Acute peritonitis and peritonitis symptoms

A SERIOUS CONDITION IN WHICH THE INSIDE WALL OF THE BODY BECOMES SWOLLEN AND INFECTED 

ACUTE PERITONITIS 

Peritonitis is an inflammatory or suppurative response of the peritoneal lining to direct irritation.It haw be decentralised or unspecialised bacterial or chemical.Localized peritonitis is due to transmural inflammation of aviscus ,e.g. accent appendicitis ,acute cholecystitis .acute diverticulitis .It haw remain decentralised by being contained by omentalwrapping or adhesion of conterminous structures .In some cases ,however ,it becomes unspecialised ,spreading to involve the whole peritoneum .Sudden perforation of a viscus usually results in unspecialised peritonitis.

In this case , the patient is usually seriosly ill .Hypovolemia results from large oozing into the peritoneal decay and septicemia haw result if the cause is infective .eg faecal peritonitis due to perforated diverticulitis.Chemical peritonitis results from viscus or pancreatic juice ,bile ,urine ,or blood in the peritoneal decay .Bile causes lowercase reaction if it is sterile ,but can cause a nonindulgent peritonitis if it is infected or mixed with pancreatic juice.Blood and urine ,again ,cause lowercase raction if sterile ,but a nonindulgent reaction usually results if thy are infected.

CAUSES OF PERITONITIS 

It haw be ACUTE OR CHRONIC

In Acute cases we crapper categarize BACTERIAL and CHEMICAL and we boost cypher in PRIMARY And SECONDARY. 

Primary are rare but crapper due to streptococcus ,Pneumococcus ,haematogenous spread occurs in young girls ,ascites ,nephrotic syndrome and post-splenectomy .

Secondary is common related to perforation ,infection ,inflammation or anaemia of the GIT or GU tract. In chemical culprits are  Gastric juice e.g cut gastric ulcer.
Pancreatic juice e.g accent pancreatitis .
Bile e.g cut gall bladder.
Blood e.g damaged spleen.
Urine e.g intraperitoneal break of the bladder.

In CHRONIC cases allow Tuberculosis and Starch ( medicine activity )

CLINICAL FEATURES

Most patients with rubor module hit abdominal pain and a fever. Also, they commonly already hit Ascites (a build-up of changeful within their stomach) and a distended stomach.  Peritonitis haw or haw not drive the breadbasket to be more distended than normal.

Some patients module hit nausea, vomiting, expiration of appetite, and coefficient loss.  Which of these symptoms are inform depends on the drive of the problem. Many patients with Ascites also hit liver problems.  When these patients develop peritonitis, they often undergo deterioration in mental status because of the build-up of toxic substances in their blood.

Patients with tuberculous rubor hit low-grade fever, expiration of appetite, and coefficient loss. Often, their Ascites module develop slowly.

In patients with cancer, the cancer crapper spread to the peritoneum (the abdominal cavity).  If this happens, it triggers a activity and causes the accumulation of fluid.  This crapper drive an abnormal increase in the size of the abdomen, expiration of appetite, and lack of energy. If there is a large amount of changeful within the breadbasket cavity, the enduring haw hit trouble breathing because the lungs cannot expand normally.  Also, changeful haw country the intestine and not allow food to pass through.Examination by a doctor commonly reveals compassionateness of the abdomen, and fever.

DIAGNOSTIC INVESTIGATIONS 

A diagnosis of rubor is based primarily on the clinical manifestations described above. If rubor is strongly suspected, then surgery is performed without further retard for another investigations. Leukocytosis, hypokalemia, hypernatremia and acidosis haw be present, but they are not specific findings. Abdominal X-rays haw expose dilated, edematous intestines, though such X-rays are mainly multipurpose to countenance for pneumoperitoneum, an indicator of gastrointestinal perforation. The role of whole-abdomen ultrasound examination is under think and is likely to expand in the future. Computed tomography (CT or CAT scanning) haw be multipurpose in differentiating causes of abdominal pain. If reasonable uncertainty ease persists, an exploratory peritoneal lavage or laparoscopy haw be performed. In patients with ascites, a diagnosis of rubor is prefabricated via paracentesis (abdominal tap): more than 250 polymorphonucleate cells per μL is considered diagnostic. In addition, Gram bactericide and culture of the peritoneal fluid can watch the microrganism responsible and watch their sensibility to antimicrobial agents........ read more

Here's another head scratcher Acute appendicitis

ACUTE APPENDICITIS

 

Scientist theorize that appendix is a remnant of an ancient digestive tract .They believe that it might have been used by early man to digest tough leaves and bark.But it can create lot of trouble by causing Acute appendicitis.

