Methodological recommendation of practical classes for students of the 4th
training course "Medical business"
Practical Lesson No. 1 "Acute Appendix"
Topic: Acute Appendix
The purpose of the lesson is to gain knowledge of the clinic, diagnosis,
complications and methods of treatment of patients with acute appendicitis.
Lesson Tasks:
1. Consolidate knowledge of abdominal clinical anatomy
2. Anatomy of the worm-like process
3. Causes and classification of acute appendix
4. To acquire the skills to evaluate the results of clinical, X-ray, ultrasound, laboratory
methods of studying patients with acute appendicitis.
5. Study the clinical picture in uncomplicated forms of acute appendicitis
6. Study the clinical picture in complicated forms of acute appendicitis
7. Study the principles of acute care for acute appendicitis
8. Study the principles of surgical treatment of acute appendicitis
Requirements to the initial level of knowledge.
To learn the topic, repeat:
- from the course of normal anatomy, topographic anatomy and operative surgery:
topographic anatomy of the organs of the abdomen and retroperitoneal space, synthopia,
holotopy and skeletotopy of the parenchymal and hollow organs of the abdomen, blood
supply and innervation of the parenchymal and hollow organs of the abdomen and
retroperitoneal space.
- normal and pathological physiology: the main functions of the parenchymal and
hollow organs of the abdomen and retroperitoneal space.
- normal and pathological anatomy of the worm-like process
Control questions from related disciplines:
1. Deontological basis of examination and treatment of surgical patients
2. Method of physical examination of abdominal cavity
3. Features of palpation, percussion, auscultation of the colon.
4. Intramuscular and intravenous injection technique
5. Rectal Finger Examination Technique
6. Anatomical structure of the hollow organs of the abdomen.
7. Blood supply and innervation of small and large intestines
8. Methods of abdominal drainage
9. Appendectomy technique
10. Retrograde appendectomy technique
Guided by the recommended literature, students should:
to know the topographic anatomy of abdominal and retroperitoneal organs, the
clinical picture, modern methods of clinical, laboratory and instrumental
examination, methods and methods of treating complicated and uncomplicated
forms of acute appendix. Principles of tactics at the pre-hospital stage.
Control questions on the topic:
1. What symptoms can be observed with acute appendix?
2. What is characteristic of the clinical picture of acute gangrenous appendicitis?
3. What additional methods can be used to confirm a diagnosis of acute
appendicitis?
4. What therapeutic tactics are justified in acute appendicitis?
5. In what cases do patients with acute appendicitis absolutely show general pain
relief?
6. With what diseases do you most often have to differentiate acute appendix?
7. What are the goals of rectal examination in acute appendicitis?
8. What accesses can be applied to an appendectomy operation?
9. What are the features of surgical management of acute appendicitis in pregnant
women?
An indicative basis for action in a practical lesson (IBA)
1. Prepare homework and lectures on the topic for testing.
2. Control of students' theoretical training.
3. Clinical anatomy of the abdominal and retroperitoneal organs.
4. The questions of pathogenesis and clinical picture in acute appendicitis are examined
5. The questions of clinical and instrumental diagnostics of acute appendicitis are
discussed
6. The issues of surgical treatment of complicated and uncomplicated forms of acute
appendicitis are discussed
Independent work of students under the supervision of a teacher:
Students examine in wards patients with abdominal pathology, who have
phenomena that may be characteristic of acute appendicitis, specify the general clinical
manifestations of this pathology,
Students solve situational tasks on the topic of the lesson, form a preliminary
diagnosis, carry out a differential diagnosis, determine urgent measures to provide
assistance to a surgical patient, outline an examination plan using laboratory and
instrumental methods, interpret the data obtained, outline a conservative treatment plan,
determine indications for surgical treatment, analyze the main methods of surgical
treatment, preparation of the patient for surgery, postoperative management of the
patient, possible complications in the postoperative period, patient rehabilitation and
follow-up. Form the ability to correctly fill out an outpatient card and medical history
Students draw up the solution of situational problems in writing and submit them to
the teacher for checking.
The teacher answers questions, monitors the end knowledge.
Upon completion of the lesson, students should be able to:
1. Examine a patient with acute appendicitis,
2. To identify common symptoms in acute appendicitis, to explain the reasons for their
occurrence.
3. To identify specific symptoms in acute appendicitis (various forms of the disease)
4. Draw up a plan for examining a patient with suspected acute appendicitis.
5. Determine the indications and contraindications for surgical intervention for acute
appendicitis
6. Make a plan of preoperative preparation for acute appendicitis
7. Draw up a plan of postoperative management of the patient, draw up a plan of
rehabilitation measures.
Questions for self-control:
1. Classification of acute appendicitis. Morphological characteristics of its forms.
2. Theories of the etiopathogenesis of acute appendicitis.
3. Surgical anatomy of the appendix. Relationship of clinical manifestations of acute
appendicitis with variants of anatomical location.
4. Clinical picture and symptomatology of acute appendicitis.
5. Clinic and course of acute appendicitis in pregnant women, children, the elderly.
Additional research methods.
6. Complications of acute appendicitis. Appendicular infiltration: clinic, diagnosis,
treatment principles.
7. Complications of acute appendicitis. Appendicular abscesses: causes of formation,
localization, clinic, diagnosis, treatment.
8. Differential diagnosis of acute appendicitis with acute cholecystitis.
9. Differential diagnosis of acute appendicitis with perforated duodenal ulcer
10. Complications after appendectomy. Intra-abdominal bleeding. Clinical picture,
diagnostics, treatment tactics.
Topic content:
Acute appendicitis is the most common acute surgical disease of the abdominal cavity.
