it is the only donor of antithrombin-III and a source of other blood coagulation factors. To normalize renal and intraorgan blood flow, low doses of dopamine (2–5 µg/kg/min) are used. If acid-base homeostasis is disturbed, it may be necessary to administer sodium bicarbonate. An essential point in the management of newborns with this pathology, which largely determines the outcome and prognosis of the disease, is the cessation of all types of enteral feeding, including the administration of medications per os, properly administered total parenteral nutrition (TPN) through a peripheral vein. The transition from PPP to natural feeding is a long, multi-stage process, which is directly dependent on the severity of the course and the stage of NEC. Enteral nutrition is resumed 3–5 days after the normalization of the evacuation function of the stomach, the X-ray picture and the disappearance of clinical symptoms of gastrointestinal dysfunction, which usually occurs by the 10–12th day from the onset of the disease. Starting with distilled water or glucose solution, you should gradually switch to mixtures diluted 4 times. Upon reaching 50% of the volume of the enterally administered mixture of the total volume of liquid, one should switch to a dilution of 1: 2, and then 3: 4 to the full volume. Thus, a child with NEC goes through the following stages of nutrition: total parenteral nutrition, combined parenteral nutrition and artificial enteral (EIP), complete EIP, additional EIP and natural feeding, and finally transferred to natural feeding. Given the requirements for mixtures used as enteral artificial nutrition, as well as the fact that against the background of long-term antibiotic therapy, severe dysbacteriosis and secondary insufficiency often develop, especially after severe reconstructive operations, it is recommended to use lactose-free and hypolactose mixtures of the Nutrimigen type as the first mixture. ”, “Nutrisoya”, “Alprem”, “Alfare”, “Pregestimil”, “Nenatal”, etc. This allows you to significantly reduce the fermentation processes in the intestines, improve the digestion and absorption of ingredients. Vitamins, electrolytes (except potassium), microelements are included in the PPP regimen from the first day. A mandatory component of therapy are broad-spectrum antibiotics. Preference is given to third-generation cephalosporins in combination with aminoglycosides. An alternative to them are imipenems with metronidazole.

Congenital intestinal obstruction may be due to: malformations of the intestine (atresia, stenosis, remnants of the vitelline duct, duplication of the intestinal tube, agangliosis); violation of the rotation of the small intestine with compression of the duodenum, high-lying caecum in combination with volvulus of the small intestine (Ledd's syndrome); infringement of loops in defects of the mesentery, etc.; anomalies of neighboring organs (annular pancreas, meconium ileus in cystic fibrosis, etc.).

Allocate acute, chronic and recurrent congenital N. to. Acute N. to. subdivided into high and low. At high N. to. the obstruction is localized in the duodenum and the beginning of the jejunum. At the same time, vomiting with an admixture of bile, bloating in the epigastric region are observed. With atresia of the duodenum or jejunum, in addition, there is a release from the rectum of lumps of light mucus, in which there are no cells of the epidermis of the fetus, swallowed by it from the amniotic fluid and excreted with meconium with preserved patency of the gastrointestinal tract. Atresia is confirmed by Farber's test - the absence of dark blue epidermal cells in a stool smear stained with gentian violet. The x-ray shows two levels of liquid with gas, corresponding to the stomach and dilated duodenum.

Low obstruction causes an obstruction at the level of the ileum and colon. It is manifested by vomiting with a fecal odor, retention of stools and gases, bloating, visible intestinal motility. Radiographs of low obstruction show multiple Kloiber's cups in the small intestine. The diagnosis is clarified with the help of irrigoscopy.

One form of acute N. to., caused by increased viscosity of meconium, is meconium ileus. It is more common in cystic fibrosis. Vomiting is noted, sometimes with an admixture of bile, bloating of the upper half of the abdomen, lack of stool; in some cases, a fusiformly expanded terminal ileum is palpated.

Chronic N. to. due to mildly pronounced stenosis (compression) of the intestine and is characterized by increasing exhaustion, periodic vomiting with an admixture of bile, bloating in the epigastric region after eating. The chair is scanty, independent or with the help of an enema. An X-ray contrast study shows a retention of barium in the suprastenotic area of ​​the intestine for a more or less long time.

Recurrent N. to. occurs due to partial torsion of the small intestine, infringement of internal hernias, etc., which is clinically manifested by attacks of cramping pain, vomiting, stool and gas retention. Seizures may subside on their own.

Differential diagnosis of congenital N. to. carried out with pylorospasm, pyloric stenosis, pseudo-occlusive syndrome of prematurity, as well as various types of acquired obstruction. With pseudo-occlusive syndrome of prematurity, which is based on functional disorders of the gastrointestinal tract, vomiting is observed due to delayed evacuation of the contents of the stomach.

Treatment of congenital N. to. operational. With atresia of the duodenum resort to duodenojejunostomy. With Ladd's syndrome, the volvulus is first straightened, and then the caecum is mobilized, retracting it to the left and down. Areas of stenosis and atresia of the ileum and colon are resected with the imposition of an anastomosis. In case of meconium ileus, the Mikulich operation is performed, which consists in resection of the terminal ileum filled with meconium, and removal of its inlet and outlet sections onto the anterior abdominal wall, followed by the formation of intestinal fistulas, which are closed after the child's condition improves. Treatment of pseudo-occlusive syndrome of prematurity is conservative: administration of prozerin, gastric lavage, siphon enemas.

Acquired intestinal obstruction in children in 89% of cases is mechanical and 11% dynamic. Among the various types of mechanical N. to., according to G.A. Bairova (1977), 65-70% is invagination, about 20% is adhesive obstruction, 5-6% is obstructive and 4-5% is torsion.

Bowel intussusception occurs mainly in infants. The introduction of the intestine into the intestine is most often due to discoordination of peristalsis, provoked, for example, by eating disorders, intestinal diseases; in 5-6% of children, the cause of intussusception is Meckel's diverticulum, polyps, and a tumor. The introduction of the small intestine into the large intestine is observed in 90-93% of cases; colonic and small intestine intussusception is much less common. Intussusception is manifested by periodically occurring cramping pains in the abdomen, vomiting, blood in the feces. Often in the abdominal cavity, a sausage-shaped tumor (intussusception) is palpated, which is easier to detect during rectal examination with simultaneous palpation of the abdomen. X-ray examination with the introduction of air through the rectum using a Richardson balloon at a pressure of 40-50 mm Hg. Art. intussusception is contrasted.

Differential diagnosis is carried out with dysentery, capillary toxicosis, bleeding diverticulum. In this case, palpation of the intussusceptum and contrasting it with air is of decisive importance.

Treatment of intussusception in the first 12-24 hours can be conservative (flattening with air injected into the rectum at a pressure of 70-80 mm Hg). At a later date, laparotomy and disinvagination are indicated. In case of necrosis of the invaginate, it is resected.

Adhesive N. to. cause adhesions that occur in the abdominal cavity due to inflammatory processes and injuries, most often after laparotomy. In children, there are early (primary and delayed), developing during the first month after surgery, and late N. to. Early primary N. to. occurs against the background of intestinal paresis, has an obstructive mechanism. Manifested by vomiting, bloating, stool retention. At the same time, the volume of vomit increases, and when intestinal motility is stimulated, a pain attack occurs. X-ray examination determines the Kloiber cups of different sizes. Early delayed N. to. develops after the restoration of intestinal motility; begins with cramping pains, vomiting, retention of stools and gases. The abdomen is asymmetric, intestinal peristalsis is visible, with a survey radiography of the abdominal cavity, Kloiber's cups are clearly defined. For late N. to., which occurs after more than 1 month. after surgery, the same symptoms are characteristic as for early delayed N. to., but they are more pronounced.

The differential diagnosis is with food poisoning, which is not characterized by stool retention and horizontal levels detected by x-ray examination.

Treatment of adhesive N. to. in 40-50% of cases it is possible with the help of conservative measures (siphon enemas, pararenal novocaine blockades, etc.). The ineffectiveness of conservative treatment in the coming hours is an indication for laparoscopy or surgery.

Obstructive N. to. caused by coprostasis, ascariasis and tumors. Clinically characterized by moderate pain, vomiting, stool retention. With coprostasis in the sigmoid colon, an accumulation of feces is palpated. The tumor is most often located in the ileocecal angle. A conglomerate formed by an accumulation of roundworms changes shape and localization; while eosinophilia is noted. Siphon enemas, palpation performed under general anesthesia, and radiopaque examination of the intestine contribute to clarifying the diagnosis. Treatment of coprostasis and helminthic obturation is conservative (enemas, antihelminthics). If a tumor is suspected, surgery is indicated.

Intestinal volvulus in children is a consequence of disturbances in the rhythm of peristalsis and an increase in intra-abdominal pressure, which develops against the background of an error in nutrition. It is manifested by very sharp cramping pains, repeated vomiting, collapse. The main difference between volvulus and food poisoning is the retention of stools and gases, because. in the first hours of the volvulus, Kloiber's cups may be absent on the radiograph. Treatment is operative.

Dynamic (paralytic) intestinal obstruction in children is observed with peritonitis, dehydration and hypoxemia. Abdominal distention, absence of intestinal noises are characteristic, intestinal pneumatosis and multiple horizontal levels are detected on the x-ray. Treatment includes a set of measures aimed at restoring homeostasis, fighting infection, and directly improving intestinal microcirculation (prolonged epidural anesthesia, UHF for the celiac plexus, etc.). At impossibility to exclude mechanical N to. or in the presence of peritonitis operation is shown.

Portal hypertension (PH) is one of the main causes of the most severe bleeding from the upper gastrointestinal tract. And although the proportion of this syndrome among all cases of bleeding from the gastrointestinal tract (GIT) is no more than 4.5%, but the severity of bleeding and the complexity of treating the disease makes us pay close attention to this syndrome. The syndrome of portal hypertension unites a large number of nosological units, which are characterized by an increase in pressure in the portal (portal) vein system. The main symptom of the disease common to all types of portal hypertension is bleeding from varicose veins of the esophagus and stomach, which is manifested by profuse vomiting like "coffee grounds" and chalk (typical signs of bleeding from the upper gastrointestinal tract).

Bleeding from varicose veins can occur at any age (in our observations, the age of the youngest child with bleeding in portal hypertension is 4 months) and is a symptom of the disease in 63% of patients. The intensity of bleeding is usually significant and requires emergency hospitalization of the child and intensive hemostatic therapy. The frequency of episodes of bleeding is individual and does not depend on any factors. It is bleeding that is the most life-threatening symptom of the patient. Even in the mid-80s, according to various authors, mortality reached 5-7%. In 50% of children with PH, the first bleeding occurs before reaching the age of 4, and in 18% - in the first 3 years after birth.

The second symptom in terms of frequency of primary manifestation is splenomegaly and hypersplenism. Enlargement of the spleen in portal hypertension occurs almost always and can reach a significant size. (Fig. 1.) In 22% of children, splenomegaly is the primary symptom, on the basis of which portal hypertension is detected. Hypersplenism or pancytopenia is secondary and is a consequence of an enlarged spleen. The most characteristic is a significant decrease in the number of platelets - 3-4 times lower than normal.