The appendix is a worm like extension of the cecum and for this reason,has been called the Vermiform appendix.The average length of the appendix is 8-10 cm ( ranging from 2-20 cm ).The appendix appears during the fifth month of gestation and  several lymphoid follicles are scattered in its mucosa.Such follicle increase in number when individuals are aged 8-20 years.

 

LOCATION

1.Base of appendix:

       it is found attached to posteromedial surface of cecum about 2.5 cm below the ileicecal junction.

2.Body and tip of appendix:

   a. Retrocecal  (74 %)

   b. Pelvic  (21 %)

   c. Paracecal (2 % )

   d .Subcecal  ( 1.5 % )

   e. Periileal  (1 %)

   f. Postileal (0.5 % )

Vermiform appendix has a complete peritoneal covering, which is attached to lower layer of mesentry of small intestine to form a short mesentry of its own.the mesoappendix,but there is some variations.distal 1/3 of its may be bereft of mesoappendix.

 

ETIOLOGY

 

SEX: Males are more commen than female.

SOCIAL STATUS: Upper and middle class

DIET: One relatively rich in meat,& devoid of simple diet rich in cellulose

Familial susceptibility.

OBSTRUCTION OF LUMEN OF APPENDIX:Fecoliyh ,a stricture,a foriegn body,a rond worm.or thread worms.

DISTAL OBSTRUCTION OF COLON: Carcinoma of right colon.

Abuse of purgatives.

BACTERIA: a mixture of E coli,enterococci,non hemolytic streptococci,anaerobic streptococci,Cl welchi,& bacteroids.

 

PATHOLOGY

 

NON OBSTRUCTIVE ACUTE APPENDICITIS

Inflammation usually begins in mucosa,& less often in ymph follicles,but on reaching the loose submucosa it progresses rapidly.Organ becomes turgid and dusky red with mucosal hemmorrhages.Vascular supply of distal part of appendix is at risk.because here is the artery is inframural & liable to occlusion by in inflammation or thrombosis,this may lead to gangrene of  tip.

Inflammation may progress sufficiently slowly for protective barriers to form ,& the resulting peritonitis is localized .It can terminate in one of the following ways:

Resoluton

Ulceration

Suppuration

Fibrosis

Gangrene

 

OBSTRUCTIVE ACUTE APPENDICITIS

Products of inflammation becomes pent up,so that it proceeds more rapidly & more certainly to gangrene or perforation.Often within 12-18 hrs,appendix distal to obstruction become gangrenous.Perforation occurs most often at the site of an impacted fecolith before protective adhesions have had time to form-Escaping purulent & gaseous contents are under high pressure ,& early widespread peritonitis is liable to ensue -Subphrenic & pelvic abcesses are a later sequel if patient survives the initial peritonitis.

 

CLINICAL FEATURES

 

Age incidence : Increasingly common during childhood & adolescence ,maximum incidence is between 20 & 30 years.

 

NON-OBSTRUCTIVE ACUTE APPENDICITIS 

SYMPTOMS

Abdominal pain which shift : Initially there is constant, vague pain around umblicus,in epigastrium,or it may be generalized.After a few hours pain become intense .& shift to the point where inflammed appendix irritates partial peritoneum ( usually in right iliac fossa ).

Gastric function Upset : Anorexia, nausea, infrequent vomiting & stops as soon as stomach is empty.Usually constipation is present ,but occasionally diarrhea occur.

SIGNS

GENERAL SIGNS :  Pyrexia ( 99 - 100 F )

                          Tachycardia  ( 80 - 90 per min ) 

                          Tongue  ( white & furred )

                          A special fetor oris

LOCAL SIGNS

Localized tenderness after the pain shifts, either at McBurney's point or elsewhere ( determined by the site of appendix ).

Muscle guarding & rigidity in right iliac fossa .

Rebound tenderness at McBurney's point in right iliac fossa.

