Parotitis is inflammation of the parotid salivary glands located on either side of the face. It is commonly caused by viral infections like mumps but can also result from other illnesses, medications that decrease saliva, or bacterial infections traveling from the mouth. Symptoms include pain in the ear and swollen glands that make swallowing difficult. Treatment involves antibiotics, pain relievers, maintaining hydration and nutrition, and discontinuing medications that reduce saliva secretion.

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2. Parotitis
 Parotitis is an inflammation of one or both parotid
glands, the major salivary glands located on either
side of the face, in humans.
 The parotid gland is the salivary gland most commonly
affected by inflammation
 Normally the salivary gland consists of
 The parotid gland, which is found one on each side of
the face below the ear
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4. The submandibular and the sumlingual glands,
which are found in the floor of the mouth
 If any inflammation occurs in parotid gland, it is
called Parotitis
Parotitis is a common inflammatory condition of
the salivary glands
Mumps or epidemic parotitis is a communicable
disease caused by viral infection and usually
affects children
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5. Risk factors for developing parotitis
 Elderly individuals
 Illness
 Chronically ill patients with decreased salivary
flow due to dehydration or medications like
antihistamine, lithium…
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6.  Pathophysiology
 Infecting organisms usually, the staphylococcus aureus travel
from the mouth through the salivary duct

 The gland swells and becomes tense and tender

 The patient fills pain in the ear, and swollen glands interfere
with swallowing.

 The swelling increases rapidly, and the overlying skin soon
becomes red and shiny
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7. Treatment
Treatment is based on lab investigation report, but for
relief you can suggest to patient, take anti-
inflammatory tablet, antibiotics
 Advise the patient to have dental examination
before any surgical procedure in the oral cavity
 Maintain adequate nutritional and fluid intake
 Advice the patient to have good oral hygiene
 Discontinue drugs that reduce the saliva secretion
 Antibiotic and analgesics
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8. • Although most people recover fully mumps can cause
complication
• Architis
• encephalitis
• meningitis
• Deafness
Prevention
• Once you have mumps, you are immune for life long
• Mumps can be prevented with mumps vaccine for
nd
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9. Ludwig’s angina
• Ludwig’s angina is a rare skin infection that occurs on
the floor of the mouth, underneath the tongue.
• This bacterial infection often occurs after a tooth
abscess, which is a collection of pus in the center of a
tooth.
• It can also follow other mouth infections or injuries.
• Ludwig’s angina often follows a tooth infection or
other infection or injury in the mouth.
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10. Symptoms
• The symptoms include swelling of the tongue and neck, neck pain,
and breathing problems.
• pain or tenderness in the floor of your mouth, which is underneath
your tongue
• difficulty swallowing
• drooling
• problems with speech
• redness on the neck
• weakness
• fatigue
• an earache
• a fever
• chills
• confusion
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11. Ludwig’s angina…
• As the infection progresses, you may also
experience trouble breathing and chest pain.
• It may cause serious complications, such as
airway blockage or sepsis, which is a severe
inflammatory response to bacteria.
• These complications can be life-threatening.
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12. Causes
• Ludwig’s angina is a bacterial infection.
• The
bacteria Streptococcus and Staphylococcus are
common causes.
• It often follows a mouth injury or infection, such
as a tooth abscess.
• The following may also contribute to developing
Ludwig’s angina:
– poor dental hygiene
– trauma or lacerations in the mouth
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13. Diagnosing Ludwig’s angina
• Physical exam, fluid cultures, and imaging
tests.
• Observations of the following symptoms are
usually the basis for diagnosis of Ludwig’s
angina:
– Your head, neck, and tongue may appear red and
swollen.
– You may have swelling that reaches to the floor of
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14. Treatment for Ludwig’s angina
 Clear the airway
• If the swelling is interfering with breathing, the
first goal of treatment is to clear airway.
• The physician may insert a breathing tube
through nose or mouth and into lungs.
• In some cases, they need to create an opening
through neck into windpipe in emergency
situations.
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15. Rx…
 Drain excess fluids
• Ludwig’s angina and deep neck infections are serious and
can cause edema, distortion, and obstruction of the airway.
• Surgery is sometimes necessary to drain excess fluids that
are causing swelling in the oral cavity.
 Fight the infection
• It’s likely to give intravenous antibiotics until the symptoms
go away. Afterward, then continue antibiotics by mouth until
tests show that the bacteria are gone and additional dental
infections treatment is recommended
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16. Rx..
• Get further treatment
• There might be need of further dental
treatment if a tooth infection caused the
Ludwig’s angina.
• If problem continues with swelling, there might
be surgery to drain the fluids that are causing
the area to swell.
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17. Ludwig angina…
• Delayed treatment increases your risk for
potentially life-threatening complications, such as:
 a blocked airway
 sepsis, which is a severe reaction to bacteria or
other germs
 septic shock, which is an infection that leads to
dangerously low blood pressure
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18. Prevention
• You can decrease your risk of developing Ludwig’s
angina by:
–practicing good oral hygiene
–having regular dental checkups
–seeking prompt treatment for tooth and
mouth infections
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19. ACHALASIA OF THE ESOPHAGUS (cardio
spasm)
 Esophagus (gullet) is a hollow muscular tube with a
length of approximately 25 cm and a diameter of
about 2 cm at its widest point.
 It extends from the pharynx in to neck and thorax
and, through an opening in the diaphragm; to the
stomach (it connects the pharynx to the stomach)
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20.  Has got two sphincter
1. The upper esophageal sphincter (Hypo
pharyngeal sphincter, which is located at the
junction of the pharynx and the esophagus)
2. The lower esophageal sphincter (Gastro
esophageal sphincter or cardiac sphincter
which is located at the junction of the
esophagus & the stomach)
 This sphincter guard the opening of the
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21. As waves of peristalsis push food through the
lower esophagus, the cardiac sphincter or
lower esophageal sphincter opens for
allowing food to enter and closes to keep food
in the stomach
If the lower esophageal sphincter (LES) dose
not close adequately, (An incompetent lower
esophageal sphincter), the contents stomach
can reenter the esophagus. The stomach
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22. • When these substances reenter the
esophagus, a burning sensation can result.
This condition is called Heart Burn (Pyrosis).
• If this reflux of acid continues, it can lead to
esophageal or gastric (stomach) ulcers
If the lower esophageal sphincter (LES) dose
not relaxes, as it should, food can be
prevented from entering the stomach.
This condition is called Achalasia (cardio
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23.  Is a chronic and progressive disease
characterized by ineffective peristalsis in the
body of the esophagus and failure of relaxation
of the lower esophageal sphincter on initiation
of swallowing.
 It is a motility disorder of the lower portion of
the esophagus, in which food cannot pass in to
the stomach
 It is also a motor disorder of the esophagus
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24.  Etiology
 Primary achalasia, which is idiopathic
Secondary Achalasia: This may be due to
gastric carcinoma, lymphoma, certain viral
infections, neurodegenerative disorders
Precipitating causes include esophageal cell
degeneration and vagal tone alteration
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25.  Pathophysilogy
The underlying abnormalities is absence of
effective or coordinated esophageal
peristalsis or failure of the cardiac sphincter
to relax
Lack of peristalsis or relaxation or spasm
dilates the esophagus and slows down
digestive transport
Degenerative cells in the mesenteric nerve
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26.  Clinical picture:
Dysphagia (difficulty swallowing) is the prominent
symptom
Patients are usually have a long history of
intermittent dysphagia
 Chest- pain /hurt burn (for both liquid and solid)
 Regurgitation
 Halitosis from food remnants retained in the
esophagus
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27.  Patient may feel sensation of food sticking in the
lower portion of the esophagus and patients often
learn to overcome this by drinking large quantities,
there by increasing the head of pressure in the
esophagus and forcing the food through
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28. Regurgitation and pulmonary aspiration are
the common complication, because of
retention of large volume of saliva and
ingested food in the esophagus
 Cancer of the esophagus is a rare complication of it
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29. Treatment
 Instruct the patient to eat slowly and to drink fluids
with meals
 For short-term benefit, give calcium channel blocker
(Like Nifedipine 10-20 mg before meal) and nitrates
to decrease esophageal pressure and improve
swallowing
 Endoscopic intrasphincter injections of botulinum
toxin
This drug acts by blocking cholinergic excitatory
nerves in the sphincter; and it inhibits the
contraction of smooth muscle
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30.  Balloon dilation (Pneumatic dilation)
It is conservative management; it helps to reduce
the LES pressure by tearing muscle fibers
 Surgically (Heller's myotomy)
Laparoscopic Myotomy is the procedure of choice/
Esophagomyotomy
In this procedure, the esophageal muscle fibers
are separated to relieve the lower esophageal
stricture
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31. 7/9/2023 31