Ascites in portal hypertension is rare. It is more characteristic of children with various liver diseases: cirrhosis, Budd-Chiarri syndrome. However, in a small part of children - 5-7%, it is a manifesting symptom. Ascites develops more often due to impaired liver function, but an increase in portal pressure also plays a pathophysiological role.

In order to understand the pathophysiology of portal hypertension, it is necessary to return to the normal anatomy of the portal portal system. (Fig. 2)

The portal vein collects blood from almost the entire abdominal cavity: the gastrointestinal tract, spleen, pancreas, gallbladder. It is formed from the confluence of the splenic (which collects blood from the spleen and stomach, pancreas) and the superior mesenteric vein (carrying blood from the stomach and small intestine). An equally large tributary of the portal system is the inferior mesenteric vein, which collects blood from the left half of the colon and rectum. At the gates of the liver, blood is divided into right and left branches.

The main physiological structure of the liver is the hepatic lobule. It is in the structure of the hepatic lobule that the terminal branches of the portal vein flow into sinusoids, which are the main physiological link in intrahepatic hemodynamics.

Based on the anatomical and physiological structure of the liver, various forms of portal hypertension are distinguished.

1) Suprahepatic (postsinusoidal) form of portal hypertension - obstruction of the hepatic veins

2) Intrahepatic (sinusoidal) form of portal hypertension

3) Extrahepatic (presinusoidal) form of portal hypertension

The suprahepatic form of portal hypertension is the rarest form of the disease in childhood (not more than 0.8% of all cases of portal hypertension). The syndrome is based on obstruction of the hepatic veins at any level, from the efferent lobular vein to the confluence of the inferior vena cava into the right atrium. This form of portal hypertension is called Budd-Chiari syndrome. Budd-Chiari syndrome develops in patients with systemic lupus erythematosus, idiopathic granulomatous vasculitis with a predominant lesion of venules, with various types of insufficiency of their own anticoagulants. Budd-Chiari syndrome can develop as a result of severe autotrauma (blunt abdominal trauma), with veno-occlusive disease, poisoning with salts of heavy metals. In about a quarter of patients, the cause of obstruction of the hepatic veins remains unclear.

The clinical manifestations of this form of portal hypertension depend on the speed of development of obstruction and the prevalence of the process in the hepatic veins. In the acute course of the disease, the development of malignant liver failure, encephalopathy and a rapid onset of death is possible. The chronic course is more common. In this case, the symptoms develop within 1-6 months. The most characteristic is a significant increase in the liver, pain in its projection, the development of ascites. Later, the spleen enlarges. In the biochemical blood test - there is hypoproteinemia, increased transaminases and other signs characteristic of a violation of the synthetic function of the liver.

Acute abdomen is a clinical syndrome that develops in acute diseases, as well as damage to the abdominal organs. The syndrome is accompanied by abdominal pain, which is characterized by a different nature and intensity, as well as muscle tension of the abdominal wall and intestinal motility disorders. If these symptoms occur, it is necessary to call an ambulance team, since the patient may require emergency surgical intervention. In some cases, the pseudo-abdominal syndrome, which is characterized by acute abdominal pain caused by diseases of various organs (colitis, pyelonephritis, gastritis, myocardial infarction, acute pneumonia), can mimic the clinical picture of this condition. These pathologies may be accompanied by symptoms of an acute abdomen, but in this case, surgical intervention is not required, since they are treated conservatively.

Causes of development and symptoms

The syndrome can occur in the case of acute nonspecific inflammatory diseases of the digestive system (gall bladder, pancreas, appendix). In some cases, the occurrence of an acute abdomen can provoke perforation of an organ, which often occurs as a result of inflammatory processes in the body or damage to the abdominal organs.

The cause of acute pain in the lower abdomen can be internal bleeding into the abdominal cavity or retroperitoneal space (for example, with an aneurysm of the abdominal aorta or with an ectopic pregnancy). In addition, traumatic ruptures of the liver, spleen or mesenteric vessels can also have an acute abdomen as their symptom.

Sudden acute pain in the lower abdomen may also indicate intestinal obstruction, which, in turn, develops with volvulus, nodulation, intussusception, strangulation of the intestine in the external or internal hernia, as well as obturation.

The main symptom is localized and spreading throughout the abdomen, a sharp pain. With extensive and severe lesions, a pronounced pain syndrome is sometimes accompanied by the development of a pain shock. And there are inexpressive pains in this syndrome in young children, as well as in malnourished patients.

A frequent manifestation of an acute abdomen is vomiting, which mainly occurs at the very beginning of the disease. And in case of irritation of the phrenic nerve, painful persistent hiccups, pain when pressing on the sternocleidomastoid muscle may appear. This condition is often accompanied by a disorder in the passage of food through the stomach into the intestines, as well as a change in the nature of feces (sometimes feces mixed with blood are possible).

With massive bleeding into the abdominal cavity and diffuse purulent peritonitis, along with a symptom of an acute abdomen, patients have severe pallor of the skin and mucous membranes, an indifferent facial expression, retracted cheeks and sunken eyes. With intraperitoneal bleeding, the patient suffers from severe tachycardia and a sharp decrease in blood pressure up to collapse.

Causes of the development of an acute abdomen in children

In children, an acute abdomen very often develops due to acute appendicitis and intestinal obstruction.

With appendicitis, the child becomes irritable, lethargic, sleeps extremely poorly. A disease such as appendicitis may at first be confused with poisoning or an intestinal infection, since it is accompanied by loose stools with mucus. In addition, at first the pain is not felt on the right side of the body, as everyone used to think, but in the umbilical region or upper abdomen. In addition, the development of the disease does not always have manifestations of nausea, vomiting and fever.

In the case of intestinal obstruction, the child has symptoms such as vomiting, lack of stool, non-excretion of gases, as well as a sharp deterioration in his condition. In children aged 6 to 12 months, the cause of the disease is quite often intestinal intussusception caused by improper feeding of the child, in particular an excess of vegetables and fruits. With an acute abdomen associated with intestinal obstruction, in some cases vomiting occurs with an admixture of bile or intestinal contents. And instead of feces, blood mixed with mucus comes out of the rectum. If these symptoms occur in a child, he should not be fed and given painkillers until a specialist examines and finds out the causes of pain. In addition, if the pain in the abdomen does not stop within an hour, then you need to quickly call the emergency medical team.

Acute abdomen in gynecology

In gynecological practice, this pathology is a whole complex of symptoms caused by various diseases of the pelvic organs. The key symptoms of an acute abdomen in gynecology are sharp pain in the lower abdomen. Stitching and cutting pain is paroxysmal or constant. In some cases, weakness, vomiting, dizziness, bleeding, and hiccups occur. In addition, signs may include problems with stools and pressure on the anus.

The most common factor in the development of an acute abdomen in gynecology is an ectopic pregnancy (more than half of all cases). Very often, such sensations occur with acute oophoritis (inflammation of the ovaries), as well as with ovarian apoplexy (their rupture into the abdominal cavity).

The cause of the appearance can sometimes be injuries and circulatory disorders in the tissues of the uterus, as well as various female inflammatory processes, such as:

This pathology can develop as a result of operations on the appendages and uterus, abortions, as well as after various infectious diseases in advanced form.

This article is posted for educational purposes only and does not constitute scientific material or professional medical advice.

Acute abdomen in a child. Abdominal pain in a child: causes of abdominal pain

Most often, abdominal pain is based on irritation of the peritoneum, the membrane lining the internal organs, or rather, its folds of the mesentery, on which the human intestine is suspended. Any problems in or near the abdomen can put pressure on or irritate the mesentery and cause pain.

Pain in the abdomen in a child- a symptom of a wide variety of diseases. By the way, it is not at all necessary that the source of pain is in the abdomen.

Causes of abdominal pain:

Esophagitis (inflammation of the esophagus);

Inflammation of the duodenum and stomach (duodenitis, gastritis, gastroduodenitis);

Ulcer of the stomach and duodenum;

Inflammation of the intestines (colitis, enteritis, enterocolitis);

Nonspecific ulcerative colitis.

Cholecystitis (inflammation of the gallbladder);

Hepatitis (inflammation of the liver);

Biliary dyskinesia and other diseases.

The initial period of measles, chickenpox, SARS and other infections.

cystitis (inflammation of the bladder);

Pyelonephritis (inflammation of the kidneys);

Pneumonia, when the process is in the lower parts of the lungs;

Pleurisy (inflammation of the pleura, the membrane that lines the lungs).

Adnexitis (inflammation of the ovary), etc.;

Salpingitis (inflammation of the fallopian tubes).

Lymphadenitis (inflammation of the lymph nodes in the abdominal cavity).

Cardiac ischemia.

Take a look at this long list again. You must think that you will not want to self-medicate after this. Of course, it is necessary to establish the reason why the stomach hurts, and for this it is necessary to consult a doctor. What? For starters - with a pediatrician. Depending on the accompanying symptoms, your pediatrician will determine what tests to take, what other examinations to undergo, and which specialist to refer the child to (gastroenterologist, nephrologist, surgeon, cardiologist, etc.) in order to establish an accurate diagnosis.

However, it is very important not to miss acute abdomen. This condition requires prompt medical and surgical care. Procrastination in the case of an acute abdomen is like death. Therefore, parents need to know well how this pathology manifests itself.

Acute abdomen in a child

Acute abdomen- a severe syndrome, which is found mainly in injuries or acute diseases of the abdominal organs and retroperitoneal space, and often requires emergency surgical care. In this case, pain occurs in the peritoneal region and as a result, inflammation, peritonitis occurs.

The main causes of the development of an acute abdomen:

Traumatic rupture of an organ, for example: kidney, liver, spleen

Acute pancreatitis (inflammation in the pancreas);

Acute cholecystitis (inflammation of the gallbladder).

Perforated stomach ulcer.

Strangulated hernia, etc.

Acute adnexitis (inflammation of the ovary);

Rupture of an ovarian cyst, etc.

Clinical picture of an acute abdomen

The appearance of the patient may be different:

Tactics of behavior in an acute abdomen

• In case of suspicion of an acute abdomen, it is imperative to call an ambulance and hospitalize the patient in the surgical department of the hospital.
• Before the arrival of the ambulance, it is strictly forbidden to use painkillers or narcotic drugs, laxatives, antibiotics, or to give an enema. The patient is forbidden to eat and drink.
• It is allowed to put cold on the stomach (ice pack).
• At acute abdomen urgent surgical intervention is needed. Without surgery, the patient will die.

What to do if the child has a stomach ache and vomiting

Pain in the abdomen in a child, which is accompanied by episodes of nausea and vomiting, is a fairly common condition in childhood. It cannot but alert parents, since it is a clear sign of the disease. Every parent is familiar with this difficult problem firsthand.

