Diagram to show the lines along which the peri...

Diagram to show the lines along which the peritoneum leaves the wall of the abdomen to invest the viscera. (Photo credit: Wikipedia)

What is Peritonitis?


Peritonitis is an inflammation (irritation) of the peritoneum, the thin tissue that lines the inner wall of the abdomen and covers most of the abdominal organs.



What are the causes of Peritonitis?


Peritonitis is caused by a collection of blood, body fluids, or pus in the abdomen (intra-abdominal abscess).


Non infective causes:


1. Endometriosis – sterile blood clots escapes during the period of menstruation


2. Gastric juice – sterile gastric acid may escape from a perforated gastric ulcer or cancer


3. Urine – can escape from the bladder during injury to the bladder


4. Bile or chemicals released by the pancreas (pancreatic enzymes) leak into the lining of the abdominal cavity.


Although initially sterile the body fluid may become infected once they leak of their organs.


Infective causes:


1. Spontaneous peritonitis is usually caused by infection of ascites a collection of fluid in the peritoneal cavity.


This usually occurs from severe liver such as Hepatitis B or C


2. Spontaneous peritonitis also occurs in patients who are on peritoneal dialysis for kidney failure.


3. Peritonitis may also occur due to inflammation, infection, or injury of the intestines such as appendicitis or diverticulitis.


4. Bacteria may enter the peritoneum through a hole (perforation) in the gastrointestinal tract such as by a ruptured appendix, stomach ulcer, perforated colon, or injury, such as a gunshot or knife wound.


5. Foreign contaminants can also cause secondary bacterial peritonitis if they get into the peritoneal cavity. This can occur during use of peritoneal dialysis catheters or feeding tubes.


6. Inflammation of the peritoneal cavity caused by bacteria can result in infection of the bloodstream (sepsis) and severe illness.


7. Secondary peritonitis can also affect premature babies who have necrotizing enterocolitis.


What are the symptoms of Peritonitis?




1. very painful abdomen or tender abdomen

The pain may become worse when the abdomen is palpated or when there is movement.


2. abdominal distention – the abdomen is bloated.


Other symptoms may include:


3. Fever and chills


4. Fluid in the abdomen


5. Passing little or no stools or gas


6. Excessive fatigue


7. Passing less urine


8. Nausea and vomiting


9. Racing heartbeat


10. Shortness of breath


How is Peritonitis diagnosed?


1. The abdomen is usually tender.


It may feel firm or “board-like.”


Persons with peritonitis usually curl up or refuse to let anyone touch the area.


2. Blood tests,


3. X-rays of abdomen may reveal dilated, edematous intestines


X-rays are mainly useful to look for gas below the diaphragm which suggest of gastrointestinal perforation.


4. CT scans of abdomen may be done.


5. Biopsy of the abdominal fluid


What are the complications of Peritonitis?


Peritonitis is life threatening and may cause a number of different complications:

1. loss of fluid and electrolyte with low blood volume


2. Shock


3. Renal Failure


4. Septicemia


What is the treatment of Peritonitis?




The cause must be identified and treated promptly.


Treatment typically involves


1. General supportive measures such as


a. vigorous intravenous rehydration


b. correction of electrolyte disturbances


2. antibiotics –

is given intravenously or into the peritoneum.


It is particularly effective against spontaneous bacterial peritonitis.


3. surgery –

laparotomy is needed to perform a full exploration and lavage of the peritoneum, as well as to correct any damage that may have caused peritonitis


What are the Preventive measures for Peritonitis?


Prevention depends on the cause.

Small intestine

Small intestine (Photo credit: Wikipedia)


What is Intussusception?


Intussusception is the telescoping of one part of the intestine into the distal (lower) part of the intestine.


Intussusception is most common in children between 3 months and 1 years of age.


Boys are affected 2 times more than girls.


It seldom occurs in children under 3 months of age or in older children.


It rarely occurs in adults.



How does Intussusception occur?


The process of intussusception involves a part of intestine (called the intussusceptum) telescopes into a more distal part (called the intussuscipiens) and pulls the accompanying mesentery, vessels, and nerves together into the intussuscipiens.


The compression of the veins and swelling of the region results in blockage of the lumen of the intestine and reduce the blood flow to the affected part of the intestine.


