Acute appendicitis(K35)
Pediatric surgery
general information
Short description
Russian Association of Pediatric Surgeons
Acute appendicitis in children(Moscow 2013)
Acute appendicitis - acute inflammation vermiform appendix of the cecum (classified according to ICD-10 in K.35).
Acute appendicitis- one of the most frequent illnesses abdominal cavity requiring surgical treatment.
IN childhood appendicitis develops faster, and destructive changes in the appendix, leading to appendiceal peritonitis, occur much more often than in adults. These patterns are most pronounced in children of the first years of life, which is due to anatomical and physiological characteristics child's body, influencing the character clinical picture diseases and in some cases requiring a special approach to solving tactical and therapeutic problems.
Acute appendicitis can occur at any age, including newborns, but is mainly observed after the age of 7 years; in children under 3 years of age, its incidence does not exceed 8%. The peak incidence occurs between the ages of 9 and 12 years. The overall incidence of appendicitis ranges from 3 to 6 per 1000 children. Girls and boys get sick equally often. Acute appendicitis is the most common cause of peritonitis in children over one year of age.
Classification
Classification
Acute appendicitis is classified according to morphological changes in the vermiform appendix. Attempts at preoperative diagnosis of the morphological form of acute appendicitis are extremely difficult and devoid of practical meaning.
In addition, there are uncomplicated and complicated appendicitis (periappendicular infiltrate and abscess, peritonitis).
Morphological classification of types of acute appendicitis
Non-destructive (simple, catarrhal);
Destructive:
Phlegmonous,
Gangrenous.
Particularly difficult for the clinician are non-destructive forms, the macroscopic assessment of which does not exclude subjectivity.
Most often, this form hides other diseases that simulate acute appendicitis.
Etiology and pathogenesis
ANATOMIC PECULIARITIES
Studying the Features surgical anatomy right iliac region in children is of great practical importance, both for diagnosing acute appendicitis and for performing surgical intervention. Of greatest interest is the topography of the ileocecal intestine - the most complex formation digestive tract. This is explained by the fact that in childhood a number of diseases can be localized in this area: birth defects development, intussusception, tumors, inflammatory processes.
Despite the variety of positions of the appendix, the following types of localization are most common.
Most often (up to 45%) the appendix has a descending position. With this location option, the appendix descends down to the area of the entrance to the pelvis. If the cecum is located low and the appendix is of sufficient length, its apex may be adjacent to bladder or the wall of the rectum.
With this variant of the location of the appendix, dysuric disorders and increased bowel movements may prevail in the clinical picture.
The anterior ascending position of the process is observed in 10% of patients. With this option, the clinical picture is most pronounced and usually does not cause diagnostic difficulties.
The posterior ascending (retrocecal) position of the appendix is observed in 20% of patients. In this option, the vermiform appendix is located behind the cecum and is directed dorsally upward. The retrocecal location of the appendix, especially if it is located retroperitoneally, creates the greatest diagnostic difficulties in appendicitis.
The lateral position of the process was noted in 10% of cases. Usually the process is located outside the cecum, directed slightly upward. Diagnosis of the disease with this location usually does not cause difficulties.
The medial position of the appendix occurs in 15% of cases. The process is directed towards the midline and its apex faces the root of the mesentery small intestine. IN in this case the clinical picture is atypical. The inflammatory process easily spreads to the entire abdominal cavity, causing diffuse peritonitis or the formation of interloop abscesses.
Knowledge of the anatomy and topography of the greater omentum is of practical importance. Depending on the age of the child, the position and size of the omentum are different. It is especially underdeveloped in children of the first years of life (thin, short, poor in fatty tissue).
Clinical picture
Symptoms, course
TOLINIC PAINTING ACUTE APPENDICITIS
The variety of clinical manifestations of acute appendicitis depends on the location of the appendix, the severity of the inflammatory process, the reactivity of the body and the age of the patient. The greatest difficulties arise in the group of children under 3 years of age.
In children over 3 years of age, acute appendicitis begins gradually. The main symptom is pain that occurs in the epigastric region or near the navel, then covers the entire abdomen and only after a few hours is localized in the right iliac region. Usually the pain is constant and aching.
Vomiting is usually observed in the first hours of the disease and, as a rule, occurs once. The tongue is slightly coated with white coating. A number of children experience stool retention. Liquid, frequent stool with an admixture of mucus is often observed with the pelvic location of the appendage.
Body temperature in the first hours can be normal or subfebrile. High fever numbers are not typical for uncomplicated forms of acute appendicitis. A characteristic symptom is tachycardia that does not correspond to the height of the fever.
The general condition of acute appendicitis suffers slightly, but can worsen when inflammation spreads to the peritoneum. Patients are usually in a forced position, lying on the right side with the lower limbs bent and pulled towards the stomach.
As a rule, in patients with acute appendicitis, sleep is disturbed; children sleep very restlessly, wake up in their sleep, or do not sleep at all. The appetite of a child with acute appendicitis is reduced or absent.
On examination, the shape of the abdomen is usually not changed. At the beginning of the disease, the anterior abdominal wall is involved in the act of breathing; as the inflammatory process spreads, a lag in the breathing of its right half becomes noticeable.
The most information for the doctor is palpation of the abdomen. Palpation of the abdomen is carried out according to generally accepted rules. It usually starts from the left iliac region in a counterclockwise direction. Superficial palpation allows you to identify local pain, tension in the muscles of the anterior abdominal wall. To ensure the absence or presence of rigidity of the muscles of the anterior abdominal wall, it is important to keep your hand on the stomach every time you change the point of palpation, waiting for the patient to inhale. This allows you to differentiate active voltage from passive.
