RU2318442C1 - Method for predicting inflammatory forms of acute appendicitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: it is necessary to carry out ultrasound inspection of the organs of a patient's abdominal cavity and retroperitoneal space. Additionally, it is important to carry out chromatic Doppler and energetic mapping the circulation of visible department of vermiform process and surrounding organs and tissues. In case of circulation only in projection of process' mesentery and adjacent intestinal loops as single vascular branches one should detect the norm. At visualizing the vessels of not only the mesentery, but in the process itself, under condition that their visible quantity is larger than it surrounding intestinal loops and under condition of no signs of inflammatory process there one should detect catarrhal appendicitis. At detecting a considerable increase of vascular picture of visible parts of the wall of vermiform process and its mesentery, against circulation in adjacent intestinal loops, where it is represented by single vascular branches, under condition of good differentiation of the vessels of arterial and venous types, and at visualizing the process in transverse section as a chromatic "crown", and in longitudinal section the presence of chromatic stripes, the length being up to 1 cm, one should diagnose phlegmonous form of inflammation. At detecting considerable weakening, or the absence of vascular picture in areas of destruction, distinct registration, circulation in area of the process' mesentery, enhanced vascular picture of adjacent intestinal loops one should diagnose gangrenous inflammation. At no detection of circulation and registration of widened vascular branches in area of the process' mesentery one should diagnose empyema of appendix. At no detection of circulation in visible departments of the process, enhanced vascular picture in adjacent intestinal loops and in omentum it is possible to diagnose periappendicular abscess. The innovation increases information value of the diagnostics conducted.

EFFECT: higher accuracy of diagnostics.

26 dwg, 4 ex

Description

The invention relates to the field of medicine, specifically to methods for differential diagnosis of acute appetite.

Known methods for the diagnosis of inflammatory forms of acute appendicitis by laparoscopy using endoscopic equipment and methods consisting in the use of criteria for ultrasound diagnosis in B-mode [1, 2, 5, 9]. However, their scope is limited, so with their help it is impossible to carry out accurate and informative diagnostics in the early stages of the disease.

Closest to the proposed is a method for diagnosing forms of acute appendicitis by ultrasound diagnosis (ultrasound) in B-mode [2]. The determination of the form of acute appendicitis is carried out on the basis of identifying the following signs: an increase in the thickness of the process, the preservation of lamination, the contrast of the layers of its walls, the quantity and nature of the contents. The following clinical and anatomical forms of acute appendicitis are distinguished: simple (catarrhal) and destructive. Destructive include: phlegmonous, gangrenous, empyema, appendicular infiltrates and periappendicular abscesses. With catarrhal appendicitis, the lamination of the wall, the increase in its contrast, is observed. The diameter of the process varies slightly. Exudate in the cavity can rarely be detected, and its structure is always homogeneous. Ultrasound does not reveal changes in the small and cecum. The phlegmonous form is characterized by an increase in the diameter of the vermiform appendix to 9-15 mm, layering is expressed, layer fusion only during the development of the destructive process. The wall is up to 4-6 mm thick, the cavity of the process disappears or is expanded with echo-negative contents, coprolites are found. With gangrenous appendicitis, grosser changes in the process wall are noted, stratification in one or several areas is necessarily violated due to the complete destruction of the mucous-submucous layer. Around can be determined loose infiltration. With empyema of the appendix, its diameter increases even more - up to 15-20 mm, the wall becomes thinner, and the liquid contents in the cavity (sometimes with a suspension). With obstruction in the base of the appendix, coprolites are detected. In the event of a loose infiltrate around the inflamed appendix, there are immobile echogenic zones corresponding to the mesentery and soldered strands of the greater omentum. The phenomena of tiflitis and thickening of the walls of the adjacent loops of the small intestine, with the suppression of their peristalsis, are noted. Between the loops of the intestine, interlayers of fluid are determined, emphasizing the shape and size of the infiltrate, the contours of which, as a rule, are fuzzy. The dense infiltrate looks like a rigid immobile hyperechoic formation with fairly clear contours. With a periappendicular abscess, a hypoechoic structure (cavity) with a fuzzy blurred contour and uneven thickened walls is detected. The internal structure of the cavity is represented by a hypoechoic heterogeneous suspension. An indirect sign is the presence of swollen, fluid-filled bowel loops that do not peristaltize.

