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1. APPENDICITIS

2. INTRODUCTION
• Appendicitis may be defined
as inflammation of the appendix.
• Acute appendicitis is a common
surgical pathology that typically
presents with acute abdominal pain.
• Paediatric appendicitis is a common
cause of acute abdominal pain in
children. Approximately 20 – 30% of
children presenting with acute
abdominal pain will be diagnosed with
acute appendicitis.

3. AETIOLOGY
ANATOMY:
• The appendix is an intraperitoneal hollow outpouching of the gut which
arises from the caecum.3
• It is suspended, by the mesoappendix, from the terminal portion of the
ileum and commonly sits retrocaecally.
• The appendix is thought to act as a reservoir for intestinal flora which
allows the gut to replenish its microbiome after gastroenteritis, but there
are usually no long-term consequences to removing it

4. PATHOPHYSIOLOGY
• Although the exact pathophysiology is unknown, the typical cause of inflammation
is obstruction of the opening of the appendix, as a result of either a faecolith
(hardened stool).
• These (FAECOLITH) are hard collections of stool that form and block the appendiceal
lumen. Other causes include lymphoid hyperplasia, fibrous stricture or carcinoid
tumours.
• Obstruction of the appendiceal lumen causes stasis and resultant bacterial
overgrowth. The proliferation of bacteria leads to an increase in intraluminal pressure.
• As the pressure rises in the appendix it causes venous and lymphatic congestion. As
the pressure rises further, the arterial supply to the appendix becomes compromised
leading to gangrene, perforation and generalised peritonitis.

6. CLINICAL FEATURES
• Patients classically complain of a colicky, peri-umbilical pain which
migrates to the right iliac fossa (RIF) and becomes constant.
• Common clinical features associated with acute appendicitis include
nausea, anorexia and constipation. Diarrhoea may be seen but is
typically mild when present.
• Acute appendicitis is uncommon at the extremes of age where it also
tends to have an atypical presentation. Pregnant women may have a
displaced appendix resulting in flank pain.
• A high degree of clinical suspicion is required as delayed treatment
results in high morbidity and mortality in both the mother and foetus.

7. SIGNS AND SYMPTOMS

8. MIGRATION OF PAIN IN APPENDICITIS
• Initial inflammation stimulates visceral afferent pain fibres which
correspond to the T10 dermatome, producing umbilical pain.
• As the appendix becomes more inflamed, it irritates the parietal
peritoneum which activates somatic nerve fibres and
produces localised pain which is most often felt in the right iliac
fossa.
Other important areas to cover in the history include:
• Urinary symptoms such as dysuria, frequency or haematuria
• Recent illnesses
• Pain history (looking for a history of migratory abdominal pain)

9. MUPHY’S TRIAD
• Murphy’s triad refers to a combination of clinical features often seen
in appendicitis and is made up of:
• Nausea and vomiting
• Low-grade fever
• Right iliac fossa pain

10. ALVADROS SCORE
The Alvarado score gives
an estimate of the likelihood
of appendicitis based
upon two major and six
minor criteria.

11. INVESTIGATION
A) Laboratory:
• There is no single lab test specific for the diagnosis of appendicitis. Many patients with
appendicitis will have leucocytosis, however, 10-20% of patients will have a normal white
blood cell count.
• The converse is also true. Many patients with leucocytosis will not have appendicitis, as
many other pathologies cause an elevated WBC.
• Both an elevated CRP and WBC have a combined sensitivity of 98%, and if both labs are
within normal limits the diagnosis is less likely.
• Urine studies should be obtained. They are useful for determining pregnancy, and evaluating
for infection and haematuria.
• Pyuria without bacteria present can be cause by inflamed appendix in close proximity to the
ureter or bladder. Haematuria without other findings could suggest a ureteral stone as the
cause of pain. Again, UA in isolation cannot rule out appendicitis.

12. B) ULTRASOUND
• Ultrasound is quickly becoming a more popular diagnostic tool in the
Emergency Department. It is the preferred imaging modality in children and
pregnant patients with suspected appendicitis due to the absence of
radiation.
• One multicentre cohort study found ultrasound to be 72.5-86% sensitive and
96% specific for appendicitis in children. The diagnostic accuracy is variable
depending on the skills of the sonographer and size of the patient.
• Ultrasound is typically much less sensitive in adults than children. A normal
appendix on ultrasound is typically less than 6 mm and compressible. An
appendix greater than 6-7 mm in diameter and non-compressible is
indicative of appendicitis.