Among the numerous symptoms of acute appendicitis, the most important are local pain in the right iliac region (94 - 95%), passive tension of the muscles of the anterior abdominal wall (86 - 87%) and symptoms of peritoneal irritation, primarily the Shchetkin-Blumberg symptom. However, symptoms of peritoneal irritation acquire diagnostic value only in children over 6-7 years of age and are not permanent (55-58%). Percussion of the anterior abdominal wall is usually painful.
A valuable diagnostic method is palpation of the abdomen during sleep, which allows one to identify local passive tension in the muscles of the anterior abdominal wall, especially in restless children, whose examination while awake is difficult.
In case of prolonged absence of stool (more than 24 hours), a cleansing enema is indicated. If the cause of abdominal pain was stool retention, then after performing an enema pain syndrome stopped.
In some cases, when there are difficulties in diagnosis, it is useful to conduct a rectal digital examination, especially in cases of pelvic location of the appendix or the presence of infiltration, which allows to identify pain in the anterior wall of the rectum. If the diagnosis of acute appendicitis is beyond doubt, a digital rectal examination is not a mandatory diagnostic procedure.
Features of the clinical picture in young children
In newborns, inflammation of the appendix develops extremely rarely and is diagnosed, as a rule, only with the development of peritonitis. Application modern means Imaging, primarily ultrasound, makes it possible to establish the diagnosis of acute appendicitis in newborns before complications develop.
The clinical picture of acute appendicitis in toddlers most often develops rapidly, against the background of complete health. The child becomes restless, capricious, refuses to eat, and body temperature rises to 38 - 39°C. Repeated vomiting occurs. Often develops multiple loose stool. Pathological impurities (blood streaks, mucus) can be detected in the stool.
Examining the abdomen in a young child is often difficult. The child is anxious and resists examination. Palpation of the abdomen in such patients should be carried out with warm hands, after calming the child.
In young children, there is a lag in the right half of the abdomen in the act of breathing and moderate swelling. Constant symptom is a passive tension of the muscles of the anterior abdominal wall, which can sometimes be difficult to identify if the child is restless.
General rule in the diagnosis of acute appendicitis in children is the following: what younger child, the more often the symptoms of intoxication prevail over the local clinical picture, reaching their peak in newborns, in whom local manifestations at the onset of the disease may be completely absent.
Diagnostics
DIAGNOSIS
The diagnosis of acute appendicitis is established on the basis of a combination of data from anamnesis, examination and a number of laboratory and instrumental diagnostic methods. In most cases, the diagnosis can be established only on the basis of the clinical picture without the use of additional research methods. Despite this, a number of diagnostic studies are mandatory.
It is mandatory to perform a clinical blood test, which reveals nonspecific changes characteristic of the inflammatory process: leukocytosis (usually up to 15 - 10 x 109/ml) with a shift of the formula to the left and acceleration of ESR.
On modern stage Patients with acute abdominal pain are advised to undergo an ultrasound examination, which allows one to identify both changes characteristic of acute appendicitis and visualize changes in the abdominal and pelvic organs, which can give a clinical picture similar to acute appendicitis. To obtain reliable information, the study should be carried out by a specialist who knows well anatomical features of the abdominal organs in children in normal and pathological conditions.
Ultrasound examination allows us to identify the appendix, which, when inflammation develops in it, is defined as a non-peristaltic tubular structure with thickened, hypoechoic walls, the lumen of which is filled with heterogeneous liquid contents or fecal stone. An accumulation of fluid is detected around the appendix, an edematous omentum adjacent to the appendix, enlarged mesenteric The lymph nodes with a hypoechoic structure.
Ultrasonography also makes it possible to detect complicated forms of appendicitis, primarily periappendicular infiltrate and abscess.
Diagnostic laparoscopy is the only way to preoperatively visually assess the condition of the appendix. The use of diagnostic laparoscopy in doubtful cases allows not only to establish the presence or absence of inflammation in the appendix, but also, when excluding the diagnosis of acute appendicitis, to conduct a gentle examination of the abdominal organs and in more than 1/3 of patients to identify the true cause of abdominal pain.
If there is any doubt about the diagnosis, the child must be hospitalized and undergo dynamic observation, which should not exceed 12 hours. The examination is carried out every 2 hours, which is recorded in the medical history indicating the date and time of the examination. If after 12 hours of observation the diagnosis cannot be excluded, surgical intervention is indicated.
Differential diagnosis
Differential diagnosis
Differential diagnosis is carried out with a number of diseases in which sharp pains in a stomach.
Pleuropneumonia, especially in young children, may be accompanied by abdominal pain. Clinical and radiological signs of pneumonia are quite typical and difficulties in diagnosis usually arise only at the very beginning of the disease. If there is doubt about the diagnosis, dynamic observation allows one to exclude the diagnosis of acute appendicitis.
Intestinal infections are accompanied by abdominal pain syndrome, however, in the vast majority of cases they are characterized by nausea, repeated vomiting, loose stools, cramping abdominal pain, and severe fever. In this case, the abdomen, as a rule, remains soft, and there are no symptoms of peritoneal irritation.
Dynamic observation also allows us to exclude the presence of acute surgical pathology.
Viral respiratory diseases often accompanied by abdominal pain. Careful history taking, clinical examination, ultrasonography and dynamic observation can exclude the diagnosis of acute appendicitis.
Abdominal Henoch-Schönlein disease syndrome accompanied by severe abdominal pain, nausea, vomiting, and increased body temperature. You should examine the child's skin very carefully, since Henoch-Schönlein disease usually has hemorrhagic petechial rashes, especially in the joint area.
Renal colic, especially in case of defeat right kidney may give a picture very similar to acute appendicitis. Conducting a urine test, ultrasound examination of the kidneys and urinary tract makes it possible to establish the correct diagnosis.
Acute surgical diseases of the abdominal organs(pelvioperitonitis, torsion of ovarian cyst, diverticulitis) can be quite difficult to differentiate from acute appendicitis.
