Gangrenous perforated appendicitis. Gangrenous form of acute appendicitis

Purulent peritonitis - serious illness, characterized by a complex course and possible appearance consequences. There are many causes and factors for the occurrence of the disease. Patients must have the necessary knowledge about the disease.

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The site provides reference information. Adequate diagnosis and treatment of the disease is possible under the supervision of a conscientious doctor. Any drugs have contraindications. Consultation with a specialist is required, as well as detailed study of the instructions! .

Definition of the concept

According to medical terminology, purulent peritonitis means an infectious disease of the peritoneum.

Peritonitis develops as a result of untimely medical attention, which helps to rupture the appendix, during or after surgery, or as a result of trauma to the peritoneum.

The disease is characterized by a high degree of danger, since any delay can cost a person his life. The disease can provoke hemorrhage, infect the internal cavity of the peritoneum and form stagnation of biological fluid.

Root causes of the disease:

• Ascites associated with liver diseases and the development of microflora unfavorable for the body in it;
• Kidney disease requiring dialysis.

In addition to these reasons, there are also circumstances that contribute to the occurrence of purulent peritonitis.


These include:

• Burst appendix;
• Diverticulosis in perforated form;
• Diseases of the pancreas;
• Organ surgery abdominal cavity;
• Gastrointestinal diseases - perforation of an ulcer;
• Inflammation in the genitourinary system;
• Complications associated with the postpartum period;
• Infection by other means.

Infection of the body with one type of harmful microorganism is almost impossible. This is helped by the simultaneous spread of a large number of bacteria, viruses and fungi.

Non-infectious causes of infection: bile, blood.

Acute appearance, its symptoms and signs

Often the patient complains of sharp pain in the abdominal area, which intensifies with any movement.

Sometimes the pain has an imaginary course, the disease suddenly subsides, which is the most dangerous period of the disease.

At this time, adaptation of receptors occurs, which will soon make itself felt with more acute pain.

Other symptoms of the development of acute peritonitis:

• State of chills and fever;
• Formation of fluid accumulations in the peritoneum;
• The appearance of the Shchetkin-Blumberg symptom;
• A feeling of fullness and distension in the abdomen;
• Overstressed anterior muscles abdominal wall;
• Constipation;
• Inability to pass gas;
• Feeling tired;
• Problems with urination;
• Nausea accompanied by gag reflexes;
• Tachycardia;
• Lack of desire to eat;
• Diarrhea;
• Feeling of dry mouth.

The occurrence of purulent inflammation can be determined during the duration of dialysis by the following signs:

• Presence of cloudy liquid;
• The appearance of threads and clots in the liquid;
• The presence of an unpleasant odor;
• Inflammation and pain around the catheter.

The primary signs of acute peritonitis include:

1. Change in body temperature towards increase. It is necessary to measure the temperature under the armpit and in the rectum. Detection of temperature changes of more than 1 degree indicates the development of an inflammatory process.
2. Rapid heartbeat, which can reach 120 to 150 beats per minute.
3. The progression of the disease is indicated by changes in appearance patient: cyanosis in the lips, sharpening of the nose, dullness and yellowness of the sclera, sunken eyeballs, acquisition of an unnatural bluish-yellow hue by the face. The changes are direct evidence of the pain the patient is experiencing.
4. The severity of the pain increases. The patient begins to show signs of intestinal paralysis, fecal vomiting and flatulence. Cardiac activity becomes difficult.
5. When you tap on the stomach, you feel the sound of a drum.

Subsequently, complete intoxication occurs and the functioning of all organs is disrupted. If misdiagnosed or untimely application see a doctor for help, acute peritonitis ends in the death of the patient within a week.

We identify the diffuse type of peritonitis, features of fibrinous-purulent pathology

By diffuse peritonitis we mean infection of the peritoneal cavity with exudate. Inflammation has no boundaries and can develop in any area of ​​the abdominal cavity.

The presence of diffuse fibrinous-purulent peritonitis is indicated by damage to the entire peritoneum, which also involves the covering of the abdominal cavity.

Signs of this form of peritonitis:

• The appearance of inflammatory exudate in the peritoneal area with the presence of leukocytes and fibrin;
• The peritoneum becomes faded and rough;
• The liquid contents become cloudy.

The prerequisite for the occurrence of diffuse fibrous-purulent peritonitis is general weakening immune system as a result of its infection with harmful microorganisms.

Complication of purulent appendicitis with peritonitis

Is a consequence of a complication acute appendicitis. Failure to operate in a timely manner leads to rupture of the appendix and release of its contents into the peritoneum, which will lead to intoxication of the body. The result will be a filling of the abdominal cavity with pus.

Characteristic symptoms of the pathology

During this period, the patient feels symptoms:

• Severe unbearable pain of an intense nature;
• Acquiring a marbled or pale skin color;
• Presence of nausea with repeated gag reflexes;
• Increase in body temperature to high;
• Tachycardia;
• Low pressure.

The patient's only salvation is an immobilized position in the fetal position.

General clinical picture depends on the degree of neglect of the disease.

The most effective treatments

If a total form of peritonitis occurs, it is impossible to save the patient’s life without surgical intervention.

During the operation, the original source of peritonitis is located and removed.

The abdominal cavity is treated with antiseptic materials, and a drain is inserted for subsequent washing of the peritoneal area. If all of the above measures are performed, the patient’s prognosis for recovery is favorable, but long-term. This is due to the weakening of the immune system as a result of infection.

Gangrenous appendicitis is added to the disease

The danger of the disease is that the walls of the appendix rupture and purulent contents fill the abdominal cavity, which helps cause peritonitis.

Reasons for this phenomenon

The root causes of purulent appendicitis with peritonitis:

1. Ignoring contacting a doctor if signs of appendicitis appear.
2. Late diagnosis of the disease and the adoption of appropriate measures to treat the disease.

IN medical practice There have been cases where gangrene occurred within 7-12 hours.

Other causes of gangrenous appendicitis with peritonitis:

• Violation of the integrity of blood vessels in elderly people;
• Multiple education cholesterol plaques on the arterial walls of the intestine;
• The presence of blood clots in the appendix.