Thus, the known method does not have high accuracy in distinguishing between norm and pathology in case of weak manifestations of the inflammatory process at the initial stage, when the diameter of the process and the thickness of its walls vary slightly. The differential diagnosis of inflammatory forms in acute appendicitis is not accurate enough. Also, in the early stages, it is difficult to assess the involvement of surrounding organs and tissues in the inflammatory process.

A new technical result is an increase in the information content and accuracy of the early diagnosis of acute appendicitis.

To solve the problem in a method for differential diagnosis of acute appendicitis, which consists in conducting an ultrasound examination of the abdominal cavity and retroperitoneal space of the patient, determining the characteristics of the appendix, rigidity during compression and the condition of surrounding organs and tissues, additionally conduct color Doppler and energy mapping of blood flow visible sections of the appendix and the surrounding organs and tissues, and in the presence of blood flow only in of the mesentery of the appendix and adjacent loops of the intestine in the form of single vascular branches determine the norm, when visualizing the vessels not only of the mesentery, but also in the appendix, provided that their visible number is greater than in the surrounding loops of the intestine, and provided there are no signs the inflammatory process is determined by catarrhal appendicitis, when a significant increase in the vascular pattern of visible sections of the wall of the appendix and its mesentery is detected, compared with blood flow in adjacent loops of the intestine, de it is represented by single vascular branches, provided that the arterial and venous types are well differentiated and when the appendix is visualized in the cross section in the form of a colored “crown”, and in the longitudinal section there are colored stripes up to 1 cm long corresponding to the vascular branches of the vermiform appendix wall, diagnose a phlegmanous form of inflammation, when determining a significant depletion or lack of a vascular pattern in the areas of destruction, clear registration, blood flow in the zone of the mesentery of the appendix, If the vascular pattern of adjacent loops of the intestine is dilated, gangrenous inflammation is diagnosed, in the absence of blood flow in the walls of the vermiform appendix and registration of the expanded vascular branches in the mesentery of the appendix, appendix empyema is diagnosed, in determining the blood flow only in the mesentery of the appendix, development of appendicular blood flow in the absence is detected; parts of the process, increased vascular pattern in adjacent loops of the intestine and omentum, limiting abscess boiling zone diagnosed abscess periappendikulyarny

The method is as follows.

To study the structural changes in the appendix, a high-resolution device, Doppler blood flow research programs and a high-frequency sensor (5-12 MHz) are used. The device is configured to register low blood flow velocities (2.5-5 cm / s). The duration of the study usually lasts 20-25 minutes.

By known methods, during an ultrasound examination of the abdominal cavity and retroperitoneal space of a patient, a vermiform appendix is searched for [1, 2]. When it is detected in B-mode, its width, wall thickness, cavity contents, rigidity during compression, and the state of surrounding organs and tissues are evaluated. When assessing the structure of the wall of the process, such elements as the clarity and evenness of the contours of each wall layer, their uniformity in thickness, and uniformity in echogenicity are taken into account. The cross section of the process has the form of a "cockade" [2]. The internal echogenic rim corresponds to the mucosa and submucosa. The muscle layer has the appearance of a ring-shaped structure of somewhat reduced echogenicity. The serous membrane is a thin echogenic line [3]. For a qualitative assessment of blood flow in the wall of the appendix (more, less, the presence or absence of it) include Doppler color and energy scanning modes [4].

The diameter of the unchanged appendix is usually not more than 6 mm, the wall thickness is 2 mm. With compression, the process is elastic. Lamination is preserved throughout, the contrast of the layers is poorly expressed. Exudate in the cavity is not determined. In the regimes of color Doppler and energy scanning, it is possible to register blood flow only in the projection of the mesentery of the vermiform appendix and adjacent loops of the intestine in the form of single vascular branches. With catarrhal appendicitis, the diameter of the process becomes more than 6 mm, the wall thickness is 2-3 mm. The exudate is scarce, it is not often detected. The lamination of the wall is preserved, while its contrast increases [1]. In the modes of color Doppler and energy scanning, the increase in blood flow is determined - not only the mesentery vessels are visualized, but also in the appendix, moreover, their visible number is greater than in the surrounding intestinal loops, provided there are no signs of an inflammatory process in them. The phlegmonous form of inflammation is characterized by a thickening of the diameter of the appendix to 7-15 mm, its rigidity. The exudate is hypoechoic; visualization of coprolites is possible. The wall thickens to 4-6 mm, the contrast of layers is increased. Lamination is preserved with the exception of destructive sections. When studying the blood flow, a significant increase in the vascular pattern of visible sections of the appendix wall and its mesentery is found, in contrast to the blood flow in adjacent loops of the intestine, where it is represented by single vascular branches. In the process, arterial and venous vessels are well differentiated. When visualizing the process in the cross section, it looks like a colored “crown”, and in the longitudinal section, colored stripes up to 1 cm in length corresponding to the vascular branches of the appendix wall are traced.

