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.

Intestinal tuberculosis is significantly increasing in developed countries with HIV

INTESTINAL TUBERCULOSIS Is a Major Health Problem in Many Underdeveloped Countries

                                           

                                                       BUT

 

A Recent Significantly Increase In Developed Countries In Association With HIV Infection

 

 

TUBERCULOSIS OF INTESTINE

Some bacterial infections are surgically  important include INTESTINAL TUBERCULOSIS usually seen in the uk as ileocecal tuberculosis and present with thickening and narrowing of the terminal ileum.It may be indistinguishable from crohn's disease on naked eye examinaton.although pale tubercle may be seen on the serosa in tuberculosis.Complications include adhesive obstruction ,perforation and malabsorption due to widespread mucosal involvement or lymphatic blockage.

 

 INTESTINAL TUBERCULOSIS is a field health problem in some underdeveloped countries. A recent momentous increase has occurred in matured countries, especially in connexion with HIV infection. Autopsies of patients with pulmonary TB before the epoch of effective treatment demonstrated viscus involvement in 55-90% of mortal cases. The previously noted regular connexion between pulmonary TB and viscus TB no longer prevails, and only a minority of patients (<50%) with abdominal TB now hit deviant dresser radiographic findings. However, approximately 20-25% of patients with GI TB hit pulmonary TB. Any conception of the GI system haw be infected, although the ileum and colon are common sites.

Pathologically GI TB is characterized by inflammation and fibrosis of the bowel surround and the regional lymph nodes. Mucosal ulceration results from necrosis of Peyer patches, lymph follicles, and vascular thrombosis. At this initiate of the disease, the changes are reversible and healing without scarring is possible. As the disease progresses, the ulceration becomes confluent, and comprehensive fibrosis leads to bowel surround thickening, fibrosis, and pseudotumoral mass lesions. Strictures and fistulae formation may occur.

 

We can categarize Intesinal Tuberculosis into Three TYPES on gross pathologic examination

ULCERATIVE modify of TB is seen in approximately 60% of patients. Multiple ostensible ulcers are largely confined to the epithelial surface. This is considered a highly active modify of the disease, with the daylong axis of the ulcers rectangular to the daylong axis of the bowel.

HYPERTROPHIC modify is seen in approximately 10% of patients and consists of thickening of the bowel wall with scarring; fibrosis; and a rigid, masslike appearance that mimics that of a carcinoma.

ULCEROHYPERTROPHIC modify is a subtype seen in 30% of patients. These patients hit a compounding of features of the ulcerative and hypertrophic forms.

 Clinical features  of viscus TB include abdominal pain, weight loss, anemia, and feverishness with night sweats. Patients may present with symptoms of obstruction, correct iliac fossa pain, or a palpable mass in the correct iliac fossa. Hemorrhage and perforation are constituted complications
 of viscus TB, although free perforation is less frequent than in doc disease.  The diagnosis of purging tuberculosis requires a broad index of suspicion. In cases where the information available does not reveal a definite differentiation between colonic tuberculosis and Crohn's disease.

 Intestinal tuberculosis is a thin disease in western countries, affecting mainly immigrants and immunocompromised patients. Intestinal tuberculosis is a diagnostic challenge, especially when active pulmonary infection is absent. It may mimic many other abdominal diseases.

The most common place of GI TB is the ileocecal region, if the area can be reached with a flexible endoscope. A rapid diagnosis can be achieved if smudge or culture results are positive or if caseating granulomas are seen in biopsy samples. In countries where GI TB is endemic, a therapeutic trial of antituberculosis treatment haw be justified if the clinical picture is compatible with TB.

 TREARMENT OF INTESTINAL TUBERCULOSIS

 

A course of chemotherapy

Surgery is required in cases of complicated obstruction in HYPERPLASTIC TUBERCULOSIS - Right hemicolectomy with removal of diseased segment of ileum or defunctioning ileocolostomy .

Surgery is required  in cases of Stricture causing intestinal obstruction or in perforation in ULCERATIVE TUBERCULOSIS

Test for appendicitis -Pinch-an-inch test

PINCH-AN-INCH TEST FOR APPENDICITIS

Its a prospective comparative assesment of two physical exam technique for evaluating patients with doubtable appendicitis.Rebound tenderness is a widely acclimated assay address for patients with doubtable appendicitis.but it can be absolutely uncomfortable.an another analysis for peritonitis is termed THE PINCH-AN-INCH TEST.

