Download Acute appendicitis

Zaporozhia State medical university
Department of Pediatrics’s Surgery
Methodical recommendations for students of VI rate of medical faculty on a
theme:
Acute appendicitis. Peritonitis.
(Etiology, pathogeny and clinical picture diesease, differential diagnostics, methods of
examination, treatment)
Confirm at methodical meeting of faculty the report № ___ from __________ 2014.
Authors: Baruchovich V., Kokorkin A.
The head of the department prof. Spakhi O.V.
Zaporozhia – 2014
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1. The topic : Acute appendicitis, Peritonitis (etiology, pathogeny and clinical
picture diesease, differential diagnostics, methods of examination, treatment).
2. Actuality of the topic :
Almost 100 surgical diseases may cause the abdominal pain in childrens.
Abdominal pain may accompany such diseases like flu, otitis, pneumonia, measles,
chickenpox, pyelonephritis, gastritis. Doctors of different specialties (surgeons,
paediatricians, family physicians) meet this syndrome in there practice. Some
children try to dissimulate the abdominal pain, fearing of
hospitalization or
operation.
Knowledge of the particular properties of the surgical and pediatric disease,
accurate assessment of the patient’s complaints and state is a key to the correct
diagnosis and necessary treatment .
3. Objects of the lesson:
3.1. General objects.
Students must know the clinical picture of the most frequent surgical diseases
of the abdominal cavity in children, methods of examination and the principles of
differential diagnosis in children with abdominal pain.
3.2. Educational objects.
As a result of lesson in students must be formed the responsible regard to
examination of children with abdominal pain, ability to deal with children and there
parents, circumspection for signs of acute abdominal diseases.
3.3. Concrete objects.
Students must know:
1.
Clinical picture and diagnostic methods in congenital diseases of
ileocecal region .
2.
Classification and clinical picture of diseases due to present of Meckel’s
diverticulum.
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3.
Etiology, pathogeny and clinical picture of acute appendicitis in cases
of typical and atypical localization.
4.
Methods of examination of children with acute appendicitis.
5.
Complications of acute appendicitis.
6.
Postoperative complications of acute appendicitis. Methods of
treatment.
7.
Clinical picture of acute appendicitis in children under 3 years.
8.
Clinical picture of the gynecologic diseases with abdominal pain in
girls.
9.
Clinical picture, diagnosis and treatment of the primary peritonitis.
3.4. Students should be able:
1.
Compile anamnesis of the disease in children with abdominal pain.
2.
Examine children of the different age with the complaint on abdominal pain.
3.
Appoint a plan of examination of the child with acute appendicitis.
4.
Make a differential diagnosis of the acute appendicitis with others diseases,
causing abdominal pain in children.
5. The contents of a topic:
Acute appendicitis
Acute appendicitis is the most common disease in childhood which calls for
emergency surgery. In contrast to adults, children suffer a more severe course of
appendicitis and the diagnosis is much more difficult. These regular features are
more marked in children of the first years of life, which is due to the anatomical
and physiological characteristics of the child’s development.
Firstly, due to the functional immaturity of the nervous system at this age
almost all acute inflammatory disease have a similar clinical picture (high
temperature,
repeated
vomiting,
intestinal
malfunction).
Secondly,
the
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inflammatory process in the vermiform process of a child is very violent, while the
mechanisms of its demarcation are very weak. Thirdly, specific difficulties in the
examination of infants exist. Restlessness, crying, and resistance to the
examination make it difficult to detect the main local signs of acute appendicitis.
The incidence of the acute appendicitis is low among infants, but gradually
grows with the children’s age and reaches maximum in the 10-12-year-olds .
The rare occurrence of appendicitis in children under the age of 12 months is
explained by the specific features of the anatomical structure of the vermiform
process ( absence of statis of the intestinal contents ) and the character of the diet at
this age ( mostly a thin milk diet ) .
The follicular apparatus of the vermiform process plays a certain role in the
development of the inflammation. The mucosa of the process in children of the
first year of life contains only a few follicles. With age their number increases, and
the appendicitis morbidity rate increases in parallel. The disease occurs equally
frequently in boys and girls.
There is no specific causative agent of acute appendicitis. The microflora
proper of the vermiform process and intestine plays the leading rope in the
development of the inflammation.
Somatic and infectious diseases suffered in the past, congenital anomalies of the
vermiform process (torsion, bending), invasion of the process by foreign bodies or
intestinal parasites, and the formation of feacal stones are conductive to the
development of the inflammatory process. Alimentary factor is also important.
Clinical picture and diagnosis
The prevalence of general non-specific signs over local signs is the most
common characteristic of clinical picture. The younger the child, the more
pronounced the general phenomena. The typical clinical picture of the acute
appendicitis in older children is clearly manifested for the most part and comprises
the following main signs: abdominal pain, increased body temperature, vomiting,
constipation, rigidity of the abdominal muscles, and leukocytosis.
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Abdominal pain usually appears gradually and is continuous and aching in
character. In the first hours of the disease it is felt in the whole abdomen or in the
epigastrium. Later it is located more distinctly in the right lower abdominal
quadrant and increases in movement. Pain is most intense in the first hours of the
disease and then diminished due to death of the nerve apparatus of the vermiform
process. Appendicitis is characterized by continuous pain which does not disappear
but just abates a little. Vomiting is a quite constant sign of acute appendicitis in
children; it is mostly observed on the first day of disease (reflex vomiting) and
occurs usually once or twice. Vomiting is of a persistent character in the late stages
of generalized purulent peritonitis and contains an admixture of bile.