In gangrenous inflammatory process, the process is thickened, its wall is 2-4 mm, the lamination is broken in the areas of destruction. In the cavity, hypoechoic exudate. Accumulations of interlobular effusion are often found. When studying blood flow in color Doppler and energy scanning, significant depletion or the absence of a vascular pattern in the destruction sites is determined. The blood flow in the zone of the mesentery of the appendix is recorded clearly. At the same time, there is an increase in the vascular pattern of adjacent loops of the intestine, often involved in the inflammatory process. With empyema of the appendix, a significant increase in the diameter of the process (10-22 mm) is determined. The wall is determined with a thickness of up to 1.5-2 mm. Lamination is broken. In the cavity, abundant hypoechoic exudate with suspension. The blood flow with the development of pronounced destructive changes in the wall is not determined, expanded vascular branches are recorded in the mesentery of the appendix. With the development of appendicular infiltrate, the process is not clearly visualized, its walls are hypoechoic, and lamination is not visible. The blood flow is determined only in the mesentery of the appendix. With a periappendicular abscess, the blood flow in the visible parts of the process is often not determined due to the destruction of the walls. In the adjacent loops of the intestine under these conditions, signs of their involvement in the inflammatory process are found: thickening of the walls, expansion of loops, lack of peristalsis, and the deposition of fluid in the cavity. In addition, in the mode of color Doppler and energy scanning, the amplification of the vascular pattern due to the expansion and increase in the number of visible vascular branches is determined.

The proposed criteria for the differential diagnosis of inflammatory forms of acute appendicitis using ultrasound diagnostics were obtained on the basis of an examination of 151 patients who were admitted to the surgical department with suspected acute appendicitis by emergency medical care.

A truly positive result was obtained in 29 patients. Of these, in 2 patients, changes characteristic of acute catarrhal appendicitis were found, in 16 cases a phlegmonous process was suggested, in 7 cases, the onset of appendix showed a gangrenous process, in 1 case appendix empyema was revealed. In 2 patients, destructive changes in the appendix with the formation of an infiltrate, in which intestinal loops were involved, were revealed, and in 1 case a periappendicular abscess was detected. In the operated patients, the results were histologically confirmed. A true negative result was obtained in 117 patients. In 4 cases, a false negative was obtained, and in 1 case, a false positive result.

The sensitivity of the method is 87.8%, specificity is 99.1%, and accuracy is 96.7%. Thus, the application of the proposed method allows to improve the quality of diagnosis of acute appendicitis, to differentiate the form of the inflammatory process, to determine the involvement of surrounding tissues in the inflammatory process.

In 117 patients with a truly negative result, the following pathology was revealed after an additional examination:

Intestinal colic - 72

Acute pyelonephritis - 4

M.K.B. Renal colic on the right - 4

Acute cholecystitis - 5

Acute pancreatitis - 3

Duodenal ulcer - 3

Intestinal obstruction - 5

Enterocolitis - 6

Terminal ileitis - 1

Intestinal bleeding - 1

Acute endometritis - 5

Apoplexy of the right ovary - 3

The threat of abortion - 1

Right-sided pneumonia - 1

Mesadenitis of the right iliac region - 3

False negative results were obtained due to acoustic noise created by the contents of the intestinal loops in the appendix location zone with coprostasis, flatulence - 3 cases. In one case, inspection of the appendix was difficult due to its retroperitoneal location.

A false-positive result was obtained in a patient with enterocolitis.

Specific examples of the application of the method.

Example 1. Patient 3., 51 years old. Case history No. 299, was admitted March 29, 2005 with a diagnosis of acute appendicitis. Complained of pain in the right half of the abdomen, fever up to 38.4 degrees. Local status: appendicular symptoms are positive. A general blood test showed leukocytosis with a significant shift of the formula to the left.