Acute appendicitis - inflammation of the appendix of the cecum
There are several theories of the etiopathogenesis of acute appendicitis:
1. Angioneurotic (Rikker) - as a result of vasospasm, ischemia of the mucous
membrane develops, which leads to its permeability to microbes from the lumen of the
appendix.
2. Infectious (Ashoff) - inflammation in the appendix is caused by microbes that have
penetrated into its wall through the "weak" areas of the mucous membrane (affects).
3. The theory of stagnation - the infection enters the wall of the appendix through the
bedsores caused by fecal stones.
4. Allergic (Fisher) - the mucous membrane of the appendix is affected as a result of an
autoimmune process. Microbes penetrate through the damaged mucous membrane.
Clinical classification of appendicitis (MI Kuzin et al.).
I. Acute appendicitis
1) simple (catarrhal, superficial) appendicitis;
2) destructive appendicitis:
a) phlegmonous,
b) empyema of the appendix,
c) gangrenous,
d) perforated (perforated),
3) complicated appendicitis:
- appendicular infiltrate,
- abscessed appendicular infiltrate,
- periappendicular abscess,
- local, diffuse, diffuse peritonitis,
- peritoneal sepsis,
- pylephlebitis.
II. Chronic appendicitis (periappendicular adhesive process).
III. A process carcinoid is a benign tumor of the epithelial type at the apex of the
process; removed along with the process with a favorable outcome.
Side location
Subhepatic location
Retrocecal
Medial
Pelvic
Clinical presentation and diagnosis of acute appendicitis.
The symptoms of acute appendicitis can be divided into two groups:
1. Subjective signs - complaints and anamnestic signs.
2. Objective signs - pulse, body temperature, provoked pain, cutaneous hyperesthesia,
muscle protection, symptoms of peritoneal irritation, data of rectal and vaginal
examination, clinical analysis of blood and urine.
1. Simple (catarrhal) appendicitis - there is moderate edema and hyperemia of the
serous membrane and its mesentery. The mucous membrane is swollen, hyperemic,
loose, there may be areas of destruction of the epithelium. A transparent, odorless
serous effusion (inflammatory exudate) can be found periappendicular.
2. Phlegmonous appendicitis - the process is sharply thickened and tense, its serous
membrane is hyperemic and covered with fibrinous plaque. There is pus in the cavity of
the appendix. There is a leukocyte infiltration of the walls of the appendix, there are
ulcerations on the mucous membrane. Serous or purulent exudate in the abdominal
cavity is observed near the process.
3. Gangrenous appendicitis - a serous or purulent effusion with an unpleasant odor is
found in the abdominal cavity. The appendix is of a dirty gray color, there are areas of
necrosis of the appendix wall, rarely the entire appendix. Mucosal necrosis is more
common in the distal regions. The peritoneum next to the process with hemorrhages,
covered with fibrin. Morphologically determined ischemia of the mucous membrane,
muscle layer, serous membrane, small abscesses, punctate necrosis, thrombosis of
mesenteric vessels. It is with this form that perforation of the appendix wall and the
occurrence of local peritonitis are observed.
For the appearance of gangrene of the appendix, the preliminary stage of phlegmonous
inflammation is not necessary, with thrombosis of the mesenteric vessels or their
prolonged spasm of coins, the primary gangrene of the appendix immediately develops.
4. Perforated appendicitis - 2-3 days after an attack of acute appendicitis, purulent
fusion of the appendix wall or necrosis of the wall section with perforation may occur,
in which the appendix spills out into the abdominal cavity, which leads to local, diffuse
or diffuse peritonitis. In this case, a through defect is always found in the wall of the
appendix.
Diagnostics
1. Symptoms of provoked pain in acute appendicitis:
- Superficial palpation.
- Deep palpation
2. Checking the symptoms:
• Voskresensky's symptom - with the left hand the doctor pulls the shirt over the
bottom edge. The tips of 2-3-4 fingers of the right hand are set in the epigastric region
and during the patient's inhalation (with a relaxed abdominal wall) begin to slide
quickly with moderate pressure on the abdomen to the right iliac region and further to
the thigh. At the moment of sliding fingers, the patient notes a sharp increase in pain in
the right iliac region. There is no pain on the left.
• Mendel's symptom - the appearance of sharp pain over the area of inflammation
when tapping with the tips of 2-3-4 fingers on the abdominal wall.
• Razdolsky's symptom - with percussion of the abdominal wall, pain in the right iliac
region is determined;
• Rovzing's symptom - the appearance of pain in the right iliac region with jerky hand
movements along the abdominal wall in the left iliac region (or left mesogastrium)
• Sitkovsky's symptom - increased pain in the right iliac region in the position of the
patient on the left side.
• Bartomier-Mikhelson's symptom - increased pain on palpation in the right iliac
region in the patient's position on the left side compared to the position on the back.
• Obraztsov's symptom - Press the abdominal wall in the right iliac region until
moderate to moderate pain appears and fix the arm. Soreness increases when the patient
lifts the straightened right leg (typical for the retrocecal position of the appendix).
• Krymov's symptom - the appearance or intensification of pain in the right iliac region
when examining the external opening of the right inguinal canal with a finger.
• Blumberg symptom - inverse sensitivity, increased pain when the hand is abruptly
removed, compared to palpation.
3. Muscular protection of the abdominal wall - this is the most important of the signs
found in acute appendicitis.
