compilation

1. Appendicitis

2. position
• 12 o clock: Retrocolic or retrocecal (behind the cecum
or colon)
• 2 o clock: Splenic (upwards and to the left – Preileal
and Postileal)
• 3 o clock: Promonteric (horizontally to the left
pointing the sacral promontory)
• 4 o clock: Pelvic (descend into the pelvis)
• 6 o clock: Subcecal (below the cecum pointing
towards inguinal canal)
• 11 o clock: Paracolic (upwards and to the right)

3. Definition:
• An inflammation of the appendix
Aetiology:
• Decreased dietary fibre and increased consumption of refined
carbohydrates
• Obstruction of the appendix lumen
– Tumour (carcinoma of caecum)
– Intestinal parasites (Oxyuris/Enterobius vermicularis – pinworm)

4. Clinical Manifestations
Symptoms
• Peri-umbilical
colic
• Pain shifts to
the right iliac
fossa
• Anorexia
• Nausea
Signs
• Pyrexia (37.2–
37.7°C)
• Localised
tenderness in
the right iliac
fossa
• Muscle guarding
• Rebound
tenderness
Signs to elicit
• Pointing sign (patient is
asked to point where the
pain began and where it
moved)
• Rovsing’s sign (deep
palpation of the left iliac
fossa may cause pain in
the right iliac fossa)
• Psoas sign (patient will lie
with the right hip flexed
for pain relief)
• Obturator sign (the hip is
flexed and internally
rotated. If an inflamed
appendix is in contact with
the obturator internus,
this manoeuvre will cause
pain in the hypogastrium)

6. Special Features Based On
Appendix Locations
Retrocecal (silent appendix)
• Rigidity is often absent but deep pressure fail to elicit tenderness
• Deep tenderness often present in the loin
Pelvic
• Early diarrhea results from an inflamed appendix being in contact with the rectum
• Complete absence of abdominal rigidity and lacking tenderness over McBurney’s point
• Deep tenderness – symphysis pubis, on the right side (on per rectal examination)
• Spasm of psoas/obturator internus muscle
• Contact with bladder – frequency of micturition (mostly in children)
Postileal
• the inflamed appendix lies behind the terminal ileum
• Greatest difficulty
• Pain may not shift
• Diarrhoea is a feature
• Marked retching (spasm which causes vomiting) may occur
• Tenderness, if any
• Ill- defined
• Immediately to the right of the umbilicus

7. Differential Diagnosis
Children
• Gastroenteritis
• Mesenteric
adenitis
• Meckel’s
diverticulitis
• Intussusception
• Henoch-
Schönlein
purpura
• Lobar
pneumonia
Adult
• Regional
enteritis
[Terminal ileitis]
• Ureteric colic
• Pyelonephritis
• Perforated
peptic ulcer
• Torsion of testis
• Pancreatitis
• Rectus sheath
haematoma
Adult Female
• Mittelschmerz
• Pelvic
inflammatory
disease
• Ectopic
pregnancy
• Torsion/rupture
of ocarian cyst
• Endometriosis
Elderly
• Diverticulitis
• Intestinal
obstruction
• Colonic
carcinoma
• Torsion
appendix
epiploicae
• Mesenteric
infarction
• Leaking aortic
aneurysm

8. Investigation
Preoperative
Investigations Routine Full blood count
Urinalysis
Selective Urea and electrolytes
Supine abdominal radiograph
Ultrasound of the abdomen/pelvis
Contrast-enhanced CT scan of the
abdomen

9. The Alvarado (MANTRELS) Score
Score
Symptoms
• Migratory right iliac fossa pain
• Anorexia
• Nausea and vomiting
1
1
1
Signs
• Tenderness (RIF)
• Rebound tenderness
• Elevated temperature
2
1
1
Laboratory
• Leucocytosis
• Shift to the left (segmented neutrophils)
2
1
TOTAL 10
• < 5 is strongly against a diagnosis of appendicitis
• 7 or more is strongly predictive of acute appendicitis
• In patients with an equivocal score of 5 or 6, abdominal USG or
contrast-enhanced CT scan is used to further reduce the rate of
negative appendicectomy

10. CT Scan images of Appendicitis:
1. enlarged appendix 2. appendiceal wall thickening

11. CT Scan images of Appendicitis
3. appendicolith 4.periappendiceal fat stranding

12. Treatment
• Intravenous fluids
• to establish adequate urine output
• Appropriate antibiotics
• Reduces the incidence of postoperative wound infection
• When peritonitis is suspected, therapeutic intravenous antibiotics to cover Gram-
negative bacilli as well as anaerobic cocci should be given
• Appendicectomy

13. Conventional Appendicectomy
Gridiron incision : right angles
to a line joining the ASIS to the
umbilicus.Centred on
McBurney’s point
Lanz incision : 2 cm below the
umbilicus centred on the mid-
clavicular-midinguinal line
2/3
1/3
2 cm