32. Oesophageal diverticula
• Diverticulosis is when pockets
called diverticula form in the walls of your
digestive tract.
• The inner layer of intestine pushes through
weak spots in the outer lining.
 A diverticulum is a sac or pouch or more
layers the wall of an organ or structure
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33. Esophageal diverticulum occur as a result of
congenital or an acquired weakness of the
esophageal wall; so it is a pouch lined with
epithelium that can produce dysphagia and
regurgitation
• It is an out-pouching of the esophagus
usually where the esophagus passes through
the neck area (this is the weak portion)
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34. 1.Immediately above the upper esophagus
sphincter (pharyngeal pouch, pharyngoesophageal
pouch); it is called Zenker's diverticulum
This causes halitosis and regurgitation of saliva
and food particles consumed several days
previously
When it becomes large and filled with, such a
diverticulum can compress the esophagus and
cause dysphagia or complete obstruction
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35. 2. Near the middle of the esophagus (mid
esophageal diverticulum)
This may be caused by traction from old
adhesions or by propulsion associated with
esophageal motor abnormalities or with
extrinsic inflammation
3.Just above the lower esophageal sphincter
(epiphrenic diverticulum) above diaghragm
 This may be associated with achalasia
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36. 7/9/2023 36

37.  Pathophysilogy
The diverticulum trap food and secretion,
which then narrows the lumen, interfere with
the passage of food in to the stomach, and
exerts pressure on the trachea
The trapped food decomposes in the
esophagus causing esophagitis or mucosal
ulceration
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38.  Clinical presentation
1/3 of patient with epiphrenic divericula are
asymptomatic and the remaining 2/3 complain
 Dysphagia  Chest pain
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39.  Patients with Zenker's diverticula usually present
with
 Difficulty in swallowing
 Fullness in the neck, belching, regurgitation of
undigested food
 Gurgling noises after eating
 When the patient assumes a recumbent position
undigested food is regurgitated, and coughing may be
caused by irritation of the trachea
 Halitosis and a sore taste in the mouth, because of
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40.  Assessment and findings
Auscultation of the middle to upper chest
may reveal gurgling sounds
 Barium swallow: To determine the exact
nature and location of a diverticulum
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41.  Management
For mild symptoms
A bland soft semi soft or liquid diet to
facilitate passage of food
 Frequent eating habit (four to six small
meals)
For sever symptoms and patients with
pharyngoesophageal diverticulum require
surgical excision of the diverticulum
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42.  Diverticulectomy
 The sac is dissected free and amputated flush with
the esophageal wall
 During the surgical procedure, care is taken to avoid
trauma to the common carotid artery and internal
jugular veins
 Post operatively the nurse must observe the surgical
incision and the NG tube for any leakage from the
esophagus and for the development of fistula
 With held food and fluids until X ray studies, show
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43. Peritonitis
• Peritonitis is inflammation of the peritoneum,
the thin layer of tissue covering the inside of
your abdomen and most of its organs.
• The inflammation is usually the result of a
fungal or bacterial infection.
• This can be caused by an abdominal injury, an
underlying medical condition, or a treatment
device, such as a dialysis catheter or feeding
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44. Peritonitis…
• Usually, it is a result of bacterial infection; the
organisms come from diseases of the GI tract or,
in women, from the internal reproductive organs.
• Also as injury or trauma (eg, gunshot wound, stab
wound) or an inflammation that extends from an
organ outside the peritoneal area, such as the
kidney.
• Escherichia coli, Klebsiella, Proteus, and
Pseudomonas are most common bacteria
• Other common causes of peritonitis are
appendicitis, perforated ulcer, diverticulitis, and
bowel perforation
• Peritonitis may also be associated with abdominal
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45. Pathophysiology
• Peritonitis is caused by leakage of contents from abdominal organs
into the abdominal cavity, usually as a result of inflammation,
infection, ischemia, trauma, or tumor perforation. Bacterial
proliferation occurs.
• Edema of the tissues results, and exudation of fluid develops in a
short time.
• Fluid in the peritoneal cavity becomes turbid with increasing amounts
of protein, white blood cells, cellular debris, and blood.
• The immediate response of the intestinal tract is hypermotility, soon
followed by paralytic ileus with an accumulation of air and fluid in the
bowel.
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46. Causes
• Spontaneous bacterial peritonitis (SBP) is the
result of an infection of the fluid in your peritoneal
cavity.
• Kidney or liver failure can cause this condition.
People on peritoneal dialysis for kidney failure are
also at increased risk for SBP.
• Secondary peritonitis is usually due to an infection
that has spread from your digestive tract.
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47. Causes…
 The following conditions can lead to peritonitis:
– abdominal wound or injury
– A ruptured appendix
– a stomach ulcer
– a perforated colon
– diverticulitis
– pancreatitis
– cirrhosis of the liver or other types of liver disease
– infection of the gallbladder, intestines, or bloodstream
– pelvic inflammatory disease
– Crohn’s disease
– invasive medical procedures, including treatment for
kidney failure, surgery, or the use of a feeding tube
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48. Symptoms
• Symptoms will vary depending on the underlying cause of
your infection. Common symptoms of peritonitis include:
tenderness in your abdomen
pain in your abdomen that gets more intense with
motion or touch
abdominal bloating or distention
nausea and vomiting, diarrhea
constipation or the inability to pass gas
minimal urine output
anorexia, or loss of appetite related to paralytic
ileus
excessive thirst, fatigue
fever and chills
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49. • Clinical Manifestations
• At first, a diffuse type of pain is felt. The pain tends to
become constant, localized, and more intense near
the site of the inflammation.
• Movement usually aggravates it. The affected area of
the abdomen becomes extremely tender and
distended, and the muscles become rigid.
• Rebound tenderness and paralytic ileus may be
present.
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50. Assessment and Diagnostic Findings
• Delaying your treatment could put your life at risk.
• Ask medical history and perform a complete physical
exam.
• The leukocyte count is elevated.
• The hemoglobin and hematocrit levels may be low if
blood loss has occurred.
• An abdominal x-ray is obtained, and findings may
show air and fluid levels as well as distended bowel
loops.
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51. Dx…
₡ A blood test, called a complete blood count, can measure
WBC.
– A high WBC count usually signals inflammation or infection.
₡ A blood culture can help to identify the bacteria causing
the infection or inflammation.
₡ If fluid buildup in abdomen, a needle used to remove
some and send it to a laboratory for fluid analysis.
₡ Culturing the fluid can also help identify bacteria.
₡ Imaging tests, such as CT scans can show any
abscess,perforations or holes in the peritoneum
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52. Rx
• Peritonitis is a serious condition that needs immediate
attention.
• The first step in treating is determining its underlying
cause.
• Treatment usually involves antibiotics to fight infection and
medication for pain.
• If there is infected bowels, an abscess, or an inflamed
appendix, there may be need of surgery to remove the
infected tissue
• If on kidney dialysis and have peritonitis, wait until the
infection clears up to receive more dialysis.
• If the infection continues, you might need to switch to a
different type of dialysis.
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53. Rx….
 Treatment must begin promptly to avoid serious and
potentially fatal complications.
 Prompt intravenous (IV) antibiotics are needed to treat the
infection.
 Surgery is sometimes necessary to remove infected tissue.
The infection can spread and become life-threatening if it
isn’t treated promptly.
 Antiemetics are administered as prescribed for nausea &
vomiting. Intestinal intubation & suction assist in relieving
abdominal distention & in promoting intestinal function.
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54. Complications from peritonitis
• If it’s not treated promptly, the infection may enter your
bloodstream, causing shock may be from Shock may result
from (septicemia or hypovolemia) and damage to other organs
which can be fatal.
• The potential complications of spontaneous peritonitis include:
• hepatic encephalopathy, which is a loss of brain function that
occurs when the liver can no longer remove toxic substances
from your blood
• hepatorenal syndrome, which is progressive kidney failure
• sepsis, which is a severe reaction that occurs when the
bloodstream becomes overwhelmed by bacteria
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55. Complications…
• The complications of secondary peritonitis include:
• an intra-abdominal abscess
• gangrenous bowel, which is dead bowel tissue
• intraperitoneal adhesions, which are bands of fibrous
tissue that join abdominal organs and can cause bowel
blockage
• septic shock, which is characterized by dangerously low
blood pressure
• The two most common postoperative complications are
wound evisceration and abscess formation.
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56. Gastric diaorders
Its (the stomach) mean capacity varies from about 30 ml at birth,
increasing to 1000 ml at puberty and about 1500 ml in adults
It has got two orifices, called gastric orifice and pyloric orifice.
1. Cardiac orifice (gastro- esophageal sphincter): This is the
opening from the esophagus in to the stomach
The part of the stomach above the level of the cardiac orifice
is called the fundus
2. Pyloric orifice (pyloric sphincter): This is the opening in
to the duodenum
• This part of the stomach is usually indicated by a circular
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57.  The stomach is divided in to four parts
1. The cardia:
 The smallest part of the stomach
 Contains abundant mucous glands
 Helps protect the esophagus from the acids and enzymes of
the stomach
2. The fundus:
 This is found superior to the junction between the stomach and
esophagus
3. The body:
 This is the area between the funds and the curve of the "J"
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58. Gastric glands (gaster= stomach) in the fundus and
body secret most of the acids and enzymes involved
in gastric digestion
4. The pylorus:
 It is the curve of "J"
 It is divided in to a pyloric antrum which is connected to
the body, and a pyloric canal that empties in to the
duodenum, the proximal part of the small intestine
 The muscular pyloric sphincter regulates the release of
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59. The mixing of ingested substance with the secretion of
the glands of the stomach produces a viscous, highly
acidic, soupy mixture of partially digested food called
Chyme
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60. The upper two- thirds of the stomach contains parietal
cells, which secrets HCl and, Chief Cells, which
secrets pepsinogen
The parietal cells in the stomach increase acid
production in response to seeing, smelling and eating
food. The parasympathetic vagus nerve releases
histamine and acetylcholine, chemicals that also
stimulate the parital cells
An increase level of acids triggers the conversion of
Pepsinogen, (inactive pro enzyme), to pepsin, (an
7/9/2023 60