This address call two patients who presented with balmy belly affliction who subsequently were begin to accept appendicitis.In both patients classic peritoneal signs were absent but the compression an inch analysis was positive.the accomplished physicians bedside analytic assay remains the most critical component for rapidly anecdotic peritonitis.Although rebound tenderness is a broadly acclimated examination.It is afflictive and may be inaccurate.

To perform the pinch-an-inch test,a bend of belly derma over McBurney's point is grasped and animated abroad from the peritoneum.The derma is recoil back briskly against the peritoneum.If the patient has added affliction if the derma bend strikes the peritoneum, the analysis is absolute and peritonitis apparently is present.

As an added feature,if the affliction seems boundless just during the antecedent compression phase,the patient may accept a actual low affliction threshold,a factor that can be taken into account when deciding if the patient has a surgical abdomen.We anecdotally accept begin the analysis to be appreciably accessible for the appraisal of appendicitis.

Delayed analysis of acute appendicitis can advance to cogent morbidity.However recent technological advances in radiological imaging, the alert analysis of acute appendicitis can be difficult.Indeed,some experts accept that overreliance on imaging at the amount of the bedside assay may in fact access appendicitis accompanying morbitity.Arguably,both of these patients ability accept been bigger served by undergoing surgery directly without the delay of of CT imaging.Therefore analysis efforts should be directed against developing and acceptance bigger bedside assesment of peritonitis.

One important admonition to clinicians is the actuality that patients with appendicitis may in fact accept hyperesthesia over McBurney's point,and an boundless affliction acknowledgment to he compression appearance should not be absolved out of the hand.

The technique potencially allows for a added objective and reproducible physical assay than rebound tenderness which requires the examiners abjure his easily rapidly abundant to break advanced of the accustomed natural recoil of the belly wall.Rebound tenderness as well requires that the physicians does not added abase his easily in a form of backswing.Pinch an inch in contrasr allows for a added accelerated and reproducible absolution of tension.

In an accomplishment to advance patient's abundance during the belly assay we developed an alternating address for detecting peritonitis.we appellation this pinch-an-inch,we accept that compression an inch after-effects in less affliction than rebound tenderness.while not compromising effectiveness.

We achievement that our pinch-an-inch assay address may eventually action a added adequate and authentic another to classic rebound tenderness.Toward this effort,we will conduct a -to-be abstraction to appraise its accurateness and about abundance in diagnosing appendicitis.
several studies have shown it to be quite accurate in the evaluation of the appendicitis so its use should not be stoped.

Intestinal pain - Acute intussusception if you avoid can lead to death

What Could Happen If You Avoid The TREATMENT ?

IT Will Get So Extreme.........Lead To DEATH

ACUTE INTUSSUSCEPTION :

INTUSSUSCEPTION is an invagination of size of intestine ( intussuscepiens ) into the immediate portion of bowl ( intussusceptum ) and  most of cases occur in children during the first 5 decades of life. This can often result in an obstructio .The part that prolapse into the other is called the INTUSSUSCEPTUM and the part that recieves it is called INTUSSUSCEPIENS.

In some of children with intussuscetion , an anatomic predisposing condition . Such as Meckle's diverticulum , Burkitt lymphoma, or hamartomatous polyps ,can be found .And in most of the cases are associated with hyperplastic lymphoid tissue.suggesting an infectious causes ,which is not confirmed in most of the cases.By using serology and virus isolation from fecal and pharyngeal swabs.Adeno virus , Rotavirus ,Enterovirus , Human herpes virus  ,Cytomegalovirus and Epstien-barr-virus.some bacterial agents can also involved in this condition include Yersinia ,enterocolitis and salmonella typhimurium and candida albican .

TYPES

Ileocolic  ( 77 % ) 

Ileoileocolic ( 12 % ) 

Ileoileal (5 % ) 

Colocolic ( 2 % ) 

Multiple (! % ) 

Retrograde ( 0.2 % )

Others  ( 2.8 % ) .

