acute adnexitis
Introduction
Introduction to acute attachment inflammation Acute attachment inflammation is salpingitis, and both otitis are inflamed at the same time. Salpingitis is most common in acute pelvic inflammatory disease. The ovary is adjacent to the fallopian tube, and when the fallopian tube inflammation continues to expand, it often causes oophoritis. Ovarianitis rarely occurs alone. Only the mumps virus has a special affinity for the ovaries. It can be spread by blood and the ovaries can be infected alone. basic knowledge The proportion of illness: 9.3% (the probability of disease in women of childbearing age is 9.3%) Susceptible people: women Mode of infection: non-infectious Complications: Infertility Chronic pelvic pain
Cause
Acute attachment inflammation
Intraluminal inflammation (35%):
Inflammation occurs in organs adjacent to the pelvic or fallopian tubes. In the case of appendicitis, the lesions can directly spread to cause salpingitis, oophoritis, and pelvic peritonitis, and inflammation usually occurs in the fallopian tubes and ovaries on the side adjacent to the lesion.
Iatrogenic infection (15%):
Infection after intraoperative operation, such as the implementation of curettage, uterine tubal iodine angiography, tubal fluid, placement of intrauterine devices, etc., due to poor sterilization or improper selection of preoperative indications, resulting in the lower genital tract The endogenous pathogens are up-suppressed and cause acute attachment inflammation.
Resistance decreased (20%):
After childbirth or abortion, due to the decline of body resistance, the pathogen is infected through the vagina and spread to the fallopian tubes and ovaries, which in turn infects the entire pelvic cavity and causes inflammation.
Unclean sex life (20%):
Failure to pay attention to menstrual hygiene, sexual intercourse during menstruation or unclean sexual intercourse can also lead to acute attachment inflammation.
Pathogenesis:
Inflammation can be spread to the paracancerous connective tissue through the cervical lymph, first invading the serous layer of the fallopian tube, inflammation of the fallopian tube occurs, and then the muscular layer of the fallopian tube is involved, while the mucosal layer is less affected, the lumen is narrowed due to swelling, and the lesion is caused by the tubal stroma. Inflammation-based, inflammation can also spread through the endometrium, first invading the mucosal layer of the fallopian tube, swelling of the mucosa of the lumen, interstitial congestion and edema and a large number of leukocyte infiltration, epithelial degeneration or exfoliation, if the end of the umbrella is closed, pus Sex secretions accumulate in the lumen, forming tubal empyema; if purulent secretions flow from the umbrella end into the pelvic cavity, adhesion to the ovary and destroy the ovarian penetration, the fallopian tube ovarian abscess is formed, the abscess is mostly located behind the uterus, after the broad ligament Between the leaves and the intestines, occasionally can be worn to the vagina, the rectum, or broken into the abdominal cavity to cause diffuse peritonitis.
Prevention
Acute attachment inflammation prevention
1 When women are sexually active, they should pay attention to the personal hygiene of themselves and their sexual partners. Before the trip, it is necessary to clean the external genitalia of both men and women to prevent the smooth invasion of germs. When women have bleeding symptoms in the vagina, they should refrain from sexual life.
2 women should pay attention to their vulva hygiene and personal hygiene; pay attention to prevent infections from sanitary ware and toilets.
3 The majority of women should pay attention to their own nutrition and health care, strengthen the nutrition during menstruation, after abortion, and after childbirth; enhance their physical fitness, increase their resistance, immunity, and reduce the chance of illness.
4 need to carry out artificial abortion, childbirth, access to intrauterine device, and other official cavity surgery, should be strictly disinfected, to avoid the bacteria into the vagina and uterus by surgery, artificial infection.
5 Female patients with acute fallopian tube disease should take a semi-recumbent rest to prevent and limit the flow of inflammatory fluids due to changes in body position. Eat high-nutrient, digestible, vitamin-rich foods.
6 Women with attachment diseases should follow the principle of treatment, take a positive attitude, thoroughly treat, control the disease as soon as possible, and prevent chronic changes.
Complication
Acute attachment inflammation complications Complications infertility chronic pelvic pain
Infertility, ectopic pregnancy, chronic pelvic pain, etc.