The reasons can be extremely serious, so you need to learn how to correctly identify possible causes and provide timely assistance before the arrival of doctors if the child has a stomach ache and vomiting. It is important to carefully monitor the manifestations of the disease state and analyze them in order to have an idea of ​​\u200b\u200bwhat exactly is happening with the baby.

The first thing you should pay attention to is that the child looks restless, his skin becomes paler and cooler, he is overcome by nausea. Then there is a contraction of the muscles of the stomach and abdominal wall, as a result of which the contents of the stomach are brought out through the mouth. The pressure can be quite strong, and the mass often has an unpleasant odor and the appearance of undigested food, sometimes with impurities.

The increased frequency of bouts of abdominal pain and vomiting takes more and more strength from the baby. Their repeated repetition, accompanied by an increase in body temperature and loose stools, increases the risk of dehydration. The nature of the pain that occurs along with this is dull, sharp, cutting, aching, cramping. The severity and duration may vary. When asked to indicate a place that worries, often the child points to the navel.

Causes, symptoms and first aid

Certain symptoms when a child has a stomach ache and vomiting are characteristic of specific diseases. To understand exactly how to act, you need to try to correctly determine the cause. Only after that it will be possible to provide first aid to the baby.

The most common causes with their characteristic symptoms are the following:

1. Food poisoning, or acute intestinal infection, is convulsive pain in the abdomen, often expressed in the left side or in the navel area. Pallor of the skin and fever are noted (t is 38-39 °). Later, diarrhea begins, which has a pungent odor, a greenish color, impurities of mucus and blood. At first, the stools are thick, but after that it becomes watery or presented with only mucus. Repeated vomiting occurs several hours after contaminated, dirty or poor-quality products enter the child's body. So the body gets rid of unusable food. Over time, the symptoms get worse. If the poisoning is of a chemical nature, then its manifestations will be determined by the type of poison that has entered the stomach and its dose. Poison refers to detergents, solvents, and other chemicals. Before the arrival of doctors, it is recommended to give the crumbs funds for rehydration;
2. Cholecystitis - inflammation of the gallbladder is primarily reflected in the child's body with a sharp increase in body temperature. This is followed by complaints of sharp cramps in the right hypochondrium, radiating to the arm, lower back or shoulder blade. A few hours later, one-time vomiting often occurs in the form of food debris that has not had time to be digested with bile. The baby does not feel relief after it, and the fever can last for several days. The causative agent of infection in this case is staphylococcus aureus. The disease develops acutely, often at night. When calling an ambulance, it is worth clarifying the diagnosis, since cholecystitis can be extremely dangerous for the baby;
3. Appendicitis - the diagnosis of this surgical pathology in babies is difficult, since often they do not give a detailed description of the areas of pain localization, but only point to the navel. Touching provokes even more soreness, so children avoid them in every possible way and try to take a pose with their legs tucked in. Initially, it is blunt in nature, gives to the right side and lower back. Later it intensifies and moves closer to the left lower iliac region. There is a violation of the stool, pallor, vomiting that does not improve well-being, fever (t 39 ° - only in the smallest), fainting. It is important to call an ambulance as soon as possible and place the baby in a hospital;
4. Viral diseases (SARS, influenza, etc.) - the onset of infection is always acute. The first symptoms are cough and runny nose. But when a fever appears, the baby refuses food, complains of fatigue, discomfort in the muscles, nausea, turning into vomiting. Most often, those who attend school or kindergarten are susceptible to infection. A young body may need 2-10 days to recover;
5. Intestinal obstruction (or its special case - volvulus of the intestines) - the first manifestation is belching and dull abdominal cramps with bloating. A few hours after eating, repeated vomiting attacks of undigested food begin, which slightly alleviates the condition. However, after the next meal, the situation repeats itself. The reason lies in the presence of a hernia, tumor, or accumulation of feces in the intestine. Its lumen is blocked, and overcooked food accumulates and begins to ferment or rot. There is a lack of stool or its delay, after which impurities of blood and mucus are found in the feces. The body tries to get rid of the excess through stomach cramps. The child should be laid on its side so that the head is higher than the body;
6. Gastritis or stomach ulcers are rare diseases at this age that do not start suddenly and can be chronic. The mucous membrane of the stomach becomes inflamed as a result of weakened immunity, frequent stress and the presence of Helicobacter bacteria. Pain from above in the left iliac region is felt for several months. Vomiting in a child is provoked by fatty, fried or spicy foods. It is one-time and brings relief. It is important to show the baby to the gastroenterologist and follow his recommendations;
7. Intestinal colic - air leaves the intestines through the release of gases or the stomach through belching. The baby is restless, but there is no fever. The phenomenon occurs in newborns and babies up to a year;
8. Cyclic vomiting syndrome - symptoms in the form of abdominal cramps and periodic vomiting, which go away on their own without treatment;
9. Inguinal hernia - the child vomited and the stomach hurts below, a bulge forms in the inguinal zone. Be sure to contact a pediatric surgeon;
10. Acetonemic syndrome - the child vomits and has a stomach ache, there is a fever, exhaled air and urine have a specific smell. The help of a pediatrician and the intake of glucose preparations are required;
11. Food intolerance - manifested by skin rashes, abdominal pain, diarrhea and vomiting. What to do: identify and exclude from the diet a product that provokes symptoms, and contact a pediatrician;
12. Functional vomiting - accompanied by abdominal pain. It is psychogenic in nature and is observed in children with increased nervous excitability. It can be triggered by stress, anxiety, or coercion to do something. Symptoms disappear with the elimination of irritating factors.

As you can see, there are a lot of reasons when a child has a stomach ache and vomiting. The final diagnosis can only be made by a doctor. In no case do not try to self-medicate!

If a child has nausea and a stomach ache, vomiting begins, then parents should immediately resort to calling an ambulance or a doctor on duty. Especially if the condition worsens markedly, dehydration begins, stool disorders, fever is noted, or blood is present in the vomit. Each of these signs may indicate a life-threatening illness for the baby. It is necessary to try to describe in detail the patient's condition, remember all the recommendations of the specialist and strictly adhere to them.

In order to alleviate the condition of a sick baby whose stomach hurts and vomits before the arrival of doctors, you first need to properly lay it down. The upper part of the body should be raised and the head turned to the side to avoid swallowing vomit. In case of dehydration, it is recommended to restore the water-salt balance with rehydration products or boiled water with the addition of salt and sugar in small quantities.

Spasms in the iliac region can be stopped with antispasmodic tablets. But it is undesirable to give them before the arrival of the doctor, since they can interfere with diagnosing the disease in time. If necessary, you can give the baby antipyretics.

If there is no fever, but the pain in the child's abdomen does not stop along with vomiting, it is recommended to transfer him to an upright position, supporting his head and shoulders. When a baby vomits, it is worth checking the absence of gastric contents in the spout. If it is clogged, you need to clean the moves with a pear or special drops.

Important: as a self-help for abdominal pain and vomiting, you can not feed the baby for 6 hours, do a gastric lavage, apply heating pads or cold compresses to his stomach.

After examining the baby, the doctor will determine the exact diagnosis, prescribe treatment and give recommendations on the next steps. To notice that the condition of the crumbs tends to improve, parents will be able to stop the symptoms, increase activity, return appetite and cheerful mood.

We hope that after reading this article, you will know exactly what to do if your child has diarrhea and vomiting. After all, anyone can get sick.

The concept of "acute abdomen" syndrome combines a symptom complex that manifests various acute surgical diseases that require urgent surgical intervention. Most often, the "acute abdomen" syndrome develops in acute inflammatory diseases of the abdominal cavity - acute appendicitis, acute diverticulitis, acute peritonitis, necrotizing ulcerative enterocolitis and intestinal necrosis with late diagnosis of acute intestinal obstruction, perforation of the stomach or intestines.

Acute appendicitis - non-specific inflammation of the vermiform appendix of the caecum.

In childhood, appendicitis develops faster, and destructive changes in the process, leading to appendicular peritonitis, are observed much more often than in adults. These patterns are most pronounced in children in the first years of life, which is due to the anatomical and physiological characteristics of the child's body that affect the nature of the clinical picture of the disease and in some cases require a special approach to solving tactical and therapeutic problems.

Clinical manifestations of acute appendicitis in children are variable and largely depend on the reactivity of the body, the anatomical position of the appendix and the age of the child. The general characteristic of the clinical picture is the predominance of general nonspecific symptoms over local ones.

Clinical picture of acute appendicitis in older children.

The clinical picture of acute appendicitis in children of the older age group is more distinct and consists of the following main signs identified from the anamnesis: abdominal pain, fever, vomiting, and sometimes intestinal dysfunction.

The initial symptom of the disease is a sudden dull pain without a clear localization in the upper abdomen or navel. After 4-6 hours (with fluctuations from 1 to 12 hours), the pain moves to the right iliac region. Parents note that children become less active, refuse to eat. Appendicitis is characterized by continuous pain that does not disappear, but only subsides somewhat for a while.

The localization of pain depends on the location of the appendix: in a typical position, the patient feels pain in the right iliac region, in a high position - almost in the right hypochondrium, in the retrocecal position - on the lateral surface of the abdomen or in the lumbar region, in the pelvic position - above the pubis.

One of the most constant symptoms of acute appendicitis in children is vomiting, which develops in almost 75% of patients and is reflex in nature. In the following days of the disease, with the development of diffuse purulent peritonitis, vomiting becomes repeated, often an admixture of bile is detected in the vomit.

Quite often, stool retention is noted, sometimes loose stools appear no earlier than on the 2nd day from the onset of the disease. When the process is located near the cecum or rectum or among the loops of the small intestine, inflammation can spread to the intestinal wall, which leads to fluid accumulation in the intestinal lumen and diarrhea, with severe secondary proctitis, fecal masses may look like "spitting" mucus, sometimes even with an admixture a small amount of blood.

The tongue at the onset of the disease is moist, often lined with white scum. With the development of toxicosis and exsicosis, the tongue becomes dry, rough, and overlays appear on it.

There are no pathognomonic symptoms of acute appendicitis, all symptoms are due to local peritonitis.

With the development of peritonitis, the forced position of the patient on the right side with the lower limbs pulled up to the stomach is noted.

When examining the abdomen, there may be a lag in the right lower quadrant of the abdominal wall during breathing. Palpation reveals muscle tension and sharp pain in the right iliac region. Positive symptoms of peritoneal irritation (Shchetkin's symptom - Blumberg, Razdolsky, Voskresensky) can also be determined here. Pain, as a rule, increases when the patient is positioned on the left side (Sitkovsky's symptom), especially during palpation (Bartomier-Mikhelson's symptom). With the retrocecal location of the process, there may be a positive symptom of Obraztsov - increased pain when raising the straightened right leg. This symptom should be checked very carefully, since with rough pressure on the abdominal wall, perforation of the process is possible. The temperature is often elevated to subfebrile numbers.

In the blood - leukocytosis up to 5-17 * 10 9 / l with a shift of the formula to the left.

