Swelling of abdominal muscles
As a rule, acute appendicitis is accompanied byprotective muscle tension of the abdomen, which clinicians have long enjoyed as an objective and early diagnostic sign of acute pathology of the abdominal cavity. Special attention was paid to this phenomenon in the 90s of the last century, when the surgical treatment of acute appendicitis and various forms of purulent peritonitis began to develop. G. Mondor in his work gave a special place to muscle tension, gave a detailed clinical description of it under various pathological conditions with a vivid illustration of the observations. We also get acquainted with the history of this symptom.
Initially, the tension of the abdominal muscles was noted anddescribed in various forms of purulent peritonitis and perforations. The earliest sources concerning the phenomenon of stress include the works of Trevers, Roux, E. Moritz, and others.
Despite the great importance of the phenomenon,experimental observations explaining its nature were far from sufficient at that time. The reflex origin of the symptom was generally recognized. And the pathogenesis of the reflex was explained in different ways.
Up to the present time, there are two points of viewon the origin of the viscero-motor reflex. Some associate its occurrence with the irritation of the interoceptors of a number of internal organs. Others believe that it can only be caused by irritation of the parietal peritoneum. In the opinion of LA Orbeli, the development of the phenomena of a defense is possible only with the participation of the sympathetic nervous system in the reflex, which determines the segmental nature of the reflex and its non-fatigability.
The central regulation of reflex muscle tension was studied by Merkulova and Chernigovskii, who viewed it as a "trigger" effect from the interoceptors to the skeletal muscle.
According to EK Zhukov, AM Dumova and SM Vereshchagin, the development of muscle protection is associated with the emergence of foci of stationary excitation in centers that have features of the dominant.
LN Zefirov and GI Poletayev believe that the defense of musculaire is one of the most constant and reliable signs of inflammation of the peritoneum, and its origin is purely functional.
At the same time it is known that with acute appendicitisdepending on the degree of manifestation of the inflammatory process, changes occur in greater or lesser intensity in the surrounding organs and tissues, in particular in the muscles of the anterior abdominal wall.
To clarify these changes, we werethe muscles taken at the edge of the surgical incision in 56 patients with acute appendicitis were examined. In 30 cases, inflammatory changes were detected in the muscles, manifested in swelling of muscle fibers, loss of transverse and longitudinal striation, expansion of blood vessels, focal and diffuse circular cell infiltration. In one of our observations in the muscle of the anterior wall of the abdomen, the phenomena of acute myositis (diffuse purulent infiltration of interlayers and purulent melting of muscle fibers) were detected.
In catarrhal appendicitis,pieces of muscle in the anterior wall of the abdomen in seven patients. Explicit inflammatory changes were not detected in this case, although edema and loss of striation of muscle fibers were detected in all cases.
With phlegmonous appendicitis, the muscles werewere studied in 37 patients: 21 of them had inflammatory changes, the latter being noted in patients who underwent surgery in 6-12 hours from the onset of the disease. We give an observation.
Patient P. 10 years old, he complained of severe pain in the right side of the abdomen and diarrhea.
Objectively: the temperature is 37.8 °. Pulse - 80 beats per minute. Skin covers and visible mucous membranes are pale. The abdomen is a regular configuration. When breathing, the patient spares the right half of the abdomen. When palpation in the right iliac region - sharp soreness and tension of the abdominal muscles. The symptom of the roving is positive, Shchetkina-Blumberg is negative. Leukocytosis - 17 000.
Operation 8 hours after the onset of the disease. Ethereal anesthesia. An oblique incision is revealed in the abdominal cavity. In the wound there is a hyperemic omentum. The cecum is hyperemic with injected vessels. The appendix is sharply infiltrated and covered with fibrinous deposits. Appendectomy.
Microscopic examination. In the vermiform appendage the picture of acute phlegmonous-ulcerative appendicitis with the spread of the process to the peritoneum and the adjacent mesentery. In muscle fibers - the loss of striation, in places between the muscle fibers there are foci of leukocyte infiltration.
