ACUTE ABDOMEN appendicitis AND peritonitis eden 2024.pptx

ACUTE ABDOMEN appendicitis AND peritonitis

1. ACUTE ABDOMEN SERIES

2. Definition Sudden onset abdominal pain requiring urgent surgical intervention M ay be caused by an infection, inflammation, vascular occlusion, or obstruction Primary symptom is: abdominal pain

3. 9 regions of the abdomen

4. Transpyloric plane

5. DDx

6. Assessment Full Hx Thorough physical examination Dx can be made 90% of time with a good Hx and proper physical examination

7. Pain

8. Pain Visceral Pain Due to stretching of fibers innervating the walls of hollow or solid organs. occurs early and poorly localized It can be due to early ischemia or inflammation.

9. Embryology

10. Parietal Pain Caused by irritation of parietal peritoneum fibers. It occurs late and better localized. Can be localized to a dermatome superficial to site of the painful stimulus.

11. Referred Pain Pain is felt at a site away from the pathological organ. Pain is usually ipsilateral to the involved organ and is felt midline if pathology is midline. Pattern based on developmental embryology.

12. ACUTE APPENDICITIS

13. Definition Appendicitis is the inflammation of the vestigial vermiform appendix is one of the most common causes of the acute abdomen and one of the most frequent indications for an emergency abdominal surgical procedure worldwide Vestigial meaning: degenerate , rudimentary, or  atrophied , having become functionless in the course of evolution. Vermiform: describes something shaped like a worm .

14. ANATOMY The appendix is located at the base of the cecum, near the ileocecal valve where the 3 taenia coli converge on the cecum

15. The appendix is a true diverticulum of the cecum. In contrast to acquired diverticular disease, which consists of a protuberance of a subset of the enteric wall layers, the appendiceal wall contains all of the layers of the colonic wall: mucosa, submucosa, muscularis (longitudinal and circular), and the serosal covering

16. Anatomy Usually, around 5–10 cm in size but can be variable. Diameter of appendix is 3–8 mm; diameter of lumen is 1–3 mm (matchstick).

17. Mesoappendix is an extension of mesentery & contains appendicular artery, a branch of ileocolic artery.

18. Variations in location

19. Histology The presence of B and T lymphoid cells in the mucosa and submucosa of the lamina propria make the appendix histologically distinct from the cecum

20. These cells create a lymphoid pulp that aids immunologic function by increasing lymphoid products such as IgA and operating as part of the gut-associated lymphoid tissue system Lymphoid hyperplasia can cause obstruction of the appendix and lead to appendicitis. The lymphoid tissue undergoes atrophy with age

21. Incidence of acute appendicitis Relatively rare in infants, equal among males & females before puberty. In teenagers & young adults, male-female ratio increases to 3:2 at age 25; - Becomes increasingly common in childhood and early adult life, reaching a peak incidence in the teens and early 20s - Then another increase is seen after 50years due to malignancies

22. Why rare in infants Prone position Diet (liquid) Funnel shaped

23. Risk factors Less fibre diet & high refined carbohydrates increases risk Viral infection may cause mucosal oedema and inflammation which later gets infected by bacteria causing appendicitis. Obstruction of lumen of appendix causing obstructive appendicitis due to- Faecoliths , stricture, FB, round worm or threadworm. -Adhesions and kinking, Ca of caecum near base, ileocaecal Crohn’s dx. -Fibrotic stricture indicates previous appendicitis that resolved with no op.

24. Organisms: E. coli (85%), Enterococci, (30%), Streptococci, Anaerobic streptococci, Cl. welchii , bacteroides . NB. Pseudoappendicitis is appendicitis due to acute ileitis following Yersinia infection. It is often due to Crohn’s disease

25. Types of appendicitis 1) Catarrhal (Non obstructive) 2) Obstructive (Acute obstructive appendicitis)

26. Pathogenesis of appendicitis: steps

27. next

28. Summary

29. PERFORATED BASE OF APPENDIX

30. Clinical manifestations History  — Abdominal pain is the most common symptom classic symptoms: Right lower quadrant (right anterior iliac fossa) abdominal pain Anorexia Nausea and vomiting NB. The pain is typically periumbilical in nature with subsequent migration to the right lower quadrant as the inflammation progresses 

31. Shift to the left

32. SIGNS Acute appendicitis is unlikely when the WBC count is normal, except in the very early course of the illness. In comparison, mean WBC counts are higher in patients with a gangrenous (necrotic) or perforated appendix Acute − 14,500±7300 cells/ microL Gangrenous − 17,100±3900 cells/ microL Perforated − 17,900±2100 cells/ microL