Ultrasound examination in some cases makes it possible to identify such conditions. If the diagnosis cannot be excluded, emergency surgery is indicated; if appropriate conditions are present, diagnostic laparoscopy is performed.
It should be noted that even an accurate diagnosis of a disease simulating acute appendicitis does not allow us to exclude acute appendicitis itself, since their combination is possible, which should always be remembered.
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Treatment
TREATMENT OF CHILDREN WITH ACUTE APPENDICITIS
Treatment of acute appendicitis is only surgical.
Indications for emergency surgical treatment
Emergency surgical intervention immediately after hospitalization in a surgical hospital, or after short-term preoperative preparation (depending on the severity of the patient’s condition) is indicated:
When a diagnosis of acute appendicitis is made;
It is impossible to exclude it after carrying out the entire complex of diagnostic measures and dynamic observation for more than 12 hours.
Ppreoperative Preparation And anesthesia.
Children with uncomplicated forms of acute appendicitis, as a rule, do not need special preoperative preparation. Preoperative preparation is indicated for patients with repeated vomiting, high fever (above 38ºC) and other symptoms of severe intoxication. Correction of water and electrolyte disturbances and reduction of body temperature (NSAIDs, physical methods) are carried out. The duration of preoperative preparation should not exceed 2 hours.
The surgery is performed under general anesthesia using muscle relaxants and mechanical ventilation.
Before surgery, as part of premedication, or, more preferably, during induction of anesthesia, an antibacterial drug is administered. I - II generation cephalosporins are used: cefazolin 20 - 30 mg/kg, cefuroxime 20 - 30 mg/kg; semisynthetic penicillins: co-amoxiclav 25 mg/kg.
Surgical treatment
The operation for acute appendicitis is performed by a qualified doctor of the department, and on duty, the senior surgeon of the team with the obligatory presence of an assistant.
Currently, preference is given to laparoscopic appendectomy, which allows for a complete revision of the abdominal organs, is associated with a lower risk of developing adhesive complications and wound infections, is less traumatic and leads to an excellent cosmetic effect. Despite this, traditional intervention has not completely lost its significance.
Appendectomy is performed according to vital indications; the only contraindication to its implementation is the agonal state of the patient.
Ttraditional appendectomy
An incision is made in the right iliac region according to McBurney-Volkovich-Dyakonov. The cecum with the vermiform appendix is brought out into the wound. In the mesentery of the appendix at its base, a “window” is made with a clamp, through which a ligature of synthetic non-absorbable material 2-0 - 3-0 is passed, the mesentery is bandaged and cut off. It is permissible to perform appendectomy using both ligature and submersible methods. When performing an appendectomy using the submersible method, a purse-string suture with absorbable synthetic material 3-0 - 4-0 is first placed around the base of the appendix separated from the mesentery. A Kocher clamp is applied to the base of the appendix, the clamp is removed, and in this place the appendix is tied with a ligature of absorbable material. A Kocher clamp is applied above the ligature and the process is crossed between the clamp and the ligature. The stump of the appendix is treated with iodine solution and, if necessary, immersed with a purse-string suture into the wall of the cecum.
In cases where the appendix cannot be brought into the wound, a retrograde appendectomy is performed. The cecum is brought out into the wound as much as possible. Then the base of the process is clamped with a Kocher clamp and tied at this place with a ligature. The process is crossed between the clamp and the ligature. The stump is treated with iodine and immersed with a purse string suture. After this, the cecum becomes more mobile. The isolated process is removed into the wound, and its mesentery is bandaged.
The surgical wound is sutured tightly in layers.
Laparoscopic appendectomy
To perform a laparoscopic appendectomy, a number of conditions must be met.
- Availability of a specialist who knows the technique of laparoscopic interventions and has the appropriate certificate;
- Availability necessary equipment: monitor, digital video camera, insufflator, coagulator, carbon dioxide supply system (central distribution or cylinder) and special tools;
- Availability of an anesthesiologist who knows the technique of anesthesia for interventions accompanied by the imposition of carboxyperitoneum.
Laparoscopic interventions are contraindicated in severe concomitant pathology from the cardiovascular and respiratory systems. A relative contraindication is the presence of a pronounced adhesive process in the abdominal cavity. In each case, the possibility of performing laparoscopic intervention is decided with the participation of the operating surgeon, anesthesiologist and specialized specialist.
To carry out the intervention, three-millimeter instruments are used in children under three or four years of age and five- and ten-millimeter instruments in older children.
Trocars are installed at three points: through the navel, at McBurney's point on the left and above the womb. After introducing trocars and applying pneumoperitoneum, the abdominal cavity is examined. The examination begins with the right iliac region, then the pelvic cavity, left sections of the abdomen, top floor abdominal cavity.
In a typical location of the appendix, it is grabbed with a clamp and gently pulled. Using standard bipolar forceps, the mesentery of the appendix is coagulated from the apex to the base, followed by its intersection with scissors.
If the appendix is located atypically (retrocecal, retroperitoneal), a retroanterograde appendectomy is performed. A window is formed in the mesentery in the place where it is accessible for manipulation. After this, the mesentery is coagulated and divided first retrogradely to the apex, and then anterogradely to the base.
Next, 2 Raeder loops are placed on the base of the skeletonized appendix. To do this, the process is placed in a loop using a clamp, grabbed and slightly pulled. In this position, the loop is tightened at its base. The ligature is crossed.
At a distance of 5 - 6 mm from the ligature, bipolar coagulation of the appendage is performed, after which it is crossed along the lower border of the coagulation zone and removed from the abdominal cavity. The abdominal cavity is sanitized and the trocars are removed. Interrupted sutures are placed on the wounds.