4. Laboratory and instrumental research
Differential diagnosis of acute appendicitis
Differential diagnosis should take into account the most specific signs of a particular
disease:
1. Perforated stomach ulcer.
2. Acute cholecystitis.
3. Acute pancreatitis.
4. Crohn's disease, Meckel's diverticulum.
5. Acute intestinal obstruction.
6. Acute adnexitis.
7. An interrupted ectopic pregnancy.
8. Renal colic.
9. Mesentery (inflammation of the lymph nodes of the mesentery of the small intestine).
Surgical treatment of acute appendicitis is indicated at any age.
Apply an oblique Volkovich-Dyakonov incision at the McBourney point, or Lenander's
pararectal incision. In case of uncertainty in the diagnosis, a median laparotomy is often
used. It is customary to consider separately the complications of the disease itself and
complications after appendectomy.
Formulation of main diagnosis, examples:
Acute appendicitis with an indication of its shape. (Acute appendicitis is assumed.
Peritonitis, no other complications or concomitant diseases.)
• Acute appendicitis, indicating its form. Local unbounded peritonitis.
• Appendicular infiltration. (The presence of acute destructive appendicitis in the
infiltrate is assumed. There are no symptoms of peritoneal irritation and other signs of
unbounded peritonitis.)
• Gangrenous appendicitis in dense infiltration. Periappendicular abscess with a
breakthrough into the abdominal cavity. Spilled purulent fecal peritonitis. Severe
abdominal sepsis. Septic shock
Classification of complications of acute appendicitis (V.I. Kolesov)
1. Complications of the preoperative period:
- appendicular infiltration;
- abscessed appendicular infiltrate;
- periappendicular abscess;
- local (limited), diffuse, diffuse peritonitis;
- peritoneal (abdominal) sepsis.
2. Complications after appendectomy.
Can be early, late, local and general. The causes of postoperative complications can be
associated with tactical errors (diagnostic difficulties with expectant tactics and late
surgery, inadequate drainage, etc.) and with technical errors (excessive tissue trauma
during surgery, failure of the invaginating process stump, failure of ligation of the
process stump and mesenteric vessels, and etc.).
2.1. Complications from the surgical wound:
- suppuration of the wound;
- infiltration of the anterior abdominal wall;
- hematoma in the wound;
- the divergence of the edges of the wound without the event, with the event;
- bleeding from a wound of the abdominal wall;
- ligature fistulas (late complications);
- incisional hernia.
2.2. Complications in the abdominal cavity:
- intra-abdominal bleeding, suppurative hematoma in the area
- appendectomy, Douglas space;
- infiltrates and abscesses of the ileocecal region, cult abscess;
- interintestinal infiltrates and abscesses, pelvic cavity;
- dynamic obstruction, acute mechanical obstruction;
- intestinal fistulas;
- progressive peritonitis.
2.3. Common complications after appendectomy:
- thrombophlebitis and phlebothrombosis of the lower extremities;
pulmonary embolism;
- thrombosis and embolism of the mesenteric vessels;
- pylephlebitis, sepsis.
Classification of complications according to the scheme adopted in the clinic:
I. Complications of acute appendicitis:
1) appendicular infiltration;
2) appendicular abscess;
3) peritonitis;
4) retroperitoneal phlegmon;
5) others (sepsis, pylephlebitis, liver abscess, etc.).
II. Postoperative complications (may be associated with the operation or with the
disease itself):
A. Early complications
1. Complications of abdominal wall wounds:
1) hematoma;
2) infiltration of the abdominal wall;
3) wound suppuration.
2. Complications in the abdominal cavity:
1) infiltration of the ileocecal region;
2) abscess of the iliac region and Douglas space;
3) subphrenic, interintestinal, subhepatic abscess;
4) widespread peritonitis;
5) intestinal fistulas;
6) adhesive obstruction;
7) intraperitoneal bleeding;
8) pylephlebitis, liver abscesses.
3. Complications of a general nature:
1) pneumonia;
2) cardiovascular insufficiency;
3) thrombophlebitis, thromboembolism;
4) sepsis.
B. Late complications:
1) ligature fistulas;
2) adhesive obstruction;
3) incisional hernias.
Appendicular infiltration. The appendicular infiltrate is morphologically a
conglomerate consisting of inflammatory altered bowel loops and omentum areas,
welded together by fibrinous adhesions and with the parietal peritoneum, delimiting the
inflamed vermiform appendix and the exudate accumulated around it from the free
abdominal cavity.
Appendicular infiltration occurs with late diagnosis, mainly as a result of medical errors
in the prehospital period.
1. Phase of progression of the process (3-5 days).
2. Phase of infiltration delimitation (5-9 days).
3. The phase of formation of an appendicular abscess or the phase of regression of the
infiltrate with a favorable course.
4. Phase of generalization of peritonitis.
Clinic of infiltration. Usually, 7-8 days from the onset of an attack of acute
appendicitis, a dense tumor-like formation is felt in the right iliac region, motionlessly
welded to the surrounding tissues. On palpation, the formation is painless or the patient
notes mild pain. The general condition of the patient is usually satisfactory, subfebrile
condition is noted. In the blood, leukocytosis is determined, a shift of the leukocyte
formula to the left, an increase in ESR. Clarifies the ultrasound diagnosis.
Conservative treatment is indicated in cases where the patient has a clearly palpable,
dense, almost painless infiltrate, with a satisfactory general condition of the patient,
subfebrile condition. In the hospital, they are prescribed: a strict pastel regimen, general
antibacterial therapy, physiotherapy (warmth, warm microclysters, diathermy, UHF),
retrocecal blockade according to Lubensky is carried out every other day with
novocaine and antibiotics.
