Who was the first to remove the appendix. The most common symptoms of acute appendicitis. Inferior borders of the lung

Six months before the main action, I had a dream: dad and his older brother (they have long been dead) invite me to go fishing with them. And both are in the boat, and so they persuade, they say, let's go, have a rest, it's so good on the river. And I answered them, once, a lot of things, you need to shoot a video, feed the children and everything in the same spirit. I woke up and I think it’s not good for a dream, only death came for me and seemed healthy, from which there’s no time to die. I have a graduating class, and there were still those problems with it. But in the spring, when the class passed a medical examination, I passed blood along with them for a general analysis, the ESR was very high, I thought, well, some muck must have gone up. And then May ... finally there’s no rest, I had three girls, so I had to constantly guard them so that they wouldn’t leave school before graduation, because there was absolutely nothing left.
And here is the graduation, my parting speech (they wouldn’t jinx it! I also thought), from which the majority shed tears (I can do it with a howl!). Then, in a close circle with a friend-colleague, without children, they slightly noted, only I started to feel something strange, it seemed like I was hungry, but nothing climbed, my appetite was gone, I didn’t want to eat or drink. Blamed it all on stress.
And a day later at night it twisted and bent. Pain in the stomach, no matter how it lay down, it still hurts. In the morning everything, I feel dying, they called an ambulance. I had to tell that this happened a long time ago, after graduating from the university, they thought appendicitis, but after the examination, they diagnosed it as gastritis ... Therefore, they injected me with an anesthetic injection and left. And the pain returned again, now we went to the hospital ourselves, looked at it, said on Monday for an appointment and sent it home, since one surgeon is on vacation and the other is on courses. The one who was on vacation (my namesake turned out to be) lived on our street, we went home to her in the evening. Myala looked, but said nothing.
On Monday, as it was said, for an appointment with a therapist, an ultrasound was prescribed in the upper abdomen and was assigned to a day hospital. Some diagnoses were made and treatment began. When I had an ultrasound scan, I asked her to look at the whole belly, but the aunt hurt her, “what is in the direction, then I will look.”
And here I am in the morning on injections and droppers, the pain will be relieved a little, and at home there are a lot of things to do, summer, a garden that I launched because of my graduation class. Especially weeding. I lay down and suddenly feel such relief, as if all the bad things had passed. Only on the third day after that, on Friday, I feel some kind of bump on my stomach began to grow. After the droppers, I went to the attending physician (and it should be noted that he once worked as a surgeon, but then he left due to an allergy to medical treatment, he was the head physician, and now he was in charge of the department), I say that I have something strange here (summer, the sarafan is thin, you don’t even need to be naked). He just looked, and immediately started calling ... then he drove home (it was already dinner), ordered to collect everything in the hospital, get ready for an ultrasound (drink a liter of water) ....
All collected as ordered. After dinner, for an ultrasound scan, I again got to that aunt. I look at her face, “well, now what do you say?”, the aunt is silent, drives her contraption across her stomach, and her pupils dilated so much from fear that the iris is not visible.
I came to surgery, and there the people are already in a joyful, Friday mood. “Lie down, they say, we will observe, after the weekend we will operate.”
And suddenly, literally, after 10 minutes, a nurse flies in and starts yelling that the former head physician ...... inserted them .... The operating room is already ready .... In general, let's go!
And I must say, when I was getting ready at home, I couldn’t find a normal (summer, it’s hot!) Bathrobe, well, a relative pinned me down, silk, to the floor, raspberry-pink (poisonous!) Color.
We enter the operating room with the nurse, and there are already a lot of people waiting for us. The anesthesiologist asks: “You didn’t drink or eat anything, of course?”, And it’s already weak from yourself, but I feel it smells like a weekend. “How I didn’t drink, if I had to drink a whole liter before the ultrasound.” The anesthesiologist muttered something indignantly and ran around the operating room.
The nurse says, "Take everything off." Well, I think a striptease is needed, please, I'm still young and I have nothing to hide. I undressed, hung my dressing gown on a hook on the wall, led me to some kind of gurney and, like, lie down. I imagined the operating table as large, for at least 12 people, but it turned out that it was not a table, but something like a folding bed. She began to climb the stairs, but the paint did not dry on them, their stockings stuck and remained. The nurse came up, tore off and again pulled on his feet. They quickly fixed me at four points - limbs. They walk and talk. I'm lying, examining everything with curiosity, when you get into the operating room! There was no fear. Mentally turned with a prayer to the guardian angel, and I feel here he is in front of me.
I lie naked, crucified, pigtails (long hair) hang down on both sides of my head. The surgeon and the anesthesiologist came up to check the readiness, one said to the other: “What a tender woman” ... and then the rest of the crowd pulled themselves up, the system in hand, started the countdown ... and I passed out.
....slow awakening, it’s dark, I hear only a voice, write it down, so many hours ... then, “look, look, crying” ... then I feel that my mouth is full of tubes and my throat hurts ... but I just can’t breathe, I wheeze, and inhale - I can’t exhale ... it’s already dark outside the window ... but I can’t breathe and I ask them to hit me on the cheek, laugh, clap ... I breathe !!!
Resuscitation, sister on duty, I can already talk, I chat with the nurse almost all night, but tears run in a stream, not stopping until the morning ...
In the morning the surgeon and the anesthetist showed up. They listened to the stomach, shook hands and said that she was born in a shirt. They ordered me to get up for dinner and move more ... well, they hinted at special gratitude. When I hinted at this to my husband, he broke out in such a selective obscenity (and it should be noted that he never cursed in front of me, unlike me), the essence of which, let them say thank you, is that we are not suing.
Well, then the jokes went generally jamb. The first dressing, I look at the seam and I don’t see the navel (Eva, damn it!). To the surgeon: "Where is my navel going, the pits are alone?" At first he did not understand: "I walked around you neatly." It turned out that postoperative suture I was so swollen that I couldn't find my navel. Two tubes of a meter and a half are sewn on the side. How to walk? Taught, tubes on hand and forward in your poisonous raspberry dressing gown ...
The surgeon loved to chat, out of the simplicity of his soul he laid out to me: “I cut it, I saw ... I immediately sent an ambulance for another doctor - three doctors should sign the death certificate” or “you had about 5-6 hours to live.”
In short, I was not sad, just laugh - my stomach hurts, then I adapted to tighten it with a large diaper so that I could neigh.
And in the extract there is a whole bunch of all sorts of crap: “appendicitis, infiltration (with a fist), peritonitis and gangrene of the anterior wall of the peritoneum” ... And, oddly enough, weeding saved me. It burst when it weeded, leaning over, everything spilled onto the front wall, and not all over the stomach. So if the horses die from work, then draft horses, working, live longer!

Gaspard Traversi, Operation, 1753

When we consider the frequency of diagnosis and treatment of appendicitis today, we can assume that this disease was well known in antiquity. It is expected that any treatments must have existed. However most of The history of appendicitis has been written over the past a little over a hundred years. This does not mean that this problem since the time of the "father of medicine" has not been considered.
Of course, abdominal surgery as we know it now is not an old art, and appendectomy in the modern sense also appeared not so long ago. But still. Given the high prevalence of appendicitis in both men and women, appendectomy in history should appear before at least that oophorectomy (removal of the ovary). So what's the deal? The thing is that about such an organ as " appendix Nothing was known. And how to treat what is not?