POpostoperative treatment
IN postoperative period carry out antibacterial therapy. As a rule, a combination of 1st and 2nd generation cephalosporins or semisynthetic penicillins with aminoglycosides is used. Only third generation cephalosporins can be used. Required in the diagram metronidazole is added to antibacterial therapy. Antibacterial therapy carried out for 4 - 5 days.
They begin to feed the child from the first postoperative day, prescribe a gentle diet for 2 - 3 days, then the patient is transferred to a general age diet.
On the 4th - 5th postoperative day, a control ultrasound examination, clinical blood and urine analysis are performed. In the absence of complications (fluid accumulation, presence of infiltrate) and a normal picture of peripheral blood and urine after removal of the sutures (on the 7th day after traditional appendectomy and on the 4th - 5th after laparoscopic), the child can be discharged.
The child can attend preschool or school a week after discharge. From classes physical culture exemption is given for 1 month.
Information
Sources and literature
- Clinical recommendations of the Russian Association of Pediatric Surgeons
- 1. Isakov Yu. F., Stepanov E. A., Dronov A. F. Acute appendicitis in childhood. – M.: Medicine, 1980. 2. Stepanov E. A., Dronov A. F. Acute appendicitis in young children. – M.: Medicine, 1974. 3. Bairov G. A. Urgent surgery for children. – Guide for doctors. – St. Petersburg, 1997. – 323 p. 4. Bairov G. A., Roshal L. M. Purulent surgery for children: A guide for doctors. – L.: Medicine, 1991. – 272 p. 5. Operative surgery with topographic anatomy of childhood / Edited by Yu. F. Isakov, Yu. M. Lopukhin. – M.: Medicine, 1989. – 592 p. 6. Practical guidance for using the WHO Surgical Safety Checklist, 2009. Printed by the WHO Document Production Services, Geneva, Switzerland. 20 s. 7. Dronov A.F., Poddubny I.V., Kotlobovsky V.I. Endoscopic surgery in children / ed. Yu. F. Isakova, A. F. Dronova. – M.: GEOTAR-MED, 2002, – 440 p. 8. Acute appendicitis / In the book. Pediatric surgery: national guidelines / ed. Ed. Yu. F. Isakova, A. F. Dronova. – M., GEOTAR-Media, 2009. – 690 p. 1. Al-Ajerami Y. Sensitivity and specificity of ultrasound in the diagnosis of acute appendicitis. East Mediterr Health J. 2012 Jan; 18 (1): 66 – 9. 2. Blanc B, Pocard M. Surgical techniques of appendectomy for acute appendicitis. J Chir 2009 Oct; 146 Spec No 1:22 – 31. 3. Bravetti M, Cirocchi R, Giuliani D, De Sol A, Locci E, Spizzirri A, Lamura F, Giustozzi G, Sciannameo F. Laparoscopic appendectomy. Minerva Chir. 2007 Dec; 62 (6): 489 – 96. 4. Drăghici I, Drăghici L, Popescu M, Liţescu M. Laparoscopic exploration in pediatric surgery emergencies. J Med Life. 2010 Jan-Mar; 3 (1): 90 – 5. 5. Doria AS. Optimizing the role of imaging in appendicitis. Pediatr Radiol. 2009 Apr; 39 Suppl 2: S 144 – 8. 6. Kamphuis SJ, Tan EC, Kleizen K, Aronson DC, de Blaauw I. Acute appendicitis in very young children. Ned Tijdschr Geneeskd. 2010;154 7. Kapischke M, Pries A, Caliebe A. Short term and long term results after open vs. laparoscopic appendectomy in childhood and adolescence: a subgroup analysis. BMC Pediatr. 2013 Oct 1; 13:154. 8. Lee SL, Islam S, Cassidy LD, Abdullah F, Arca MJ. Antibiotics and appendicitis in the pediatric population: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review., 2010 American Pediatric Surgical Association Outcomes and Clinical Trials Committee. J Pediatr Surg. 2010 Nov; 45 (11): 2181 – 5. 9. Müller AM, Kaucevic M, Coerdt W, Turial S. Appendicitis in childhood: correlation of clinical data with histopathological findings. Klin Padiatr. 2010 Dec; 222 (7): 449 – 54. 10. Quigley AJ, Stafrace S. Ultrasound assessment of acute appendicitis in pediatric patients: methodology and pictorial overview of findings seen. Insights Imaging. 2013 Aug 31. 22 11.Sinha S, Salter MC. Atypical acute appendicitis. Emerg Med J. 2009 Dec; 26(12): 856. 12.Vainrib M, Buklan G, Gutermacher M, Lazar L, Werner M, Rathaus V, Erez I. The impact of early sonographic evaluation on hospital admissions of children with suspected acute appendicitis. Pediatr Surg Int. 2011. Sep; 27 (9): 981 – 4.
Information
DEVELOPERS PUBLICATIONS
Chief Editor ROSINOV Vladimir Mikhailovich, doctor medical sciences, professor, deputy director of the Moscow Research Institute of Pediatrics and Pediatric Surgery of the Russian Ministry of Health
METHODOLOGY WITHBUILDINGS AND PROGRAM SECURITYQUALITIES CLINICAL RECOMMENDATIONS
ANDinformational resources, used For development clinical recommendations:
· Electronic databases (MEDLINE, PUBMED);
· Consolidated clinical experience of leading pediatric clinics in Moscow;
· Thematic monographs published in the period 1952 - 2012.