With a digital examination of the rectum, pain is noted on palpation of the right pelvic wall (especially in the pelvic position of the process).

The presence of erythrocytes and leukocytes in the urine does not exclude acute appendicitis.

Clinical picture and diagnosis of acute appendicitis in young children.

Due to the functional immaturity of the nervous system at this age, almost all acute inflammatory diseases have a similar clinical picture (high body temperature, repeated vomiting, impaired bowel function).

If in older children complaints of pain in the right iliac region are of leading importance, then in children of the first years of life there are no direct indications of pain, it is possible to judge the presence of this symptom only by indirect signs. The most important of these is changing the behavior of the child. In more than 75% of cases, parents note that the child becomes lethargic, capricious, with little contact. The restless behavior of the patient should be associated with an increase in pain. The continuity of pain leads to sleep disturbance, which is a characteristic feature of young children and occurs in almost a third of patients. The disease often develops at night, children wake up from pain.

An increase in body temperature in acute appendicitis in children of the first years of life is almost always. Often the body temperature reaches 38-39 0 C. A rather constant symptom is vomiting. For young children, repeated vomiting is characteristic (3-5 times).

In almost 15% of cases, loose stools are noted. Stool disorder is observed mainly in complicated forms of appendicitis and pelvic location of the appendix. Complaints of pain in the right iliac region in children of this age group are almost never found. Usually the pain is localized near the navel. Such localization is associated with anatomical and physiological features: the inability to accurately localize the place of greatest pain due to insufficient development of cortical processes and a tendency to irradiate nerve impulses, the close location of the solar plexus to the root of the mesentery. An important role is played by the rapid involvement of the mesenteric lymph nodes in the inflammatory process.

When diagnosing, they are also guided by the main symptoms, as in older children (passive muscle tension and local pain in the right iliac region). However, it is extremely difficult to detect these signs in children of the first years of life. This is due to the age-related characteristics of the psyche, primarily motor excitement and anxiety during examination. When conducting palpation of the abdomen, it is important to carefully monitor the behavior of the child. The appearance of motor anxiety, reactions of mimic muscles can help assess the pain of the examination. The method of examining children in a state of medical sleep is justified. At the same time, passive muscle tension of the anterior abdominal wall and local pain persist.

Rectal digital examination in younger children provides less diagnostic information and brings clarity only in the presence of infiltrate, which is relatively rare at this age. Nevertheless, digital rectal examination should be performed in all young children, since in many cases it helps to differentiate other diseases (intussusception, coprostasis, etc.)

In young children with acute appendicitis, an increase in the number of leukocytes in the peripheral blood up to 15-20 * 10 9 / l is most often noted. Often observed and hyperleukocytosis (25-30*10 9 /l).

Appendicitis in newborns

The disease develops mainly in premature babies weighing 1 to 2 kg at the age of 7-20 days. All children had a history of perinatal hypoxia, infection, cerebrovascular accident. The disease begins acutely, with an increase in symptoms of infectious toxicosis, vomiting with an admixture of bile, bloating, and stool retention appear. When examined in the first 12 hours from the onset of deterioration, it is possible to identify local symptoms: local pain in the right iliac region, passive muscle tension, Shchetkin-Blumberg symptom, and if the process tends to be limited, infiltrate can be palpated. As a rule, there is no temperature reaction, the number of leukocytes fluctuates over a wide range (from 7 to 18 * 10 9 / l) with a tendency to increase. Later, due to the rapid progression of the inflammatory process and the increase in toxicosis, symptoms of diffuse peritonitis are detected.

Diagnosis of acute appendicitis in premature infants at risk is difficult due to the complexity of differential diagnosis with necrotizing enterocolitis. Radiographically, with appendicitis in newborns, darkening is often determined in the right half of the abdomen against the background of paretically swollen loops of the intestine (especially the large intestine), the absence of thickening of the intestinal walls. With necrotizing enterocolitis, gas filling of the intestine is sharply reduced; due to significant hydroperitoneum, the outer contours of the intestinal loops lose their sharpness. However, the decisive factor in the diagnosis is the dynamics of these symptoms over the next 3-6 hours of intensive detoxification, rehydration and anti-inflammatory therapy. The absence of positive dynamics in the general condition of the child and the increase in local symptoms indicate an inflammatory process in the abdominal cavity and require emergency surgical care.

Differential diagnosis. In children of the older age group, acute appendicitis is differentiated from diseases of the gastrointestinal tract, biliary and urinary systems, diseases of the genital organs in girls, and hemorrhagic vasculitis. At a younger age (mainly in children of the first 3 years of life), differential diagnosis is often carried out with acute respiratory viral infections, coprostasis, urological diseases, otitis media, childhood infections.

Treatment is operative. The operation is indicated not only in every case that is clear from a diagnostic point of view, but also with a reasonable suspicion of acute appendicitis, if it is impossible to exclude acute inflammation of the appendix on the basis of clinical signs and special research methods (including laparoscopy).

Anesthesia for children, especially young children, should only be general.

Treatment of appendicitis in newborns

Due to immaturity, the dome of the caecum is located high under the liver and deep in the lateral canal, therefore, a right-sided transmuscular or pararectal access 3-4 cm long is used. Appendectomy is performed using a ligature method with drainage left. Intraoperatively and in the next 3 days after the operation, a 1% solution of dioxidine is injected into the drainage. In the postoperative period, the started intensive therapy is continued.

Gives a clinical picture of appendicitis: the patient develops vomiting, fever, stool retention, general anxiety are noted. When probing the abdomen, the pain is localized mainly closer to the navel or in the suprapubic region.

And also, in children, peptic ulceration of islands of ectopic gastric mucosa (the adjacent ileal mucosa) occurs, which is often the cause of massive intestinal bleeding. Bleeding can occur acutely and be profuse, but chronic bleeding in small portions is also observed. These bleedings occur in full health, recur at intervals of 3-4 months, which leads to anemia, pallor, tachycardia, and collapse. The first stools are usually dark in color, in the subsequent ones dark (scarlet) blood appears without clots and mucus. Unlike gastrointestinal bleeding of other origins, Meckel's diverticulum does not cause hematemesis.

Surgical treatment (wedge-shaped resection of a section of the intestine with a diverticulum) is carried out after appropriate preoperative preparation.

Peritonitis- an acute inflammatory complication (disease) of the peritoneum that occurs when the local protective functions of the peritoneum are impaired due to the pathological effects of exogenous or endogenous causative factors. The causes of peritonitis in children are varied. In most cases, it is the result of infection from the abdominal organs. There are also hematogenous and cryptogenic peritonitis, the causes of which are difficult to establish. Perforative peritonitis in children older than 1 year most often develops against the background of acute appendicitis. In children, peritonitis has a number of specific features. Depending on the origin of peritonitis, the duration of the disease and the age of the child, the course and prognosis change significantly. Especially quickly and malignant peritonitis occurs at an early age, when diffuse forms of inflammation of the peritoneum are mainly found. This is due to the anatomical and physiological features of the child's body, in particular, the short omentum, which reaches the lower abdominal cavity only by the age of 5-7 years and cannot contribute to the delimitation of the process. There is an infection of the reactive effusion, which appears very quickly and in significant quantities. The immaturity of the immune system and the peculiarities of the absorption capacity of the peritoneum also play a role (the younger the patient, the longer the resorption from the abdominal cavity occurs). The severity of the course of diffuse peritonitis is largely determined not only by the nature of the local process, but also by a violent and profound violation of homeostasis. Of the many causes of homeostasis disorders in peritonitis in children, water-salt imbalance and hyperthermic syndrome are of the greatest importance. Loss of water and salts in peritonitis in children, especially young children, is associated with vomiting, loose stools, accumulation of fluid and electrolytes in the free abdominal cavity and in the intestine as a result of its paresis. Of great importance is also an increase in imperceptible perspiration - the loss of fluid and salts through the lungs (rapid breathing) and skin, especially with a significant increase in body temperature. In the origin of hyperthermic syndrome, the direct effect on the center of thermoregulation of toxins and other products of inflammation, the decrease in heat transfer through the skin as a result of peripheral hemodynamic disorders, is important. It is worth noting the features of diagnosing peritonitis in young children: difficulties in verbal and psycho-emotional contact with the child; the need to use subjective, often insufficient anamnestic information; inability of young children to localize pain; inability to detect pain signs of abdominal syndrome; the need for examination with restless behavior of the child. The appendicular, cryptogenic Primary peritonitis and neonatal peritonitis. The disease most often occurs in girls aged 3 to 7 years. The infection enters the abdominal cavity through the vagina with the development of endosalpingitis. Clinically, two forms of primary peritonitis are distinguished - toxic and local. The toxic form occurs quite rarely: no more than 5% of cases. The toxic form is characterized by an acute and rapid onset of the disease. Severe abdominal pain is noted, usually in the lower sections. Body temperature rises to 38-39 C. Vomiting can be repeated. Loose stools are often inherent, which occurs with increased peristalsis due to a pronounced inflammatory process in the abdominal cavity. A significant severity of the general condition is noted with a short period from the onset of the disease (2-6 hours). The child is usually restless, the skin is pale, the eyes are shining. Tongue dry, covered with white coating. When examining the abdomen, all signs of severe peritonitis are found: sharp pain and a clear rigidity in all parts of the anterior abdominal wall, but somewhat more in the navel and on the right. Shchetkin's symptom — Blumberg positive. Moderate intestinal paresis is also noted. In the study of peripheral blood, high leukocytosis is noted. With a localized form, the clinical picture is erased, intoxication is not expressed, pain is often localized in the right iliac region. In this case, the body temperature reaches subfebrile figures. However, a more acute onset, the presence of ARVI at the time of examination or ARVI transferred the day before are important factors in the differential diagnosis of primary peritonitis with another pathology. Both localized and toxic forms of the disease are difficult to differentiate from appendicitis, therefore, with traditional tactics, patients undergo appendectomy. Diagnostic laparoscopy is often curative. Aspiration of pus is performed, a solution of antiseptics is injected. All patients are prescribed antibiotic therapy with penicillins or cephalosporins for 5-7 days. The prognosis is favorable. appendicular peritonitis Peritonitis is the most common complication of acute appendicitis in childhood, occurring in 8-10% of cases, and in children of the first 3 years of life 4-5 times more often than at an earlier age. Of the many classifications, the principle of dividing peritonitis according to the staging of the course of the process and the prevalence of peritoneal lesions, the severity of intestinal paresis, is most widely used. appendicular peritonitis -Local -General —Delimited -Unlimited The most widespread in peritonitis is the allocation of three phases of its course, reflecting the severity of the clinical course of the disease: Reactive phase: It is characterized by a violation of the motor-evacuation, digestive function of the gastrointestinal tract; hanging the functions of the respiratory and hemodynamic systems within their functional reserves. Toxic phase: Characterized by the exclusion of the gastrointestinal tract from life support processes; dysfunction of the liver, kidneys; compensated metabolic changes; violation of respiratory and hemodynamic systems in the absence of functional reserves; depression or excitation of the central nervous system. Terminal phase: generalized lesions of hemodynamics and hemostasiological disorders; ineffectiveness of spontaneous breathing; damage to the central nervous system; discrediting the metabolism and turning off the liver and kidneys from life support processes; oppression of the general and immune reactivity of an organism. In newborns and young children, by the end of the first day of the onset of peritonitis, it is possible to identify signs of the terminal phase. With postoperative peritonitis against the background of intensive therapy, the duration of the phases can be from several days to several weeks, which is confirmed by changes in central hemodynamics, microcirculation, and immunological reactivity. The pathogenesis of diffuse peritonitis is a complex chain of functional and morphological changes in systems and organs. Anatomical and physiological features of the child's body affect the course of appendicular peritonitis - intoxication and metabolic disorders increase faster, many protective reactions become pathological. The leading role in the pathogenesis of peritonitis belongs to the microbial factor and the immunoreactivity of the body. In most cases, peritonitis is a polymicrobial disease. The dominant role in its development belongs to E.Coli, enterococci, Klibsiella, etc., as well as anaerobes. One of the leading factors in the development of pathophysiological changes that occur with peritonitis is the resorption of toxic products of purulent exudate from the abdominal cavity by the peritoneum. It is the absorption of toxic products that causes a chain of various pathophysiological disorders, including dehydration, circulatory disorders, impaired immunological reactivity of the body, hyperthermia, acid-base disorders, metabolic disorders, and dysfunction of vital organs. In severe cases of the disease, these disorders can be considered as a manifestation of peritoneal shock. It should be borne in mind that in children under 3 years of age, protective mechanisms quickly turn into pathological ones, and general clinical symptoms prevail over local ones. Most of these disorders are manifested in clinical symptoms. In the clinical picture, abdominal, infectious-inflammatory, and adaptation syndromes can be distinguished. Abdominal Syndrome:

Visible signs of damage to the abdominal wall;

Change in skin color (hyperemia, Mondor's spots), pastosity, increased subcutaneous venous pattern of the anterior abdominal wall in newborns;

Non-localized pain in the abdomen with often detected local pain;

Passive protective muscle tension of the anterior abdominal wall;

Symptoms of peritoneal irritation;

Symptoms of mass formation, the presence of gas or liquid in the free abdominal cavity.

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GOU VPO Saratov State Medical University. V.I. Razumovsky Federal Agency for Health and Social Development (GOU VPO Saratov State Medical University of Roszdrav)

Department of Pediatric Surgery named after prof. N.V. Zakharova

abstract

Acute abdomen syndrome in children

Completed by: student of the 6th year of the 13th group

medical faculty

Romanova M. A.

Head of the department - Doctor of Medical Sciences, Professor Goremykin Igor Vladimirovich

Teacher- Krasnova Elena Ivanovna

1. Acute appendicitis in children (classification, clinic, features.)

2. Meckel's diverticulum

3. Intestinal obstruction

Bibliography

1. Acute appendicitis

1. Relevance of the problem.

a) The most common surgical pathology of the abdominal cavity in children, in which time determines the result.

b) The number of diagnostic errors at the prehospital stage is over 50-70%.

2. Morphofunctional features of the abdominal organs in children.

a) The "peak" incidence occurs at the age of 7 to 12 years (80%), and in children from 0 to 3 years the disease occurs only in 3% of cases. This is due to the funnel-shaped form of the appendix (up to 2 years); an insignificant amount of lymphoid tissue in the wall of the process (up to 1 month there are no follicles, the first 3 years - their number is small, only at 3 years reactive centers appear); V. GERLACHI is not expressed or absent at this age; the wall of the process is thin, the crypts are not expressed; nervous system immature

b) Features of the ileocecal angle - only in 60% of cases the cecum is located in the iliac fossa, in the other 40% it can be: highly located, hypermobile, located on the left.

c) The abdominal cavity is relatively small, the peritoneum has poor plastic qualities, the omentum is short (it reaches the level of the navel only by the age of 3).

In addition, in young children there is an immaturity of the central nervous system, which together leads to the rapid spread of the purulent process in the abdominal cavity and the prevalence of general symptoms over local ones in young children.

Clinical forms (Sprengel classification by A. V. Rusakov):

I) Simple - acute catarrhal appendicitis - the process looks hyperemic, edematous.

II) Destructive - phlegmonous appendicitis - the process is covered with a fibrinous-purulent layer, there is purulent contents in the abdominal cavity; gangrenous appendicitis - there are areas of gangrene on the wall of the process.

ІІІ) Perforated appendicitis - the wall of the appendix has a perforated hole, the contents in the peritoneal cavity are purulent.

ІV) Complicated: appendicular infiltrate, peritonitis.

Stages of urgent measures for acute appendicitis:

Inspection at the prehospital stage. Definition of local symptoms: Filatov, Sitkovsky, Kocher, Shchotkin-Blumberg, Obraztsov, Moskalenko).

Referral to the surgical hospital.

Additional diagnostic methods. Digital rectal examination, thermometry, pulse measurement, blood and urine tests. If necessary, ultrasound examination.

General anesthesia. Laparoscopic or open appendectomy: examination of the abdominal cavity, exclusion of Meckel's diverticulum and pathology of the pelvic organs in girls.

clinical picture.

In typical cases, acute appendicitis begins gradually. Initially, pain appears, which during the first hours of the disease is localized in the epigastric region or near the navel, and then moves to the right iliac region - the pain of the final localization (GP Krasnobaev). Localization of pain depends on the location of the process: retrocecal - pain in the lumbar region, with subhepatic - in the liver. Due to pain, older children often take a forced position: on the right side, on the back, as this reduces the tension of the mesentery and inflamed peritoneum; in the position on the left side, the pain intensifies (symptom of M. B. Sitkovsky).

Most often, the pain is constant, aching in nature. Pain is a subjective symptom, and if older children indicate pain, then small children are capricious (the equivalent of pain is a violation of behavior), restless, children refuse to eat, sleep is disturbed. Describing the behavior of young children, T. P. Krasnobaev points out: “A child with acute appendicitis does not sleep himself and does not let others sleep.”

A frequent symptom of acute appendicitis is vomiting in the first hours of the disease, which is reflex in nature. Vomiting in older children is 1-2 times, observed in 80% of cases, in 20% of cases there may be only nausea. If the process is located at the root of the mesentery, repeated vomiting is observed. In young children, in 85% of cases, vomiting is repeated.

A typical picture of acute appendicitis is characterized by subfebrile temperature, but in young children and with complicated appendicitis it is high. The symptom of "scissors" (discrepancy between pulse and temperature) is characteristic only for children of the older age group.

With catarrhal appendicitis, the tongue is usually moist, but coated with a coating at the root, with phlegmonous appendicitis, it is wet, coated all over; gangrenous changes are accompanied by dryness and furryness of the entire tongue; with peritonitis, plaque becomes massive. In 35% of cases, stool retention occurs, but in young children, the stool is liquid, frequent, in connection with which Fevre introduces the term "diarrheal appendicitis". Frequent stools can sometimes be observed in older children under conditions of the medial location of the process. Urination, as a rule, is not disturbed, but with a pelvic location of the appendix, there may be pollakiuria, which is associated with irritation of the bladder and may be accompanied by leukocyturia.

Considering the foregoing, abdominal pain is the main leading symptom, but in young children general manifestations prevail (disturbance of behavior, anxiety of the child, high temperature, repeated vomiting, frequent stools), which can incorrectly orient the doctor, forcing him to think about infectious pathology. As for newborns, the diagnostic difficulties here are so great that the diagnosis of appendicitis is made, as a rule, already during surgical intervention for peritonitis, and not in the preoperative period.

In an objective study, the recognition of acute appendicitis in children is based on the identification of three main symptoms:

1. Provoked pain;

2. defense muscles;

3. Symptoms of peritoneal irritation.

On examination, the shape of the abdomen is not changed; in the initial stages of the disease, it participates in the act of breathing. Superficial palpation of the abdomen begins with the left iliac region and is performed in a counterclockwise direction. The pain will increase with deep palpation (F. F. Filatov). When moving to the right half of the abdomen, it is necessary to monitor the child's reaction, facial expression and distract his attention with a conversation. In young patients, provoked pain is indicated by the doctor's "arm repulsion" symptom and the child's right leg pulling up.

Palpation of the abdomen reveals tension in the muscles of the anterior abdominal wall in the right iliac region (passive muscle tension) - one of the leading objective symptoms of acute appendicitis. B. P. Voznesensky, S. D. Ternovsky, T. P. Krasnobaev, emphasizing its significance, write: “Where there is no defense musculaire, there is no acute appendicitis.” For a clearer identification, it is necessary to simultaneously palpate the abdomen on both sides - both hands of the doctor parallel to the planes of the palms are placed on the anterior abdominal wall of the child (left - on the right half, right ~ on the left) and, like a “playing scale”, the doctor alternately presses from right to left , determining the difference in muscle tone. In children, a board-shaped abdomen is rarely determined, only a very moderate, but constant rigidity, tension of a "testy" consistency is noted.

The symptom of Shchetkin-Blumberg, which is detected traditionally or using sparing methods, has a diagnostic value: local pain during percussion (Mendel symptom); dosed percussion (with percussion from clearly intact areas in the direction of the focus according to A.R. Shurink, the pain intensifies).

Most of the symptoms in pediatric practice are not used. Mendel wrote: “The symptoms of appendicitis should not be counted, but weighed,” and the most important of these are pain and defense. S.Ya. Doletsky considers pain (independent and provoked) and defense to be the “diagnostic key” of acute appendicitis. There may be no symptoms of peritoneal irritation (retrocecal, retroperitoneal appendicitis, dense surrounding of the process with an omentum).

S. Ya. Doletsky introduced the concept of “negative symptoms” at the diagnostic stage: headache, muscle pain, rumbling in the abdomen, liquid and fetid stools, hyperthermia, hyperleukocytosis. The first five symptoms indicate against acute appendicitis, and the last two indicate a complication of peritonitis .

Given the difficulty of collecting an anamnesis, contact with a small child, the definition of a “diagnostic key” in babies is of paramount importance and for this purpose they resort to auxiliary examination methods:

1. Palpation by the child's hand (the child will resist deep pressure);

2. Palpation in the mother's arms (the doctor is behind the baby, who sits in the mother's arms);

3. Inspection during physiological sleep;

4. Examination during medical sleep (enema with 3% chloral hydrate, anesthesia; during sleep, active muscle tension due to the child's anxiety is leveled, and the provoked pain and passive defense musculaire remain);

5. Recto-abdominal bimanual examination (verifies pelvic appendicitis and infiltration in the lower abdomen).

Diagnosis of acute appendicitis in children of different ages.

Clinical picture with an atypical location of the appendix.

