apendicita curs
DESCRIPTION
curs chirurgie apendicita, medicina generala, apendicectomieTRANSCRIPT
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Patologia chirurgicala aapendicelui
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Generalitati
• cea mai frecventa cauza de suferinta abdominala chirurgicala
• afectiuni in deosebi inflamatorii, mai rar tumorale
• apendicita acuta - cel mai mare numar de interventii chirurgicale in urgenta
• apendicita cronica - cauzeaza multe din sindroamele dispeptice atribuite altor organe
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Apendicele cecal
• Berangario de Carpi (1521), Leonardo da Vinci (1492) - reprezentare in planse anatomice
• considerat organ vestigial, fara functie cunoscuta, astazi: organ imunologic – prod. de IgA, dar neesential
• topografie: fosa iliaca dreapta, dependenta de baza cecului• lungime 8-9 cm, extreme 3-33 cm• diametru exterior 5-8 mm• structura peretelui identica cu a cecului (2 sapt dupa
nastere - tesut limfoid, foliculi limfoizi = 200 la 20-30 ani, dupa care regreseaza, “ amigdala abdominala”)
• a. apendiculara ramura a A.M.S.• drenajul limfatic - ggl duodeno-pancreatici sau ovar !?
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Apendicita acuta
• Definitie = sd abdominal acut determinat de inflamatia acuta a apendicelui (Reginald Fitz - 1886)
• 1889 – Charles McBurney – importanta interventiei chirurgicale– punctul de maxima sensibilitate
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Etiopatogenie• Incidenta 1/500 - 1/600, max la copil si adultul tanar• M = F, apendicectomii mai frecvente la femei• etiologie
– actiune unitara a unui complex de factori• determinanti - ag microbieni (Escherichia coli asociata uneori cu
steptococ, stafilococ , anaerobi)– teoria enterogena– teoria hematogena
• favorizanti – anatomic– traumatic– vasculari
• factorii etiopatogenici imprima in functie de diversi parametrii evolutie variabila a procesului patogen - forme clinice diverse
NB - apendicita din neoplasmul de colon, sau herniara
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Fiziopatologie
• obstructie acumulare de mucus cresterea presiunii intraluminale
• staza - proliferare de germeni - cresteri presiune - jena drenaj limfatic si venos = edem
• presiunea si inflamatia - irita terminatiunile nervoase• distensia stimuleaza miscarile peristaltice• procesul septic apendicular in totalitate irita peritoneul
parietal durere fosa iliaca dreapta• iritatia peritoneului aparare si/sau contractura• febra, tahicardie, leucocite crescute datorita resorbtiei si
tesuturilor necrozate
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Anatomie-patologica
• forme endogene, in ordinea gravitatii (Abricosoff)
• catarala sau congestiva• flegmonoasa (purulenta, supurata, empiem apendicular)• gangrenoasa
• forme exogene • peritonita localizata• plastron apendicular• peritonita generalizata
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Simptomatologie
• Tablou clinic variat in functie de• topografie,• stadiu evolutiv• teren
• poate nimic mai potrivit pentru aforismul ca nu exista boala ci bolnav decat modul variat de manifestare a numeroaselor forme clinice de suferinta apendiculara in raport cu multiplii factori etiopatogenici si reactivitatea bolnavului
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Forme clinice
• dupa gravitate– a.a. forma tipica– a.a. forma subacuta– a.a. forma toxica– a.a. cu peritonita
• dupa topografie– in functie de localizarea apendicelui
• dupa varsta si anumite stari fiziologice (sarcina)
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Forme clinice dupa gravitate
• debut de regula brusc• semne functionale:
– durere abdominala– inapetenta, semn precoce, precede durerea– greturi si varsaturi– tulburari de tranzit– succesiunea simptomelor
• ANOREXIE – DURERE – GRETURI, VARSATURI• esentiala pentru diagnosticul pozitiv si diferential
• semne generale– temperatura sub 38 grade Celsius– tahicardie– frison
1. Forma acuta tipica
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• Examenul obiectiv– inspectie
• pozitie antalgica• diminuarea miscarilor respiratorii la nivelul hemiabdomenului drept inferior
(abdomen mobil cu miscarile respitatorii, dar retinut de la orice miscare ampla – tuse, stranut, etc.)
– palparea• durere provocata
– palparea fosei iliace drepte– palparea punctelor apendiculare:
» Mac Burney 1/3 ext –2/3 int linia omb - SIAS» Lanz 1/3 ext - 1/3 medie bispinoasa» Morris - 3-4 cm de omb linia omb-SIAS» Sonneburg - inters l bispinoase cu marg ext a dreptului abdominal» manevra contravine recomandarii clasice de a nu folosi palparea unidigitala (Mondor)
» triunghiul Iacobovici
• aparare musculara - contractura musculara• hiperestezie cutanata
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• manevre ajutatoare– Rowsing– Javorski-Lapinski – manevra psoasului– Blumberg
• percutie – poate delimita sediul maxim al durerii– semnul Mandel - Pott - al “clopotelului”
• auscultatie– silentium abdominal
• apararea si contractura abdominala de mai mica intensitate la bolnavii tarati, varstnici, multipare sau apendicele situat la distanta de peritoneul parietal
TRIADA DIEULAFOY
durere provocata, aparare musculara, hiperestezie cutanata,
• tuseul rectal si/sau vaginal
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• Examene paraclinice– leucocitoza - 10 000 / mmc (cu sau fara polinucleoza– cresterea L peste 15 000 - ! perforatie– ! Nu exista paralelism intre forma anatomo-clinica si leucocitoza – VSH crescut– sediment urinar - normal dar poate fi modificat insa nu ca intr-o
afectiune renala– rx abdominala simpla – ecografia – tomografia computerizata– laparoscopia
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2. Forma subacuta
• semne clinice de intensitate mai mica
• virulenta microbiana este scazuta• obstructia lumenului apendicular
nu este totala• tratamente prealabile cu
antibiotice
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3. Forma toxica
• evolutia rapida data de virulenta excesiva a germenilor microbieni
• sindrom toxic grav– predomina fenomenele generale
• adinamie, somnolenta
– se accentueaza rapid• hipotensiune, puls accelerat, afebrilitate, varsaturi,
diaree, deshidratare
– semne abdominale reduse: lipseste apararea musculara
• laparoscopia: de mare importanta
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3. Forma cu peritonita d’emblee
• peritonita localizata sau generalizata
• dupa debutul de apendicita• instalare a fenomenelor clinice de
peritonita acuta generalizata sau localizata– diagnosticul trebuie diferentiat de alte
peritonite secundare
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Forme clinice topografice
• a. a. retrocecala - 30%– simptomatologie lombara sa lombo-abdominala cu
accent de colica renala sau ureterala
• a. a. pelviana – simuleaza afectiuni vezicale, urinare, rectale, genitale– pt. diagnostic - T.R., T.V.
