Acute appendicitisAcute appendicitis

MINISTRY OF EDUCATION AND SCIENCE OF UKRAINE V.N. Karazin Kharkov National University

Acute appendicitis is an Acute appendicitis is an inflammation of vermiform appendix inflammation of vermiform appendix caused by festering microflora. It is caused by festering microflora. It is the most common acute surgical the most common acute surgical

disease of the abdomen. It affects 6-disease of the abdomen. It affects 6-7 % of the population. The mortality 7 % of the population. The mortality is about 0,2-0,3 % and depends on is about 0,2-0,3 % and depends on complication of acute appendicitis. complication of acute appendicitis.

AnatomyAnatomya blind muscular tube with a blind muscular tube with mucosal, submucosal, muscular and mucosal, submucosal, muscular and serosal layersserosal layersAt birth, appendix is short and At birth, appendix is short and broad at its junction with the broad at its junction with the caecum, but differential growth of caecum, but differential growth of the caecum the caecum typical tubular typical tubular structure by about the age of 2 structure by about the age of 2 years years During childhood, continued During childhood, continued growth of the caecum commonly growth of the caecum commonly rotates the appendix into a rotates the appendix into a retrocaecal but intraperitoneal retrocaecal but intraperitoneal positionpositionPosition of the base of the Position of the base of the appendix is constant, being found appendix is constant, being found at the confluence of the three at the confluence of the three taeniae coli of the caecum, which taeniae coli of the caecum, which fuse to form the outer longitudinal fuse to form the outer longitudinal muscle coat of the appendix.muscle coat of the appendix.

AnatomyAnatomyThe blood supply by the appendicular artery which arises from the ileocolic artery and the only blood supply so therefore an end artery which arises from the superior mesenteric artery drain by ileocolic vein. The lymphatic pass to the lymphatic noduls in the mesoappendix and to the ileocolic lymphatic noduls along the ileocolic artery than to superior mesenteric lymphatic noduls.

Various positions of the Various positions of the appendix:appendix:

The position of the appendix is variableThe position of the appendix is variableretrocaecal (75%)retrocaecal (75%)pelvic (20%) pelvic (20%) front or behind the ileum (5%)front or behind the ileum (5%)paracolicparacolicsubhepatic. subhepatic.

Special Features Based OnSpecial Features Based OnAppendix LocationsAppendix Locations

Etiology and pathogenesisEtiology and pathogenesisMost frequent causes of acute appendicitis are festering microbes: Most frequent causes of acute appendicitis are festering microbes: intestinal stick, streptococcus, staphylococcus. Microflora can be intestinal stick, streptococcus, staphylococcus. Microflora can be present in the cavity of appendix or range by hematogenic, present in the cavity of appendix or range by hematogenic, lymphogenic ways. lymphogenic ways. Factors which promote the beginning of appendicitis : Factors which promote the beginning of appendicitis : 1. Change of reactivity of organism; 1. Change of reactivity of organism; 2. Constipation and atony of intestine; 2. Constipation and atony of intestine; 3. Excrement stone in its cavity; 3. Excrement stone in its cavity; 4. Thrombosis of vessels of appendix and gangrene of the wall as a 4. Thrombosis of vessels of appendix and gangrene of the wall as a part of inflammatory process; part of inflammatory process; 5. Obstruction (lymph glands, mechanical reason, excrement stone 5. Obstruction (lymph glands, mechanical reason, excrement stone in its cavity, food residue, ascarid, tumor, etc. in its cavity, food residue, ascarid, tumor, etc. 6. Gastrointestial disease; 6. Gastrointestial disease; 7. Bacteria invasion. 7. Bacteria invasion.

ClassificationClassification (by V.I. Kolesnikov)(by V.I. Kolesnikov)1. Appendiceal colic.2. Simple superficial appendicitis.3. Destructive appendicitis:

а) phlegmonous;б) gangrenous;в) perforated.