Recall that in the history of surgery, the anatomical description of the human body was practically the only source information is almost one and a half thousand years old. During these one and a half millennia, according to his works, conclusions were drawn about various diseases. The important thing is that Galen did not find the appendix. Open to examine the body Ancient Rome was forbidden and he had to examine the Barbary monkeys, which did not have an appendix. And what Galen did not describe and did not see, no one in the Middle Ages investigated. So. There was a disease, but they did not know anything about the organ.

The first person to describe the appendix was Berengario Da Carpi, professor of surgery in Pavia and Bologna (Italy). It happened only in 1522. He writes that "at the end of the caecum there is a kind of appendage, descending medially, about the thickness of the little finger and about 3 inches long." In 20 years, he will write about the appendix and supplement his description with several illustrations in his legendary seven-volume book.
It is worth saying, however, that the appendix was depicted in the sketch Leonardo Da Vinci, dated 1492, that is, 30 years earlier than Da Carpi, but the drawing was published only in the 18th century

1492. Drawing of the appendix by Leonardo da Vinci

The first author to call the appendage of the caecum "appendix" was Gabriel Fallopius in 1561.
Shortly thereafter, a Swiss anatomist and botanist (yes, everyone studied!) Kaspar Baugin described the valve in the region of transition of the ileum (small) to the caecum (large) intestine. In addition to the ileocecal valve, he also described the appendix. Rumbling in the abdomen is most often the “ileocecal valve song”. Many anatomists later on (Midi, Morgagni, Santorini, and others) did not add anything significant. Basically, they argued for a long time about the function, location options and the name of the appendix.

The appendix as the cause of the disease

The first thoughts that the process could lead to inflammation came from a German surgeon, Lorenz Geister. During an autopsy in the anatomical theater of the body of an executed criminal, in whom a small abscess was found next to the blackened appendix. An autopsy was performed in 1711, but Geister wrote about it in an article only 42 years later, in 1753.
Then there was a theory that foreign bodies were the cause of inflammation of the appendix (At autopsy, they found bones, pins, fecal stones in the appendix. Now this also occurs, but rarely).
1812 John Parkinson(J.W.K.Parkinson) for the first time recognized perforation of the appendix as a cause of death (not as a fact of a foreign body).

At the end of the 18th century, the microanatomy of the appendix was fairly well studied: its three layers, the presence of mucous glands, the mesentery, and the folds that the peritoneum forms in this area. A number of researchers worth noting due to the importance of discoveries:
— In 1847 Gerlach drew attention to the fold of the mucous membrane in the area of ​​​​the transition of the appendix to the caecum. This fold can block the exit from the appendix during inflammation. Usually 1-2 such folds are revealed. Now they are called Gerlach valves.
- Study Lockwood, 1891, who counted about 150 lymphatic follicles in the appendix.
- Next year clado described the fold of peritoneum running from the ovary to the appendix as an extension of his mesentery.

It was all about anatomy. And now about the clinic. As with microbes that they saw through a microscope, they did not understand that they cause diseases for a long time. Same with the appendicitis clinic.

How was appendicitis described in history

Since there was no specialization at the dawn of medicine as such, a description of a disease similar in symptoms to appendicitis can be found in different doctors. For example, in the "Hippocratic Miscellany" there is a description of "severe suppuration around the intestines", which makes many researchers think that Hippocrates knew about the appendicular abscess.

It must be understood that many of these abscesses were not associated with inflammation of the appendix. But this is the most common cause inflammation in the right iliac region. Here is how the doctor Fernelius describes and such descriptions are typical for that time (the clinic did not seem to be something serious until a large abscess formed or a serious complication in the form of intestinal obstruction began):
“A nine-year-old child suffered from diarrhea, and the grandmother, having listened to the advice of “other old women”, decided to give the child a quince. The quince fruit is known to be very tart in its green state and can help with diarrhea. Diarrhea not only disappeared, but was complicated by intestinal obstruction the very next day. A doctor was called, who applied enemas and soothed the stomach - without effect. Soon uncontrollable vomiting developed and two days later the child died. At autopsy, remains of quince were found in the cavity of the appendix. There was a perforation in the appendix blocked by quince, through which intestinal contents entered the abdominal cavity. It is curious that even those who opened such cases rarely blamed the appendix for the inflammatory process.

But what? Any appendicitis at that time is certain death? Medieval medical records (Saracen, 1642) contain a description of the illness of a woman who developed a large abscess in her right side and opened with a fistula. AT different time there are 14 descriptions of fistula formation followed by recovery (obviously there were many more recoveries).

Some doctors believed that the problem in the right iliac region was caused by intestinal obstruction and suggested that the obstruction could be removed by swallowing small lead balls. Doctors did not yet understand the essence of the problem, so there was a big debate about where the true pathology of the right iliac fossa lay. There were such terms as: "simple typhlitis", "perityphlitis", "chronic typhlitis", "apophysitis", "epityphlitis". This showed that the problem was seen in the caecum.

Reginald Heber Fitz

Such confusion reigned until 1886, when a pathologist from Boston, Reginald Heber Fitz(Reginald H. Fitz) published his famous monograph on diseases of the appendix. He showed that the symptoms of 209 cases of typhlitis (inflammation of the dome of the caecum) were identical to the symptoms observed in 257 cases of appendix perforation. This convinced the medical world of the key role of the appendix in inflammation of the caecum. The term "appendicitis" was just introduced by Reginald Fitz and soon it was widely used.

Now about the treatment of appendicitis in the past

It is clear that people have suffered from appendicitis since the dawn of mankind. For example, purulent inflammation in the right iliac fossa has been known since ancient times. The English Egyptologist and anatomist, Grafton E. Smith, examined the mummy of an Egyptian woman, "whose adhesions originated from the appendix near its apex and attached to the wall of the pelvis, which indicates old appendicitis." In the early Christian era there is a description of abscesses in the right iliac region, but surgery always postponed until last moment when suppuration was obvious. Many doctors in ancient times preferred that the abscess opened itself. And in general ... If destined, let the patient die himself, rather than the doctor having a hand in this (they could easily blame the doctor for the death of the patient, especially since we are talking about a time when they did not hear about antiseptics).

So who was the first to remove the appendix?

Or, as the hunters argue: whose shot was the last. If you are interested in the question: who was the first to perform an appendectomy and you search the World Wide Web, you will get confused very soon. To be honest, I took a long time to figure it out myself.
So, in order. Let's try to understand why doctors still argue.

It is very important to understand that "appendicitis" is what we understand it now, as individual disease doctors began to be perceived by the world community since 1886 after the report of Reginald Fitz. And of course, before this date, the treatment was carried out, but in the understanding of the surgeon, the concept of "appendicitis" was not at all. They treated "abscesses of the right iliac fossa", "peritonitis of the muscular wall", "typhlitis" (inflammation of the dome of the caecum). Or, in general, the uterus was considered the cause: "uterine abscesses."
And further.
Conservative-waiting tactics, i.e. wait until appendicitis suppurates, and only then operate was predominant until the beginning of the 20th century! That is, the doctors were waiting for a favorable outcome without surgery, if not, they operated on suppuration. In fact, appendectomy became "popular" only after the case of King Edward VII's appendicitis in 1902.
Well, one little note:
General anesthesia first appeared only in 1846, so let's try to imagine what difficulties the patient and the doctor had before that. The use of large doses of opium in the treatment of intra-abdominal inflammatory diseases was introduced in 1838 by the Irish physician William Stokes of Dublin and became the standard until the practice was challenged by surgeons 50 years later. Although the anti-peristaltic effect of opium may have helped to localize the inflammatory process in some cases of appendicitis, its main benefit was likely to be that the patient was allowed to die in peace.