Methods, used For assessments quality And reliability clinical recommendations:
· consensus of experts (composition of the specialized commission of the Ministry of Health of Russia in the specialty “pediatric surgery”);
· significance assessment in accordance with the rating scheme (table).
|
Level A |
High reliability |
Based on findings from systematic reviews and meta-analyses. Systematic review - a systematic search of data from all published clinical trials with a critical assessment of their quality and synthesis of the results using meta-analysis. |
|
Level IN |
Moderate confidence |
Based on the results of several independent randomized controlled clinical trials |
|
Level WITH |
Limited validity |
Based on results from cohort and case-control studies |
|
Level D |
Uncertain validity |
Based on expert opinion or case series |
ANDindicators benign practices (Good Practice Points - GPPs): Recommended good practice is based on the clinical experience of members working group for developing recommendations.
Eeconomic analysis: was not carried out
ABOUTscripture method validation recommendations:
The preliminary version of the recommendations was reviewed by independent external experts, whose comments were taken into account in the preparation of this edition.
ABOUTTindoor discussion clinical recommendations:
· in the form of discussions held at the round table “Acute appendicitis in children” within the framework of the Moscow Assembly “Capital Health” (Moscow, 2012);
· Russian Symposium of Pediatric Surgeons “Peritonitis in Children” (Astrakhan, 2013);
· a preliminary version was posted for wide discussion on the RADH website, so that persons not participating in the congress had the opportunity to take part in the discussion and improvement of the recommendations;
· Text clinical recommendations published in the scientific and practical journal “Russian Bulletin of Pediatric Surgery, Anesthesiology and Reanimatology”
Working group:
The final revision and quality control of the guideline were re-reviewed by members of the working group, who concluded that all expert comments were taken into account and the risk of bias in the development of guidelines was minimized.
WITHOholding
Recommendations include detailed description sequential actions of the surgeon in certain clinical situations. In-depth information about the epidemiology and etiopathogenesis of the processes under consideration is presented in special manuals.
Guarantees
The relevance of clinical recommendations, their reliability, generalization based on modern knowledge and world experience, applicability in practice, and clinical effectiveness are guaranteed.
ABOUTbinnovation
As new knowledge emerges about the essence of the disease, appropriate changes and additions will be made to the recommendations. These clinical guidelines are based on research published between 2000 and 2013.
WITHAfashion sufficiency
The format of clinical recommendations includes the definition of the disease, epidemiology, classification, including, in accordance with ICD-10, clinical manifestations, diagnostics, different kinds treatment. The choice of the topic of clinical recommendations is motivated by the high frequency of occurrence of the pathological condition in question, its clinical and social significance.
Aataudience
Clinical recommendations are intended for pediatric surgeons, general surgeons providing medical care children, students of higher education and postgraduate education.
Attached files
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Acute appendicitis- the most common childhood disease that requires emergency surgical care. Unlike adults, the clinical course of acute appendicitis in children is more severe, and diagnosis is much more difficult. These patterns are most pronounced in children in the first years of life, which is due to the anatomical and physiological characteristics of the child’s development.
- Firstly, due to functional immaturity nervous system at this age almost everyone is acute inflammatory diseases have a similar clinical picture ( heat, repeated vomiting, impaired bowel function).
- Secondly, the inflammatory process in the appendix in children is extremely violent. At the same time, the mechanisms of its delimitation are poorly expressed.
- Thirdly, there are specific difficulties in examining young children. Anxiety, crying, and resistance to examination make it difficult to identify the main local symptoms of acute appendicitis.
Acute appendicitis occurs in children of all ages, including newborns. However, in infancy it occurs extremely rarely, but later its frequency gradually increases, reaching a maximum by 10-12 years.
The rarity of appendicitis in children under one year of age is explained by the characteristics anatomical structure vermiform appendix (no stagnation of intestinal contents) and the nature of nutrition at this age (mainly liquid dairy foods).
The follicular apparatus of the appendix plays a certain role in the occurrence of the inflammatory process. In children of the first year of life, there is a small number of follicles in the mucous membrane of the appendix. With age, the number of follicles increases, and in parallel with this, the incidence of appendicitis increases. Boys and girls get sick equally often.
There is no specific microbial pathogen for acute appendicitis. In the development of inflammation, the leading role belongs to the own microflora of the appendix and intestines. A hematogenous and lymphogenous route of infection is possible, since there is a direct connection with past diseases: acute respiratory viral infections, follicular tonsillitis, otitis media, etc.
The influence of the neurovascular factor also leaves no doubt: the younger the child, the faster destructive-necrotic changes in the wall of the appendix occur, which is apparently associated with the immaturity of the nervous apparatus of the appendix and ileocecal region. The role of local immunity cannot be excluded.
A number of morphological characteristics of young children predispose to the rapid development of vascular reactions and the addition of a bacterial component. In children, the intestinal mucosa is more permeable to microflora and toxic substances than in adults, therefore, when vascular trophism is disrupted, rapid infection of the affected appendix and accelerated development of severe destructive forms of appendicitis, including gangrenous-perforative, occurs.
In the prevention of appendicitis in children great importance it is necessary to give proper diet, monitoring regular bowel function and treating chronic inflammatory diseases.
Consequently, acute appendicitis in children, as in adults, has common fundamental patterns in the main etiological and pathogenetic links. However, the anatomical and physiological characteristics of the ileocecal region and the abdominal cavity as a whole determine significant differences in the frequency and development of the inflammatory process in the appendix in children of different age groups.
Clinical picture and diagnosis of acute appendicitis in children
Clinical manifestations of acute appendicitis in children are very diverse and largely depend on the reactivity of the body, the anatomical position of the appendix and the age of the child. The most general characteristic of the clinical picture of the disease is the predominance of general nonspecific symptoms over local ones. In the genesis of such reactions, the relative immaturity of individual organs and systems, primarily the central and autonomic nervous systems, is important. These phenomena are more pronounced the younger the child.
The difficulties of diagnosis are also aggravated by the difficulties of examining children and identifying objective local signs of the disease. Their reliability depends on a number of factors (degree of contact with the child, mastery of examination techniques, individual experience of the doctor, etc.). The influence of these factors is especially noticeable when recognizing acute appendicitis in young children.
