surgery appendicular filltrate about definition to treatment

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1. APPENDICULAR INFILTRATE BY: PRIYANKAN POOJARI 20/13

2. Appendiceal infiltrate/Appendicular infiltrate : Appendiceal infiltrate is one of the complications of acute appendicitis in the intermediate period (3-5 days). It is a conglomerate of inflammatory tissues tightly fused to each other, including the appendix itself , as well as the surrounding formations: cecum , small intestine , omentum . As a rule, appendiceal infiltrate develops on the 2-4th day from the onset of the disease. In this case, in the right iliac region, less often in other areas, a limited, painful on palpation, dense and immobile formation appears. The Shchetkin -Blumberg symptom and other symptoms of peritoneal irritation persist . The leukocyte formula shows neutrophilia with a band shift, accelerated ESR . Temperature 37-38 °C. After a few days, the appendicitis clinic ends. The presence of appendiceal infiltrate is practically the only contraindication to appendectomy (the second contraindication is the patient’s refusal to undergo surgery), due to the lack of technical ability to isolate the appendix from the inflammatory conglomerate. Appendicular infiltrate must be differentiated primarily from a colon tumor and Crohn's disease .

3. HISTORY : Leonid Ivanovich Rogozov Russian: Леони́д Ива́нович Ро́гозов ; 14 March 1934 – 21 September 2000) was a Soviet general practitioner who took part in the sixth Soviet Antarctic Expedition, 1960–1961. In April 1961 he had developed appendicitis while at Novolazarevskaya Station, and being the only medical professional there at the time, had to perform his own appendectomy.

4. Anatomy. The appendix extends from the posterior internal segment of the cecum at the site of the muscle bands fusion. Its length varies from 1-1,5 to 20-25 cm, averaging 7-8 cm. The thickness of the vermiform appendage varies from 5 to 8 mm. The clinic for acute appendicitis is largely determined by the position of the cecum and vermiform appendix. The cecum is most often located in the right ileal region, but with incomplete in ontogeny turning the colon may be in the meso gastric or in the hypochondrium on the right. At the reverse arrangement of organs and with the presence of a mesentery of the cecum location, can be left parts abdominal cavity. Finally, the cecum is located in the small pelvis. Location variants of the appendix: in the left iliac region (situs viscerum inversum ), caecum mobile, medial location elongated vermiform appendage); low (pelvic) location ( viscero enteroptosis ), pelvic position of an elongated appendix); high (subhepatic) location (high location of the cecum, subheading of an elongated appendix, during pregnancy); retrocecal location (25-30%) with intraperitoneal, retroperitoneal and the intra-wall position of the appendix. The blood supply of the appendix is carried out from the arterial system iliac- of the superior mesenteric artery, venous outflow occurs on the same veins. Lymph outflow from the appendix is carried out in the lymph nodes of the ileocecal angle and the root of the mesentery.

5. ETIOLOGY: can be caused by a number of things, including food, bacteria, and parasites. Infection can also cause appendicular infiltrate. This can be caused by bacteria, viruses, or fungi. Inflammation can also cause appendicular infiltrate. This can be caused by a number of things, including injury, infection, and autoimmune diseases.

6. Complications of acute appendicitis : Appendicular (peri appendicular) infiltration. This is a kind of local bordered peritonitis. The leading sign of this complication is the appearance in the abdominal cavity of a moderately pain, and its localization roughly corresponds to the location vermiform appendix. At first, this is relatively mild, painful, has fuzzy edges. Then, the infiltration decreases, becomes denser and less painful. During this period, he can easily be mistaken for a tumor of the cecum. Further in a significant part of patients appendicular infiltration gradually dissolves and ceases to be determined. Diagnostics peri appendicular infiltrate is based on the detection of symptoms -acute appendicitis at the onset of the disease, which gradually subside, and revealing a palpable infiltrate. It should be remembered that some patients infiltrate may not be located in the right ileal region, but under liver with a sub-hepatic location of the appendage; appendicular Infiltration in the small pelvis is often found only when rectal or vaginal examination. After the resorption of complete restoration of the vermiform function, the process does not occur. In most cases in the appendage some sclerotic changes remain, peri appendicular cords. It is customary to combine these changes the term "residual chronic appendicitis"