Acute appendicitis can occur with moderate pain in the right hypochondrium, without vomiting and with normal temperature or frequent loose stools and dysuric phenomena, without muscle tension. The atypical course of acute appendicitis depends primarily on the location of the appendix in the abdominal cavity.

With retrocecal intra-abdominal appendicitis, muscle tension and pain on palpation will be less than with a typical location. With the retroperitoneal location of the process, the abdomen can be soft throughout, not painful, the Shchetkin-Blumberg symptom is usually negative. In such cases, soreness and muscle tension are detected in the right lumbar region, and the pain radiates to the genitals or along the ureter.

With the pelvic location, pain is localized in the lower abdomen, above the pubis, muscle tension is absent or mild. Pain can radiate to the genitals, there are dysuric phenomena, loose stools with mucus. When involved in the inflammatory process of the bladder, urinalysis reveals leukocytes, erythrocytes, and squamous epithelium. With the subhepatic location of the appendix, its inflammation begins with pain in the right hypochondrium, muscle tension and pain on palpation and on tapping along the right costal arch are also determined here. With the reverse arrangement of the internal organs, the movable caecum or a long appendix, all clinical manifestations of appendicitis will be localized in the left side of the abdomen. With gangrenous appendicitis, the originality of the clinical picture is due to the defeat of the nervous apparatus of the appendix, which is manifested by subsiding pain in the abdomen. The abdomen is involved in the act of breathing, soft throughout, there is a slight soreness with deep palpation. Relative well-being is noted before the development of a picture of peritonitis. In such children, tachycardia that does not correspond to the degree of hyperthermia, leukocytosis with a shift of the leukocyte formula to the left can be detected.

Clinical picture in young children. The clinical picture of acute appendicitis in children under 3 years of age is characterized by a rapid onset. The child becomes restless, refuses to eat, there is repeated vomiting and a rise in temperature to 38-40 degrees. Loose stools often appear, urination is frequent and painful. On palpation of the right iliac region, the child resists examination, repels the surgeon's hand, pulls up the right leg, the child's cry intensifies significantly. It is advisable to examine young children with suspected acute appendicitis during medical or physiological sleep, when active muscle tension disappears, and passive tension due to inflammation persists.

In children with suspected acute appendicitis, a digital examination of the rectum is performed. At the same time, a sharply painful overhang and pastosity of the rectal wall can be detected, with a late admission of the child, an infiltrate is detected. An electromyographic study of the anterior abdominal wall allows an objective assessment of muscle tension. Laparoscopic examination in doubtful cases allows you to visually almost unmistakably confirm or reject the destructive process in the appendix. In the absence of acute appendicitis, laparoscopy allows in 1/3 of cases to reveal the true cause of abdominal pain.

Diagnosis of atypical forms of acute appendicitis.

Complications of acute appendicitis. With late diagnosis of acute appendicitis, one has to meet with its complications: peritonitis and appendicular infiltrate. Perforation of the appendix is ​​manifested by increased pain in the abdomen and worsening of the patient's condition.

There is repeated vomiting, the temperature rises to 39 - 40 degrees. The skin becomes pale and dry, facial features are sharpened. Peritonitis is characterized by a symptom of a discrepancy between the pulse rate and temperature. The abdomen does not participate in the act of breathing; on palpation, sharp pain and muscle tension are determined in all parts of the abdomen, more in the right iliac region. Shchetkin's symptom

Blumberg is also positive in all departments. As the intoxication increases, the child becomes adynamic, lethargic, drowsy, the intensity of abdominal pain decreases. Laboratory studies confirm the presence of a severe inflammatory process.

Appendicular infiltrate can form in older children on the 3rd - 5th day from the onset of the disease. In young children, the possibilities of limiting the inflammatory process in the abdominal cavity are insufficient due to the weak plastic properties of the peritoneum and the underdevelopment of the omentum. With the formation of an infiltrate, the intensity of pain decreases, but the effects of intoxication and high temperature persist. In the right half of the abdomen, a dense, sharply painful, tumor-like formation without clear boundaries is determined. With an atypical location of the appendix, the infiltrate can be detected in the small pelvis, the left half of the abdomen, and the right lumbar region. Dysuric phenomena and loose stools are often noted. In the blood, leukocytosis, a shift of the leukocyte formula to the left, and an increased ESR are detected.

Taking into account the difficulty of diagnosis, and especially in children, one should adhere to the tactics enshrined in the order of the Ministry of Health of Ukraine:

“Children under three years of age with vague abdominal pain should be hospitalized in a surgical hospital”, where surgeons can correctly assess the entire range of clinical symptoms, detect a “diagnostic key” and act adequately.

With untimely diagnosis, complications of acute appendicitis develop due to the destruction of the process and, first of all, this is perforative peritonitis, which, depending on the prevalence of the process, can be diffuse and local (unlimited and delimited - infiltrate, abscess). During peritonitis, three phases are distinguished (reactive, toxic, terminal according to K.S. Simonyan), the duration and severity of which mainly depend on the age of the child and the prevalence of the pathological process - the smaller the child, the faster peritonitis develops and the more pronounced the violation of the general and local state, the basis of which is progressive toxicosis and dysmetabolism against the background of morpho-functional immaturity of systems, organs and tissues. With the development of diffuse appendicular peritonitis, the child's condition is severe, the temperature rises significantly, repeated vomiting with an admixture of bile, the skin is pale, the eyes are sunken, the nose is pointed (facies Hippocrates), the tongue is dry with a coating, tachypnea and tachycardia are pronounced, the stomach does not take part in breathing, painful and tense throughout, symptoms of peritoneal irritation are pronounced, oliguria is noted, small children may have loose stools. Local peritonitis is also characterized by high fever, intoxication, but the course is milder, pain, defense musculaire and peritoneal irritation are limited, and with appendicular infiltrate, the latter is defined as a painful tumor in the right iliac region.

Treatment. Early surgical intervention remains the main principle of treatment of acute appendicitis. Appendectomy is typically carried out with immersion of the stump of the appendix under the purse-string suture, in infants - without immersion of the stump (to prevent v. Bauhini deformation and perforation of the intestine with sutures). Children with severe symptoms of intoxication, metabolic disorders need short-term and intensive preoperative preparation. The only indication for conservative treatment is the presence of a dense fixed infiltrate. Treatment consists in prescribing broad-spectrum antibiotics, retroperitoneal administration of antibiotics through a microirrigator according to the method of the department, physiotherapy procedures with anti-inflammatory effects, and active restorative therapy.

With active treatment, the reverse development of the infiltrate is noted. A child with an appendicular infiltrate should be hospitalized 1 month after completion of treatment for appendectomy. With suppuration of the appendicular infiltrate, it is necessary to open it. In the postoperative period, active antibacterial, anti-inflammatory and detoxification therapy is carried out.

After 2-3 months, an appendectomy is performed in a planned manner.

With peritonitis, a 2-3 hour preoperative preparation is carried out, aimed at detoxification and correction of impaired functions, and then laparotomy and sanitation of the abdominal cavity (removal of the appendix, washing) are performed.

Differential diagnosis.

Diseases with which it is most often necessary to differentiate acute appendicitis in children under 3 years of age:

Intestinal colic, coprostasis.

SARS, acute bronchitis, pneumonia, pleurisy.

Intestinal infection (salmonellosis, dysentery, yersiniosis, amoebiasis), dysbacteriosis, helminthic invasion.

Childhood infections - measles, rubella, scarlet fever, chickenpox.

For older children:

Diseases of the biliary system - biliary dyskinesia, acute cholecystitis.

Diseases of the urinary system - pyelonephritis, glomerulonephritis, cystitis, urolithiasis.

Diseases of the genital area in girls - vulvovaginitis, adnexitis, apoplexy and ovarian torsion, hematocolpos.

primary peritonitis.

Mezadenitis.

Crohn's disease.

Inflammation of Meckel's diverticulum.

Rheumatism, collagenoses.

Abdominal form of Schonlein's disease - Henoch. Malformations of the ileocecal angle - Jackson's membrane, spike

Leina, movable caecum.

Psychogenic abdominal pain.

2. Meckel's diverticulum

Meckel's diverticulum (ileal diverticulum) is a congenital anomaly of the small intestine associated with a violation of the reverse development of the proximal vitelline duct (the duct between the navel and the intestines), when its proximal part remains unobliterated (unclosed).

In the first weeks of intrauterine development of a person, the embryonic ducts function - vitelline (ductus omphaloentericus) and urinary (urachus), which are part of the umbilical cord. The first serves to nourish the fetus, connecting the intestines with the yolk sac, the second is the outflow of urine into the amniotic fluid. At 3-5 months of intrauterine life, the reverse development of the ducts is observed: the vitelline duct completely atrophies, turning into a middle ligament, located on the inner surface of the anterior abdominal wall. Depending on the extent and at what level the non-obliterated vitelline duct is preserved, there are:

1. Fistulas of the navel are complete and incomplete;

2. Meckel's diverticulum;

3. Enterocystoma.

This anomaly was discovered by Johann Friedrich Meckel Jr. (1781 - 1833), a German anatomist from Halle. He distinguished between two types of small bowel diverticula:

1) acquired on the mesenteric side of the small intestine, consisting only of mucosa;

2) congenital real diverticulum, capturing all layers of the wall and leaving antimesenterically.

In works published between 1808 and 1820, he pointed out that the second of these diverticula should be considered as a remnant of the ductus omphaloentericus (ductus omphalomesentericus, ductus vitellinus), argued this as follows:

One individual never has more than one diverticulum with a structure resembling that of the small intestine;

The diverticulum is always located in the distal small intestine on the antimesenteric side;

The presence of a diverticulum is often accompanied by other congenital disorders;

It is also found in animals which, in their embryonic development, have a yolk sac;

A case was recorded when the diverticulum persisted to the umbilicus.

The diverticulum arises from the embryonic communication between the yolk sac and the midgut, so various forms of total or partial persistence with or without a lumen are possible. They can be subdivided as follows.

1. Persistence of the entire duct:

* fully open;

* partly open:

a) from the intestinal side - Meckel's diverticulum,

b) on the umbilical side - omphalocele,

c) in the middle - enterocystoma;

* completely closed.

2. Persistence of a part of the duct:

* open from the umbilical side - omphalocele

* open from the intestinal side - Meckel's diverticulum

Meckel's diverticulum, with or without junction, is the most common (70% of cases). The frequency of Meckel's diverticulum, according to different authors, is 1 - 4%, the ratio of men and women is approximately 2:1, in case of complications even 5:1. 50% of cases are children under 10 years old, the rest manifest at the age of 30 years. The frequency of combination with other congenital malformations is up to 12%. There are no indications of familial occurrence.

The diverticulum averages 2 to 3 cm (1 to 26 cm) in length, can be as thick as a finger or as narrow as an appendix, and is conical or cylindrical. Usually, the diverticulum is located on the side of the ileum opposite to the mesentery (along the free edge of the intestine, anti-mesenteric), on average, at a distance of 40–50 cm (from 3 to 150 cm) from the Bauhinian valve. It can be soldered with a connective tissue cord (the remnant of the vitelline duct) to the mesentery, anterior abdominal wall, or intestinal loops.