In connection with these circumstances, it is necessary to separately consider the issues of clinical picture and diagnosis in children of the first 3 years of life and the older age group.
Typical clinical picture of acute appendicitis in older children is more distinct and consists of the following main features:
- abdominal pain,
- temperature rise,
- vomiting,
- stool retention,
- abdominal muscle tension,
- leukocytosis.
Stomach ache most often arise gradually and have a constant aching character. In the first hours of the disease, they are noted throughout the abdomen or in the epigastric region. Subsequently, the pain is more clearly localized in the right iliac region, intensifying with movement.
The highest intensity of pain is observed in the first hours of the disease, then due to the death of the nervous apparatus of the appendix, the pain decreases. Appendicitis is characterized by continuous pain that does not disappear, but only subsides somewhat. Continuity of pain leads to sleep disturbances, causing children to wake up frequently.
During an attack, patients most often lie on their back or right side. Very rarely, the child lies on his left side, since the movement and tension of the cecum with the inflamed appendix increases the pain.
Sometimes the pain syndrome is of significant intensity. At the same time, children periodically complain of sharp abdominal pain, rush about, and take a forced position. A pronounced pain reaction is associated with overstretching of the appendix, which is filled with pus.
Vomit- a fairly constant symptom of acute appendicitis in children, mainly observed on the first day of the disease (reflex) and usually occurs once or twice. In the later stages of development of diffuse purulent peritonitis, vomiting is more persistent; an admixture of bile appears in it.
Temperature, as a rule, does not exceed 37.5-38°C. Only in severe, complicated forms of appendicitis (diffuse peritonitis, periappendiceal abscess, infiltrate in the abscess stage) does the temperature reach 39°C and higher. At the same time, it must be remembered that in some cases (about 15%), the temperature can be normal in all stages of the disease, and during surgery in these patients, gross destructive changes in the appendix are sometimes detected, up to perforation and the development of peritonitis.
Symptom of discrepancy between pulse and temperature in children It is very rare and, as a rule, is observed with severe diffuse purulent peritonitis.
At the beginning of the disease, the tongue is usually clean, sometimes slightly coated. As the inflammatory process in the abdominal cavity generalizes, the tongue becomes dry, and more pronounced overlays appear on it. Many patients experience stool retention. Loose stools are rare and occur no earlier than on the 2nd day from the onset of the disease. On the blood side, there is an increase in the number of leukocytes in the range of II,000-15,000 and a shift of white blood to the left.
When examining the abdomen, pay attention to three main peritoneal symptoms expressed in the right iliac region: pain on palpation, passive muscle tension and Shchetkin-Blumberg symptom. All other symptoms in children are non-specific.
Palpation of the child's abdomen always begins from the left iliac region in a counterclockwise direction. In the presence of acute appendicitis, increased pain on palpation in the right iliac region (Filatov's symptom) can be noted. This is very important sign, which in practice is called “local soreness”.
Another leading objective symptom of acute appendicitis is passive muscle tension in the right iliac region. To ensure the absence or presence of “rigidity” of the muscles of the anterior abdominal wall, each time you change the point of palpation, hold your hand on the stomach, waiting for the patient to inhale. Thus, it is possible to differentiate active tension from passive (true) tension, which is detected only with comparative repeated palpation. Sometimes the doctor puts his right hand on the left iliac region of the patient, and the left hand on the right iliac region and, alternately pressing on the right and left, tries to find the difference in muscle tone.
The described clinical picture is observed in the majority of patients. However with atypical location of the appendix (15%) the clinical picture of acute appendicitis is blurred, which makes it much more difficult timely diagnosis. So, with a low location of the vermiform appendix in pathological process organs and peritoneum of the small pelvis are involved. In this case, the pain is localized above the womb and somewhat to the right, usually cramping. Loose stools and frequent urination may occur. If the apex of the process is located medially (closer to the root of the mesentery), then cramping pain in the abdomen, closer to the navel, and increased intestinal motility are observed. Sometimes there is moderate bloating and loose stools.
With retrocecal localization, the process is covered by the dome of the cecum and the peritoneum of the anterior abdominal wall is involved in the inflammatory process later, hence the pain and muscle weakness are less pronounced. The retroperitoneally located vermiform appendix significantly complicates the diagnosis of acute appendicitis. Its clinical manifestations resemble renal colic. Typically, children complain of moderate pain in the right lumbar region, radiating to the groin area, sometimes to the liver area, simulating the clinical picture of acute cholecystitis.
An atypical clinical picture is also characteristic of appendicitis that develops due to the use of antibiotics. It should be noted that this is the most dangerous group of patients, since the fading of the severity of clinical manifestations in them does not at all mean that the destructive and purulent process has stopped.
Diagnosis of acute appendicitis in older children with a typical clinical picture does not present any particular difficulties. It should only be noted that plank-shaped muscle defence is rarely observed. Most often, moderate but constant rigidity of the anterior abdominal wall is noted. The Shchetkin-Blumberg symptom usually indicates involvement of the peritoneum in the inflammatory process and, depending on the extent of peritonitis, is determined either in the right iliac region or throughout the entire abdomen. This symptom is determined by gradual deep pressure on the anterior abdominal wall, followed by “quick withdrawal of the hand in various parts of the abdomen. With a positive Shchetkin-Blumberg symptom, the child reacts to the pain that arises.
The above variants of the position of the vermiform appendix pose a significant difficulty for diagnosis. They give an atypical course of acute appendicitis and are often the reason for an erroneous diagnosis. In this case, to correctly establish it, dynamic observation of the patient in a hospital setting is necessary. It can be difficult to correctly assess the subjective and objective data of atypical acute appendicitis in children at the first examination. Firstly, the clinical picture of acute appendicitis can be simulated by other diseases; secondly, abdominal pain in a child is not always caused only by inflammation of the appendix. School-age children, in some cases, tend to hide pain, fearing surgery; sometimes, on the contrary, they aggravate it. This is of great practical importance, since many surgeons perform appendectomy in children for extended indications, that is, they prefer overdiagnosis of appendicitis, which is not always justified.