61.  The antrum contains mucus secreting and G- cells,
which secrete gastrin (Two forms, G 34 and G 17 (this
is the major form))
 Gastrin is a hormone that stimulate the activity of gastric
glands
 Mucus secreting cells are present throught the
stomach and secrete mucus and bicarbonate which is
trapped in the mucus gel
 Prostaglandin E, a lipid compounds secreted in the
stomach, apparently promotes the production of mucus,
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62.  The duodenal mucosa contains Brunner's glands,
which secrete alkaline mucus: This along with the
pancreatic and biliary secretions helps to neutralize
the acid secretion from the stomach, when it reaches
the duodenum
 The low PH of the stomach
 Kills most of the microorganism
 Denatures proteins and inactivates most of the
enzymes
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63. Gastric disorders
• ACUTE GASTRITIS
– Acute gastritis is an inflammation of the stomach
Cause
 Most commonly by ingesting that is irritating to the
stomach. They include
– Highly spiced food
– Infected food
– Drugs (e.g. A.S. A)
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64. • Pathophysology Gastritis
• in gastritis the gastric mucous membrane
becomes edematoes and Hyperemic
(congested with fluid and blood) and undergoes
surfaced erosion it secret a scanty amount of
gastric juice, containing very little acid but much
mucous superficial ulceration may occur and
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65. • S/S
– nausea
– hiccupping
– anorexia
– vomiting
– heart burning and sometime bleeding
– if the irritant is not costumed the mucosa repairs it
self in just 1 to 2 days
– Tiredness
– Dehydration and electrolyte in balance
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66. • Assessment and Diagnosis
–endoscope
–upper G.I radiographic studies
–Histological exam of tissue biopsy
–Detect in H.pylori
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67. Managements
–RX depends on the severity of the SX
–Identify and treat the cause
–Non- irritating diet
–Iv fluid
–MgOH(if caused by strong acid)
–Diluted lemon Juice (diluted vinegar) if strong
Alkaline
–Analgesics
–Sedative
–Teat H. pylori
–Surgery —removes gangrenous or perforated
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68. • CHRONIC GASTRITIS
– occurs with prolonged and repeated irritation of the
mucosa and results atrophic changes in the
mucosa and glands
• Cause
– Gastric carcinoma
– a cirrhosis of the liver
– ulcers of the stomach
– Chronic uremia
– Results of aging can cause an atrophic gastritis
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69. • S/S
– Anorexia
– Belching
– Bad taste in the mouth
– Nausea and vomiting
– Epigastria pain
– Wt loss and constipation
– Anemia
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70. Diagnosis
– Barium X-ray
– biopsy
– gastric analysis
– stool exam for occult blood
Managements
– Avoid aggravating factor
– Spicy hot
– fatty food
– Alcoholic drinks
– Treat H.pylori
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71. Pyloric stenosis
• Pyloric obstruction occurs when the area distal to
the pyloric sphincter becomes scarred and
stenosed from spasm or edema or from scar
tissue that is formed when the ulcer alternately
heals and breaks down
Symptoms
– Nausea ,Vomiting , Anorexia
– Epigastric fullness,
– Constipation
– Weight loss
Rx
– decompression of the stomach by NGT
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72. Pyloroplasty is a surgery performed to widen the
opening at the lower part of the stomach, also known
as the pylorus
• When the pylorus thickens, it becomes difficult for food
to pass through
• the surgery is performed to widen the band of muscle
known as the pyloric sphincter, a ring of smooth,
muscular fibers that surrounds the pylorus and helps
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73. 7/9/2023 73