4. Complicated appendicitis:а) appendicular infiltrate;б) appendicular abscess;в) diffuse purulent peritonitis.

5. Other complications of acute appendicitis (pylephlebitis, sepsis, retroperitoneal phlegmon, local abscesses of abdominal cavity).

Acute simple appendicitisAcute simple appendicitis

In simple appendicitis the changes are In simple appendicitis the changes are observed, mainly, in the distal part of appendix. observed, mainly, in the distal part of appendix.

There is stasis in capillaries and venules, There is stasis in capillaries and venules, edema and hemorrhage. Focus of festering edema and hemorrhage. Focus of festering inflammation of mucus membrane with the inflammation of mucus membrane with the

defect of the epithelium is seen in 1-2 hours defect of the epithelium is seen in 1-2 hours (primary affect of Ashoff). This characterizes (primary affect of Ashoff). This characterizes

acute superficial appendicitis. acute superficial appendicitis.

Acute phlegmonous appendicitisAcute phlegmonous appendicitis

The phlegmon of appendix develops by the end of The phlegmon of appendix develops by the end of the day. The organ increases, it serous layer the day. The organ increases, it serous layer

becomes dimmed, sanguineous, stratifications of becomes dimmed, sanguineous, stratifications of fibrin appear on its surface, and there is pus in fibrin appear on its surface, and there is pus in

cavity. cavity.

Acute gangrenousAcute gangrenous appendicitisappendicitis

In gangrenous appendicitis the appendix is In gangrenous appendicitis the appendix is thickened, its serous thing tunic is covered by thickened, its serous thing tunic is covered by dimmed fibrinogenous, differentiating of the dimmed fibrinogenous, differentiating of the

layer structure through destruction is not layer structure through destruction is not succeeded. succeeded.

Simple (superficial) and destructive (phlegmonous, gangrenous) appendicitis which are morphological stages of acute inflammation that is completed by necrosis.

DiagnosticsDiagnostics

1. Anamnesis.1. Anamnesis.

2. Objective examination.2. Objective examination.

3. General blood and urine analyses.3. General blood and urine analyses.

4. Vaginal examination for women.4. Vaginal examination for women.

5. Rectal examination for men.5. Rectal examination for men.

Symptoms of simple appendicitisSymptoms of simple appendicitis

1. Pain localized in a right iliac area.

In 70 % of patients the pain arises in a epigastric area – it is an epigastric phase of acute appendicitis. In 2-4 hours it migrates to the area of appendix (the Kocher’s sign).

2. Single nausea and vomiting.

3. Fever to 37.5-380C.

4. Retention of stool or single diarrhea.

5. Muscular tension in a right iliac area.

Symptoms of phlegmonous Symptoms of phlegmonous appendicitisappendicitis

1. Expressed pain in a right iliac area.

2. Fever to 38-390C.

3. Muscular rigidity in a right iliac area.

4. Peritoneal signs (Blumberg’s sign. After gradual pressing by fingers of anterior abdominal wall quick taking off the hand causes the sharp increase of pain.)

Symptoms of gangrenous Symptoms of gangrenous appendicitisappendicitis

1. Expressed pain in a right iliac area.

2. Grave condition of the patient.

3. Signs of local peritonitis.

4. Signs of intoxication

Symptoms of pelvic appendicitisSymptoms of pelvic appendicitis

1. Clinic of irritation of pelvic organs (dysuria, pulling rectal pain, tenesmi).

2. Absence of muscular tenderness.

3. Painfulness of anterior rectal wall and posterior vaginal vault.

Symptoms of Symptoms of acuteacute appendicitis appendicitisAbout 100 pain symptomscharacteristic of acute appendicitis are known, however only some of them have the real practical value. •Blumberg’s sign. After gradual pressing by fingers of anterior abdominal wall quick taking off the hand causes the sharp increase of pain.•Voskresenky’s sign. The increase of pain during quick sliding movements by the tips of fingers from epigastric to right iliac area.•Bartomier’s sign - the increase of pain intensity during the palpation of right iliac area when the patient lies on the left side.•Rovsing's sign - pain in right lower quadrant during palpation of left lower quadrantRozdolskyy’s sign. Painfulness in a right iliac area during percussion.

