Gangrenous appendicitis: symptoms, consequences, operation, postoperative period

The concept of "appendicitis" is known to everyone, but few know about such a diagnosis as "gangrenous appendicitis".

Speaking of gangrenous appendicitis, they usually mean the complication of an ordinary appendix inflammation, at which processes of necrosis of the processes of the appendage begin - as a rule, this occurs on the second or third day after the onset of development of acute appendicitis. This condition is considered critical and represents a considerable threat to the patient.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10]

Epidemiology

Inflammatory processes in the appendix are recorded in five people out of a thousand. Surgery for acute appendicitis is approximately 70% of all emergency surgical interventions.

According to the latest statistics, gangrenous appendicitis is found in about 9% of all cases of acute appendicitis. The disease is equally susceptible to both men and women.

[11], [12], [13], [14], [15], [16], [17]

Causes of the gangrenous appendicitis

The main reason for the development of gangrenous appendicitis is insufficient blood supply to the appendix. Even a relatively small microcirculation disorder can cause oxygen deficiency in tissues, metabolic disorders, ischemia and necrosis.

Gangrenous appendicitis can occur in patients of any age. In old people and elderly people, pathology occurs simultaneously with a massive atherosclerotic vascular lesion. In children and young people, gangrenous appendicitis can be a consequence of birth defects in blood vessels. In addition, regardless of age, the pathology can develop as a result of increased thrombogenesis in the appendicular vessels.

Disorder of appendix cleansing processes from the contents of the intestine, additional entry of microbial infection increase the degree of danger of development of the gangrene of the appendage. Also gangrenous appendicitis can be a consequence of untreated acute purulent inflammation.

[18], [19], [20], [21], [22], [23], [24], [25], [26], [27]

Risk factors

Among the main risk factors that are considered for gangrenous appendicitis, there are:

• age from 50 years;
• tendency to thrombosis;
• atherosclerotic changes in the vessels;
• adverse heredity (if the next of kin had cases of development of gangrenous appendicitis).

Virtually all factors are related to the violation of microcirculation in patients. Disturbance of blood circulation in the appendix leads to a deterioration in the nutrition of the tissues of the appendix. With the simultaneous presence of infection or autoimmune processes, the development of gangrenous appendicitis is aggravated and accelerated.

[28], [29], [30], [31], [32], [33], [34], [35]

Pathogenesis

With gangrenous appendicitis there are processes of necrosis of the processes of the appendage.

Complete necrosis occurs relatively rarely. In most patients, the necrotic area extends to a limited part of the appendix.

The processes of necrosis are accelerated if there are deposits of fossilized feces or foreign objects inside the organ.

With macroscopic examination, the necrotic zone is characterized by a dark green color, a loose structure: such tissues are easily damaged. The portion of the appendix that has not been necrosis has the form of usual phlegmonous appendicitis.

The tissues surrounding the appendix may contain fibrinous layers. The abdominal cavity may include a purulent fluid with a characteristic "fecal" odor and an accumulation of intestinal microflora, which is determined after sowing.

When carrying out the microscopy, the damaged layers of the appendix can not be distinguished: they have all the signs characteristic of necrotic tissues. Other areas of the appendix are tissues involved in the phlegmonous inflammatory process.

Old people often develop a primary form of gangrenous appendicitis, associated with the formation of an atherosclerotic thrombus in the appendicular artery. In fact, this pathology is a kind of a heart attack of an appendix, the consequence of which is its gangrene. A similar course of the disease proceeds without a preliminary catarrhal and phlegmonous stage.

[36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46]

Symptoms of the gangrenous appendicitis

Gangrenous appendicitis occurs if treatment of acute inflammation has not been started during the first day. Since the second day of acute appendicitis, the sensitivity of the nerves is lost, and the pain can stop disturbing. Unfortunately, most patients think that their condition has returned to normal, and you can not go to the doctor. In such a situation, the danger of developing peritonitis is almost 100%.

The first signs of the onset of acute inflammation are repeated attacks of vomiting, after which there is no relief. General intoxication increases, body temperature often remains unchanged or even decreases.

The first stage of gangrenous appendicitis is called "toxic scissors": the patient's heart rate increases (about a hundred beats per minute), but there is still no increase in temperature. A typical yellow coating is found when examining the tongue.

With senile primary gangrenous appendicitis, pain in the abdomen on the right abruptly appears and also disappears sharply. At palpitation the stomach is dense and painful. The patient's condition is difficult.

If the patient does not receive the necessary medical care, then the gangrenous process is complicated by perforation - perforation of the appendix wall. At this moment the patient feels the strongest pain spreading throughout the abdominal cavity. The temperature rises, the heart rate increases, the surface of the tongue becomes dry, with a brownish coating. There is exhausting vomiting.

Gangrenous appendicitis in children

In childhood, gangrenous appendicitis, as a rule, is the end of the stage of acute appendicitis. With this type of disease there is necrosis of the shoots, there is a danger of infection in the peritoneum.

