Appendicitis, Peritonitis, Gastro enteritis,Diverticulitis: introduction, definition, etioology, pathophysiology , clinical manifestaions, diagnosis and management of

1. INFLAMMATORY INTESTINAL DISORDERS
By
Y.V Vanaja
Lecturer
Vijay Marie College of Nursing

2. A part from the lower GI tract is susceptible to acute inflammation
caused by bacterial, viral or fungal infection.
 Appendicitis
 Peritonitis
 Gastroenteritis
 Diverticulitis

3. APPENDICITIS

4. Introduction
• The appendix is a small, finger-like appendage attached to the cecum
just below the ileo-cecal valve.
• Because it empties into the colon inefficiently and its lumen is small, it
is prone to becoming obstructed and is vulnerable to infection.
• The obstructed appendix becomes inflamed and edematous and
eventually fills with pus, this is called appendicitis

5. Definition
 Appendicitis is an acute Inflammation of the vermiform appendix.
Inflammation occurs when the lumen of the appendix is obstructed,
leading to infection as bacteria invade the wall of the appendix
“ “Ignatavivcious”
• Appendicitis is an inflammation of the appendix, a narrow blind tube
that extends from the interior part of the cecum. “Lewis”
• the appendix becomes inflamed and edematous as a result of either
kinked or occluded by a fecalith, tumor or foreign body
“Brunner”

6. INCIDENCE
• Males are affected more than females.
• Teenagers more frequently than adults.
• The highest incidence is in those between the ages
of 10 and 30years

7. Types of appendicitis

12.  Lumen of the appendix is obstructed as a result of fecaliths
 Less common causes are – malignant tumors
 Trauma to the abdomen
 Intramural thickening caused by hyper
growth of lymphoid tissue
 Venous engorgement
 Accumulation of mucus and bacteria

13. Pathophysiology
Obstruction can result from food matter, adhesion, or lymphoid hyperplasia
Mucosa continues to secrete fluid.
Increase in the intraluminal pressure and restricting the blood flow.
End result is perforation and spillage of infected appendiceal contents into the
peritoneum
as inflammation continues, serosa and adjacent structures become inflammed

14.  Resulting in the generalized or upper abdominal pain that becomes localized in the
RLQ
 eventually the inflamed appendix fills with pus
 If rapid process may result in peritonitis

15. Clinical manifestation

19. Painful urination
Severe cramps
Dunphy’s sign (increased pain with
coughing).
Obturator sign( pain on internal
rotation of right thigh)
Psoas sign (pain on extension of right
thigh).

20. Complications
 Perforation
 Peritonitis
 Abscess

26. Diagnostic evaluation
• Complete physical examination.
• Abdominal x-ray.
• Ultrasound
• Complete blood count
• CT scan
• Rectal exam
• Urine test

29. • Antibiotics
• NPO
• Iv fluid
• Analgesics
• Antiemetics
Medical
managemen

30. Surgical management
 laparoscopic Appendectomy
 A new procedure is known as Natural orifice transluminal endoscopic
surgery , does not require an external skin incision

32.  Laparotomy is an open surgical approach with a larger abdominal incision for complicated or
atypical appendicitis or peritonitis

33. PERITONOTIS

34. Introduction:
The peritoneum is the serous membrane forming the lining of the abdominal
cavity
Peritonitis is an inflammation of the peritoneum, the tissue that lines the inner
wall of the abdomen and covers and supports most of abdominal organs.
Peritonitis is usually caused by infection from bacteria or fungi.

35. Definition:
Peritonitis is an inflammation of the peritoneum, the serous membrane lining the abdominal cavity and
covering the viscera.
“Brunner”
Peritonitis is a life threatening, acute inflammation of the visceral/ parietal peritoneum and endothelial
lining of the abdominal cavity.
“ Ignatavicious”

36. Types of peritonitis
Primary peritonitis:
• Infection develops in the
peritoneum
Secondary
• Develops when an injury or
infection in the abdominal
cavity allows infectious
organism into the
peritoneum

37. Risk factors
Riskfactors for primary peritonitis:
 Liver disease (cirrhosis)
 Fluid in the abdomen
 Weakened immune system
 Pelvic inflammatory disease
Risk factors for secondary peritonitis include:
 Appendicitis (inflammation of the appendix)
 Stomach ulcers,
 Twisted intestine,
 Pancreatitis
 Inflammatory bowel disease,
 Injury caused by an operation.
 Peritoneal dialysis,
 Trauma.