CLINICAL FEATURES :

SYMPTOMS

• Sudden paroxymsm of abdominal pain ,with drawing up of legs and screaming  :each attack lasts a few minutes and recur about every 15 minutes.
• Facial pallor 
• Vomiting
• Listleness and somewhat drawn between the attacks .
• Stool : intially normal later  blood and mucus are evacuated called  "red currant jelly stool " 
• when not relieved upto 24-36 hours

        a . Pain becomes contineous

          b. Abdomen distends

          c. Vomiting becomes copious

          d. Absolute intestinal obstruction follows

SIGNS

• A lump is felt ,which may harden on palpation .
• PR examination : if intussuscetion has travelled far enough ,its apex ( a conical ) mass will be felt .
• When not relieved ,upto 24 - 36 hours  

         a . Dehydration

         b . Abdominal distension

         c . Abdominal guarding , tenderness and rebound tenderness if gangrene has occured.

DIAGNOSTIC INVESTIGATIONS :

INTUSSUSCEPTION is often suspected based on history and physical examination , including observation of Dance's sign .Per rectal examination is particularly helpful in children as part of thintussusceptum may be felt by the finger .A definite  diagnosis often requires confirmation by diagnostis imaging modalities .

ULTRASOUND is today considered the imaging advanced technology of choice for diagnosis and exclusion of intussusception due to its high accuracy and lack of radiation.A target like mass ,usually around 3 cm in diameter confirm the diagnosis.

PLAIN ABDOMINAL X-RAY
Revealed increased gas shadow in small intestine and at times absence of cecal gas shadow .

X-RAY WITH BARIUM ENEMA :
Reveal characteristic " claw sign " in ileocolic intussusception .

TREATMENT :

The condition is not usually immediately life threatning.The intussusception can be treated with either a barium or water soluble contrast enema or an air contrast enema .which both confirms the diagnosis of intussusception, and inmost cases successfully reduce it . The success rate is over 80% .Therefore approximately 5 - 10 % of these recur within 24 hours .If it cannot be reduced by an enema or if the intestine is damaged , then surgical reduction is necessary.

PRELIMINARY TREATMENT 


Gastric aspiration should be carried out and contiued during and after operation.
Give IV dextrose - saline solution.

REDUCTION OF INTUSSUSCEPTION
REDUCTION BY HYDROSTATIC PRESSURE


OPERATIVE REDUCTION :


Abdomen is opened through a right lower paramedian incision .First part of reduction is accomplished by squeezing lower part of sausag like mass ,and little intussusception is reduced.Last part is most difficult to reduce and should br withdrawn and gently compressed in a warm saline soaked pack,to

lessen the edema.
After reduction if a specific cause is revealed appropriate treatment is carried out ,eg Meckle's diverticulum.

PROGNOSIS :

The outlook for intussusception is excellent .when treated immediately .but when untreated it can lead to death within 2-5 days .Quick treatment can avoid this surgery .Prolonged intussusception can lead to ischemia and necrosis and it requires surgical resection.

AFTER TREATMENT


Gastric aspiration should be continued for 12-24 hours
Dextrose-saline is given IV or SC with hyaluronidase.
On 2nd day ,gastric tube is removed and sips of water are given.
Few hours later ,feeding is commenced with mother's milk ( if infant is still being breast-fed ).

COMPLICATIONS:

Intestinal obstruction
Gangrene

Biliary stricture

IT CAN OCCUR AS A RESULT OF A TECHNICAL MISHAP......

DURING CHOLECYSTECTOMY IF IGNORED CAN DRIVE  LIFE- THREATENING COMPLICATIONS

STRICTURE OF BILE DUCT 
  

A bile duct stricture is caused by narrowing of the bile duct. The narrowing bile duct prevents the bile from draining into the intestine. The bile then backs up in the liver and spills over into the blood feat obstructive jaundice  ,it crapper cause through Surgical trauma ( postoperative ) ,Stones ,Primary sclerosing cholangitis ,Carcinoma of bile funiculus Carcinoma of head of pancreas.

