Appendicits, diverticulitis and peritonitis

Question 1

what is appendicitis?

Answer 1

an acute inflammation of the veriform appendix, most likely due to obstruction of the lumen of the appendix by faecolith, normal stool, infective agent or lymphoid hyperplasia

Question 2

what bacteria are found in the appendix?

Answer 2

bacteriodes fragilis and E. Coli

Question 3

what are the three types of appendicitis?

Answer 3

mucosal - mildest form
phlegmonous - slow onset and slow progression
necrotic - acute bacterial infection with ischaemic necrosis

Question 4

what are the clinical features of appendicits?

Answer 4

Abdominal pain

• starts centrally
• moves to RIF as inflammation progresses
• anatomical variation in appendix location so pain site varies
• pain made worse by coughing or moving

malaise, anorexia and fever

Nausea and vomiting

Rosvig’s sign

Question 5

what is Rosvig’s sign ?

Answer 5

palpation of LIF causes pain in RIF

Question 6

what is Dunphy’s sign?

Answer 6

abdominal pain when coughing

Question 7

what are signs of appendix perf and peritonitis?

Answer 7

tense, rigid abdomen

hypotension and tachycardia (shock)

palpable mass (peri-appendiceal abscess caused by perf that is contained by omentum)

decreased bowel sounds

Question 8

what are InV for appendicitis?

Answer 8

FBC
- leucocytosis

Increased CRP

urinalysis
- exclude renal cause

Abdo US or CT
- diameter >6mm or faecolith

Question 9

where is McBurney’s point?

Answer 9

1/3 distance from ASIS to umbilicus. appendicitis pain is usually worse here

Question 10

what are the possible locations of the appendix?

Answer 10

75% retrocaecal

20% subcaecal/pelvic

5% = pre-ileal and post-ileal

Question 11

what is Psoas sign ?

Answer 11

RIF pain with extension of the right hip

Specifically suggests an inflamed appendix abutting psoas major muscle in a retrocaecal position

Question 12

what is the management options for acute appendicitis?

Answer 12

lap appendectomy - appendix sent for histological study (1% have malignancy)

IV ABx - Amox and Met

Analgesia

Fluids

Question 13

what are the complications of acute appendicitis?

Answer 13

Perforation
- if left untreated the appendix can perforate and cause peritoneal contamination. This is particular note in children who may have a delayed presentation

Surgical site infection
- Rates vary depending on simple or complicated appendicitis (ranging 3.3-10.3 %)

Appendix mass
- where omentum and small bowel adhere to the appendix

Pelvic abscess
- Presents as fever with a palpable RIF mass, can be confirmed CT scan for confirmation; management is usually with antibiotics and percutaneous drainage of abscess

Question 14

what is a diverticulum?

Answer 14

A diverticulum is an outpouching of the bowel wall where there is herniation of the mucosa and submucosa through the muscular layer of the colonic wall. They are most commonly found in the sigmoid colon, but can be present throughout the large and small bowel.

Question 15

what are the four manifestations of a diverticulum?

Answer 15

Diverticulosis – the presence of diverticula (asymptomatic, incidental on imaging)

Diverticular disease – symptoms arising from the diverticula

Diverticulitis – inflammation of the diverticula

Diverticular bleed – where the diverticulum erodes into a vessel and causes a large volume painless bleed

Question 16

what are features of diverticular disease?

Answer 16

Features of diverticular disease include an intermittent lower abdominal pain, typically colicky in nature and may be relieved by defecation.

Other symptoms include an altered bowel habit, associated nausea, and flatulence. There will be no systemic features present.

Question 17

what are the features of acute diverticulitis?

Answer 17

lower left quadrant pain with guarding

Fever

N&V

abdominal tenderness and bloating

constipation and occasionally diarrhoea

rectal bleeding as complication

Question 18

what InV are done in diverticular disease and acute diverticulitis ?

Answer 18

FBC and CRP

• leucocytosis and elevated CRP
• polymorphonuclear WBCs
• group and save should be done in acute

CT abdo
- thickening of bowel wall, mass, abscess, streaky mesenteric fat

Double contrast barium enema
- done in elective setting

Colonoscopy
- diverticula, inflammation of mucosa, bleeding

flexi Sig

Question 19

what is the management of diverticular disease?

Answer 19

high fibre diet
increase oral fluid intake
stool softeners
analgesia

Question 20

what is the managment of acute diverticulitis?

Answer 20

Most patients with acute diverticulitis can be managed conservatively with
antibiotics - Co-amox or triple therapy
intravenous fluids
analgesia.

Question 21

when is surgery indicated in acute diverticulitis and what can be done?

Answer 21

Surgical intervention is required in those with perforation with faecal peritonitis or overwhelming sepsis.

This is a major procedure and usually involves a Hartmann’s procedure (a sigmoid colectomy with formation of an end colostomy.

An anastomosis with reversal of colostomy may be possible at a later date (but this only occurs in ~50% of cases

Question 22

what are the complications of diverticular disease aside from perforation and peritonitis?

Answer 22

Diverticular Stricture
- A patient can develop a diverticular stricture following repeated episodes of acute inflammation. The bowel becomes scarred and fibrotic, resulting in a benign stricture.

• This can result in a large bowel obstruction. In such cases, a sigmoid colectomy is required, either electively or urgently, depending on the presentation (colonic stenting can be used as a temporising measure, however surgery will eventually be required).

Fistula Formation

Due to the repeated inflammation, fistula can form secondary to diverticulitis, which will nearly always require surgical intervention. The most common types are:

• Colovesical fistula form between the bowel and the bladder. They generally present with recurrent UTIs, pneumoturia (gas bubbles in the urine), or passing faecal matter in the urine
• Colovaginal fistula form between the bowel and the vagina. They generally present with copious vaginal discharge or recurrent vaginal infections

Question 23

what is peritonitis and what are the causes?

Answer 23

acute inflammation of the peritoneal cavity

Primary = staphylococcal infection with entry via bloodstream rather than organs

Secondary

• perforated diverticular disease
• Upper GI perf
• perf ischaemic bowel
• acute pancreatitis
• peritoneal dialysis related

Question 24

what are the signs and symptoms of peritonitis?

Answer 24

anorexia and fever

severe, generalised abdo pain

• radiate to shoulder and back
• worse on movement, coughing and sneezing

abdo tenderness with rigidity, guarding and rebound tenderness

differential maximal tenderness may indicate underlying cause

signs of sepsis

Question 25

what InV are done in suspected peritonitis?

Answer 25

FBC, CRP, ESR and G&S
- increased WCC, ESR and CRP

U&E’s

• hypokalaemia
• hypernatraemia

amylase
- ?pancreatitis

CT abdomen

laparoscopy

ABGs if shocked or ischaemic bowel or pancreatitis suspected

Question 26

what is the management of peritonitis?

Answer 26

IV ABx
- Met and cefuroxime

IV fluids and correct electrolytes

laparotomy