In children, the clinical picture of gangrenous appendicitis is similar to that of adults:

• diffuse pain in the abdomen;
• vomiting, after which the child does not become lighter;
• normal or even low temperature;
• thirst, dryness of the oral mucosa.

It is worth noting that in children, due to the continued growth of the body, atypical location of the intestinal process is often diagnosed - this point must necessarily be taken into account in diagnostic activities. Relatively distributed overestimation of the appendix - roughly under the liver. In a similar situation, the disease can be confused with cholecystitis. If the process is located behind the caecum, then the tension of the anterior abdominal wall may be absent, and the pain will be localized in the lumbar region.

Forms

• Acute gangrenous appendicitis is an acute inflammation with uncharacteristic symptoms for common appendicitis. Among such symptoms is a weak diffuse pain without a clear localization, which can not be probed. The pain is weakened as the destructive processes increase, and sometimes even completely disappears for a certain period of time. Vomiting and nausea are present.
• Gangrenous-perforated appendicitis happens if there is no timely assistance to a patient with acute gangrenous appendicitis. Complication is characterized by perforation of the walls and outpouring of the contents of the appendix into the abdominal cavity, after which purulent peritonitis is inevitably developing. In turn, purulent peritonitis can pass into a limited abscess, or into a widespread widespread peritonitis.
• Purulent gangrenous appendicitis is a combination of purulent inflammatory process in the intestinal process with destructive necrotic processes in it. This kind of appendicitis is the most insidious and requires the most urgent surgical intervention.

[47], [48], [49], [50]

Complications and consequences

If a patient with gangrenous appendicitis has time to operate before the moment of organ perforation, then the probability of adverse effects is practically reduced to zero. In such a situation, only a postoperative complication may occur-for example, suppuration, or wound infection.

If the patient has not had a timely operation, the consequences can be much more serious:

• perforation of the appendix with further release of pus and fecal masses into the abdominal cavity;
• auto-amputation of the appendix (retraction of the necrotic process from the intestine);
• purulent peritonitis, fecal peritonitis;
• multiple abscessing;
• septic complications;
• divergence of pyogenic infection in the circulatory system.

All of the above complications appear and grow rapidly. The patient has severe intoxication and a deficiency in the function of vital organs, which together can lead to death.

• The increased temperature after gangrenous appendicitis can normally remain for three days. If the condition does not normalize on the fourth day, then you need to look for the cause and prescribe the treatment. Why can the temperature rise? First, infection of the wound can occur. A postoperative traumatic inflammatory process may develop. In some patients, an increase in temperature is the body's response to stress - usually this condition develops in persons with weakened immunity. In order to pinpoint the cause of such complications, the doctor usually prescribes the diagnosis: a general blood test, ultrasound. In addition, antibiotic therapy will be required.
• Purulent peritonitis is a complicated course of appendicitis, in which the peritoneum is inflamed - the thinnest sheet that serves as a covering for internal organs. Purulent peritonitis occurs after rupture of the process, when the pus enters directly into the abdominal cavity. With a rupture, the patient immediately becomes significantly worse: pain from localized becomes diffuse and becomes unbearable. The patient can not rise, he lies on his side, bending over. The condition can be accompanied by vomiting, a sharp drop in blood pressure, tachycardia and an increase in temperature.

[51], [52], [53]

Diagnostics of the gangrenous appendicitis

Diagnosis of the disease sometimes causes difficulties. This is due to the frequent cases of "smoothing" of symptoms and atypical forms of appendicitis. Nevertheless, doctors follow the generally accepted diagnostic scheme:

1. Gathering anamnesis, or easier - asking the patient about the signs, location, duration of the pain syndrome, the presence of other symptoms and diseases.
2. Examination of the patient: external examination of the skin, palpation of the abdomen, assessment of signs of Shchetkin-Blumberg, Rovzing, Sitkovsky.
3. Analyzes: general blood test (leukocytosis or leukopenia accelerated by ESR), general urine analysis (needed for differentiation from urological pathology).
4. Instrumental diagnostics (ultrasound, computed tomography, radiography, laparoscopy, both diagnostic and therapeutic).

[54], [55], [56], [57], [58], [59], [60], [61], [62], [63], [64]

Differential diagnosis

Differential diagnosis is carried out with such pathological conditions:

• closed abdominal injuries with lesions of hollow or parenchymal organs;
• acute obstruction of the intestine;
• acute mezadenitis;
• acute inflammation of the pancreas, gall bladder;
• pneumococcal peritonitis;
• perforation of stomach ulcers and 12 duodenal ulcers;
• stratification of an aneurysm of the abdominal aorta;
• thromboembolism of mesenteric vessels.

In women, gangrenous appendicitis should be distinguished from ectopic pregnancy (tube rupture or tubal abortion), from ovarian apoplexy, from acute inflammation of the uterine appendages, from pelvic peritonitis and necrosis of the myomatous node.

Treatment of the gangrenous appendicitis

The only possible option for the treatment of gangrenous appendicitis is surgical intervention - removal of the appendix.

