Colostomy is an artificial opening to divert faeces and flatus.

Bowel diversion surgery for artificial opening in large bowel in order to divert faces to exterior

COLOSTOMY

In simple terms, a colostomy is when the colon is cut in half and the end directive to the stomach is brought finished the surround of the abdomen and attached to the skin. The end of the colon that leads to the rectum is closed soured and becomes dormant. In other words we can say that its a artificial opening made into large bowel in order to divert feces ( & flatus ) to exterior  ,where they may be collected in an adhesive bag.

Usually a colostomy is performed for infection, blockage, or in rare instances, severe trauma of the colon. This is not an activeness to be taken lightly. It is truly quite serious and demands the close attention of both patient and doctor. A colostomy is ofttimes performed so that an incident crapper be stopped and/or the affected colon tissues crapper heal. The alternative to the colostomy is ofttimes pretty grim, death. Just be glad you are here. It is essential actualise that, with a few exceptions, you crapper look forward to having the colostomy reversed.

A colostomy is sometimes necessary for destined upbeat conditions or diseases. Some of these include cancer, diverticular disease, Crohn's disease and trauma or injury. A temporary colostomy may be necessary to allow the colon to rest and ameliorate for a period of time. A temporary colostomy may be in locate for weeks, months, or years. The temporary colostomy module eventually be closed and bowel movements module return to normal. A imperishable colostomy is usually necessary when a part of the colon staleness be distant or cannot be utilised again.

  

This is famous as a "Hartmann's Colostomy". There are other types of colostomy procedures, but this one is the most common.

It may be TEMPORARY or PERMANENT

TEMPORARY COLOSTOMY

A temporary colostomy haw be used when the conception of the colon (typically the lower section) needs to heal, such as after trauma or surgery. After the colon is healed, the colostomy can be reversed, backward the bowel function to normal. In a colostomy reversal, the digit ends of the colon are reconnected and the area where the stoma was created in the cavum is closed. The large gut is made, erst again, into a continuous tube between the small gut and the rectum. Bowel movements are eliminated through the rectum.

  

INDICATIONS to relieve a distal obstruction of sigmoid colon either by a carcinoma or diverticulitis ,vesicocolic fistula ,protection of a low colorectal anastomosis after anterior resection .To prevent fecal peritoniyis developing after traumatic injury to rectum or colon .To facilitate operative treatment of a high fistula-in-ano.

PROCEDURE

The operation usually takes between digit and four hours depending on difficulty, infection, and the severity of trauma if that is the case. Most of the reasons for a colostomy are: diverticulitis, other inflammatory bowel conditions, or cancer.

Since you are having the operation, you should discuss with your student whether or not you should hit the appendix distant at the same time, since they are going to be in there anyway. It is not a necessary organ and, if removed, it crapper never cause you problems in the future.

 It is normal practice to unstoppered the cavum with an incision from meet below track distinction to meet below the sternum. This gives unstoppered admittance to the internal organs. If you have infection, the student module suction and flush out the contaminates until you are clean.

A loop of bowel ( loop colostomy ) is brought to the surface , where it is held in place by a plastic or glass rod passed through mesentry .Bowel is opened & edges of colonic incision stitched to surrounding skin margins.When firm adhesion of colostomy to abdominal wal has taken place after 7 days , then rod can be removed.

Closure of colostomy performed ,following surgical cure of distal lesion .Done when the stoma is matured ,ie after 2 months .Usually performed by an intraperitoneal technique

PERMANENT COLOSTOMY

A imperishable colostomy (sometimes also called an end colostomy) is necessary for some conditions, including most 15% of colon cancer cases. This type of surgery is commonly utilised when the rectum needs to be removed because of disease or cancer. Most of the colon may also be removed, and the remaining assets utilised to create a stoma.

INDICATIONS after excision of rectum for a carcinoma by abdominoperineal technique ,through the lateral edge of rectus sheath 6cm above & medial to bony prominence.

PROCEDURE distal end ( end colostomy ) of divided colon is brought to surface in left iliac fossa ,where it is stitched in place immediately by sutures placed between colonic margin 7 surrounding skin .A colostomy bag is applied without impinging on bony prominence of anterior superior iliac spine.
  