And if you try to answer the question: who was the first, you need to correctly formulate it. Was first in what?

30 AD. Roman doctor Aretheus(Aretaeus Cappodocian) writes: "I myself made an incision of a colon abscess on right side, next to the liver when ran out a large number of pus that flowed out for several days, after which the patient recovered"
This is the first information that has come down to our days about the opening of an abscess of the right iliac fossa.

In the Middle Ages, there were almost no daredevils. One of these: . Only this French surgeon dared to use incisions.

1735. Claudius Amiand(Claudius Amyand), a Frenchman who, after the persecution of the Huguenots, was forced to flee with his family to England.
Claudius' patient was an eleven-year-old boy who had an inguinal hernia and a fecal fistula formed in it. Moreover, the fistula was formed from the appendix, which fell into the hernial sac and was perforated by a pin swallowed by the child. Amiand opened the hernia and removed the festering appendix. This very modest (as contemporaries spoke of him) surgeon is absolutely worthy of the right to be the first to remove the appendix. Only it was not an appendectomy in the modern sense of the word. That 1% of inguinal hernias, when the appendix enters the hernial sac, is now called the Amianda hernia.

1759. Revenge(J.Mestivier) performed an autopsy of an abscess in the right groin of a 45-year-old man who, despite treatment, nevertheless died. The cause of the inflammation was a swallowed needle that had entered the appendix.
(Mestivier J. Journ. gen. de med. et de chir., 1759, X, 441)

Just after these two cases, there were long fascinations with the theory, suggesting the obstruction of the appendix by foreign bodies.

1848 Henry Hancock(H.Hancock), London performed an autopsy of an appendicular abscess in the right iliac region in a pregnant woman. Also recommended such treatment before the onset of fluctuation or abscess formation. But despite the recovery of the patient, many doctors treated this tactic with restraint.
(Hancock H. Disease of the appendix caeci cured by operation. Lancet 1848; 2:380-381)

1852 Russian surgeon, P.S. Platonov performed an autopsy of the appendicular abscess (helped him himself) and described the operation in his doctoral dissertation "On abscesses of the ileum" (the abscess was opened, but the appendix was not removed).
(Platonov P.S. About abscesses of the ileum Military medical journal, 1854, 68, 1. p. 75)

1853 Russian surgeon, professor Petr Yurievich Nemmert made an opening of the abscess with the removal of the appendix with the imposition of a ligature. The patient was Professor V.E. Enk, who is in Pirogov's clinic. P.Yu. Nemmert, a professor at the Medical and Surgical Academy of St. Petersburg, can be considered the first to perform an appendectomy for an appendicular abscess with ligation using the ligature method. Like most foreign colleagues, Russian surgeons adopted a wait-and-see policy.

1867 Willard Parker(W.Parker), USA. The appendix was not removed, only the abscess was opened. He reported a total of four cases and advocated surgical drainage after the fifth day of illness, but without waiting for fluctuation. This surgical approach gained some recognition and was later credited with reducing mortality in appendicitis.
Parker W. An operation for abscess of the appendix vermiformis caeci. Med Rec. (NY), 1867, 2, 25-27

1880 Robert Lawson Tite(Robert Lowson Tait) opened the abscess and removed the appendix - this is probably the first appendectomy in England. The talented Lawson Tite, the leading British abdominal surgeon and gynecologist in those years, removed a gangrenous appendix to a 17-year-old girl. The patient recovered. This operation was not reported until 1890, during which time Tite became an opponent of appendectomies. Interestingly, he also had a negative attitude towards "". In The Lancet, Tait wrote: "Yes, festering occurs under the influence of microorganisms, nevertheless, the practice of prophylactic use of antiseptics interferes with wound healing and has a general adverse effect on the entire body." By the way, Lawson Tite, along with Marion Sims, are considered the "fathers of gynecology."

1883 But this year is remembered in Canada. Canadian surgeon Abraham Groves. On May 10, 1883, after examining a 12-year-old boy with pain and defence in the right lower quadrant of the abdomen, he advised an operation to remove the inflamed appendix. The operation was successful and the boy recovered. Although Groves wrote several scientific papers, he only mentioned this case in his autobiography, published in 1934.

1884 This figure in the English-language literature is most often found as the date of the first appendectomy. Independently, an English surgeon Frederic Magomed(F.Mahomed) and German - Abraham Kronlein(Abracham Kronlein). However, in the same English-language literature there is a clarification (Trans Clin Soc Lond 1884-1885,18,285) that Frederick Magomed planned the operation, and the sire operated Charters James Symond(sir Charters James Symonds). That Simond, that Krenlein opened an appendicular abscess, then removed the appendix, bandaging it with a ligature. But we remember Peter Nemmert, who performed a similar operation 31 years before, right?

1886 R.J. Hall Surgeon Richard John Hall from the Roosevelt Hospital in New York operated on a 17-year-old boy with an irreducible inguinal hernia. The hernia was found to contain a perforated appendix. It was successfully removed and the pelvic abscess drained. How similar it is to the clinical case faced by Claudius Amiand 150 years ago!
Hall RJ. Suppurative peritonitis due to ulceration and suppuration of the vermiform appendix; laparotomy; resection of the vermiform appendix; toilette of the peritoneum; drainage; recovery. NY Med J, 1886, 43,662-662.

1887 Thomas Morton(Th.G. Morton), founding member of the American Surgical Association of Philadelphia, performed a successful appendectomy with abscess drainage in 1887 on a 27-year-old patient. Ironically, Morton's brother and son had previously died of acute appendicitis.

1889 A.A.Bobrov removes part of the appendix from the appendicular infiltrate

1894 P.I. Dyakonov was the first in our country to successfully remove the appendix from a child.

1897 G.F. Zeidler in 1897, Zeidler is considered the first in Russia to remove the appendix from a pregnant woman.

New in appendectomy associated with the name of the gynecologist Kurta Semma, who removed his appendix in 1981.

Finally

The development of methods for the treatment of acute appendicitis in history is the merit of a team of doctors from different countries, the consolidation of experience.
The "appendicitis race" began at the end of the 19th century. There were heated discussions: who was the first?
So, abscesses of the iliac fossa were opened two millennia ago. The works of the Roman physician Areteus, who opened the abscess of the iliac fossa as early as 30 AD, have come down to us. The first to remove the process in 1735 was Claudius Amiand, a Frenchman living in England. Still, he was the first, although the essence of the disease was not understood then, and the appendix appeared before him as an artifact during the opening of an inguinal hernia. The first to open an abscess of the iliac fossa and performed an appendectomy was our compatriot, Pyotr Yurievich Nemmert, in 1853 (and although the purulent appendix was removed as an artifact, the goal was to drain the abscess). The first Scot in England - Lawson Tight, 1880, a talented gynecologist, however, reported this to the world community only a few years later. The first Canadian - Abraham Groves, 1883, alas, also announced his clinical case only in 1932. The first German - Abraham Kronlein (also opened an abscess with subsequent removal of the process, like Nemmert) 1884. The first in the US was Richard John Hall in 1886. The first to remove the appendix laparoscopically was the gynecologist Kurt Semm in 1981 (although the operation technique was so complicated that only the master could repeat it).