13. C) CT SCAN
• CT is currently the preferred imaging study for evaluating acute appendicitis in adult males and
non-pregnant females.
• CT of the abdomen/pelvis is also more useful for evaluating alternative diagnoses, and
diagnosing complications of appendicitis (perforation, abscess, etc.).
• As with ultrasound, an enlarged appendix over 6-7 mm, increased wall thickness, fecalith, and
peri-appendiceal stranding can support the diagnosis.
• The overall sensitivity for IV contrast enhanced CT ranges from 95-100%, which is
considerably better than ultrasound.
• Similarly, specificity is around 96%. One study showed that non–contrast CT (90 % sensitivity
and 86% specificity) was inferior to CT with rectal only administered contrast (93% sensitivity
and 95% specificity) and CT with both IV and oral contrast (100 % sensitivity and 89%
specificity).

14. MANAGEMENT
• Appendicectomy is the most common management strategy for appendicitis, although
there are a few cases where this is not the immediate treatment:
 Stable patients who present overnight are generally not operated on overnight, with the
severity of their systemic inflammatory response guiding time to theatre
 In some cases of appendix masses, antibiotic therapy is commenced and appendectomy
is delayed by several months to allow inflammation to settle
 Children with large intraperitoneal abscesses are more commonly managed with
percutaneous drainage than surgery
• A laparoscopic approach is preferred for appendicectomy, and pre-operative antibiotic
therapy is usually given in both simple and perforated appendicitis.

15. ACTIVE OBSERVATION
• Active observation is a new concept in the management of appendicitis in children
with an appendiceal mass, and involves antibiotics and fluid therapy, without a
planned interval appendicectomy.
• During a recent trial, less than 25% of children randomised into the active observation
pathway had to undergo an appendicectomy, and the overall healthcare cost was less
than the traditional interval appendicectomy approach.
• These findings may lead to a change in practice in paediatric surgery to favour a
more conservative management style

16. COMPLICATIONS
If there is a delay in presentation with appendicitis, complications can
include:
Perforation, leading to generalised peritonitis
Abscess formation, usually requiring drainage
Complications of surgery include:
Bleeding
Wound infection

17. ACUTE
CHOLANGITIS

18. INTRODUCTION
• Acute cholangitis refers to infection of the biliary tree characteristically
resulting in pain, jaundice and fevers.
• Acute cholangitis almost always occurs due to bacterial infection secondary
to biliary obstruction. The terms acute and ascending cholangitis can be
used interchangeably.
• Biliary obstruction is often secondary to choledocholithiasis (gallstones in
the biliary tree) or biliary strictures (both benign and malignant).
Management involves antibiotics, supportive care and urgent
decompression of the obstructed biliary system.

19. ETIOLOGY
• Choledocholithiasis, stones in the bile duct, are the most common cause
of acute cholangitis.
1. Choledocholithiasis: Choledocholithiasis refers to gallstones within the
bile ducts. It occurs in around 10-20% of people with cholelithiasis
(gallstones).
• It should be noted that not all patients with choledocholithiasis develop
cholangitis, and such stones may be asymptomatic.
• Acute cholangitis occurs due to impaired drainage and bacterial
overgrowth. It is the most common cause of ascending cholangitis,
implicated in around 80% of cases.

20. 2. Benign strictures, leading to obstruction, may occur in the biliary tree
for numerous reasons: Chronic pancreatitis, Iatrogenic injury (e.g. during
cholecystectomy), Radio / chemo-therapy, Idiopathic
• Primary Sclerosing cholangitis is a chronic, progressive condition
associated with ulcerative colitis.
• It is characterised by inflammation and structuring of bile ducts. Although
the strictures are typically benign, patients are at increased risk of many
cancers including cholangiocarcinoma, gallbladder cancer and
hepatocellular carcinoma.
3. Malignant stricture: Malignant biliary strictures may lead to acute
cholangitis. Malignancies include cholangiocarcinoma, pancreatic cancer
and gallbladder cancer

21. CLINICAL FEATURES
• Ascending cholangitis often presents with
upper abdominal pain, jaundice and fevers.
• Ascending cholangitis was first described
by Charcot as a life-threatening condition.
We now know it may present with a wide
spectrum of symptoms though fever,
jaundice (may be sub-clinical) and pain are
common. Two sets of symptoms are often
described:
• Charcot's triad: RUQ pain, fever, jaundice
• Reynolds pentad: RUQ pain, fever,
jaundice, shock, confusion

23. INVESTIGATIONS
• Acute cholangitis is most commonly
investigated with USS, CT
abdomen/pelvis and MRCP.
• Patients typically presented with upper
abdominal pain, tenderness, jaundice
and fever.
• Blood tests reveal elevated
inflammatory markers and an
obstructive picture (raised bilirubin and
ALP, though transaminases may also be
elevated) on liver function tests.