The pressure created by the walls of the intestine pressing together causes:


1. Decreased blood flow


2. Irritation


3. Swelling


Most cases affect the junction where the small intestine meets the large intestine.


Intussusception because of its obstruction effect on the intestine requires urgent attention and treatment.



What are the causes of Intussusception?


The causes of intussusception are not fully known although some viral and bacterial infections of the intestine may be a possible cause.


In older children and adults possible causes of intussusception may be due to polyps or tumors.



What are the symptoms of Intussusception?


Typical Symptoms of intussusception are:


1. abdominal pain or cramps often with the baby drawing up its knees when crying


2. vomiting episodes together with the abdominal pain.


The vomiting is not associated with food and may be like bile in color (yellow-green).


3. bloody and mucous stool (also called black currant jelly stools) may be present


Others symptoms are:


1. paleness,


2. lethargy,


3. fever


4. dehydration


5. shock



How is the diagnosis of Intussusception made?


Intussusception is diagnosed by:


1. history of abdominal pain, vomiting and black currant stools may suggest the diagnosis of intussusception.


2. On examination an abdominal “sausage-shaped” mass (the intussusception itself) can sometimes be felt on palpation of the abdomen.


3. Diminished bowel sounds may suggest obstruction.


4. Abdominal X-rays can show signs of an intestinal obstruction, with air-fluid levels, decreased gas, and unexplained masses, usually seen in the right lower region of the abdomen.


5. Ultrasound and CT scans are not necessary to make the diagnosis.


Early diagnosis and treatment of intussusceptions is essential in order to prevent complications such as:


1. injury to the intestine from blockage


2. perforation of the bowel,


3. sepsis


4. death.



What is the treatment of Intussusception?


The most important treatment in children is to treat dehydration.


Intravenous fluids are given to the child.


In additional a nasogastric tube is passed from the nose to the stomach


The treatment of intussusception may not require surgery.


1. In some cases, the intestinal obstruction can be reversed using a barium enema.


The barium liquid enters the large intestine and pushes its way up to the small intestine.


The pressure of the flow of the enema may push the telescoped small intestine out of its receptor and reverse the process of telescoping.


There is a risk of intestinal rupture.


2. If the above procedure is unsuccessful, surgery is necessary to reverse the intussusception and relieve the obstruction.


3. Any part of the intestine which has become gangrenous must be removed.


4. Intravenous feeding and fluids after surgery are continued until normal bowel movements returns.


What is the prognosis of Intussusception?


The prognosis for intussusception is usually good with early diagnosis and treatment.





The gallbladder and the bile ducts. Also calle...

The gallbladder and the bile ducts. Also called biliary system or biliary tree. (Photo credit: Wikipedia)

This article is from my Kindle ebook

English: Gallbladder
English: Gallbladder (Photo credit: Wikipedia)

A Simple guide to Gallstones and Gallbladder Diseases

E. Cholangitis – Inflammation of the bile duct.

Acute cholangitis is usually caused by a bacterial infection resulting from stagnation of the bile in the duct.

Choledocholithiasis which is a gallstone that gets stuck or lodged in the bile duct can create an obstruction that results in an infection.

Less often infections can occur due to a stricture or narrowing of the duct itself such as in Primary Sclerosing Cholangitis or may be associated with a cancer.

There is a blockage of the free flow of the bile causing a stagnant condition which allows the bacteria to take hold.

Symptoms associated with cholangitis are pain, fever, chills, jaundice, or yellowing, abdominal pain

F. Primary Sclerosing Cholangitis or PSC

PSC is a disease where the bile ducts of the liver harden blocking the flow of bile.

It is characterized by inflammation, breaking down of and eventual hardening or fibrosis of the bile ducts within the liver and outside the liver both (intrahepatic and extrahepatic bile ducts.)

It is most likely an autoimmune liver disease.

Symptoms include itching (caused by bile backing up into the blood stream), jaundice (yellowing also caused by back of bile into bloodstream), tenderness in upper abdomen caused by inflammation to the ducts (cholangitis) with possible fever and chills.

This is a very serious disease.