With perforated appendicitis, the muscle was examinedin 12 patients. In nine of them phlegmonous inflammation was found, in one even phlegmonous with purulent melting of muscle fibers. In the remaining three patients, the muscles of the abdominal wall were swollen with loss of longitudinal and transverse striation. For illustration we give the following observation.
Patient V. at the age of three, was taken to the clinic for severe pain in the right ileal region. Nausea and vomiting were noted. He's sick for 20 hours.
Objectively: the temperature is 39.9 °. Pulse - 140 per minute, satisfactory filling. The stomach is slightly inflated. When palpation, there is a sharp pain and muscle tension in the ileocecal region. Symptoms of Rowing and Shchetkin-Blumberg are positive. Under ether anesthesia an oblique incision along Volkovitch-Dyakonov was performed by laparotomy. The parietal peritoneum was sharply infiltrated, with a fibrinous-purulent coating. A thick creamy pus emerged from the abdominal cavity. The cecum is sharply infiltrated. The appendix is intimately intertwined with the caecum, phlegmonically altered and has two perforating holes - on the apex of the appendage and at its base. The perforating hole at the base is covered with a calculous stone. Appendectomy. Tampon in the abdominal cavity. Layered seams. On the 4th day after the operation the patient died at the phenomena of peritonitis and intoxication. On an autopsy the diffuse purulent-fibrinous peritonitis is found out.
Microscopic examination of the muscles of the anterior wall of the abdomen: the phenomenon of acute myositis with diffuse infiltration of leukocytes of muscle layers.
Cited medical records and resultsmicroscopic examination of muscles indicate that in cases of acute appendicitis, which occurs without clinical signs of phlegmon in the anterior wall of the abdomen, there are inflammatory changes in the type of myositis in muscles. We believe that pathogenic microorganisms penetrate into the muscles through the parietal peritoneum, thanks to the contact of the latter with the focus of inflammation in the process, especially since in almost all cases where changes in muscles were found, there was also inflammation in the parietal peritoneum in parallel.
Clinically, this myositis of the anterior wall of the abdomenis painful when palpation of the affected muscles, their intensity, reflex contracture and immobility during respiratory movements. The appearance of these phenomena in the muscles of the anterior abdominal wall, that is, the defense musculaire, is explained only by functional reflex muscle tension as a result of stimulation of the interoceptors of the internal organs involving the visceral or parietal peritoneum. In fact, as our studies confirm, they depend both on changes in the peritoneum, and often on changes in the muscle itself and changes in the nerves of the abdominal wall.
For the study of neural-reflex processes,going from the region of the inflammation focus along the nerves of the anterior abdominal wall, we performed experimental electrophysiological studies on 20 dogs. On the anterior abdominal wall was applied a through wound with a gut ligation and subsequent infection. A few days later, a laparotomy was performed, and biocurrents were taken from the central segments of the intercostal nerves going directly from the wound, which were recorded with a cathode oscilloscope with a balanced rheostatic-capacitor amplifier at the input. The results of the research show that in the animals from the inflammatory focus of the anterior abdominal wall, continuous impulses go through the nerves to the central nervous system, and from the wound complicated by an abscess, continuous impulses of high frequency and intensity pass through the nerves. From the uncomplicated granulating wound there are rhythmic impulses of low intensity. When the wound was healed, hardly noticeable fluctuations of the biopotentials were found, approaching the normal electroneurogram.
Histological examination revealed peri-and endoneurrites in the nerve trunks adjacent to the inflammatory focus, and sometimes fragmentation of the nerve fiber.
With acute appendicitis, as shown by ourMorphological studies in the parietal peritoneum and inflammatory foci develop relatively quickly in the muscles of the abdominal wall with involvement in the inflammatory process of the nerve endings and nerve Stalks. And if in our previous work we have succeeded in electrophysiological studies show that going to the central nervous incessant pulses of the system along the nerves from inflammatory focus of the abdominal wall, then at the moment we set out to study the function of the intrinsic muscles of the anterior abdominal wall in acute appendicitis in a state of muscle tension in people.
100 patients with acuteappendicitis. The electromyogram was recorded using a loop-type oscilloscope of the MPO-2 type with a balanced rheostat-capacitor amplifier at the input. Bipolar lead was used. Silver plates with a diameter of 2 cm were used as discharge electrodes. The interelectrode distance is 8-10 cm.