7. Chronic appendicitis it is accepted to subdivide into three forms: 1) chronic residual (residual) appendicitis; 2) chronic recurrent appendicitis; 3) Primarily chronic appendicitis. Chronic residual appendicitis characterized by the presence of pain, defined in the projection vermiform appendage, which is associated, as a rule, with the previously transferred fit. Chronic recurrent appendicitis is characterized by the presence of frequent attacks of the disease. Primary chronic appendicitis, In contrast to residual, does not have a typical episode at the beginning of the disease .

8. Sufficiently controversial from the theoretical standpoint is the selection primary of chronic appendicitis. It should be noted here that the majority researchers deny the possibility of a primary occurrence in the appendage chronic inflammation. However, experience shows that the typical morphological changes in patients who did not have a single history, even the easiest attack of appendicitis. Therefore, from the point of view of the clinician, the division of this form is justified.  Diagnosis of all forms of chronic appendicitis is based on the history. With the primary chronic appendicitis, it can be difficult. And here it is necessary to make a differential diagnosis with tuberculosis of the appendage, tumors of the appendix, and, possibly, diverticulum of appendix. In some cases, the statement diagnosis of chronic appendicitis can be obtained with a contrast examination of the intestine with barium. Presence of stable contrasting process within a few days and even weeks after taking the barium and emptying it from the intestine testifies to the presence of the chronic appendicitis patient.

9. APPENDICEAL INFILTRATE : Clinically, appendicular infiltrate is most often detected 3-5 days after the onset of the disease. Clinical recognition of appendicular infiltrate in most cases is not particularly difficult. From the anamnesis, it turns out that a few days before admission to the hospital, the patient had abdominal pain. The general condition of such patients usually remains satisfactory. Body temperature rose to subfebrile figures. Independent abdominal pain is either insignificant or absent. When feeling, the abdomen remains soft and painless, with the exception of the right iliac region, where a formation with more or less clear contours, with a smooth surface, dense consistency (dense infiltrate) is determined. Stools and urination are normal. There is low leukocytosis in the blood, a slight shift of the leukoformula to the left and accelerated ESR.

10. Classification of appendicular infiltrate : According to the separation of the process from the free abdominal cavity: 1. Complete (full) – in this case, the process is completely separated from the free abdominal cavity, the risk of developing widespread peritonitis is minimal. 2. Incomplete – in this situation, part of the destructively altered process is located in the free abdominal cavity. This form of infiltration is potentially dangerous by perforation of the process into the free abdominal cavity and the development of widespread peritonitis. According to the clinical course This classification feature is applicable in the case of dynamic observation of a patient with complete appendicular infiltrate hospitalized for medical treatment. The effect of drug treatment is evaluated in dynamics. At the same time , there are two possible options for the development of infiltration: 1. Progressive - the inflammatory process spreads to the surrounding organs and tissues, or the infiltration abscess occurs. This indicates the ineffectiveness of drug therapy and requires surgical intervention. 2. Regressive – against the background of drug-induced inflammation, manifestations of the inflammatory syndrome are stopped, the infiltrate decreases in size. In this case, drug treatment is effective, urgent surgical treatment is not required. In the outcome of the regressing infiltrate, chronic residual appendicitis is formed.