G. Cholestasis

Cholestasis is impairment of bile flow due to obstruction in small bile ducts (Intrahepatic Cholestasis) or obstruction in large bile ducts (Extrahepatic Cholestasis)

Symptoms are:

The blocking of the secretion of bile results in the bile backing up into the circulation.

This may result in excess bilirubin in the blood which would cause:

1. Jaundice – yellowing of the skin

2. Dark or tea colored urine

3. Stools pale or chalk colored.

The excess of bile salts in the systemic circulation may cause

4. Intense itching and skin irritation.

5. Fat in the stools due to malabsorption of fats

6. Clotting time of blood due to poor absorption of Vitamin K that various clotting factors are dependent upon.

H. Gallbladder Cancer

Rarely any symptoms with gallbladder cancer are noted early on.

In fact, it is often only discovered when the gallbladder is removed for other causes such as gallstones.

Because of this the gallbladder cancer is often quite advanced by the time it is diagnosed.

If detected early, removing the gallbladder and affected tissues in bile ducts is the standard treatment.

I. Gallbladder Polyps

Gallbladder polyps are benign growths that protrude from the lining of the gallbladder.

They are usually not obvious and seldom cancerous.

95% are non-cancerous. 10% are the result of inflammation.

Most polyps are the result of cholesterol deposits.

Gallbladder polyps do not usually show any symptoms and need no treatment.

They may be found accidentally on an ultrasound of the gallbladder done for some other reason.

There is usually no pain involved and any pain that is there is most likely due to something else such as gallstones.

Sometimes they may grow large enough to need surgical removal.




A Family Doctor’s Tale – COLON DISEASES


This article is from my Kindle ebook

A Simple Guide to Irritable Bowel Syndrome and Colon Diseases

Colonic pseudopolyps of a patient with intract...

Colonic pseudopolyps of a patient with intractable ulcerative colitis. Colectomy specimen. (Photo credit: Wikipedia)

What are Colon Diseases?

The colon is also known as the large intestine and a part of the digestive system.

It’s a long, hollow tube about 6 feet in length at the end of the digestive tract where the body makes and stores stool.

It can cause various symptoms including bleeding, infection and perforation.

Many disorders affect the colon’s normal ability to function properly.

Some of these include

1. Irritable bowel syndrome – an uncomfortable condition causing abdominal cramping and other symptoms

2. Diverticulitis – inflammation or infection of pouches in the colon

3. Ulcerative colitis – ulcers of the colon and rectum

4. Megacolon – abnormal dilation of the colon

5. Colonic polyps – extra tissue growing in the colon that can become cancerous

6. Colorectal cancer – malignant disease of the colon and rectum

7. Pseudomembranous Enterocolitis

Some symptoms of the colon are:

1. Abdominal pain can be crampy, achy or sharp, and can be intermittent or constant. Abdominal pain related to colon disease may come and go in waves and may be accompanied by bloating.

2. Most colon diseases cause changes in normal bowel habits; stools may become looser than normal and more frequent or less frequent, hard and difficult to pass

3. Weight loss and fatigue often accompany colon cancer, diverticulosis and ulcerative colitis.

 Treatment for colonic diseases varies greatly depending on the disease and its severity.

Treatment may involve diet, medicines and in some cases, surgery.



A Family Doctor’s Tale – GALLBLADDER POLYP


English: Gallbladder

English: Gallbladder (Photo credit: Wikipedia)

What is a Gallbladder Polyp?

A gallbladder polyp is a polyp present in the gallbladder/

Gall bladder polyps are rare.

The commonest type is known as the Mucosal Cholesterol Polyps (Polypoid Cholesterolosis).

They are often multiple small filling defects

Cholesterol Polyp of Gallbladder

Cholesterol Polyp of Gallbladder (Photo credit: euthman)

less than 10mm in diameter and are usually located in the middle 1/3 of gallbladder and do not become malignant.

The cholesterol polyps occur when excessive amounts of cholesterol are laid down in cells below the surface of the lining of the gall bladder.

They are associated with cholesterol gallstones 50-70% of the time.

There are other types of polyps that can occur in the gall bladder which can become malignant but are very rare.

The differentiation of benign from malignant lesions includes:

1. patient age,

2. polyp size,

3. number of polyps,

4. speed of growth of polyps

What are the symptoms of Gallbladder Polyp?