Usually, the infiltrate resolves after 2-3 weeks. Clinical signs of resorption of the
infiltrate are as follows: stable normalization of body temperature, good general
condition, normalization of the white blood count and COE, painless palpation of the
abdomen and the absence of infiltration both by palpation through the anterior
abdominal wall and by rectal examination, normalization of the motor-evacuation
function of the intestine. The dynamics of resorption is monitored using a U3 scan.
Appendectomy is performed 2-3 months after resorption of the infiltrate.
In children, the infiltration is usually soft and loose, it easily separates along loose
adhesions.
Absolute appendicular infiltrate (appendicular abscess). With suppuration of the
infiltrate, an appendicular abscess occurs. Suppuration of the formed infiltrate is 1.6%
of all complications of acute appendicitis. In most cases, these are patients who
underwent conservative treatment for infiltration.
The appearance of symptoms characteristic of abscess formation (high temperature;
sharp local pain on palpation; local symptoms of peritoneal irritation; high leukocytosis
with a clear shift of the leukocyte formula to the left; ultrasound determined fluid
cavity) are an indication for surgery - opening and draining the abscess infiltrate.
Periappendicular abscess
The complication is found most often only during surgery. Based on the materials of our
clinic, all patients were operated on from the McBurney incision. Around the
destructive appendix in this case, a purulent exudate is determined, delimited by
adhesions and a fibrous (fibrinous) capsule. Pus (usually 60-100 ml) is removed by
aspiration or gauze napkins. Usually it is possible to make an appendectomy (in 71.8%
of patients). The wound is drained by a graduate from glove rubber and a micro irrigator
for the introduction of antibiotics into the cavity of the opened abscess. The wound is
superimposed on rare converging sutures.
For the suppuration of the formed infiltrate, the following symptoms are characteristic:
- high temperature, sharp local pain on palpation, local positive symptoms of
peritoneal irritation, high leukocytosis with a clear shift of the leukocyte count
to the left,
- Ultrasound gives a liquid or gas in abdominal cavity.
In this case, the most active tactics should be applied - an urgent operation - opening
and draining the abscess.
Peritonitis as a complication of acute appendicitis. With the spread of inflammation
to the entire thickness of the wall of the appendix, the surrounding organs and tissues
are involved in the process. More or less significant serous effusion quickly appears,
which is sterile at first. Later, with an increase in destructive phenomena, the effusion
becomes purulent, the process and the peritoneum of the adjacent organs become
covered with abundant fibrinous-purulent overlays, and the process, especially when the
process is perforated, quickly spreads along the peritoneum, more and more acquiring
the character of diffuse purulent peritonitis.
Local limited peritonitis. It is characterized by pronounced symptoms of acute
appendicitis with a positive local symptom of Shchetkin-Blumberg. In the area of the
bed of the appendix, the dome of the cecum, a serous, serous-purulent, or purulent
effusion with an unpleasant odor is found, the adjacent peritoneum is hyperemic,
covered with fibrin.
Drainage of the abscess is performed under local anesthesia and potentiated anesthesia.
Puncture and drainage of the Douglas abscess, rectotomy is performed only after bowel
preparation, as is required for any surgical intervention on this segment.
Douglas space abscess drainage through colpotomy. Colpotomy is performed after a
flawless vaginal toilet and alcohol disinfection. With the help of two vaginal mirrors,
the posterior vaginal fornix is exposed. Every day, the cavity of the abscess and vagina
is sanitized with antiseptic solutions (1% dioxidine solution, etc.), a sterile gauze swab
is changed. After the cessation of discharge from the drain, the latter is removed.
Methods for draining the abdominal cavity in acute appendicitis. Drainage of the
abdominal cavity is always necessary when there is no certainty that the process is
completely removed, when the process is removed from the abscessed infiltrate, with
local unlimited peritonitis with purulent exudate with an unpleasant odor, after removal
of the gangrenous altered process with perforation.
In cases of accumulation of a large amount of exudate in the Douglas space, it is
necessary to introduce two drains: one into the Douglas space, the other into the
abdominal cavity, not far from the site of the remote process.
Spilled purulent peritonitis (Peritonitis purulent). When formulating a diagnosis, the
main disease (destructive appendicitis) is put in the first place, and then its complication
is peritonitis, indicating the signs of classification.
The clinical manifestations of diffuse peritonitis of appendicular origin do not differ
from the manifestations of peritonitis of another genesis. The symptomatology of the
disease is determined by the virulence of the microflora, the state of the body's
reactivity, the time elapsed since the beginning of the development of the inflammatory
process in the abdominal cavity, the stage of peritonitis.
Usually, with widespread peritonitis, symptoms are expressed: pain, a positive
Shchetkin-Blumberg symptom, intoxication, tachycardia, repeated vomiting, intestinal
paresis, etc. In blood tests - high leukocytosis with a shift of the leukocyte count to the
left, a sharply increased ESR.
Treatment of diffuse and diffuse peritonitis of appendicular origin. Complex
therapy (surgical and conservative treatment) for peritonitis should be directed to:
1) to fight infection - to eliminate the source of infection in the abdominal cavity by
early surgery, effective sanitation of the abdominal cavity and drainage of the
abdominal cavity, massive antibacterial therapy;
2) to eliminate paralytic intestinal obstruction;
3) to detoxify the body;
4) to correct violations of water-electrolyte metabolism, acid-base state, protein
metabolism using massive infusion-transfusion therapy;
5) to correct dysfunction of the cardiovascular system, lungs, liver, kidneys.
Surgical intervention is performed under endotracheal anesthesia through a midline
laparotomic incision. A typical appendectomy is performed. Obligatory moments of the
operation for diffuse purulent peritonitis is intubation of the small intestine with a
nasoenteric probe for intestinal decompression. The tube can also be passed through the
rectum. With its help, fluid and gases are aspirated from the intestinal lumen, and the
intestines are periodically washed. At the end of the operation, 100-120 ml of 0.25%
novocaine solution is injected into the mesentery root of the small intestine to prevent
intestinal paresis.