 After the colostomy, squander is composed on the outside of the body with an ostomy appliance. Today’s ostomy appliances become in a variety of shapes, sizes, colors, and materials to meet the wearer’s lifestyle. The aperture and the surrounding wound (peristomal skin) will order primary care that is taught to patients post-surgery by an enterostomal therapy (ET) nurse....... read more

Colostomy products

DIFFERENT TYPES OF PRODUCTS FOR COLOSTOMY

Pouch
There are a variety of sizes and styles of colostomy pouches. Pouches are lightweight and odor-proof. Pouches have a special concealment that prevents the pouch from sticking to the body. Some pouches also have charcoal filters which release pedal tardily and support to decrease pedal odor. The mass is general aggregation most types of colostomy pouches



Stoma covers and caps
Stoma caps or covers crapper be placed on the aperture when the aperture is not active (draining). People with descending or colon colostomies who wet may use aperture covers or caps. The cover or cap is attached to the wound in the same artefact as a pouch.



COLOSTOMY CARE



Psychic activity of the enduring for the necessity of colostomy is a daylong first step toward his adjustment to experience with an artificial anus. Proper surgical positioning of the activity module assist tending of the bowel. Control of fecal property and peristaltic rate should ideally display degradation susceptible exclusive to habit or enemata. 


The goal of the enema is to display an evacuation thorough enough to prevent soiling for a day or two. The goal of fare variations is to display a manageable volume and property of fecal stream. The framework of enemas and pick of diet can be personalised when the underlying principles are understood.



COMPLICATIONS OF COLOSTOMIES



Prolapse , Retraction ,Necrosis of distal ends , Stenosis of orifice , Colostomy of hernia , Bleeding ( usually from granulomas around the margin of colostomy ) Colostomy diarrhea ( usually an infective enteritis responds to metronidazole )



Recovery at home is mostly most six weeks, although it haw be longer for patients who are very ill before surgery or who hit complications. Activity module be limited at first, and lifting, housework, and driving are not recommended. The infirmary staff module advise you most your diet when you prototypal get home, which haw be limited to low fiber. Regular appointments with your surgeon module help ensure that your cavum and the surface  around the aperture are sanative well........read more

70% adult cases of chronic pancreatitis are caused by chronic alcohol use

Main culprits are heavy alcohol consumption and gallstones for chronic pancreatitis

CHRONIC PANCREATITIS 

is a relapsing disorder which may arise  insidiously or following repeated attacks of acute pancreatitis .The most commonest cause is chronic alcohol consumption and accompanied by a protien and fat rich diet .Other causes include cystic fibrosis ,hypercalcemia ,hyperlipidemiaand a rare familial pancreatitis .Pathological changes include parenchymal destruction ,fibrosis ,loss of acini ,calculi and duct stenosis with dilatation behind the stenosis.At operation the gland feels hard and irregular and may be mistaken for carcinoma .Calcification is often seen on plain abdominal X-ray.This is thought to be due to calcification of protien precipitates in ducts .

 Pancreatic duct obstruction : due to Stricture e.g.after trauma or acute pancreatitis.Occlusion by pancreatic cancer.

 Hyperparathyroidism ,cystic fibrosis ,Hereditory pancreatitis ,Infantile malnutrition ,Idiopathic ,Stenosis of ampulla of vater . In 12 % of adults ,etiology is unknown.

 Initially pancreas may appear normal.Later pancreas enlarges and becomes hard due to sclerosis ,while the ducts become distorted and dilated with areas of ectasia .Calcified stones ,weighing from a few mg 200 g ,may form within ducts .Ducts become occluded with gelatinous protein-rich fluid and debris ,to form cysts.

Lesions affect a particular lobule producing ,Ductular metaplasia and hyperplasia ,Atrophy of acini ,Interlobular fibrosis .

In clinical features there is symptom of discompose in epigastrium ,which alter to left and correct hypochondrium and finished to back .boring discompose to biliary colic in character .duration about 3-4 days ,and exacerbated by beverage consumption.Vomiting ,anorexia ,Steatorrhea ,and Weight loss ( results from anorexia ,malabsorption steatorrhea and vomiting .It can cause some symptoms of diabetes mellitus ,these are late feature and includes polyuria ,polydipsia ,weight loss and imperfectness.

Signs of jaundice haw be present ( due to narrowing of retropancreatic bile duct ) A protective ,hard epigastric mass haw indicate formation of a sac . ( best way to palpate pancreas is to invoke the enduring to correct and hips and knees are flexed .Left costal margin is deeply palpated.This will evoke tendrness in accent and habitual pancreatitis ( Mallet-Guy's sign ).

