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.

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