38. I- Infected peritonitis:
 1) Generalized Infected peritonitis:
Perforation of the part of the gastrointestinal tract is the most
common cause of peritonitis
2) Systemic or localized infections (such as tuberculosis)
may rarely have a peritoneal localisation.
II –Non Infected Peritonitis
 Leakage of sterile body fluids into the peritoneum such as blood gastric juice

39. Pathophysiology
Due to etiological factors
Leakage of contents from abdominal organs into the abdominal cavity
Bacterial perforation
Edema of the tissues results and exudation of the fluid develops in short time
Fluid in the peritoneal cavity becomes turbid with increasing amounts of protein, white blood cells,
cellular debris and blood
Hyper motility of intestinal tract followed by paralytic ileus with an accumulation of air and fluid in
the bowel

40. Clinical manifestations:
 Abdominal pain
 Tenderness over the involved area
 Rebound tenderness
 Muscular rigidity and spasm
 Abdominal distention
 Fever
 Tachycardia
 Tachypnea
 Nausea, vomiting
 Altered bowel disease

41.  Muscular rigidity
 Peristalsis slows or stops in response to severe peritoneal
inflammation and the lumen of bowel becomes distended with
gas and fluid
 Respiratory problems can occur as a result of increased
abdominal pressure against the diaphragm from intestinal
distention and fluid shifts to the peritoneal cavity.

42. Diagnostic Evaluation:
 History collection
 Physical Examination
 CBC
 Serum electrolytes
 Abdominal X-ray
 Abdominal paracentesis & culture of fluid

43. Management
Nonsurgical management
 IV fluids and broad spectrum antibiotics
 Monitor daily weight and I/O chart carefully
 NG tube decompresses the stomach and the intestine.
 Patient is NPO
 Monitor O2 saturation and Apply O2 as prescribed
 Administer analgesics
 Antiemetics
 Intestinal intubation and suction assist in relieving abdominal
distention and in promoting intestinal function

44. Surgical Management
 Exploratory Laparotomy – surgical opening into the abdomen
Laparoscopy is used to remove or repair the inflamed or perforated organ
 Colon resection with or without colostomy for a perforated diverticulum
 Before the incision is closed the surgeon irrigates the peritoneum with antibiotic
solutions
 Several catheters may be inserted to drain the cavity and provide a route for
irrigation after surgery.

45. GASTROENTERITIS

46. Introduction
 Gastroenteritis is a medical condition characterized by inflammation of
the gastrointestinal tract that involves both the stomach the small
intestine resulting in some combination of diarrhea, vomiting, and
abdominal pain and cramping. It usually happens because of infection
by a virus or bacteria.
 It affects mainly the small bowel and can be caused by either viral or
bacterial infections, which have similar manifestations.

47. Definitions:
 Gastroenteritis is an increase in the frequency and water content of
stools and/or vomiting as a result of inflammation of the mucous
membranes of the stomach and intestinal tract
“ Ignatavicious”
Gastroenteritis is an inflammation of the mucosa of the stomach and
small intestine “ Lewis”

48. Types of Gastroenteritis:
TYPE CHARACTERISTICS
Viral Gastroenteritis :
Epidemic viral:
Rotavirus & Norwalk virus
• Caused by many parvovirus –type organisms
transmitted by the fecal-oral route in food and water
• Incubation period is 10-51hrs
• Communicable during acute illness
o Transmitted by the fecal-oral route or by contact with
infected animals or infants
o Incubation period 1-10 days
o Rotavirus is most common in infants and young
children
o Norwalk virus affects young children and adults

49. TYPE CHARACTERISTICS
Bacterial Gastroenteritis:
Campylobacter enteritis:
Escherichia coli diarrhea
Shigellosis:
• Transmitted by the fecal- oral route or contact
with infected animals or infants
• Incubation period – 1-10 days
• Communicable for 2-7 weeks
 Transmitted by fecal contamination of food,
water, or fomites
• Transmitted by direct and indirect fecal- oral
routes
• Incubation period 1-7 days
• Communicable during the acute illness to 4
after the illness
• Humans possibly carries for months

50. Etiology
 Most causes are self limiting and do not require hospitalization
 Gastroenteritis is usually caused by viruses. However, bacteria, parasites,
and fungus can also cause gastroenteritis.
 In children, rotavirus is the most common cause of severe disease.
 In adults, norovirus and Campylobacter are common causes.
 Eating improperly prepared food
 drinking contaminated water
 close contact with a person who is infected can spread the disease

52. Clinical Manifestations
 Nausea
 Vomiting
 Diarrhea
 Abdominal cramping and distention
 Fever
 Increased WBC
 Blood or mucus in the stool may be present
 In Patient with epidemic viral gastroenteritis – myalgia, headache, and malaise
 Weakness
 cardiac dysrhythmias due to hypokalemia

53.  Infection with the Norwalk virus has a rapid onset of nausea,
 abdominal cramps and diarrhea
 Campylobacter enteritis – foul smelling stools containing blood,
 20 to 30 stools per day for up to 7 days.
 E-coli GE – may or may not have blood in the stool.
 Diarrhea can last for up to 10days
 Shigella - causes stools to have blood acidic mucus which can continue for up
to 5 days