Removal of gangrenous appendicitis can be carried out in several ways:

• The standard method of appendectomy: the surgeon makes an oblique incision length of 10 to 12 cm. Through it, the outgrowth is released and removed, after which the doctor puts seams on the cecum. The operation is always accompanied by a revision of the cavity and the installation of drainage devices.
• The method of transluminal appendectomy involves carrying out a puncture transvaginally (in the vaginal wall) or transgastral (in the wall of the stomach), after which the surgeon applies a special elastic instrument.
• Laparoscopy - today it is the most popular method, in which three punctures are carried out in the abdominal wall - near the navel, between the pubis and the navel, in the right ileal region. Laparoscopic access allows you to assess the condition of all internal organs, remove gangrenous appendicitis, remove spikes. This method is less traumatic for the patient, and healing takes place as soon as possible.

It is up to the doctor to determine the exact way to perform the operation, first of all, on the availability of the necessary equipment and instruments in the hospital.

Recovery after gangrenous appendicitis

In the recovery period, the patient is prescribed drug therapy, physiotherapy, exercise therapy, manual therapy.

Typically, these drugs are prescribed:

• Antibiotics:
  • cephalosporin series (Ceftriaxone, Cefixime);
  • fluoroquinolone series (Levofloxacin, Ofloxacin).
• Analgesics:
  • narcotic analgesics (promedol);
  • non-narcotic analgesics (Baralgin, Ibuprofen).
• Infusion solutions:
  • glucose solution;
  • isotonic sodium chloride solution;
  • reosorbylact.
• Drugs that prevent thrombogenesis (heparin).

Nutrition after gangrenous appendicitis

Gangrenous appendicitis almost always leads to a disorder of the motor function of the intestine. If there are complications - for example, peritonitis, then the difficulties with peristalsis are only aggravated. As a result, the slowing down of food digestion processes and feces removal processes.

The diet after the operation with gangrenous appendicitis is as follows:

• The first day after surgery is actually the most "hungry" day. Most often, there is no appetite in postoperative patients. However, it is allowed to drink a small amount of pure still water, slightly boiled sweetened tea, compote, low-fat kefir. In some cases, the doctor may allow you to eat a couple of spoons of a weak chicken broth.
• If there are no complications, on the second day after the surgical intervention it is allowed to add mashed potatoes, rubbed cottage cheese, liquid cereals and soups to the ration. With a weak peristalsis and poor wound healing, the doctor can recommend dietary restrictions, as on the first day.
• On the third day in most postoperative patients, the work of the intestine resumes. If the patient has an act of defecation, then he can be recommended dietary treatment table number 5, the essence of which - in the exclusion of fatty, fried, smoked and pickled dishes, as well as in fractional and frequent meals. This principle of nutrition the patient should adhere to as long as possible - weeks and months after the operation, depending on the severity of the condition.

Postoperative period

The period after the surgical treatment of gangrenous appendicitis has significant differences from the treatment of conventional inflammation of the appendix.

• After the surgery, they must start antibiotic therapy with the use of strong antimicrobial drugs.
• The postoperative period may be accompanied by severe pain, therefore, adequate painkillers are prescribed, both non-narcotic and drug groups.
• In view of the fact that gangrenous appendicitis usually causes severe intoxication, after the operation, infusions of saline solutions, albumin, glucose solution, xylitol, etc. Are prescribed.
• To avoid the formation of blood clots in the vessels, as well as for the prevention of post-medication diseases of the digestive system, anticoagulants and preparations are prescribed to regulate the secretory activity of the stomach (omeprazole, squametel, etc.).
• Within a few days after the operation, a general blood test is performed daily.
• Every day, a dressing and washing of the drainage system in the wound is carried out.
• After normalization of the patient's health, massage, physical exercise and breathing exercises are prescribed.

Prevention

Preventive measures, first of all, should be directed to preventing infection into the circulatory and digestive system, as well as to prevent the development of diseases of the digestive tract.

It is important to establish a regular defecation, as constipation contributes to the stagnation of stool in the intestines, which can serve as an impetus to the development of gangrenous appendicitis.

In addition, it is necessary to observe the rules of intimate and personal hygiene, to eat properly and fully:

• adhere to the mode of food intake;
• Do not overeat;
• use a sufficient amount of fiber, which is contained in vegetables, fruits, dried fruits, cereals;
• Do not allow the development of dysbiosis (avoid prolonged and chaotic antibiotic intake, use sour-milk products).

[65], [66], [67], [68], [69], [70], [71]

Forecast

If the patient with gangrenous appendicitis was timely and correctly operated, then the disease prognosis can be considered positive. Workability in most patients is fully restored throughout the month.

With the development of complications - for example, with peritonitis, with the development of adhesions and intestinal obstruction - treatment can be more difficult and prolonged.

Unfavorable outcome is observed with a belated address to a doctor - in a similar situation, gangrenous appendicitis can result in even a fatal outcome.

[72], [73], [74], [75], [76], [77]