Pathophysiology: Appendicitis

Obstruction of proximal lumen of appendix often caused by fecalith (hard mass of feces), foreign body, tumor, inflammation, edema of lymphoid tissue Appendix becomes distended, leading to inflammation, edema, ulceration and infection Within 24-36 hours tissue necrosis and gangrene result, leading to perforation and bacterial peritonitis if untreated

Appendicitis, Peritonitis, Diverticulitis mmagaldi@qcc.cuny.edu

Manifestations: Appendicitis

Initially: mild, generalized upper abdominal pain

Over 4 hours: Pain intensifies and localizes in RLQ of abdomen (McBurneys point) with rebound tenderness (relief of pain with direct palpation; followed by pain on release of pressure) Pain is aggravated by moving, walking, coughing Rovsings sign: palpation of LLQ causes pain in RLQ
Appendicitis, Peritonitis, Diverticulitis mmagaldi@qcc.cuny.edu

Manifestations: Appendicitis (contd.)

Low-grade temperature Anorexia Nausea Vomiting

Pain and local tenderness may be less acute in older adults, delaying diagnosis and treatment

Appendicitis, Peritonitis, Diverticulitis mmagaldi@qcc.cuny.edu

Diagnostic Tests: Appendicitis

WBC count with differential: neutrophils elevated Elevated C reactive protein Ultrasound Abdominal X-ray (flat/upright): fecalith may be visualized in RUQ or localized ileus noted FACT: focused appendicial computerized tomography
Appendicitis, Peritonitis, Diverticulitis mmagaldi@qcc.cuny.edu

Diagnosis: Appendicitis

Abdominal ultrasound: most effective for diagnosis; quick procedure; useful with older adult clients with atypical symptoms Pelvic examination: usually done on female clients of child bearing age to rule out gynecologic disorder or pelvic inflammatory disease Intravenous pyelogram (IVP): differentiate appendicitis from urinary tract disease
Appendicitis, Peritonitis, Diverticulitis mmagaldi@qcc.cuny.edu

Complications: Appendicitis

Perforation in 10-32% 24 hours after onset of pain Peritonitis Ileus Abscess

Appendicitis, Peritonitis, Diverticulitis mmagaldi@qcc.cuny.edu

Treatment: Appendicitis

IV fluids Electrolytes Antibiotic therapy Appendectomy

Laparoscopic Laparotomy (open abdominal)

Appendicitis, Peritonitis, Diverticulitis mmagaldi@qcc.cuny.edu

Post Op: Appendicitis

Analgesia NPO advance diet Antibiotics Wound Care

Appendicitis, Peritonitis, Diverticulitis mmagaldi@qcc.cuny.edu

Peritonitis

Inflammation of peritoneum with infection or chemical irritant Release of bile or gastric juices initially causes chemical peritonitis Enteric bacteria enter peritoneal cavity through a break of intact GI tract (i.e. perforated ulcer, ruptured appendix, diverticulum) Inflammatory process causes third spacing; leading to Hypovolemia, then septicemia

Appendicitis, Peritonitis, Diverticulitis mmagaldi@qcc.cuny.edu

Signs and Symptoms: Peritonitis

Abrupt onset of diffuse, severe abdominal pain Pain may localize near site of infection; intensifies with movement referred to shoulder Abdomen is tender, board-like:

Fever, malaise, hiccups, tachycardia Dehydration, shock (hypovolemic/septic) Respiratory compromise

Appendicitis, Peritonitis, Diverticulitis mmagaldi@qcc.cuny.edu

Decreased peristalsis Paralytic ileus Abdominal distention Nausea Vomiting

Diagnosis: Peritonitis

WBC with differential: elevated WBC (to 20,000) Blood cultures: identify bacteria in blood Abdominal X-ray: detect intestinal distension, air-fluid levels, free air under diaphragm (sign of GI perforation) Diagnostic paracentesis

Appendicitis, Peritonitis, Diverticulitis mmagaldi@qcc.cuny.edu

Treatment: Peritonitis

Antibiotics:

IV isotonic fluids: shock protocol Analgesics Laparotomy Peritoneal Lavage with isotonic fluid, antibiotics Drain in place, wound open O2 NG tube, NPO
Appendicitis, Peritonitis, Diverticulitis mmagaldi@qcc.cuny.edu

Cephalosporin Aminoglycoside Penicillin

Diverticular Disease

Diverticula are saclike projections of mucosa through muscular layer of colon, mainly in sigmoid colon Incidence increases with age; less than a third of persons with diverticulosis develop symptoms Risk Factors:

Cultural changes in western world with diet of highly refined and fiber-deficient foods Decreased activity levels Postponement of defecation

Appendicitis, Peritonitis, Diverticulitis mmagaldi@qcc.cuny.edu

Diverticulum

Appendicitis, Peritonitis, Diverticulitis mmagaldi@qcc.cuny.edu

Signs & Symptoms: Diverticulitis

Mild to severe LLQ pain Nausea Vomiting Fever Chills Leukocytosis

Appendicitis, Peritonitis, Diverticulitis mmagaldi@qcc.cuny.edu

Management: Diverticulosis

High residue diet:

Bulk forming laxative Avoid alcohol, seeds and nuts Increase fluids

Whole wheat Fresh fruit Vegetables

Appendicitis, Peritonitis, Diverticulitis mmagaldi@qcc.cuny.edu

Diagnostic Tests: Diverticulitis

Increased WBC and ESR (erythrocyte sedimentation rate) Decreased Hgb, Hct CT Scan Abdominal X-ray Ultrasonography Barium enema and colonoscopy after acute stage
Appendicitis, Peritonitis, Diverticulitis mmagaldi@qcc.cuny.edu

Complications: Diverticulitis

Perforation Peritonitis Abscess formation Bleeding Bowel obstruction Shock

Appendicitis, Peritonitis, Diverticulitis mmagaldi@qcc.cuny.edu

Treatment: Diverticulitis
<101F Monitor abdominal pain Clear liquids Antibiotics (Flagyl, Ciprofloxin or Bactrim) Mild Analgesics Avoid straining and bending Progress to low residue diet >101F IV fluids Antibiotics NPO, NG tube Anticholinergics Narcotics Surgery

Appendicitis, Peritonitis, Diverticulitis mmagaldi@qcc.cuny.edu

Surgical Management: Diverticulitis

Resection end-to-end anastomosis Resection with colostomy Multistage surgery:

Temporary Colostomy Patient returns for reversal of colostomy and anastomosis of bowel

Appendicitis, Peritonitis, Diverticulitis mmagaldi@qcc.cuny.edu