14. Conventional Appendicectomy
• Caecum is identified
• Base of mesoappendix is clamped in artery forceps, divided, and ligated
• The freed appendix is crushed near its junction with the caecum in artery forceps,
which is removed and reapplied just distal to the crushed portion
• An absorbable ligature is tied around the crushed portion close to the caecum
• The appendix is amputated between the artery forceps and the ligature
• An absorbable purse-string or ‘Z’ suture may then be inserted into the caecum
about 1.25 cm from the base
• The stump of the appendix is invaginated while the purse-string or ‘Z’ suture is tied,
thus burying the appendix stump

16. CROHN’S DISEASE

17. Introduction
• Inflammatory Bowel Disease encompasses two distinct chronic, idiopathic
inflammatory diseases of the GI tract : Crohn’s disease which can affect any
part of the GI tract and Ulcerative colitis which affect only the large bowel

18. Aetiopathogenesis
• Familial
• Genetic factor
• Lifestyle

19. lifestyle
• Breastfeeding may provide protection against IBD in the offspring
• Nutritional : high sugar and fat intake have been suggested to play a role in
the pathogenesis of IBD
• Smoking : patients with CD are more likely to be smokers and smoking has
been shown to exacerbate CD

20. Pathology
• may affect any part of the GI system from mouth to anus but has a particular
tendency to affect the terminal ileum and ascending colon(iliocolonic
disease)
• The disease may affect one small part of the gut such as the terminal ileum
or multiple areas wt relatively normal bowel in between(skip lesions)
• May involve the whole colon sometimes without small bowel involvement

21. Clinical features
• The major symptoms are diarrhoea, abdominal pain and weight loss
• Constitutional symptoms of lethargy, anorexia, nausea, vomitting and low-
grade fever may be present
• Other clinical manifestations include bleeding

22. Investigations
• FBC: normocytic, normochromic anaemia of chronic disease, deficiency of
iron/folate also occurs
• Hypoalbuminaemia is present in severe disease
• Liver biochemistry may be abnormal

23. • Blood cultures are required if septicaemia is suspected
• Stool cultures should be performed on presentation if diarrhoea is present

24. Radiology and imaging
• Barium follow-through: the findings include an assymetrical alteration in the
mucosal pattern with deep ulceration, and areas of narrowing or stricturing
• Although commonly confined to the terminal ilium, other areas of small
bowel can be involved and skip lesions can also be seen between affected
sites

26. • Colonoscopy: is performed if colonic involvement is suspected
• ultrasound and CT scanning to define thickness of the bowel wall and
mesentry as well as intra-abdominal and paraintestinal abscesses
• Rectal ultrasound and MRI are used to evaluate perianal disease

27. Medical management
• Cigarette should be stopped, diarrhoea can be controlled
• Diarrhoea in long standing disease may be due to bile acid malabsorbtion
and should be treated with cholestyramine

28. • Anaemia if due to vit B12,folic acid or iron def should be treated wt
appropriate hematinics

29. Surgical management
• Indications for surgery include: failure of medical therapy with acute or
chronic symptoms producing ill-health, complications( eg toxic dilatation,
obstruction, perforation etc), failure to thrive in children despite medical
therapy

30. Diverticulitits

32. Overview
• A diverticulum is an abnormal sac or pouch protruding from the wall of a
hollow organ.
• Diverticula ; pouches
• Diverticulosis ; condition of having diverticula
• The formation of diverticula is also related to aging

33. Pathogenesis
• Diverticula are actually herniations of mucosa through the colon at sites of
penetration of the muscular wall by arterioles
• Sigmoid colon
• The most common site (50%)
• The smallest luminal diameter.
• Low fiber diet
-> decreased colonic luminal content
-> high intraluminal pressures to propel the feces forward
-> herniations of mucosa through the anastomically weak points in the colonic wall

34. Diverticular bleeding
• The most common cause of hematochezia in patients over the age of 60
• Risk factor ; HT, Artherosclerosis, NSAID
• Usually self limited, but rebleeding risk (25%)
• Localization ; Colonoscopy,Angiography
• Surgery
• Without localization ;Total colectomy

35. Diverticulitis
•Definition
• Inflammation of a diverticulum, is related to the retention of
particulate material within the diverticular sac and the
formation of a fecalith
•Presentation
• Pain : may radiate to the suprapubic, groin, back
• Bowel habit change, Anorexia, Fever, Chill, Urinary urgency

36. Diverticulitis
•Physical Findings
• Tenderness, Muscle guarding
• Tender mass :abscess
• Abdominal distension :obstruction
• Tender fluctuant pelvic mass on rectal or vaginal exam

37. Diverticulitis
•DiagnosticTests
• CT
• The preferred test to confirm the suspected diagnosis
• Location of infection, extent of inflammatory process, presence and
location of an abscess, secondary complications
• sigmoid diverticula, thickened colonic wall >4 mm, inflammation within the pericolic fat ±
the collection of contrast material or fluid
• MRI, U/sound
• Water soluble contrast enema
• Distinguish acute diverticulitis from perforated cancer
• Risk of increasing the colonic pressure, extravasation of feces
through the perforated diverticulitis

38. Primary bowel resection
• surgeon removes the diseased part of intestine and then reconnects the
healthy segments of your colon (anastomosis).
• Allows to have normal bowel movements. Depending on the amount of
inflammation, you may have open (traditional) surgery or laparoscopic
surgery.