11. By the nature of the infiltrate: (appendicular infiltrate was detected during surgery) During intraoperative revision, the infiltrate is divided into: 1. Friable - separation of the infiltrate in a blunt way without traumatization of the organs that make up it, perhaps appendectomy is technically feasible. 2. Dense – in this case, the inflammatory infiltrate cannot be separated in a blunt way. In the case of "acute" separation of the infiltrate, there is a risk of perforation of the small or caecum entering the infiltrate. In this case, the separation of the infiltrate is categorically contraindicated. Appendectomy is not performed. The operation ends with the introduction of a cigar swab (Penrose drainage) to the infiltrate. The meaning of abdominal tamponing in appendicular infiltrate is to further delimit the inflammatory focus from the free abdominal cavity. A cigar tampon for 6-7 days causes the formation of a channel from the abdominal cavity to the anterior abdominal wall, in the bottom of which there is an appendicular infiltrate. In the case of abscess infiltration or perforation of the process, the infected contents will flow out through this channel, without causing the development of widespread peritonitis.

12. Appendiceal infiltrate graph shown by different age groups

13. Appendicular infiltration is currently considered as a complication of acute appendicitis. The incidence rate of this disorder ranges between 0.2 and 5.8%. Despite a large number of studies dedicated to the issue of acute appendicitis and its complications, including appendicular infiltration, surgeons’ interest to this issue remains undiminished. Materials and methods. The paper presents the results of a retrospective analysis of diagnosis and treatment of 57 patients admitted to MI CTH No. 8, Ufa, with a diagnosis of acute appendicitis complicated with appendicular infiltration in 2012-1017. Results and discussion. In 32 (56.1%) patients, the infiltration was diagnosed during the surgery or diagnostic laparoscopy as an incidental find, the so-called ‘find-infiltration’. Of these, in 19 (33.3%) patients, the intraoperative find was evaluated as hard infiltration, in 13 (22.8%) — as soft. In 25 (43.9%) of patients admitted to the clinic with acute appendicitis, it was suspected that the infiltration had developed prior to surgery. Dynamic clinical and ultrasound examination in 11 patients left no doubt regarding the presence of infiltration. These patients were treated conservatively. In the remaining 14 patients, it was impossible to exclude acute appendicitis or infiltration and it was decided that diagnostic laparoscopy was indicated. Conclusion. Diagnostic laparoscopy is the leading method for diagnosis of this complication that helps determine a treatment strategy. Surgical strategy was strictly differentiated — at the infiltration stage — conservative, at the abscess stage — surgical; abscess cavity dissection and draining was recommended. Appendectomy was considered acceptable in technically uncomplicated situations. All the patients following the resolution of appendicular infiltration and dissection of periappendicular abscess should receive the recommendation to have appendectomy 3–4 months after discharge

14. Diagnostics of appendicular infiltrate : 1. Ultrasound examination. Allows you to determine the presence of a bulky formation in the right iliac region, which includes loops of the small and caecum. Ultrasound, performed in dynamics, allows you to monitor the course of the process during drug therapy, timely diagnose abscess infiltration. 2. Diagnostic laparoscopy (used in case of doubts about the diagnosis: to exclude incomplete infiltration, in case of differential diagnosis with another urgent pathology of the abdominal cavity).

15. Ultrasound Ultrasound is the first investigation advised to evaluate a suspected appendicular pathology. Findings of an appendicular abscess include: fluid collection (hypoechoic) in the appendicular region which may be well circumscribed and rounded or ill-defined and irregular in appearance the appendix may be visualised within the mass

16. In the right iliac area and pelvis visualized hyperechoic mass with increased bloodflow at DPD, with hypoechoic tubular structure in the middle - possible ultrasound picture of local appendicular infiltrate(complicated acute appendicitis) encapsuled by inflamed omentitis