Refused in the future due to problems with digestion in the operated in the future. The appendix is ​​needed for full development. And so, in the history of surgery, the principle - "no organ - no problem", is quite often traced))

But is it possible? We live in 2018...

Reply

1. Appendectomy is now the treatment of choice for acute appendicitis. Laparoscopically or not is a matter of equipping the hospital. There are many more laparoscopic operations now than 10 years ago.

STATE BUDGET GENERAL EDUCATIONAL INSTITUTION OF HIGHER PROFESSIONAL EDUCATION "VORONEZH STATE MEDICAL UNIVERSITY them. N.N.BURDENKO» MINISTRY OF HEALTH OF THE RUSSIAN FEDERATION

(GBOU VPO "VGMU named after N.N. Burdenko")

Department of Pediatric Surgery

Disease history

FULL NAME. supervised patient: Ivan Kupitman

Diagnosis: acute phlegmanous appendicitis

Teacher

Fulfilled

PASSPORT PART

Blood type, Rh factor: A(II) Rh(+)

FULL NAME. patient: Kupitman Ivan

Gender: male

Age: 15 years old

Diagnosis at admission: acute appendicitis

Main clinical diagnosis: acute phlegmonous appendicitis

Associated diseases: no

Complications: no.

Operation name: Appendectomy, drainage of the abdominal cavity

Pain relief: intravenous sodium thiopental (general anesthesia)

Postoperative complications: no

Outcome of the disease - recovery

COMPLAINTS OF THE PATIENT AT THE TIME OF ADMISSION

For persistent pain in the lower abdomen on the right, aching, temperature rise to 37.4°C.

ANAMNESIS MORBI (HISTORY OF PRESENT ILLNESS)

At 8 o'clock in the morning, severe persistent pain suddenly appeared in the lower abdomen on the right (intense persistent pain in the right iliac region). At home he took the drug No-Shpa, the pain did not go away. Contacted for medical care to a polyclinic at the place of residence, after which he was sent to the hospital.

On examination objectively: the patient's condition is of moderate severity, the skin is pale pink, the temperature is 37.4°C. Pulse 106 beats per minute. BP 150/80 mmHg Tongue dry, covered with white coating. The abdomen is not swollen, anterior abdominal wall participates in the act of breathing. On palpation, the abdomen is tense, sharply painful in the right iliac region. Symptoms of Sitkovsky, Bartomier-Michelson, Rovsing, Shchetkin-Blumberg are positive. Performed a general detailed blood test. With a diagnosis of acute appendicitis, the patient was hospitalized in the surgical department. An emergency operation was performed: appendectomy, drainage of the abdominal cavity. Against the background of antibacterial, symptomatic therapy, the patient's condition improved: pain syndrome body temperature returned to normal. The patient is currently in hospital.

COMPLAINTS AT THE TIME OF CURATION: slight pain in the suture area.

ANAMNESIS VITAE (LIFE HISTORY OF THE PATIENT).

Born in Voronezh as the third child. Grew and developed according to age and sex. Of the diseases transferred in childhood, he notes ARVI, chicken pox. Tuberculosis, oncological, venereal, hereditary diseases, hepatitis, diabetes denies at home and close relatives. Material and living conditions are good. The food is complete. Bad habits: no. Allergic history prosperous.

(DATA OF OBJECTIVE EXAMINATION).

General condition of moderate severity. Consciousness is clear. The position is active. Skin pale pink in color. Eyelid conjunctiva Pink colour, white sclera. Pigmentation, bruising, redness, rash, scratching, peeling, vascular "asterisks", no scars. Male pattern hair. Skin turgor is not reduced. rounded nails, pale pink. There are no edema.

Respiratory system.

Inspection chest: The chest is cylindrical. The left and right halves of the chest are symmetrical. epigastric angle is 90°. The type of breathing is mixed. The respiratory rate is 19 per minute. The rhythm of breathing is correct. Palpation of the chest: Palpation of the chest is painless. The elasticity of the chest is satisfactory. Voice jitter done the same way on both sides.

Auscultation of the lungs: Auscultation over the lungs is determined by vesicular breathing; side respiratory sounds (wheezing, crepitus, pleural friction rub) are not heard.

The cardiovascular system.

Auscultation of the heart: clear heart sounds. Heart rate-85 per minute. The heart rate is correct. Pathological noise is not auscultated. Rubbing noise of the pleura and pericardium is absent. BP 115/80 mm Hg,

The digestive system.

Appetite is normal. Taste sensations are not changed. The chair happens every day, in the morning. stools of shaped consistency, Brown color without visible impurities. Passage of gases is free, moderate.

Examination of the abdomen: On examination, the abdomen is of a normal shape, symmetrical, not swollen.

Does not participate in the act of breathing. Visible peristalsis of the gastrointestinal tract is not observed. In the iliac region there is postoperative wound, on which an aseptic bandage is applied, there are no traces of blood.

Approximate superficial palpation of the abdomen: the abdomen is soft, painless. Protective tension of the anterior abdominal wall is not detected.

Deep palpation of the abdomen: In the left iliac region is palpable sigmoid colon, soft, mobile, elastic, painless, no rumbling. There is mild pain in the right iliac region. Palpable at the level of the umbilicus transverse colon, dense, mobile, painless, does not growl.

There is no protective tension of the muscles of the anterior abdominal wall. Symptoms of Razdolsky, Rovsing, Bartomier, Sitkovsky, Obraztsov, Voskresensky, Shchetkin-Blumberg are negative.

Auscultation of the abdomen: characteristic peristaltic intestinal noises are heard. Pathological bowel sounds no.

Stomach: the greater curvature of the stomach is palpable as a smooth, smooth, painless ridge 2 cm above the umbilicus.

Liver and gallbladder: the liver is palpated along the edge of the costal arch, painless. The anteroinferior edge of the liver is rounded, soft-elastic consistency.

Liver sizes according to Kurlov:

along the right parasternal line - 7 cm; on the right midclavicular line - 7 cm; on the left costal arch - 6 cm.

The gallbladder is not palpable.

Pancreas: There are no tumor-like formations in the pancreas.

Spleen: On palpation, the spleen is not determined.

Urinary system.

Urination free, painless, 5-6 times a day. The kidneys are not palpable.

Neuropsychic status.

Consciousness is clear. The patient is correctly oriented in time and space self. Sociable, adequate, willingly makes contact. The level of intelligence is average. Speech is not disturbed, there is no dysarthria and stuttering. There were no disturbances in pain, temperature and tactile sensitivity.

Status localis :

The abdomen is rounded, symmetrical, not swollen. Visible peristalsis of the gastrointestinal tract is not observed. There is a lag in the right half of the abdomen in respiratory movements, pain and local tension of the muscles of the anterior abdominal wall in the right iliac region are noted. Symptoms of Razdolsky, Rovsing, Bartomier, Sitkovsky, Obraztsov, Voskresensky, Shchetkin-Blumberg are positive.

differential diagnosis.

