ACUTE APPENDICITIS

Аннотация

Acute appendicitis is the most common reason for abdominal surgery. Luminal obstruction of the appendix progresses to suppurative inflammation and perforation, which causes generalised peritonitis or an appendix mass/abscess. Classical features include periumbilical pain that migrates to the right iliac fossa, anorexia, fever, and tenderness and guarding in the right iliac fossa. Atypical presentations are particularly common in preschool children. A clinical diagnosis is possible in most cases, after a period of active observation if necessary; inflammatory markers and an ultrasound scan are useful investigations when the diagnosis is uncertain. Treatment is by appendicectomy after appropriate fluid resuscitation, analgesia and intravenous antibiotics. Laparoscopic appendicectomy is better than open appendicectomy in most cases because it is associated with less postoperative pain and a shorter hospital stay, but recovery after acute appendicitis is mostly dictated by whether the appendix was perforated or not. Management of the appendix mass remains controversial and not all affected children need an interval appendicectomy. This article discusses tips and pitfalls in diagnosis and addresses many of the controversies that surround the management of this condition. Key words: abdominal pain; appendix; laparoscopic appendicectomy; surgery. ОСТРЫЙ АППЕНДИЦИТ Аннотация. Острый аппендицит является наиболее частой причиной абдоминальной хирургии. Обструкция просвета аппендикса прогрессирует до гнойного воспаления и перфорации, что вызывает генерализованный перитонит или массу аппендикса/абсцесс. Классические признаки включают боль в области пупка, которая мигрирует в правую подвздошную ямку, анорексию, лихорадку, болезненность и напряжение в правой подвздошной ямке. Атипичные проявления особенно распространены у детей дошкольного возраста. Клинический диагноз возможен в большинстве случаев после периода активного наблюдения, если необходимо; маркеры воспаления и ультразвуковое сканирование являются полезными исследованиями, когда диагноз неясен. Лечение заключается в аппендэктомии после соответствующей инфузионной терапии, анальгезии и внутривенных антибиотиков. Лапароскопическая аппендэктомия лучше открытой аппендэктомии в большинстве случаев, поскольку она связана с меньшей послеоперационной болью и более коротким пребыванием в больнице, но восстановление после острого аппендицита в основном диктуется тем, был ли аппендикс перфорирован или нет. Лечение аппендикса остается спорным, и не всем пострадавшим детям 537 ResearchBib IF - 11.01, ISSN: 3030-3753, Volume 2 Issue 2 требуется интервальная аппендэктомия. В этой статье обсуждаются советы и подводные камни в диагностике и рассматриваются многие противоречия, которые окружают лечение этого состояния. Ключевые слова: боль в животе; аппендикс; лапароскопическая аппендэктомия; хирургия. Etiology Luminal obstruction from mucosal inflammation, lymphoid hyperplasia or faecolith causes appendiceal distension and inflammation, which progresses to suppurative transmural inflammation, ischaemia, infarction and perforation. Minor episodes of mucosal inflammation can probably resolve spontaneously and may account for reports of prior self-limiting episodes of similar pain in some patients with acute appendicitis. The inflamed appendix may become walled off by omentum and surrounding viscera to form an inflammatory mass. The incidence of macroscopic appendiceal perforation is variable but is around 25–35% in large series. Appendiceal perforation progresses to generalised peritonitis or a localised walled off collection of pus. A faecolith is found in about 28% of children with acute appendicitis. Common bacterial isolates in perforated appendicitis include Bacteroides fragilis, Escherichia coli, Pseudomonas aeruginosa, Peptostreptococcus species and Fusobacteria. Pinworms are found in a small but variable proportion of appendicectomy specimens removed for suspected acute appendicitis, and there is debate about whether these worms actually cause acute appendicitis. Since pinworms are most often seen in non-inflamed appendices, the general perception is that they very rarely cause appendicitis but may sometimes cause abdominal pain mimicking acute appendicitis. Twin studies suggest that there may be a small genetic predisposition to acute appendicitis, and a positive family history is often elicited Presentation Most diagnoses are made based upon the history, clinical examination and laboratory tests. In all cases there is no value in with holding analgesia for fear of concealing symptoms. Active monitoring is a useful strategy in systemically well patients with equivocal symptoms, serial examinations and blood tests performed over a 24e 48 hour period significantly improves sensitivity. Imaging is mostly performed when there is diagnostic uncertainty and widely employed in children, young women and older adults. Particular vigilance is needed in high-risk groups, extremes