Bile duct pathology (biliary stricture) is an uncommon but hard clinical condition that requires a integrated multidisciplinary approach involving gastroenterologists, radiologists, and surgical specialists. Unfortunately, most benign bile duct strictures (biliary strictures) are iatrogenic, resulting from operative trauma , Bile duct strictures (biliary strictures) may be well but, if ignored, can drive life-threatening complications, such as ascending cholangitis,  liver abscess, and secondary biliary cirrhosis

POSTOPERATIVE STRICTURE it is the result of a preventable non achievement in technique , during the performance of cholecystectomy ;Blind plunge application of a hemostat to a bleeding cystic or accessory cystic artery ,or to right hepatic artery.Should cholecystectomy be performed by dissecting from fundus ,too such traction applied to freed gall sac may so tent the bile funiculus that some forceps witting for cystic funiculus apprehension angulated main channel .Failure to identify anatomy in Calot's polygon when there is such inflammation .Common hepatic funiculus is tied instead of cystic duct.Ignorance of anatomical anomalies o bile ducts.Laceration of bile patch explration for stones.Injury to bile funiculus during partial gastrectomy.

CLINICAL PRESENTATION OF POSTOPERATIVE STRICTURE

Bile funiculus injuries may be rcognized at the instance of surgery .

Postoperatively by profuse and persistent discharge of bile if evacuation has been provided.Bile peritonitis if evacuation

has not been provided.Deepening obstructive jaundice.

In the absence of symptoms of the primary disease, most patients with bile funiculus strictures (biliary strictures) rest asymptomatic until the lumen of the bile funiculus is sufficiently narrowed to drive position to the flow of bile. Occasionally, patients may hit intermittent episodes of right upper line pain (biliary colic), with or without laboratory features of biliary obstruction. Patients most often inform with features of obstructive jaundice. On occasion, a patient may inform dramatically with sepsis and hypotension due to ascending cholangitis.

Cholangitis occurs in the proximity of partial or complete obstruction of the common bile funiculus , with accumulated intraluminal pressures, bacterial infection of the bile with procreation of the organisms within the duct, and seeding of the bloodstream with bacteria or endotoxin. Cholangitis can apace embellish a life-threatening condition. Clinical show varies, with the Charcot set of fever and chills, jaundice, and right upper line abdominal pain occurring in most patients. A smaller proportion of those with cholangitis may also hit altered mental position and hypotension (ie, Reynold pentad). In the epilepsy of previous instrumentation, cholangitis is uncommon with malignant strictures.

Tests that shows stricture in the bile duct: ERCP (endoscopic retrograde cholangiopancreatography) , PTC (percutaneous transhepatic cholangiogram)  ,MRCP (magnetic kinship cholangiopancreatography)

Blood tests that indicate deviant function of biliary system:

Bilirubin level is higher than normal
ALP (alkaline phosphatase) is higher than normal

TREATMENT 

PREOPERATIVE TREATMENT temporary external biliary drainage ,by passing a cather percutaneously into an intrahepatic duct ,or by passing a cather through stricture at ERCP and left to drain through mouth.

OPERATIONS

Roux-en-Y choledochojejunostomy

Cholecystojejunostomy

Choledochoduodenostomy

Insertion of a stent  

COMPLICATIONS 

Recurrent inflammation of the biliary duct and stricture can occur in whatever patients. Patients are at risk for infection developing above the stricture. Long-standing strictures can advance to cirrhosis.

Complications of bile duct strictures (biliary strictures) include development of stones in the gallbladder and bile ducts proximal to the stricture, pyogenic liver abscess due to recurrent episodes of ascending cholangitis, secondary biliary cirrhosis, and weight loss and malnutrition from steatorrhea with fat-soluble vitamin deficiency.

Diverticulum common birth defect in about 2% of all infants

MECKLE'S DIVERTICULUM  The vitello-intestinal funiculus is the remnant of the yolk cover which is attached to the primitive midgut in the first some weeks of embryonic development .

It was first described by FABRICIUS HILDANUS in the sixteenth century and later named after Jhann friedrich meckle , who described the embryological origin of this type of diverticulum in 1809.

It should completely obliterate during the six week ,but haw persist completely or in conception .if it persist completely , there is a diverticulum ,the Meckle's diverticulum ,which arises from the terminal ileum .The classical description in adults is that it is present in 2% of he population , is 2 inches ( 5 cm ) daylong and 2 feet (60 cm )from the ileocaecal valve .

The diverticulum is usually supplied by the omphalomesenteric artery (a remnant of the vitelline artery), which arises from the ileal branch of the superior mesenteric artery. Usually, the artery terminates in the diverticulum; however, it has been reported to continue up to the abdominal wall in some cases. Rarely, these blood vessels persist in the form of fibrous remnants that run between the Meckel diverticulum and the abdominal wall or small bowel mesentery.

