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General Surgery

Infections and Inflammations

An infection is the condition of multiplication of parasitic organisms or microorganisms within the body. An inflammation is the reactions that occur in the affected blood vessels and adjacent tissues in response to an injury or abnormal stimulation caused by a physical, chemical, or biologic agent. Many people use the terms interchangeably since they have several symptoms in common and usually are treated similarly.

Appendicitis :: Pancreatitis :: Hepatitis :: Cholecystitis
Esophagitis :: Peritonitis

Appendicitis

Appendicitis is an inflammation of the appendix, a small worm-like pouch attached to the large bowel. It can happen at any age but most cases are between 8 and 25 years of age. For young people, appendicitis is probably the most common cause of stomach pain requiring emergency surgery.

Causes

In most cases, the specific reason for the inflammation is not known but it is due to blocking of the opening connecting the large intestine and appendix. In many cases it is caused by small pieces of hardened stool (faecaliths) that get stuck in the appendix.

Symptoms

The first sign is usually a pain or discomfort in the centre of the abdomen. The pain usually begins near the umbilicus and moves down and to the right. This pain comes and goes in waves and increases on movement. Pain is often thought at first to be a simple stomach upset.

  • Nausea
  • Vomiting
  • Constipation
  • Diarrhoea
  • Inability to pass gas
  • Low fever that begins after other symptoms
  • Abdominal swelling
  • Anorexia

Diagnoses

  • The doctor takes a medical history from the patient and checks their temperature.
  • Blood and urine tests are performed to look for infection.
  • The doctor examines the patient by pressing on the lower right part of the abdomen and sometimes by inserting a finger in the anus (back passage) in order to exclude other causes of pain.
  • Women are often given a vaginal examination.

There is no one test that will diagnose appendicitis with certainty, usually doctors use CT scan or ultrasound to see whether the appendix looks inflamed. Surgery is performed on the basis of the doctor’s examination and results of the tests. Many diseases can cause the same symptoms as appendicitis.

Course of illness

The inflammation can cause infection, a blood clot, or rupture of the appendix. Because of the risk of rupture, appendicitis is considered an emergency. Anyone with symptoms needs to see a doctor immediately.

Treatment

  • Surgical removal of the appendix (appendicectomy) is the most common procedure. A 3-6cm horizontal incision is made in the lower part of the abdomen on the right side, through which the appendix is removed.
  • In some hospitals, the appendix is routinely removed by a keyhole operation or the insertion of a three-fibre optic camera through the stomach (laparoscopy).

In uncomplicated cases, a two to three day hospital stay is typical. The person can go home when their temperature is normal and their bowel starts to function again. The stitches are removed 10 days after the operation. A return to ordinary daily life within four to six weeks is usual.

Pancreatitis

Pancreatitis is an inflammation of the pancreas. The pancreas is a large gland behind the stomach and close to the duodenum. The duodenum is the upper part of the small intestine. The pancreas secretes digestive enzymes into the small intestine through a tube called the pancreatic duct. These enzymes help digest fats, proteins, and carbohydrates in food. The pancreas also releases the hormones insulin and glucagon into the bloodstream. These hormones help the body use the glucose it takes from food for energy.

Normally, digestive enzymes do not become active until they reach the small intestine, where they begin digesting food. But if these enzymes become active inside the pancreas, they start digesting" the pancreas itself. This process is called autodigestion and causes swelling, haemorrhage, and damage to the blood vessels. An attack may last for 2 days

Types

  • Acute pancreatitis occurs suddenly and lasts for a short period of time and usually resolves. Acute pancreatitis is usually caused by drinking too much alcohol or by gallstones. A gallstone can block the pancreatic duct, trapping digestive enzymes in the pancreas and causing pancreatitis.
  • Chronic pancreatitis does not resolve itself and results in a slow destruction of the pancreas. Chronic pancreatitis occurs when digestive enzymes attack and destroy the pancreas and nearby tissues. Chronic pancreatitis is usually caused by many years of alcohol abuse, excess iron in the blood, and other unknown factors. However, it may also be triggered by only one acute attack, especially if the pancreatic ducts are damaged.

Either form can cause serious complications. In severe cases, bleeding, tissue damage, and infection may occur. Pseudocysts, accumulations of fluid and tissue debris, may also develop. And enzymes and toxins may enter the bloodstream, injuring the heart, lungs, and kidneys, or other organs.