17. Surgical tactics for appendicular infiltration 1. All patients with appendicular infiltrate are urgently hospitalized in a surgical hospital. 2. A clinical diagnosis indicating the clinical and morphological form of acute appendicitis and the form of infiltration (complete or incomplete) should be established in the first 2 hours of the patient's stay in the hospital. 3. The established diagnosis of incomplete appendicular infiltrate is an absolute indication for emergency surgery. In case of a serious condition of the patient, short-term (no more than 2 hours) preoperative preparation is carried out 4. The established diagnosis of complete appendicular infiltration is an indication for dynamic observation and drug therapy. Emergency surgery in case of complete appendicular infiltration is not indicated. ( contraindicated ) Tactics: 1) Dynamic observation: clinical, laboratory (CBC control), ultrasound dynamics of the course of the disease. 2) Treatment: an easily digestible diet with the exception of vegetable fiber, cold on the right iliac region, antibiotic therapy (cephalosporins, metronidazole), NSAIDs (indomethacin).The duration of treatment is determined by the period of infiltration regression (2-3 weeks). In case of infiltration regression, the patient is discharged from the hospital under the supervision of a polyclinic therapist. Appendectomy is performed as planned in 3-4 months.

18. 5 . In the case of progressive infiltration (abscess formation), abdominal pain does not subside, but increases; there is an increase in the soreness of the infiltrate during palpation. The fever continues, the body temperature rises. Pulse quickens. The boundaries of the infiltrate sometimes expand, leukocytosis increases, ESR accelerates. Symptoms of irritation of the peritoneum in the right half of the abdomen may appear. Finger examination of the rectum often allows you to determine the soreness of its walls or compaction, sometimes softening. In such cases, urgent surgical intervention is indicated. Results and discussion. In 32 (56.1%) patients, the infiltration was diagnosed during the surgery or diagnostic laparoscopy as an incidental find, the so-called ‘find-infiltration’. Of these, in 19 (33.3%) patients, the intraoperative find was evaluated as hard infiltration, in 13 (22.8%) — as soft. In 25 (43.9%) of patients admitted to the clinic with acute appendicitis, it was suspected that the infiltration had developed prior to surgery. Dynamic clinical and ultrasound examination in 11 patients left no doubt regarding the presence of infiltration. These patients were treated conservatively. In the remaining 14 patients, it was impossible to exclude acute appendicitis or infiltration and it was decided that diagnostic laparoscopy was indicated.

19. Conclusion. Diagnostic laparoscopy is the leading method for diagnosis of this complication that helps determine a treatment strategy. Surgical strategy was strictly differentiated — at the infiltration stage — conservative, at the abscess stage — surgical; abscess cavity dissection and draining was recommended. Appendectomy was considered acceptable in technically uncomplicated situations. All the patients following the resolution of appendicular infiltration and dissection of periappendicular abscess should receive the recommendation to have appendectomy 3–4 months after discharge

20. Appendicular infiltrate Results: 1. Resolution: pain decreases, infiltrate resorbs, temperature normalizes discharge with planned hospitalisation in 3 month for planned appendectomy 2. abscess operation Pain increase Hyperthermia Leucocytosis

21. Interventions variants 1) Wolkowitch-Diakonov’s Laparotomy 2) Pirogov’s method (extraperitoneal); 3) Punction drainage under US control; 4) Laparoscopy (risk!). 5) appendectomy

22. REFERENCES: https://www.surgonco.ru/jour/article/view/413?locale=en _ US https://www.researchgate.net/publication/337420912_Some_Aspects_of_Diagnosis_and_Treatment_of_Appendicular_Infiltration https://kazanmedjournal.ru/kazanmedj/article/view/75692 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5566752/ https://ulsu.ru/media/uploads/charyshkin%40yandex.ru/2017/11/26/uch_met_rec_appendex.docx https://www.researchgate.net/publication/359824291_To_the_treatment_of_appendicular_infiltrates https://radiopaedia.org/articles/appendicular-abscess https://ksma.elpub.ru/jour/article/view/708?locale=en_US https://kazanmedjournal.ru/kazanmedj/article/view/101352 https://europepmc.org/article/med/7423806 https://www.semanticscholar.org/paper/bd05ca3ff15f8f9ce88efc80063e81f19af15640 https://surgical-school.com.ua/index.php/journal/article/view/313 https://www.iate.obninsk.ru/edu-progs https://emedicine.medscape.com/article/773895-overview

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