Differential diagnosis of acute appendicitis should be carried out with

five groups of diseases: with diseases of the abdominal cavity,

retroperitoneal organs, with diseases of the chest,

With infectious diseases, with diseases of blood vessels and blood.

For perforated gastric ulcer or duodenum pain

appear suddenly, are sharp, extremely intense,

localized in the epigastric region, there is also a "board-like"

tension in the muscles of the anterior abdominal wall. And our patient also has pain

appeared suddenly, but were less intense and sharp,

board-like tension of the muscles of the anterior abdominal wall also does not

was observed. On palpation, pain occurred only in the right

iliac region, in contrast to a perforated ulcer in which a sharp

pain occurs in the epigastric region and right hypochondrium.

Percussion with a perforated ulcer is determined by free gas in the abdominal

cavity, percussion of our patient with acute appendicitis did not

determined. Radiographically, it is also possible to determine with a perforated ulcer

free gas in the abdominal cavity. The difference also lies in the fact that

the first hours after perforation (before the development of peritonitis) body temperature

patients remains normal, since in our case there was an increase

temperature. With a perforated ulcer, the Shchetkin-Blumberg symptom is good

determined on a vast area of ​​the epigastric region and right

hypochondrium, and in our case this symptom had limited localization in

right iliac region.

Acute cholecystitis is characterized by localization of pain in the right hypochondrium with

characteristic irradiation in right shoulder, shoulder girdle, multiple

vomiting of bile, which does not bring relief, which this patient did not have.

Pain often occurs after errors in the diet, and this patient ate

everything. On palpation of the abdomen, soreness, muscle tension and symptom

Shchetkin-Blumberg is determined in the right hypochondrium, while similar

symptoms in this patient are determined in the right iliac region. So

an enlarged, tense gallbladder is often palpated, and in our

The patient's gallbladder was not palpable. Body temperature in patients with

acute appendicitis is usually higher than in appendicitis (the patient has the most

the highest was 37.2°C).

Acute pancreatitis, the difference is that in acute pancreatitis, vomiting, as

as a rule, repeated, pains are localized in the epigastric region, very

intense, with palpation, a sharp pain is determined here,

pronounced protective tension of the abdominal muscles, the temperature is normal,

some bloating as a result of intestinal paresis. All

the above symptoms differ from the clinical picture in this

sick. With pancreatitis, pain with pressure in the left costal

spinal angle, which was not observed in this patient. pathognomonic

for acute pancreatitis, an increase in the blood and urine levels of diastase, which is not

in this patient.

Acute intestinal obstruction it is necessary to differentiate when

the cause is invagination of the small intestine into the blind, which is often observed in children.

Characteristic cramping pains, but there is no tension in the abdominal muscles, and

symptoms of peritoneal irritation are mild. On palpation determine

painless mobile formation of intussusception. Distinct symptoms

intestinal obstruction - bloating, delayed stool and

gases, with percussion of the abdomen, tympanitis is determined. Often in the rectum

detect mucus with blood.

Pleurisy and right-sided pneumonia, as they are sometimes accompanied by pain in

abdomen and tension of the muscles of the abdominal wall. Need to look carefully

patient, conduct a physical examination of the lungs, all this allows

avoid diagnostic errors. With pleuropneumonia, cough, shortness of breath, cyanosis

lips, rales in the lungs, sometimes pleural rub

Acute gastroenteritis and dysentery are more intense

cramping pains, repeated vomiting of food, diarrhea, which this

there was no patient. Also, patients indicate the reception of poor-quality

food. On palpation, it is not possible to accurately determine the place of the greatest

soreness, no tension in the muscles of the abdominal wall and symptoms of irritation

peritoneum, which contradicts the results of palpation in this patient. At

gastroenteritis and dysentery in the blood test is a normal amount

leukocytes.

Laboratory, instrumental, special studies.

Detailed blood test (+ determination of the blood group according to the AB0 and Rh-factor system):

Detailed blood test

Hemoglobin 124 g/l

Erythrocytes 3.96*10 12 /l

Leukocytes 17.3*10 9 /l

e-1, b-1, p/b - 4, s/b - 73, l - 12, m - 9.

ESR - 16 mm/h

Conclusion: Leukocytosis with a shift of the leukocyte formula to the left, an increase in ESR.

Blood type: A(II) Rh(+)

Diagnosis and its justification.

Based on the patient's complaints about persistent pain in the lower abdomen on the right, aching, fever up to 37.3 ° C, anamnesis of the disease (At 8 o'clock in the morning, severe persistent pain suddenly appeared in the lower abdomen on the right. At home, he took the drug No-Shpa, the pain did not go away, they asked for medical help at the polyclinic at the place of residence, after which he was sent to the City Clinical Hospital No. 1)

Local status: tongue dry, covered with white coating. The abdomen is not swollen, the anterior abdominal wall is involved in the act of breathing. On palpation, the abdomen is tense, sharply painful in the right iliac region. Symptoms of Sitkovsky, Bartomier-Michelson, Rovsing, Shchetkin-Blumberg are positive. And data changes laboratory research: leukocytosis, increased ESR. You can make a diagnosis: acute appendicitis.

Indications for surgery:

The presence of acute appendicitis in a patient is an indication for emergency surgery.

Scheduled for an appendectomy general anesthesia- intravenous sodium thiopental. There are no contraindications. The patient's consent to the operation was obtained.

Operation protocol:

Operation: Appendectomy, drainage of the abdominal cavity.

Under general anesthesia, after treatment of the surgical field with an antiseptic solution twice, in the right iliac region from the Volkovich-Dyakonov access, the abdominal cavity was opened in layers. The dome of the caecum with the vermiform appendix was brought into the wound, the latter measuring 12.0 x 1.5 cm, hyperemic, infiltrated, edematous. The appendix is ​​bandaged at the base, the mesentery of the appendix is ​​clamped, cut off, sutured, bandaged. The stump of the appendix is ​​immersed in the purse-string and "Z" sutures. The ileum was examined for Meckel's diverticulum - no. The abdominal cavity was revised for hemostasis and foreign bodies. A tubular irrigator was introduced into the small pelvis. The wound was sutured in layers. An aseptic bandage was applied.

Macropreparation: appendix measuring 12.0 x 1.5 cm, hyperemic, infiltrated, edematous, at the top of the fibrin overlay. Sent for histological examination.

Postoperative diagnosis: Acute phlegmonous appendicitis.

results histological examination

In the preparation - appendix, differentiation of layers is difficult, there is thrombosis of capillaries, lymphohistiocytic infiltration of the wall, mesentery. Pathological picture corresponds to the diagnosis: phlegmonous appendicitis.

Rationale for the final clinical diagnosis:

Based on the clinic of the disease in a patient, in which the following syndromes are distinguished: pain, inflammatory, dyspeptic; positive appendicular symptoms (Sitkovsky, Bartomier-Michelson, Rovsing, Shchetkin-Blumberg), taking into account intraoperative data (the appendix is ​​hyperemic, infiltrated, edematous); the results of a histological study (differentiation of the layers of the process wall is difficult, thrombosis of capillaries, lymphohistiocytic infiltration of the wall, mesentery is noted) can be put final clinical diagnosis:

Acute phlegmonous appendicitis

Appointments

1. General treatment.
2. Diet No. 1a
3. Stationary mode.
4. Antibiotic therapy (Ampicillini 1.0 x 4 times / m).
5. Painkillers, anti-inflammatory therapy
   (Sol. Ketanov 3% - 2 ml).
6. Local treatment: daily dressings, in the Sol microirrigator. Dioxydini1%-10.0
   1 per day.