Pressure on left iliac fossa may cause pain in right iliac fossa.

Release of pressure on left iliac fossa may cause pain in right iliac fossa.

Last three manoeuvres cause pain because they move the inflamed appendix.

 

OBSTRUCTIVE ACUTE APPENDICITIS

Sequence of clinical events occurs much more quickly:

Onset is abrupt .& there may be severe generalized abdominal colic from start.However ,the pain shifts in the usuall way.

Vomiting is common

Temperature can be normal

Local signs are as mentioned above.

 

INVESTIGATIONS

 

Appendicitis is essentially a clinical diagnosis.

The following may be useful.

• Urine analysis may exclude urinary tract infection.
• Pregnancy test to exclude ectopic pregnancy.
• Abdominal x-ray is of little value.
• A normal white cell count does not exclude appendicitis.
• Ultrasound may be helpful in the assesment of an appendix mass or abcess.
• Ultrasound adds little to the clinical diagnosis of acute appendicitis.
• Scoring system and computer-aided diagnosis may be helpful.
• Meta analysis suggest the following  to be useful predictor of appendicitis in patients with abdominal pain. 

              Raised inflammatory markers '

              Clinical signs of peritoneal irritation.

              Migration of abdominal pain.

Treatment for acute appendicitis

THE APPENDIX DOES NOT APPEAR TO HAVE ANY FUNCTION IN THE HUMAN BODY ...SO HOW CAN WE PANIC THROUGH NON FUNCTION ORGAN ???

TREATMENT

INDICATION FOR SURGICAL CONSULTATION AND SURGERY
A surgeon should evaluate any patient with classic migrating abdominal  tenderness. Because only a little more than half of patients with appendicitis present with a classic history and physical findings, acute appendicitis should be on the list of possible diagnoses for any patient with abdominal pain. Thus, a surgeon should also evaluate patients with focal RLQ tenderness or progressively worsening abdominal pain.
To minimize the time between show and appendectomy, obtain surgical conference prior to performing additional diagnostic studies, such as CT scan, ultrasound, and technetium (Tc)-labeled WBC scan.3

Indications for operation
Any patient with suspected appendicitis who has
(1) persistent discompose and becomes febrile,
(2) an increasing WBC count, or
(3) worsening clinical examination findings should undergo extirpation or at least diagnostic laparoscopy. In patients with an atypical presentation, the most important determination for extirpation is serial physical examinations. The WBC count often does not process after the patient is admitted and hydrated; therefore, any patient sent home from the emergency department should undergo a follow-up evaluation the incoming day.3

APPENDICECTOMY
Open by giving INCISION

• Grid-iron incision.
• Paramedian incision.
• Rutherford Morison's incision.

REMOVAL OF APPENDIX
A retractor is placed under the medial side of peritoneum & abdominal wall is lifted up.Any pus or serous exudate is removed with a sucker & a pack is inserted into wound on medial side.Using a a swab,cecum is withdrawn.A finger may be inserted into wound to aid delivery of appendix.Cecum is grasped by an assistant. Atissue -holding forceps is applied around the appendix in such a way as to encircle the organ & yet not damage it .Base of mesoappendix is clamped in a hemostat,tied & severed.when mesoappendix is broad,procedure must be repeated with a 2nd or a 3rd hemostat.Appendix ,now completely freed,is crushed near its junction with cecum in a hemostat,which is removed & reapplied just distal to crushed portion.A catgut ligature is tied around crushed portion close to cecum,& an atraumatic catgut purse-string suture is inserted into cecum about 1.25 cm frombase  & is left  untied until appendix has been amputated with a scalpal below hemostat.Stump is invaginated while purse -string suture is tied,thus burying the appendix stump.

PERITONEAL LAVAGE
Peritoneum is washed out with antibiotic laden irrigating fluids.

ANTIBIOTICS
Prophylactic antibiotics active against aerobic & an aerobics organism are given in 2 doses ( one at the time of surgery & next 8-12 hours later )

DRAINAGE OF PERITONEAL CAVITY
Unnecessary, provided adequate peritoneal lavage has been done.However ,performed if there is considerable purulent fluid in retrocecal space or pelvis, or if there is persistent oozing.

DRAINAGE OF PARIETES
Indicated if there is any soiling of wound ,especially in obese & in children.