Clinic of appendicitis in childrenIn infants acute appendicitis occurs infrequently, but quite In infants acute appendicitis occurs infrequently, but quite often has atypical character. It results from the peculiarities often has atypical character. It results from the peculiarities of anatomy of appendix, insufficient plastic properties of of anatomy of appendix, insufficient plastic properties of

the peritoneum, short omentum and high reactivity of the peritoneum, short omentum and high reactivity of child’s organism. The inflammatory process in the child’s organism. The inflammatory process in the

appendix of children rapidly progresses in the first half of appendix of children rapidly progresses in the first half of the day, resulting in destruction, even perforation. The the day, resulting in destruction, even perforation. The children suffer from vomiting more frequently than an children suffer from vomiting more frequently than an

adult. General condition worsening quickly and the adult. General condition worsening quickly and the positive peritoneal symptoms have been shown already positive peritoneal symptoms have been shown already during the first hours of the disease. The temperature during the first hours of the disease. The temperature

reaction is also considerably expressed. In blood revealed reaction is also considerably expressed. In blood revealed high leukocytosis. It is necessary to remember, that the high leukocytosis. It is necessary to remember, that the

examination of anxious children requires to use a examination of anxious children requires to use a chloralhydrate enema.chloralhydrate enema.

Clinic of appendicitis in elderly Clinic of appendicitis in elderly patienspatiens

This group of patients is hospitalized rather late, usually in This group of patients is hospitalized rather late, usually in 2-3 days after the beginning of the disease. Because of the 2-3 days after the beginning of the disease. Because of the

increased threshold of pain sensitivity, the pain in such increased threshold of pain sensitivity, the pain in such patients is slightly expressed, therefore they almost do not patients is slightly expressed, therefore they almost do not

pay attention to the epigastric phase of appendicitis. pay attention to the epigastric phase of appendicitis. Frequently nausea and vomiting is present, and the Frequently nausea and vomiting is present, and the

temperature reaction is expressed poorly. Tension of temperature reaction is expressed poorly. Tension of muscles of abdominal wall is absent or is insignificant due muscles of abdominal wall is absent or is insignificant due

to old-age relaxation of muscles. But the symptoms of to old-age relaxation of muscles. But the symptoms of irritation of peritoneum keep the diagnostic value in this irritation of peritoneum keep the diagnostic value in this

group of patients. Thus, the sclerosis of vessels of group of patients. Thus, the sclerosis of vessels of appendix results in initially-gangrenous forms of appendix results in initially-gangrenous forms of

appendicitis in this group. appendicitis in this group.

Clinic of appendicitis during Clinic of appendicitis during pregnancypregnancy

Enlarged uterus bends the appendix and disturbs its Enlarged uterus bends the appendix and disturbs its blood flow resulting in appendicitis. In the first half blood flow resulting in appendicitis. In the first half

of pregnancy the clinic of appendicitis usually of pregnancy the clinic of appendicitis usually without peculiarities. In the second half of without peculiarities. In the second half of

pregnancy, the enlarged uterus displaces the pregnancy, the enlarged uterus displaces the caecum together with the appendix upwards, and caecum together with the appendix upwards, and overdistension of abdominal wall does not create overdistension of abdominal wall does not create

adequate tension. It is necessary also to remember, adequate tension. It is necessary also to remember, that pregnant women periodically can have a that pregnant women periodically can have a

moderate pain in the abdomen and changes in the moderate pain in the abdomen and changes in the blood test. blood test.