Definitions were carried out at restalternately: from the right and left rectus muscles below the navel, the right and left rectus muscles above the navel, the muscle groups of the right and left iliac regions, and the lumbar muscles in the lumbar region on both sides (if the patient's condition allowed). In some cases, the abduction from the muscle groups of the right and left hypochondrium was done.
Produced electromyographic studiesmuscles of the abdomen in healthy people showed that in the state of rest during relaxation, the electrical reaction of muscles is absent or very poorly expressed. With an arbitrary reduction, the amplitude of the biopotential increases and reaches 150-200 μv or more. It is also established that the amplitude of the oscillations and the frequency of the muscle group of the right and left halves of the abdomen are symmetrical.
In 42 patients (42%), the protective muscle tensiondifferent intensity and prevalence was noted palpation, in 58 - was absent. Electromyograms showed an increased electrical response and asymmetry of potentials with a predominance on the side of the pathological process in 90 cases (90%). In 10 patients, the electrical reaction of the muscles was almost identical to the electromyograms of healthy people, of them - in 9 with subacute appendicitis and in one - with an appendicular infiltrate.
Studies have found that with acuteappendicitis shows a pronounced electrical response of the muscles of the right ileal region and, less frequently, of the right muscles below the navel. The intensity of manifestation of biopotentials and their prevalence in most cases depended on the degree of manifestation of the inflammatory process in the vermiform appendage.
Electromyograms show that in healthya person at rest, biopotentials from symmetrical groups of abdominal muscles are absent. With an arbitrary reduction, the amplitude sharply increases and reaches 140-150 μv or more.
Patient C. is 20 years old. with catarrhal appendicitis, the amplitude of biopotentials from the muscle group of the right iliac region reaches 15-20 uv. The electromyogram from the left ileal region almost does not differ from normal.
With phlegmonous appendicitis in patient K. 9 years, with perforated appendicitis in patient K. 53 years, the amplitude of biopotentials (right) increases significantly and reaches 50-85 microvolts. With the group of muscles of the left ileal region, the electrical reaction is not very pronounced.
Consequently, the tension of the muscles of the anterior abdominalwalls in acute appendicitis (and, presumably, in other inflammatory processes in the abdominal cavity) is an indication of a complex inflammatory and degenerative process occurring in the appendix and in complex tissues adjacent the anterior abdominal wall: parietal peritoneum, muscle and nerves.
In the smooth course of the postoperative period with wound healing by primary tension, the electromyogram of the patient, at discharge, almost does not differ from the control electromyogram of a healthy person.
In cases of complications (infiltration,suppuration of the wound), the decrease in electrical muscle activity is delayed and even a clinical recovery shows a slight increase in biopotentials from the muscle group in the area of the operating wound. This is confirmed by our experimental data. Apparently, the method of electromyography can be used in the future as an objective indicator for the examination of temporary disability and the patient's stay on the sick leave sheet.
1. With phlegmonous and perforated appendicitis, inflammatory changes in the muscles of the ileocecal region were found in all patients. With catarrhal appendicitis, no apparent inflammatory changes in the muscles were detected, although edema and loss of striation of muscle fibers were detected in all cases.
2. In an animal experiment, studies show that continuous impulses go from the inflammatory focus to the nerves of the anterior abdominal wall to the central nervous system. Histological examination revealed peri-and endoneurrites and sometimes fragmentation of nerve fibers in these nerve trunks adjacent to the inflammatory focus.
3. By the method of electromyography it was established that in a healthy person at rest, the biopotentials in the abdominal muscles are absent or very weakly expressed; at an acute appendicitis asymmetry of biopotentials with prevalence on the party of pathological process is noted. Asymmetry is more pronounced with destructive forms of appendicitis.
4. Thus, based on our clinical, morphological and electrophysiological (elektroneyrograficheskih and electromyographic) observation revealed that electromyographic test may serve as an objective diagnostic indicator of acute appendicitis and other inflammatory processes of the abdominal cavity, even in the absence of the abdominal muscles voltage determined by palpation.