Factors that increase the risk of gangrenous appendix with peritonitis:

• Damage to the body by various infections;
• Increased activity of immune cells;
• Disturbance of outflow in the appendix process.

Urgent diagnosis and characteristic signs

Diagnosis of the disease involves examining the patient and analyzing complaints from the patient, laboratory tests and the use of other diagnostic methods.

If not responded to in a timely manner, purulent peritonitis can take a person’s life.

Symptoms of gangrenous appendicitis with peritonitis:

1. The patient's condition is very difficult. Tachycardia. There is no increase in body temperature.
2. There is a white or yellowish coating on the tongue.
3. The peritoneal area is tense. The slightest touch provokes acute pain.
4. The state of intoxication is increasing.

Hospitalization and the professionalism of surgeons can save the patient.

Fecal subtype of the disease

The reason is bacterial infection located in the gastrointestinal tract. The disease develops unnoticed by the patient.

Marked by an increased degree of speed. It is treated by surgery.


Symptoms of fecal peritonitis:

1. Painful sensations in the stomach for no apparent reason.
2. Change skin person. The epidermis acquires a pale tint.
3. High degree of sweating.
4. Low blood pressure.
5. Relief occurs in a supine position.
6. Noted great loss liquids, up to 5 kg per day.
7. The blood is affected by toxins.
8. Possible heart attack.

These symptoms should alert the patient and the doctor, since all manifestations indicate the possibility of developing appendicitis.

Only a doctor is able to correctly diagnose the disease and distinguish it from ordinary poisoning or gastric upset.

Diagnosis of fecal peritonitis is carried out through a comprehensive examination. The patient is required to donate blood for biochemistry, which can confirm the presence of fecal peritonitis. A more detailed picture can be seen by performing an ultrasound or x-ray examination.

Treatment of fecal peritonitis is long-term, so the patient needs patience and endurance. This is the only way to achieve a favorable prognosis and speed up the recovery process.

Fecal peritonitis is a secondary symptom of the underlying disease. The first are appendicitis, cholecystitis, ulcers and pancreatic diseases.

Surgical treatment tactics

The purulent form of peritonitis requires emergency surgery. Treatment varies in complexity and duration.

Emergency intervention by surgeons involves the following stages:

• Pain relief for the patient;
• Carrying out laparotomy to remove fluid purulent accumulation and the source of peritonitis;
• Inspection and sanitation of the peritoneal area;
• Decompression of the gastrointestinal tract;
• Analysis of the choice of technique for completing surgical intervention.

Surgery for peritonitis is beyond doubt. The duration of the operation depends on the severity of the damage to the peritoneal area and the stage of the disease. Preoperative preparation of the patient can take from 2 to 6 hours.

Diagnosis of peritonitis before surgery. To alleviate the patient's condition, analgesic therapy is carried out during the preoperative period.

Prescribed antibacterial drugs, drugs for anemia, correction of cardiac activity, anti-enzyme and preparatory drug therapy for the operation. Laparoscopic operations have become in demand.

During the operation, the peritoneal cavity is cleared of purulent contents using an electric suction and cotton swabs.

The surgeon then treats the peritoneum antiseptics and examines it to identify the primary source of the disease.

After its removal, the peritoneum is re-sanitation with antiseptics, antibiotics or novocaine solution, which depends on the form of the disease.

The attending physician decides which method of surgical intervention to perform based on the results of the diagnosis. Despite the timely measures taken to treat peritonitis, the statistics look depressing, since the mortality rate of the disease remains at a high level.

Recovery after surgery

After surgery, it takes time for the body to recover vitally. important functions. Do not try to treat yourself with any herbs or grandma’s methods.

Only strict adherence to doctor's recommendations and diet. If you experience the slightest negative reaction in your body, tell your doctor immediately. After surgery, the patient is prohibited from eating any food for the first few days.

In the first hours, it is possible to wet the patient’s lips with water. You can drink water per day.

In the future, a diet with the following list of dishes is provided:

• Eating soft fruits with antioxidant properties: tomatoes, cherries;
• Fortifying the body and saturating it with calcium by consuming cereals, herbs and seaweed;
• Refusal of refined products and white bread;
• Refusal of strong coffee, tea, alcohol and smoking;
• Inclusion of an additional multivitamin complex into the general diet;
• Drink 1.5-2 liters of liquid daily;
• Adding probiotic supplements to your diet.

If approved by a physician, it is possible to consume green tea, cat's claw extract, olive leaf extract, or milk thistle as antioxidants.

All of these drugs with excellent antioxidant and antibacterial effects can speed up the healing process.

Possible consequences and prognosis for life

The main consequences of purulent peritonitis include:

• Intestinal gangrene;
• Formation of intraperitoneal adhesions;
• The appearance of septic shock;
• Abscess;
• Hepatic encephalopathy;
• Blood poisoning;
• Lung infection.

The prognosis depends on the treatment provided and the stage of the disease.


For example, for older people who are repeatedly exposed to the disease and seek help within 2 days, the prognosis is not encouraging.

This also applies to patients suffering from liver diseases. The prognosis for treatment of the primary stage of peritonitis in children is favorable.

Purulent type of peritonitis - infection, which is a secondary symptom of the underlying disease. It is treated strictly surgically.

The prognosis for recovery depends on the timeliness of visiting a doctor, the provision of medical care and the characteristics of the patient. Ignoring the first signs of the disease can lead to death for the patient.

Gangrenous appendicitis is named according to the nature of the inflammation in the wall vermiform appendix. In form it is classified as destructive. This means the inevitable destruction of the integrity of the wall.

In the abdominal cavity, surgeons find fluid (effusion) of a serous or purulent nature with the smell of rot. The disease almost always occurs with severe complications. A definitive diagnosis can only be made by visual inspection of the appendix.

The older the patient, the greater the likelihood of rapid development of gangrene. If in children and adolescents it is found in 8% of operated cases, then in older people after 60 years the frequency reaches 33%.