Postoperative complications
1. Intra-abdominal bleeding:
- arrosive bleeding from purulent fusion of tissues, from a pressure ulcer under the
drain;
- bleeding from destroyed adhesions with insufficient hemostasis;
- bleeding from the stump of the appendix and the mesentery of the appendix during
eruption, weakening or slipping of the ligature.
The clinical manifestations of intra-abdominal bleeding depend on the caliber of the
bleeding vessel. Bleeding due to slipping of the ligature from the mesentery or from the
stump of the appendix is severe and threatens the patient's life in the first minutes of
onset. In this case, the symptoms of internal bleeding develop very quickly.
Treatment. Anti-shock and hemostatic therapy is performed. The patient can only be
saved by relaparotomy with continued bleeding. The purpose of the operation is
hemostasis of a bleeding vessel in the abdominal cavity.
2. Acute intestinal obstruction (AIO):
- pronounced perifocal inflammation in destructive forms of acute appendicitis;
- traumatization of the visceral and parietal peritoneum during surgery and the
subsequent adhesive-adhesive process in the appendectomy zone;
- rough methods of drainage of the abdominal cavity in the postoperative period;
- postoperative intestinal paresis.
The complication usually occurs on the 2-5th day of the postoperative period. The
patient's condition worsens, abdominal pain intensifies, bloating and repeated vomiting,
dry tongue, tachycardia appear. The skin and mucous membranes become bluish in
color. The characteristic symptoms of AIO appear - abdominal asymmetry, Valya's
symptom, splash symptom, visible peristalsis. In the later stages, a positive Shchetkin-
Blumberg symptom is revealed. Shortness of breath associated with displacement of the
diaphragm from bloating may occur. In blood tests, increasing leukocytosis with a shift
of the formula to the left, thickening of the blood, hypochloremia. X-ray reveals
Kloyber's bowls, the presence of arches, and transverse striation.
Treatment. With the symptoms of acute mechanical intestinal obstruction, an
emergency operation is indicated. Under endotracheal anesthesia, a midline laparotomy
is performed with a revision of the abdominal cavity and the establishment of the causes
of mechanical obstruction. Decompression of the small intestine is mandatory, with the
evacuation of intestinal contents from the adductor (nasoenteric tube, enterostomy).
3. Intestinal fistulas as a complication of appendectomy
A rare but formidable complication can occur in the postoperative period in patients
who, during the operation, have a severe pyoinflammatory and adhesive process with a
retrocecal or retroperitoneal location of the process. Appendectomy in such cases can be
technically difficult. In such a situation, due to possible avascular disorders in the
intestinal wall, a cecum fistula may form.
4. Infiltrates of the right iliac region
Infiltrates of the right iliac region occur, as a rule, in patients with destructive forms of
appendicitis. The cause of the infiltration in the postoperative period may be a strong
perifocal inflammation of the para-appendicular tissues even before the operation, the
apex of the appendix in the abdominal cavity during retrograde appendectomy, which
fell out of the appendix cavity during perforation and examined fecal stones. The
epicenter of the infiltrate can be the invaginated stump of the appendix, the place of
piercing the intestinal wall through and through when a purse-string suture is applied to
the cecum.
Clinic. Usually 3-5 days after appendectomy, dull aching pains appear in the right iliac
region. On palpation, the pain and tension of the muscles of the anterior abdominal wall
in the right iliac region is determined, in depth the formation of a densely elastic
consistency without clear contours is palpable. The body temperature rises to 37.5-38
, in the blood there is moderate leukocytosis with a shift of the formula to the left,
accelerated ESR. In more severe cases, the clinic of dynamic intestinal obstruction
joins.
Treatment. Treatment is conservative. Anti-inflammatory therapy, antibiotics,
antiplatelet agents, blockades, physiotherapy are carried out. However, an abscess of the
right iliac region may form.
5. Abscess of the right iliac region after appendectomy
An abscess usually forms 4-6 days after appendectomy, passing through the stage of
infiltration. Pains appear in the iliac region, body temperature rises, chills and sweats.
Sometimes the phenomena of dynamic intestinal obstruction are added. The appearance
of a hectic temperature, high leukocytosis, the indication of an ultrasound scan for a
liquid intra-abdominal formation does not raise doubts about the diagnosis.
Treatment. When making a diagnosis, an emergency operation is indicated - opening
and draining the abscess. In most patients, abscesses in this area are located parietally,
outward from the cecum. With a superficial location of the abscess, it is quite stupid to
dilute the postoperative wound or scar, go to the abscess cavity, sanitize and drain it.
6. Abscesses of the abdominal cavity of other localization
An abscess of the Douglas space in the postoperative period occurs with the formation
and breakthrough of a periculous abscess, with bleeding from the mesentery of the
appendix, followed by suppuration of the hematoma in the pelvic region. It can develop
with diffuse purulent peritonitis of appendicular origin due to defects in the quality of
sanitation of the abdominal cavity during surgery.
Characterized by dull pain in the lower abdomen, deterioration of the general condition,
disorders appear. The functions of the pelvic organs in the form of tenesmus diarrhea,
mucus discharge from the rectum, may be difficult or painful urination, frequent urge to
urinate, urinary retention.
During the examination, pain above the bosom is determined, there are no symptoms of
peritoneal irritation, body temperature rises, tachycardia, neutrophilic leukocytosis, shift
of the leukocyte formula to the left, accelerated ESR. Rectal examination reveals pain in
the anterior rectal wall. Vaginal examination reveals overhanging and tenderness of the
posterior fornix.