Symptom
Acute attachment inflammation symptoms Common symptoms Urinary pain Lower abdominal pain High heat fatigue Cold war Abdominal pain Purulent secretion Facial flushing Cervix lifting pain Abdominal tonic
Fever
High fever occurs at the onset of the disease, 39 to 40 ° C, there may be aversion to cold or chills, and the body temperature is irregular relaxation heat, such as inflammatory lesions are isolated due to adhesion, body temperature can be quickly reduced; such as high fever once After the decline, it rises again, suggesting that the inflammation spreads or produces purulent lesions. The pulse rate is proportional to the body temperature. If the two are not proportional, the inflammation may spread widely.
2. Abdominal pain
Initially limited to lower abdominal pain, mostly bilateral, less vomiting, different from appendicitis metastatic pain, in addition to abdominal pain increased during stool, sometimes with dysuria, often constipation, bloating, stool with mucus, is the colon wall The result of inflammatory irritation.
3. General situation
Acute disease, facial flushing, general condition is still good, the pulse does not exceed 100 times / min, such as prolonged disease course, the general condition after the suppuration lesions worse, weak and weak, pulse > 100 times / min, sweating, complexion yellow.
4. Signs
Abdominal tenderness is significant, most obvious at 1.5~2cm above the midpoint of the inguinal ligament. In severe cases, the abdominal muscles are stiff and the rebound pain is obvious. The gynecological examination has purulent secretions in the vagina. The cervix has different degrees of redness and swelling. Cervical pain is more dramatic. Because of abdominal muscle tension, the pelvic condition is difficult to find out. Under normal circumstances, the uterus is relatively fixed and has severe tenderness. The attachment areas on both sides are markedly painful, and it is difficult to find the attachment lumps.
Examine
Examination of acute attachment inflammation
1. Total number of white blood cells and classification count
The total number of white blood cells (20 ~ 25) × 10 9 / L, neutrophils 0.8 ~ 0.85 (80% ~ 85%), nuclear left shift, suggesting that the inflammatory lesions are not completely surrounded, isolated or toxins are absorbed, there are pus Sexual or other inflammatory fluids exist, the total number of white blood cells continues to rise, it is the formation of suppuration and abscess, such as the total reduced to (10 ~ 15) × 10 9 / L, generally no abscess formation, even if there is abscess is also lack of virulence.
2. Determination of erythrocyte sedimentation rate (erythrocyte sedimentation rate)
ESR is a non-specific reaction, which should be compared with body temperature, pulse rate and total number of white blood cells. However, erythrocyte sedimentation rate has a great reference value for occult lesions with insignificant clinical manifestations. It is necessary to further search for potential inflammatory lesions. Pelvic inflammatory erythrocyte sedimentation rate is often >30 ~ 40mm / h.
3. Posterior iliac puncture
(1) routine examination: if the inflammatory lesion is still in a limited stage, often a thin serous puncture can be drawn for white blood cell counting and smear, directly for Gram staining, check the number of neutrophils and identify the type of bacteria, except It can also be used as a basis for selecting antibiotics.
(2) Bacterial culture: The puncture fluid is used for aerobic and anaerobic bacterial culture.
(3) Determination of amylase: aspiration of uterine rectal fossa as the same amylase (amylase produced by the oviduct mucosa) was measured, and blood was taken to determine the enzyme value in the blood. When the oviduct mucosa had inflammatory infiltration, the enzyme content was obvious. Reduced (normal value 300U / L), the degree of reduction is directly proportional to the severity of inflammation, and the serum concentration of patients can still be maintained at 140U / L, the ratio of the two such as <1.5, can be diagnosed as acute salpingitis, such as simultaneous detection and extraction The increase in the number of white blood cells in the fluid is more reliable in diagnosing acute salpingitis.
4.B ultrasound and CT examination
For severe abdominal muscle tension, those who refuse to press and the pelvic examination are not satisfied can be diagnosed by B-ultrasound or CT. The B-ultrasound properties of the accessory inflammatory mass can be summarized into three types:
(1) Substantial type, there may be a solid mass in the side of the uterus, and the boundary of the mass is unclear.
(2) Cyst type, when there is empyema in the mass, it presents an irregular heterogeneous cystic mass.
(3) Semi-cystic and semi-solid type, which is of little help to the diagnosis in the early stage of acute or subacute infection. Color Doppler ultrasonography can be used to show that the blood vessels are rich and reticular or clumpy.