COMPLICATIONS OF APPENDICECTOMY

EARLY

• ILeus
• Wound sepsis
• Residual abscess
• Intestinal obstruction from adhesins
• Fecal fistula
• Pyelophlebitis
• Postoperative thrombosis & embolism
• Actinomycosis
• Pulmonary complications (pulmonary collapse or pneumonia )

LATE

• Intestinal obstruction from adhesions
• Incisional hernia
• Right inguinal hernia following grid iron incision
• Sterility in female from frozen pelvis.

Acute pancreatitis

ACUTE PACREATITIS 

Its an acute inflammatory process caused by the effects of enzymes released from the pancreatic acini . There are numerous aetiological factors .

The pancreas is a super gland behind the breadbasket and close to the duodenum—the first part of the diminutive intestine. The pancreas secretes digestive juices, or enzymes, into the duodenum through a tube titled the pancreatic duct. Pancreatic enzymes join with bile—a liquefied produced in the liver and stored in the gallbladder—to digest food. The pancreas also releases the hormones insulin and glucagon into the bloodstream. These hormones help the body regulate the glucose it takes from food for energy.

PATHOGENESIS of acute pancreatitis is obscureb,but two main mechanism may be involved 

1.DUCT OBSTRUCTION __ this may lead to reflux of bile into the pancreatic ducts causing injury .Alternatively increased intraductal pressure may damage the pancreatic acini ,leading to leakage of pancreatic enzymes which may further damage the pancrease .

2.DIRECT ACINAR DAMAGE __ this may be caused by viruses ,bateria ,drugs or trauma .

The appearance of the pancrease in acute pancreatitis may be explained by release of pancreatic enzymes. Protease release causes widespread destruction of the pancrease and increases further enzyme release ,with consequent further damage.Release of lipase causing fat necrosis resulting in characteristic yellowish-white flecks on the pancrease ,mesentry and omentum .Often with calcium deposition.Other enzymes ,e.g. elastase ,destroy blood vessels ,leading to haemmorrhage within the pancrease and haemmorrhagic exudate into the peritoneum .Haemmorrhage may be extensive ,leading to acute haemmorrhagic pancreatitis.

BIOCHEMICAL CHANGES increased serum amylase. Amylase is released from the damaged acini and enters the blood stream .The serum amylase is released in the acute phase ( 24 - 48  h) but later falls to normal .Occasionally with acute haemmorrhagic pancreatitis the destruction of pancreatic acini is so swift and complete that the serum amylase may not be raised by th time the patient reaches hospital. Hypocalcaemia ,this arises become of deposition of calcium in areas of fat necrosis .Hyperglycemia ,this occurs because of associated damage to the pancreatic islets .Abnomal liver function tests may occur , especially raised bilirubin and alkaline phosphatase due to mild obstruction of the bile ducts by oedema .

Sudden, unceasing discompose in the upper part of the abdomen is a hallmark of acute pancreatitis, though other medical conditions crapper also cause this type of pain. The discompose may wrap around your upper body and involve the back in a band-like pattern. The discompose typically lasts days and is ofttimes relieved by leaning forward. Some grouping hit only slight abdominal tenderness and in 5 to 10 percent of people, there is no discompose at all.

In grouping with gallstone pancreatitis, gallbladder discompose may become before pancreatic pain. Gallbladder discompose (referred to as biliary colic) occurs in the right upper abdomen, extending to the back and right shoulder. The discompose gradually increases in intensity, is constant, and may be attended by sickness and vomiting. Gallbladder discompose ofttimes follows a meal.

In grouping with alcoholic pancreatitis, the symptoms of acute pancreatitis ofttimes become digit to three days after an alcohol binge or after stopping drinking. Pain is attended by sickness and regurgitation in most people. In severe cases, the initial symptom may be shock or coma. 

Other conditions that have been linked to pancreatitis are:

Damage to the ducts or pancreas during surgery
High murder levels of a fat titled triglycerides (hypertriglyceridemia)
Injury to the pancreas from an accident
Blockage of the pancreatic duct or common bile duct, the tubes that pipage enzymes from the pancreas 

Diagnosing accent pancreatitis is often difficult because of the deep location of the pancreas. The student will likely visit one or more of the mass tests:

•Abdominal ultrasound. Sound waves are dispatched toward the pancreas finished a handheld device that a technician glides over the abdomen. The good waves bounce soured the pancreas, gallbladder, liver, and other organs, and their echoes make electrical impulses that create a picture—called a sonogram—on a recording monitor. If gallstones are causing inflammation, the good waves will also bounce soured them, showing their location.