In difficult to diagnose cases, a digital rectal bimanual examination is necessary. This makes it possible in many cases to identify the presence of a complication (appendicular infiltrate) or clarify the diagnosis, especially in the prepubertal and pubertal periods in girls (follicular and luteal cysts, torsion of ovarian cysts, pain during an unsteady menstrual cycle).
Examination through the rectum in the presence of acute appendicitis reveals pain in the rectal wall in front and on the right, and in some cases, overhang of the arch on the right. These data and the constantly detected local pain on palpation are, in combination with other symptoms, a certain criterion for making a diagnosis.
Differential diagnosis of acute appendicitis in children is very difficult. This is due to the fact that acute appendicitis in childhood in its clinical manifestation (especially with atypical locations of the appendix) simulates a large number of diseases, which generally do not require surgical intervention. There are even more diseases, both somatic and surgical (with localization in the abdominal cavity and outside it), which in turn are disguised as acute appendicitis.
Of great practical importance is the question of the duration of observation of the patient in cases of unclear clinical picture and the difficulties of differential diagnosis that arise. In children, one should never rely on delineating the inflammatory process in the appendix. It is important to carry out all the necessary clinical studies as soon as possible, involving, if necessary, doctors of related professions (pediatrician, infectious disease specialist, otolaryngologist) for consultations. Usually 2-6 hours of active observation are sufficient to make a final diagnosis. In some cases, these deadlines may be changed.
The complexity of diagnosis in children is also explained by the fact that the range of diseases with which acute appendicitis has to be differentiated changes depending on age. In children of the first years of life, diagnostic errors are often caused by diseases that occur mainly at this age (otitis media, intussusception, childhood infections, pneumonia, etc.). In older age differential diagnosis it is necessary to carry out mainly with diseases of the gastrointestinal tract, pathology of the genitals in girls and urological diseases. Finally, there are a number of diseases (for example, acute respiratory infections), which are accompanied by abdominal pain, are common in children of all ages, but most often they occur with a clinical picture simulating acute appendicitis in early childhood. This is due to a number of anatomical and physiological characteristics of the child’s body.
Isakov Yu. F. Pediatric surgery, 1983
Features of the course of acute appendicitis in children:
1) rarely develops in children under 2 years of age, most often over 7 years of age, because at an early age the lymphatic apparatus is not yet developed.
2) in young children the greater omentum is underdeveloped. It is smaller, thinner and shorter than in adults, and only by 7-8 years does it reach the right iliac region, and then not always. The plastic properties of the peritoneum in children are not sufficiently developed and their resistance to infections. demoted. Inflammatory process p.o. progresses faster in them than in adults, and often already in the first sex. days from the onset of the disease leads to destruction and perforation. Therefore, diffuse peritonitis quickly developed.
3) Har-but hyper-reactive. condition, predominant general symptoms(does not have local reactions to the process), often toxic forms: getting sick. began acutely, the child behaves restlessly due to the strong abdominal pain, repeated vomiting, in some cases at the beginning of the disease - frequent liquid. chair. t has increased to 38.5-39.5 degrees, the pulse is frequent, corresponding to t. The tongue is coated and moist.
4) Children are difficult to examine, so take them medicated sleep or chloral hydrate enemas. Currently - mask anesthesia (fluoroethane) - pain and muscle tension with appendicitis are preserved. In this case - + the symptom of “pushing away the hand” (palpation of the left half of the abdomen does not cause noticeable anxiety in the child, with palpation of the right half the anxiety intensifies, and the child pushes the doctor’s hand away with his own hands), + the symptom of “pulling up the legs” (with symmetrical palpation of both palpation of the iliac regions on the right is accompanied by flexion of the child’s right leg).
Features of the course of acute appendicitis in pregnant women (usually from 4 months of pregnancy):
1) change the position of the c.o. (due to uterine enlargement)
2) it is difficult to determine muscle tension, because the uterus stretches them
3) take it. woman during examination. being in a position on the left side (the uterus shifts to the left and the right iliac region is released during palpation) + per rectum.
4) Difficult diagnosis during childbirth
5) Inflammatory exudate easily spreads throughout all parts of the abdominal cavity, because h.o. pushed upward by the pregnant uterus, lies freely between the loops of intestines, the greater omentum is pushed upward - a condition for peritonitis.
6) You can remove the fallopian tube instead of p.o.
7) After the operation, m.b. miscarriage.
8) In the second trimester of pregnancy, tissue hydration increases significantly, so the wound heals more difficult.
Features of the current appendicitis in the elderly:
1) all symptoms are blurred - unresponsiveness, connection. with involutionary processes
2) flabbiness of the muscles of the anterior abdominal wall (weak muscle tension)
3) the patient cannot localize abdominal pain
4) more often destruction of the c.o., because there are sclerotic changes on the part of the vessels
5) it is difficult to differentiate appendiceal infiltrate from cecal cancer
6) after surgery it is often complicated. from the outside; lungs, heart, blood vessels
7) older people have life experience; they have had stomach pain more than once. He won’t follow the direction on his own, he needs to be convinced.
Acute appendicitis occurs less frequently than in adults, up to 5 years of age it is especially rare due to the funnel-shaped shape of the appendix, which empties well, and the weakness of the lymphoid apparatus of the appendix at this age.
Its incidence is 0.5–0.8 per 1000 children, mortality varies from 0.008 in the older age group to 3–4% in children of the first three years of life.
