Choanal Atresia: aetiology, symptoms, signs, investigations and treatment

Here we're going to illustrate how to diagnose and manage a case of Acute Appendicitis , which is a surgical emergency ?

 Aetiology

Age  : 20 - 30 yrs (If old age à suspect malignancy)

Diet : High protein diet predisposes to constipation à stasis & infection.

Causative organism  : E.coli, staph, strept

Route of infection   : Lumen, rarely blood & lymph

Predisposing Factors

Obstruction  à Due to hard faeces, adhesion, kink, oxyuriasis, F.B., tumors.

Anatomical factors  à Narrow lumen, wall rich in lymphoid follicles .

Pathology

A. Acute obstructive Appendicitis (2/3 of cases)

1.   Catarrhal inflammation à mucocele.

2.   Suppurative à pyocele or empyema

3.   Gangrenous inflammation

B. Acute non obstructive appendicitis (1/3 of cases)

Catarrhal, Suppurative, Gangrenous

Complications

General à Septicemia, toxemia, bacteremia or pyemia.

Local

1. Appendicular Mass

It is a localizing process by greater omentum to prevent spread of infection, needs 48 hrs (guided by chemotactic material)

Fate of Appendicular Mass :

1. Usually it resolves within few weeks.

2. Appendicular abscess.

Fate of Appendicular Abscess

·         point on abdominal wall, or vagina

·         or burst into peritoneal cavity à generalized peritonitis.

Position of appendicular abscess & mass à Depends on position of appendix

2. Diffuse peritonitis

·         If perforation < 48 hours,

·         Mucocele à pseudomyxoma peritonii.

·         Empyema or gangrenous type à diffuse suppurative peritonitis.

·         Appendicular abscess. (>48 hrs à points à rupture).

3. Chronicity

·         In non obstructive type

·         C/P: Dyspepsia due to reflex pylorospasm.

Clinical Picture

a. Symptoms

General: Fever , Headache , Malaise . (Fever is of low grade).

Local.

1. Pain à Colicky in obstructive type .

1- At first:  Generalized  , marked around the umbilicus .

2- After few hours : localized in right iliac fossa , at MacBerney’s point .

 3- Pain in the epigastrium due to reflex pylorospasm

2. History of recent constipation is common

3. Nausea, vomiting More in obstructive type (once or twice)

4. Anorexia is always present

b. General Examination à CB4 but fever not marked

c. Local Examination (more evident on McBurney's point)
1.     Rigidity
2.     Guarding
3. Rebound tenderness
4. ↓ intestinal movement.
5. Appendix may be felt on P.R.

Special Signs

·         Rovesing sign à pressure on Lt iliac fossa à pain on Rt iliac fossa

·         Hyperaesthesia of triangle of Sheren

·         Zachary cope à flexion, internal rotation of hip joint à pain in hypogastrium

·         Psoas test à Patient flexes right hip if appendix in contact with muscle.

·         Blumburg's sign à On & of pr. on Lt iliac fossa à pain in Rt iliac fossa.

Picture of complications

a. Appendicular mass:

·         History from 2-3 days.

·         Temp. > 38^oC, more tachycardia & vomiting.

·         Mass might be felt

b. Appendicular abscess: à History from 5-6 days + S, S of pus loculus

c. Peritonitis: History of appendicitis, Fever > 38C, Signs of diffuse peritonitis

Atypical forms

1. Retro caecal 75%. à Pain is minimal, But it might touch ureter à ureteric colic, loin pain & may be hematuria

2. Pelvic 20% à Pain in pelvis, Appendix felt in P.R

3. Paracaecal 1%.

4. Post ileal 0.5% à Touch ileum à diarrhea then constipation

5. Sub hepatic à as acute cholecyctitis but pt. is young & hyperaesthesia in usual site.

Investigation CB4 + leucocytosis, Urine analysis.

Treatment

1. Acute appendicitis =à Appendectomy.

2. Appendicular mass = (Oschner-Sherren’s) then appendectomy after 3 m.

What is Oschner-Sherren’s regimen ? 1.      Semi sitting position 2.      Ryle 3.      Intravenous fluids, Antibiotics 4.      Hot fomentation 5.      Follow up chart, Mark of the mass to follow it. 6.      Follow up of abdominal signs.

3. Appendicular abscess = (complicated mass)

1.      Muscle cutting incision

2.      Extraperitoneal drainage

3.      In pelvic abscess we drain through vagina,

4.      Appendectomy after 3-6 months.

4. Diffuse peritonitis CB4