24. IMAGING
• Ultrasound: allows assessment of the gallbladder for gallstones and
assessment of the CBD
• Computed tomography: good visualisation of the biliary tree, including the
distal portion, used where USS inconclusive, to evaluate for abnormal
lesions/tumours or where other diagnoses are suspected.
• MRCP: Magnetic resonance cholangiopancreatography offers excellent
visualisation of the biliary tree. Often used where CT/USS are inconclusive.
• ERCP: Endoscopic retrograde cholangiopancreatography involves the
endoscopic intubation of the ampulla of Vater. It offers excellent views of the
biliary tree whilst allowing therapeutic intervention such as drainage. ERCP is
now generally a therapeutic rather than diagnostic intervention

25. MANAGEMENT
• NB: Patients with an infected, obstructed biliary system require urgent drainage.
1. Medical care: Initial management should follow an ABC approach in those who
are acutely unwell. The sepsis 6 protocol should be implemented when indicated.
Key components of management include:
• Antibiotics: IV Augmentin or Tazocin would be standard initial agents. A stat
dose of an aminoglycoside (e.g. Gentamicin) may also be given. Antibiotics may
be adjusted to reflect culture results as they come in.
• Fluids: Intravenous fluids should be commenced in most patients, both
resuscitation and maintenance fluids are required.
• Analgesia: Should be tailored to the patient's needs, age and co-morbidities.
An example regimen would include regular codeine and paracetamol with
oramorph as required for breakthrough pain.

26. 2. Biliary drainage
• Drainage of the infected biliary system is key to effective management. It is now
achieved utilising non-operative techniques (except in very rare cases). There are
two main options:
a) ERCP: Typically first line and conducted by the gastroenterologists, it relies on the
passage of an endoscope into the duodenum and intubation of the ampulla of Vater.
b) PTC: Percutaneous transhepatic cholangiography may be used if ERCP fails, is
unavailable or inappropriate. Conducted by interventional radiologists it involves
percutaneous puncture to access the biliary tree through the liver. PTC allows for
drainage of the biliary system, stone retrieval and stent placement

27. • Further management depends on the underlying aetiology.
Elective cholecystectomy is indicated in those with gallstones
after a period of recovery.
• Those with strictures need the cause identified (if not already)
and may require further surgery/endoscopic management.
Malignancies are managed via appropriate MDTs

28. BOWEL OBSTRUCTION

29. INTRODUCTION
• Bowel obstruction refers to complete or partial disruption of the
normal flow of gastrointestinal content.
• It may occur in the small or large intestines, and is secondary to
mechanical obstruction and/or peristaltic failure (non-
mechanical).
• Classifying bowel obstruction depends on the location,
segments of intestines involved, underlying aetiology and
whether blood flow is compromised, which could lead to
ischaemia and perforation.

30. CLASSIFICATION

31. CLASSIFICATION
• Complete obstruction: no fluid or gas is able to pass beyond the site of
obstruction.
• Partial/incomplete obstruction: some fluid or gas is able to pass beyond
the site of obstruction.
• Mechanical obstruction: physical blockage to the flow of gastrointestinal
content.
• Non-mechanical obstruction (ileus): obstruction to flow secondary to
neuromuscular dysfunction (e.g. failure in peristaltic activity).
• Closed loop obstruction: the bowel is obstructed at two points, this
prevents proximal or distal decompression of contents. High-risk of rapid
necrosis and perforation.

32. 1. Mechanical (or dynamic) bowel obstruction refers
to physical obstruction to normal flow of bowel
contents.
a) Small bowel
• The most common cause of mechanical small
bowel obstruction within the western world is post-
operative adhesions. These refer to strands of
fibrous tissue that form following surgery and can
lead to the abnormal adhesion between intra-
abdominal tissue.
• Another major cause of mechanical small bowel
obstruction are hernias (e.g. inguinal hernias).
Loops of bowel can become trapped within the
hernial sac leading to obstruction and potentially
strangulation and infarction if not managed urgently.

33. b) Large bowel
• It is estimated that 60% of patients with mechanical large bowel
obstruction occurs secondary to colorectal malignancy.
• Other causes of mechanical large bowel obstruction are listed
below:
• Diverticular stricture (approx. 20% of mechanical large bowel
obstruction)
• Volvulus (approx. 5% of mechanical large bowel obstruction)
• Hernia

34. 2. NON-MECHANICAL
• Non-mechanical (or adynamic) bowel obstruction refers to a dilatation
of the bowel in the absence of mechanical blockage through failure of
normal peristalsis.
• Non-mechanical bowel obstruction is caused by impairment of the
muscles or nerves responsible for peristalsis. It may be divided into a
number of clinically distinct conditions.
• Terminology varies widely here and some texts would only consider
paralytic ileus here. We will also discuss acute colonic pseudo-
obstruction and toxic megacolon.