Body temperature is no higher than 37,7 -380 C as a rule . At the same time it
must be borne in mind that in some cases body temperature may be normal,
whereas gross destructive changes are sometimes found in the vermiform process
of such patients during operation. Constipation is encountered in many patients. A
loose stool is rare and appears no earlier than the second day of the disease.
Increased blood leukocyte count of 11-15 G/l and a shift of the differential count to
the left are found.
In examination of the abdomen attention is focused on three main peritoneal
signs elicited in the right lower quadrant – localized pain to palpation, passive
rigidity of muscles and Shchetkin-Blumberg ‘s sign.
Clinical picture and diagnosis of acute appendicitis in young children
The clinical manifestations of acute appendicitis in children of the first years
of life are marked by specific features. This is due firstly to the prevalence in the
clinical picture of general symptoms inherent in many diseases of this age group.
In contrast to older in whom complaints of pain in the right lower abdomen are of
principal importance, children of the first years of life have no direct indications of
pain and the presence of this symptom can only be judged from a number of
indirect signs. The most important is the child’s changed behavior. The child
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became languid, capricious, and that it was difficult to establish contact with him.
The child’s restlessness should be attributed to intensification of pain. The
continuous pain disturbs sleep.
Vomiting is a rather constant sign. It is characteristically repeated (3 to 5
times), which is one of the specific features of appendicitis at this age. Body
temperature is almost always increased in acute appendicitis in children, under 3
years of age. Quite often it reaches 38-39C. The invariable presence of these signs
in young children at the onset of the disease is explained by the non-differentiable
character of the child’s central nervous system reaction to the location and degree
of the inflammatory process. A loose stool is present in more than 10% of cases.
Stool disorders are mainly encountered in gangrenous-perforative appendicitis.
Hyperleucocitosis is a common occurrence.
Hardly any children of this age complain of pain in the right lower abdomen.
Pain is usually localized around the umbilicus, as is the case in any intercurrent
diseases marked by the abdominal syndrome. Such location of the pain is linked
with a number of anatomical and physiological factors: the inability to localize
exactly the site of the most severe tenderness due to deficient development of the
cortical processes and the tendency of the nerve impulses to irradiate; the close
relation of the solar plexus to the root of the mesentery; rapid development of
inflammation of the lymph nodes of the mesentery and its root.
The ability for establishing contact with a young child plays an important
role. This applies to children already starting to speak. Examination is prefaced by
a simple talk easily understood by a child. As a result the child calms down and
can be examined. The abdomen is examined without haste by gentle movements of
a warm hand, hardly touching the abdominal wall at first and then gradually
increasing the pressure. Palpation is started from a region, which is known to be
not tender, i.e. from the left lower abdomen, and then continued along the colon
towards the right lower quadrant. Many surgeons prefer examining the child when
he is sleeping. The “push-away sign” is sometimes produced during palpation of
the right lower quadrant: the sleeping child pushes away the examiner’s hand with
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his own hand. The onset of physiological sleep in a child, however, often takes a
long time. Examination of children during medication sleep is justified under such
circumstances, especially in restless children. The method consist in the following:
after a cleansing enema a 3% chloral hydrate solution heated to body temperature
is administrated into the rectum with a syringe through the catheter advanced for a
distance of 10-15 cm. The dose is determined by the child’s age: 10-15 ml under
12 months of age; 15-20ml from 1 to 2 years of age; 20-25 ml from 2 to 3 years of
age. Sleep is produced 15-20 min. after the medication, and examination of the
abdomen can be began. Passive rigidity of the anterior abdominal wall and local
tenderness are maintained in this case, the signs are easily produced because motor
excitation disappears and psycho-emotional reactions and active rigidity of
muscles are completely relieved. Examination of the patient during the medication
sleep has no noticeable effect on the body’s most important systems
(cardiovascular, respiratory, excretory) and induces no side or toxic reaction.
The Shchetkin-Blumberg sign is tested during natural and medication sleep
after careful abdominal palpation as the conclusive stage of examination. In a
positive sign the child either awakes or reacts to the pain while still sleeping.
Other methods providing evidence of irritation of the peritoneum (percussion of
the abdomen, stroking the abdomen through clothing) possess definite diagnostic
importance.
Digital rectal investigation yields less diagnostic information in young
children and contributes to the diagnosis only in the presence of an infiltrate, which
is relatively rare finding at this age. Nonetheless, digital rectal examination must
be undertaking in all young children because it helps in differentiating from other
diseases (invagination, coprostasis, intestinal infections, etc.) in many cases.
Leukocytosis of 15000-20000 is most frequently found in young children with
appendicitis. Hyperleukocytosis (above 20000) is also often encountered.
Electromyography of the anterior abdominal wall is carried out to detect and
appraise objectively the most important sign of acute appendicitis, the defence
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muscular rigidity. The electromyogram is recorded at rest and during abdominal
palpation.
In many instances, particularly when the clinical picture is vague and a
concomitant disease is present, the diagnosis of appendicitis can be established
with the aid of laparoscopy.
Differential diagnosis
The differential diagnosis of acute appendicitis in children presents great
difficulties. This is associated with the fact that acute appendicitis in children
simulates in its clinical manifestations (particularly in atypical location in the
vermiform process) many diseases most of which do not require operation. Active
surveillance for 2 to 6 hours is usually sufficient for establishing the final
diagnosis. The diagnostic difficulties in children are also attributed to the fact that
the spectrum of diseases from which acute appendicitis has to be differentiated
differs with the child’s age. The frequent causes of diagnostic errors in children of
the first years of life are diseases, which prevail at just this age (otitis, invagination,
childhood infections, pneumonia, etc.). At an older age, differential diagnosis has
to be mostly made with diseases of the gastro-intestinal tract, diseases of the
genitals in girls, and with urological diseases.