Most of the gallbladder polyp patients have no symptoms

How is diagnosis of Gallbladder Polyp made?

Usually gallbladder polyps are detected during abdominal ultrasonography performed for unrelated conditions such as gastritis or liver conditions

New imaging techniques such as

1. endoscopic ultrasonography

2. enhanced computed tomography,

may aid in the differential diagnosis of these lesions and help in the treatment.

What is the treatment of Gallbladder Polyp?

Surgery is the main treatment for Gallbladder Polyp.

Surgical removal of the gallbladder is done for:

1. asymptomatic individuals over 50 years of age

2. polyps are solitary,

3. polyp is greater than 10 mm in diameter

4. associated with gallstones or

5. polyp growth on serial ultrasonography

Nowadays, the operation is usually done by keyhole (laparoscopic) surgery with very small cuts in the abdominal wall.

Hospital stay is only for one or two nights

The patient should be able to get back to work in two or three weeks.

Sometime a more traditional operation involving a larger cut into the abdomen may be necessary .This will require a stay of a week in the hospital and a slightly longer recovery period.

Both types of operation are very safe.

The traditional operation may be painful after the operation but this can be treated by strong painkillers.

After a gallbladder operation it is healthier to avoid fatty foods if possible.

A low fat diet can help, preferably including steamed or boiled vegetables, fruit, pasta which is oil free, steamed or poached fish or skinless chicken, grilled lean meat, skimmed milk, soya protein such as tofu, brown bread, various types of beans and pulses such as lentils.

Most people can eat moderate amounts of all their favorite foods without trouble.

It is best to avoid alcohol if you have liver or gallbladder trouble.

It is also best to avoid smoking because of all the toxins in the cigarette’s chemicals.




What are Stomach Polyps?


Stomach. (Photo credit: Wikipedia)

Stomach polyps are benign abnormal swellings that can grow out of the lining of the stomach and protrude above the mucosal lining.

Very rarely a gastric polyp can go on to form cancer.

Most stomach polyps are often not undetected for long periods of time.

What are the causes of Stomach Polyps?

1. Benign Stomach polyps are formed when the lining of the stomach mucosa forms abnormally or when an inflammatory event takes place.
Ninety percent of stomach polyps found are non-neoplastic.

There are three types of non-neoplastic polyps:
1, hyperplastic
They occur singly in the antrum, or in multiples at the more distal regions of the stomach. Hyperplastic polyps are small, often measuring less than two centimeters in diameter. They are either sessile (without a stalk) or pedunculated (with a stalk).

2 inflammatory,
Inflammatory types of polyps may be associated with chronic gastritis that is caused by Helicobacter pylori, a bacterium residing in the stomach.
Gastritis is an inflammation of the mucosal lining in the stomach.

3. Fundic polyps.
Fundic polyps are usually found in the upper part of the stomach and are common in middle aged women.
They are associated with the:

Congenital conditions such as
a. familial adenomatous polyposis
b attenuated familial adenomatous polyposis syndromes
c. Cowden’s syndrome

and acquired causes such as
a. chronic use of proton pump inhibitors
b. Zollinger-Ellison syndrome

2. Malignant Stomach Polyps form the other ten percent.
These polyps may form full-fledged carcinomas.
Most Adenomatous polyps are neoplastic.
Most Stomach polyps on endoscopy are usually tiny, numerous and sessile and never have a stalk
They have the same color as the gastric mucosa,

What are the symptoms of Stomach Polyps?

They present with the same symptoms of gastritis:
1. epigastric pain

2. nausea

3. vomiting

4. weight loss

5. Bloating of the abdomen

6. heart burn or acid reflux

How is diagnosis of Stomach Polyp made?

Usually gastroscopy of the stomach will reveal the presence of stomach polyps.
A biopsy of the polyps seen on gastrocsopy will confirm whether they are benign or malignant.

What are the complications of Stomach Polyps?

Only rare cases (ten %) the polyps may become cancerous

What is the treatment of Stomach Polyps?

When polyps are seen in the stomach on gastroscopy they are usually removed and sent for biopsy.
If benign, the removal of the polyps is all that is necessary.
If malignant, surgical removal of the part of stomach may be required followed by radiotherapy or chemotherapy depending on the stage of the cancer.

