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Острый аппендицит у детей   06.09.2014

Острый аппендицит у детей это самое распространенное хирургическое заболевание в этом возрасте. Операции при остром аппендици­те составляют 75% всех экстренных оперативных вмешательств. Со­общается следующая заболеваемость острым аппендицитом: от года до 3 — 0,6 на 1000; от 4 до 7 — 2,6 на 1000; 13 лет — 8 на 1000.
Анатомо-физиологические особенности илеоцекального от­дела и аппендикса у детей.

Высокая подвижность слепой кишки в возрасте до трех лет из-за длинной брыжейки и нарушения процесса эмбрионального разви­тия оказывает существенное влияние на клинические проявления заболевания.

У детей первого года жизни аппендикулярный клапан отсутствует или слабо развит, что обусловливает сво­бодное отхождение кишечного содержимого из аппендикса в слепую кишку, отсутствие возможности формирования каловых камней и застойных процессов в отростке.

Вариабельность расположения червеобразного отростка: нисходящее положение (35%); медиальное и срединное положе­ние (26%); ретроцекальное положение (20%); латеральное поло­жение (15%), что обусловливает разнообразие симптомов острого аппендицита у детей.

У детей до трех лет червеобразный отросток формы конуса, что не способствует возникновению застойных явлений, и редкость заболевания в этом возрасте.

Тонкость стенки червеобразного отростка и слабое развитие мышечных слоев обусловливают более раннее развитие острого аппендицита у детей до 3 лет.

Недостаточное развитие фолликулярного аппарата черве­образного отростка, играющего важную роль в патогенезе аппен­дицита.

Наличие анастомозов между лимфатическими сосудами илеоцекального отдела кишечника с лимфатической системой внутренних органов брюшной полости и забрюшинного простран­ства, создающих условия для генерализации воспалительного про­цесса лимфатическим путем.

Морфофункциональная незрелость нервных сплетений чер­веобразного отростка, особенно у детей младшего возраста, чем объясняется тяжесть острого аппендицита у детей в первые годы жизни.

Недоразвитие сальника у детей в первые годы жизни обуслов­ливает генерализацию воспалительного процесса при осложненном аппендиците.

Обильное кровоснабжение брюшины, быстрое вовлечение ее в воспалительный процесс, с низкой способностью к отграниче­нию воспалительного процесса и высокой всасывающей способ­ностью.

Патогенез острого аппендицита у детей

Существуют две теории, объ­ясняющие механизм развития воспаления в отростке: нерв но-сосудистая и теория застоя.

Нервно-сосудистая теория объясняет возникновение острого аппендицита через нарушения деятельности ЖКТ и висцеро-висцеральную импульсацию, которая отражает­ся на сосудистой трофике аппендикса. Спазм гладких мышц и сосудов приводит к нарушению питания стенки отростка вплоть до некроза. Изменяется про­ницаемость слизистой оболочки для микрофлоры с последующим развитием воспаления.

Теория застоя объясняет развитие острого аппендицита об­струкцией червеобразного отростка кишечным содержимым с последующим повышением давления в его просвете, ухудшени­ем лимфатического оттока, ведущим к отеку и набуханию ткани отростка. Нарушение венозного оттока в условиях высокого внутрипросветного давления и отека приводит к ишемии слизистой оболочки и инвазии микрофлоры.

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