◼️Colonic diverticula are acquired herniations that occur through the circular muscle coat of the colon at the site where blood vessels penetrate the colonic wall.
◼️They are most common in the sigmoid colon (90%).
◼️They may associate with gallstones and hiatus hernia (Saint Triad).
◼️Complications include diverticulitis, pericolic abscess, peritonitis, intestinal obstruction, hemorrhage, and fistula formation.
#Intestinal
#Surgery
◼️They are most common in the sigmoid colon (90%).
◼️They may associate with gallstones and hiatus hernia (Saint Triad).
◼️Complications include diverticulitis, pericolic abscess, peritonitis, intestinal obstruction, hemorrhage, and fistula formation.
#Intestinal
#Surgery
Corner stones of managing Intestinal obstruction :
(Suck and Drip)
-Gastrointestinal decompression.
-Fluid and electrolyte resuscitation.
-Relief of the obstruction.
#Intestinal
#Surgery
(Suck and Drip)
-Gastrointestinal decompression.
-Fluid and electrolyte resuscitation.
-Relief of the obstruction.
#Intestinal
#Surgery
Benefits of Gastrointestinal decompression in intestinal obstruction:
1)Relief the distension and thereby improve respiration.
2)Relief pain.
3)Makes operation easier to perform.
4)Prevent aspiration pneumonia upon induction of anaesthesia.
5)Minimize absorption of toxins following relief of the obstruction, this may occur when the obstruction is relieved and the fermented toxin filled proximal fluids are passed to the downstream healthy intestine which inturn absorb these toxins and cause postoperative toxaemia.
#Intestinal
#Surgery
1)Relief the distension and thereby improve respiration.
2)Relief pain.
3)Makes operation easier to perform.
4)Prevent aspiration pneumonia upon induction of anaesthesia.
5)Minimize absorption of toxins following relief of the obstruction, this may occur when the obstruction is relieved and the fermented toxin filled proximal fluids are passed to the downstream healthy intestine which inturn absorb these toxins and cause postoperative toxaemia.
#Intestinal
#Surgery
Parts of the intussusception:
-The intussusception itself is three parts
A) The outer tube or the sheath aka intussuscipiens.
B) The middle tube or the returning tube.
C) The inner tube or the entering tube aka intussusceptum.
-The apex is the advancing part.
-The neck is the junction between the proximal tube of bowel and the intussusception mass it self.
#Intestinal
#Surgery
-The intussusception itself is three parts
A) The outer tube or the sheath aka intussuscipiens.
B) The middle tube or the returning tube.
C) The inner tube or the entering tube aka intussusceptum.
-The apex is the advancing part.
-The neck is the junction between the proximal tube of bowel and the intussusception mass it self.
#Intestinal
#Surgery
Postoperative complication of appendicectomy
¶ Wound infection (most common)
¶ Intra abdominal abscess.
¶ Paralytic ileus (significant if it last more than 72 hours).
¶ Portal pyaemia (With gangrenous appendicitis).
¶ Respiratory complications (pneumonitis/Collapse).
¶ Venous thromboembolism.
¶ Right inguinal hernia (Said to be more common with Gridiron incision due to injury of the Rt iliohypogastric nerve).
¶ Adhesive intestinal obstruction (most common late complication).
¶ Faecal fistula (more when the stitch at appendix base is taken too deeply or when edema of caecal wall is extensive, also may follow cases of crohns disease).
#Appendix
#Surgery
¶ Wound infection (most common)
¶ Intra abdominal abscess.
¶ Paralytic ileus (significant if it last more than 72 hours).
¶ Portal pyaemia (With gangrenous appendicitis).
¶ Respiratory complications (pneumonitis/Collapse).
¶ Venous thromboembolism.
¶ Right inguinal hernia (Said to be more common with Gridiron incision due to injury of the Rt iliohypogastric nerve).
¶ Adhesive intestinal obstruction (most common late complication).
¶ Faecal fistula (more when the stitch at appendix base is taken too deeply or when edema of caecal wall is extensive, also may follow cases of crohns disease).
#Appendix
#Surgery
Acute appendicitis Vs mesentric adenitis
◼️ Pain = Both present with colicky abdominal pain, but in mesentric adenitis pain is interspersed with periods of complete freedom from pain.
◼️Tenderness= in acute appendicitis tenderness is classically in the Rt iliac fossa, in mesentric adenitis tenderness is maximal along the line of the mesentry with shifting tenderness (put the patient on the left side, the point of maximum tenderness will move to the left side as the inflamed lymph nodes gravitate to the left).
◼️Lymphadenopathy = Mesentric adenitis may be accompained by cervical nodes enlargement.
◼️ History = A history of respiratory tract infection is present in 25% of those with mesentric adenitis.
#Appendix
#Surgery
◼️ Pain = Both present with colicky abdominal pain, but in mesentric adenitis pain is interspersed with periods of complete freedom from pain.
◼️Tenderness= in acute appendicitis tenderness is classically in the Rt iliac fossa, in mesentric adenitis tenderness is maximal along the line of the mesentry with shifting tenderness (put the patient on the left side, the point of maximum tenderness will move to the left side as the inflamed lymph nodes gravitate to the left).