Meckel's diverticulum occurs on the antimesenteric abut of the ileum, commonly 40-60 cm proximal to the ileocecal valve. On average, the diverticulum is 3 cm long and 2 cm wide. Slightly more than one half include ectopic mucosa. Meckel diverticulum is typically lined by ileal mucosa, but another paper types are also institute with varied frequency.

The heterotopic membrane is most commonly gastric. This is important because peptic ulceration of this or conterminous membrane can lead to painless bleeding, perforation, or both. In one study, heterotropic viscus membrane was institute in 62% of cases, pancreatic paper was institute in 6%, both pancreatic paper and viscus membrane were institute in 5%, jejunal membrane was institute in 2%, Brunner paper was institute in 2% and both viscus and duodenal membrane were institute in 2%.2 Rarely, colonic, rectal, endometrial, and hepatobiliary tissues have been noted.

A persistent vitello-intestinal funiculus can present at birth , as a swelling at the base of the umbilical cord ,or as a fistulous connection to the umblicus ,or as an umblical polyp, which does not move like simple granulation tissue to cautery , because it has a mucosal surface , Surgical excision is required .It haw be lined by ileal membrane ,or contain ectopic gastric membrane ,which haw unergo peptic lesion with ensuant bleeding .

Most people who have a Meckel's diverticulum have no symptoms or problems. Only about 1 in 25 persons who are born with it will have problems. These problems vary by age. In infants and children, the problem is commonly injury from the rectum. Sometimes blood stained stool can be seen .

In adults, the gut may become blocked. If this happens, the mortal may have breadbasket pain and vomiting. Other symptoms allow fever, degradation and swelling of the stomach.

It haw present with

SEVERE HAEMORRHAGE blood is passed per rectum , and is blakish red in colouration.


INTUSSUSCEPTION ,MECKALIAN DIVERTICULITIS ( Without Perforation ) clinical features simulate those of acute appendicitis ,(With Perforation ) clical features simulate those of cut ulcer  .

CHRONIC PEPTIC ULCERATION symptomatic peptic ulcer pain , related to meals , but is felt around the umblicus ( because diverticulum is conception of midgut ).


INTESTINAL OBSTRUCTION a adornment present between apex of diverticulum and umblicus , haw cause obstruction either by adornment itself or by a volvulus around it .


LITTER's HERNIA meckle's diverticulum is found in an inguinal or femoral hernial cover .


SILENT MECKLE's DIVERTICULUM encouraged in barium meal follow-through or during an abdominal operation . 

DIAGNOSTIC INVESTIGATIONS 1 . X-RAY with BARIUM MEAL  may demonstrate Meckle's diverticlum  ,and failure to visualize is of no significance ,because so often the entrance of diverticulum is blocked by edema .

TECHNETIUM (Tc ) SCANNING may localize heterotopic gastric mucosa in a diverticulum .There is no definitive scan or investigation to confirm the existence of a Meckle's diverticulum .A radiolabelled technetium  scan looking for ectopic gastric mucosa ( that is outside the stomach ) is only positive in about 70 % of patients with a Meckle's diverticulum who present with rectal bleeding .

TREATMENT : management is by excision after the diagnosis has been made - which is often only at laparotomy , although it may be suspected beforehand.

MECKELIAN DIVERTICULECTOMY a broad base Meckle's diverticulum is resected with invagination technique in the same way as a vermiform appendix ,If the base of Meckle's diverticulum is indurated  and especially .when such induration  extends into neighboring ileum ,resect a short segment  of ileum containing the Meckle's diverticulum ,and restore the continuity of bowel by end-to-end anastomosis .

FREQUENCY

The figure of Meckel diverticulum is usually noted to be approximately 2% of the population,3 but publicised program arrange from 0.2-4%.4 Complications are only seen in about 5% of those with the anomaly.