Acute pancreatitis generally causes severe pain and the sufferer will need emergency treatment in a hospital. Pancreatitis is generally diagnosed quickly, by examination of the abdomen, and confirmed using a series of medical tests, including:

  • General tests – such as blood tests, physical examination and x-rays.
  • Ultrasound – sound waves form a picture that detects the presence of gallstones.
  • CT scan – a specialised x-ray takes three-dimensional pictures of the pancreas.

Complications

Some of the complications from pancreatitis are: low blood pressure, heart failure, kidney failure, ARDS (adult respiratory distress syndrome), diabetes, ascites (accumulation of fluid in the abdomen) and cysts or abscesses in the pancreas.

Treatment options

Treatment depends on the causes and severity of the condition, but may include:

Acute pancreatitis

  • Hospital care– in all cases of acute pancreatitis.
  • Intensive care in hospital – in cases of severe acute pancreatitis.
  • Fasting and intravenous fluids – until the inflammation settles down.
  • Endoscopy – a thin tube is inserted through your esophagus to allow the doctor to see your pancreas.
  • Surgery – if gallstones are present, removing the gallbladder will help prevent further attacks. In rare cases, surgery is needed to remove damaged or dead areas of the pancreas.
  • Lifestyle change – eliminating alcohol.

Chronic pancreatitis

  • Lowering fat intake.
  • Supplementing digestion by taking pancreatic enzyme tablets with food
  • Eliminating alcohol.
  • Insulin injections, if the endocrine function of the pancreas is compromised
  • Analgesics for pain.

Hepatitis

The word "hepatitis" means inflammation of the liver. This can be caused by a number of things, such as chemicals, alcohol, drugs and infection by viruses.

The symptoms of acute viral hepatitis include fever, headache, lethargy, nausea, dark urine, pale stools and jaundice. The most commonly encountered viral hepatitis are type A, type B and type C.

Viral Hepatitis

Hepatitis A

Hepatitis A is a viral disease that affects the liver. It is spread by direct contact or by touching items that have been handled by, and contaminated with faeces from, an infected person. These can include food, drinks and other objects.

Hepatitis B

Hepatitis B is a viral infection that causes liver inflammation and can lead to serious illness or death. It is transmitted in several ways, including through unsafe sex and using other people’s needles. It can be passed from an infected mother to her baby. You can be immunised against hepatitis B.

Most people recover completely, but it can lead to cirrhosis (scarring) of the liver, increased risk of liver cancer and, in extreme cases, death. It is passed on by carriers who may not even know they have the virus.

Hepatitis C

Hepatitis C is a blood-borne virus which causes inflammation of the liver. It is most often transmitted through sharing needles, syringes and other equipment during drug use. There is currently no cure for hepatitis C and no vaccine to prevent it.

pdf Click here to open a PDF document on "An overview of Heptatitis A, B and C from Hepatitis C Council of NSW.

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Cholecystitis

An acute condition in which the gall bladder becomes inflamed and swollen because flow of bile into duodenum is blocked by Gallstones; result is biliary colic – intense pain in upper right abdomen or between shoulders, Indigestion, especially after fatty food, and Nausea with or without vomiting; untreated, condition can lead to Jaundice and occasionally, if gall bladder bursts, to Peritonitis. If site of pain is as described above, and pain persists for more than 3 hours, consult your doctor if there is no improvement in 2 hours.

Causes

  • Gallstones
  • Ischemia (decrease blood supply to gallbladder)
  • Secondary Infections

Symptoms

  • Often starts after a large fatty meal
  • Sudden, steady pain in the middle or right upper abdomen
  • Vomiting
  • Fever

Diagnoses

  • Medical History
  • Clinical examination
  • Abdominal X-ray
  • Ultrasound

Course of illness

If untreated cholecystitis may lead to

  • gangrene in the gallbladder may occur. This is a severe infection with destruction of tissue. Diabetics and the elderly are at highest risk.
  • Cholangitis– infection that occurs in common bile duct outside the gallbladder

Treatment

  • Bowel rest (no food or drink)
  • Intravenous fluid/feeding
  • Antibiotics to combat Infections. I.V. antibiotics may be used.
  • Pain medications
  • Laparoscopic Cholecystectomy, Surgical removal of the gallbladder 2-3 days after cholecystitis for most patients

What you should do?