39. PEPTIC ULCER DISEASE

40. • H. pylori,
• Alcohol,
• Smoking,
• Cirrhosis,
• Stress
• Usually 50 and over
• Male higher risk
• Gastritis,
• Use of NSAIDs
RISK FACTORS

41. • Acute
• Chronic
Types

42. • Is associated with superficial erosion and minimal inflammation it is of short
duration and resolves quickly when the cause is identified and removed
Acute

43. • Chronic ulcer is one of long duration eroding through the muscular wall with
the formation of fibrous tissue it may be present continuously for many
months or intermittently throughout the person’s life time
Chronic

44. ETIOLOGY
• stress and anxiety
• gram-negative bacteria H. pylori
• Stress
• Excessesive secretion of HCL
• Familial tendency
• Use of NSAID
• Alcohol
• Excessive smoking
• Hyperacidity
• Gastrin secreting malignant tumers
• Esophagial ulcers
• GERD

45. • inflammation caused by H.pylori infection
• Peptic ulcer occurs mainly in the gastro duodenal mucosa because this tissue
cannot withstand the digestive action of gastric acid HCl and pepsin.
• Vagus nerve stimulates the parietal cells to secrete gastric acid.The erosion is
caused by the increased concentration or activity of pepsin, or by decreased
resistance of the mucosa.
• A damaged mucosa cannot secrete enough mucus to act as a barrier against HCl.
The use of NSAIDs inhibits the secretion of mucus that protects the mucosa.
PATHOPHYSIOLOGY

47. CLINICAL MANIFESTATIONS
• dull, gnawing pain or a burning
• Pain is usually relieved by eating
• Tenderness
• pyrosis (heartburn),
• vomiting, constipation or diarrhea, and
bleeding
• burping
• vomiting
• bleeding
• tarry stools

48. ASSESSMENT AND DIAGNOSTIC FINDINGS
• pain,
• epigastric tenderness,
• or abdominal distention.
• A barium study
• Stools study
• . Gastric secretory studies
• H. pylori infection
• breath test that detects H. pylori

49. • Antibiotics
• Eradicate H. pylori
• Rest
MEDICAL MANAGEMENT

50. • proton pump inhibitors
• antibiotics
• bismuth salts
• histamine 2 antagonist
PHARMACOLOGICTHERAPY

51. • stressful or exhausting.
• A rushed lifestyle
• irregular schedule
STRESS REDUCTION AND REST

52. • smoking decreases the secretion of bicarbonate from the pancreas into the
duodenum resulting in increased acidity of the duodenum.
SMOKING CESSATION

53. • avoiding extremes of temperature
• overstimulation from consumption of meat extracts
• alcohol,
• coffee (including decaffeinated coffee,
• Milk
• cream
DIETARY MODIFICATION

54. • Principles of surgery
• Reduce acid secreting ability
• Remove malignant or potentially malignant lesions treat surgical
emergency
• Treat clients do not respond to medical intervention
SURGICAL MANAGEMENT

55. • Vagotomy is performed to eliminate the acid secreting stimulus to gastric cells
• Truncal
• Completely cutting each vagus nerve
• Selective
• The surgeon partially severs the nerves to preserve the hepatic and celiac branches
• Proximal
• Only paritel cell mass is denerveted
VAGOTOMY

56. Truncal

57. VAGOTOMY WITH PYLOROPLASTY

58. • Permits regurgitation of alkaline deodenal contents thereby neutralizing
gastric acid in this procedure a drain is made on the bottom of the stomach
and sewn to an opening made in the jejunum
GASTROENTEROSTOMY

59. • The surgeon removes a part of distal portion of the stomach including the
andrum the remainder of the stomach is anastomosed to duodenum this
combined procedure called gastrodeodenostomy this decreases dumping
syndrome
BILROTH 1

60. BILROTH 1

61. • This involves reanastomosis of the proximal remnant of the stomach to the
proximal jejunum pancreatic secretions and bile continue to secrete in
jejunum even after surgery surgeons prefer Billroth 2 technique for
treatment of duodenal ulcers because recurrent ulcer develops less frequent
in this procedure
BILROTH II

62. BILROTH II