Treatment:

cold on the wound painkillers:Rp.: Sol. Ketanov 3% - 2 ml D. t. d № 10 in ampoule.

1. In / m for 2 ml. 2 times a day.

antimicrobial therapy:

Rp.: Ampicillini 1,0 D. t. dNo. 25 S. 1.0 intramuscularly 4 times a day, previously diluted in 2 ml of water for injection.

Stage epicrisis:

Patient Oreshkov D.S., 15 years old, is hospitalized in the surgical department with a diagnosis of acute phlegmonous appendicitis. The patient underwent an operation: appendectomy, drainage of the abdominal cavity under general anesthesia.

AT postoperative period the patient receives anti-inflammatory therapy, against which a positive trend is noted.

On the second day, the drainage from the abdominal cavity was removed. The patient is currently in hospital. It is planned to remove the sutures on the 7th day and discharge under the supervision of a surgeon on an outpatient basis.

The prognosis for life and working capacity is favorable.

In 1961, a new Soviet Antarctic station, Novolazarevskaya, was opened. Leonid Rogozov worked at the station as a doctor on an expedition of 13 people. Unique event, which made the 27-year-old surgeon famous throughout the world, occurred on April 29 during the first wintering at the station.

1 hour 45 minutes

April 29 Leonid Rogozov felt bad. The temperature jumped, weakness and nausea, pain in the right iliac region appeared. Antibiotics did not help, and because of a strong snowstorm, they simply could not send a plane for a sick doctor.

Given all the symptoms, the surgeon realized that he had acute appendicitis, and this diagnosis required urgent surgical intervention. Rogozov's condition only worsened, it was decided to perform the operation on the spot.

Rogozov disinfected the instruments, gave instructions to his assistants and began the operation. The surgeon performed the operation in a half-sitting position, with a half-tilt to the left side. Having performed local anesthesia with a novocaine solution, Rogozov made a 12-cm incision in the right iliac region with a scalpel. Rogozov worked mainly by touch and without gloves. He removed the inflamed appendix and injected an antibiotic into the abdominal cavity. At times, the surgeon developed weakness and dizziness, but even with breaks for rest, by midnight the operation, which lasted 1 hour and 45 minutes, was completed. Within a few days, the temperature subsided, after a couple of days, the stitches were removed.

The story of the courageous feat of a surgeon Leonid Rogozova and an unusual operation became known throughout the country. By correctly diagnosing and deciding not to delay, he saved his life. To date, there is no other treatment than surgery for appendicitis. In the case of appendicitis, in no case should pain be tolerated, since this condition is fraught with complications. If the operation is not done on time, then the inflammation can develop into peritonitis - and this is a fatal complication.

Appendicitis Can't Wait

Inflammation of the appendix is ​​one of the most common diseases in abdominal surgery. It accounts for almost 70% of all abdominal surgeries. the main task patients - in time to suspect something was wrong and call an ambulance.

The appendix is ​​a mobile organ, in all people it is located in different places, and it depends clinical picture with inflammation of the appendix.

Symptoms may be similar to renal colic, cystitis, cholecystitis, and sometimes even with pneumonia.

The most common symptoms of acute appendicitis are:

• sudden pain above the navel upper divisions abdomen);
• after 2-4 hours the pain descends to the right lower part abdomen
• the pain becomes cramping and intensifies;
• there is a feeling of nausea and vomiting;
• belly swollen.

However, acute appendicitis can also hide behind atypical symptoms, for example, the patient may have diarrhea, pain in the uterine appendages (in women), toxicosis (in women in early dates pregnancy), in children often the temperature rises to 37.5. In addition, the pain may radiate to the arm or leg. If there is even the slightest suspicion of acute appendicitis, you need to call an ambulance as soon as possible.

While waiting for an ambulance, in no case should you take painkillers, apply a warm heating pad to the sore spot, drink Activated carbon and choleretic drugs, doing enemas - all this will prevent you from putting correct diagnosis and may accelerate the development of peritonitis.

At the hospital, patients are given blood tests, urinalysis, abdominal ultrasounds, and other tests to confirm the diagnosis. The operation is most often performed using laparoscopic equipment - a laparoscope with a video camera is inserted through one hole, laparoscopic clamps and scissors are inserted through others. Anesthesia is used only general, and after the operation there are practically no traces on the skin.

The absence of an appendix does not threaten a person, since its role in immune protection organisms are taken over by other organs.

Story

Even ancient surgeons drew attention to cases of inflammatory processes in the right iliac region, but they were interpreted as inflammation of the muscles or postpartum complications and were treated conservatively. The first appendectomy was done in 1735 in London, the surgeon and founder of St. George's Hospital operated on an 11-year-old boy, who soon recovered. The term "appendicitis" appeared in 1886, at the same time doctors came to the conclusion that the best treatment in this case is the removal of the appendix.

In Russia, the first operation for an appendicular abscess was performed in 1888. At the Peter and Paul Hospital, a doctor K. P. Dombrovsky three year old child bandaged the appendix at the base. In 1890 the doctor A. A. Troyanov in the Obukhov hospital in St. Petersburg, he performed the first appendectomy in Russia. But despite this, still for a long time Russian surgeons adhered to a wait-and-see approach, resorting to surgical intervention only when complications appeared. Active operation for appendicitis began only in 1909.

If the patient already has a mention in the case history of acute catarrhal appendicitis, there is no doubt - the person knows well how dangerous abdominal pain is and how it can end. However, if an operation to remove an organ has already been experienced, over time a person breathes a sigh of relief: it will not be possible to get sick a second time, which means that everything is for the better. Everyone has heard about the possibility of inflammation of the appendix (section of the gastrointestinal tract) since early childhood, but what is it and what are the features of the pathology? Let's consider it in more detail.

general information

Appendicitis is a disease whose history in surgery is perhaps the simplest and most straightforward. As soon as people understood what exactly provokes pain in the abdomen, when it became clear that inflammatory processes sooner or later overtake an impressive percentage of the population, it was decided to practice preventive measures. Perhaps, one cannot find another organ of the human body that is removed with the same high frequency, both due to the presence of a pathological process, and in its absence. As they say, "out of sight, out of mind", only in our case - not from the heart, but from the gastrointestinal tract. By removing the appendix, doctors thereby exclude the possibility of appendicitis in a person for the rest of his life. True, as it turned out, such a measure leads to certain undesirable results.

An acute variant of inflammation, called appendicitis, is a disease that occurs very, very often in the history of a surgical patient. Today, among the clients of surgeons, patients with such disorders are the most typical case. The majority of diseases require urgent intervention.