Differential diagnostic of the acute appendicitis in older children
Acute gastro-intestinal diseases. In acute gastro-intestinal diseases, as
distinct from acute appendicitis, dyspeptic disorders come to the forefront while
pain appears later or at the same time. Toxicosis increases rapidly and is attended
by repeated vomiting and intestinal dysfunction. Vomiting brings relief, as distinct
from acute appendicitis. Though toxicosis is quite severe, the objective abdominal
signs are minimal: the abdomen is soft to palpation, but irregular active rigidity of
muscles may be left which disappears in careful palpation during inhalation.
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Tenderness is elicited in the epigastrium and in the umbilical area. Dietary faults
are often detected in the case history. Toxicosis, exicosis, and a frequent loose
stool may be encountered in acute appendicitis in already complicated cases when
palpation of the abdomen reveals local tenderness and passive muscular rigidity.
Such a clinical picture is encountered in later stages of acute appendicitis as a rule.
Among gastro-intestinal diseases of an infectious character, dysentery
deserves special atte4ntion because it is often mistaking for acute appendicitis. The
typical or, as it is also called, the “classic” picture of dysentery is recognized
without any great difficulties; the onset is acute, with a rise in body temperature,
vomiting, and paroxysmal abdominal pain.
Tenesmus, spasm of the sigmoid
colon, and anal pliancy are found. The stool is loose (in small amounts) and
contains abnormal admixtures.
Subclinical ore atypical forms of dysentery cause considerable diagnostic
difficulties. Purposeful taking of the epidemiological history and critical analysis
of the first clinical signs in the dynamics of changes in the disease are particularly
important in such cases. Abdominal examination reveals borborygmus and
moderate rigidity of muscles as a rule, and local tenderness in the left lower
quadrant; the sigmoid colon is palpated as a thick-elastic sliding cord. The
condition of the anus and the color and odour of the faeces are also important
factors.
Urological diseases form quite a large group of pathological conditions
which have to be differentiated from acute appendicitis. Most frequently these are
the inflammatory processes developing in patients with congenital or acquired
diseases of the urinary tract. In such instances a clot of mucus moving in the ureter
may cause pain in the right lower abdomen. In contrast to acute appendicitis, this
condition is marked by paroxysmal pain, the child is agitated and changes his
position all the time. Pain is often referred to the lumbar region, or the inner
surface of the thigh and the inguinal region. Urination is frequent and painful.
Rigidity of the abdominal muscles on the right is often encountered, but it is more
diffuse in character than the rigidity in acute appendicitis and disappears in the
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clear period. The zone of the tenderness is projected along the length of the ureter.
Pasternatsky’s signs is positive. Procaine block of the seminiferous tubule and the
round ligament of the uterus is advisable in diagnostically difficult cases. In acute
appendicitis the block fails to relive pain or the rigidity of the muscles.
Emergency diagnostic nephrourological examination is conducted in doubtful
cases.
Coprostasis retention of faeces in the intestine, is a quite frequent occurrence
in childhood; it is attended by abdominal pain and often mistaken for acute
appendicitis. In distinction from acute appendicitis, coprostasis does not disturb the
child’s general condition which remains satisfactory. Faecal toxucosis may
develop only in neglected cases. Body temperature rarely increases (37,2-37,6C) in
coprostasis. The leucocyte count is normal as a rule, and only in occasional cases
leucocytosis of 10000-15000 is found.
Examination of the child often reveals moderate abdominal distention and
tenderness which is diffuse though more pronounced in the left lower quadrant. A
cleansing enema is of diagnostic and therapeutic importance in this situation. In
coprostasis, a copious stool is produced after the enema, pain is partly or
completely relieved, and the abdomen relieved, and the abdomen becomes soft and
painless to palpation, which can be conducted in all parts. A cleansing enema fails
to bring relief in acute appendicitis and even induces pain.
Forms of acute secondary mesadenitis constitute a large group of
pathological conditions distinguished from acute appendicitis by paroxysmal
abdominal pain located closer to the umbilicus, often by a marked rise of body
temperature, and presence of a primary focus of infections (tonsillitis, adenovirus
infections, influenza, etc.). Pain is felt in the region of the umbilicus and also
slightly below and to the right of it, where there is a zone of most pronounced
tenderness which moves to the midline when the patient lies on the left side. The
Shchetkin-Blumberg sign is negative as a rule. Rigidity of muscles is found above
the most tender zone, but it is not constant.
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The differential diagnosis between acute appendicitis and diseases of the
genitals in girls is very important because it allows unnecessary appendectomy to
be avoided in some cases and the true cause of the abdominal identified in time.
Pathological conditions of the genitals prevail in girls in the pubertal period
(at the age of 10-14 years). It is at this age that ovulatory and functional
(premenstrual) pains and some other diseases of the genitals occur most frequently.
In view of this, the gynaecological history (the first menstruation, their character,
regularity and cycles) must be carefully taken in all girls who come to a physician
because of abdominal pain. Rectoabdominal examination must be performed
without fail. Premenstrual pains are quite persistent as a rule and paroxysmal.
Vomiting and disorders of intestinal passage (diarrhoea) may occur. Emotional
lability and vegetative disorders may be found in such cases. Pains occur mostly in
asthenic and infantile girls and are induced by peristalsis of the uterine tubes and
sharp contraction of the muscles.