Meckel's diverticulum is considered a true diverticulum, because in histological examination, all layers of the intestine are found in its wall. But it has been known for 100 years that heterotopically located gastric mucosa can also be found there (1882, Timmans) - the epithelium of about one third of the diverticula is classified as glandular type epithelium, capable of producing hydrochloric acid; as well as pancreatic tissue (1861, Zenker). This is the cause of one of the complications - erosion of its wall and intestinal bleeding. appendicitis meckel diverticulum intussusception

Uncomplicated diverticulum (95% of cases) is asymptomatic. An ileal diverticulum is most often discovered incidentally during a laparotomy (surgery on the abdominal organs) undertaken for another reason or in connection with the development of complications.

Complications of Meckel's diverticulum include:

* peptic ulcer with possible bleeding and perforation - 43%;

* intestinal obstruction due to strand, obturation, volvulus and intussusception - 25.3%;

* diverticulitis - 14%;

* hernia formation (often Littre's hernia - 11%);

* umbilical fistula - 3.4%;

* Tumors - 3%.

In children, peptic ulceration of islands of ectopic gastric mucosa (the adjacent ileal mucosa) occurs, which is often the cause of massive intestinal bleeding. Bleeding can occur acutely and be profuse, but chronic bleeding in small portions is also observed. These bleedings occur in full health, recur at intervals of 3-4 months, which leads to anemia, pallor, tachycardia, and collapse. The first stools are usually dark in color, in the subsequent ones dark (scarlet) blood appears without clots and mucus. Unlike gastrointestinal bleeding of other origins, Meckel's diverticulum does not cause hematemesis. A rare complication of Meckel's diverticulum is perforation by foreign bodies (particularly fish bones).

Diagnostics. Differential Diagnosis

The main method is an x-ray examination with contrasting the intestines with a suspension of barium sulfate. As an auxiliary method, ultrasound is used. Diagnosis of Meckel's diverticulum can be established by radioisotope scintigraphy with Hechnetium-99m (the so-called "Meckel scan"). At the same time, heterotopic gastric mucosa can be detected (technetium has an affinity for the parietal cells of the stomach). The sensitivity of this test in children reaches 75-100% and is somewhat lower in adults. False-positive and 25% false-negative results are obtained in 15% of cases.

With ongoing bleeding from Meckel's diverticulum, the diagnosis can be established using arteriography.

differential diagnosis.

One of the most important clinical manifestations of Meckel's diverticulum is recurrent abdominal pain (RAP). It is also characteristic of other organic diseases, as well as various functional and psychogenic disorders.

Asymptomatic diverticula should not be removed. Meckel's diverticulum is to be removed for diverticulitis, diverticulum ulcers, intestinal obstruction caused by diverticulum, navel fistulas, and also, according to a number of experts, if it is accidentally discovered during surgery. Resection of the diverticulum is performed with suturing of the intestinal wall (resectio diverticuli Meckelii).

Operation technique. After opening the abdominal cavity, the ileum is removed along with the diverticulum. If the diameter of the diverticulum is small, then the technique for removing it is no different from a conventional appendectomy. In cases where the diverticulum is wide and has a mesentery, the latter is ligated and transected, freeing the base of the diverticulum. Then a soft intestinal pulp is applied to the intestine and the diverticulum is cut off at its base. The wound of the intestine is sutured in the transverse direction to its axis with a two-row suture). The abdominal cavity is sewn up tightly.

Recently, laparoscopic diagnosis and laparoscopic treatment of Meckel's diverticulum have been most widely used all over the world.

At laparoscopy, Meckel's diverticulum, which does not have pathological changes, is found in the form of a protrusion of the ileum wall of various lengths and shapes. The diverticulum is usually located on the antimesenteric border of the intestine. Its base may be quite wide, and in these cases the diverticulum is usually short. With a narrow base, the diverticulum is often more extended.

An important diagnostic sign of a diverticulum is the presence of a well-defined feeding vascular bundle or a small mesentery. The vessel is found on one side of the diverticulum and is located in its central part. It is, as it were, flattened on the diverticulum and, giving off small branches, gradually decreases towards the apex. In the presence of a small mesentery, the diverticulum may be located along the small intestine, closely adjacent to it.

Near the diverticulum, a thin dense fibrous cord is sometimes found, extending from the mesentery of the small intestine to the parietal peritoneum in the umbilical ring. Apparently, it represents the remains of embryonic umbilical communications. With instrumental palpation, the diverticulum is soft, easily displaced and does not present any differences from the wall of the small intestine.

In pathological conditions, the diverticulum often undergoes significant changes. A bleeding diverticulum appears as a fairly dense protrusion, sometimes whitish in color. Often the diverticulum is located at the mesenteric margin. The small intestine may be deformed and, as it were, pulled up to the diverticulum.

The degree of pathological changes, apparently, is related to the duration of the bleeding ulcer of the diverticulum and its vastness. In any case, with a long history of previous intestinal bleeding, more pronounced changes in the diverticulum should be expected. Deep damage to the intestinal wall by the ulcer process leads to a pronounced perifocal reaction. The omentum and surrounding intestinal loops are soldered to the diverticulum. All this leads to the formation of a conglomerate with coarse adhesions, inside which there is a strongly deformed diverticulum with thinned walls.

In diverticulitis, pathological changes are extremely similar to those in appendicitis. Due to inflammatory infiltration of the wall, the diverticulum looks thickened, hyperemic, and may have a fibrin coating. With inflammation of the diverticulum, its fusion with the surrounding loops of the small intestine and the omentum occurs rather quickly, which is detected externally in the form of an inflammatory infiltrate.

A diverticulum involved in small bowel intussusception is usually not detected at laparoscopy. In rare cases, with a small prescription of the intussusceptum and a shallow introduction of the diverticulum, its base can be detected. However, invagination can also begin with the diverticulum itself, in which case it completely turns into the lumen of the small intestine and disappears without a trace in the depth of the intussusceptum.

The frequency of Meckel's diverticulum and its complications is very variable, as it is sometimes determined on the basis of the results of large series of autopsies, as well as findings during laparotomy, and Meckel's diverticulum can also be detected by chance. The question is whether the possible complications of resection of an incidentally found Meckel's diverticulum outweigh the 4-5% risk of complications. It is believed that 800 resections are needed to prevent fatal complications in one (!) patient.

Previously, the so-called open resection was usually performed with the closure of the wall defect with two layers of absorbable sutures. In recent years, resection is usually performed using a "stapling machine". Sometimes it is necessary to perform a block resection of the diverticulum with a part of the small intestine.

There are no data on complications of resections of accidentally detected diverticula. Under ideal circumstances, such a resection can be performed without risk, and thus it is possible to prevent a second operation due to complications in the future. On the other hand, caution is needed in patients with peritonitis, Crohn's disease, or intestinal obstruction, in which the diverticulum is located in the expanded part. The use of a "stapling device" reduces the already small risk due to the fact that the intestinal lumen is not opened. Whether to remove an accidentally discovered diverticulum or not still depends on the personal opinion of the surgeon.

3. Intestinal obstruction

In children, as in adults, acquired intestinal obstruction is divided into two main types - mechanical and dynamic. In childhood, in the group of mechanical obstruction, obturation, strangulation and intussusception of the intestine are distinguished. In turn, the cause of obstructive obstruction is often coprostasis in congenital stenosis of the rectum, Hirschsprung's disease, megacolon, or fistulous form of rectal atresia. Strangulation ileus is sometimes caused by a violation of the regression of the vitelline duct or a consequence of other malformations. Nevertheless, in pediatric surgery, one often has to deal with adhesive intestinal obstruction, intestinal intussusception, and dynamic obstruction.

Acute adhesive intestinal obstruction in children is one of the most severe and common diseases in abdominal surgery. It is important to always remember: if a child has abdominal pain, and there has been any surgical intervention on the abdominal organs in the anamnesis, it is necessary first of all to think about acute adhesive intestinal obstruction. Most often, adhesive intestinal obstruction occurs after surgery for acute appendicitis (about 80%), much less often after laparotomy with malformations of the intestine, intestinal intussusception and traumatic injuries of the abdominal organs.

To the generally accepted classification of acute adhesive intestinal obstruction (early and late, with a distinction between both acute and subacute forms), it is advisable to single out a hyperacute form of the disease in late adhesive obstruction.

The division of intestinal obstruction according to the severity of clinical manifestations largely determines the diagnostic and therapeutic tactics.

Indications for surgical intervention are determined not so much by the stage of the disease (early, late), but by its severity.

Clinic and diagnostics. The hyperacute form of adhesive intestinal obstruction is manifested by a clinical picture similar to a state of shock. In the early stages, toxicosis is noted, a rapid increase in the phenomena of exsicosis, a sharp, cramping pain in the abdomen occurs, during which the patient sometimes does not find a place for himself, indomitable vomiting appears, a pronounced increase in peristalsis. With late admission, intoxication is pronounced, profuse, congestive vomiting (fecal vomiting), "peritoneal" abdomen are noted; Intestinal peristalsis is sharply weakened or absent. This picture is most typical for strangulation obstruction.

Radiologically, clear horizontal levels (Kloyber's cups), "arches" in sharply stretched loops of the small intestine are determined.

In acute and subacute forms, the symptoms of the disease are less pronounced, but children also complain of paroxysmal pain in the abdomen; vomiting occurs, intestinal peristalsis increases. Clinical manifestations depend on the duration of the disease. In the later stages, the clinical picture is characterized by exsicosis, repeated vomiting of congestive nature, moderate bloating and asymmetry of the abdomen, more rare, but enhanced peristaltic contractions. X-ray reveals multiple horizontal levels and gas bubbles in moderately distended bowel loops. The traditional X-ray method for diagnosing acute adhesive intestinal obstruction on average requires at least 8-9 hours and only allows to confirm or exclude the fact of mechanical intestinal obstruction. Diagnostic errors in these cases lead to untimely or in vain surgical interventions. In this regard, a promising and highly informative diagnostic method is laparoscopy.

Patients with a hyperacute form of the disease are operated on an emergency basis after a short preoperative preparation.

In subacute or acute forms, treatment should begin with a set of conservative measures, including:

1) emptying the stomach (permanent probe) with periodic washing after 2-3 hours;

2) ganglion blockade;

3) intravenous stimulation of the intestine: 10% sodium chloride solution, 2 ml per 1 year of life; 0.05% solution of prozerin, 0.1 ml for 1 year of life;

4) siphon enema 30 - 40 minutes after stimulation.

At the same time, the passage of a suspension of barium sulfate through the intestine is controlled radiographically. These activities are carried out against the background of correction of homeostasis disorders, stabilization of hemodynamics, restoration of microcirculation. The use of this tactic in subacute and acute forms makes it possible to stop adhesive intestinal obstruction by conservative measures in more than 50% of patients.