03/29/2005 an ultrasound examination of the abdominal cavity and retroperitoneal space was performed according to the standard technique in B-mode. The examination was carried out without preliminary preparation, in the position of the patient on the back. To examine the organs of the abdominal cavity and retroperitoneal space, a convex sensor with a frequency of 3.5 MHz was used. For a more detailed examination of organs and tissues of the right iliac region, a linear multifrequency (5-12 MHz) sensor was used that supports the modes of color Doppler and energy scanning of blood flow. The apparatus for ultrasound examination (PHILIPS En Visor) was tuned to a program for examining superficial organs, with registration of low blood flow velocities (2.5 cm / s). In B-mode, a thickened to 8-9.8 mm appendix was found in the right iliac region in longitudinal and transverse sections (Fig. 1). The thickness of its walls is 2-2.5 mm, the contrast of the layers is increased. Due to the bending of the appendix, different layers of its wall fall into the slice of the image, which gives the impression of a violation of layering. Given these signs, a phlegmonous form of acute appendicitis was suspected. To clarify the form of the inflammatory process, a study was carried out according to the proposed method — the CDC and energy scanning modes are included. When studying the blood flow of the appendix wall in all its visible departments, single vascular branches are recorded (Figs. 2, 3 — longitudinal and cross sections), which proves the course of the inflammatory process, but its shape is determined by the catarrhal. In the adjacent loops of the intestine, the vascular pattern is not visualized. Conclusion: acute catarrhal appendicitis. The result of our study is histologically confirmed.

Example 2. Patient B., 19 years old. Case history No. 1129, was received on April 25, 2006 with suspicion of acute appendicitis. Complained of pain in the lower abdomen, more on the right. Body temperature is 37 degrees. In local status, positive appendicular symptoms were determined. In the general analysis of blood pathological changes were not detected. The examination of the patient was carried out in B-mode according to the method described above without prior preparation, in the supine position. In the right iliac region, a vermiform appendix was found, gradually thickening to the apex from 6 to 9 mm (Fig. 4). The thickness of its walls is 3 mm, the lamination is preserved (figure 5). Exudate in the appendix cavity is scarce, hypoechoic. Around the process a small amount of effusion. Adjacent bowel loops without signs of pathological changes. A phlegmonous form of acute appendicitis is suspected. A study according to the proposed method.

In the modes of color Doppler (Fig.6, 7) and energy (Fig.8, 9) scanning of blood flow, a significant increase in the number of vascular branches is determined, both in the visible zone of the mesentery of the appendix and in the visible parts of the appendix wall, while in the adjacent only single vascular branches are located in the loops of the intestine. The appendix is in the cross section in the form of a “crown”, and during longitudinal scanning along its walls colored stripes are visualized due to increased blood flow. Conclusion: phlegmonous form of acute appendicitis. The result is confirmed histologically.

Example 3. Patient X., 17 years old. Case history No. 2587. Received October 19, 2004 with a diagnosis of acute appendicitis. Complained of pain in the lower abdomen on the right, dry mouth. In the local status, positive appendicular symptoms and symptoms of peritoneal irritation were determined. In the general analysis of blood, marked leukocytosis was noted. The examination of the patient was carried out in B-mode according to the method described above without prior preparation, in the supine position. A small amount of free fluid was found in the right iliac region. In B-mode, the appendix is visualized in longitudinal and transverse sections (Fig. 10, 11) at the iliac wing, thickened to 8-10 mm. The wall thickness of 2-3 mm, layered in some places broken. In the cavity, hypoechoic contents and an echopositive clot are similar to coprolite. Initially, it was suggested that there is a phlegmonous form of acute appendicitis. A study according to the proposed method.

When you enable the color Doler scan in the appendix wall, a single color signal from the vascular branches is determined (Fig. 12), indicating a depletion of the vascular pattern in the process wall. At the same time, a clear registration of blood flow in the mesentery of the process and numerous color signals from the vessels of the walls of the adjacent loops of the intestine are determined (Fig. 13). Conclusion: gangrenous form of acute appendicitis. The result is confirmed histologically.

