Info Symptoms Investigation Hypothesis

8 years male boy

ushed face,
morphine injection is
Pain complaints started sunken eyes,
done intramuscularly.

in the morning
stomach-ache painkiller cream

vomited twice,
complaints.
0.9% sodium chloride
solution

pain is located right at

the bottom of the dry mouth;

stomach;
Did appendectomy

sunken eyes;
Appendix is pale, with a
caught a cold and had a slight pink color.
sore throat for the past temperature 38;

48 hours.
pulse 120;

blood pressure of 80 \
60;

respiratory rate 20

painful stomach during

coughing;

active bowel sounds;

concentrated urine.

*Describe the gross anatomy of the caecum, appendix and ileum

the cecum is the most proximal part of the large intestine and can be
found in the right iliac fossa of the abdomen. It lies inferiorly to the
ileocecal junction and can be palpated if enlarged due to faeces,
in ammation, or malignancy
Superiorly, the cecum is continuous with the ascending colon. Unlike
the ascending colon, the cecum is intraperitoneal and has a variable
mesentery
Between the cecum and ileum is the  ileocecal valve. This structure
prevents re ux of large bowel contents into the ileum during peristalsis
and is thought to function passively, as opposed to a de ned muscular
sphincter
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 The appendix is a wormlike 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 fth month of gestation, and several
lymphoid follicles are scattered in its mucosa. Such follicles increase
in number when individuals are aged 8-20 years

The ileum is the longest part of the small intestine, making up about
three- fths of its total length. It is thicker and more vascular than the
jejunum, and the circular folds are less dense and more separated

. At the distal end, the ileum is separated from the large intestine by
the ileocaecal valve, a sphincter formed by the circular muscle layers
of the ileum and caecum, and controlled by nerves and hormones.
The ileocaecal valve prevents re ux of the bacteria-rich content from
the large intestine into the small intestine

The ileum is rich in immune tissue (lymphoid follicles). A characteristic

feature is Peyer’s patches, found lying in its mucosa, which are an
important part of gut-associated lymphoid tissue. One Peyer’s patch is
around 2-5cm long and consists of around 300 aggregated lymphoid
follicles. These are concentrated in the distal ileum and serve to keep
bacteria from entering the bloodstream
Peyer’s patches are most prominent in young people and become
less distinct with age, which re ects the age-related reduction in
activity of the gut’s immune system

*the causes of acute abdominal pai

Acut
The various conditions that cause acute abdominal pain are usually
accompanied by other symptoms that develop over hours to days.
Causes can range from minor conditions that resolve without any
treatment to serious medical emergencies, including
• Abdominal aortic aneurys
• Appendiciti
• Cholangitis (bile duct in ammation
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 • Cholecystiti
• Cystitis (bladder in ammation
• Diabetic ketoacidosi
• Diverticuliti
• Duodenitis (in ammation in the rst part of the small intestine
• Ectopic pregnancy (in which the fertilized egg implants and
grows outside of the uterus, such as in a fallopian tube
• Fecal impaction (hardened stool that can't be eliminated
• Heart attac
• Injur
• Intestinal obstructio
• Intussusception (in children
• Kidney infection (pyelonephritis
• Kidney stone
• Liver abscess (pus- lled pocket in the liver
• Mesenteric ischemia (decreased blood ow to the intestines
• Mesenteric lymphadenitis (swollen lymph nodes in the folds of
membrane that hold the abdominal organs in place
• Mesenteric thrombosis (blood clot in a vein carrying blood away
from your intestines
• Pancreatitis (pancreas in ammation
• Pericarditis (in ammation of the tissue around the heart
• Peritonitis (infection of the abdominal lining
• Pleurisy (in ammation of the membrane surrounding the lungs
• Pneumoni
• Pulmonary infarction (loss of blood ow to the lungs
• Ruptured splee
• Salpingitis (in ammation of the fallopian tubes
• Sclerosing mesenteriti
• Shingle
• Spleen infectio
• Splenic abscess (pus- lled pocket in the spleen
• Torn colo
• Urinary tract infection (UTI
• Viral gastroenteritis (stomach u) (stomach u
y

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 *clinical features, investigation, management and complications

of acute appendicitis

https://teachmesurgery.com/general/large-bowel/appendicitis

Clinical Features

The main symptom of appendicitis is abdominal pain. This is

initially peri-umbilical, classically dull and poorly localised (from
visceral peritoneum in ammation), but later migrates to the right iliac
fossa, where it is well-localised and sharp (from parietal peritoneum
in ammation).

Other symptoms can include vomiting (typically after the pain, not

preceding it), anorexia, nausea, diarrhoea, or constipation.

On examination, there may be rebound tenderness and percussion

pain over McBurney’s point (Fig. 2), as well as guarding (especially if
the appendix is perforated). In severe cases, patients can show
features of sepsis, being tachycardic and hypotensive, especially in
untreated cases.