Surgical treatment with the failure of conservative measures is to remove the obstacle (dissection of adhesions).

With a total adhesive process, even in the acute period, it is possible to perform complete viscerolysis and horizontal intestinal plication (Noble's operation) using medical glue without suturing.

In recent years, laparoscopy has been successfully used in the diagnosis and treatment of acute adhesive intestinal obstruction in many clinics.

The developed technique of puncture laparoscopy makes it possible to confirm or exclude the diagnosis of acute adhesive obstruction in the shortest possible time with high accuracy. Performing laparoscopic operations using the endovideo system makes it possible to stop intestinal obstruction and avoid laparotomy in more than 90% of patients with acute adhesive intestinal obstruction, which indicates a high therapeutic potential of the method.

Intussusception

Invagination - the introduction of one section of the intestine into the lumen of another - the most common type of acquired intestinal obstruction. This variant of intestinal obstruction occurs predominantly in infants (85 - 90%), especially often in the period from 4 to 9 months.

Boys get sick almost 2 times more often than girls. In children older than 1 year, intussusception is rarely observed and in most cases is associated with an organic nature (ileal diverticulum, lymphoid tissue hyperplasia, polyp, malignant neoplasm, etc.).

The disorder of the correct rhythm of peristalsis is also important, which consists in a violation of the coordination of the contraction of the longitudinal and circular muscles with a predominance of the contractility of the latter. Changes in diet, the introduction of complementary foods, inflammatory bowel diseases, including enterovirus infection, can lead to uncoordinated contraction of the muscle layers.

Invagination refers to a mixed, or combined, type of mechanical obstruction, since it combines elements of strangulation (strangulation of the mesentery of the implanted intestine) and obturation (closing of the intestinal lumen with intussusception). Depending on the localization, ileocecal (more than 95%) small intestine and large intestine intussusception are distinguished.

The term "ileocecal intussusception" is collective and is used to refer to all types of intussusception in the ileocecal angle.

Of all the forms of intussusception in this area, the ileocolon is most common, when the small intestine is introduced through the ileocecal valve (Bauginian damper) into the ascending colon.

The reasons for this topical and age-related frequency lie in a number of background factors:

1. Immaturity of the nervous system of the intestine (producing discoordination of peristalsis due to dysfunction of the longitudinal and circular muscles);

2. Immaturity v.Bauhini;

3. Long mesentery, mobile caecum;

4. Significant difference in the diameter of the large and small intestines. Less commonly, blind-colon intussusception occurs, in which the bottom of the caecum invaginates into the ascending colon along with the appendix. Isolated introduction of the small intestine into the small intestine (small intestinal intussusception) and the large intestine into the large intestine (colonic intussusception) in total is observed in no more than 2–3% of all patients with intestinal intussusception. With intussusception, the outer tube (vagina) and the inner tube (intussusception) are distinguished. The initial section of the invading intestine is called the head of the invaginate.

The immediate factors (starters) are as follows:

A. Functional:

1. Alimentary (improper introduction of complementary foods, violation of the diet);

2. Inflammatory diseases (enterocolitis, dysentery),

B. Organic:

1. Intestinal tumors;

2. Malformations of the intestines (diverticulum, doubling).

Functional reasons (95%) are triggering factors mainly at a critical age (in infants), organic (5%) - in children after one year of life.

Clinic and diagnostics. Clinical manifestations of invagination depend on its type and duration. As a result of the introduction of the intestinal wall, infringement occurs; with peristalsis, the length of the body of the intussusceptum increases, the head remains unchanged. The advancement of the invaginate due to peristalsis increasingly stretches and compresses the vessels and nerves of the mesentery. The venous outflow is disturbed, stasis, edema occurs, followed by diapedetic bleeding, edema of the intestinal wall, inflammatory changes in it, deposition of fibrin between the outer and inner cylinders, their gluing.

Intussusceptum migrates along the intestine, as a result of which it can fall out through the rectum - prolapsus invaginati. Circulatory disorders lead to necrosis of the intestine (primarily in the head of the invaginate - the zone of greatest infringement), which can lead to peritonitis. Thus, as Mondor wrote, "... the disease flies at a gallop and we clinicians should not follow it at a snail's pace."

Typical symptoms are:

Paroxysmal anxiety (equivalent to abdominal pain);

Single or double vomiting

Retention of stool and gases,

Dark spotting from the rectum

Palpable "tumor" in the abdomen.

In most cases, the disease begins suddenly, among full health and occurs, as a rule, in well-fed children.

Suddenly, the child begins to worry sharply, screaming, pushing, kicking his legs. “... The child is in great horror, his cry is carried throughout the house. It is similar to the cries of a woman in labor, but the woman blushes, and the child turns pale ”(Harris). Mondor writes that “pinching is an intra-abdominal drama to which the child reacts with such force that it terrifies parents.” Older children try to take the knee-elbow position, which is a pathognomonic sign.

An anxiety attack ends as suddenly as it begins, but repeats again after a short period of time. Typically, such vivid clinical manifestations are observed in children suffering from ileocolic implantation.

Attacks of pain at the onset of the disease are frequent with small intervals of calm (3-5 minutes). This is due to the waves of intestinal peristalsis and the promotion of invaginate inside the intestine. During the light period, the child usually calms down for 5-10 minutes, and then a new attack of pain occurs. Soon after the onset of the disease, vomiting appears, which has a reflex character and is associated with infringement of the mesentery of the invaginated area of ​​the intestine. In the later stages of the development of invagination, the occurrence of vomiting is due to complete intestinal obstruction.

The temperature most often remains normal. Only with advanced forms of invagination, an increase in temperature is noted. In the first hours, there may be a normal stool due to the emptying of the distal intestine. After some time, blood mixed with mucus leaves the rectum instead of feces. This is due to a pronounced circulatory disorder in the invaginated area of ​​the intestine; most often, the symptom appears no less than 5-6 hours after the onset of the first attack of abdominal pain.

In a number of cases, there is no bleeding throughout the entire period of the disease and is mainly observed with the blind-colic form of intussusception. This is due to the fact that in such patients there is practically no strangulation, and obturation phenomena prevail. Accordingly, the clinical manifestations in blind-colon and colonic forms of intussusception are less pronounced: there is no sharp anxiety of the child, attacks of pain in the abdomen are much less frequent and less intense. With these forms of invagination in the initial stages of the disease, vomiting is observed only in 20-25% of patients.

Examination of the abdominal cavity for suspected intestinal intussusception should be done between attacks of pain. Unlike all other forms of intestinal obstruction, intussusception does not cause bloating, especially in the first 8–12 hours of the disease. This is due to the fact that intestinal gases for some time penetrate into the lumen of the invaginate. During this period, the abdomen is soft, accessible to deep palpation in all departments. To the right of the navel, more often to the region of the right hypochondrium, one can detect a tumor-like formation of a soft elastic consistency, which is not painful on palpation. In 60% of cases, a “roller” (moderately mobile and painful) is found along the large intestine, more often in the right hypochondrium.

A symptom of Dance is revealed (desolation in the right iliac region). Since blood, a “saving sign”, appears in the first 3-6 hours only in 40% of children, as Mondor writes, “... you don’t need to wait, but you need to meet halfway”. For this, a rectal examination or an enema is performed (isotonic solution, 0.5 l).

The timing of the manifestation of these symptoms depends on the level of obstruction, the duration of the disease (the lower the obstruction, the later the vomiting becomes repeated and the earlier the discharge of stool and gases is disturbed; flatulence appears over time).

Ombredane writes: “Recognition can be done with the accuracy of an algebraic equation: signs of obstruction + blood from the anus (intestinal epistaxis) = strangulation of the intestines. This is the basic equation." The clinical picture of intussusception is so typical that Mondor says that “... the diagnosis can be made by phone”, i.e. the diagnosis can be made even by anamnesis.

The amount of blood is small, it can only be on diapers. As a rule, blood is mixed with mucus, has the character of "currant jelly" (Mondor). Allocations do not contain bile, pus. Mondor writes: “Blood on the diapers indicates to the doctor both the diagnosis and the therapy”, and regarding the importance of this symptom, the same author emphasizes: “Intestinal bleeding during intussusception is the main symptom. This is a threatening symptom, a terrible symptom, but it is also a beautiful, most valuable, most essential, saving symptom.

X-ray examination is of great importance for the early diagnosis of invagination. In the first 12 hours of the disease on the survey radiograph, one can see a slight decrease in intestinal pneumatization, in later periods - signs of mechanical obstruction (Kloiber cups of various sizes).

A contrast study - pneumoirrigography - is carried out in the early stages as follows. Air is carefully injected into the rectum under X-ray control using a Richardson balloon (40 mm Hg) and its gradual spread through the colon is monitored until the head of the intussusceptum is detected - a block is found for the passage of air and the shadow of the intussusceptum in the form of a “cockade”, “ sickle”, “trident”, etc.. Intussusception is clearly visible against the background of gas in the form of a rounded shadow with clear contours, more often in the region of the hepatic angle of the colon.

differential diagnosis. Intestinal intussusception is often mistaken for dysentery. However, in dysentery, the disease is preceded by a prodrome (weakness, loss of appetite, sometimes an increase in overall body temperature), during the period of a detailed clinical picture, there is a 2-3-day fever, rumbling in the abdomen, stool in the form of “rectal spit” (contains feces, pus, mucus ), “crimson jelly” (mucus with blood of a light red color due to haemorrhagia per diabrosin), while with intussusception, the disease unfolds among full health, the temperature in the first 12 hours is not increased, and the stool is dark red (“currant jelly” due to haemorrhagia per diabrosin), does not contain feces and pus.

Treatment. Invagination can be eliminated by both conservative and surgical treatment. Conservative straightening is indicated for early admission of the child to the clinic (in the first 12 hours from the onset of the disease). During a diagnostic X-ray examination, air is continued to be injected in order to straighten the intussusceptum - pneumodesivagination (under a pressure of 120 mm Hg). At the end of the examination, a gas tube is inserted into the rectum to remove excess gas from the colon. After straightening the intussusceptum, the child usually calms down and falls asleep.

Clinical criteria for the effectiveness of devagination will be:

1. Disappearance of the symptom of Dance;

2. Phenomenon of “cotton”;

3. Pressure drop on the tonometer;

4. Outgassing;

5. Regurgitation of air or the exit of the latter through a gastric tube.

The radiological criterion for the effectiveness of pneumodesiginadia is a symptom of "honeycombs" ("small air bubbles"), which is caused by the passage of air into the small intestine.

In order to finally make sure that the intussusceptum has fully expanded, the child must be hospitalized for dynamic observation and examination of the gastrointestinal tract with a barium suspension, which is given in jelly and its passage through the intestines is monitored.

Usually, in the absence of small bowel intussusception, a contrast agent is found in the initial sections of the large intestine after 3-4 hours, and after a while the barium suspension appears with the stool. The method of conservative straightening of invagination is effective on average up to 65%.

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