Appendicits, diverticulitis and peritonitis Flashcards
what is appendicitis?
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
what bacteria are found in the appendix?
bacteriodes fragilis and E. Coli
what are the three types of appendicitis?
mucosal - mildest form
phlegmonous - slow onset and slow progression
necrotic - acute bacterial infection with ischaemic necrosis
what are the clinical features of appendicits?
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
what is Rosvig’s sign ?
palpation of LIF causes pain in RIF
what is Dunphy’s sign?
abdominal pain when coughing
what are signs of appendix perf and peritonitis?
tense, rigid abdomen
hypotension and tachycardia (shock)
palpable mass (peri-appendiceal abscess caused by perf that is contained by omentum)
decreased bowel sounds
what are InV for appendicitis?
FBC
- leucocytosis
Increased CRP
urinalysis
- exclude renal cause
Abdo US or CT
- diameter >6mm or faecolith
where is McBurney’s point?
1/3 distance from ASIS to umbilicus. appendicitis pain is usually worse here
what are the possible locations of the appendix?
75% retrocaecal
20% subcaecal/pelvic
5% = pre-ileal and post-ileal
what is Psoas sign ?
RIF pain with extension of the right hip
Specifically suggests an inflamed appendix abutting psoas major muscle in a retrocaecal position
what is the management options for acute appendicitis?
lap appendectomy - appendix sent for histological study (1% have malignancy)
IV ABx - Amox and Met
Analgesia
Fluids
what are the complications of acute appendicitis?
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
what is a diverticulum?
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.
what are the four manifestations of a diverticulum?
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
what are features of diverticular disease?
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.
what are the features of acute diverticulitis?
lower left quadrant pain with guarding
Fever
N&V
abdominal tenderness and bloating
constipation and occasionally diarrhoea
rectal bleeding as complication
what InV are done in diverticular disease and acute diverticulitis ?
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
what is the management of diverticular disease?
high fibre diet
increase oral fluid intake
stool softeners
analgesia
what is the managment of acute diverticulitis?
Most patients with acute diverticulitis can be managed conservatively with
antibiotics - Co-amox or triple therapy
intravenous fluids
analgesia.
when is surgery indicated in acute diverticulitis and what can be done?
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
what are the complications of diverticular disease aside from perforation and peritonitis?
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
what is peritonitis and what are the causes?
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
what are the signs and symptoms of peritonitis?
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
what InV are done in suspected peritonitis?
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
what is the management of peritonitis?
IV ABx
- Met and cefuroxime
IV fluids and correct electrolytes
laparotomy