DIAGNOSTIC INVESTIGATIONS

The identification of habitual pancreatitis is typically based on tests on pancreatic structure and function, as direct biopsy of the pancreas is thoughtful excessively risky. Serum amylase and lipase may well not be elevated in cases of advanced habitual pancreatitis, but are often utilised as markers for sleuthing pancreatic inflammation in acute pancreatitis. A secretin stimulation effort is thoughtful the gold standard functional effort for identification of habitual pancreatitis but not often utilised clinically. The observation that bi-carbonate production is impaired early in habitual pancreatitis has led to the rationale of ingest of this effort in early stages of disease (sensitivity of 95%). Other ordinary tests utilised to determine habitual pancreatitis are faecal elastase measurement in stool, serum trypsinogen, Computed tomography (CT) scans, ultrasounds, EUS, MRI's, ERCP and MRCP's. Pancreatic calcification crapper often be seen on plain abdominal X-rays, as well as CT scans.

There are other non-specific laboratory studies useful in identification of habitual pancreatitis. Serum bilirubin and alkaline phosphatase crapper be elevated, indicating stricturing of the ordinary bile funiculus cod to edema, fibrosis or cancer. When the habitual pancreatitis is cod to an autoimmune process, elevations in ESR, IgG4, rheumatoid factor, ANA and antismooth hooligan antibody may be seen. The ordinary symptom of habitual pancreatits, steatorrhea, crapper be diagnosed by two assorted studies: Sudden staining of feces or soiled fruitful organic over 24hr on a 100g fruitful diet. To check for pancreatic exocrine dysfunction, the most sensitive and specific effort is the measurement of soiled elastase, which crapper be done with a azygos crap sample, and a value of inferior than 200 ug/g indicates pancreatic insufficiency.

TREATMENT

MEDICAL TREATMENT  

Aimed at controlling discompose and malabsorption .Intermittent attacks treated like accent pancreatitis.Alcohol and super fatty meals must be avoided .Narcotics for severe discompose ,but subsequent addiction is common ,Patients unable to maintain adequate hydration should be hospitalized ,while those with milder symptoms crapper be managed on an ambulatory basis. Surgery haw curb discompose if there is a ductal stricture .Subtotal pancreatectomy haw also curb discompose but at the outlay of exocrine insufficiency and diabetes .Malabsorption is managed with a low fat diet and pancreatic enzymes equal ( 8 customary tablets or 3 viscus glazed tablets with meals ).Because pancreatic enzymes are inactivated by Elvis ,agents that turn Elvis creation ( e.g . omeperazole or sodium bicarbonate ) haw improve their efficacy ( but should not be presented with viscus glazed preparation ) Insulin haw be needed to curb serum glucose .

SURGICAL TREATMENT

Traditional Surgery for Chronic Pancreatitis tends to be divided into two areas - resectional and drainage procedures.New and proven transplantation options preclude the patient from decent diabetic following the surgical removal (resection) of their pancreas. This is achieved by transplanting backwards in the patients own insulin-producing beta cells.

DISTAL PANCREATOMY it consist of distal pancreatic resection up to portal vein ,and it is performed if head of pancreas is relatively normal .

PANCREATODUDENECTOMY it is performed if head of pancreas is mainly involved .

LONGITUDINAL  PANCREATOJEJUNOSTOMY  it is performed if pancreatic duct is grossly dilated .

COMPLICATIONS  

Vitamin B6 malabsorption in 40 % of alcohol induced and all cystic fibrosis cases.Impaired glucose tolerance .Nondiabetic retinopathy due to vitamin A and/ or zinc deficiency,Gastrointestinal bleeding ,icterus ,effusion ,subcutaneous fat necrosis and bone pain occasionally occur .Increased risk for pancreatic carcinoma .Narcotic addiction common.

Here's some information when your intestine is inactive or Paralytic ileus

PARALYTIC ILEUS 

 

It is  a state in which intestine fails to transmit peristaltic waves and is due to failure in neuromuscular mechanism and Obstruction of the gut cod to paralysis of the viscus muscles. The paralysis does not need to be complete to cause ileus, but the viscus muscles must be so inactive that it prevents the passage of food and leads to a useful closure of the intestine.

 

IN POSTOPERATIVE ETIOLOGY  

Ileus commonly follows some types of surgery, especially abdominal surgery  ,Normal lyintestinal motility and absorption returns in about 16 hours ,However ,postoperative ileus may br prolonged , if there is  Hypoproteinemia ,Latent renal failure , If gastrointestinal suction is continued beyond the point at which effective bowl sounds have returned .PERITONITIS initially as a normal response to prevent dissemination .Later bacterial toxins  prevent normal activity of nerve plexuses.