74. Gastroduodenostomy and Gastrcjejunostomy
• Gastroduodenostomy is a surgical procedure
creates a new connection between
the stomach and the duodenum
• This procedure may be performed in cases
of stomach cancer or in the case of a
malfunctioning pyloric valve
• Gastrojejunostomy is a surgical procedure in
which an anastomosis is created between the
stomach and the proximal loop of the
jejunum.
• This is usually done either for the purpose of
draining the contents of the stomach or to
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75. Gastroduodenostomy and
Gastrcjejunostomy
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76. INTESTINAL OBSTRUCTION
• Intestinal obstruction exists when blockage
prevents the normal flow of intestinal
contents through the intestinal tract.
Two types of processes can impede this flow.
o The blockage also can be temporary and the
result of the manipulation of the bowel
during surgery
o The obstruction can be partial or complete.
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77. • Obstruction most frequently occurs in the young
and the old.
 The small bowel is most commonly affected, with
the ileum as the most common site of obstruction.
 Large bowel obstruction accounts for only 15% of
cases of bowel obstruction and the sigmoid colon
is the most common site of obstruction.

78. Intestinal obstruction…
Intestinal obstruction implies that there is
interference with the normal forward progress of
intestinal contents
 It may be either
 Mechanical (dynamic)
 Non mechanical (A dynamic) or Function
 Or it could be classified as: partial/ complete,
acute/chronic, small intestinal or colonic
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79. 1. Mechanical obstruction
 In this case there is physical occlusion of the lumen
preventing the intestinal contents from passing along the
intestine
 Most of the intestinal obstructions are due to mechanical
causes
 Causes of mechanical obstruction includes
 In the lumen
• Bolus of incompletely digested food
• Faecolith
• Plug of round worms or foreign materials
• Gallstone
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80.  In the wall
 Strictures (tuberculosis stricture)
 Thickening of the gut wall Crohn's disease)
 Tumors
 Outside the wall
 Hernia
 Adhesions
 Volvulus (twisting of the bowel)
 Intussusceptions (telescoping of the bowel)
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81. 2. Functional (Non –mechanical) or adynamic
In these case there is no –mechanical
obstruction, It is due to neurogenic failure (in the
myenteric plexus and the sub mucous plexus) of
peristalsis to propel the intestinal contents
 Causes includes
 Postoperative:
(Some degree of ileus occurs after every abdominal
operation.
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82.  The intestine can become adynamic (lacking peristalsis, a
condition referred to as paralytic ileus, which is common 12 to 36
hours after abdominal surgery) from an absence of normal nerve
stimulation to the intestinal muscle fibers
 Infective:
 Intraperitoneal inflammation
 Reflex (retroperitoneal pathological conditions)
 Fracture of the spine/fractured ribs
 Ureteric colic, hematoma
 Systemic disease
•Uremia, endocrine disorders (hyponatraemia/ hypokalaemia,
DM)
•Neurological disorders (Parkinson's disease)
7/9/2023 82

83. Risk Factors:
• Diseases and conditions that can increase risk of
intestinal obstruction include:
 Abdominal or pelvic surgery, which often causes
adhesions.
Crohn's disease.
 Cancer within your abdomen, especially if their a
surgery to remove an abdominal tumor or radiation
therapy.

84. Clinical Manifestations:
– Abdominal distention.
– Abdominal fullness, gas.
– Abdominal pain and cramping.
– Breath odor.
– Constipation.
– Diarrhea.
– Vomiting.
– Fever, peritoneal irritation, increased WBC count, toxicity,
and shock may develop with all types of intestinal
obstruction.