◼️Lymphadenopathy = Mesentric adenitis may be accompained by cervical nodes enlargement.
◼️ History = A history of respiratory tract infection is present in 25% of those with mesentric adenitis.
#Appendix
#Surgery
Gynaecological causes that are frequently mistaken for appendicitis :
¶ Pelvic inflammatory disease
Here you will find a history of dysmenorrhea, offensive vaginal discharge and burning micturition, cervical tenderness will help, its always a good idea to consult a gynaecologist when in doubt.
¶ Torsion/Hemorrhage of ovarian cyst
This is challenging as it presents very closely as appendicitis, but the pain start in the same place and remain in the same place, its helpful to do pelvic ultrasound.
¶ Ectopic pregnancy
Can be excluded by pelvic ultrasound and pregnancy test, a history of missed menstrual cycle is helpful.
¶ Endometriosis.
¶Mittelschmerz pain
-This one is due to rupture of a follicular cyst, pain classically happen midcycle.
#Appendix
#Surgery
¶ Pelvic inflammatory disease
Here you will find a history of dysmenorrhea, offensive vaginal discharge and burning micturition, cervical tenderness will help, its always a good idea to consult a gynaecologist when in doubt.
¶ Torsion/Hemorrhage of ovarian cyst
This is challenging as it presents very closely as appendicitis, but the pain start in the same place and remain in the same place, its helpful to do pelvic ultrasound.
¶ Ectopic pregnancy
Can be excluded by pelvic ultrasound and pregnancy test, a history of missed menstrual cycle is helpful.
¶ Endometriosis.
¶Mittelschmerz pain
-This one is due to rupture of a follicular cyst, pain classically happen midcycle.
#Appendix
#Surgery
Q:Why appendicitis in infants is much dangerous than older patients?
A: Because the condition itself is rare and the patient is unable to give history, these reasons will cause delayed diagnosis and the condition can progress to perforation, furthurmore the greater omentum in infants is so small and underdeveloped, this makes the omentum unable to provide good help in localising the infection, thus the condition will more likely end up with life threatening diffuse peritonitis.
#Appendix
#Surgery
A: Because the condition itself is rare and the patient is unable to give history, these reasons will cause delayed diagnosis and the condition can progress to perforation, furthurmore the greater omentum in infants is so small and underdeveloped, this makes the omentum unable to provide good help in localising the infection, thus the condition will more likely end up with life threatening diffuse peritonitis.
#Appendix
#Surgery
Diarrhea in appendicitis
-This may occur in two situations
1- Pelvic appendix, here the inflamed appendix is in contact with the rectum, irritation of which cause diarrhea.
2- Post ileal appendix, this is rare, here the inflamed appendix is in contact with the terminal ileum, producing diarrhea and marked retching.
#Appendix
#Surgery
-This may occur in two situations
1- Pelvic appendix, here the inflamed appendix is in contact with the rectum, irritation of which cause diarrhea.
2- Post ileal appendix, this is rare, here the inflamed appendix is in contact with the terminal ileum, producing diarrhea and marked retching.
#Appendix
#Surgery
Special clinical features of retrocaecal position of the inflamed appendix
•Tenderness in Rt iliac fossa may be abscent ( this is because the appendix is located behind the caecum that may prevent the pressure elicited by the hand to reach the inflamed structure).
•Rigidity at Rt iliac fossa may be abscent, again because the caecum protect the anterior peritoneum from being irritated by the inflamed appendix, instead Rigidity may be found at the quadratus lumborum.
•Psoas spasm
Here the inflamed appendix is behind the caecum and in contact with this muscle, spasm of which causes flexsion of the hip joint, at this point when you hyperextend the hip joint pain in abdomen may be felt.
#Appendix
#Surgery
•Tenderness in Rt iliac fossa may be abscent ( this is because the appendix is located behind the caecum that may prevent the pressure elicited by the hand to reach the inflamed structure).
•Rigidity at Rt iliac fossa may be abscent, again because the caecum protect the anterior peritoneum from being irritated by the inflamed appendix, instead Rigidity may be found at the quadratus lumborum.
•Psoas spasm
Here the inflamed appendix is behind the caecum and in contact with this muscle, spasm of which causes flexsion of the hip joint, at this point when you hyperextend the hip joint pain in abdomen may be felt.
#Appendix
#Surgery
SIGNS OF APPENDICITIS
◼️ Pyrexia
-Which is low grade and usually occur after 6 hours. May be absent in 20% of early cases.
◼️ Muscle guarding
-Start gentle superficial palpation from the left iliac fossa, work your way in anticlockwise fashion until you reach the right iliac fossa, guarding will be felt over the area of maximum tenderness classically the McBurney's point.
◼️ Rebound tenderness
-This can be shown by gentle percussion over the area of maximum tenderness.
◼️ Pointing sign
-Ask the patient to point where the pain has began and where it has shifted, the patient typically point around the umbilicus and then move to the right iliac fossa, this demonstrates the classic visceral-somatic pain sequence, which is present only in about half of all proven cases.
