ACUTE INFLAMMATORY
INTESTINAL DISORDERS
Any part of the lower GI tract is susceptible to acute inflammation
caused by bacterial, viral, or fungal infection.Two such conditions are
appendicitis and diverticulitis,both of which may lead to peritonitis, an
inflammation of
the lining of the abdominal cavity.
Appendicitis
The appendix is a small, fingerlike appendage about 10 cm(4 in) long that is
attached to the cecum just below the ileocecal valve. The appendix fills with fo
od and empties regularly
into the cecum. Because it empties inefficiently and its lumen is small, the
appendix is prone to obstruction and is particularly vulnerable to infection (ie,
appendicitis).
Appendicitis, the most common cause of acute surgical abdomen in the
United States, is the most common reason for emergency abdominal surgery.
Although it can occur at any age, it more commonly occurs between the ages
of 10 and 30 years (NIH, 2007).
Pathophysiology
The appendix becomes inflamed and edematous as a result of becoming
kinked or occluded by a fecalith (ie, hardened mass of stool), tumor, or foreign
body. The inflammatory
process increases intraluminal pressure, initiating a progressively severe,
generalized, or per umbilical pain that becomes localized to the right lower
quadrant of the abdomen
within a few hours. Eventually, the inflamed appendix fills with pus.
Clinical Manifestations
Vague epigastric or periumbilical pain (ie, visceral pain that is dull and poorly
localized) progresses to right lower quadrant pain (ie, parietal pain that is
sharp, discrete, and well localized) and is usually accompanied by a low-
grade fever and nausea and sometimes by vomiting. Loss of appetite is
common. In up to 50% of presenting cases, local tenderness
is elicited at McBurney’s point when pressure is applied. Rebound tenderness
(ie, production or intensification of pain when pressure is released) may be
present. The extent of tenderness and muscle spasm and the existence of
constipation or diarrhea depend not so much on the severity of the
appendiceal infection as on the location of the appendix. If the appendix curls
Pain on defecation suggests that the tip of the appendix is resting against the
rectum; pain on urination suggests that the tip is near the bladder or impinges
on the ureter. Some rigidity of the lower portion of the right rectus muscle may
occur. Rovsing’s sign may be elicited by
palpating the left lower quadrant; this paradoxically cause Spain to be felt in
the right lower quadrant If the appendix has ruptured, the pain becomes more
diffuse;
, abdominal distention develops as a result of paralytic ileus, and the patient’s
condition worsens. Constipation can also occur with appendicitis. Laxatives
administered in this instance may result in perforation of the inflamed
appendix. In general, a laxative or cathartic
should never be given when a person has fever, nausea, and abdominal pain.
Assessment and Diagnostic Findings
Diagnosis is based on results of a complete physical examination
and on laboratory findings and imaging studies. The complete blood cell count
demonstrates an elevated white blood cell count with an elevation of the
neutrophils. Abdominal
x-ray films, ultrasound studies, and CT scans may reveal a right lower
quadrant density or localized distention of the bowel. A pregnancy test may be
performed for women
of childbearing age to rule out ectopic pregnancy and before x-rays are
obtained. A diagnostic laparoscopy may be used to rule out acute appendicitis
in equivocal cases.
Complications
The major complication of appendicitis is perforation of the
appendix, which can lead to peritonitis, abscess formation
(collection of purulent material), or portal pylephlebitis,
which is septic thrombosis of the portal vein caused by vegetative
emboli that arise from septic intestines. Perforation
generally occurs 24 hours after the onset of pain. Symptoms
include a fever of 37.7_C (100_F) or greater, a toxic appearance,
and continued abdominal pain or tenderness.
Medical Management
Immediate surgery is typically indicated if appendicitis is diagnosed.
To correct or prevent fluid and electrolyte imbalance,dehydration, and sepsis,
antibiotics and IV fluids are administered until surgery is performed.
Appendectomy (ie surgical removal of the appendix) is performed as soon as
possible to decrease the risk of perforation. It may be performed using
general or spinal anesthesia with a low abdominal
incision (laparotomy) or by laparoscopy. Both laparotomy and laparoscopy are
safe and effective in the treatment of appendicitis with perforation. However,
recovery
after laparoscopic surgery is generally quicker. Consequently, laparoscopic
appendectomy is more common. When perforation of the appendix occurs, an
abscess may
form. If this occurs, the patient may be initially treated with antibiotics, and the
surgeon may place a drain in the abscess. After the abscess is drained and
there is no further evidence
of infection, an appendectomy is then typically performed.