85. Tests and Diagnosis:
• Physical exam.
• Fecal material aspiration from NG tube
• Abdominal and chest X-rays:
o May show presence and location of small or large
intestinal distention, gas or fluid.
o Foreign body visualization.

86. Continue……
• Contrast Studies:
 Barium enema may diagnose colon obstruction or intussusception.
 Ileus may be identified by oral barium or Gastrografin.
• Laboratory Tests:
 May show decreased sodium, potassium, and chloride levels due to
vomiting.
 Elevated WBC counts due to inflammation; marked increase with
necrosis, strangulation, or peritonitis.
 Serum amylase may be elevated from irritation of the pancreas by the
bowel loop.
• Flexible sigmoidoscopy or colonoscopy may identify the source
of the obstruction such as tumor or stricture.

87. Management
1. Nonsurgical Management
2. Surgery

88. Nonsurgical Management:
1) Correction of fluid & electrolyte imbalances with normal
saline or Ringer's solution with potassium as required.
2) NG suction to decompress bowel.
3) TPN may be necessary to correct protein deficiency from
chronic obstruction, paralytic ileus, or infection.
4) Analgesics and sedatives, avoiding opiates due to GI
motility inhibition.
5) Antibiotics to prevent or treat infection.
6) Ambulation for patients with paralytic ileus to encourage
return of peristalsis.

89. Surgery:
• Consists of relieving obstruction. Options include:
Closed bowel procedures: lysis of adhesions,
reduction of volvulus, intussusception, or
incarcerated hernia
Enterotomy for removal of foreign bodies.
Resection of bowel for obstructing lesions, or
strangulated bowel with end-to-end anastomosis
Intestinal bypass around obstruction
Temporary ostomy may be indicated.

90. Complications:
Dehydration due to loss of water, sodium, and
chloride.
Peritonitis.
Shock due to loss of electrolytes and dehydration.
Death due to shock.

91. Most bowel obstructions occur in the small
intestine. Adhesions are the most common
cause of small bowel obstruction, followed by
hernias and neoplasms.
• Other causes include intussusceptions, volvulus
(ie, twisting of the bowel), and paralytic ileus.
• About 15% of intestinal obstructions occur in
the large bowel; most of these are found in the
sigmoid colon
The most common causes are carcinoma,
diverticulitis, inflammatory bowel disorders, and
benign tumors.
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92. SMALL BOWEL OBSTRUCTION
(SBO)
Pathophysiology
• Intestinal contents, fluid, and gas accumulate above
the intestinal obstruction.
• The abdominal distention and retention of fluid reduce
the absorption of fluids and stimulate more gastric
secretion.
• With increasing distention, pressure within the
intestinal lumen increases, causing a decrease in
venous and arteriolar capillary pressure.
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93. • This causes edema, congestion, necrosis, and
eventual rupture or perforation of the
intestinal wall, with resultant peritonitis.
• Reflux vomiting may be caused by abdominal
distention.
• Vomiting results in a loss of hydrogen ions and
potassium from the stomach, leading to a
reduction of chlorides and potassium in the
blood and to metabolic alkalosis.
7/9/2023 93

94. Clinical Manifestations
• The initial symptom is usually crampy pain
that is wavelike and colicky.
• The patient may pass blood & mucus, but no
fecal matter and no flatus.
• Loud sounds from the belly
• Constpation
• Vomiting occurs. If the obstruction is
complete, the peristaltic waves initially
become extremely vigorous and eventually
assume a reverse direction, with the intestinal
contents propelled toward the mouth instead
7/9/2023 94

95. SBO…
7/9/2023 95

96. • First, the patient vomits the stomach contents,
then the bile-stained contents of the
duodenum and the jejunum, and finally, with
each paroxysm of pain, the darker, fecal-like
contents of the ileum.
• The signs of dehydration become evident:
intense thirst, drowsiness, generalized
malaise, aching, and a parched tongue and
mucous membranes.
• The abdomen becomes distended.
• The lower the obstruction is in the GI tract, the
the more marked the abdominal distention.
7/9/2023 96

97. Assessment and Diagnostic Findings
• Diagnosis is based on the symptoms described
previously and on x-ray findings.
• Abdominal x-ray studies show abnormal
quantities of gas, fluid, or both in the bowel.
• Laboratory studies (ie, electrolyte studies and a
complete blood cell count) reveal a picture of
dehydration, loss of plasma volume, and
possible infection
7/9/2023 97

98. Medical Management
• Decompression of the bowel through a nasogastric or
small bowel tube is successful in most cases.
• When the bowel is completely obstructed, the
possibility of strangulation warrants surgical
intervention.
• Before surgery, intravenous therapy is necessary to
replace the depleted water, sodium, chloride, and
potassium.
• The surgical treatment of intestinal obstruction
7/9/2023 98

99. Adhesion
Most common causes of small bowel
obstruction
Mostly occur after abdominal operation.
Loops of intestine may become adherent to
these area.
Results- kinking of an intestinal loop.
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100. 7/9/2023 100
Volvulus
• Axial twist of a portion of the gastrointestinal (GI) tract
around axis of mesentery more than 180 degrees
about the axis causing partial or complete obstruction
of the bowel twisting of the intestines
 Bowel twists and turns on itself.
• Blood supply compromised by venous congestion,
leading to gangrene of the bowel and potential
infarction due to arterial obstruction
• Third most common cause of colonic obstruction (10-