How it all began

Officially, the history of the disease "appendicitis" in patients begins in the sixteenth century. It was during that period that a case of an inflammatory process in the vermiform section of the intestinal tract was first fully described. True, medicine was rather poorly developed, so doctors did not have the tools and methods to differentiate inflammatory processes localized in the intestinal tissues and occurring in the appendix. Famous modern man the term characterizing the disease was proposed in 1886. It was during that period that the leading physicians of our world, evaluating and analyzing clinical manifestations pathologies, came to the conclusion that in an impressive percentage of cases the most effective and efficient therapeutic method- radical removal of the intestinal area, namely the worm-like element.

Statistical studies on the history of the disease "appendicitis", chronic and acute form, show that the risk group is the age group under 33 years old. No unequivocal relationship with gender was found, but certain nuances of the influence of lifestyle were found. Doctors pay attention: despite the agreed risk group, the danger of an acute form haunts any person throughout life. In progressive countries, on average, about 12% of the population underwent surgery due to appendicitis. And in Asian and African countries, such cases are rare.

Men and women: sick and healthy

Studies of various forms (catarrhal, phlegmonous, gangrenous) of appendicitis, case histories and features of its appearance made it possible to establish: among patients of clinics, women are somewhat more common than men. Statistics show that the representatives of the stronger sex are less susceptible to inflammatory processes. If the pathology develops, it proceeds similarly in all sufferers, regardless of age, but there are some specific syndromes: some appear only in women, while others are more characteristic of men.

Features of manifestation

If the patient has not yet had a history of the disease (and other forms of pathology), the man is prescribed additional specific measures to clarify the diagnosis. The classic test involves the determination of Horn's symptom: appendicitis leads to the appearance of sharp and severe pain during low pressure on the scrotum. Another classic manifestation is Laroque's symptom, which consists in involuntary raising of the testicle on the right. The phenomenon is observed both during palpation and in a calm, undisturbed state. Another specific fact is the symptom named after Britten. On the right, the testicle is pulled up, if you press on the iliac region, at the same time muscle tension. The person notes pain. If you stop the pressure, the testicle returns to its original position.

Studying information about different patients, their surgical histories, in which appendicitis is mentioned exceptionally often, it can be noted that many had positive reaction when checking the pubis. It has been established that this is inherent primarily in males: a person notes soreness in this part, sometimes completely covering the genitals. This indicates a displacement of the inflamed intestinal area into the pelvic region.

Women get sick: manifestations

AT women's history diseases with acute appendicitis, other specific manifestations of the pathological condition are usually mentioned. Studies show that the danger of the inflammatory process for women is significantly higher due to the nuances anatomical features. Every month cyclic menstruation are associated with active blood flow in the pelvic region, which leads to irritation of the intestinal mucosa, affecting the region of the appendix.

The manifestations of the pathological condition are close to many other diseases - however, this is typical for both sexes. Quite often, instead of acute appendicitis, cholecystitis or pyelonephritis, colic or intestinal obstruction are first entered into the medical history, and only after additional tests reveal an inflammatory focus in the appendix. However, such a mistake will not occur if the doctor carefully examines the patient. It must be remembered that the manifestations of appendicitis are to some extent close to the signs of conception with the attachment of the fetal egg outside the uterine cavity.

Childbearing and inflammatory processes

The period of pregnancy is difficult for many women to endure, in their cards appears great amount new records that add to the individual medical history. Appendicitis will not be an exception - it is diagnosed quite often in pregnant women. Dangers are associated with any timing and periods of gestation. Symptoms are often blurred, and it is quite difficult to determine where the inflammatory focus is localized: in the appendix or other areas of the intestinal tract.

In the history of surgery, acute phlegmonous appendicitis may appear if the patient turned to a specialist because of severe pain in the abdomen, accompanied by nausea, vomiting. Since during the period of bearing a child, such symptoms at first seem natural to women and do not disturbing, the process progresses to a severe degree before the patient receives the qualified assistance she needs. Additional difficulties are associated with the study of the body: by the fourth month, palpation of the abdomen is complicated, which means that identifying the causes of pain becomes a difficult task.

Worrisome pregnant appendicitis manifests itself as pain, but the picture as a whole can differ significantly from the classical one, which is especially evident in a retrospective study of the history of the disease with phlegmonous appendicitis or another stage. This is due to the growth of the uterus, due to which the organs nearby are displaced, which affects the caecum and its process. As in other cases, the therapeutic course for appendicitis involves urgent surgery of the patient. Pregnancy will not be a contraindication to intervention.

tender age

Appendicitis is often found in a child's medical history, and in recent decades, the frequency of such cases has increased significantly. The appendix is ​​formed by lymphoid nodules, the first of which appear already in the second week after birth, which means that an inflammatory process may begin already during this period. It can be provoked by factors that are completely uncharacteristic of adults.

In former times, there was an opinion that the vermiform appendix is ​​a rudiment that must be removed immediately after birth, so that later the person would not be disturbed by the disease. Relatively recent studies on different stages and forms (including phlegmonous) of appendicitis, case histories, showed that the appendix is ​​significant for normal operation immunity. If this section of the caecum is removed, the strength of the immune response to various dangerous factors decreases, and than earlier operation carried out, the more significantly it will affect a person's life.

Infants and minors: subtleties of the case

If acute appendicitis appeared in the child's medical history even before the child reached the age of three, it is likely that both parents and doctors had to face considerable difficulties in diagnosing and treating the disease. As is known from specialized studies, in children the problem of clarifying the diagnosis is due to the inability of the patient to explain to others where pain and what character they are. Additional problems associated with the structure child's body: the vermiform intestinal process is located differently than in an adult, fully developed person.

In babies younger than three years of age, the pain caused by appendicitis often appears in the umbilical region. It is possible to suggest that you need to show the child to the doctor before acute phlegmonous appendicitis appears in the medical history of surgery, if the child is worried, cries, behaves lethargically and is naughty. Due to appendicitis, a sick child unconsciously seeks to take the fetal position, pulling his knees up to his stomach, and usually lies on his right side. If parents notice something is wrong in time and show the child to a specialist, it will be possible to avoid serious consequences. Delay increases the risk of the condition progressing to a severe stage, which is associated with a risk of death.

Childhood diseases: in three-year-olds and older

In a child older than three years of age, appendicitis in the history of the disease can appear more than easily: it is known that many suffer from pathology. Manifestations are in many respects similar to typical adult patients. The patient feels sick and vomits, the child feels pain in the abdomen. Observation of the suffering allows you to notice that unconsciously the child bends right leg in the knee and presses it to the stomach. Having noticed such symptoms, one should not pull: the sooner it is possible to determine the inflammatory process and take measures to eliminate it, the lower the risks. A protracted pathology can provoke the death of the patient, which is especially likely due to the weakness of the young organism.

What provoked?

If a certain form is detected (including in the medical history of surgery, the doctor enters not only the features and manifestations of the case, but also the causes that provoked the pathology in a particular patient. Several factors are known that can start the inflammatory process. The walls of the appendix, as scientists have established, are formed by lymphoid structures , and the dimensions of the endangered zone are up to 10 cm long, up to a centimeter in diameter. The process is sometimes filled with various substances and is normally emptied. Violation of this process provokes congestion, as a rule, this is due to blockage of a small lumen. In children, it is often due to the proliferation of follicles of lymphoid tissue, and in adults, the cause may be too dense feces.