33. Signs a) Tachycardia b) Abdominal tenderness- maximum at McBurney‘s point c) Pointing sign d) Psoas test - for retrocaecal appendix, hyperextension of right hip, causes pain in right iliac fossa- due to irritation of psoas muscle e) Obturator test – for pelvic appendix, internal rotation of right hip causes pain in RIF due to irritation of obturator internus muscle f) Rovsing sign – On pressing/palpating left iliac fossa, pain occur in RIF due to shift of bowel loops which irritate the peritoneum (parietal peritoneum) g) Blumberg sign – tenderness & rebound tenderness in right iliac fossa

34. Investigations.. May be normal and are non-diagnostic FBC, Urea and electrolytes U/S of the abdomen/pelvis X-ray and CT (CECT)-Pelvis & abd Laparoscopy Gravid index in female Urinalysis Supine abdominal radiograph Complications 1. Perforation (peritonism) – local or generalized peritonitis 2. RIF appendix Mass, (appendicitis + densely adherent caecum & omentum ) 3. RIF abscess 4. Pelvic abscess

35. Differential DISCUSS?????

36. TREATMENT Resuscitation Operative management.. Appendicectomy Incisions Gridiron Rutherford Rocker davis lanz

37. APPENDICULAR MASS It involves the appendix, the caecum, terminal ileum and the omentum . It may also be called caecal mass  It is the localisation of infection occurring 3 to 5 days after an attack of acute appendicitis.

38. Symptoms Mass right ilia fossa Usually no fever Signs Afebrile, swelling right iliac fossa. Irregular mass in the same site Some tenderness+, smooth, firm, well localised , not moving with resp, not mobile & resonant on percussion No rebound tenderness Investigation White cell count normal U/S abdomen-solid mass

39. Treatment Ochsner- Sherren Regimen- NON OP Mgx Observation: Temp, BP, pulse chart. Marking the mass to identify the progression/regression Antibiotics : Benzyl pen 2mu QID iv x 5/7, Gentamycin 80mg TDS iv x 5/7, Flagyl 500mg iv 5/7 IV fluids. Analgesics 90% respond to non-op mgx by 48 to 72hrs & mass reduces in size, TPR normalizes and appetite is regained. Discharge and advise to come for interval appendicectomy after 3- 6 weeks

40. Contraindications for Ochsner- Sherren regimen 1. When diagnosis is in doubt. 2. In acute appendicitis in children and elderly. 3. In burst, gangrenous appendicitis. 4. In patients in whom diffuse peritonitis sets in.

41. Appendicular abcess An abscess that forms in the right iliac fossa secondary to an inflamed appendix. Failure of resolution of an appendix mass or continued spiking pyrexia usually indicates suppuration within phlegmonous appendix mass. Pelvic abscess formation is an occasional complication of appendicitis

42. Symptoms Pain in the right iliac fossa Swelling in the same region +/- Nausea +/- Vomiting High grade fever Pelvic discomfort associated with loose stool or tenesmus is common.

43. Signs  High temperature ≥ 390 c several days after appendicitis;  Mass in the right iliac fossa  Fluctuant, Tender, smooth, dull (to percuss), soft swelling in right iliac fossa  DRE - reveals a boggy mass in the pelvis, anterior to the rectum, at the level of the peritoneal reflection Diagnosis - Clinical as above 1. FBC-raised WBC-especially neutrophils 2. Abdominal U/S-cystic swelling

44. Treatment Resuscitate Drainage of pus surgically via transrectal drainage or percutaneous retroperitoneal drainage Drugs Benzyl penicillin 2mu 6 hourly x 5/7 Metronidazole 500mg 8 hourly iv x 5/7 Gentamycin 80mg 8 hourly iv x 5/7 Then interval appendicectomy after 3/12 Supportive Treatment: Analgesics post operatively

45. Percutaneous drainage

46. PERITONITIS

47. Definition inflammation of the parietal and serosal layer of the peritoneum either due to chemical like acid (gastric) or bile or due to bacterial infection. RECALL: Peritoneal cavity is sterile normally.

48. TYPES It can be primary peritonitis without any documented source of infection) like bowel perforation or pelvic infection (SBP). MOST Common is secondary peritonitis which is due to some known source like bowel (hollow viscus) perforation. Tertiary peritonitis is seen in post-operative patients(after laparotomy) due to leak or bowel necrosis and seen on 7th or later day after laparotomy

49. TYPES OF PERITONITIS

50. Discussion: causes and modes of developing peritonitis Clinical presentation investigations

51. Principles of therapy in peritonitis To control source of infection—perforation To eliminate bacteria and sepsis To maintain vital organ function—cardiac, pulmonary, renal Nutrition and metabolic support

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