It also crapper result from certain DRUGS  like Uremia ( in renal failure ,following prostatectomy ) , HYPOKALEMIA, IN REFLEX ETIOLOGY Spinal injuries or ribs injuries, ,sometime Retroperitoneal haemorrhage , inflammation anywhere within the abdomen that touches the intestines, and diseases of the viscus muscles themselves  and Application of the plaster jacket.

Irrespective of the cause, closure causes constipation ( no passage of flatus ,for upto 48 hours after laparotomy ), abdominal distention, ( more marked and drum like tympanitic ) and sickness and vomiting ( effortless ,large volume and with dirty fluid ) Respiratory distress. On listening to the abdomen with a stethoscope, some or no bowel sounds are heard (because the bowel is inactive) after laparotomy. Also titled disfunction ileus. Also simply titled ileus.with sign of Tachycardia ,there may be wound dehiscence .

Ileus may increase bond formation, because intestinal segments have more prolonged contact, allowing fibrous adhesions to form, and intestinal distention causes serosal injury and ischemia. Intestinal distention has been shown to drive adhesions in foals . Repeat celiotomy to decompress chronically distended small gut and vanish fibrinous adhesions is also a multipurpose method of treating ileus and reducting adhesions, and it has been related with a good outcome  

DIAGNOSTIC TEST FORPARALYTIC ILEUS: 

The list of diagnostic tests mentioned in various sources as used in the diagnosis of Paralytic ileus includes:

Stethoscope Examination of the abdomen : when a doctor ty o listen with a stethoscope to the abdomen there will be few or no bowel sounds ,indicating that the intestine has stopped functioning .ileus can be confirmed by X-ray of abdomen .computed tomography scans (CT  scan ) or ultrasound .it may be necessary to do more invasive test msuch as barium enema or upper GI series if the obstruction is mechanical.Blood test also are useful in diagnosing paralytic ileus .barium enema used in some obstruction cases but it can cause few problems by increasing pressure or intestinal contents if used in ileus Also in doubtful cases with mechanical obsruction involving the gastrointestinal tract .

So its use is contraindicated in these typs of cases .but in some caes it should be used first . 

TREATMENT OF PARALYTIC ILEUS 

Always seek professional medical advice about any treatment or change in treatment plans, patients may be treated with supervised bed rest in a infirmary , and bowel rest ,where nothing is taken by representative ,and patients are feed intravaneously or finished the ingest of a nasogastric

tube .A nasogastric plaything is a plaything inserted finished the nose down to the throat and into the breadbasket.A kindred plaything can be inserted in the gut .The contents are then suctioned out .In some cases ,especially where there is a machine like obstruction ,surgery may be needed . Drug therapies that encourage intestinal motility ( ability of the gut to more spontaneously ) such as morphine or pethidine , in repeated small doses .Fluid and electrolytes balance ,especially serum K and blood urea.

PROPHYLACTIC TREATMENT 

Routine nasogastric suction and withholding fluids by representative after laparotomy until normal bowel sounds returns ,and /or passage of flatus occurs .in most of the cases ileus are not preventable  ,surgery to remove a tumr or other intestinal obstruction will help prevent a repetition .

Treatment for diverticular disease of colon

Diverticulosis is generally discovered through one of the following examinations for appropriate treatment

Barium enema: This x-ray test involves injection of liquid material into the colon through a tube inserted in the rectum. The x-ray image shows the anatomy of the colon, and can identify if diverticula, large polyps or growths are present.

Colonoscopy: This test uses a thin, flexible tube with a light and camera to view the inside of the colon. Diverticula as well as polyps and other growths can be seen with this instrument.

CT scan: This x-ray test takes multiple cross section pictures of the body. It is not generally performed to make a diagnosis of diverticulosis, but this type of exam may identify diverticula.

Patients with diverticular disease should be counselled on the benefits of a high fibre diet. Bulking agents and laxatives could also be added until stools are soft and defaecation is painless.

Patients with acute diverticulitis are admitted to hospital for bed rest, nil by mouth (with iv fluids), analgesics, and IV antibiotics (e.g. cefuroxime and metronidazole). Patients presenting with PR bleeding are resuscitated and given blood transfusion.

