INTESTINAL OBSTRUCTION COMPLICATING ACUTE PERFORATIVE APPENDICITIS

Upon preoperative diagnosis of acute small bowel obstruction, without an obvious cause, acute perforative appendicitis must be considered. Reevaluation of the history and careful reexamination of the physical findings with that diagnosis in mind should be carried out. If appendiceal disease is likely, maximum antibiotic therapy must be begun immediately along with the administration of fluids, electrolytes and other corrective therapy. A mercury-weighted small bowel tube should be inserted and every effort made to advance it into the small bowel before operation. Operative treatment should be restricted to the least possible. A McBurney incision is best unless wider operation is indicated. If an abscess is present, drainage alone may be the procedure of choice. Severely distended and decompensated small bowel must be decompressed, for if not relieved it can be the cause of death in acute perforative appendicitis. Decompression may be accomplished either by small bowel intubation with continuous suction or by enterotomy and aspiration. If not relieved, small bowel distention will be the mechanism responsible for death in a large percentage of patients with acute perforative appendicitis.     

ACUTE APPENDICITIS COMPLICATING PREGNANCY

Acute appendicitis occurs as a complication of pregnancy in about 0.1 per cent of cases. Diagnosis may be somewhat more difficult during the second and third trimesters dur to the displacement of viscera and the increased incidence of pyelitis and constipation. It is based on the same symptoms and signs as in nonpregnant patients.The treatment is immediate operation regardless of the stage of pregnancy. A McBurney incision is preferred and it is placed somewhat higher than usual in the later stages of pregnancy. When operation is done promptly there is little danger to either mother or fetus.     

UNDESCENDED TESTICLE COMPLICATING ACUTE APPENDICITIS

1. Symptoms referable to compression of the spermatic cord and incarceration of right testicle, obscure the underlying pathologic changes occurring in the vermiform appendix.2. Testicular underdevelopment and resulting subnormal cerebration.3. Operative technique:(a) Pre-operative diagnosis: Incarceration of right testicle and possible perforative appendicitis.(b) Descent of right incarcerated testicle. Bassini closure.(c) Exploratory laparotomy: Intramuscular gridiron incision.4. Operative findings:(a) Strangulation and incarceration of undescended right testicle and spermatic cord in inguinal canal.(b) Copious pus, free in peritoneal cavity. An adherent, sloughing, perforative, retrocecal appendix identified, left undisturbed and free drainage established.5. Progress:(a) Eventful recovery from acute suppurative appendicitis following drainage of appendical focus.(b) Marked development following the operative descent of an incarcerated testicle in a backward boy, age twelve, who had a bilateral cryptorchism.     

THE PREOPERATIVE AND POSTOPERATIVE CARE OF ACUTE ARTERIAL OBSTRUCTION

Acute arterial obstruction may result not only from arterial injuries but also from thrombosis or embolism. The fate of the extremity is generally decided in the first few hours following the obstruction of the major artery. It is therefore essential that physicians should be able to recognize acute ischemia of the extremities and institute treatment which will prevent permanent damage and facilitate the reestablishment of normal circulation.Direct application of heat should be scrupulously avoided since the reduced blood flow is unable to supply increased metabolic demand. The extremity should be placed at or just below heart level so as to avoid both the ischemia of elevation and the edema of dependency. Pressure in the form of either encircling plaster or even compression bandages should be avoided and the extremity simply immobilized by a posterior splint. General supportive treatment is essential to maintain adequate pressure and composition of the arterial blood. In selected cases, agents to overcome vascular spasm or to prevent extension of intravascular thrombosis are indicated.