7. Interloop abscesses. As a rule, they appear as a residual abscess after diffuse
purulent peritonitis. The clinic is manifested by the phenomena of dynamic intestinal
obstruction, hectic fever, sharp pains in the abdomen, pronounced leukocytosis. On
palpation in the abdominal cavity, infiltration around the abscess is determined.
Treatment.
Laparotomy. Opening an abscess through the free abdominal cavity, which must be
carefully delimited from the purulent cavity and drained.
8. Subphrenic abscesses. Abscesses are - right - and left-sided; front and back, under
and above the liver.
Complaints of pain during inhalation in the right half of the chest and upper abdomen,
fever, tachycardia, chills, leukocytosis, accelerated ESR, anemia, significant
deterioration of the general condition (intoxication). Reactive pleurisy on the affected
side. A positive symptom of Kryukov is pain on palpation of the intercostal spaces). Xray can detect the high standing of the diaphragm and pleurisy. Ultrasound - scanning
shows a liquid cavity under the diaphragm - gas and gasless abscess.
Treatment.
To sanitize the abscess, a puncture method of treatment is used with the help of an
ultrasound scanning probe and a microcatheter passed through a puncture needle into
the abscess cavity.
9. Phlegmon of the retroperitoneal space
Clinic. There are aching pains in the right half of the abdomen and lower back, high
fever, chills. With paracolitis, the infiltrate is palpated along the ascending intestine,
along the ridge of the ilium. In advanced cases, a psoas symptom is revealed - flexion
contracture of the right hip. In blood tests, leukocytosis, accelerated ESR.
Treatment.
The incision for drainage of the phlegmon of the retroperitoneal space is made
depending on the location:
• subphrenic zone - according to Melnikov;
• lumbar region - lumbotomy;
• the right iliac region - above the pipart ligament according to Pirogov.
10. Pylephlebitis
Pylephlebitis is a purulent thrombophlebitis of the portal system. This is a rare, but
extremely serious complication of both the disease itself and appendectomy. The
inflammatory process begins in the veins of the appendix, spreads higher along the
iliocolic and superior mesenteric vein to the extra- and intraorgan branches of the portal
system with the formation of multiple liver abscesses.
The disease is characterized by: periodic high rises in body temperature (hectic fever);
tremendous chills; torrential sweats; adynamic; icteric staining of the sclera and skin;
pain in the right hypochondrium radiating to the back; enlarged liver; tachycardia up to
120 / min. In blood tests: neutrophilic leukocytosis with a shift of the leukocyte formula
to the left, progressive anemia, accelerated ESR, hyperbilirubinemia. General septic
condition. Liver abscesses (ultrasound, CT).
Treatment.
Pylephlebitis is treated with intensive antibiotic therapy. If the process is not removed,
appendectomy, necrectomy, drainage and sanitation of a purulent focus in the
abdominal cavity are indicated.
Situational tasks
Task number 1
A 36-year-old patient complained of sudden onset of pain in the right abdomen,
radiating to the groin and right lumbar region. He got sick 2 hours ago and has never
had such pains before. The pain was accompanied by a single vomiting. The patient is
restless. Temperature at admission is 37.5 ° C. Pulse 100 beats. min., tongue moist,
coated with white bloom. The abdomen in the right half is painful, the Blumberg
symptom is negative. The symptom of tapping on the right lumbar region is positive.
Leukocytosis 14.0 x 109 / l. In the general analysis of urine, traces of protein, relative
density 1.018, fresh erythrocytes 8-10 in the field of view, leached erythrocytes 1-2 in
the field of view, leukocytes 8-10 in the field of view. Was admitted to the urology
department with a diagnosis of urolithiasis, right-sided renal colic. After 3 days from the
onset of the disease, positive symptoms of Obraztsov and Blumberg appeared.
Hospitalized in the surgical department with suspicion of a surgical disease.
Questions
1) Make a preliminary diagnosis.
2) What was the reason for the diagnostic error and what research methods would help
to avoid it, their results?
3) What are the six main possible positions of the appendix?
4) What are the possible features of the clinical manifestations of acute appendicitis
depending on the variant of the appendix position?
5) Prescribe postoperative treatment.
Task number 2
Patient M., 62 years old, was admitted to the surgical department 4 days after the onset
of the disease with complaints of moderate pain in the right iliac region, an increase in
body temperature up to 37.6 ºС. From the anamnesis: 4 days ago, there was an attack of
pain in the right iliac region. Objectively: the tongue is moist, the abdomen participates
in the act of breathing, soft. On palpation in the right iliac region, a rounded formation
is determined.
Questions
1. Make a preliminary diagnosis.
2. With what is it necessary to carry out differential diagnostics?
3. What laboratory methods of research will you prescribe to the patient, the expected
results?
4. What instrumental research methods will help in making the final diagnosis?
5. Describe the tactics of treating the detected pathology.
Task number 3
A patient who was operated on for acute phlegmonous appendicitis 7 days ago had a
fever. It is hectic in nature. The patient does not notice pain in the area of the surgical
wound. Complains of soreness at the end of the act of urination, frequent urge to
defecate. Tongue dry. Pulse 110 per minute. The abdomen takes part in the act of
breathing, soft on palpation, painful in the lower parts. There are no symptoms of
peritoneal irritation. In the general analysis of blood, leukocytosis is 18.0 x 10 9 / l.
There is no inflammatory reaction in the area of the wound.