Girls may also experience intermenstrual pains which are linked with
follicular and lutein cysts of the ovaries. The pains in such cases are of short
duration and usually appear in the period of ovulation or 2 or 3 days before
menstruation.
Haematocolpos may cause the abdominal syndrome. Menstrual blood
accumulates in the vagina and sometimes in the uterus due to congenital absence of
the natural orifice in the hymen (hymen imperforatus). The disease usually sets in
slowly with paroxysmal abdominal pain, weakness, indisposition and headache.
These phenomena are sometimes attended by subfebrile temperature, nausea and
vomiting. The pain acquires a cyclic character and recurs almost every month for a
year. The medical history supplies information on complete absence of
menstruation.
Objective examination reveals an imperforate hymen which bulges out like a
dome. A tumor-like structure is detected in the lower abdomen by rectoabdominal
investigation.
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Children’s infectious diseases such as measles, scarlet fever, chicken-pox
and rubella, as well as infectious hepatitis, are often attended by abdominal pain. as
a consequence, patients are often sent to a surgical hospital with the erroneous
diagnosis of acute appendicitis.
The abdominal syndrome in all the childhood infectious mentioned is due to
the development of secondary mesadenitis or even to changes of the lymphoid
apparatus of the appendix itself. As a result, pain is often experienced in the right
half of the abdomen in the prodromal period of these diseases. This circumstances
should always be borne in mind and the skin, throat, and mucous membranes must
be carefully examined. Another fact to bear in mind is that in childhood infectious
diseases abdominal palpation elicits tenderness near to the umbilicus. The caecum,
rather distended and field with air, can be palpated. True muscular rigidity,
however, is not determined as a rule.
Observation of the patient by a surgeon and pediatrician in a department with
isolation wards is indicated if his condition is satisfactory and there are no signs of
toxycosis or progressive abdominal signs.
The abdominal form of haemorrhagic capillary toxycosis (SchoenleinHenoch purpura) often simulates the clinical picture of acute appendicitis. The
pain syndrome in this disease is associated with haemorrhagic exanthemas in the
typical places (extensor surfaces of the limbs, the buttocks, the ankle joints) is an
important sign distinguishing this disease from acute appendicitis.
Abdominal pain in capillary toxicosis is generalized as a rule. A history of
abnormal predisposition to bleeding and preceding haemorrhages helps in making
the correct diagnosis.
Particular diagnostic difficulties arise when the haemorrhagic eruption
appears late (in 10 – 15 days) after the development of the abdominal syndrome. In
doubtful cases the patient must be kept under observation of the surgeon until the
acute abdominal phenomena abate.
Pancreatitis. Acute inflammation of the pancreas is a rare condition in
children, but in most cases it takes a violent course with manifestations of general
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toxicosis. The abdominal syndrome in children with pancreatitis has no specific
features. The girdle pain characteristic of adults is usually not encountered in
children. High fever of 38 – 39 C, signs of severe toxicosis and exiccosis,
sometimes even delirium and hallucinations, occur in most children. The
abdominal pain is diffuse, and signs of peritoneal irritation are often present.
Observation of the patient in a hospital and laboratory tests (considerable
increase of diastase in the urine and blood) are of decisive significance in making
the correct diagnosis.
Differential diagnosis of acute appendicitis in young children
Problems concerned with making the differential diagnosis in children under
3 years of age are very important because most diseases in them begin with a rise
of body temperature, abdominal pain, vomiting, and a loose stool, i.e. signs also
characteristic of acute appendicitis.
Diseases most commonly encountered among young children are commonly
mistaken for acute appendicitis. These are acute respiratory diseases, coprostasis,
diseases of the gastro-intestinal tract, pneumonia, otitis, urological diseases,
children's infections, and intussusception.
Acute respiratory infections are very common at very young age. A case
record of the abdominal syndrome, i.e. the triad of symptomsalso typical of acute
appendicitis (abdominal pain, vomiting, increased body temperature), is usually the
reason why the child is hospitalized.
Acute respiratory infections are marked by an acute onset. Rhinitis with a
seromucous discharge, hyperaemia of the fauces and looseness of its mucosa, and
conjunctivitis are the most regular symptoms of these infections. Signs of toxicosis
and disturbed general condition come to the forefront.
Toxicosis usually does not develop in children of this age with acute
appendicitis, it occurs in complicated forms as a rule. The findings of inspection
and examination along with the signs listed above are decisive in making the
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diagnosis. It should only be borne in mind that the disturbed general condition and
the toxicosis in acute respiratory infections do not correspond to the local abdominal signs. Tenderness to palpation in the right lower abdominal region and passive
muscular rigidity are not found in such cases.
The diagnostic errors are linked with the difficulties of the child's
examination; active rigidity of muscles is often mistaken for defense musculaire. In
a child with whom contact is established, palpation usually elicits tenderness in the
region of the umbilicus or in the whole abdomen, but not in the right lower
quadrant; passive rigidity is also not detected.
Pneumonia. Pain is quite often felt in the abdomen when an inflammatory
process develops in the right lung and sometimes when the left lung is involved.
This leads to diagnostic errors.
Tenderness in the right lower abdominal quadrant and even rigidity of the
muscles are found in cases with an inflammatory process in the lungs, which
makes it difficult to differentiate pneumonia from acute appendicitis. This is linked
with stimulation of the intercostal nerves whose branches contribute to innervation
of the diaphragm and abdominal skin and muscles.