Pathanatomy of the inflamed appendix

The inflammatory process begins with the catarrhal stage, dilation of capillaries, influx of lymphocytes trying to stop and localize the disease. Edema and infiltration of the wall are detected. Small purulent foci are possible. Conventionally, this stage occurs up to 6 hours from the onset of the patient’s attack.

Before the end of the first day, the appendix enlarges significantly and is filled with pus. In 90% of cases it is regarded as phlegmon (circumscribed abscess).

If the appendix is ​​not removed during this period, then foci of necrosis appear on the walls, and in the abdominal cavity the effusion takes on a purulent character. All layers are subject to melting. The appendix looks dirty green in color, enlarged, the wall is flabby with areas of hemorrhage and necrosis. It takes up to three days for necrosis to develop.

The intermediate picture of appendicitis in a patient is caused by phlegmonous-gangrenous changes. In the gangrenous stage, neighboring tissues and organs join the inflammation of the appendix. Intestinal loops, omentum, and peritoneal layers are affected. Fibrin deposits and hemorrhages are found on them. In the blind and ileum hyperemia and infiltration appear.

The combination of an abscess and dead tissue is more often found in the very terminal zone of the appendix

The outcome is possible self-amputation of the appendix (detachment from the cecum) or perforation of the wall (perforation) due to a rupture. Surgeons know that any manipulation against the background of a patient’s gangrenous appendix always leads to a breakthrough of purulent contents.

There is also an opinion that the speed of anatomical changes does not depend on the timing of the onset of an attack of pain. Therefore, the attitude towards the given references to time is rather conditional.

What causes gangrenous disorders?

Important risk factors for the transition of inflammation to the stage of gangrene are:

• impaired blood circulation in an elderly patient due to widespread atherosclerosis;
• intestinal ischemia due to obstructed patency of the mesenteric arteries (thrombosis);
• congenital underdevelopment of the feeding arteries (in pediatric patients).

These changes in the patient's body lead to the development main reason- impaired microcirculation in the wall of the process. Further joining:

They aggravate the course of the disease. A gradual change in forms of inflammation from catarrhal to phlegmonous, untimely provision of specialized assistance, transition to destruction and purulent melting.

Manifestations

Symptoms of gangrenous appendicitis begin according to the classical canons with catarrhal inflammation. The patient experiences epigastric pain, nausea, vomiting, and fever. Within 2 hours, the pain “descends” to the right iliac region with the normal position of the appendix. They can radiate to the hypochondrium on the right, to the coccyx, to the central area of ​​the abdomen.

Acute gangrenous appendicitis, developing from phlegmonous, first causes twitching or throbbing pain, then subsides due to the complete destruction of the sensory nerve endings in the wall. Phlegmonous appendicitis can be mistaken for gangrenous, which has no practical significance with timely surgical intervention.

Vomiting becomes repeated, repeated. The temperature rises to high levels, which is accompanied by chills. The patient turns pale and breaks out in a cold sweat. Upon examination, the doctor discovers dryness of the tongue.

Local soreness and board-like density of the patient’s abdominal muscles are a sign of irritation of the peritoneum; the abdomen does not take part in the act of breathing

In a blood test, leukocytosis does not always increase sharply, but a significant shift is noticed leukocyte formula to the left. Differential diagnosis especially difficult in female patients. It is necessary to exclude right-sided adnexitis, rupture and torsion of the ovarian cyst, ectopic pregnancy, apoplexy of the appendages.

With an atypical location of the process, the disease gives a mask:

• diverticulitis of the large intestine;
• right-sided pyelonephritis;
• renal colic;
• acute cholecystitis;
• gastritis or duodenitis;
• perforated stomach ulcer;
• acute pancreatitis.

What helps in diagnosis?

The doctor has to rely on his practical experience and laboratory indicators, since ultrasound of the abdominal cavity is not an informative enough study for appendicitis. But hardware methods make it possible to exclude gynecological pathology in women, pancreatitis, ectopic pregnancy, urolithiasis, and pyelonephritis. A gynecologist is called for a consultation and a rectal examination is performed in men.

What is the difference between the gangrenous-perforative form?

Gangrenous-perforative is a form of inflammation of the appendix with obligatory violation of the integrity of the wall. Its isolation emphasizes the severity of the course, substantiates complications and the risk of surgical intervention.

The danger lies in the presence of penetration of purulent contents into the abdominal cavity. Local or diffuse peritonitis occurs. The patient has pronounced signs of peritoneal irritation, there is no intestinal peristalsis. Worried about palpitations, dizziness, weakness.

In blood tests, leukocytosis and ESR are increasing, the formula is shifting to the left. Changes appear in the urine (casts, protein), which indicates toxic damage kidney

Treatment

If there are still opinions about the possibility of conservative treatment for catarrhal appendicitis, then the gangrenous and gangrenous-perforated form can only be cured surgically. To stop the spread of the inflammatory process to the peritoneum, it is necessary to remove the source of pus.

The operation is most often performed emergency indications 2–4 hours after the onset of the attack

A planned approach at a later date is possible, but it should rather be called a “deferred” approach. Time is spent on stabilizing the patient’s condition in case of a drop in blood pressure, heart failure caused by intoxication, or decompensation diabetes mellitus.

In preparation for surgery, patients are detoxified, fluids, antibiotics, and cardiac support are administered by drip. The contents of the stomach are removed through a tube. Doctors must find out whether the patient is prone to allergic reactions.

This is important to know when choosing a processing method. surgical field, anesthesia. The patient must sign his consent to undergo surgery; parents or guardians do this for the children.

For complete pain relief, one of the following methods is used:

• creation of anesthetic infiltrate;
• conductive block of the nearest nerve plexuses;
• general anesthesia.

It is chosen by the anesthesiologist depending on the patient’s age, excitability, and drug tolerance. Sufficient pain relief helps reduce the time of surgical intervention, the risks of postoperative complications, and complete healing.