Differential diagnosis Differential diagnosis Acute food poisoningAcute food poisoning Acute pancreatitisAcute pancreatitis Acute cholecystitisAcute cholecystitisPerforative peptic and duodenum ulcerPerforative peptic and duodenum ulcer Right-side renal colicRight-side renal colic The apoplexy of ovaryThe apoplexy of ovary Extra-uterine pregnancyExtra-uterine pregnancy

Differential diagnostics of acute appendicitis Differential diagnostics of acute appendicitis with pancreatitiswith pancreatitis

Constant pain in the right Constant pain in the right iliac regioniliac regionMuscular tenderness in the Muscular tenderness in the right iliac regionright iliac regionSingle vomiting and Single vomiting and diarrheadiarrhea

violation of diet and use violation of diet and use of alcoholof alcohol Vomiting is frequent Vomiting is frequent and does not bring the and does not bring the relief to the patientsrelief to the patients Pain is more intensive, Pain is more intensive, and is concentrated in the and is concentrated in the upper half of abcupulaupper half of abcupula

Differential diagnostics of acute Differential diagnostics of acute appendicitis with perforative peptic ulcerappendicitis with perforative peptic ulcer

Pain in the right iliac Pain in the right iliac regionregion

Muscular tenderness Muscular tenderness in the right iliac regionin the right iliac region

Single vomiting and Single vomiting and diarrheadiarrhea

Sharp acute diffuse painSharp acute diffuse pain Ulcerative anamnesisUlcerative anamnesis Absence of hepatic Absence of hepatic

dullnessdullness On X-ray of the On X-ray of the

abdomen air above the abdomen air above the liver (air sickle)liver (air sickle)

Rigidity of anterior Rigidity of anterior abdominal wallabdominal wall

Differential diagnostics of acute Differential diagnostics of acute appendicitis with acute cholecystitisappendicitis with acute cholecystitis

Constant pain in the Constant pain in the right iliac regionright iliac region

Muscular tenderness Muscular tenderness in the right iliac regionin the right iliac region

Single vomiting and Single vomiting and diarrheadiarrhea

Acute pain in a right Acute pain in a right hypohondrium with irradiation hypohondrium with irradiation to the scapulato the scapula

Muscular tenderness in a right Muscular tenderness in a right hypohondrium hypohondrium

Vomiting by bile and nausea Vomiting by bile and nausea without any reliefwithout any relief

Ortner's symptom, phrenic Ortner's symptom, phrenic symptom, Murphy’s signsymptom, Murphy’s sign

Increased serum bilirubinIncreased serum bilirubin

Differential diagnostics of acute Differential diagnostics of acute appendicitis with gynecologic disordersappendicitis with gynecologic disorders

Constant pain in the Constant pain in the right iliac regionright iliac region

Muscular tenderness Muscular tenderness in the right iliac regionin the right iliac region

Single vomiting and Single vomiting and diarrheadiarrhea

Acute pain in a lower part of Acute pain in a lower part of the abdomenthe abdomen

Dependence on menstrual Dependence on menstrual cyclecycle

Vaginal dischargeVaginal discharge Blood by punction of Blood by punction of

vaginal vaultvaginal vault Bimanual vaginal Bimanual vaginal

investigationinvestigation

Differential diagnostics of acute Differential diagnostics of acute appendicitis with renal colicappendicitis with renal colic

Constant pain in the Constant pain in the right iliac regionright iliac region

Muscular tenderness Muscular tenderness in the right iliac regionin the right iliac region

Single vomiting and Single vomiting and diarrheadiarrhea

Periodic acute pain in the Periodic acute pain in the lumbar region with lumbar region with irradiation to thighirradiation to thigh

Vomiting and nauseaVomiting and nausea Pasternatsky’s signPasternatsky’s sign Fresh erythrocytes in Fresh erythrocytes in

urine analysisurine analysis

TreatmentTreatment

Intravenous fluids Intravenous fluids to establish adequate urine outputto establish adequate urine output