Example 4. Patient I., 20 years old. Case history No. 80, was admitted January 17, 2006 with a diagnosis of acute appendicitis. Complained of pain in the right iliac region, dry mouth, nausea, weakness. Locally: the abdomen is tense, painful in the right iliac region. Appendicular symptoms are positive. In a general blood test, pronounced leukocytosis. A study according to the proposed method. In the right iliac region, a fragment of a thickened to 22 mm appendix was detected (Fig. 14). Wall thickness up to 3 mm, layering in some places broken. In the cavity of the process abundant hypoechoic exudate. In the CDC, the vascular pattern is determined only in the mesentery of the appendix (Fig. 15). In the course of the visible part of the appendix wall, blood flow was not detected, which confirms the destructive changes. Conclusion: empyema of the appendix. The result is confirmed histologically.

Example 5. Patient G., 19 years old. Case history No. 2167, was received on 08.11.2005, with a diagnosis of acute appendicitis. Complained of pain in the right iliac region. Locally: the abdomen is soft, moderately painful in the right iliac region. Appendicular symptoms are doubtful. In a general blood test, a shift in the leukocyte formula to the left is noted. According to the above methodology, a study was conducted. A group of enlarged lymph nodes, ranging in size from 0.5 to 1.5 · 0.7 cm, was found in the right iliac region. In the B-mode, the visible sections of the appendix are 5-6 mm wide. Wall thickness 2 mm. Lamination saved. Exudate in the cavity was not detected. A study according to the proposed method. In the color Doppler scanning mode, increased blood flow is detected in the enlarged lymph nodes (Fig. 16), confirming their inflammation. No blood flow in the walls of the appendix was detected - the absence of an inflammatory process (Figs. 17, 18). Conclusion mesadenitis of the right iliac region. After conservative treatment, the patient was discharged for further observation by a therapist.

Example 6. Patient M., 53 years old. Case history No. 801, received May 24, 2005. With the diagnoses: Acute appendicitis? Intestinal obstruction?

Complained of pain in the right iliac region and epigastrium, fever up to 39 degrees. Local status: the abdomen is tense, painful in the right iliac region and mesogastrium. In the right iliac region, an infiltrate of 6 × 10 cm is palpated, painful on palpation. The appendicular symptoms are doubtful, peritoneal symptoms are doubtful. In a general blood test, marked leukocytosis is noted. When examining the abdominal organs according to the above method in B-mode, an infiltrate with clear boundaries was found. Marked pronounced thickening of the walls of the intestine involved in the process, and especially of the cecum (Fig.20). Behind the cecum (retrocecal) is determined by a fragment of the appendix, up to 8 mm thick (Fig. 20). Its wall thickness is up to 3 mm, lamination is not traced. Around the appendix, an accumulation of heterogeneous liquid, limited by intestinal loops, is defined as an abscess cavity (Fig. 20, marked by arrows). A study according to the proposed method.

When regimes are switched on by color Doppler and energy scanning, a significant increase in blood flow is determined in the walls of the intestinal loops involved in the infiltrate, mainly in the wall of the cecum, as well as in the adjacent omentum (Fig. 25), which confirms their participation in the inflammatory process. Retrocecal in the projection of the abscess cavity, blood flow was not detected (Fig.22, 26). In the walls of the appendix, blood flow is not recorded, but is recorded in the energy scan mode only in the mesentery of the appendix (Fig.23). Conclusion: appendicular infiltrate with abscess formation, retrocecal location of the appendix. The result of our study was verified by operation: the process is destructively changed, located retrocecal, the abscess is bluntly opened there, its cavity is up to 8 cm in diameter.

Thus, the application of the proposed method allows a more accurate and reliable analysis of the structure of the walls of the appendix and the surrounding organs and tissues.

These clinical examples illustrate the possibilities of the proposed method in an objective assessment of the form of the inflammatory process of the appendix.

The proposed method is informative, not invasive, allows dynamic monitoring of the state of the appendix in patients with an unclear clinical picture. The results obtained allow us to determine the issues of conservative or operational tactics of patient management.

The obtained criteria for a differentiated assessment of inflammatory changes in the appendix allow the surgeon to aim for convenient operative access at atypical locations of the appendix and to more accurately determine the amount of intervention in cases with a complicated course of the disease.

Bibliography

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Diagnosis of difficult cases of acute appendicitis. Moscow, Triad-X, 1998

2. A.S. Ermolov, E.Yu. Trofimova.

Emergency ultrasound. Acute appendicitis. A practical guide. Moscow, 2003

3. E.B. Olkhova, V.E. Shchitinin.

Abdominal pain in children, (echographic options),

SonoAce-International No. 12, 2004

4. I.V. Babkova, L. B. Mishukova, S. E. Larichev.

Ultrasound diagnosis of impaired intraparietal blood flow in acute small bowel obstruction using dopplerography. J. Medical imaging, 2000, No. 3.