Local anesthesia is not used in children; fear and excitement do not allow them to completely relax the abdominal wall and examine the cavity. For adult patients, local anesthesia for catarrhal appendicitis is sufficient, but possible peritonitis and the need to expand the operation for gangrene require general anesthesia. Because it suppresses the gag reflex, it relaxes the muscles when muscle relaxants are administered.

After treatment of the surgical field and anesthesia, the surgeon performs a layer-by-layer dissection of the peritoneal wall. The method allows you to close bleeding vessels and injure less muscles. The length of the incision should be sufficient to allow the doctor to examine the cavity. The muscles and their aponeuroses are separated along the fibers manually.

The omentum and intestines are brought into the open abdominal cavity. The inspection requires checking 50 cm of length on each side of the appendix. The inflamed appendix is ​​identified by the beginning of the bands of the large intestine.

The process is isolated very carefully so as not to cause spontaneous rupture

The appendix is ​​removed, and the remaining stump is sutured with a special sealed purse-string suture. It consists of immersion inside and the possibility of connecting the serous membranes. If effusion is detected in the peritoneum, it is washed with sterile solutions and an antibiotic is administered. The patient's abdominal wall is sutured using dense threads that dissolve after some time.

7–10 stitches are applied to the skin. The need to combat peritoneal phenomena requires leaving a drainage tube. Once the patient's condition has stabilized, the drainage is removed. The operation usually lasts up to three hours. There are no special standards. The time is determined by the severity of the condition, age, complicating factors (adhesions in the abdominal cavity, abnormal location of the appendix).

How is the patient's postoperative period progressing?

The first day is called the early postoperative period. The patient continues to receive detoxification agents and antibiotics. The doctor monitors temperature, urine output and daily diuresis, and listens to bowel sounds.

In the following days, a gradual recovery of the patient’s condition is observed: appetite and bowel movements appear, and the temperature normalizes. During daily dressings, the surgical suture is inspected and the wound is washed through the drainage. Pain in the suture area, discrepancy, and prolonged absence of stool causes anxiety.

Unlike the simple form of appendicitis, the patient needs:

• stronger antibacterial agents(from the group of cephalosporins, antibiotics Levofloxacin, Ornidazole, Amikacin);
• painkillers;
• administration of Albumin to relieve intoxication, fresh frozen plasma, Reosorbilact, Refortan;
• prevention of the development of thromboembolism and stress gastric ulcers.

Infusion therapy is the basis of recovery

Consequences of delayed surgical care

With timely surgical intervention, if the appendix has not ruptured, patients quickly recover. It has been noticed that in them, more often than in other forms, wound suppuration is possible. Refusal of the operation threatens with serious consequences.

Delayed appendix removal provokes:

• perforation (perforation) of the wall, pus flows into the abdominal cavity;
• separation (self-amputation) of the cecum due to tissue melting;
• development of purulent and purulent-fecal peritonitis, while the patient’s condition becomes more severe before our eyes, the temperature is rarely significant, there is no usual dependence on pulse rate, conduction plain radiography abdominal cavity confirms peritonitis by the presence of fluid levels in the intestines;
• multiple abscesses in the abdominal and pelvic organs;
• abdominal sepsis;
• pylephlebitis - purulent inflammation portal vein liver.

These conditions progress quickly, even lightning fast, and provoke failure internal organs. Irreversible violations lead to the death of the patient.

Diet after surgery

A special approach to nutrition for gangrenous appendicitis is associated with a longer-term disturbance of intestinal motility. The abdominal organs are more severely injured, which slows down the patient’s digestion. In the first 24 hours you are allowed to drink only boiled water, low-fat kefir, dried fruit decoction. Liquid broth, soup with cereals are given in small portions six to seven times a day.

It is allowed to drink mineral water without gas, slightly sweet weak tea, rosehip decoction

On the second day, if there are no signs of complications, pureed boiled meat, mashed potatoes, sausages, cottage cheese, liquid porridge with butter are added. Patients maintain this diet until sufficiently pronounced peristalsis appears.

From the third day, when the intestines and bowel movements are fully functioning, it is allowed to expand the diet to table No. 5. You will have to avoid fatty and spicy foods, smoked foods, marinades, lard, spices, eat little and often.

What regimen do patients need?

If the course is uncomplicated, the patient can and even needs to get up 5–6 hours after the operation. Early active movements, therapeutic exercises, and deep breathing exercises prevent pneumonia.

Due to complications, walking is delayed for 2 days. It is best to get out of bed for the first time in the presence of relatives or medical personnel. Extension of the regimen is permitted by the doctor individually. It is recommended to wear a bandage or tie a towel tightly to reduce pain.

Typically, the patient is discharged on the tenth day. A gentle regime of physical activity is required for a month. Heavy lifting is contraindicated for three months. Exercises to strengthen the muscles of the legs, arms, and leisurely walking are acceptable.

Sutures are removed in the treatment room when good condition wounds

Sports activities (running, weightlifting, football, volleyball) will have to be postponed for at least 3 months. The decision to allow exercise should be made with your doctor. The clear dependence of the complications and results of the operation in the patient on the advanced stage of the disease requires one’s own monitoring of abdominal pain, timely calling an ambulance, and observation by specialists.

Gangrenous-perforated appendicitis (ICD code 10 - K35) is the last stage of acute purulent appendicitis, which is characterized by tissue death.

Without timely assistance, at the beginning of the stage, perforation of the abdominal wall with feces and pus into the abdominal cavity occurs, which leads to peritonitis. Surgical intervention in late stage useless. The patient dies due to perforation of the walls of the appendix.

Causes

Gangrenous-perforated appendicitis is one of the stages of inflammation of the appendix. The reason why the appendix becomes inflamed is artery thrombosis. The next stage is the development of harmful bacteria in the intestinal microflora.

The danger is:

• cocci;
• bacteroides;
• coli;
• enterococci.

Destructive changes characteristic of initial stage inflammation of appendicitis:

1. Reduced protection of the mucous membrane of the appendix and local immunity.
2. Disturbances in the outflow of digestive tract contents from the appendix.
3. Loss of elasticity of the walls of the appendix.