• a. a. mezoceliaca (a promontoriului)– tablou clinic de ocluzie intestinala febrila– dureri subombilicale clinic si la palpare
• a. a. subhepatica• a.a. pe stanga• a.a herniara
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• a.a. la sugari– rara si grava
• a.a. la copil– in timpul sau dupa afectiune infecto-contagioasa– de obicei toxica– semne obiective neclare - atentie mimica fetei
• a.a. la batrani – ocluzie febrila– pseudotumorala– in doi timpi
• a.a. in sarcina– survine dupa luna a IV-a– examinare in decubit lateral stang
• consensul unanim - mai bine sa se opereze un apendice indemn decat sa se lase un apendice bolnav
Forme clinice dupa varsta si stari fiziologice
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Evolutia apendicitei acute
• retrocedarea simptomatologiei sub tratament medical
• aparitia complicatiilor
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Plastronul apendicular
Definitie: peritonita plastica fibrinoasa interviscerala si epiploica ce formeaza un baraj de protectie in jurul focarului septic intraperitoneal izolandu-l de restul cavitatii peritoneale
• germeni cu virulenta scazuta• reactivitate buna a organismului• limitarea procesului inflamator printr-o peritonita circumscrisa• a doua perioada in evolutie
– ex obiectiv• formatiune tumorala in FID• TR - polul inferior al tumorii• stare generala alterata• hiperleucocitoza• febra• rx abdominala simpla - nivele hidroaerice FID
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Plastronul apendicular
– tratament• medical - leucocitoza, temperatura, termografie
– evolutie• remisiune • nefavorabila: abces local, la distanta, fistulizare la tegument, in
organ cavitar, ocluzie intestinala, flegmon retroperitoneal, peritonita in “trei timpi”
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Abcesul apendicular
– evolutie in doua stadii• presupurativ - urmeaza perforatiei apendiculare• colectie delimitata de organele vecine
– tablou clinic• faza presupurativa - apendicita acuta• faza supurativa
– curba termica oscilanta– frisoane, stare generala alterata– curba leucocitozei ascendenta
• examen local - fluctuenta• punctie exploratorie• complicatii locale • complicatii generale
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• Forme clinice de abces apendicular– fosei iliace drepte– pelvin– retrocecal– mezoceliac– suhepatic
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Peritonitele apendiculare
• acuta generalizata d’emble• hipertoxica• in doi timpi
– I ul timp - apendicita acuta– al II -lea timp perforatia apendicelui
• in trei timpi– I-ul timp apendicita acuta– al II -lea timp abcesul sau plastronul apendicular– al III-lea timp peritonita
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Diagnosticul diferential al apendicitei acute
• depinde de trei factori majori– pozitia anatomica a apendicelui– stadiul procesului evolutiv– varsta si sexul pacientului
• afectiuni digestive– limfadenita acuta mezenterica– gastro-enterita acuta– inflamatia diverticulului Meckel– neplasmul de cec/ascendent– ocluzia intestinala
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Diagnosticul diferential al apendicitei acute
• afectiuni ginecologice– boala inflamatorie pelvina (anexita, metroanexita)– ruptura foliculului deGraff– sarcina ectopica– chistul de ovar torsionat
• afectiuni urologice– litiaza reno-ureterala– pielonefrita acuta dreapta
• alte afectiuni– respiratorii: pneumonii, pleurezii, viroze
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Tratamentul apendicitei acute
– apendicectomia profilactica - Ledeard • nu a fost acceptata ca principiu• actual - nici in indicatiile ei de electie (persoane in izolari
indelungate: submarine, statii orbitale)
– tehnica• clasica
– anterograda– retrograda– subseroasa– aseptica
• laparoscopica
– tratamentul peritonitei• apendicectomie, drenaj, antibioterapie
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Complicatii postoperatorii
• infectii
• hemoragie
• ocluzii
• fistule
• mortalitate 0,2%
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Apendicita cronica
• Leziuni micro si macroscopice rezultate in urma unui proces inflamator acut care a evoluat catre rezolutie
• Anatomie patologica– sclero-atrofica– sclero-hipertrofica
• Limfangita regionala - retractii ale epiplonului si mezenterului, aderente, membrane Jackson, bride = leziuni de peritonita adeziva pericecala
• leziuni de vecinatate prin interesare limfatica - periduodenite, pericolecistita
• Semne clinice de imprumut• Forme clinice: digestiva, extradigestiva, claudicanta, nervoasa• diagnostic - “retrospectiv”
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