Appendicitis

position

• 12 o clock: Retrocolic or retrocecal (behind the cecum or colon)

• 2 o clock: Splenic (upwards and to the left – Preileal and Postileal)

• 3 o clock: Promonteric (horizontally to the left pointing the sacral promontory)

• 4 o clock: Pelvic (descend into the pelvis)

• 6 o clock: Subcecal (below the cecum pointing towards inguinal canal)

• 11 o clock: Paracolic (upwards and to the right)

Definition:

• An inflammation of the appendix

Aetiology:• Decreased dietary fibre and increased consumption of

refined carbohydrates

• Obstruction of the appendix lumen

–Tumour (carcinoma of caecum)–Intestinal parasites (Oxyuris/Enterobius vermicularis –

pinworm)

Clinical Manifestations

Special Features Based OnAppendix Locations

Differential Diagnosis

Investigation

The Alvarado (MANTRELS) Score

Score

Symptoms•Migratory right iliac fossa pain•Anorexia•Nausea and vomiting

111

Signs•Tenderness (RIF)•Rebound tenderness•Elevated temperature

211

Laboratory•Leucocytosis•Shift to the left (segmented neutrophils)

21

TOTAL 10

• < 5 is strongly against a diagnosis of appendicitis• 7 or more is strongly predictive of acute

appendicitis • In patients with an equivocal score of 5 or 6, abdominal

USG or contrast-enhanced CT scan is used to further reduce the rate of negative appendicectomy

CT Scan images of Appendicitis:

1. enlarged appendix 2. appendiceal wall thickening

CT Scan images of Appendicitis

3. appendicolith 4.periappendiceal fat stranding

Treatment

• Intravenous fluids

• to establish adequate urine output

• Appropriate antibiotics

• Reduces the incidence of postoperative wound infection

• When peritonitis is suspected, therapeutic intravenous antibiotics to cover Gram-negative bacilli as well as anaerobic cocci should be given

• Appendicectomy

Conventional Appendicectomy

Gridiron incision : right angles to a line joining the ASIS to the umbilicus. Centred on McBurney’s point

Lanz incision : 2 cm below the umbilicus centred on the mid-clavicular-midinguinal line

2/31/3

2 cm

Conventional Appendicectomy

• Caecum is identified

• Base of mesoappendix is clamped in artery forceps, divided, and ligated

• The freed appendix is crushed near its junction with the caecum in artery forceps, which is removed and reapplied just distal to the crushed portion

• An absorbable ligature is tied around the crushed portion close to the caecum

• The appendix is amputated between the artery forceps and the ligature

• An absorbable purse-string or ‘Z’ suture may then be inserted into the caecum about 1.25 cm from the base

• The stump of the appendix is invaginated while the purse-string or ‘Z’ suture is tied, thus burying the appendix stump

CROHN’S DISEASE

Introduction

• Inflammatory Bowel Disease encompasses two distinct chronic, idiopathic inflammatory diseases of the GI tract : Crohn’s disease which can affect any part of the GI tract and Ulcerative colitis which affect only the large bowel

Aetiopathogenesis

• Familial

• Genetic factor

• Lifestyle

lifestyle

• Breastfeeding may provide protection against IBD in the offspring

• Nutritional : high sugar and fat intake have been suggested to play a role in the pathogenesis of IBD

• Smoking : patients with CD are more likely to be smokers and smoking has been shown to exacerbate CD

Pathology

• may affect any part of the GI system from mouth to anus but has a particular tendency to affect the terminal ileum and ascending colon(iliocolonic disease)

• The disease may affect one small part of the gut such as the terminal ileum or multiple areas wt relatively normal bowel in between(skip lesions)

• May involve the whole colon sometimes without small bowel involvement

Clinical features

• The major symptoms are diarrhoea, abdominal pain and weight loss

• Constitutional symptoms of lethargy, anorexia, nausea, vomitting and low-grade fever may be present

• Other clinical manifestations include bleeding

Investigations

• FBC: normocytic, normochromic anaemia of chronic disease, deficiency of iron/folate also occurs

• Hypoalbuminaemia is present in severe disease

• Liver biochemistry may be abnormal

• Blood cultures are required if septicaemia is suspected

• Stool cultures should be performed on presentation if diarrhoea is present

Radiology and imaging

• Barium follow-through: the findings include an assymetrical alteration in the mucosal pattern with deep ulceration, and areas of narrowing or stricturing

• Although commonly confined to the terminal ilium, other areas of small bowel can be involved and skip lesions can also be seen between affected sites

• Colonoscopy: is performed if colonic involvement is suspected

• ultrasound and CT scanning to define thickness of the bowel wall and mesentry as well as intra-abdominal and paraintestinal abscesses

• Rectal ultrasound and MRI are used to evaluate perianal disease

Medical management

• Cigarette should be stopped, diarrhoea can be controlled

• Diarrhoea in long standing disease may be due to bile acid malabsorbtion and should be treated with cholestyramine

• Anaemia if due to vit B12,folic acid or iron def should be treated wt appropriate hematinics

Surgical management

• Indications for surgery include: failure of medical therapy with acute or chronic symptoms producing ill-health, complications( eg toxic dilatation, obstruction, perforation etc), failure to thrive in children despite medical therapy

Diverticulitits

Overview

• A diverticulumdiverticulum is an abnormal sac or pouch protruding from the wall of a hollow organ.

• Diverticula ; pouches

• Diverticulosis ; condition of having diverticula

• The formation of diverticula is also related to aging

Pathogenesis

• Diverticula are actually herniations of mucosa through the colon at sites of penetration of the muscular wall by arterioles

• Sigmoid colon

• The most common site (50%)

• The smallest luminal diameter.