Abscesses - Subphrenic abscess is a pus filled cavity and misdiagnosis lead sepsis and death

SUBPHRENIC ABSCESS 

 

There are a number of spaces below the diaphragm in relation to the liver which may become the site of abscess formation ( a subphrenic abscess ).Abscess may arise from such lesions as perforated peptic ulcer ,perforated appendicitis ,or perforated diverticulitis .Only two of the spaces are in fact directly subphrenic , the other two being subhepatic.The right and left subphrenic spaces lie between the diaphragm and the liver and are separated from one another by the falciform ligament. The right subphrenic space ( pouch of Rutherford Morrison ) is bounded by the posterior abdominal wall behind and by the liver above.The gall bladder, duodenum and right kidney are immediate relations. 

The left subphrenic space is the lesser sac itself.It may distend with fluid as a result of a perforated posterior gastric ulcer or as a result of acute pancreaitis ( pseudocyct of the pancrease ).At the present time most subphrenic abscess are drained percutaneously under the ultrasound control . However , the occasional one still requires open surgery and may be accessed if they are posteriorly placed by an incision below or through the bed of the twelfth rib. If they are placed anteriorly they can be drained through an incision below and parallel to the costal margin.

Any anastomosis leakage or another harm contamination tends to advance to a subphrenic abscess. The pressures from the diaphragmatic movements with respirations are such that there is a movement of the ascitic fluid of the cavum into the subphrenic space and with it travel any bacteria that strength be present, which facilitates abscess formation.

Patients are ofttimes elderly. Symptoms can be very impalpable and start perhaps with a fever and a loss of appetite approximately 1 month after the surgery. There might be a non-productive cough due to an atelectasis in the lung of the strained side or a pleural effusion (fluid in the chest cavity) on that side. Abdominal pain on the strained side in the upper cavum is common, which is severe on deep palpation by the physician. Blood tests exhibit a leukocytosis, there haw also be a lack of red blood cells (anemia).

 

Plain abdominal X-ray films haw exhibit the abscess decay with gas in it from gas producing bacteria. Chest X-rays ofttimes exhibit abnormalities in the lungs (atelectases, lower lobe pneumonia) and pleural effusions as well as an immobile diaphragm. Other tests are useful much as an ultrasound for a right- sided subphrenic abscess and a CT scan for a left-sided subphrenic abscess. The unification here shows a subphrenic abscess before (upper image) and after (lower image) drainage. Because it can be rather arduous to become to a diagnosis, hot isotope scanning much as an indium-111-labeled leukocyte scan could be useful in sleuthing a hidden intra-abdominal or subphrenic abscess.

 

TREATMENT

PERCUTANEOUS DRAINAGE insert a percutaneous drainage tube blindly, under combined ultrasonic and fluroscopic control. Same tube can be used to instill antibiotic solutions into abscess cavity.

SURGICAL DRAINAGE

INCISION if a swelling can be detected , incision is made over the site of maximum tenderness , or over any area where edema or redness is present. If no swelling is apparent , subphrenic spaces should be explored either by anterior subcostal approach or from behind after removal of outer part of 12th rib.

CLEANSING AND DRAINAGE When the cavity is reached ,all the fibrinous loculi must be broken down with finger .One or two drains or drainage tubes must be fully inserted.Drains are withdrawn gradually during next 10 days and closure of the cavity checked by x-ray sinograms.

X-ray shows sub-phrenic abscess

Tuberculous peritonitis

A bacterial contamination from spillage an intraabdominal viscus it could be life threatening event


TUBERCULOUS PERITONITIS
Infection occurs most commonly mass reactivation of latent tuberculous foci in the peritoneum that were established from hematogenous spread from a primary lung focus , It can also become via hematogenous spread from active pulmonary or miliary TB. Much less frequently, the organisms enter the peritoneal cavity transmurally from an infected diminutive intestine or contiguously from tuberculous salpingitis .


Peritoneal T.B. is an uncommon site of extrapulmonary infection caused by Mycobacterium T.B. (TB). The venture is accumulated in patients with cirrhosis, retrovirus infection, diabetes mellitus, underlying malignancy, mass treatment with anti-tumor necrosis factor (TNF) agents, and in patients undergoing continuous ambulatory peritoneal dialysis.


As the disease progresses, the visceral and parietal peritoneum become progressively studded with tubercles. Ascites develops alternative to "exudation" of proteinaceous fluid from the tubercles, similar to the mechanism leading to ascites in patients with peritoneal carcinomatosis. More than 90 percent of patients with TB rubor have ascites at the time of presentation, while the remainder present with a more advanced "dry" phase, representing a fibroadhesive modify of the disease.