Speci c signs that may be found on examination include*:

• Rovsing’s sign: RIF fossa pain on palpation of the LIF

• Psoas sign: RIF pain with extension of the right hip

• Speci cally suggests an in amed appendix abutting psoas

major muscle in a retrocaecal position

Investigations

Laboratory Tests

Urinalysis should be done for all patients with suspected

appendicitis to help exclude any renal or urological cause*. For any
woman of reproductive age, a pregnancy test is also essential.

Routine bloods, importantly FBC and CRP, should be requested to

assess for raised in ammatory markers, as well as baseline blood
tests required for potential pre-operative assessment

. A serum β-hCG may also be taken, if ectopic pregnancy still has

not been excluded.

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*Leucocytes can be present in the urine in low levels for those with an
appendicitis, especially if the appendix lies on the bladder

Imaging

Imaging is not essential to diagnose an appendicitis, as cases can be

a clinical diagnosis. Indeed, in certain cases (especially
paediatrics), serial examinations may be the only method employed
to make the diagnosis.

Ultrasound scan or CT imaging (Fig. 3) are often requested if the

clinical features are inconclusive and an alternative diagnoses are
equivocal:

• Ultrasound – good rst line investigation (especially with a

transvaginal approach) if the di erential includes gynaecological
pathology

• Useful in children as can minimise radiation exposure

• Computed Tomography – Good sensitivity and speci city, able

to delineate multiple di erentials including gastrointestinal and
urological causes

Management

The current de nitive treatment for appendicitis

is laparoscopic appendicectomy (Fig. 4).

There is some debate surrounding the use of conservative antibiotic

therapy in uncomplicated appendicitis; a Cochrane analysis found
that appendicectomy should remain the standard treatment for acute
appendicitis. Indeed, primary antibiotic treatment for simple in amed
appendix may be successful, but has a failure rate of 25-30 % at one
year.

If cases of an appendiceal mass, antibiotic therapy is favoured, with

an interval appendectomy then performed approximately 6-8 weeks
later

Surgical Intervention

Laparascopic appendectomy* (Fig. 4) still remains the gold

standard for treating appendicitis, due to a low morbidity from the
procedure. In females it also allows for better visualisation of the
uterus and ovaries, for assessment of any gynaecological pathology.

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 The appendix should routinely be sent to histopathology to look for
malignancy (found in 1%, typically carcinoid, adenocarcinoma, or
mucinous cystadenoma malignancy). As per any laparoscopic
procedure, the entirety of the abdomen should be inspected for any
other evident pathology, including checking for any Meckel’s
diverticulum present.

Complications

The mortality associated with appendicitis in developed health

systems is low (0.1% to 0.24 %). The complications of acute
appendicitis include:

• Perforation, if left untreated the appendix can perforate and

cause peritoneal contamination

• This is particular note in children who may have a delayed

presentation

• Surgical site infection

• Rates vary depending on simple or complicated

appendicitis (ranging 3.3-10.3 %)

• Appendix mass, where omentum and small bowel adhere to

the appendix

• Pelvic abscess

• Presents as fever with a palpable RIF mass, can be

con rmed CT scan for con rmation; management is usually
with antibiotics and percutaneous drainage of abscess

*Describe the clinical features, surgical ndings and

histology of mesenteric adenitis.
!! It is not possible to accurately distinguish acute mesenteric
lymphadenitis from acute appendicitis in children using clinical evaluation
alone. Ultrasound should be performed in equivocal cases.

Mesenteric adenitis is a condition that more often a ects

children and teenagers. It causes in ammation and
swelling in the lymph nodes inside the abdomen.
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 Mesenteric adenitis a ects lymph nodes in tissue called
mesentery. This tissue connects the intestines to the
abdominal wall. Another name for mesenteric adenitis is mesenteric
lymphadenitis

Mesenteric adenitis vs. appendicitis : In mesenteric adenitis, the

pain may also be in other parts of your child’s belly. The
symptoms could start after a cold or other viral infection.
Appendicitis typically comes on suddenly, without any other
illness before it
The main difference is that mesenteric adenitis is less serious than
appendicitis. It usually gets better on its own. Appendicitis usually
requires surgery called an appendectomy to remove the appendix

The tenderness is also felt more deeply in lymphadenitis

*Describe the clinical signs of dehydration, and how

these allow the gross estimation of the degree of uid
loss

The signs and symptoms of dehydration also may differ by age

Infant or young chil
• Dry mouth and tongu
• No tears when cryin
• No wet diapers for three hour
• Sunken eyes, cheek
• Sunken soft spot on top of skul
• Listlessness or irritabilit
Adul
• Extreme thirs
• Less frequent urinatio
• Dark-colored urin
• Fatigu
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 • Dizzines
• Confusio
*Describe the main body uid compartments
(intracellular, interstitial and plasma), the major
differences in their composition, the factors
affecting water and solute transport between
the
The intracellular uid (ICF) compartment is the system that
includes all uid enclosed in cells by their plasma
membranes. Extracellular uid (ECF) surrounds all cells in the
body. Extracellular uid has two primary constituents: the uid
component of the blood (called plasma) and the interstitial uid
(IF) that surrounds all cells not in the blood