As the disease develops into a severe - gangrenous stage, the patient's condition deteriorates sharply. Sometimes gangrenous inflammation occurs without previous stages, as an independent disease.

This is due to:

1. Circulatory disorders in the appendix.
2. Lack of fiber in the daily diet.
3. Formation of cholesterol plaques in the gastrointestinal tract.
4. Vessel thrombosis of the appendix.

These data indicate that the main reason for the development of complications is poor circulation in the appendix. Other factors: infections associated with the development of harmful microflora, impaired outflow of food masses and immune autoaggression - are secondary factors and contribute to the development of gangrene, but do not provoke it.

Delayed assistance leads to purulent melting of the walls of the appendix, and the patient dies.

Symptoms at different stages

The dangerous gangrenous stage occurs two to three days after the first signs of acute appendicitis. Upon visual examination, changes in the appendix are observed:

• The appendage is increased in size due to edema.
• Covered with fibrin and purulent dissection.
• Has hemorrhages and dark areas of tissue necrosis.

The development of gangrene is preceded by five stages of inflammation of appendicitis, with characteristic symptoms for each.

Acute catarrhal

Catarrhal is an inflammation with accumulation of fluid. In children and the elderly, symptoms are disguised as food poisoning.

Symptoms of acute catarrhal stage:

1. Digestive discomfort, which is accompanied by pain in the right iliac region, above the navel and lower back.
2. The nature of the pain is sharp and aching. Intensifies with movement.
3. When the patient lies on his right side, he feels better.
4. Low-grade fever or heat.
5. Nausea with urge to vomit.
6. Dry mouth.
7. Increased pain if the patient lies on the left side.

Destructive stage

Acute inflammation of the appendix, which is accompanied by tissue decay. The main reason is blockage of the intestinal lumen foreign body or fecal stones.

Symptoms:

1. Wandering pain in the navel or upper abdomen. Later it becomes localized and intensifies.
2. Lack of appetite and vomiting.
3. White coating on the tongue.
4. Muscle tension in the appendix area, which can be felt during palpation.
5. Increased pain when turning on the left side in a lying position.
6. Low-grade fever.
7. Gradual bloating.

Phlegmonous stage

A severe form of inflammation, which is accompanied by the accumulation of pus inside the appendix and an increase in its size. The stage is complicated by the formation of ulcers that spread to nearby organs.

Symptoms:

1. Severe, throbbing pain localized in the right iliac region.
2. Nausea without vomiting.
3. Heat.
4. Sweating, rapid heartbeat.
5. Tension in the abdominal walls.

Gangrenous stage

Occurs 1-3 days after the previous stage. Painful sensations are dulled due to necrotic processes. The tissues die and the abdominal area becomes inflamed. The development of inflammation is determined by general signs.

Symptoms:

1. Chills, cold sweat.
2. Heat.
3. Uncontrollable vomiting.
4. Dry mouth.
5. White coating on the tongue.
6. Cardiopalmus.
7. Weakness.

Perforated stage

Acute gangrenous appendicitis without timely surgery turns into a perforated form, when accumulating pus breaks through the walls of the appendix. The contents enter the sterile area of ​​the peritoneum and purulent peritonitis develops. Without urgent surgery, the patient dies.

Symptoms:

1. Unbearable pain in the abdomen.
2. Weakness and thirst.
3. Heat.
4. Vomiting without relief.
5. High sweating.
6. The tongue is covered with a brown coating.
7. Dry mouth.

In rare cases, a local abscess appears. If the abdomen quickly swells, then this is evidence of the development of acute purulent peritonitis.

Treatment of acute appendicitis

Acute gangrenous appendicitis is treated surgically. Used for pain relief local anesthesia or general anesthesia. In advanced cases with the development of peritonitis, doctors use endotrichial anesthesia with ventilation.

Appendectomy involves two types of surgical intervention: traditional and laparoscopic.

Traditional appendectomy

The preparatory stage for the operation lasts no more than two hours. It includes the collection of blood and urine tests, as well as a number of diagnostic procedures:

• CT scan.
• Rectoscopy.
• Visit to the radiologist.
• For women – consultation with a gynecologist.
• ECG for heart problems.

After the tests are collected, the patient is prepared for surgery. Held:

1. Bladder catheterization.
2. Shaving the abdominal wall.
3. Disinfecting the skin with an antiseptic.

Surgery to remove appendicitis

The operation is performed through an incision in the iliac zone on the right. The cecum is pulled out and the appendix is ​​excised. After this, doctors suture or drain the wound. Inflammatory fluid is removed from the peritoneal cavity using an electric suction device and wipes.

In some cases, surgeons leave drainage - gauze swabs - in the abdominal cavity. This happens if:

• The appendicitis was not completely excised.
• Despite all measures, bleeding continues from the excision site.
• An abscess has opened and the pus needs to be drained.
• An infiltrate has been detected and removal of the appendage is impossible.

Video of appendectomy

Laparoscopy

A progressive method of surgical intervention, which is performed with a laparoscope and special surgical instruments. A laparoscope is a flexible tube with a video camera and lighting. With its help, the surgeon looks into the most remote places of the peritoneum and examines the organs from all sides. If necessary, organs are examined using a laparoscope before surgery.

Removing appendicitis using a laparoscope

Advantages of laparoscopy compared to traditional resection of appendicitis:

1. Less tissue is injured.
2. Wounds heal faster after surgery.
3. The recovery period is halved.
4. Minimal risk of complications.
5. Scars after laparoscopy are almost invisible.

The disadvantages of laparoscopy are high cost and individual contraindications to surgery. In rare cases, due to equipment malfunction, unforeseen consequences occur: intestinal burns and damage to adjacent organs.

