PERITONITIS & ACUTE ABDOMEn

ACUTE ABDOMEN AND PERITONITIS

1. ANATOMY

*  The  abdominal cavity and the viscera contained within it  are

   lined  by  a smooth glistening layer  called  the  peritoneum. 

   There are two subdivisions of the peritoneum Fig. 21.1

*  The parietal layer covers the inside of the abdominal cavity.

  

*  The  visceral layer covers   the various organs and these  two

   divisions are continuous with one another

*  The  abdominal  cavity  is divided into a greater  sac  and  a

   lesser sac by the visceral layer of the peritoneum.

   The lower half of the greater sac is further sub-divided  into

   a upper right  half and a lower left half by the attachment of

   the root  of  the mesentry.

*  There is usually about 150 cc of clear straw coloured fluid in

   the peritoneal cavity.  This fluid facilitates the movement of

   abdominal viscera.

*  The  surface  area  provided  by  this  peritoneal  layer   is

   approximately equal to the skin surface area and is more  than

   the surface area provided by the glomeruli of the kidney.

*  This  large   surface  area (1.8 meters) is important  and  is

   made use in peritoneal dialysis in cases of renal failure  for

   it  allows  exchange  of fluids and  electrolytes  across  its

   surface.

*  In  cases of inflammation of the peritoneum due  to  bacterial

   peritonitis, this surface area plays an important part in  the

   clinical  picture for it allows transfer of fluids,  bacterial

   toxins  and  other metabolites across its  surfacee  and  thus

   produces  a state of profound shock and toxaemia seen in  this

   condition.

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APPENDECTOMY

 APPENDECTOMY

The  patient  is  prepared (skin) lower abdomen  and  draped  end

aenesthelised.    A   skin  incision   transverse(Fig.20.3a)   is

preferred.   The ceacum is identified and the  appendix  isolated

and brought out of the wound.  The base clamped, ligated and  cut

(Fig.20.3b).  The stump is inverted and the wound closed.

Using a McBurny’s incision passing through MeBurry’s point

The incision cuts skin and subcutaneous tissues

External oblique aponeurosis cut in the same direction

The internal oblique fibers separated blunt in the natural direction of fibers

Peritonenium is now exposed and is opened

The underlying ceacum is delivered by rotating up and out

Appendix identified (follow the tenia)

Vessels in the mono appendix double ligated

Base of appendix crushed and clamped

Crushed base lighted end cut beyond ligature

Stump inverted by purse string suture

The wound is closed in layers.

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Appendicitis 5 inveatigation treatment

INVESTIGATION

- A blood count to establish rise in white cell count.

- A urine examination to eliminate pus cells and RBC.

- A plane X-ray abdomen to eliminate stone in urinary tract.

5. TREATMENT

*  The  best treatment for all patients of early appendicitis  is

   appendectomy.

*  The  patients  with early non-fixed mass operation  should  be

   advised  especially  in children, pregnant women  and  elderly

   patients.

*  Patients  with evidence of perforated appendix  and  spreading

   peritonitis  too need to be operated early for the purpose  of

   removing the appendix and drainage of the peritoneal cavity.

*  Patients with fixed mass in the right iliac fossa.

   If,  when  the  patient is first seen, and  the  symptoms  are

   subsiding  a well localised mass is palpable in the region  of

   the right iliac fossa.  It is reasonable to start the  patient

   on   antibiotics,  snalgesics  and  nasogastric  suction   and

   intravenous  feeding  regime till the mass  subsides  and  the

   patients can be taken up for surgery six to eight weeks later.

*  All  the  categories  of the  patients  mentioned  above  will

   require varying periods of fluid replacement  and  nasogastric

   suction  so  that  their  fluid  and  mutritional  balance  is

   maintained and they may be able to stand the operative  trauma

   with the minimum risk in the post-operative period.

*  The patients will also require a frequent re-examination while

   under conservative resuscitative measures to detect early  any

   change in the local and general progress of the disease.

*  Early  surgical  intervention can be restorted to at  any  time

   provided the circumstances demand it.

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APENDICITIS 4 Signs

SIGNS 

There  is a rise of temperature of upto one degree centigrade  in

most cases.

*  There  is tenderness at McBurney's point   (McBurney's

   point  on the line joining right anterior superior iliac  spine

   to umbilicus, junction of lateral to medial 2/3).

*  There is rebound tenderness (pressure applied away from  R.I.F.

   pain on release of pressure).

*  The  positive Rovsing sign  (pressure applied to  LIF

   pain felt in RIF).

*  Palpation  of the right iliac fossa may reveal  resistance  in

   the  form  of  guarding  which may leter  be  converted  to  a

   rigidity  because  of constant contraction  of  the  abdominal

   muscle overlying the inflamed organs.

The position of the appendix may produce slight variation in the

signs .

*  In  retrocaecal appendix the tenderness may be more marked  in

   the flank.

*  Obturator sign is positive in patients with inflamed  appendix

   close the obdurator internus, and they get pain on  stretching

   of obdurator internus .

*  The Psoas sign is positive when the appendix lies close to the

   Psoas  muscles and patient gets pain on hyperextension of  the

   hip 

*  When  the appendix is lying in the pelvix, tenderness is  felt

   in the pouch of Douglas on rectal examination.

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