Questions
1. What complication should you think about?
2. Classification the identified complication.
3. What objective research can be done and what information will it give?
4. What instrumental studies should be used to clarify the diagnosis?
5. What is the tactics in the treatment of such a complication?
Task number 4
Patient S., 46 years old, was admitted to the surgical department with complaints of pain
in the right iliac region. From the anamnesis: considers himself ill for about 4 days.
Objectively, the patient has no respiratory and hemodynamic disturbances. In the right
iliac region, an infiltrate is palpable. The patient underwent conservative therapy,
however, after 4 days from the moment of admission to the hospital, he had pains in the
lower abdomen, the temperature took on a hectic character with ranges of up to one and
a half degrees. On examination: tongue moist, pulse 92 per minute; the abdomen is soft,
painless, except for the right iliac region, where sharp pain is determined. With digital
rectal examination, no overhang of the anterior rectal wall was found.
Questions
1. What complication did the patient have?
2. What instrumental methods can diagnose this complication - its result?
3. Define a treatment strategy?
4. If the patient should be operated on, what kind of access would be rational?
5. Prescribe postoperative treatment
Task number 5
On the 2nd day after the operation of appendectomy for acute phlegmonous appendicitis
in a 61-year-old patient, the general condition deteriorated sharply. A tremendous chill
arose, the temperature rose to 39.6 ° C, pains appeared in the right hypochondrium. In
the lungs, vesicular breathing, no wheezing. On palpation, an enlarged and painful liver
began to be determined. The abdomen remained soft, moderately painful in the right
half. In the next 2 days, tremendous chills continued, yellowness of the sclera appeared.
Leukocytosis 20 • 109 / l, ESR 43 mm / h, a sharp shift of the general blood test to the
left. X-ray changes in the chest and abdominal cavity were not revealed.
Questions
1. What complication did the patient develop?
2. Describe the cause of this complication.
3. What information can be obtained from ultrasound in this case?
4. What treatment should be given to the patient?
Task number 6
A 32-year-old patient was admitted on the 4th day of illness. Pains appeared in the right
iliac region, nausea. I did not go to the doctor, took analgesics, the pain subsided. In the
right iliac region, a dense immobile formation measuring 18x12 cm is determined,
adjacent to the iliac crest, painful on palpation. The abdomen is soft, the symptoms of
peritoneal irritation are negative; body temperature 37.8 ° C.
Questions
1. Make a preliminary diagnosis.
2. Describe the process of the formation of this disease.
3. With what diseases should the pathology revealed in the patient be differentiated
most often?
4. What laboratory tests need to be performed to make the final diagnosis and the
expected results?
5. Assign treatment to the patient.
Task number 7
A 52-year-old patient was admitted to the hospital with complaints of pain all over the
abdomen, bloating, nausea, and repeated vomiting. She fell ill about 3 days ago, when
pain appeared in the right iliac region. I did not go to the doctor, I applied a heating pad,
after a day the pain spread down, then to the whole stomach. Pale skin, pointed facial
features, body temperature 38.7 ° C, pulse 128 beats per minute, BP 100/60 mm Hg.
Tongue dry, coated with brown bloom. The abdomen is evenly distended, painful on
palpation in all parts. Shchetkin-Blumberg's symptom is positive in all departments. A
positive symptom of Voskresensky. Intestinal peristalsis is not audible.
Questions
1. Make a preliminary diagnosis.
2. What are the main laboratory tests should be performed before the operation in the
patient, their expected results?
3. Assign the patient's preoperative preparation. How long can it be spent?
4. Prescribe premedication and prescribe medications, method of pain relief.
5. What are the main stages of the operation that should be performed on the patient.
Task number 8
A 24-year-old female patient was operated on for acute catarrhal appendicitis (simple).
Already 3 hours after the operation, she began to notice increasing weakness, dry
mouth. On the second day after the operation, when trying to sit up in bed, a collapse
occurred. The patient is pale. Pulse 124 beats. in min. BP 90/60 mm Hg. The abdomen
is painful on palpation in the area of the surgical wound, in the lower half, where the
weakly positive Shchetkin-Blumberg symptom is determined. When percussion above
the bosom, there is a dullness of the percussion sound. The patient urinated in the
morning, enough urine. In the clinical analysis of blood: Er. 2.2 • 1012 / l, Hb 80 g / l,
leukocytes - 11 • 109 / l, P - 12%, C - 75%, L - 8%, M - 2%.
Questions
1. What type of complications can be attributed to the complication identified in the
patient?
2. What is the classification of complications that can occur in acute appendicitis and its
surgical treatment?
3. Schedule a preoperative examination. What laboratory parameters confirm the
diagnosis?
4. What are the main stages of the operation.
5. Prescribe postoperative treatment.
Test tasks
1. Acute appendicitis is not characterized by a symptom:
1) Rovzing
2) Voskresensky
+3) Murphy
4) Obraztsova
5) Bartomier-Michelson
2. A symptom is specific for acute appendicitis.
1) Kocher-Volkovich
2) Rovzing
3) Sitkovsky
+4) all three symptoms
5) none of them
3. Symptoms are referred to as peritoneal in acute appendicitis;
1) Voskresensky (shirt symptom)
2) Shchetkin-Blumberg
3) Razdolsky's symptom
+4) all named symptoms
5) none of them
4. Acute appendicitis should be differentiated from all the listed diseases, except
for:
+1) glomerulonephritis
2) acute pancreatitis
3) acute adnexitis.