Video of laparoscopic appendectomy

Postoperative period

Surgery is the first stage in the treatment of acute gangrenous-perforated appendicitis. After surgery, the patient needs complex complex therapy, which includes:

1. Treatment with antibiotics from the groups of macrolides, cephalosporins and tetracyclines.
2. Intramuscular injection of strong painkillers.
3. Cleansing the body of decay products. Solutions of potassium and sodium chloride, glucose and albumin are administered intravenously.
4. Prevention of thrombosis. Elastic bandages are applied to the sutures, anticoagulants are prescribed, and compression stockings are prescribed.
5. Taking medications to improve the functionality of the gastrointestinal tract. Digestive enzymes and hydrochloric acid blockers are prescribed.
6. Daily blood test for general indicators.
7. Daily dressing and drainage. Complete sanitary treatment of wounds is carried out using sterile bandages and napkins.

Complications after appendix removal

Common complaints after resection of gangrenous appendicitis are accumulation of gases in the intestines and pain in the suture area. These effects disappear within a few days and do not require medical intervention.

The following complications require intervention:

• Spikes. Accompanied nagging pain. Not diagnosed using ultrasound and x-rays. For removal, laparoscopy is performed and absorbable medications are prescribed.
• Hernias. Protrusion of the intestines between the muscles. From the outside they look like suture swellings. They require suturing or truncation of part of the intestine. They occur when the rest regime is not observed during the recovery period.
• Abscesses. A common complication after appendicitis with peritonitis. To eliminate it, doctors prescribe a course of antibiotics and physiotherapy.
• Intestinal fistulas. These are openings that connect the walls of internal organs and the skin on the surface. A rare complication that occurs due to poor hygiene.
• Constipation and diarrhea. Treated with a balanced diet.
• Fever. The complication is relieved by taking antipyretic drugs, and the patient is referred for diagnostics to determine the causes of the increase in temperature.

In order to avoid complications, doctors prescribe preventive measures and special care by medical staff. Failure to comply with the daily routine, diet and suture hygiene is fraught with undesirable consequences and complications of an organism weakened by gangrene.

Rehabilitation

After the gangrenous-perforated form, recovery takes a long time due to the fight against the consequences of gangrene. In the first days after surgery, the patient is weak and unable to independently change the dressing and monitor the hygiene of the sutures. All assistance is provided by medical staff, who also monitor compliance with preventive measures.

After complications, the patient requires special care

On the first day, it is forbidden to eat or lie on your right side. You are allowed to drink boiled water and get up a day after the operation. After laparoscopy you can get up after 6 hours. To facilitate bowel movements, an enema is used, because the patient should not strain the injured abdominal muscles.

Usually in the first days the patient's temperature is elevated. If it lasts more than a week, then this is a sign of complications. The patient is treated in a hospital for 10 days, after which rehabilitation takes place at home.

1. Before the stitches are removed, you should not shower or wash in the bathroom. Hygiene is maintained with wet wipes. Until complete healing, it is forbidden to visit the pool and sauna.
2. You should not sunbathe until the stitches have healed permanently.
3. Be active in sports. Recommended breathing exercises, exercise therapy and walking to improve blood circulation. Heavy physical exercise resolved after six months.
4. Smoking is prohibited for a week after surgery.
5. Return to intimate life only after the stitches are removed.

Diet

The diet is prescribed to normalize stool. The patient is advised to avoid constipation and get an enema if necessary. In addition, a balanced diet helps the body recover.

Sample diet plan:

1. The first day after surgery the patient fasts. It is allowed to drink still water and to restore strength, take chicken broth in small portions 5-6 times a day.
2. On the second day, the following are added to the menu: mashed potatoes, steamed vegetables and dried fruits. It is allowed to eat yogurt and cottage cheese with a low fat content. To avoid complications, the diet is kept in a “liquid” form.
3. On the third day, peristalsis improves and the intestines begin to work. Puree soups, butter and black bread are added to the menu.

Dishes after surgery are served without salt and spices. The liquid-fresh nature of the diet is maintained to reduce the risk of gas formation. The diet is followed until the sutures are completely healed.

Be healthy!

When pain occurs in the lower abdomen on the right, the first thing that comes to mind is appendicitis. Inflammation of the appendix is ​​a very common situation; the problem can occur in both children and adults, and at the same time it is extremely dangerous. Delayed medical attention can lead to widespread infection and death. There are several varieties of this inflammatory process, one of the most unfavorable is gangrenous appendicitis.

What is gangrenous appendicitis

The gangrenous form of inflammation of the appendix of the cecum implies necrotic processes in the tissues of the appendix, which are irreversible. Often, death occurs only in some part of the organ, but sometimes it affects it completely. In the vast majority of cases, the gangrenous process is one of the stages of acute appendicitis, which develops after a couple of days if the patient does not seek help. In old age, this process can be an independent disease.

Gangrenous appendicitis is a common occurrence in children and adults.

If a patient with gangrenous appendicitis does not receive correct medical care, then the process becomes more complicated, turning into a gangrenous-perforating form - perforations form on the walls of the appendix.

At risk are older people due to specific age-related changes in their body and those patients who ignore the symptoms of developing appendicitis. IN childhood the process is most dangerous, since in case of infection it will spread extremely quickly throughout the body.

Causes

As already mentioned, gangrenous inflammation is a consequence of the development purulent form appendicitis, thus, the main cause of the disease is a prolonged inflammatory process. Usually it takes two days for the disease to develop into this form, but some factors can have an impact. Negative influence and significantly speed up this process:

• infectious infection;
• autoimmune diseases;
• disruption of the normal outflow of the contents of the appendage of the cecum.

However, there are also situations where the inflammatory-necrotic process is primary, and factors such as:

• old age, when the blood supply system to organs is disrupted due to damage to the walls of blood vessels;
• arterial atherosclerosis (the presence of cholesterol plaques on the walls of blood vessels);
• thrombosis blood vessels, supplying the appendix;
• congenital form of arterial hypoplasia (narrowing of the lumen) - in this case, appendicitis will most likely manifest itself in childhood.

When blood flow is disrupted, a so-called appendix infarction occurs, which is the impetus for the development of necrotic processes.