Rigidity of the abdominal muscles is not constant and disappears
completely when the child's attention is distracted. Objective examination often
reveals diminished respiration on the side of the lesion and moist rales are
sometimes heard. The establishment of the diagnosis of pneumonia is also aided by
the X-ray findings.
The clinical picture of otitis has some manifestations similar to those of
acute appendicitis in young children: the child is usually restless, capricious, twists
his legs; body temperature increases (to 38°C and more), and vomiting occurs once
or twice. The first examination of the child gives the impression of a disaster in the
abdominal cavity. The abdomen is soft to palpation and painless in all parts.
Neither passive rigidity nor local tenderness is encountered as a rule. At the same
time, pressure on the tragus induces pain, to which the child responds by increased
agitation and crying.
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Treatment. The surgical tactics in acute appendicitis in children hardly
differs in essence from those in adults. Some specific features of operative
treatment of different forms of acute appendicitis exist, however, especially in the
case of a child of the first years of life.
Only general anaesthesia is advisable for children, particularly for young
children. Psychological preparation of the patient before the anaesthesia is an
important moment.
The most widely used approach for removal of the vermiform process in
paediatric surgery is the McBurney-Volkovich-Dyakonov incision. In view of the
higher position of the caecum in young children, the incision is made 3-4 cm above
the projection line accepted in older children and adults. The vermiform process is
mainly removed by the ligature method (without burying the stump into a pursestring and Z-shaped sutures).
The postoperative management of patients with uncomplicated forms of
appendicitis has no distinguishing features. Analgesics are applied in the first two
days after the operation.
Intramuscular injections of antibiotics are advisable for 5 to 7 days.
Increase of the ESR or leukocyte count, and the more so aggravation of the general
condition and fever, are an alarm signal of the development of complications
(infiltrate or abscess in the abdominal cavity). The sutures are removed on the
seventh day. Control digital rectal examination is carried out on the same day for
an infiltrate in Douglas' space. In a favorable postoperative course, the child is
discharged from the hospital on the next day.
Peritonitis
Among pyoseptic diseases in children, a considerable share belongs to
peritonitis, i.e. inflammation of the peritoneum.
According to the generally accepted classification, the following forms of
peritonitis are distinguished: according to aetiology: aseptic and infectious;
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according to the route of origin: perforative, septic (contact, haematogenic), and
cryptogenic; according to the spread of the process: general and localized; general
peritonitis may be diffuse and generalized, the localized form may be noncircumscribed and circumscribed (infiltrate, abscess); according to the character of
the exudate: serous, purulent, chylous, haemorrhagic, biliary, etc.
The course and prognosis differ depending on the origin and duration of
peritonitis and the child's age. Peritonitis develops particularly rapidly and takes a
malignant course in children of early age at which localized and circumscribed
forms are less frequent than the generalized forms.
The short omentum is conducive to the development of generalized forms.
It may reach the lower parts of the abdominal cavity only by the age of 5 to 7 years
and therefore contributes to a lesser measure to demarcation of the process in
young children. As the result of the poor plastic properties of the peritoneum, the
intestinal loops fail to demarcate sufficiently the focus of inflammation.
Study of the pathogenesis of peritonitis makes it possible to distinguish 4
main syndromes of homeostasis impairment: toxicosis proper ("toxic shock"),
disturbed acid-base balance, water-salt disorders, and the hyperthermal syndrome.
The severity of each of the syndromes differs with the length of the period
from the onset of the disease, which is determined by the rate of the development
of generalized peritonitis, the child's age, the premorbid condition, and other
factors.
In accordance with this, three phases are distinguished in peritonitis: phase
one, prevalence of toxicosis, dehydration, hyperthermia, and respiratory disorders;
phase two (in peritonitis following a slower course), prevalence of metabolic shifts,
ion imbalance, and disturbed renal function; phase three, complications of
peritonitis with signs of septicopyaemia, intestinal obstruction, marked
hypoproteinaemia and dysproteinaemia.
Diplococcal peritonitis
Diplococcal peritonitis prevails among children of the older preschool age,
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mostly among girls. It is claimed that the infection enters the abdominal cavity
from the vagina, but the enterogenic, haematogenic, route cannot be excluded.
Clinical picture. "The symptom of the first hours", an acute and violent
onset, is characteristic of diplococcal peritonitis. Severe pain in the abdomen,
usually in the lower parts or non-localized pain, and a fever of 39-40°C appear.
Vomiting may be repeated many times. The stool is often loose and frequent. The
general condition is grave despite the short time that has passed from the onset of
the disease. The child suffers, he is restless and moans. In graver cases, on the contrary, the patient is languid, apathic and in some cases loss of consciousness and
delirium are observed. The skin is pale and the eyes sparkle. The tongue is dry and
with a white coating. Herpes labialis is sometimes found. The pulse is rapid and
may be small. The abdomen is tender in all its parts, but especially in the lower
parts, more on the right side. Moderate diffuse muscular rigidity is found, more
pronounced below the umbilicus and on the right. The Shchetkin-Blumberg sign is
positive. The lower parts of the anterior abdominal wall and the right ileal portion
are moderately oedematous in some cases. A mucopurulent vaginal discharge is
noted in some cases.
