Acute appendicitis

Introduction
• Anatomy--- located at the base of the cecum, near the
ileocecal valve where the taenia coli converge on the
cecum.
• Blood supply--- appendiceal artery
• Attachment of the appendix to the base of the cecum is
constant. However, the tip may migrate to the retrocecal,
subcecal, preileal, postileal, and pelvic positions
• Function– immunologic organ, reservoir to recolonize the
colon with healthy bacteria.
• Epidemiology– most frequent in the 2 nd and 3rd decades of
life. M:F = 1.4: 1
 Pathogenesis

• Appendiceal obstruction --- increase in luminal and

intramural pressure--- thrombosis and occlusion of
small vessels and stasis of lymphatic flow.
• As lymphatic and vascular compromise progress, the
wall of the appendix becomes ischemic and then
necrotic.
• Intraluminal bacteria subsequently invade the
appendiceal wall and further propagate a neutrophilic
exudate. The influx of neutrophils causes a
fibropurulent reaction on the serosal surface, irritating
the surrounding parietal peritoneum
 Initial evaluation
• Clinical evaluation
• Laboratory tests
• Alvarado score
• Imaging
Management
Acute pancreatitis
 Introduction
• Pancreas is retroperitoneal organ
• Has 4 regions
• Embryologically formed by the fusion of a
ventral and dorsal bud.
• Blood supply is from multiple branches from
the celiac and superior mesenteric artery.
 Classification
• Acute interstitial edematous pancreatitis
• Acute necrotizing pancreatitis
• Based on severity----mild, moderate, severe
and critical.
 Etiology
• Genetic
• Congenital
• Mechanical
• Toxic
• Metabolic
• Drugs
• Infection
• Trauma
• Vascular
• miscellaneous
 Incidence and mortality
• Accurate assessment of the incidence and
mortality of acute pancreatitis is difficult
• Reported annual incidence– 4.9- 35 per
100000.
• Mortality in acute pancreatitis is usually due
to SIRS and organ failure in the first two
weeks, and due to sepsis and its complications
after two weeks.
Pathophysiology
 Diagnosis
• Acute onset persistent severe epigastric abdominal pain
• Associated nausea and vomiting.
• Dysnea
• Physical findings vary depending upon the severity and
cause of acute pancreatitis.
• Lab findings--- increase in pancreatic enzymes and
products--serum amylase and lipase; increase in TAP,
trypsin, phospholipase, pancreatic isoamylase; markers of
immune activation
• Imaging--- abdominal and chest radiographs; abdominal
ultrasound; abdominal CT;
 Complications
• Local--- acute peripancreatic fluid collection,
pancreatic pseudocyst, acute necrotic
collection and walled off necrosis.
• Systemic--- exacerbation of the underlying
comorbidity; pulmonary, cardiovascular,
hematologic, GI hemorrhage, renal,
metabolic, CNS and fat necrosis
• Organ failure
 Management
• Initial management---- resuscitate, pain
control, monitoring
• nutrition
• Antibiotics
• Treat complications– pancreatic,
peripancreatic, vascular complications and
systemic complications.
• Manage underlying predisposing condition
Perforated Peptic Ulcer Disease
 Perforated PUD
• Incidence 7-10% per 100,000 population per yr.

• M:F=2:1

• 30% no previous History PUD

• DU >GU

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 Risk factors
• NSAIDS
• H. pylori infection

• Smoking
• Ulcer character

• Post operation Stress

• MOF
 Predictors of poor outcomes
• Co morbid disease
• Advanced age
• The magnitude of physiological insult
• Persisting or advancing signs of peritonitis
• Pre operative delay of > 12 hours
• Perforated gastric ulcers
 Diagnosis
• History--- antecedent typical ulcer symptoms,
but some may present with silent ulcers.
• Clinical manifestation— depend whether
there is free perforation or walled off
perforation.
• Free perforation--- 3 phases
 Diagnostic Investigation
• Chest X-ray
– Air Under the diaphragm(70%)
– H.Pylori Test
– CBC
Rarely
• Plain Abdominal X-ray
• Abdominal Ultrasound
• Serum Amylase /lipase

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 Treatment
• Surgical Treatment(>95%)
– Preoperative Preparation
• IV-Fluids—NS/RL
• Antibiotics
• Analgesics
• NG-tube
• Catheterization
• Acid Suppression

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 Surgical options
• Simple patch closure
• Patch closure and HSV
• Patch closure and V+ D
• Distal gastrectomy
• Patch closure with biopsy
• Wedge excision and V+ D
 Mortality
• Average 5%
• Over 30% in some groups
• Delay >24 hours

• Preoperative Shock

• Comorbid Diseases

• Elderly
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