What are the preventive measures for Stomach Polyp?

There is no way to prevent stomach polyp except by.
1. Living a healthy lifestyle
2. Not drinking a lot of alcohol or smoking.
3. Avoid preserved food
4. Treat H.pyrori infections of the stomach early.
5. Eat a diet high in fresh fruits and vegetables, and vitamin C.
Vitamin C is found in foods such as oranges, grapefruit and broccoli.

A Family Doctor’s Tale – DIVERTICULOSIS


Endoscopic image of diverticulosis

Image via Wikipedia


Diverticulosis are pouches in the wall of the colon.

Main symptoms are abdominal pain and bloating and constipation.

Treatment is mainly by control of diet, prevention of constipation and antispasmodics for pain.

Rarely diverticulitis  a infection of the colon pouches may be needed to be treated with antibiotics.

Generally prognosis is good.

Diverticulosis is a disorder of the colon or large intestine where there are one or more sac-like pouches(called diverticula) in the walls of the colon.

It is more common in the descending and sigmoid colon.

Diverticulosis becomes more obvious with age.
50% of people over the age 0f 60 years have Diverticulosis.

The exact cause of Diverticulosis is not known.

It has been suggested that a low-fiber diet is the main cause of diverticular disease.

Diverticulosis is common in developed countries where low-fiber diets are common whereas it is rare in Asia and Africa where people eat high-fiber vegetable diets.

Fiber prevents constipation which can make the muscles strain and increase pressure in the colon.

This increased pressure makes the weak spots in the colon lining to bulge out like pouches and become diverticula.

Most cases of Diverticulosis have no or little symptoms.

In the more severe cases, the main symptoms of Diverticulosis are:

1.Abdominal pain or cramps-usually over the left side or over the lower abdomen



The symptoms can range from mild to severe.

Diagnosis of Diverticulosis is made by:

1.A history of abdominal pain especially on the left lower abdomen, bloating and constipation

2.The physical exam consists of
a.palpation of the left abdomen for tenderness or masses rectal exam to detect tenderness or blood.

3.stool may be tested for blood

4.blood tests(WBC,ESR,bood culture) are done for evidence of infection.

5.Xrays of the abdomen and barium enema may be done to show evidence of pouches in the colon

6.Colonoscopy is also done to confirm evidence of diverticulosis and exclude malignant tumours.

Complications of Diverticulosis are:

Diverticulitis occurs when diverticula become infected with bacteria, viruses or become inflamed.
Bacteria are caught in the pouches and develops into diverticulitis suddenly.

The symptoms and signs of diverticulitis are:
1.abdominal pain usually continuous in the lower left abdomen with tenderness

2.fever due to infection,

3.nausea, vomiting,



6.rectal tenderness

Diverticulitis can lead to:

Bleeding can be severe caused by a small blood vessel in a diverticulum that weakens and finally bursts.
Surgery may be needed to stop bleeding if bleeding continues.

2.Abscess, Perforation, and Peritonitis
Often a few days of treatment with antibiotics will cure the diverticulitis.
If the infection gets worse, an abscess which is an infected area with pus may form in the colon.

Small abscesses usually clear up with antibiotics.

More severe abscesses may require drainage of the pus using a catheter.

If pus leaks from perforations in the lining of the colon, then it can cause infection in the abdominal cavity and results in peritonitis.

This is an emergency and requires immediate surgery to clean up the pus in the abdominal cavity and removal of the damaged part of the colon.

3.Intestinal Obstruction
The infection of the diverticula can cause scarring of the lining of the colon resulting in partial or total blockage of the large intestine.

If the obstruction blocks the intestine completely, emergency surgery is required to allow faecal matter to pass through.

A temporary colostomy may be necessary.

occurs as an abnormal connection between two organs or between an organ and the skin.

It results from the damaged tissues coming together and an opening is left between the two tissues.

Usually the bladder, small intestine, vagina, and skin are the organs involved.

The most common fistula occurs between the bladder and the colon especially in men. This can cause a long-lasting infection of the urinary tract.

Surgery may be necessary to remove the fistula as well as the damaged part of the colon.