Symptoms

The main feature of gangrenous appendicitis, which is the result of an acute purulent form, is the presence of specific symptoms that are not typical for other forms of the disease. Thus, due to the necrotic process, the nerve endings also die - at first the patient feels a decrease in painful sensations, and some do not feel any significant pain at all. Other symptoms may also occur:

• frequent and profuse vomiting, which does not alleviate the condition;
• manifestations of intoxication of the body - severe weakness, however, body temperature can be either absolutely normal or even low;
• the surface of the tongue is covered with a yellowish or whitish coating, the main density of the layer of which is concentrated at the root;
• “toxic scissors” syndrome - against the background of a serious condition and normal temperature, there is pronounced tachycardia, the heart rate can be twice as high as normal.

Doctor's note: the problem has no symptomatic features depending on age and gender, but if the disease occurs in a child, the manifestations will increase catastrophically quickly, and the time to provide assistance will be significantly less than with gangrenous appendicitis in an adult.

If appendicitis occurs as primary disease, then it is characterized by other manifestations. In such a situation, the pain is pronounced and sharp, but episodic. The serious condition is characterized by an increase in temperature, and the abdomen is tense and painful.

Separately worth noting specific symptoms gangrenous-perforated appendicitis:

• when a wall rupture forms, the patient experiences sharp pain which does not stop and gradually spreads throughout the abdominal area;
• the temperature rises significantly;
• heart rate increases;
• the surface of the tongue becomes dry, the coating becomes brown;
• vomiting becomes continuous;
• the stomach is swollen, intestinal peristalsis completely disappears;
• no stool;
• tension gradually spreads throughout the abdominal cavity.

Diagnostic measures

Diagnosis of gangrenous appendicitis as a secondary disease is considered difficult due to atypical symptomatic manifestations: There is practically no pain, as well as temperature, the abdomen is soft. Such indicators often force doctors to determine that there is no reason for hospitalization, however, at the slightest suspicion, it is still necessary to undergo a series of studies. Diagnostic methods for gangrenous and perforated appendicitis:

• the first stage is palpation. In the absence of painful sensations, the specialist must examine the muscles extremely carefully and very carefully - the slightest change in them should be the reason for further measures;
• CT scan, ultrasonography and X-ray;
• blood tests (signs of leukocytosis) and urine (appearance of protein in it).

Treatment methods

Regarding treatment methods, the patient has no choice - this is only surgery. The procedure is called appendectomy, involves removal of the appendix and can be performed by two methods: conventional resection or a less traumatic method - laparoscopy. The traditional option involves creating a small incision through which the appendix is ​​removed along with the cecum. The inflamed appendage is bandaged in the area of ​​connection with the intestine, after which it is cut off and sutures are applied. If there has been a rupture of the organ, the abdominal cavity is washed antiseptic solutions and dried with tampons, after which a drainage system is installed.

During laparoscopy, the appendage is cut off without bringing the organs out, that is, a special device with a camera is inserted into the abdominal cavity through several small holes, thanks to which all procedures are performed by the doctor inside the body. The operation in any case involves general anesthesia.

Postoperative period

Recovery period after surgical treatment Gangrenous appendicitis has its own characteristics compared to other forms of the disease. Thus, it is necessary to take measures such as:

• active antibacterial therapy using drugs such as Levofloxacin or Cephalosporin;
• introduction of detoxifying compounds into the bloodstream (glucose, albumin, refortan, etc.);
• Blood tests are carried out daily;
• They also carry out dressings daily - changing the bandage with washing the wound and drainage;
• taking painkillers;
• prevention of complications depending on the condition of the patient’s body (anticoagulants and proton pump blockers may be prescribed to reduce the level of secretion gastric juice etc.).

Expert opinion: it is believed that the patient simply needs early activation after surgery, so the patient is prescribed breathing exercises, physiotherapy and massage treatments.

A very important element of correct recovery after surgery is diet, since after the gangrenous form of appendicitis, the functioning of the digestive system is much more damaged than in other forms.

Nutrition after surgery - table

Day after surgery	Patient nutrition
First	A minimal diet and the patient’s appetite usually corresponds to this. Still water, sweet tea, uzvar, pureed potato soup and well-cooked cereals, weak chicken broth or low-fat kefir are allowed. It is better to divide your meals into 5 meals, and eat about 7 spoons or sips at one time.
Second	If the recovery period proceeds normally, you can supplement the diet with liquid mashed potatoes, chopped dietary meat, thin porridge with a little butter. If complications are observed, then the diet is kept similar to the first day.
Third	Usually on the third day the intestines begin to function normally, and the first bowel movement occurs after surgery. The diet can be expanded, it should be based on general rules exceptions harmful products, a list of which is given below.
next week	Unleavened foods that must be prepared in a liquid or pureed form to lighten the load on the digestive system. You can eat vegetable and chicken broths; zucchini, potatoes, carrots, and beets will be useful. A small amount of rice won't hurt. It is recommended to add fresh greens to your food to improve digestion. It is also worth drinking liquid in large quantities, this can be self-prepared sweet juices, compotes, tea. Fresh and natural fermented milk products are necessary during recovery.

During the recovery period, you should avoid products such as:

• spices;
• legumes;
• tomatoes;
• minimize, or better yet, stop eating salt altogether for at least a couple of weeks;
• smoked meats, fatty meats and fish;
• sausages;
• sauces – ketchup and mayonnaise;
• carbonated drinks.

Prohibited products after surgery in the photo

Possible complications and consequences

Lack of immediate medical care for gangrenous and gangrenous-perforative types of the disease can lead to extremely life-threatening consequences, such as:

• the formation of purulent abscesses in different pelvic cavities;
• purulent peritonitis is a large-scale inflammatory process in the peritoneum, which without urgent medical intervention leads to sepsis and death of the patient;
• thrombophlebitis of the septic type - inflammation of the walls of the veins with the formation of thrombotic formations.

How appendicitis develops - video

Gangrenous appendicitis is one of the most complex forms of inflammation of the appendix, in which there is a high risk fatal outcome. At the first suspicion of the development of a problem, you should consult a doctor, because the only way to treat the disease is surgical intervention and strict rules during the recovery period.