4) acute gastroenteritis
5) right-sided renal colic
5. Clinically acute appendicitis can be mistaken for:
1) salpingitis
2) acute cholecystitis
3) Meckel's diverticulum
4) ectopic pregnancy
+5) any of these types of pathology
6. Wrong for acute appendicitis is the statement that;
1) the rigidity of the abdominal wall may be absent when the process is retrocecal
2) there may be no stiffness in the pelvic position
+3) vomiting always precedes pain
4) pain can start in the navel
5) pain often begins in the epigastric region
7. Primary-gangrenous appendicitis most often occurs in;
1) children
2) seriously ill
3) men
4) women
+5) elderly patients
8. Acute appendicitis in children differs from that in adults in everything except:
1) cramping nature of pain, diarrhea, repeated vomiting
2) rapid development of diffuse peritonitis
3) high temperature
4) severe intoxication
+5) a sharp muscle tension in the right iliac region
9. In case of acute appendicitis in the elderly, it is advisable to use:
1) endotracheal anesthesia
2) intravenous anesthesia
+3) local anesthesia
4) peridural anesthesia
5) spinal anesthesia
10. Perforated appendicitis is characterized by:
1) Razdolsky's symptom
2) an increase in the clinical picture of peritonitis
3) sudden increase in abdominal pain
4) muscle tension of the anterior abdominal wall
+5) all of the above
11. Decisive in the differential diagnosis of acute appendicitis with impaired
ectopic pregnancy is;
1) Kocher-Volkovich symptom
2) Prompt's symptom
3) dizziness and fainting
4) Bartomier-Michelson symptom
+5) puncture of the posterior vaginal fornix
12. For the diagnosis of acute appendicitis, do not use:
1) palpation of the abdominal wall
2) clinical blood test
3) digital rectal examination
+4) irrigoscopy
5) vaginal examination
13. Contraindications for emergency appendectomy are:
+1) appendicular infiltrate
2) myocardial infarction
3) the second half of pregnancy
4) hemorrhagic diathesis
5) diffuse peritonitis
14. The optimal length of a skin incision for an appendectomy in an adult is:
1) 2-2.5cm
2) 3-4 cm
3) 5-6 cm
4) 6-8 cm
+5) 10-12 cm
15.With diffuse purulent peritonitis of appendicular origin, apply:
1) midline laparotomy
2) appendectomy
3) flushing of the abdominal cavity
4) drainage of the abdominal cavity
+5) all of the above
16. Washing of the abdominal cavity is indicated for:
1) the established diagnosis of appendicular infiltration
2) periappendicular abscess
3) gangrenous appendicitis and local delimited peritonitis
4) inflammation of the lymph nodes of the mesentery of the small intestine
+5) diffuse peritonitis
17. Leaving tampons in the abdominal cavity after appendectomy is indicated for;
+1) unstoppable capillary bleeding
2) gangrenous-perforated appendicitis
3) local peritonitis
4) diffuse peritonitis
5) all these conditions
18.Typical complications of acute appendicitis are all except:
1) appendicular infiltration
2) paraappendicular abscess
3) local peritonitis
4) diffuse peritonitis
+5) inflammation of Meckel's diverticulum
19.To diagnose acute appendicitis, the following methods are used:
1) laparoscopy
2) clinical. blood test
3) rectal examination
4) thermography
+5) all of the above is true
20.For the differential diagnosis between right-sided lower lobe pneumonia and
acute appendicitis, everything should be considered except;
1) data of auscultation of the respiratory system
2) laparoscopic data
3) data of fluoroscopy of the chest organs
+4) the number of blood leukocytes
5) thermography data
21. In acute phlegmonous appendicitis, the symptom is not observed:
1) Blumberg symptom
2) Bartomier-Michelson
3) Kocher-Volkovich
+4) Gergievsky-Mussi
5) Krymova
22.Douglas space abscess after appendectomy is characterized by all signs except:
1) hectic temperature
2) pain in the depth of the pelvis and tenesmus
+3) restriction of diaphragm mobility
4) overhang of the walls of the vagina or the anterior wall of the rectum
5) soreness during rectal examination
23. Emergency appendectomy is not indicated for:
1) acute catarrhal appendicitis
2) acute appendicitis in the second half of pregnancy
3) the first attack of acute appendicitis
+4) an unknown cause of pain in the right iliac region in the elderly
5) acute appendicitis in infants
24.Symptoms of appendicular infiltration are all except:
1) subfebrile temperature
2) the symptom of Rov ching
+3) profuse diarrhea
4) leukocytosis
5) palpable tumor formation in the right iliac region
25. It is not typical for the gangrenous form of appendicitis:
1) board-shaped belly
+2) increased pain in the right iliac region
3) reduction of pain in the right iliac region
4) tachycardia
5) Shchetkin-Blumberg symptom
26.The most important in the diagnosis of Douglas space abscess is:
1) sigmoidoscopy
2) laparoscopy
3) percussion and auscultation of the abdomen
+4) digital rectal examination
5) fluoroscopy of the abdominal cavity
27. Development of the pathological process in acute appendicitis begins:
1) from the serous cover of the appendix
+2) from the mucous membrane of the appendix
3) from the muscular layer of the appendix
4) from the dome of the cecum
5) from the terminal section of the small intestine
28. After appendectomy in acute catarrhal appendicitis, appoint:
1) antibiotics
+2) analgesics
3) sulfonamides
4) laxatives
5) all of the above
29. The most rational method of treating the stump of the appendix in adults is,
1) dressing with a silk ligature with immersion of the stump
2) ligation with lavsan ligature with immersion of the stump
3) immersion of an undigested stump
4) ligation with catgut ligature without immersion of the stump
+5) ligation with catgut ligature with immersion of the stump
30. Meckel's diverticulum is localized on:
1) jejunum
+2) ileum
3) the ascending colon
4) the cecum
5) sigmoid colon