Appropriate antibioticsAppropriate antibioticsReduces the incidence of postoperative wound Reduces the incidence of postoperative wound infectioninfectionWhen peritonitis is suspected, therapeutic When peritonitis is suspected, therapeutic intravenous antibiotics to cover Gram-negative intravenous antibiotics to cover Gram-negative bacilli as well as anaerobic cocci should be givenbacilli as well as anaerobic cocci should be given

AppendicectomyAppendicectomy

AppendicectomyAppendicectomy

Conventional AppendicectomyConventional AppendicectomyLaparoscopic AppendicectomyLaparoscopic AppendicectomyPostoperative ComplicationsPostoperative Complications

Conventional AppendicectomyConventional Appendicectomy

McBurney’s incision is typical. Right angles to a line joining the spina iliaca anterior superior to the umbilicus. Centred on McBurney’s point

Conventional AppendicectomyConventional Appendicectomy

Caecum is identified Caecum is identified Base of mesoappendix is clamped in artery forceps, divided, and Base of mesoappendix is clamped in artery forceps, divided, and ligatedligatedThe freed appendix is crushed near its junction with the caecum in The freed appendix is crushed near its junction with the caecum in artery forceps, which is removed and reapplied just distal to the artery forceps, which is removed and reapplied just distal to the crushed portioncrushed portionAn absorbable ligature is tied around the crushed portion close to An absorbable ligature is tied around the crushed portion close to the caecumthe caecumThe appendix is amputated between the artery forceps and the The appendix is amputated between the artery forceps and the ligatureligatureAn absorbable purse-string or ‘Z’ suture may then be inserted into An absorbable purse-string or ‘Z’ suture may then be inserted into the caecum about 1.25 cm from the basethe caecum about 1.25 cm from the baseThe stump of the appendix is invaginated while the purse-string or The stump of the appendix is invaginated while the purse-string or ‘Z’ suture is tied, thus burying the appendix stump‘Z’ suture is tied, thus burying the appendix stump

Laparoscopic appendicectomyLaparoscopic appendicectomy

Laparoscopic appendicectomyLaparoscopic appendicectomyThe placement of operating ports may vary according to operator The placement of operating ports may vary according to operator preference and previous abdominal scars. preference and previous abdominal scars. The operator stands to the patient’s left and faces a video monitor placed The operator stands to the patient’s left and faces a video monitor placed at the patient’s right foot.at the patient’s right foot.A moderate Trendelenburg tilt of the operating tableA moderate Trendelenburg tilt of the operating tableThe appendix is identify & controlled using a laparoscopic tissue-holding The appendix is identify & controlled using a laparoscopic tissue-holding forceps. forceps. By elevating the appendix, the mesoappendix is displayed By elevating the appendix, the mesoappendix is displayed A dissecting forceps is used to create a window in the mesoappendix to A dissecting forceps is used to create a window in the mesoappendix to allow the appendicular vessels to be coagulated or ligated using a clip allow the appendicular vessels to be coagulated or ligated using a clip applicator.applicator. The appendix, free of its mesentery, can be ligated at its base with an The appendix, free of its mesentery, can be ligated at its base with an absorbable loop ligature,divided, & removed through one of the operating absorbable loop ligature,divided, & removed through one of the operating ports. ports. It is not usual to invert the stump of the appendixIt is not usual to invert the stump of the appendixA single absorbable suture is used to close the linea alba at the umbilicus, A single absorbable suture is used to close the linea alba at the umbilicus, and the small skin incisions may be closed with subcuticular sutures.and the small skin incisions may be closed with subcuticular sutures.Patients who undergo laparoscopic appendicectomy are likely to have Patients who undergo laparoscopic appendicectomy are likely to have less postoperative pain & to be discharged from hospital and return to less postoperative pain & to be discharged from hospital and return to activities of daily living sooner than those who have undergone open activities of daily living sooner than those who have undergone open appendicectomy.appendicectomy.