5.Urinary tract infections occurs frequently due to the fistula and proximity of the bladder to the infected colon.

6.Discharge of faecal material may occur through a fistula between the colon and vagina in some women.

Treatment of Diverticulosis is by:

1.pain medications will relieve any pain symptoms.

2.Antispasmotic medication for spams of the colon

3.Antibiotics may be needed in diverticulitis and complications such as urinary infection and peritonitis.

1.high-fiber diet

a.whole grain breads and cereals;
b.fruit like apples and peaches;
c.vegetables like carrots, broccoli, spinach, carrots, cabbage, beans.

2.fiber product such as Metamucil once a day.

3.Avoid nuts, popcorn, pumpkin, and sesame seeds or any food which can cause discomfort in the abdomen

1.Antibiotics to treat the infection and inflammation,

2.resting the colon by bed rest, nasogastric suction and a liquid diet stay to prevent complications such as abscess. if the attacks are severe or there are complications.
The surgeon resects the affected part of the colon and then joins the remaining sections.

Surgery is also done for complications such as a fistula or intestinal obstruction.

Emergency surgery may be done for a large abscess, perforation, peritonitis, or continued bleeding.

Prognosis of Diverticulosis is fair.

About 1% develop diverticulitis.
70% of patients with acute attacks of diverticulitis can be treated with medical management and have no further attacks

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( A Simple Guide to


Intestines (Photo credit: Wikipedia)

Constipation)  by definition is a condition which is characterized by fewer than normal bowel movement than usual.
It is accompanied by straining, incomplete evacuation and passage of hard stools. 

Many people do not realize the discomfort and abdominal cramps a patient with constipated hard stool stuck in his rectum and anus. Because of the pressure of the hard stool, he is sometimes unable to pass urine. His tummy feels bloated and constant peristaltic wave causes constant abdominal cramps and cold sweats. 
There are even patients who are unable to stand straight because of the pain. 
In the severe cases I have to evacuate the hard stools manually. Once the hard stools comes out from his anus, the patient could relax and breathe again. Unfortunately the stink in the consultation room may need the family doctor evacuate his room and use another consultation room.
Constipation is particularly common among the elderly and younger children because of:

1. Insufficient fiber (fruits,vegetables) to form bulk in the stools.

2. Insufficient fluid in the diet(at least 8 glasses of water).

3. Insufficient time to go to toilet when there is the urge to pass motion.

4. Insufficient exercise to help the intestine to move especially after meals, common in sedentary jobs and older people

5. Stress cause the constriction of the anal sphincter preventing the stools from passing.

6. Depression on the other hand depress the movement of the intestines.

7. Drugs like cough mixture containing codeine, antispasmodic, antacids may also reduce the motility of the intestine.

8. Pregnancy in the later stage cause the womb to press against the intestine.

9. People with low thyroid hormone slows down the movement of the intestines.

10.People with piles or pelvic space occupying swelling which may press against the intestine or rectum.

Avoidance of constipation include:

1. Increase in daily fiber intake to at least 15gm (eg. 1 bowl of bran cereal for breakfast), fruits and vegetables).
Fiber increases the bulk of the stool allowing easy passage of stools through the large intestine.

2. Drink at least 8 glasses of water a day (2 liters). Water reduces the hardness of stools.

3. Regular exercises at least 2-3 times a day especially after meals. Exercise will enhance intestinal movement.

4. Allow a distraction free period of 15 min a day for bowel movement. The strongest intestinal movement occurs after breakfast.

5. Do not ignore or suppress the urge to pass bowel movement. This may impair the sensation to detect initiation of bowel movement leading to constipation.

Treatment of  Constipation
1.Follow the advice above.

2.Consult your family doctor to exclude any abdominal swelling which may be blocking the passage of stools.
A colonoscopy may be needed to check the large intestines for tumors or early cancer.
Your piles may be removed during the colonoscopy if found to be obstructing passage of stools.

3.Try Yogurt or fermented milk with lactobacillus as a method to stimulate more production of bulk in stools.

4.Try not to take laxatives unless it is deemed necessary by your doctor.
Most doctors preferred not to use medicine in combating constipation because it may lead on dependency on laxatives.

5. Learn to relax the anal sphincter by doing some pelvic exercises. This will help your constipation

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