Composition of Body Fluid

The compositions of the two components of the ECF—plasma

and IF—are more similar to each other than either is to the ICF.
Blood plasma has high concentrations of sodium, chloride,
bicarbonate, and protein. The IF has high concentrations of
sodium, chloride, and bicarbonate, but a relatively lower
concentration of protein. In contrast, the ICF has elevated
amounts of potassium, phosphate, magnesium, and protein.
Overall, the ICF contains high concentrations of potassium and
phosphate , whereas both plasma and the ECF contain high
concentrations of sodium and chloride

Most body uids are neutral in charge. Thus, cations, or positively

charged ions, and anions, or negatively charged ions, are
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balanced in uids. As seen in the previous graph, sodium (Na+)
ions and chloride (Cl–) ions are concentrated in the ECF of the
body, whereas potassium (K+) ions are concentrated inside cells.
Although sodium and potassium can “leak” through “pores” into
and out of cells, respectively, the high levels of potassium and low
levels of sodium in the ICF are maintained by sodium-potassium
pumps in the cell membranes. These pumps use the energy
supplied by ATP to pump sodium out of the cell and potassium
into the cell

Solute Movement between Compartment

The movement of some solutes between compartments is active,

which consumes energy and is an active transport process,
whereas the movement of other solutes is passive, which does
not require energy. Active transport allows cells to move a speci c
substance against its concentration gradient through a membrane
protein, requiring energy in the form of ATP. For example, the
sodium-potassium pump employs active transport to pump
sodium out of cells and potassium into cells, with both substances
moving against their concentration gradients

Passive transport of a molecule or ion depends on its ability to

pass through the membrane, as well as the existence of a
concentration gradient that allows the molecules to diffuse from
an area of higher concentration to an area of lower concentration.
Some molecules, like gases, lipids, and water itself (which also
utilizes water channels in the membrane called aquaporins), slip
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 fairly easily through the cell membrane; others, including polar
molecules like glucose, amino acids, and ions do not. Some of
these molecules enter and leave cells using facilitated transport,
whereby the molecules move down a concentration gradient
through speci c protein channels in the membrane. This process
does not require energy. For example, glucose is transferred into
cells by glucose transporters that use facilitated transport

*Explain how drugs work, using paracetamol and

opiate analgesics as examples. MECHANISMS of
paracethamol and morphine – compare the

Patient and Docto

*De ne the term “vital signs” and be aware of age

related changes in values

Vital signs are measurements of the body's most basic

functions. The four main vital signs routinely monitored by
medical professionals and health care providers include the
following
• Body temperature.
• Pulse rate.
• Respiration rate (rate of breathing)
• Blood pressure (Blood pressure is not considered a vital
sign, but is often measured along with the vital signs.)
BODY TEMPERATUR
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 Normal body temperature does not change much with aging. But as

you get older, it becomes harder for your body to control its
temperature. A decrease in the amount of fat below the skin makes
it harder to stay warm. You may need to wear layers of clothing to
feel warm

Aging decreases your ability to sweat. You may have di culty telling
when you are becoming overheated. This puts you at high risk of
overheating (heat stroke). You can also be at risk for dangerous
drops in body temperature

Fever is an important sign of illness in older people. It is often the

only symptom for several days of an illness. See your provider if you
have a fever that is not explained by a known illness

A fever is also a sign of infection. When an older person has an

infection, their body may not be able to produce a higher
temperature. For this reason, it is important to check other vital
signs, as well as any symptoms and signs of infection

HEART RATE AND BREATHING RAT

As you grow older, your pulse rate is about the same as before. But
when you exercise, it may take longer for your pulse to increase and
longer for it to slow down afterward. Your highest heart rate with
exercise is also lower than it was when you were younger

Breathing rate usually does not change with age. But lung

function decreases slightly each year as you age. Healthy older
people can usually breathe without e ort

BLOOD PRESSUR

Older people may become dizzy when standing up too quickly. This

is due to a sudden drop in blood pressure. This kind of drop in
blood pressure when standing is called orthostatic hypotension
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 Risk of having high blood pressure (hypertension) increases as you

get older. Other heart-related problems common in older adults
include

• Very slow pulse or very fast puls

• Heart rhythm problems such as atrial brillation

*Understand the core/basic principles of

cardio-respiratory examinatio

*Describe the use of the audit cycle and

the role of structured re ection in
professional development
Audit in healthcare is a process used by health professionals
to assess, evaluate and improve care of patients in a
systematic way. Audit measures current practice against a
de ned (desired) standard. It forms part of clinical
governance, which aims to safeguard a high quality of clinical
care for patients.
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 *De ne what is meant by clinical

governance
Clinical governance may be defined as ‘the framework through which
healthcare organisations are accountable for continuously improving the
quality of their services and safeguarding high quality of care
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