Diseases of Small Bowel and Appendix Flashcards
incidence of appendicitis
rare in infancy
peaks in childhood and young adults
peaks again in elderly
aetiology of appendicitis
obstruction of lumen with faecolith
bacterial
viral
parasites
pathology of appendicitis
lumen may or may not be occluded mucosal inflammation lymphoid hyperplasia obstruction build up of mucus and exudate venous obstruction ischaemia - bacterial invasion through wall perforation small bowel adheres phlegmonous mass peritonits
symptoms of appendicitis
anorexia
nausea +/- vomiting
rectal tenderness
+/- fever
signs of appendicitis
mild Pyrexia mild tachycardia central abdominal pain, later localised pain in right iliac fossa guarding rebound rosving's psoas obturator
rosving’s sign
pressing on the left causes pain on the right
psoas sign
patient keep the right hip flexed as this lefts an inflamed appendix off the posts
obturator signs
if appendix is touching obturator internus, flexing the hip and internally rotating with cause pain
special cases of appendicitis
retrocacal appendix pelvic appendix postileal the obese the elderly children pregnancy
retrocaecal appendix
may be very few signs
pelvic appendix
diarrhoea
frequency of micturition
postilieal apendicitis
rare
diarrhoea
vomiting
differential diagnosis of appendicitis in children
Gastroenteritis Mesenteric adenitis Meckel’s diverticulum Intususseption Henoch-Schonlein Purpura Lobar pneumonia
differential diagnosis of appendicitis in adults
Terminal ileitis Ureteric colic Acute pyelonephritis Perforated ulcer Pancreatitis Rectus sheath haemotoma
differential diagnosis of appendicitis in the elderly
Sigmoid diverticulitis
Intestinal obstruction
Carcinoma of the caecum
differential diagnosis of appendicitis in woman
Mittelschmerz
Ovarian cyst
Salpingitis
Ectopic pregnancy
rare differential diagnosis of appendicitis
Pophyria
Diabetic ketoacidosis
typhilitis
tests for appendicitis
it is a clinical diagnosis; ultrasound - first line AXR - exclude other causes FBC urinalysis Alvarado score
describe the Alvarado score
MANTRELS; migration of pain to lower right quadrant anorexia nausea and vomiting tenderness in right lower quadrant rebound pain elevated temperature leukocytosis shift of white blood cell count to left
management of appendicitis
analgesia (pain)
antipyretics (reduce fever)
appendicectomy
antibiotics
treatment of an appendix mass
antibiotics - first line
can choose whether or not to operate
complications of surgical intervention of appendicitis
tachycardia
worsening pain
increase in pain
vomiting or copious NG aspirates (ileus)
describe an appendix abscess
not an appendix mass
usually has liquidised
usually delayed
treatment of appendix abscess
radiological drains
complications of appendix abscess
Pelvic abscess Wound infection Intra-abdominal abscess Ileus Respiratory DVT/PE Portal pyaemia Faecal fistula Adhesions Right sided inguinal hernia
describe carcinoid of the appendix
appears in crypts of Lieberkuhn
metastatic risk relates to size
stains for chromagrannin
obstruction of the small bowel
proximal bowel will dilate and develop altered motility
swells due to build up of fluid and gas
where does the gas come from that causes the small bowel to swell
anaerobic and aerobic metabolism that occurs with the overgrowth of organisms in the obstructed bowel - nitrogen and hydrogen sulphide
where may the small bowel be obstructed
within the lumen
within the wall
outside the wall
what may cause the lumen of the small bowel to be obstructed
gallstone
food
bezoar
what may cause the inside wall of the small bowel to be obstructed
tumour
Crohn’s disease
radiation
what may cause the outside wall of the small bowel to be obstructed
adhesions
herniation
symptoms of obstruction of the small bowel
look for a cause of obstruction (groins both femoral and inguinal) - scars, hernias pain constipation vomiting burping abdominal distension borborygmi
tests for obstruction of small bowel
urinalysis bloods gases AXR CT gastrograffin studies
treatment for obstruction of small bowel
analgesia fluids + K+ catheterise NG tube (ryles, not feeding) anti-thromboembolism measures
causes of mesenteric ischaemia
embolus - from AF (forms in left atrium and sticks in narrow Superior mesenteric artery)
thrombosis (arterial and venous) - Virchow’s triad
chronic mesenteric ischaemia
superior mesenteric artery affected
cramps
‘angina of the gut’
atherosclerosis
acute mesenteric ischaemia
small bowel usually infarcts - dies
colon lives due to marginal artery
presentation of mesenteric ischaemia
pain out of proportion to clinical findings
acidosis
lactate elevated
elevated WBC
tests for mesenteric ishcaemia
blood gases
CT angiogram
treatment for mesenteric ischaemia
very quick treatment required
resect in non-viable
re-anastomose or staple and planned return
superior mesenteric artery embolectomy