5. V.A. Bykovsky, S.A. Zarubina, E.B. Olkhova, L.I. Petukhova. The possibilities of ultrasound in the diagnosis of acute appendicitis. http://www.ultraland.ru/s4.htm.

6. M.V. Zinyakova, L.G. Kurtenok, S.V. Kharitonov, I.M. Titkova, N.Sh. Sultanov, S.A. Kachurin State Clinical Hospital No. 13, Department of General Surgery, Faculty of Medicine, Russian State Medical University.

The role of ultrasound in the diagnosis of acute appendicitis. http://dkb13.webzone.ru/public/surgery O7.htm

7. Pokrovsky E.Zh., Fedorov I.V.

Ultrasound diagnosis of acute appendicitis.

Russia, Ivanovo, Medical Academy, Department of General Surgery.

8. Is ultrasound necessary in the diagnosis of acute appendicitis?

A.M. Shulutko, F.N. Nasirov, A.G. Natroshvili.

Department of Surgical Diseases No. 3, Faculty of Medicine, M.M.A. named after I.M.Sechenov.

9. T.V. Shevyakova. - Ultrasound investigation in the complex diagnosis of acute appendicitis. Abstract of thesis for Candidate of Medical Science. M., 1992

10. Possibilities of echographic differentiation of tissue structures in the diagnosis of tissue structures in children.

V.A. Bykovsky, S.A. Zarubina, E.B. Olkhova, L.I. Petukhova, Interpretation of figures (sonograms)

Description to figures

1. Longitudinal (right) and transverse (left) sections of the appendix. Catarrhal form of acute appendicitis. B-mode. Increasing the width of the appendix to 9.7 mm and thickening its walls to 2.5 mm. The contrast of the wall layers is increased, which is better displayed in the cross section. On the longitudinal section, due to the bends of the process, the impression of a violation of the layering of the wall is created.

1. Catarrhal form of acute appendicitis. The longitudinal section of the appendix in color Doppler scanning mode. Single color signals from the vessels of the appendix wall are determined. The vascular pattern of adjacent tissues is not determined.

2. Catarrhal form of acute appendicitis. Cross section of the appendix in color Doppler scanning mode. Single color signals from the vessels of the appendix wall are determined. The vascular pattern of adjacent tissues is not determined.

3. Phlegmonous form of acute appendicitis. B-mode. Cross (left) and longitudinal (right) appendix sections. The process is thickened to 9 mm. The lamination is preserved, the contrast of the wall is increased. In the cavity of the process hypoechoic exudate. Measure appendix width.

4. Phlegmonous form of acute appendicitis. B-mode. Cross (left) and longitudinal (right) appendix sections. Wall thickness up to 3 mm. The lamination is preserved, the contrast of the wall is increased. Measurement of the wall thickness of the appendix.

5. Phlegmonous form of acute appendicitis. The longitudinal section of the appendix is in B-mode (left) and CDK (right). VTsDK significant strengthening of the vascular pattern of the appendix wall. The blood flow in adjacent tissues is less visualized.

6. Phlegmonous form of acute appendicitis. Cross section of the appendix in B-mode (left) and CDK (right). VTsDK significant strengthening of the vascular pattern of the wall of the appendix, it has the form of a colored "crown".

7. Phlegmonous form of acute appendicitis. Cross section of the appendix in the energy scan mode of blood flow. The vascular pattern is significantly enhanced. The shoot looks like a “crown” of orange color.

8. Phlegmonous form of acute appendicitis. The longitudinal section of the appendix in the mode of energy scanning of blood flow. The vascular pattern is significantly enhanced.

9. Gangrenous form of acute appendicitis. B-mode. Longitudinal sections of the appendix at different levels. The process is thickened, the layering of the walls in some places is broken. The walls are thickened to 3 mm. In the cavity of the process hypoechoic exudate and coprolite. The appendix is marked by arrows.

10. Gangrenous form of acute appendicitis. B-mode. Cross sections of the appendix at different levels. The process is thickened, the layering of the walls in some places is broken. The walls are thickened to 3 mm. In the cavity of the process hypoechoic exudate and coprolite. The appendix is marked by arrows.