Pathologically Gastrointestinal tuberculosisis characterized by rousing and fibrosis of the bowel surround and the regional lymph nodes. Mucosal lesion results from necrosis of Peyer patches, lymph follicles, and vascular thrombosis. At this stage of the disease, the changes are rechargeable and healing without scarring is possible. As the disease progresses, the lesion becomes confluent, and extensive fibrosis leads to bowel surround thickening, fibrosis, and pseudotumoral accumulation lesions. Strictures and fistulae formation may occur.


ORIGIN OF INFECTION from tberculous mesentric lymph nodes .from tuberculosis of ileocecal region ,from tuberculous pyosalpinx ,Blood-borne infection from pulmonary tuberculosis ,usually milliary.


CLINICAL TYPES


ASCITIC FORM peritoneum is studded with tubercles and peritoneal cavity becomes filled with pale ,straw colored fluid .its onset is insidious .with loss of energy , facial pallor and some loss of weight ,enlargement of abdomen ,pain often completely absent ,but there may br abdominal discomfort ,usually associated wih constipation or diarrhea . Even pyrexia and night sweats.


Dilated veins can be seen coursing beneath the skin of abdominal wall. shifting dullness and fluid thrill present , congenital hydrocele sometimes appear in male child .Umblical hernia may develop .A transverse solid mass can often be palpated per abdominally ,( this is rolled up greater omentum infiltrated with tubercles )


ENCYCTED ( LOBULATED ) FORM pathologically it is similar to ascitic form , but one part of abdominal cavity alone is involved .clinical features also resemble to ascitic form ,but there is a localized intraabdominally lump . .localized intraabdominally swelling .fluid thrill and shifting dullness may or may not be present ,depending upon the site of collection .


FIBROUS ( PLASTIC FORM ) there is widespread intraperitoneal adhesions .which causes coils of intestine especially the ileum , to become matted together and distended.These distended coils act as a blind loop. There are symptoms of steatorrhea , loss of weight , attacks of abdominal pain ,Evening pyrexia and night sweats ,and some symptoms of acute and subacute intestinal obstruction , with signs of wasting ,a palpable swelling or swellings per abdominally ( this is adherent intestine with omentum attached ,together with thickened mesentry ).


PURULENT FORM pathlogically there is mass of adherent intestine and omentum ,is surrounded by tuberculous pus to form a cold abscess .This may point to the surface ,commonly near umblicus ,or burst into bowel . In clinically it shows loss of weight ,abdominal pain .discharge from an opening on abdominal skin .evening pyrexia and night sweats ,with signs of discharge from a sinus or fistula ,the opening of which is often wide ,with thin blue and undermined margin. A swelling may be palpated per abdominally ( consisted of adherent intestine and omentum )


ACUTE FORM pathologically resemble with ascitic form and clinically resembles acute bacterial peritonitis .


Some investigations can reveal this lesion such as


PERITONEAL ASPIRATION fluid is pale yellow .usually clear , rich in lymphocytes and have a high specific gravity.1.020 or more .Mycobacterium tuberculosis can be demonstrated by culture and microscopy with Ziehl-Neelsen staining.
MANTOUX TEST a positive test is strongly suggestive ,in non immunized patients .
CHEST X-RAY may reveal pulmonary tuberculosis
LAPROSCOPY can demonstrate the clinical type
PERITONEAL BIOPSY reveal characteristic tuberculous granuloma.


TREATMENT


CHEMOTHERAPY initial phase ethambutol .plus isoniazid plus rifampin plus pyrazinamide for two months .and in continuation phase ethambutol plus isoniazid plus rifampin for four to seven months .


SURGICAL TREATMENT


IN CASES OF FLUID COLLECTION laparotomy is performed ,fluid is evacuated and abdomen is closed without drainage .
IN FIBROUS FORM
On laparotomy ,bands of adhesion are divided. if adhesions are accompanied by fibrous strictures of ileum ,then excise the affected bowel, if adhesions only are present , a plication may be performed.
IN PURULENT FORM
On laparotomy ,cold abscess are evacuated ,fecal fistula is closed , combined with some form of anastomosis between segment of intestine above the fistula and an unobstructed area below.