When sharp pain occurs in the abdominal area (especially in the right side of the abdominal cavity), you involuntarily begin to think about appendicitis. This disease is widespread. It occurs in both children and adults.

At the first symptoms, it is important to immediately consult a specialist and undergo a full diagnosis. Otherwise, serious complications may develop. One of them is gangrenous appendicitis. As a rule, it occurs 2-3 days after the onset of the disease. We'll tell you what you need to know about this serious illness in today's article.

What is gangrenous appendicitis?

Acute gangrenous appendicitis is one of the final stages of this disease. The walls of the process die and, as a consequence, necrosis of nearby tissues occurs.

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Gangrenous appendicitis does not occur spontaneously. It appears 2-3 days after the first signs of this disease appear. But there are exceptions:

• Children. In their case, the disease is acute, counting not in days, but in hours. Symptoms: pain in the abdominal area, high fever. Sometimes the mark can reach 40 degrees.
• Aged people. In this case, vomiting and constipation are added to the main symptoms.
• Changes occurring in vascular cells. May occur due to concomitant chronic diseases.
• The presence of cholesterol plaques in the body.
• Attachment of viruses or infection.

But in most cases, gangrenous appendicitis occurs due to untimely removal of the appendix.

Symptoms

The main problem of gangrenous appendicitis is that its symptoms are “floating”. For example, a sharp pain that torments a patient may pass. Doctors attribute this to tissue death. It is these erroneous signs that allow a person to think that everything is over and there is no need to see a doctor.

Symptoms of gangrenous appendicitis are as follows:

1. Severe vomiting that does not stop even after taking anti-vomiting medications.
2. Pain in the abdominal area that subsides and returns. Mostly discomfort occur in the right side of the abdominal cavity and can radiate to the tailbone and lower back.

1. Separately, we need to talk about body temperature. It may be within normal limits. High indicators appear after purulent discharge entered the abdominal cavity. As a rule, the thermometer shows 37.2–37.5 degrees, no more.
2. Complete refusal to eat. The patient feels so bad that, thinking about food, he begins to develop a gag reflex.
3. Dry mouth, constant thirst.
4. The color of the tongue changes, a white coating appears.
5. The patient's pulse and blood pressure are increased.

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In children and older people, symptoms are more pronounced. The following signs can be identified:

1. A sharp rise in body temperature.
2. Cutting pain in the abdomen. The patient cannot accurately determine the location of the pain.
3. Diarrhea.
4. Cold sweat.
5. Severe fatigue, the child constantly asks to sleep.

If there are such signs, it is necessary to exclude appendicitis. This cannot be done without a blood test or ultrasound. In the gangrenous form, patients' abdomen is soft and there is no severe pain when pressed. Only when the situation reaches a critical point can you observe that a small protrusion has appeared on the right side of the peritoneum.

Treatment

Treatment of gangrenous appendicitis is carried out only after full diagnostics patient. It includes the following steps:

• External examination of the patient.
• Palpation of the abdominal cavity. The doctor needs to be extremely careful, one wrong move and strong pressure on the muscles can cause the appendix to rupture.
• Blood analysis. If the number of leukocytes increases (several times), the diagnosis is confirmed.
• Analysis of urine. Protein may appear.
• Ultrasound. If tissue necrosis occurs, the appendix is ​​not clearly visible.

It is important! Examination by one therapist will not be enough. You should definitely consult a surgeon. If the symptoms increase, the patient becomes worse, you need to call ambulance and go straight to the hospital.

Gangrenous appendicitis is not treated with medication; the only way is to remove the appendix.

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The main types of operation are as follows:

1. Cavity. Carried out only under general anesthesia. It lasts about 2-2.5 hours. An incision (10-15 cm) is made in the abdominal cavity, through which the appendage of the cecum is removed. The operation is quite complicated, the recovery period takes 7-10 days. For the first 2 days, the patient is in intensive care under the constant supervision of doctors.
2. Laparoscopy. Several punctures are made in the abdominal cavity. A special device with a camera is inserted, the doctor cuts off and removes the appendix. The operation takes 40-60 minutes. In this case, the patient can move around already on the first day. The rehabilitation period is 2-3 days. There is no need to remove stitches.

It is important! If possible, appendectomy (removal of the appendix) is not performed. Over the past few years, doctors have increasingly insisted on laparoscopy. This operation is much easier to tolerate and can be performed under epidural anesthesia, when the patient is conscious but does not feel bottom part of your body.

Rehabilitation period

After any operation, the patient needs a period of rehabilitation to regain his strength. As a rule, it takes up to 10 days. During this period the following manifestations are characteristic:

• temperature rise to 38 degrees;
• general malaise;
• drowsiness;
• pain in the abdominal area;
• constipation.

After removal of gangrenous appendicitis, the following treatment is necessary:

• Mandatory use of antibiotics. As a rule, the patient is administered drugs intravenously to achieve maximum effect.
• Taking painkillers. Prescribed on the first day after surgery.
• Saline solutions, glucose, plasma. Needed to maintain the required blood composition.
• Daily dressings. If they are not done, the seam may become inflamed. In this case, you cannot do without installing drainage.
• Special diet. It is an important component of treatment. IN as soon as possible After the operation, it is necessary to restore and normalize the functioning of the stomach and intestines. Constipation is one of the serious complications. If such problems are observed, the patient is prescribed gentle enemas of the Microlax type.

Possible complications after appendectomy

The consequences of gangrenous appendicitis can be serious, including death. The sooner the patient consults a doctor, the lower the risk of complications.

If there was no rupture of the appendix, the operation is performed as planned. As a rule, the patient is transferred to the general ward within 24 hours.

If peritonitis begins, the risk of complications after surgery is high:

• Inflammation of nearby tissues and organs. Occurs if the doctor made a mistake during the operation. Typically, repeat surgery is required.
• Supuration of the suture. Occurs if the dressing is not changed on time. Often it is necessary to install a drainage to drain the pus.
• Attachment of a viral or bacterial infection. This happens if the patient has a weakened immune system. Antiviral, antibacterial and other drugs are added to the main treatment.