◼️ Rovsing's sign
-Deep palpation of left iliac fossa causes pain in the right iliac fossa, this may arise from the fact that bowel is displaced toward the right side when you push on the left side irritating the inflamed area, and may arise from the fact that when you push in the left iliac fossa this will displace the gas in the colon toward the right side, either ways it is useful to support the diagnosis.
◼️ Psoas sign
-Sometimes when the inflamed appendix lie over the psoas muscle, you will find the patient flexing the right hip in attempt to Relief the pain, such position is known as psoas sign.
◼️ Obturator sign
#Appendix
#Surgery
◼️ Pyrexia
-Which is low grade and usually occur after 6 hours. May be absent in 20% of early cases.
◼️ Muscle guarding
-Start gentle superficial palpation from the left iliac fossa, work your way in anticlockwise fashion until you reach the right iliac fossa, guarding will be felt over the area of maximum tenderness classically the McBurney's point.
◼️ Rebound tenderness
-This can be shown by gentle percussion over the area of maximum tenderness.
◼️ Pointing sign
-Ask the patient to point where the pain has began and where it has shifted, the patient typically point around the umbilicus and then move to the right iliac fossa, this demonstrates the classic visceral-somatic pain sequence, which is present only in about half of all proven cases.
◼️ Rovsing's sign
-Deep palpation of left iliac fossa causes pain in the right iliac fossa, this may arise from the fact that bowel is displaced toward the right side when you push on the left side irritating the inflamed area, and may arise from the fact that when you push in the left iliac fossa this will displace the gas in the colon toward the right side, either ways it is useful to support the diagnosis.
◼️ Psoas sign
-Sometimes when the inflamed appendix lie over the psoas muscle, you will find the patient flexing the right hip in attempt to Relief the pain, such position is known as psoas sign.
◼️ Obturator sign
#Appendix
#Surgery
Notes of worth
-A family history is useful because one third of children with appendicitis show a similar family history in first degree relatives.
-In first 6 hours, there is rarely any change in temperature and heart rate, after that time, usually there is slight pyrexia (37.2-37.7C) and slight increase in heart rate to about 80-90 bpm.
-In children a temperature of greater than 38.5 C tend to suggest another diagnosis such as acute mesentric adenitis.
#Appendix
#Surgery
-A family history is useful because one third of children with appendicitis show a similar family history in first degree relatives.
-In first 6 hours, there is rarely any change in temperature and heart rate, after that time, usually there is slight pyrexia (37.2-37.7C) and slight increase in heart rate to about 80-90 bpm.
-In children a temperature of greater than 38.5 C tend to suggest another diagnosis such as acute mesentric adenitis.
#Appendix
#Surgery
CLASSIC SYMOTOMS OF ACUTE APPENDICITIS¶ PERIUMBILICAL COLIC
-At first the pain is poorly localised and classically felt around the umbilicus, it has a colicky nature similar to that of small bowel obstruction but has less intensity, the underlying pathophysiology is stimulation of the visceral nerves of visceral peritoneum, which is casted to the midline.
¶ PAIN SHIFT TO RIGHT ILIAC FOSSA
-Here, when the inflammatory process extend through the appendix wall, and reach the parietal peritoneum, the latter will be irritated and since it is heavily enriched with somatic nerves, patients typically describe that the pain has moved to the right iliac fossa, became more intense, and changed in nature from colicky to constant.
¶ ANOREXIA
-A very useful and constant clinical feature especially in children.
¶ NAUSEA
-Which can be accompained by one or two episodes of vomitting that follow the onset of abdominal pain due reflex pylorus spasm (as described by john murphy a professor of surgery chicago USA).
#Appendix
#Surgery
IMPORTANT NOTEIschemic necrosis of the appendix is a result of venous occlusion secondary to excessive distension of the inflamed appendix.
#Appendix
Sequence of appendicitis
Occlusion of lumen (Inflammation may precede occlusion in many cases possibly due to viral infection) ➡️ Accumulation of mucous and inflammatory exudate within the lumen ➡️ aid in bacteria proliferation and increase lumen pressure ➡️ Distension ➡️ Occlusion of venous drainage ➡️ ischaemia of appendix wall ➡️ translocation of bacteria throughout the wall ➡️ bacteria may enter the peritoneal cavity ➡️ furthur ischaemia can cause gangrene of appendix ➡️ Perforation ➡️ life threatening peritonitis.
#Appendix
#Surgery
Occlusion of lumen (Inflammation may precede occlusion in many cases possibly due to viral infection) ➡️ Accumulation of mucous and inflammatory exudate within the lumen ➡️ aid in bacteria proliferation and increase lumen pressure ➡️ Distension ➡️ Occlusion of venous drainage ➡️ ischaemia of appendix wall ➡️ translocation of bacteria throughout the wall ➡️ bacteria may enter the peritoneal cavity ➡️ furthur ischaemia can cause gangrene of appendix ➡️ Perforation ➡️ life threatening peritonitis.
#Appendix
#Surgery