Problems Encountered During Problems Encountered During AppendicectomyAppendicectomy

Problems Management

A normal appendix is found Demands careful exclusion of other possible diagnosisRemove the appendix to avoid future diagnostic difficulties

The appendix cannot be found Caecum should be mobilised, and the taeniae coli should be traced to their confluence on the caecum before the diagnosis of ‘absent appendix’ is made

An appendicular tumour is found Small tumours (< 2.0 cm in diameter) can be removed by appendicectomyLarger tumours should be treated by a right hemicolectomy

An appendix abscess is found and the appendix cannot be removed easily

Should be treated by local peritoneal toilet, drainage of an abscess and intravenous antibiotics

ComplicationsComplications

1. Appendicular infiltrate.1. Appendicular infiltrate.

2. Appendicular abscess.2. Appendicular abscess.

3. Diffuse peritonitis.3. Diffuse peritonitis.

4. Pilephlebitis4. Pilephlebitis

Appendicular infiltrateAppendicular infiltrateAppendiceal infiltrate is the conglomerate of organs and tissue not Appendiceal infiltrate is the conglomerate of organs and tissue not densely accrete round the inflamed vermiform appendix. It develops, densely accrete round the inflamed vermiform appendix. It develops, certainly, on 3-5th day from the beginning of disease. Acute pain in certainly, on 3-5th day from the beginning of disease. Acute pain in the abdomin decreases, the general condition of the patient gets the abdomin decreases, the general condition of the patient gets better. Dense, not mobile, painful, with unclear contours, mass is better. Dense, not mobile, painful, with unclear contours, mass is palpated in the right iliac area. There are different sizes of infiltrate, palpated in the right iliac area. There are different sizes of infiltrate, sometimes it occupies all right iliac region. The abdominal wall round sometimes it occupies all right iliac region. The abdominal wall round infiltrate during palpation is soft and nontender. infiltrate during palpation is soft and nontender. At reverse development of infiltrate (when resorption begins) the At reverse development of infiltrate (when resorption begins) the general condition of the patient gets better, activity grows, the general condition of the patient gets better, activity grows, the temperature of body and indexes of blood is normalized. Pain in the temperature of body and indexes of blood is normalized. Pain in the right iliac area decreases, infiltrate diminishes in size. In this phase right iliac area decreases, infiltrate diminishes in size. In this phase of infiltrate physiotherapeutic procedure is appointed, warmth on the of infiltrate physiotherapeutic procedure is appointed, warmth on the iliac area. Two months after resorption of infiltrate appendectomy is iliac area. Two months after resorption of infiltrate appendectomy is conducted. conducted. Patients with appendiceal infiltrate are managed conservatively. Patients with appendiceal infiltrate are managed conservatively. Taking it into account, bed rest, restricted diet, cold compress on the Taking it into account, bed rest, restricted diet, cold compress on the area of infiltrate and antibiotic therapy. According to resorption of area of infiltrate and antibiotic therapy. According to resorption of infiltrate, within or after two month, elective appendectomy is infiltrate, within or after two month, elective appendectomy is performed. performed.

Appendicular infiltrateAppendicular infiltrate

If an appendicular infiltrate is present & the condition of the If an appendicular infiltrate is present & the condition of the patient is satisfactory, the standard treatment is the patient is satisfactory, the standard treatment is the conservativeconservative

Careful recording of the patient’s condition and the extent of Careful recording of the patient’s condition and the extent of the mass should be made and the abdomen regularly re-the mass should be made and the abdomen regularly re-examined.examined. mark the limits of the mass using a skin pencil. mark the limits of the mass using a skin pencil.

Temperature and pulse rate should be recorded 4- hourly Temperature and pulse rate should be recorded 4- hourly and a fluid balance record maintainedand a fluid balance record maintained

A contrast-enhanced CT examination of the abdomen A contrast-enhanced CT examination of the abdomen should be performed and antibiotic therapy instigated. should be performed and antibiotic therapy instigated.