SYMPTOMS AND DIAGNOSIS
In children, the clinical manifestations of acute illness are more pronounced. Abdominal pain is cramping in nature and does not have a clear dynamics; children cannot localize the pain. Vomiting in children is often repeated, stools do not tend to be delayed, and in young children they even become more frequent. The position of the child is typical: he lies on his right side or on his back, bringing his legs to his stomach and placing his hand on the right iliac region, protecting it from inspection.
Feeling the child’s abdomen should begin with its left half, placing the entire palm on it and gently stroking and very light pressure with your fingertips, determining the difference in tension in the left and right sides.
With careful palpation it is determined increased sensitivity, muscle tension and greatest pain in the right iliac region. Local pain when palpating the abdomen is manifested by the child's cry. It is better to examine restless children in their mother's arms or during sleep.
Already in the first hours of the disease, the symptoms of Shchetkin - Blumberg, Voskresensky, Krymov, Rovziig, Sitkovsky, Bartomier - Michelson are clearly expressed. Body temperature 39–40 °C, leukocytosis is moderate. In children under 3 years of age, general symptoms of the disease prevail over local ones; in them, inflammation from the appendix quickly spreads to the surrounding peritoneum.
In children, the doctor makes a differential diagnosis of acute appendicitis with acute pneumonia, gastroenteritis, dysentery, and hemorrhagic capillary toxicosis.
In case of acute pneumonia, you need to remember that the disease is manifested not only by pain spreading to the abdominal area, but also by cough, blue lips, wings of the nose, shortness of breath; the ratio of respiratory rate and pulse changes (in pneumonia 1:2, in healthy children 1:4). Wheezing and decreased breathing are heard in the lungs.
Gastroenteritis and dysentery, as a rule, begin not with abdominal pain, but with vomiting and the appearance of loose stools with mucus and blood. Abdominal pain appears later and has a clear cramping character, accompanied by false urges to defecation (tenez-mami). The temperature is elevated, leukocytosis is absent.
With capillarotoxicosis, abdominal pain is caused by many small subserous hemorrhages and does not have a clear localization. Hemorrhagic exanthems are visible on the skin on symmetrical areas of the trunk and limbs, rectal examination reveals blood in the rectum.
TREATMENT
A cleansing enema of a 1% solution is often used for abdominal pain and flatulence. table salt room temperature; with intestinal dyskinesia, coprostasis and extra-abdominal diseases, after bowel movement the child’s posture improves, the size of the abdomen decreases, which makes it possible to ensure that there is no tension in the abdominal wall and pain.
After an enema for acute surgical pathology, the picture does not change or even worsens. But an enema can be prescribed only if perforation of a hollow organ is excluded. Due to diagnostic difficulties, children under 3 years of age with abdominal pain are subject to hospitalization in surgery department for observation; All children, regardless of age, are subject to hospitalization if they re-apply with complaints of abdominal pain.
Surgical tactics in children are more active than in adults, since in them appendicitis becomes destructive during the first day of the disease, an appendicular seal is formed already on the second day of the disease, surgical treatment indicated even with a developing appendicular compaction.
Acute appendicitis may develop in children with infectious diseases. In 5-10% of patients it develops against the background of acute infectious gastroenteritis and enterocolitis. More often than others, salmonellosis, yersiniosis, and dysentery play a role in the development of acute appendicitis.
In the mechanism of development of appendicitis in infectious gastroenteritis, rapid penetration is important pathogenic organisms into the wall, increased intestinal peristalsis, leading to the throwing of fecal stones into the appendix and disturbances in the blood supply to the wall of the appendix, reaction of the lymphoid tissue of the appendix, damage to the serous membrane in chickenpox, compression of the appendix by enlarged lymph nodes.
In acute intestinal infectious diseases, inflammation of the peritoneum develops as a result of the prolonged entry of endogenous microflora through the resulting defect in its wall. Major complaints of abdominal pain various localizations, temperature increase; nausea, vomiting, frequent loose stools, general malaise, anxiety, signs of dehydration. Patients with such symptoms should undergo abdominal ultrasound and diagnostic laparoscopy. Patients arrive late, on the 2-14th day from the moment of illness.
When examining and treating suspected appendicitis and the presence of infectious diseases, the following tactics are used:
Anxiety, loss of appetite, refusal to eat, vomiting, abdominal pain, repeated loose stools require hospitalization in a multidisciplinary hospital; antibiotics and analgesics cannot be prescribed at home;
Performance general analysis blood, calculation of leukocyte index of intoxication;
Ultrasound examination of the abdominal organs in patients with suspected acute appendicitis and infectious diseases;
To reduce the amount of purulent postoperative complications in patients with acute appendicitis combined with infectious diseases, use modern antibacterial drugs - cephalosporins (cephalosporins of the III, IV generations), combination drugs of penicillins and clavulanic acid, fluoroquinolones. These drugs are bactericidal against most pathogens intestinal infection;
In complex diagnostic cases, diagnostic laparoscopy is performed, which can lead to therapeutic laparoscopic appendectomy;
Express microscopy of stool and vomit is required. Treatment of intestinal infection in patients operated on for appendicitis should be etiotropic; when the pathogen is isolated, its sensitivity to antibiotics and bacteriophages should be established.
Be sure to restore the water balance, preferably with rehydron; transfusion of glucose-salt solutions. Enterosorbents - smecta, filtrum, activated carbon to eliminate enterotoxins. Biological products - normoflorin A and B, linex, probifor, bifidumbacterin, lactobacterin to restore the normal composition of intestinal microflora.
Digestive enzymes - Pancreatin, Mezim-Forte, Creon - restore impaired pancreatic function, which often accompanies intestinal infections. Antibacterial drugs are prescribed from the first day after surgery; they act directly on pathogens of intestinal infections in the intestinal lumen.