101. 7/9/2023 101
Etiology
• Sigmoid (75%):
• Elderly
– Associated with chronic constipation and
concomitant laxative use
• Cecal volvulus (22%):
– Associated with increased gas production
(malabsorption and pseudoobstruction)
• Transverse colon (3%)

102. 7/9/2023 102
Physical Exam
• Presence of gangrenous bowel:
– Increased pain
– Peritoneal signs: rebound, and rigidity
– Fever
– Blood on rectal exam
– Tachycardia and hypovolemia
• Hx: Abdominal pain, distension, no flatus
or no bowel movements
• Exam: tympanic abdomen, distension,
mild tenderness, palpable mass

103. 7/9/2023 103
Tests
Lab
• CBC:
– Leukocytosis suggests strangulation with
infection/peritonitis.
• Electrolytes, blood urea nitrogen, creatinine, glucose:
– lactic acidosis
– Prerenal azotemia due to dehydration
• Urinalysis:
– Elevated specific gravity and ketones

104. 7/9/2023 104
Treatment
• Initial Stabilization
• ABCs
• Aggressive fluid resuscitation with 0.9% NS bolus of
20 mL/kg (peds) or 2 L bolus (adult)
• NGT
• Foley catheter
Medical
 Antibiotics
 Operative management

105. 7/9/2023 105
Intussusception
• The proximal bowel invaginates into the distal
bowel, producing infarction and gangrene of the
inner bowel:
 Is a telescoping of the bowel on itself.
 Is the tube with in a tube
• Morbidity increases with delayed diagnosis.

106. Etiology
• Most cases (85%) have no apparent underlying
pathology.
• Idiopathic (most common in children)
• Predisposing conditions for invagination:
– Masses/tumors:
– Infection:
• Adenovirus or rotavirus infection
• Parasites
– Foreign body
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107. 7/9/2023 107

108. 7/9/2023 108
Diagnosis
• Signs and Symptoms
• Fever
• Abdomen distended and swollen
• Classic triad (present in <50% of patients):
– Abdominal pain
– Vomiting
– Stools have blood and mucus
• Serum electrolytes, BUN
• Abdominal radiograph:
– Abdominal mass
– Apex of intussusceptum outlined by gas

109. 7/9/2023 109
Treatment
• Intravenous access and initiation of 0.9% NS at 20
mL/kg bolus
• Nasogastric tube
• Antibiotics:
– Initiate if evidence of peritonitis, perforation, or
sepsis.
– Ampicillin, clindamycin, and gentamicin
• Laparotomy:
– Procedure:
• Gentle milking of the intussusceptum

110. LARGE BOWEL OBSTRUCTION
(LBO)
• Pathophysiology
• As in small bowel obstruction, large bowel
obstruction results in an accumulation of
intestinal contents, fluid, and gas proximal to
the obstruction.
• a blockage that keeps gas or stool from passing
through the body
• Obstruction in the large bowel can lead to
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111. … LBO…
ꝊIf the blood supply is cut off, however, intestinal
strangulation and necrosis (ie, tissue death)
occur; this condition is life threatening.
ꝊIn the large intestine, dehydration occurs more
slowly than in the small intestine because the
colon can absorb its fluid contents and can
distend to a size considerably beyond its
7/9/2023 111

112. Clinical Manifestations
• LBO differs clinically from small bowel obstruction
in that the symptoms develop and progress
relatively slowly.
• In patients with obstruction in the sigmoid colon or
the rectum, constipation may be the only symptom
for days.
• Eventually, the abdomen becomes markedly
distended, loops of large bowel become visibly
7/9/2023 112

113. Assessment and Diagnostic Findings
• Diagnosis is based on symptoms and on x-ray
studies.
• Abdominal x-ray studies (flat and upright) show
a distended colon.
• Barium studies,if not perforated
7/9/2023 113

114. Medical Management
• A colonoscopy may be performed to untwist and
decompress the bowel.
• The procedure provides an outlet for releasing gas
and a small amount of drainage.
• A rectal tube may be used to decompress an area that
is lower in the bowel.
• The usual treatment, however, is surgical resection to
remove the obstructing lesion.
• A temporary or permanent colostomy may be
7/9/2023 114

115. Acute abdomen :-
• Is refers to a sudden, severe abdominal
pain.
• It is in many cases a medical emergency,
requiring urgent and specific diagnosis.
• may be caused by an infection,
inflammation, vascular occlusion, or
7/9/2023 115

116. Appendicitis
 The appendix: The normal adult appendix measures
9cm in average length, but it varies from 3-30cm
 It is a narrow blind tube and its only open end
communicates with the caecum
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117. Appendicitis
• Is an inflammation of a narrow blind protrusion
called the vermiform appendix, located at the tip
of cecum in the right lower quadrant (RLQ) of
the abdomen
 It is the most common cause of surgical
emergency
 Males are affected more than females and
teenagers, more than adults
7/9/2023 117