5. Laparoscopy
Diagnosis
Diagnosis and identification of acute attachment inflammation
diagnosis
Combined with medical history, clinical manifestations, local signs and laboratory tests, it is not difficult to diagnose patients with late course of disease. It is important to give a clear diagnosis at an early stage. Some people have investigated the symptoms within 2 days after the symptoms appear. Later, hysterosalpingography shows the fallopian tubes. All are smooth; if they start treatment on the 7th or later days, only 70% of the fallopian tubes are unobstructed, but the symptoms and signs of early cases are lack of specificity, and mild cases are often misdiagnosed. Jacobson (1980) is based on acute lower abdominal pain. The following 2 to 3 symptoms or signs: vaginal discharge abnormalities, fever, nausea, abnormal menstruation, urinary and rectal symptoms, attachment tenderness, touching mass, erythrocyte sedimentation rate >15mm/h, etc., clinical diagnosis of 814 cases of acute pelvic inflammatory disease, all for abdominal cavity Microscopic examination, only 512 cases (65%) were diagnosed; 184 cases (23%) had no obvious lesions in the pelvis; 98 cases (12%) were misdiagnosed, and there were false negatives, that is, clinically undiagnosed pelvic inflammatory disease. The fact is that pelvic inflammatory disease is 15%. The diagnosis of salpingitis is most accurate under laparoscopic direct vision. However, this method is a traumatic examination and cannot be widely carried out in the clinic.
Diagnostic criteria
1.Hager (1983) diagnostic criteria
(1) Must have the following three items:
1 history of lower abdominal pain and lower abdominal tenderness (with or without rebound pain).
2 cervical pain or uterine tenderness.
3 There is tenderness in the attachment area.
(2) The above three articles are subjective and therefore must have any of the following six:
1 body temperature > 38 ° C.
2 The total number of white blood cells is >10.5×109/L.
3 ESR is 15mim/h.
4 pelvic examination or B-ultrasound scan with inflammatory mass.
There are purulent substances (white blood cells) in the posterior Qianlong puncture fluid.
6 smear of cervical secretions see glibenclus in white blood cells.
2. Kahn (1991) proposes a new diagnostic protocol in view of the fact that abdominal tenderness is non-specific and often lacks tenderness, and new diagnostic protocols are proposed.
(1) There are two prerequisites:
1 cervix pain or swing pain.
2 The attachment area is tender.
(2) and have any of the following 9 minor conditions:
1 abnormal vaginal discharge.
2C-reactive protein concentration increased.
3 ESR increased.
4 endometrial biopsy has inflammatory changes.
5 cervical mucus smear found in the white blood cell gram-negative - diplococcus.
6 Chlamydia test positive.
7 body temperature rises.
8 touches the attachment lumps.
9 Laparoscopy has evidence of pelvic inflammatory disease.
Differential diagnosis
The clinical manifestations of acute attachment inflammation are sometimes confused with acute appendicitis, ectopic pregnancy, ovarian cyst torsion or ovarian endometriosis cysts, and should be identified during diagnosis.
Acute appendicitis
The right side acute inflammation is easily confused with acute appendicitis. There is mild umbilical pain in the medical history accompanied by gastrointestinal symptoms such as nausea, vomiting or diarrhea. The pain gradually worsens and shifts to the right lower abdomen. It is persistent and the body temperature can be raised. There are abdominal muscle tension, Mai's point fixed tenderness, rebound tenderness, right side acute attachment inflammation tenderness is often below the Mai's point, gynecological examination of cervical pain or tenderness, contralateral attachments are often tender.
Ectopic pregnancy
Ectopic pregnancy has a history of menopause, vaginal bleeding and internal bleeding signs such as pale, pulse speed, blood pressure drop or shock, abdominal muscle tension during examination, tenderness and rebound tenderness, urinary human chorionic gonadotropin (HCG) often Positive, the posterior iliac puncture was not coagulated blood.
3. Ovarian cyst pedicle torsion
Among the ovarian cysts with pedicle torsion, the most common is ovarian teratoma, which may have a history of lower abdominal mass, sudden severe abdominal pain, often accompanied by nausea, vomiting, fever and even shock. Different from the fallopian tube ovarian abscess, there are abdominal muscle tension, tenderness and rebound tenderness in the examination. The accessory area on one side of the gynecological examination can be used to treat a cyst with a large force, clear boundary and obvious tenderness. B-ultrasound can assist diagnosis.
4. Ovarian endometriosis cyst
There is a history of dysmenorrhea, infertility, pain of sexual intercourse, abdominal pain often occurs in the menstrual period, generally without fever, gynecological examination can be sputum and posterior uterus, fixed, the posterior wall of the uterus has tender nodules, uterine ligament thickening, there are Painful nodules, the attachment area can be licked and lumps, there is mild tenderness, B-ultrasound can be performed, and laparoscopic examination can confirm the diagnosis.