11. Gangrenous form of acute appendicitis. Color Doppler scan mode of blood flow. The longitudinal section of the appendix. A single color signal from the vessel of the appendix wall is determined.

12. Gangrenous form of acute appendicitis. CDK mode. Scanning bowel loops adjacent to the appendix. Numerous color signals from blood vessels are determined in their walls, which indicates their participation in the inflammatory process.

13. Empyema appendix. B-mode. Cross sections of a fragment of the vermiform appendix thickened to 21 mm. Its wall thickness is up to 3.6 mm. Lamination is broken due to destructive changes. In the cavity, abundant hypoechoic exudate.

14. Empyema appendix. CDK mode. Cross section of a fragment of a thickened appendix. In the projection of the mesentery of the appendix, several color signals representing the vessels are determined. In other parts of the appendix wall, blood flow is not recorded, which confirms the presence of destructive changes.

15. The enlarged lymph node in the right iliac region in the CDK mode. The size of the lymph node and the presence of color signals in its projection indicate its inflammation.

16. Cross section of unchanged appendix in a patient with an enlarged lymph node. CDK mode. The dimensions of the appendix and the thickness of its walls are within the normal range. The blood flow in the walls of the appendix is not determined, which confirms the absence of an inflammatory process in it.

17. A longitudinal section of an unchanged appendix in a patient with an enlarged lymph node. CDK mode. The blood flow in the walls of the appendix is not determined, which also confirms the absence of an inflammatory process in it.

18. Retrocecal location of the appendix. Fragments of the appendix in the infiltrate with abscess formation. Their walls are thickened. Stratification is not traceable due to destructive changes. Walls of adjacent intestinal loops with fuzzy borders (involved in infiltration). B-mode.

19. A fragment of the appendix directly in the cavity of the abscess. The boundaries of the abscess are clear, marked by arrows. B-mode. The process is thickened to 7.6 mm. The walls are thickened to 3.5 mm, the lamination is broken (destruction).

20. B-mode. Thickened walls of the cecum in the infiltrate.

21. CDK mode. Blood flow in the abscess area is not recorded.

22. Power scan mode. Blood flow was detected only in the mesentery of the appendix. In the wall of the appendix, blood flow is not determined - destruction.

23. B-mode. Cross section of the appendix (marked by arrows) in the abscess cavity. The structure of its walls is broken.

24. The mode of energy scanning of blood flow. Numerous color signals from the vessels of the adjacent loop of the intestine indicate its involvement in the inflammatory process.

25. CDK mode. No bleeding in the projection of the abscess. Confirmation of tissue destruction (similar to Fig. 22, another section).

Claims (1)

A method for differential diagnosis of forms of acute appendicitis, which consists in conducting an ultrasound examination of the abdominal organs and retroperitoneal space of the patient, determining the characteristics of the appendix, rigidity during compression and the condition of surrounding organs and tissues, characterized in that they additionally carry out color Doppler and energy mapping of blood flow visible departments of the appendix and the surrounding organs and tissues, and in the presence of blood flow only in the projection of the mesentery process and adjacent bowel loops and a single vascular branches define a norm; when visualizing vessels not only the mesentery, but also in the appendix, provided that their visible number is greater than in the surrounding loops of the intestine, and provided there are no signs of an inflammatory process, catarrhal appendicitis is determined; upon detection of a significant increase in the vascular pattern of visible sections of the wall of the appendix and its mesentery, compared with the blood flow in the adjacent loops of the intestine, where it is represented by single vascular branches, provided that the arterial and venous types are well differentiated, and when the appendix is visualized in cross-section, it is colored “Crowns”, and in the longitudinal section in the presence of colored stripes, up to 1 cm long, corresponding to the vascular branches of the wall of the appendix, they diagnose phlegm anoznuyu form of inflammation; when determining a significant depletion or lack of a vascular pattern in the areas of destruction, a clear registration of blood flow in the area of the mesentery of the appendix, an increase in the vascular pattern of adjacent loops of the intestine, gangrenous inflammation is diagnosed; in the absence of determination of blood flow and registration of dilated vascular branches in the mesentery of the appendix, appendix empyema is diagnosed; in the absence of a definition of blood flow in the visible sections of the appendix, an increase in the vascular pattern in the adjacent loops of the intestine and in the omentum limiting the abscess zone, a periappendicular abscess is diagnosed.

Images