Blockage of the lumen creates conditions that are comfortable for pathogenic microflora, associated with a violation of the circulation of substances and an increase in local pressure. If acute appendicitis is indicated in the medical history, the person knows how the problem gradually progresses, inflammatory processes cover other parts of the intestinal mucosa, which sooner or later initiates vascular thrombosis. The walls of the process lose their integrity, the tissues are transformed into necrotic masses.

Anatomical subtleties

Probably, if the patient has a mention in the history of acute gangrenous appendicitis, a person knows from his own experience the features of the anatomical location of the zone prone to inflammatory processes. However, many people who are faced with pathology only sigh with relief after the operation, realizing that there will be no recurrence, therefore they are not interested in structural features. human body. But doctors are required to know how the appendix is ​​arranged, and where it is located, what specifics this gives to the diseases of the site.

The caecum is localized in the fossa on the right, while it is impossible to say in advance and exactly what the position of the worm-like area is. In some it is a descending variant, in others it is a lateral variant (this occurs in about one in four). Up to 20% of people live with a medially located appendix, and the rarest option is retrocecal, when the process is either localized in the peritoneal cavity or goes beyond it. The point of connection with the caecum is always constant - the nuances of the position do not play a role. Soreness associated with inflammatory processes is most pronounced in the place where the navel connects with the spine of the iliac region. The point was named after McBurney, who created the first official description clinical progress of pathology.

What provoked?

It is far from always possible to understand in a particular case, which is why a person has acute appendicitis in his medical history (gangrenous stage or any other). Doctors know several factors that trigger inflammation. Statistical studies have shown that the risk of such a condition is reduced for people who eat plant foods.

The mechanism of development of appendicitis is associated with the structural features of the site. First, there is a blockage of the area associated with certain features of life or other pathologies. This creates a comfortable environment for pathogenic microflora, which normally lives in the intestinal tract in a minimum concentration, which harms the mucosa. This is how the inflammatory process begins, forcing a person to go to the clinic, where he is urgently sent to the surgeon to remove the worm-like area.

About causes and consequences

With appendicitis in the medical history, the doctor will try to list all the possible phenomena that influenced the appearance of blockage in a particular case. It has been established that the quality of blood flow in the intestinal zone plays a role. In case of violation of the circulation of the main fluid of our body and the appearance of blood clots, the arteries are blocked, the appendix does not receive normal nutrition, the wall suffers from hypoxia, loses its ability to defend itself against pathological microflora, which means that the risk of an inflammatory process increases.

There is a higher probability of developing pathology with a lack of dietary plant fibers that stimulate the contractility of the intestinal walls. Such batteries enable the tract to be cleared of faeces. If in the history of surgery for phlegmonous appendicitis, the doctor notes that the patient in everyday life adheres to an unreasonably unhealthy diet and does not receive a normal volume of food dietary fiber, the disease can be explained by stagnation of feces and the formation of stones from this substance. Such elements block the lumen of the appendix. Less unpleasant symptom indicating malnutrition - frequent constipation. Doctors pay attention: this phenomenon in itself can provoke a blockage of the appendix.

It has been found that in some cases pathological processes associated with an allergic response. The reason is excessive activity cell structures responsible for natural protection. The appendix is ​​an element of the gastrointestinal tract, whose functionality is close to the work of the tonsils in respiratory system, and it is for this reason that an impressive percentage of it is formed by lymphoid tissue. Blockage is accompanied by the accumulation of mucous secretions, while the outflow into the intestinal tract is disturbed, and this harms the mucosa and initiates the inflammatory process.

Chronic form

Pronounced symptoms, acute pain, going to an ambulance and subsequent surgery are characteristic stages in the development of an acute form of appendicitis, but this option is not the only one. The disease can proceed in chronic mode. This happens if a person has suffered an acute inflammatory process without going to a surgeon, and timely surgery has not been performed: a secondary chronic form, constantly threatening the risk of acute relapse.

If the pathology persists in a chronic mode, acute attack will happen as soon as the conditions described above for the start of inflammation appear. With partial overlap of the process area, its inflection or adhesion, under the influence of other factors, almost immediately begins strong pain and other characteristic symptoms.

Some doctors distinguish primary chronic appendicitis, but not the entire medical community agrees with such a division. The very fact of the existence of pathology is disputed by many, since cases that can be classified in this way are extremely rare, and almost always there is a possibility medical error.

About types

Suspicion of appendicitis is sufficient reason for urgent hospitalization. Already in the clinic, doctors during the examination determine what stage of the process is and how the disease proceeds. At first they talk about the catarrhal variant. This diagnosis is made if the inflammatory process indicates itself for no more than six hours. The focus is localized in the mucosa, which swells under the influence of prostaglandins.

The next step is phlegmonous. The focus of inflammation covers the entire wall of the vermiform section of the intestinal tract. This period begins around the end of the sixth hour of symptom onset and lasts until the end of the first day. Studies show swelling of the mucous membranes of the appendix, the appearance of areas of pus discharge.

The third stage is gangrenous. It is characterized by necrotic processes in organic tissues that form the appendix. The inflammatory process spreads to nearby tissues and organs. The duration of the stage is up to three days.

Perforative - the most dangerous stage of development for the patient. The walls of the affected area lose their integrity, the contents penetrate into the peritoneal cavity. This gives rise to the inflammatory process, initiates peritonitis. If at the first steps of the disease the patient is almost always curable, the perforative stage is associated with significant risks of death.

Issues of the situation

It so happened that the first manifestations of appendicitis rarely become the basis for applying for qualified help. The person does not understand why the stomach hurts, and hopes that the symptom will pass on its own over time. Diagnostics even in clinical setting happens to be difficult. Complaints and fixation of basic manifestations suggest appendicitis, but the disease can be clarified only on the basis of the results of instrumental, laboratory studies, for which there is not always time - much depends on the severity of the patient's condition. In total, about 120 typical manifestations of appendicitis have been identified, the presence of which helps to make a diagnosis, but even checking all of them does not always allow you to immediately determine exactly in which part of the gastrointestinal tract inflammation is localized. Most reliable way detection of the focus of inflammation - laparoscopy.

It is not uncommon in modern clinics for cases when a patient is admitted in a serious condition, and the symptoms almost unequivocally point to appendicitis. The patient is referred for urgent surgery, during which it is established that the worm-like area is healthy, and typical clinical manifestations are explained by some other factor.

Surgery scheduled

Removal of the inflamed element of the intestinal tract is a classic treatment option for appendicitis. After admission to the clinic, the patient is sent for research to confirm the diagnosis, then the time of the operation is scheduled. When in doubt about the causes of pain, a person is left under observation for a while.

Removal is usually done by appendectomy. There are two options for the event. More often do open surgery requiring local or general anesthesia. Standard intervention is performed through a small incision in the wall of the peritoneum. In the presence of complications, this approach is the only acceptable one. Sanitation of the site is carried out by the method of lower median laparotomy. During the intervention and after it, the patient needs antibiotics to prevent infectious complications.

The alternative is laparoscopy. This is such a unique method of removing a worm-like area, which begins with a clarification of the diagnosis, after confirming it, the surgeon conducting the study immediately removes the diseased area. To carry out the event, a puncture is made in the wall of the peritoneum, the equipment is inserted into the abdomen. To control the actions, the doctor has a video camera, which makes it possible to examine the diseased areas, determine the diagnosis and immediately cut out the necessary areas.