Diseases of the small bowel and appendix Flashcards
Where is the appendix found?
Retrocaecal
Tip can vary in location
Base is at convergence of the 3 teniae coli
Vestigail origin
What is the blood supply to the appendix and what is special about it?
Appendicular artery (branch of the SMA) It lies posterior to the ileum and is an end artery with no anastamosis
Which patient groups typically get appendicitis?
Usually childhood/young adulthood (not infancy)
More common in males than females up to age 25
Also common in the elderly
Why is the incidence of appendicitis declining?
Better sanitation and living conditions
Where is McBurney’s point?
1/3 of the way from the ASIS to the umbilicus
What causes appendicitis?
Obstruction of the lumen with faecolith
Bacterial
Viral (common in clusters so they come in waves of cases)
Paracites in other parts of the world
What are the gross pathological features of appendicitis?
Huge variation Lumen may/may not be occluded Mucosal inflammation Lymphoid hyperplasia Obstruction Build up of mucus and exudate Venous obstruction Ischemia (bacterial invasion through the wall Perforation
What is the role of the greater omentum in appendicitis?
Presence of inflammation causes the omentum to migrate towards the appendix. It sticks to the appendix and small bowel to wall off infection but if you leave this it can be very hard to operate
Peritonitis is a complication of appendicitis and can be fatal. WHat can predispose you to this?
Age- older people
Immunosupression- this will mask all the signs and will often present late
Diabetes
Absence of omentum due to previous surgery
Why are most perforated appendices found in the elderly?
They present later and grumble on whereas parents/ carers will bring children who are unwell
What are the symptoms of appendicitis?
Not hungry
Nausea ?vomited once or twice
No bowel movements
What are the signs of appendicitis?
Mild pyrexia-38-39 degrees
Mild tachycardia
Localised pain in right iliac fossa. May have moved from umbilicus
Guarding
Rebound tenderness- pain when you stop pushing and the organs move together
Flushing
Sore to move, cough, laugh
What is Rosving’s sign?
Pressing on the left causes pain on the right. Sign of appendicitis
What is Psoas sign?
Patient keeps right hip flexed as this lifts an inflamed appendix off the psoas.
Sign of appendicitis in thin people
What is obturator sign?
If appendix is touching the obturatur internus, flexing the hip and internally rotating will cause pain. Sign of appendicitis.
What are the signs of retrocaecal appendicitis?
Often little pain and best to get a CT done
What are the signs of pelvic appendicitis?
Rectal irritation and diahorroea. Vage pain localisation in the pelvic area. Increased frequency of micturition
What are the signs of a postileal appendicitis?
Irritation of the small bowel causing diarrhoea and vomiting
What happens to the appendix during pregnancy?
Moves up and out.
Appendicitis is more common in a first pregnancy due to ligaments stretching. What would you do if you suspected appendicitis in a pregnant women?
MRI as no radiation involved or ultrasound scan.
<20 weeks a laprotomy is safe.
What is the risk of foetal loss if appendicitis in preganacy?
3-5% but 20% if perforated so operate early
What is the differential diagnosis of appendicitis in children?
Gastroenteritis-usually has more vomiting
Mesenteric adenitis- swelling of lymph nodes- stretching pain due to stretching of the peritoneum
Meckel’s diverticulum
Intususseption- bowel folds in on itself
Henoch Schonlein Purpura- inflammation of small blood vessels => leaky
Lobar pneumonia
What is Henoch Schonlein Purpura?
Inflammation of small blood vessels in children which leads to leakiness. Effects the skin, intestines, kidneys and joints.
What is the differential diagnosis of appendicitis in adults?
Terminal ileitis Ureteric colic Acute pyelonephritis Perforated ulcer Pancreatitis Rectus sheath haematoma
What is a rectus shealth haematoma?
It is the result of bleeding into the rectus sheath from damage to the superior or inferior epigastric arteries or their branches or from a direct tear of the rectus muscle.
What is ureteric colic?
obstruction of the urinary tract by calculi. Urinary stones
What is acute pyelonephritis?
sudden and severe kidney infection.
What are the differential diagnosis of appendicitis in women?
Mittelschmerz
Ovarian cyst
Salpingitis
Ectopic pregancy
What is Salpingitis?
Inflammation of the Fallopian tubes
What is Mittelschmertz?
one-sided, lower abdominal pain associated with ovulation.
What are the diferential diagnosis of appendicitis in the elderly?
Sigmoid diverticulitis
Intestinal obstruction
Carcinoma of the caecum
What investigations may you consider in appendicitis?
Clinical diagnosis
Ultrasound in women and kids
AXR (not in every patient as lots of radiation)
Bloods (CRP and white cell count)
Urinanalysis for UTI or pregnancy in female
What is the mantreals/alvarado score?