Go to the Hospital emergency or call the local emergency number if you have symptoms that may indicate peritonitis, as it is a medical emergency.

Esophagitis

Alternative names: Indigestion and Heartburn

The term ‘indigestion’ is a layman’s term and is used to cover the symptoms of a few different medical conditions.

Medical conditions that are often described as ‘indigestion’ and which have ‘indigestion’ as a symptom are:

  • Heartburn (Gastoesophogeal reflux);
  • Ulcers;
  • Non-ulcer dyspepsia (when you have symptoms of an ulcer but no sign of ulcer on investigation);
  • Food intolerance, e.g. lactose intolerance;
  • Bloating and flatulence; and
  • Aerophagia (swallowing excessive amounts of air).

Many people with indigestion suffer in silence, sometimes for years, receiving little or no medical treatment apart from over-the-counter antacids.

While these are very effective in medicating heartburn, there are now many more medications available, which can provide perfect symptomatic relief.

There is also a greater awareness that acid reflux which causes the heartburn may damage the lining of the esophagus and increase the potential for serious health problems due to the process of chronic inflammation.

It is becoming increasingly important to treat your symptom of heartburn less casually and discuss the prospects for treatment with your doctor.

Peritonitis

Peritonitis is an inflammation of the peritoneum, which is the membrane that lines the wall of the abdomen and covers the abdominal organs.

Causes, incidence, and risk factors

Types of peritonitis include:

  • Spontaneous Peritonitis– an infection that occurs as a complication of ascites (a collection of fluid in the peritoneal cavity), which is usually related to liver or kidney failure.
  • Secondary Peritonitis – , caused by another condition, most commonly the spread of an infection from the digestive organs or bowels.
  • Dialysis associated Peritonitis – , This is an acute or chronic inflammation (irritation and swelling) of the peritoneum (lining of the abdominal cavity) that occurs in people receiving peritoneal dialysis.

Intra-abdominal abscess (abdominal abscess). This condition involves a collection of pus in the abdomen and may cause peritonitis. Before peritonitis develops, it can still cause symptoms that are similar or identical to peritonitis.

  • An intra-abdominal abscess may arise following:
  • Localisation of peritonitis
  • Gastrointestinal perforation
  • Anastomotic leak
  • Haematogenous (bloodstream) spread
  • They develop in sites of gravitational drainage
  • Pelvis
  • Subhepatic spaces
  • Subphrenic spaces
  • Paracolic gutters

Symptoms

  • Nausea
  • Vomiting
  • Abdominal pain, which increases on movement.
  • Abdominal tenderness
  • Abdominal distension
  • Fever
  • Low urine output
  • Point tenderness
  • Thirst
  • Fluid in the abdomen
  • Constipation
  • Inability to pass faeces gas
  • Signs of shock in extreme cases.

Diagnoses

  • Physical examination and medical history.
  • Blood tests including blood culture and X-rays or CT scans may be ordered.
  • Peritoneal fluid analysis( paracentesis) & culture

Treatment

The cause must be identified and treated promptly.

Treatment typically involves fluid infusion to control shock, surgery to drain the peritoneal cavity and repair the cause, and antibiotics to deal with the infection. In cases associated with peritoneal dialysis, antibiotics may be infused through the dialysis catheter, but if the infection is severe, the catheter itself must often be removed.

Treatment typically involves surgery and antibiotics. In cases associated with peritoneal dialysis, antibiotics may be infused through the dialysis catheter, but if the infection is severe, the catheter itself must often be removed.

Course of illness

The outcome is often good with treatment, but can be poor without treatment.
Sometimes the outcome is poor even with prompt and adequate treatment.

Complications

Peritonitis can be life-threatening and cause a number of different complications, depending on the type.

Complications may include

  • Peritonitis stops the movement of bowel contents (peristalsis), which can block the bowel (paralytic ileus).
  • Septic shock – Fluid from the blood accumulates in the abdominal cavity and the loss of fluid from the circulation may also cause shock.
  • Abscess
  • Intraperitoneal adhesions

What you should do?

Go to the Hospital emergency or call the local emergency number (such as 000, for Australia) if you have symptoms that may indicate peritonitis, as it is a medical emergency.