Complicated disease (perforation, abscess, multiple attacks, uncontrollable bleeding) usually requires surgery to remove the diseased segment of colon. There are various surgical techniques available depending on the site of the disease, and a temporary stoma is usually needed (a "stoma bag"), although this is reversed after around 6 weeks.

CONSERVATIVE MANAGEMENT

Patients with acute diverticulitis are admitted to hospital for bed rest, nil by mouth (with iv fluids), analgesics, and IV antibiotics (e.g. cefuroxime and metronidazole). Patients presenting with PR bleeding are resuscitated and given blood transfusion.

Complicated disease (perforation, abscess, multiple attacks, uncontrollable bleeding) usually requires surgery to remove the diseased segment of colon. 

There are various surgical techniques available depending on the site of the disease, and a temporary stoma is usually needed (a "stoma bag"), although this is reversed after around 6 weeks.

SURGICAL TREATMENT

INDICATIONS :Recurrent attacks -and Complications

OPERATIVE PROCEDURES 

IDEAL OPERATION 

This is a one stage resection ,which involves removal of affected segment 10 - 20 cm long and restoration of continuity by end-to-end anastomosis .

IN CASES OF OBSTRUCTION & INFLAMMATORY EDEMA AND ADHESIONS a preliminary transverse colostomy can be done as a first stage. In second stage of resecion is performed after 3 weeks or later when inflammation has subsided.Colostomy is closed after a further 2 weeks.
IN ACUTE PERFORATION proximal colostomy can be done ,Exteriorization , Primary resection.

HARTMANN'S OPERATION colostomy after excision with closure of defunctioned distal bowel .

Restoration of bowel continuity can be done at a later stage by means of stapling guns .

IN FISTULA resection of diseased bowel. ,closure of fistula .

IN HAEMORRAHAGE resection of bleeding segment ...... read more

Diverticular disease of colon common in western society

WHERE REFINED DIETS ARE MORE COMMON THAN RICH IN FIBRE

DIVERTICULAR DISEASES OF COLON 

Diverticula of colon are acquired rupture of colonic mucosa ,protruding through broadside muscle at points where murder vessels understand colonic surround .They consist of mucosa and submucosa that have cut the muscular coats . They are pulsion diverticula being pushed out by increased intraluminal push .Although they haw involve the whole of the colon .They are most ordinary in the colon

Diverticular disease is most ordinary in Western society ,where civilised diets are more ordinary than diets rich in fibre and hence the stool is inferior bulky . Patients with diverticular disease have shortened ,thickened colonic muscle which reflects work hypertrophy from years of  a baritone fibre diet and resulting small hard stools .High intra-luminal pressure occur ,pushing the diverticulae out through the surround .The inclination of divertculae to form in the colon colon is explained by Laplace's law which states that the push within a tube is

inversely proportional to the radius.

PATHOGENESIS 

DIVERTICULOSIS two factors are essential 1.exaggerated peristaltic contractions with abnormal elevation of intraluminal push ,and foci of muscle imperfectness in colonic surround.

DIVERTICULITIS it is the secondary land and is cod to rousing of one or more diverticula.

MICROSCOPIC FEATURES

DIVERTICULOSIS 

Muscular hypertrophy in colonic segments affected by diverticular changes.saccule are found penetrating between the mesentric and lateral teniae at points where entering arterioles branch out into submucosa .Diverticulae are small ,flask like or spherical outpouchings usually 0.5 to 1 cm in diameyer .Walls of diverticula are usually thin ,made up of mucosa and submucosa enclosed within fat or an intact peritoneal covering .

DIVERTCULITIS 


Inflammatory changes are present ,to produce both diverticulitis and periverticulitis and sometimes localized peritonitis .

SIGN AND SYMPTOMS OF DIVERTICULOSIS AND DIVERTICULITIS

Most patients with diverticulosis have no symptoms. Many will never know they have the condition until it is discovered during an endoscopic or radiographic (Xray) examination. While most people have no symptoms, some individuals may experience pain or discomfort in the left lower abdomen, bloating, and/or a change in bowel habits.

Other conditions such as irritable bowel syndrome and stomach ulcers cause similar problems, so the symptoms do not always mean a person has diverticulosis. People with chronic symptoms should visit their doctor or health care provider.

The most common symptom of diverticulitis is abdominal pain. The most common sign on examination is tenderness in the lower left side of the abdomen. Usually, the pain is severe and comes on suddenly, but it can also be mild and become worse over several days. The intensity of the pain can fluctuate. A person may experience cramping, nausea, vomiting, fever, chills, or a change in bowel habits...... 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.

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