Appendicular peritonitis
After 24 – 36 hours of abdominal pain, vomiting, increasing of body
temperature due to acute appendicitis, the pain abates a little, the general condition
may also improve a little, but temperature remains increased. After a clear period
the patient’s condition deteriorates: abdominal pain grows again, repeating
vomiting occurs and general condition gradually worsens. The existence of the
clear period is linked with destruction and necrosis of nerve endings in the
appendix.The deterioration is explained by involvement of the whole peritoneum
in the inflammation as the result of perforation of the appendix. The time needed
for the occurrence of perforation and the duration of the clear period depends on
the patient’s age: the younger the child, the quicker will perforation occur and the
shorter will be the period of the imaginary improvement.
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Examination of a child with appendicular peritonitis shows that his general
condition is very grave. The skin is pale, sometimes with a “marble” tinge. The
limbs are covered with sticky cold sweat. The lips and tongue are very dry and
coated with a white film. Dyspnoea is usually encountered, which is more severe in
younger children. The abdomen is distended and does not take part in the act of
respiration. Generalized muscular rigidity, tenderness, and the Shchetkin –
Blumberg sign are found. A loose stool passed frequently. Rectal examination
reveals sharp tenderness and an overhanding rectal wall. Respiratory insufficiency
may come to the forefront and is followed some time later by decompensation of
the cardiovascular and respiratory systems and metabolic processes, as a result of
which the patient’s condition grows progressively worse. Medication with
antibiotics sharply diminishes the acuteness of the clinical manifestation of the
appendicitis, reduces the severity of the pain syndrome, fever, and general
disorders, but antibiotics fail to arrest the already developing destructive process
and inflammation of the peritoneum progresses. Therefore, the application of
antibiotics when the cause of the abdominal pain is still not identified is absolutely
contraindicated.
In development of peritonitis 3 main phases are distinguished:
reactive, toxic and terminal.
Treatment
The management of peritonitis is applied in stages: preoperative preparation,
operation and postoperative management. The immediate performance of an
operation in marked disorders of the body’s internal medium is a serious mistake.
Preoperative management consists in correction of the disturbed haemodynamics,
acid-base balance and water-salt metabolism. Evacuation of the stomach and upper
parts of the intestine through a gastric tube, oxygen therapy, relieving the pain
reflex by means of peridural anesthesia, treatment with broad-spectrum antibiotics
is also necessary.
The object of operation in peritonitis is to remove the primary focus, cleanse
and drain the abdominal cavity. A large amount of purulent exudates of pus,
evident intestinal paresis and even paralysis and severe circulatory disorders with
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fibrin deposits on the intestinal loops are found in abdominal cavity. Intestinal
paralysis leads to stasis and distention of the small intestine by the fluid and gases
accumulated in it. Circumscribed abscesses are often found in the abdomen.
Appendectomy, aspiration of the pus and fibrin, cleansing of the abdominal cavity
with solution of furacillinum or antibiotics, introduction of a catheter into
abdominal cavity for the subsequent administration of antibiotics are the stages of
the operation.
Stability of the organism’s internal environment (homeostasis) is maintained
after the operation according to the same schedule as before surgery. Broadspectrum antibiotics must be administered intravenously. Care must be taken to
watch protein and electrolyte metabolism because protein and potassium losses are
frequent.
The management of peritonitis in children, those of young age in
particular, requires an individual approach with due consideration for many
factors. Massive complex therapy is only effective measure in this severe disease.
Peritonitis in the newborn
The disease is polyaetiological and is due to perforation of the wall of the
gastro-intestinal tract, mostly the large intestine, in 80 per cent of cases. A much
rarer cause of peritonitis in the newborn is hematogenic, lymphogenic or contact
(in periarteritis and periphlebitis of the umbilical vessels and inflammation of the
organs of the retroperitoneal space) infection of the peritoneum.
Perforation peritonitis
1. Necrotic enterocolitis:
a)
posthypoxic
b)
septic
2. Developmental anomalies of the gastro-intestinal tract:
a)
segmental anomalies of the wall of a hollow organ ( defect in the
muscular coat, haematolymphangiomatosis )
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b)
developmental anomalies inducing mechanical obstruction of the
gastro-intestinal tract ( intestinal atresia, meconium ileus, Hirschsprung’s disease,
volvulus)
3. Acute appendicitis.
4. Iatrogenic perforation of the gastro-intestinal tract.
Non-perforation peritonitis
1. Haematogenic or lymphgenic infection of peritoneum.
2. Contact infection of peritonitis.
Necrotic enterocolitis is the main cause of perforative peritonitis. The
etiological factors are perinatal hypoxia (intrauterine hypoxia of the foetus in
toxicosis of pregnancy, anemia, heart diseases, rhesus and group blood
incompatibility, asphyxia in birth, respiration failure in the newborn due to
pneumopathy, and pneumonia, in decompressed congenital heart disease, shock,
hypovolemia) as well as intrauterine or postnatal sepsis attended by severe
dysbacteriosis. A combination of several factors is encountered most frequently.
Beginning from the second to sixth day of life the newborn is reluctant to
suck at the breast, regurgitates with admixture of bile at times, and loses weight
rapidly. The abdomen is distended, tenderness and oedema of the anterior
abdominal wall develop. X-ray shows uniniform filling of the different parts of the
gastro-intestinal tract with gases, thickened shadows of the intestinal walls. Stool is
passed often and contains mucus. The haemorrhagic intestinal syndrome (bright
red blood discharged from the rectum) develops in attendance. Perforation of the
ulcers manifested by a sharp deterioration of the child’s condition and signs of
peritoneal shock .The skin is pale with grayish hue and cold. Vomiting of stagnant
intestinal contents occurs. Breathing is frequent, shallow and arrhythmic.he
abdomen is distended, rigid, and tender to palpation. The hepatic dullness is not
produced because free air is present in the abdominal cavity. Intestinal peristalsis is
absent. The stool and gases are not passed. The abdominal wall is oedematous,
especially in the lower half, hyperaemic, and its venous network is dilated. X-ray
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in vertical position shows a cresent-shaped area of free air under the diaphragmatic
cupula.