118.  Appendicitis, could be acute or chronic (which is a rare
situation)
 Acute appendicitis can be obstructive or non obstructive
in nature
 Obstructive Appendicitis
 This is Kinking of the appendix (obstruction)to the lumen
of the appendix due to foreign body; fecoliths, worms,
and tumor of intestinal parasite like Entamoeba
Non-Obstructive Appendicitis
 This is due to bacteria like E. coli, enterococci proteus,
7/9/2023 118

119.  Clinical picture:
 May be classified under three groups
 Group I
 Group II
 Group III
Group I
 These are clinical features which are common for all
cases of appendicitis
 The classical triad of symptoms
1. Pain
2. Vomiting
3. Mild fever
7/9/2023 119

120. 1. Pain:
This pain is visceral pain starting around the umbilical,
aching and cramping
The reason of the pain occurring in the umbilical area
is due to the fact that, the area has the same
segmental nerve supply as the appendix it self (T10)
 After a few hours the pain is shifts (shifting pain) to
the right iliac fossa, this pain is somatic pain, sharp in
type
The somatic pain is due to inflammation of parietal
7/9/2023 120

121. 2. Vomiting
This is due to reflux (Reflux vomiting), because of
an associated pylorospasm.
Therefore, Vomiting in appendicitis, occurs only
once or twice, till the stomach is empty
3. Fever
Low grade fever (100oF)
Fever indicate bacterial inflammation
High temperature will be found in established
peritonitis and with some abscesses
7/9/2023 121

122.  Physical sign
 Patient in pain
 Tongue looks dry
 Pulse become rapid
 Tenderness and rigidity over the right iliac fossa
 Rebound tenderness
 It is called Blumberg's sign or release sign; The
examiner apply gentle pressure in the suspected area
and withdrawn the hand suddenly and completely, if the
patient cry out in pain then the test is positive for
7/9/2023 122

123.  Rovsing's sign
 Palpation of left iliac region of abdomen
producing pain on the right iliac region (this may
be due to shift of coils of ileum to the right
impinging on an inflamed appendicitis)
 The intestinal sound may be absent, because of
7/9/2023 123

124. Group II
These features are according to anatomical location of the
appendix
 Retrocecal appendix
The distended caecum may prevent the palpating hand
from reaching the inflamed appendix. However it may lie
in contact with the psoas major, causing spasm of psoas
major muscle and cause low back pain, pain with hip
extension
o The client may report dysuria and urinary frequency due
to the inflamed appendix irritating the bladder
7/9/2023 124

125. … Group II…
Cope's Psoas test
When there is irritation of psoas major the patient may
prefer to keep the right hip fixed; any attempt to extend the
hip causes pain over the appendicular area (Cope's Psoas
test positive)
By instructing the client to lie on the unaffected side, and
hyperextending the right hip joint causes positive when
pain/irritation induced by stretching iliopsoas muscle
7/9/2023 125

126. …Group II…
Cope's obturator test
Due to irritation of the obturator muscle; when the
hip is flexed and internally rotated, the patient feels
pain in the appendicular area
In pelvic appendicitis
There may be frequency of micturation (this is
because of an inflamed appendix can contact ureter
and bladder resulting urinary syptoms) and also,
7/9/2023 126

127. o Group III: These features differentiating
between obstructive and non obstructive
In obstructive Appendicitis
 Acute onset
 Generalized abdominal pain from the start
 Vomiting is common (similar to intestinal
obstruction)
7/9/2023 127

128. Assessment and diagnosis
 Physical examination
 Laboratory and abdominal X ray findings
 Ultrasound, CT scan
 CBC: Elevated WBC count, leukocytosis count may
exceed 10,000 cells/ mm3
7/9/2023 128

129. Differential diagnosis
 Ameobic colitis (amoebiasis of the caecum)
 Ascariasis,
 Intestinal obstruction
 There is persistent colicky pain around the umbilicus with vomiting
 Peptic ulcer perforation, Acute cholecystitis, Acute salpingitis
 Ruptured graffian follicle, Twisted right ovarian cysts
 Ruptured ectopic gestation, Right ureteric colic
 Complications
 Perforation: the major complication
 Leads to peritonitis or an abscess
7/9/2023 129

130. Management
 Surgery is indicated if appendicitis is diagnosed
 Until surgery
 Administer fluid, electrolyte, antibiotic and
analgesics
Appendectomy with or without drainage is the
usual surgical management
For uncomplicated appendectomy, the patient can
be discharged on the day of surgery, if the
temperature is within normal range
7/9/2023 130

131. …… management…..
 Relieving pain
 Preventing fluid volume deficit, Attain optimal nutrition
 Reducing anxiety, Maintain skin integrity
 Eliminating infection from the potential or actual disruption of the
GIT
 Place the patient in a semi fowler position after surgery, this
helps to reduce the tension on the incision and abdominal
organs, helping to reduce pain
 Observe for complications, such as wound infection, peritonitis,
intra abdominal abscess and post operative ileus
7/9/2023 131

132. Complications
• Gangrene or perforation of the appendix, which
can lead to peritonitis, abscess formation, or
portal pylephlebitis, which is septic thrombosis
of the portal vein caused by vegetative emboli
that arise from septic intestines.
• Perforation generally occurs within 6 to 24
hours after the onset of pain and leads to
peritonitis
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