54. Diagnosis
 Stool culture
 serum glucose levels
 CBP
 Serum electrolytes

55. Management
 Monitoring of intake and output
 Fluid replacement
 IV fluids such as half strength normal saline to replace sodiulm lost in
vomitus
 Obtain weight and orthostatic B.P
 Until vomitings has ceased the patient should be on NPO status
 Skin care -

56. Drugs:
 Antiperistaltic agents an initial dose of loperamide
(Imodium) 4mg
 Antibiotics eg – ciprofloxacin, levofloxacin, azithromycin
 If GE due to shigellosis, antiinfective agents such as
trimethoprim/sulfamethoxazole

57. Diverticulitis

58. Introduction
Diverticula are small, bulging pouches that can form in the
lining of your digestive system. They are found most often in
the lower part of the large intestine (colon). Diverticula are
common, especially after age 40, and seldom cause problems.
Sometimes, however, one or more of the pouches become
inflamed or infected. That condition is known as diverticulitis .

59. Definitions:
Diverticulitis is the inflammation of one or more diverticula
“Ignatavicious”
Diverticulitis results when food and bacteria retained in
diverticulum produce infection and inflammation that can
impede drainage and lead to perforation or abscess formation.
“ Brunner”

60. Risk factors
 Congenital predisposition id suspected when the disorder occurs in those
younger than 40 yrs of age.
 Aging: The incidence of diverticulitis increases with age.
 Obesity.
 Smoking.
 Lack of exercise.
 Diet high in animal fat and low in fiber.
 Certain medications Several drugs are associated with an increased risk of
diverticulitis, including steroids, opioids and nonsteroidal anti-inflammatory
drugs, such as ibuprofen (Advil, Motrin IB, others) and naproxen sodium
(Aleve).

61. Causes
 Diverticula usually develop when naturally weak
places in your colon give way under pressure. This
causes marble-sized pouches to protrude through
the colon wall.
 High intraluminal pressure.
 Diet low in fiber
 Retained undigested food in diverticula

62. Pathophysiology
Due to High Intraluminal pressure
The muscle of the colon hypertrophies, thickens, and becomes rigid, and herniation of the mucosa and
sub mucosa through the colon wall
Decreased muscle strength in the colon wall
If undigested food or bacteria become trapped in a diverticulum, however blood supply to that area is
reduced
Bacteria invade the diverticulum
A diverticulum can become obstructed and then inflamed if the obstruction continues

63.  Which can perforate and develop a local abscess
 A perforated diverticulum can progress to an intra abdominal perforation with peritonitis.
 Inflammation can also result in fistulas to other organs, such as the bladder and the vagina

64. Clinical Manifestations:
 Signs of acute diverticulosis are bowel irregularity
 intervals of diarrhea
 Abrupt crampy pain in the left lower quadrant of the abdomen .
If diverticulitis is suspected
 Low-grade fever
 Nausea
 Abdominal pain
 Constipation
 Bleeding from the rectum
 Tenderness over the abdominal palpation
 Elevated temperature with chills
 Tachycardia

65. Diagnosis
 History collection
 Physical examination
 CBP
 Stool test for occult blood
 Urine analysis may show a few RBC
 X ray of the intestinal tract barium contrast
 Barium enema shows the diverticula of the large intestine
 Abdominal X ray too identify free air and fluid indicating perforation
 CT scan
 Abdominal Ultrasonography
 Colonoscopy 4 to 8 wks after acute phase– if rectal bleeding

66. Management
Nonsurgical management
 A combination of drug and no nutrition therapy with rest is used to decrease the
inflammation.
 Broad- spectrum antimicrobial drugs, such as metronidazole plus trimethoprim/
sulfamethoxazole or ciprofloxacin
 Opioid analgesics – such as morphine sulfate.
 IV fluids to correct Dehydration & IV drug therapy
 antispasmodics such as propantheline bromide and oxyphencyclimine
 Assess the patient on ongoing basis for manifestations of fluid and electrolyte
imbalance.
 Restriction of high fiber diet because it may cause irritation
 NPO
 NG tube - if nausea, vomiting or abdominal distention is severe.
 When inflammation is resolved and bowel function returns to normal, fiber
containing diet is introduced gradually

67. Surgical management
 Emergency surgery if peritonitis, bowel resection, or pelvic abscess is present.
 Colon resection with or without colostomy
 Some patients may have colostomy closure and anastomosis after the bowel
has been allowed to rest for 3 to 6 months
 The patient may have one of two surgical approaches
 Conventional open approach or
 Minimally invasive surgery via a laparoscopy

69. Postoperative care
 The patient may have drain in place at the abdominal incision site for
several days
 The stoma may be covered with a petroleum gauze dressing because the
colostomy does not drain for about 2 days or colostomy bag may be
placed over the stoma
 If the stoma is visible monitor for color and integrity
 The may be NPO with an NGT until peristalsis returns if open surgery is
performed
 A tight seal around the stoma is essential to avoid contact feces with the
skin
 Colostomy care