• Low fiber diet -> decreased colonic luminal content -> high intraluminal pressures to propel the feces forward -> herniations of mucosa through the anastomically weak points in the colonic wall

Diverticular bleeding

• The most common cause of hematochezia in patients over the age of 60

• Risk factor ; HT, Artherosclerosis, NSAID

• Usually self limited, but rebleeding risk (25%)

• Localization ; Colonoscopy, Angiography

• Surgery

• Without localization ; Total colectomy

Diverticulitis

•Definition• Inflammation of a diverticulum, is related to the retention

of particulate material within the diverticular sac and the formation of a fecalith

• Presentation• Pain : may radiate to the suprapubic, groin, back

• Bowel habit change, Anorexia, Fever, Chill, Urinary urgency

Diverticulitis

• Physical Findings

• Tenderness, Muscle guarding

• Tender mass :abscess

• Abdominal distension :obstruction

• Tender fluctuant pelvic mass on rectal or vaginal exam

Diverticulitis

•Diagnostic Tests

• CT

• The preferred test to confirm the suspected diagnosis

• Location of infection, extent of inflammatory process, presence and location of an abscess, secondary complications

• sigmoid diverticula, thickened colonic wall >4 mm, inflammation within the pericolic fat ± the collection of contrast material or fluid

• MRI, U/sound

• Water soluble contrast enema

• Distinguish acute diverticulitis from perforated cancer

• Risk of increasing the colonic pressure, extravasation of feces through the perforated diverticulitis

Primary bowel resection

• surgeon removes the diseased part of intestine and then reconnects the healthy segments of your colon (anastomosis).

• Allows to have normal bowel movements. Depending on the amount of inflammation, you may have open (traditional) surgery or laparoscopic surgery.

PEPTIC ULCER DISEASE

• H. pylori,

• Alcohol,

• Smoking,

• Cirrhosis,

• Stress

• Usually 50 and over

• Male higher risk

• Gastritis,

• Use of NSAIDs

RISK FACTORS

• Acute

• Chronic

Types

• Is associated with superficial erosion and minimal inflammation it is of short duration and resolves quickly when the cause is identified and removed

Acute

• Chronic ulcer is one of long duration eroding through the muscular wall with the formation of fibrous tissue it may be present continuously for many months or intermittently throughout the person’s life time

Chronic

ETIOLOGY

• stress and anxiety

• gram-negative bacteria H. pylori

• Stress

• Excessesive secretion of HCL

• Familial tendency

• Use of NSAID

• Alcohol

• Excessive smoking

• Hyperacidity

• Gastrin secreting malignant tumers

• Esophagial ulcers

• GERD

• inflammation caused by H.pylori infection

• Peptic ulcer occurs mainly in the gastro duodenal mucosa because this tissue cannot withstand the digestive action of gastric acid HCl and pepsin.

• Vagus nerve stimulates the parietal cells to secrete gastric acid. The erosion is caused by the increased concentration or activity of pepsin, or by decreased resistance of the mucosa.

• A damaged mucosa cannot secrete enough mucus to act as a barrier against HCl. The use of NSAIDs inhibits the secretion of mucus that protects the mucosa.

PATHOPHYSIOLOGY

CLINICAL MANIFESTATIONS

• dull, gnawing pain or a burning

• Pain is usually relieved by eating

• Tenderness

• pyrosis (heartburn),

• vomiting, constipation or diarrhea, and bleeding

• burping

• vomiting

• bleeding

• tarry stools

ASSESSMENT AND DIAGNOSTIC FINDINGS

• pain,

• epigastric tenderness,

• or abdominal distention.

• A barium study

• Stools study

• . Gastric secretory studies

• H. pylori infection

• breath test that detects H. pylori

• Antibiotics

• Eradicate H. pylori

• Rest

MEDICAL MANAGEMENT

• proton pump inhibitors

• antibiotics

• bismuth salts

• histamine 2 antagonist

PHARMACOLOGIC THERAPY

• stressful or exhausting.

• A rushed lifestyle

• irregular schedule

STRESS REDUCTION AND REST

• smoking decreases the secretion of bicarbonate from the pancreas into the duodenum resulting in increased acidity of the duodenum.

SMOKING CESSATION

• avoiding extremes of temperature

• overstimulation from consumption of meat extracts

• alcohol,

• coffee (including decaffeinated coffee,

• Milk

• cream

DIETARY MODIFICATION

• Principles of surgery

• Reduce acid secreting ability

• Remove malignant or potentially malignant lesions treat surgical emergency

• Treat clients do not respond to medical intervention

SURGICAL MANAGEMENT

• Vagotomy is performed to eliminate the acid secreting stimulus to gastric cells

• Truncal

• Completely cutting each vagus nerve

• Selective

• The surgeon partially severs the nerves to preserve the hepatic and celiac branches

• Proximal

• Only paritel cell mass is denerveted

VAGOTOMY

Truncal

VAGOTOMY WITH PYLOROPLASTY

• Permits regurgitation of alkaline deodenal contents thereby neutralizing gastric acid in this procedure a drain is made on the bottom of the stomach and sewn to an opening made in the jejunum

GASTROENTEROSTOMY

• The surgeon removes a part of distal portion of the stomach including the andrum the remainder of the stomach is anastomosed to duodenum this combined procedure called gastrodeodenostomy this decreases dumping syndrome

BILROTH 1

BILROTH 1

• This involves reanastomosis of the proximal remnant of the stomach to the proximal jejunum pancreatic secretions and bile continue to secrete in jejunum even after surgery surgeons prefer Billroth 2 technique for treatment of duodenal ulcers because recurrent ulcer develops less frequent in this procedure

BILROTH II

BILROTH II