Treatment in stages without perforation is nonoperative and includes
decompression of the gastro-intestinal tract by completely discontinuing enteral
feeding and irrigation the stomach with Ringer’s solution, infusion therapy, which
is prescribed with due consideration for the fluid loss and daily requirements of the
child’s organism .antibiotic therapy with broad-spectrum antibiotics. Surgery in
necrotic enterocolitis is indicated in perforative peritonitis. The operation consists
in resection of the necrotic intestinal segment, creation of stoma on anterior
abdominal wall, and irrigation of the abdominal cavity with antiseptic solutions.
Meckel’s diverticulum
This is a pathological condition in which the proximal part of the vitelline
duct remains unobliterated. Various forms of the diverticulum are known. It
usually forms on the side of the ileum opposite to the mesentery at a distance of
20-70 cm from the ileocaecal (Bauhin’s) valve and resembles a short vermiform
process. Meckel’s diverticulum is mostly conical or cylindrical. It may be joined
closely with the mesentery, anterior abdominal wall or intestinal loops by means of
a connective-tissue strand (remnant of the vitelline duct). Histological examination
of the wall of the diverticulum reveals in some cases dystopic mucosa of the
stromach or different parts of the interstine (duodenum or colon). Pancreatic tissue
is a less frequent finding. Dystopia of atypical glandular tissue is the cause of one
of the complications of Meckel’s diverticulum, errosion of its wall and intestinal
haemorrhage.
Meckel’s diverticulum is commonly a chance finding during laparotomy
undertaken for some other reason or because of the development of complications
among which of most importance are haemorrhage, inflammation (diverticulitis),
invagination, and other forms of interstinal obstruction (strangulation, volvulus).
Diverticulitis is marked by symptoms simiral to those of acute appendicitis
(nausea, vomiting, abdominal pain, elevated body temperature, leucocytosis). It is
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practically impossible to distinguish between these diseases, and if the vermiform
process is found to be normal on laparotomy it is therefore to inspect the snall
intestine for a distance of about 70 cm.
Intestinal invagination, beginning from the diverticulum, produces typical
symptoms (sudden onset, paroxysmal abdominal pain, vomiting, intestinal
bleeding). The diverticulum is discovered during operation after correction of the
invagination.
Intestinal obstruction may be caused by torsion of the intestinal loops about
Meckel’s diverticulum fused to the anterior abdominal wall or by strangulation of
the loops in fixation of the diverticulum to them or to the mesentery. A clinical
picture of intestinal obstruction is produced.
The diagnosis of Meckel’s diverticulum is very difficult. It is usually
suspected in cases of recurrent intestinal haemorrhages. X-ray examination yields
no clues as a rule. Exploratory laparotomy is undertaken to exclude the diagnosis
finally.
Treament of Meckel’s diverticulum consists in its surgical removal, for
which two methods exist. A diverticulum on a thin pedicle is removed like the
vermiform process. If the diverticulum has a wide base, its wedge resection in the
obligue divection is conducted and the intestinal wall is then closed with
interrupted double-row sutures. A developed mesentery of Meckel’s diverticulum
is ligated separately.
6. Methodical support of the lesson.
6.1. Control of the original level of knowledge:
I.
Histological classification of the acute appendicitis :
II.
Atypical localizations of the appendix :
III.
Diagnostic key of the acute appendicitis by S.Doletskiy :
IV.
A 9-year-old boy presents with 7-hour history of weakness, fever,
headache, muscle pain, abdominal pain, vomiting and diarrhea. He is listless and
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appears pale. The abdomen is soft, distended. There are abdominal murmur and pain in
the epigastric and right flank. Stool is loose, foul-smelling with admixture of mucus.
a) Make the provisional diagnosis.
b) What of the present symptoms are negative for acute
appendicitis?
Answers:
I.
Catarrhal, phlegmonous, gangrenous appendicitis.
II.
Retrocecal, pelvic, subhepatic, left-sided localization.
III.
Muscular tension and provoked pain.
IV.
a) Acute gastroenteritis.
c) Headache, muscle pain, high temperature, abdominal murmur,
loose and foul-smelling stool.
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6.2. Literature
1. Ashkraft K.W., Cholder T.M. Pediatric surgery , V.I / S-Pb. - 1996. – P.328 .
2. Ashkraft K.W., Cholder T.M. Pediatric surgery , V. II / S-Pb. - 1997. –P.358 .
3. Ashkraft K.W., Cholder T.M. Pediatric surgery , V. III / S-Pb. - 2000. – P.306 .
4. Castile R.G., Telander R.L. Chron’s disease in children / J. Pediatr Surg . –
1990. – V. 24. – P.462-469.
5. Dixon P.M. The diagnosis of Meckel’s diverticulum : A continuing challenge/
Clin Radiol.- 1997. – V.38. – P.2239-2250.
6. Golden N., Neuhoff S. Pelvic inflammatory disease in adolescents / J.Pediatric.
– 1989. - V. 144. – P.138-143.
7. Grosfeld J.L. Common problems in pediatric surgery / Mosby YB . – St. Louis.
– 1991. – P. 310.