•Computerized picturing (CT) scan. The CT construe is a noninvasive x ray that produces three-dimensional pictures of parts of the body. The person lies on a table that slides into a donut-shaped machine. The effort may exhibit gallstones and the extent of alteration to the pancreas.

•Endoscopic ultrasound (EUS). After spraying a solution to numb the patient’s throat, the student inserts an endoscope—a thin, flexible, aflame tube—down the throat, finished the stomach, and into the small intestine. The student turns on an ultrasound adhesion to the scope that produces good waves to create seeable images of the pancreas and bile ducts.

•Magnetic kinship cholangiopancreatography (MRCP). MRCP uses attractable kinship imaging, a noninvasive effort that produces cross-section images of parts of the body. After being lightly sedated, the patient lies in a cylinder-like plaything for the test. The technician injects dye into the patient’s veins that helps exhibit the pancreas, gallbladder, and pancreatic and bile ducts.

 

Treatment of pancreatitis

Treating pancreatitis

IT OCCURS SUDDENLY AND SUBSIDE IN FEW DAYS IF TREATS PROPERLY.

EACH YEAR ABOUT 210,000  PEOPLE IN THE US ARE ADMITTED TO THE HOSPITAL WITH ACUTE PANCREATITIS.

TREATMENT

The goals of communication of accent pancreatitis are to alleviate pancreatic inflammation and to correct the inexplicit cause. Treatment commonly requires hospitalisation for at small a few days."Treatment of accent pancreatitis"

BED REST
SUPPORTIVE INTRAVENOUS THERAPY  restore adequate blood volume as soon as possible e.g by physiological saline .A careful fluid balance chart should be kept ,with appropiate allowance made for insensible loss .Daily serum electrolyte estimations are made ,together with acid-base studies.Full water replacement is given by intravenous route .Calories are given as glucose .Na ,K ,and Cl are given in appropriate amounts .ca deficiency, if develops , is treated by Ca gluconate IV

NASOGASTRIC ASPIRATION   continuous suction removes gastric HCl from entering duodenum,that suppressing hormonal stimulation of exocrine secretions of pancrease .It also brings relief from persistent nausea and vomiting.

PAIN RELIEF  
Originally it was thought that analgesia should not be provided by morphine because it haw drive symptom of the musculus of Oddi and exacerbate the pain, so the drug of choice was meperidine. However, due to lack of effectualness and risk of toxicity of meperidine, more recent studies hit institute morphine the analgesic of choice. Meperidine haw ease be utilised by some practitioners in more secondary cases, or where morphine is contraindicated.

PROPHYLACTIC ANTIBIOTICS  given as a prophylactic against infection of necrotic retroperitoneal tissue ,and also against bronchopneumonia .A  broad spectrum antibiotic ,e.g. cefoperazone should  be given for 3-5 days.

EDOSCOPIC SPHINCTEROTOMY gallstone pancreatitis will be improved ,if a stone is obstructing the ampulla of vater .

Surgical options for pussy necrosis include:

• Minimally intrusive management - necrosectomy through small incision in wound (left flank) or breadbasket
• Conventional management - necrosectomy with ultimate drainage
• Closed management - necrosectomy with closed continuous postoperative lavage
• Open management - necrosectomy with planned staged reoperations at definite intervals (up to 20+ reoperations in some cases)

COMPLICATIONS include : Pancreatic Pseudocyst __  this is a localized collection of fluid in the lesser sac of peritoneum. Pancreatic Abscess , Stress induced gastric erosion with haemate mesis or melena .Acute renal failure  ,Toxic psychosis ,Multiple organ failure ,chronic pancreatitis .

PROGNOSIS  the overall mortality is between 10 % and 20 % .With severe haemmorrhagic pancreatitis the mortality rate reaches 50 % .The usual cause of mortality is multiple organ failure .

Acute pancreatitis
Sign and symptoms
Causes
Patophysiology
Diagnosis