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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 1 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. 2 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 3 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. 4 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 5 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 6 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 7 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. 8 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 9 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. 10 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. 11 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 12 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 13 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. 14 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; 15 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, 16 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. 17 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 18 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 ) 19 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 20 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 21 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 22 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. 23 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. 24 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 25 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 38C, 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 – 37,3C. 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 26 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. 27 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 . 28