8. Isakov Y.F. Surgical diseases in children, V.I / Moscow . – Medicine. - 1990. –
P. 426.
9.Isakov Y.F. Surgical diseases in children , V.II / Moscow . – Medicine. - 1990. –
P. 410
10. Isakov Y.F., Stepanov E.A., Krasovskaja T.V. Abdominal surgery in children /
Moscow.- Medicine . – 1988. - P.294.
11. Rickam P.P., Lister J. Neonetal surgery / London. – 1988. – P.621.
7. Control material:
A. Questions:
What complications may cause Meckel’s diverticulum?
What methods are used for diagnostics of the diseases of ileocecal angle?
What additional methods of examination are used in diagnostic of acute
appendicitis?
What pathologic changes may be found at rectal palpation in children with pelvic
localization of the appendix?
Call complications of the acute appendicitis.
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What is a treatment of the acute appendicitis is in young children?
Call the stages of the acute pancreatitis.
Classification of peritonitis ?
B. Tests with the samples of answers:
1. Localization of the Meckel’s diverticulum :
A. Duodenum.
B. Jejunum
C. Ileum
D. Cecum
2. Sign the symptom of migration of the pain from umbilical region at the right
iliac region in acute appendicitis.
A. Koher’s symptom.
B. Rowzing’s symptom
C.Sytcovsky’s symptom
D. Voskresensky’s symptom
3. What localization of the appendicitis is characterized with the pain in the lower
abdomen, dysuria and loose stool?
A. Retrocecal.
B. Pelvic
C. Subhepatic
D. Left-sided
4. What change is found in blood analysis in acute appendicitis?
A. Leucocytosis .
B. Leucopenia
C. Anemia
D. Thrombocytopenia.
5. What method of investigation is crucial in diagnosis of acute appendicitis?
A. Ultrasonography.
B. X-ray of the abdominal cavity
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C. Irrigoscopy.
D. Laparoscopy.
C. Tasks with the samples of answers:
1. A 6-year-old girl was brought into the surgical department in 3 hours from the
beginning of the disease with complaints of the pains in the abdomen, increasing of
the temperature up to 38C, vomiting. Examination found the pain all over the
abdomen, tension of the abdominal muscles (more intensive in the right iliac area),
moderate discharge from the vagina were revealed.
Make a diagnosis.
Answer: Primary peritonitis.
2. A 3-year - old child was brougth to the receiving department with complaints of pain
in the abdomen, vomiting, hyperthermy, diarrhea. Palpation of the abdomen is
impossible because the child is very restless.
What method must be undertaken for exception the surgical disease?
Answer: Examine of the child in sleep ( by medications or physiologically)
3. A child of 10 years old was brought into the surgical receiving department with
complaints of pain in the abdomen, vomiting, hyperthermia – 37,3C. Initial diagnosis
is “Acute appendicitis”.
What sign is more reliable for acute appendicitis?
Answer: Pain and guarding in the right lower abdomen .
4. A 2-year-old boy was brought into the surgical department in 10 hours from the
beginning of the disease with complaints of the pain in the abdomen. The boy is flabby,
capricious. He vomited twice and had fluid stool. The temperature is 38.5 ºC, Ps 140.
Muscular tension in the right lower abdomen was found on the examination in sleep,
the sign of the pushing off the hand is positive.
What disease is characterized by the such signs?
Answer: Acute appendicitis.
5. A 13-year-old boy complains of the pain in the abdomen, increase of the temperature
up to 37,5ºC. He have been ill for 6 days. The asymmetry of the abdomen, deficiency of
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its respiratory movement in the right lower part was found in examination. A firm,
painful, fixed tumor-like formation was found on the right iliac area.
What is your diagnosis?
Answer: Appendicular infiltrate.
6.A 12-year-old child was referred because of abdominal pain , frequent painful
urination , loose stool on two occasions .Temperature was 37,4 C. Physical examination
showed the moderate right-lower-quadrant tenderness and muscle spasm . The WBC
count was 12 G/l. Leukocytes , erythrocytes and cylinders were found in urine .
What investigation should be done to specify a diagnosis ?
Answer: Rectal examination .
7. A 6-year-old boy suffering from the upper respiratory infection began to complain of
the abdominal pain and fever (38 C ) and vomited on two occasions . Physical
examination showed tenderness of the abdomen with the maximum in the right-lower
quadrant. A muscle spasm was not observed. Rectal examination was unremarkable.
The WBC count was 12 G/l.
What disease should be differentiated with an acute appendicitis first?
Answer: Mesenteric adenitis.
8. Material for intra-lesson preparations:
Practical attainments:
1. Take the anamnesis of disease in senior child with complaint on abdominal pain .
2. Take the anamnesis of disease in child under 3 year.
3. Examine the child with complaint on abdominal pain.
4. Appoint the plan of examination of child with acute appendicitis.
5. Evaluate the results of laboratory analysis.
6. Examine the Blumberg’s symptom.
7. Appoint the plan of treatment in postoperative period after appendectomy.
8. Appoint the plan of treatment of the appendicular infiltrate.
9. Appoint the plan of treatment of the acute pancreatitis.
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9. Material for the control of acquirements and practical attainments
A 9-year-old boy developed mid-epigastric pain, which subsequently localized to the
right lower abdomen .He had vomiting and fever 37,5 C .On physical examination pain
and guarding were found in the right lower abdomen .The white blood cell count was
11 G/l with a slight shift to the left on the differential smear . The urinalysis and stool
were unremarkable. Make a diagnosis.
A. Acune cholecystitis .
B. Duodenal ulcer .
C. C. Acute appendicitis.
D. D. Acute pyelonephritis.
E. E. Salmonellosis .
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