35. a) Paralytic ileus
• Paralytic ileus is the general slow-down of the intestines and affects the
entire intestinal tract (small and large bowel).
• Its aetiology is poorly understood though it is commonly seen post-
operatively. Other triggers include abnormal electrolytes and systemic upset.
b) Acute colonic pseudo-obstruction
• Also termed Ogilvie syndrome, ACPO refers to the dilations of the colon in
the absence of mechanical obstruction. Its aetiology is poorly understood
and likely multifactorial. A combination of systemic illness, medications and
biochemical abnormalities are implicated.
• The condition is also often seen in the post-partum setting, particularly
following caesarean section

37. CLINICAL FEATURES
• The classical features of bowel obstruction include abdominal pain,
distension, vomiting & obstipation.
• It is important to remember that each patient presents uniquely and
no one feature is diagnostic. If the overall picture fits with a diagnosis
of bowel obstruction arrange surgical review and consider imaging
options.
• Signs of systemic upset may be present if significant dehydration or a
complication (e.g. perforation, ischaemia) has occurred

39. INVESTIGATION
• Biochemical abnormalities frequently seen in bowel
obstruction include a raised lactate and
inflammatory markers.
• As bowel obstruction typically presents with acute
abdominal pain it is important to investigate other
potential causes.
• Furthermore, bowel obstruction can cause
significant dehydration, electrolyte derangements
and complications such as perforation.
• Therefore, investigations are essential to help
exclude and treat these potential issues.

40. LARGE AMOUNTS OF SUB
DIAPHRAGMATIC GAS ON CX

41. MANAGEMENT
• The management of bowel obstruction largely
depends on the underlying aetiology and
whether there is any evidence of complications
(e.g. ischaemia, perforation).
• Surgical management is dependent on
numerous factors including the underlying
aetiology, patient factors and the presence of
complications.
• It should be noted emergency surgery for bowel
obstruction carries significant morbidity and
mortality which must be conveyed to the
patient and next of kin.

42. 1. Supportive
• Supportive therapy should be employed in all patients presenting with
bowel obstruction, which involves bowel decompression and fluid
resuscitation.
• ‘Drip and suck’: this commonly used phrase refers to the administration
of IV fluid (drip) and the placement of an NG tube (suck).
• The use of a nasogastric tube (with regular aspirations) helps
decompress the stomach and prevent aspiration.
• Fluid resuscitation is essential due to the inability to maintain oral
hydration and the large amount of third spacing that occurs in bowel
obstruction.

43. 2. Large bowel obstruction
• Malignant obstruction: Surgical options (almost always via laparotomy) include de-
functioning stoma and resection with primary anastomosis. Non-surgical options include
endoscopic stenting.
• In non-surgical candidates this may represent the ‘definitive’ therapy, otherwise elective
intervention should be planned.
• Benign stricture: Typically require surgical intervention.
• Volvulus: A sigmoid volvulus may resolve with a promptly placed flatus tube. Following
this the patient should be considered for a definitive surgical procedure particularly if
recurrent.
• Caecal volvulus more commonly requires immediate surgical intervention. Immediate
surgical intervention is also indicated if there is evidence of perforation or ischaemia.

44. 3. Small bowel obstruction
• Obstructing lesions/complications: An obstructing lesion, evidence of
ischaemia or perforation, or a closed-loop are all indications for surgical
management. Options include resection and primary anastomosis or resection
with a de-functioning stoma. Surgery may be laparoscopic or via a laparotomy.
• Uncomplicated adhesional obstruction: Most will trial conservative
management, with early administration of an oral contrast agent (such as
gastrografin).
• If the gastrografin passes to the colon, there is evidence of resolving
obstruction, and the patient should be closely monitored.
• If there is deterioration or no resolution of the obstruction then surgical
management with adhesiolysis (+/- bowel resection) is indicated.

45. 4. Paralytic ileus
• Reversible causes should be considered and treated. Any electrolyte
abnormality should be corrected and adequate IVF administered.
• NG tube decompression is often indicated. Exacerbating agents such as
opiate analgesia should be reviewed.
• Commonly seen in the postoperative setting, it tends to settle with
conservative management

46. 5. Acute colonic pseudo-obstruction
• The treatment of ACPO involves the identification and treatment of any
underlying cause.
• Neostigmine, a cholinesterase inhibitor, may be given to encourage
motility. Endoscopic colonic decompression can be used in those failing
to respond.
• Those at increasing risk of or who have developed complications (e.g.
necrosis, perforation) will typically need surgical management if they are
appropriate candidates