INTESTINAL DISORDERS
Any part of the lower GI tract is susceptible to acute inflammation
caused by bacterial, viral, or fungal infection.Two such conditions are
appendicitis and diverticulitis,both of which may lead to peritonitis, an
inflammation of
the lining of the abdominal cavity.
Appendicitis
The appendix is a small, fingerlike appendage about 10 cm(4 in) long that is
attached to the cecum just below the ileocecal valve. The appendix fills with fo
od and empties regularly
into the cecum. Because it empties inefficiently and its lumen is small, the
appendix is prone to obstruction and is particularly vulnerable to infection (ie,
appendicitis).
Appendicitis, the most common cause of acute surgical abdomen in the
United States, is the most common reason for emergency abdominal surgery.
Although it can occur at any age, it more commonly occurs between the ages
of 10 and 30 years (NIH, 2007).
Pathophysiology
The appendix becomes inflamed and edematous as a result of becoming
kinked or occluded by a fecalith (ie, hardened mass of stool), tumor, or foreign
body. The inflammatory
process increases intraluminal pressure, initiating a progressively severe,
generalized, or per umbilical pain that becomes localized to the right lower
quadrant of the abdomen
within a few hours. Eventually, the inflamed appendix fills with pus.
Clinical Manifestations
Vague epigastric or periumbilical pain (ie, visceral pain that is dull and poorly
localized) progresses to right lower quadrant pain (ie, parietal pain that is
sharp, discrete, and well localized) and is usually accompanied by a low-
grade fever and nausea and sometimes by vomiting. Loss of appetite is
common. In up to 50% of presenting cases, local tenderness
is elicited at McBurney’s point when pressure is applied. Rebound tenderness
(ie, production or intensification of pain when pressure is released) may be
present. The extent of tenderness and muscle spasm and the existence of
constipation or diarrhea depend not so much on the severity of the
appendiceal infection as on the location of the appendix. If the appendix curls
Pain on defecation suggests that the tip of the appendix is resting against the
rectum; pain on urination suggests that the tip is near the bladder or impinges
on the ureter. Some rigidity of the lower portion of the right rectus muscle may
occur. Rovsing’s sign may be elicited by
palpating the left lower quadrant; this paradoxically cause Spain to be felt in
the right lower quadrant If the appendix has ruptured, the pain becomes more
diffuse;
, abdominal distention develops as a result of paralytic ileus, and the patient’s
condition worsens. Constipation can also occur with appendicitis. Laxatives
administered in this instance may result in perforation of the inflamed
appendix. In general, a laxative or cathartic
should never be given when a person has fever, nausea, and abdominal pain.
Assessment and Diagnostic Findings
Diagnosis is based on results of a complete physical examination
and on laboratory findings and imaging studies. The complete blood cell count
demonstrates an elevated white blood cell count with an elevation of the
neutrophils. Abdominal
x-ray films, ultrasound studies, and CT scans may reveal a right lower
quadrant density or localized distention of the bowel. A pregnancy test may be
performed for women
of childbearing age to rule out ectopic pregnancy and before x-rays are
obtained. A diagnostic laparoscopy may be used to rule out acute appendicitis
in equivocal cases.
Complications
The major complication of appendicitis is perforation of the
appendix, which can lead to peritonitis, abscess formation
(collection of purulent material), or portal pylephlebitis,
which is septic thrombosis of the portal vein caused by vegetative
emboli that arise from septic intestines. Perforation
generally occurs 24 hours after the onset of pain. Symptoms
include a fever of 37.7_C (100_F) or greater, a toxic appearance,
and continued abdominal pain or tenderness.
Medical Management
Immediate surgery is typically indicated if appendicitis is diagnosed.
To correct or prevent fluid and electrolyte imbalance,dehydration, and sepsis,
antibiotics and IV fluids are administered until surgery is performed.
Appendectomy (ie surgical removal of the appendix) is performed as soon as
possible to decrease the risk of perforation. It may be performed using
general or spinal anesthesia with a low abdominal
incision (laparotomy) or by laparoscopy. Both laparotomy and laparoscopy are
safe and effective in the treatment of appendicitis with perforation. However,
recovery
after laparoscopic surgery is generally quicker. Consequently, laparoscopic
appendectomy is more common. When perforation of the appendix occurs, an
abscess may
form. If this occurs, the patient may be initially treated with antibiotics, and the
surgeon may place a drain in the abscess. After the abscess is drained and
there is no further evidence
of infection, an appendectomy is then typically performed.
