Appendicitis

Clinical Features

• Symptoms: Abdominal pain starting around the navel, moving to right lower quadrant (McBurney’s point), nausea, vomiting, loss of appetite, low-grade fever (37.5–38°C).

• Signs: Tenderness at McBurney’s point, rebound tenderness (pain when pressure is released), Rovsing’s sign (pain in right lower quadrant when left side pressed), guarding/rigidity in severe cases.

• Explanation: Pain shifts as inflammation irritates the peritoneum; rebound tenderness indicates peritoneal irritation.

Basic Pathophysiology

• Appendix obstruction (e.g., by fecalith or lymphoid hyperplasia) leads to bacterial overgrowth, inflammation, and possible perforation.

• Explanation: Blockage traps bacteria, causing swelling and pressure that can rupture the appendix if untreated.

Management

• Diagnosis: Clinical assessment; ultrasound/CT scan if unclear.

• Treatment: Appendectomy (open or laparoscopic), antibiotics to prevent infection, IV fluids, pain relief (e.g., paracetamol).

• Explanation: Surgery removes the inflamed appendix to prevent rupture; antibiotics target infection.

Complications

• Perforation, peritonitis, abscess, sepsis.

Cholecystitis

Clinical Features

• Symptoms: Severe right upper quadrant pain, radiating to right shoulder, nausea, vomiting, fever, worse after fatty meals.

• Signs: Murphy’s sign (pain on gallbladder palpation during inspiration), right upper quadrant tenderness, possible jaundice.

• Explanation: Murphy’s sign occurs because the inflamed gallbladder is irritated when pressed during breathing.

Basic Pathophysiology

• Gallstones block cystic duct, causing bile stasis, inflammation, and sometimes bacterial infection.

• Explanation: Trapped bile irritates the gallbladder wall, leading to swelling and potential infection.

Management

• Diagnosis: Clinical evaluation, ultrasound (detects gallstones), blood tests (elevated white cell count, liver function tests).

• Treatment: Fasting, IV fluids, antibiotics, pain relief (e.g., NSAIDs), cholecystectomy (laparoscopic or open).

• Explanation: Fasting reduces gallbladder stimulation; surgery removes the gallbladder to prevent recurrence.

Complications

• Empyema, perforation, gangrene, pancreatitis.

Inguinal Hernia

Clinical Features

• Symptoms: Groin bulge (often reducible), discomfort/pain with coughing/lifting, dragging sensation.

• Signs: Visible/palpable bulge, cough impulse (bulge expands with cough), strangulated hernia shows severe pain, nausea, irreducible bulge.

• Explanation: The bulge is abdominal content protruding through a weak spot; strangulation cuts off blood supply.

Basic Pathophysiology

• Abdominal wall weakness allows protrusion of intra-abdominal contents; strangulation compromises blood supply.

• Explanation: A weak inguinal canal lets intestines or fat push through, risking tissue damage if trapped.

Management

• Diagnosis: Clinical examination; ultrasound if unclear.

• Treatment: Elective herniorrhaphy/hernioplasty for reducible hernias, emergency surgery for strangulated/incarcerated hernias, pain management.

• Explanation: Surgery reinforces the abdominal wall; urgent repair is needed if blood flow is compromised.

Complications

• Incarceration, strangulation, bowel obstruction.

Bowel Obstruction

Clinical Features

• Symptoms: Crampy abdominal pain, vomiting (more in small bowel obstruction), constipation, no gas passage, abdominal distension.

• Signs: Distended abdomen, hyperactive/absent bowel sounds, tenderness in complicated cases.

• Explanation: Pain and vomiting result from blocked intestinal contents; distension occurs from gas/fluid buildup.

Basic Pathophysiology

• Causes: adhesions, hernias, tumors, volvulus; obstruction causes fluid/gas accumulation, distension, potential ischemia.

• Explanation: Blockage stops normal intestinal flow, leading to pressure and possible tissue damage.

Management

• Diagnosis: Clinical assessment, abdominal X-ray (air-fluid levels), CT scan.

• Treatment: Nasogastric tube decompression, IV fluids, electrolyte correction, surgery for mechanical obstruction (e.g., adhesiolysis, resection).

• Explanation: Nasogastric tube removes trapped contents; surgery clears the blockage if conservative measures fail.

Complications

• Bowel ischemia, perforation, peritonitis, sepsis.

Perforated Peptic Ulcer

Clinical Features

• Symptoms: Sudden, severe epigastric pain (“burning/stabbing”), shoulder radiation, nausea, vomiting, fever.

• Signs: Rigid “board-like” abdomen, guarding, rebound tenderness, reduced/absent bowel sounds.

• Explanation: Pain is intense due to stomach contents leaking into the abdomen, irritating the peritoneum.

Basic Pathophysiology

• Chronic ulceration (H. pylori, NSAIDs) erodes mucosal wall, causing perforation and peritonitis.

• Explanation: Ulcer eats through stomach/duodenum, spilling contents into the peritoneal cavity.

Management

• Diagnosis: Clinical assessment, upright chest X-ray (free air under diaphragm), CT scan.

• Treatment: Urgent laparotomy/laparoscopic repair, antibiotics for peritonitis, proton pump inhibitors, IV fluids, pain relief.

• Explanation: Surgery closes the hole; antibiotics and PPIs treat infection and reduce acid.

Complications

• Peritonitis, sepsis, abscess.

Key Nursing and Healthcare Considerations

• Pre-operative: Monitor vital signs, give IV fluids/antibiotics, prepare patient (nil by mouth, consent).

• Post-operative: Check for complications (e.g., infection, bleeding), manage pain, encourage early ambulation, educate on wound care.

• Explanation: Monitoring prevents deterioration; early movement reduces risks like blood clots.

Review Questions

1. What are the key clinical signs of acute appendicitis?

2. Why does Murphy’s sign occur in cholecystitis?

3. How does a strangulated hernia differ from a reducible one?

4. What causes abdominal distension in bowel obstruction?

5. Why is urgent surgery needed for a perforated peptic ulcer?