Used in paediatrics for risk of appendicitis .
Migration of pain to LRQ Anorexia Nausea and vomiting Tenderness in RLQ Rebound pain Elevated temperature Leukocyctosis Shift of WCC to left
How is appendicitis managed?
Analgesia
Antipyrexials
Antibiotics
Appendectomy (laprascopic is best, may convert to open rarely. Laparotomy only in severe cases
How is an appendix mass treated?
Antibiotics first line
Only require operation if perforated, worsening or increasing in size)
How is an appendix abscess treated?
This is NOT an appendix mass. I is a complication of appendicitis when presenting late.
Usually require radiological drains
What is an appendix mass?
inflamed appendix with an adherent covering of omentum and small bowel
What are the complications of appendicitis?
Pelvic abscess Wound infection Intra-abdominal abscess Ileus Adhesions Faecal fistula Right sided inguinal hernia
Can you get cancer of the appendix?
Yes- carcinoid of the appendix in crypts of Lieberkuhn.
How is carcinoid of the appendix managed?
<1cm appendectomy alone
>2cm right hemicolectomy to remove all the lymph nodes.
92% 5 year survival
What are the symptoms of small bowel obstruction?
Colicky central pain Absolute constipation Vomiting Burping Abdominal distention
What are the causes of small bowel obstruction?
1) Within the lumen (gallstone, food, bezoar)
2) Within the wall (tumour, Crohn;s, Radiation)
3) Outside the wall (Adhesions, Herniations)
What is the most common cause of small bowel obstruction?
Adhesions due to previous abdominal surgery.
Increased pressure in the small bowel can lead to ischemia and perforation. How?
Because the increased pressure can compress the blood vessels supplying the bowel.
Infarction => perforation
If the patients presents with ho history of abdo surgery and you suspect small bowel obstruction, what must you look for?
Hernias,
especially femoral hernias in older ladies
What investigations are important for small bowel obstruction?
Urinanalysis Bloods ABGs- acidosis AXR to confirm diagnosis Contrast CT to look for cause
What is the typical signs of small bowel obstruction on plain AXR?
Looks like the patient swallowed the hungry caterpillar
Air/fluid lines
What is the conservative management for small bowel obstruction and when do you review the patient?
Analgesia
Fluids with potassium (usually hypokalaemic and alkalotic)
Catheterise
NG tube (Ryles tube for aspiration)
Anti VTE treatment (TED stockings and fragmin)
Review after 72 hours
Most causes of small bowel obstruction will resolve with supportive management, especially due to adhesions. When must you operate to resolve the problem?
Hernias
After 72 hours of no improvement or earlier if strangulation, perforation or ischemia
What is the surgical management of small bowel obstruction?
Laparotomy- mid line incision. Can try laproscopic but its hard to pump air into the abdomen to see.
Obstruction is found by followin collapsed or dilated bowel.
Remember anti coagulants and antibiotics
Why is the small bowel more likely to die than the large bowel?
No collateral circulation.
The Large bowel has the middle colic/left colic anastamosis
What causes mesenteric ischemia?
Acute- emboli often from AF
Chronic- thrombosis (especially on vasoconstricting drugs)
What is in situ thrombosis?
When the flow to the SMA is very low due to haemorrhage etc and the artery just thromboses and cuts off
What are the symptoms of chronic mesenteric ischemia?
Cramps and colicky pain, similar to angina
Investigations are often normal.
Pain on eating => fear of food
Older people, very thin
Pain is out of proportion to the clinical findings
How is mesenteric ischemia diagnosed?
Acidotic gases Lactate elevated 3-4 CRP normal (delayed by 24 hours) WCC raised at 15 ish CT angiogram- MOST IMPORTANT
How do you treat mesenteric ischemia?
Fast- do not wait and prepare the family for the worst.
Resect if non viable in young and fit. Bring out 2 stomas and you may consider a small bowel transplant
Partial resection. If the patient is sick- bring out 2 stomas and consider anastamosis later. If well and mechanical rather than vascular cause anastamose. If all viable you can perform as SMA embolectomy.
Sometime you just open and close and let the patient die.
What causes a small bowel haemorrage?
Vascular malformations
Ulceration.
How is a small bowel haemorrhage diagnosed and treated?
CT angiogram and treated with interventional radiology.
BUT must do a laproscope 24 hours later to check for ischemia as the small bowel has no collateral supply
What is Meckel’s diverticulum?
60cm from the ileocaecal valve. 2 inches long
2% of the population and develops before 2 years of age.
Remnant of the omphalomesenteric duct
What are the complications of Meckel’s diverticulum?
Bleed
Ulcer/Meckel’s diverticulitis
Obstruction
Malignancy (rare)