An abscess, if present, should be drained radiologically. An abscess, if present, should be drained radiologically. Clinical deterioration or evidence of peritonitis is an Clinical deterioration or evidence of peritonitis is an

indication for early laparotomy. indication for early laparotomy. Clinical improvement is usually evident within 24–48 hoursClinical improvement is usually evident within 24–48 hours

Appendicular abscess.Appendicular abscess.In abscess formation the condition of the patient gets worse, the In abscess formation the condition of the patient gets worse, the symptoms of acute appendicitis become more expressed, the temperature symptoms of acute appendicitis become more expressed, the temperature of body rises, the fever appears. Next to that, pain in the right iliac area of body rises, the fever appears. Next to that, pain in the right iliac area increases. Tender mass is palpable in the right iliac region. Blood test increases. Tender mass is palpable in the right iliac region. Blood test shows leukocytosis with the acutely expressed shift of leukocyte formula shows leukocytosis with the acutely expressed shift of leukocyte formula to the left. to the left. Local abscesses of abdominal cavity, develops mainly in cases of the Local abscesses of abdominal cavity, develops mainly in cases of the atypical location of appendix or due to suppuration. Pelvic abscesses are atypical location of appendix or due to suppuration. Pelvic abscesses are seen more frequently, thus a patient is disturbed by pain, dysuria, seen more frequently, thus a patient is disturbed by pain, dysuria, diarrhea and tenesmus. The temperature of body rises to 38,0-39,0oC, diarrhea and tenesmus. The temperature of body rises to 38,0-39,0oC, and rectal temp is considerably higher. In the blood test leukocytosis, and rectal temp is considerably higher. In the blood test leukocytosis, shift of formula of blood is fixed to the left. shift of formula of blood is fixed to the left. During the rectal examination the weakened sphincter of anus is During the rectal examination the weakened sphincter of anus is weakened. The anterior wall of rectum at first is only painful, and then weakened. The anterior wall of rectum at first is only painful, and then its overhanging is observed as dense painful infiltrate. its overhanging is observed as dense painful infiltrate. Treatment of appendiceal abscess must be only operative. Opening and Treatment of appendiceal abscess must be only operative. Opening and drainage of the abscess, through retroperitoneal route (incision), is drainage of the abscess, through retroperitoneal route (incision), is performed. In this case removal of the appendix is not necessary, because performed. In this case removal of the appendix is not necessary, because of denger of bleeding, peritonitis and intestinal fistula. of denger of bleeding, peritonitis and intestinal fistula.

Pylephlebitis Pylephlebitis

Pylephlebitis is a complication of both appendicitis and post Pylephlebitis is a complication of both appendicitis and post appendectomy period. The cause of this pathology is acute retrocecal appendectomy period. The cause of this pathology is acute retrocecal appendicitis. There’s thrombophlebitis of veins of appendix, which appendicitis. There’s thrombophlebitis of veins of appendix, which passes to the veins of bowel mesentery, and then to the portal vein. passes to the veins of bowel mesentery, and then to the portal vein.

Patients complain of general weakness, pain in right Patients complain of general weakness, pain in right hypochondrium, high temperature of body, fever and increased hypochondrium, high temperature of body, fever and increased

sweating. Patients are adynamic, with slightly icteric of the scleras. sweating. Patients are adynamic, with slightly icteric of the scleras. During palpation painfulness is observed in the right half of During palpation painfulness is observed in the right half of

abcupula often and the symptoms of irritation of peritoneum are not abcupula often and the symptoms of irritation of peritoneum are not acutely expressed. acutely expressed.

In case of rapidly progress of disease the icterus appears, the liver is In case of rapidly progress of disease the icterus appears, the liver is increased, incine hepato-venat insufficiency progresses, and patients increased, incine hepato-venat insufficiency progresses, and patients

die in 7-10 days after the onset of disease. At gradual subacute die in 7-10 days after the onset of disease. At gradual subacute development of pathology the liver and spleen is increased in size, development of pathology the liver and spleen is increased in size,

and after the septic state of organism ascites arises.and after the septic state of organism ascites arises.

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