Medicurio

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Cardiovascular disease (CVD) is one of the leading causes of death worldwide and is the leading cause of death in the United States.

Cardiac rehabilitation is a complex, interprofessional intervention customized to individual patients with various cardiovascular diseases such as:

• Coronary artery disease (CAD),
• Heart failure
• Myocardial infarctions
• Patients who have undergone cardiovascular interventions such as coronary angioplasty or coronary artery bypass grafting

Coronary bypass surgery redirects blood around a section of a blocked or partially blocked artery in your heart. The procedure involves taking a healthy blood vessel from your leg, arm or chest and connecting it below and above the blocked arteries in your heart. With a new pathway, blood flow to the heart muscle improves.

Coronary bypass surgery doesn’t cure the heart disease that caused the blockages, such as atherosclerosis or coronary artery disease. However, it can ease symptoms, such as chest pain and shortness of breath. For some people, this procedure can improve heart function and reduce the risk of dying of heart disease.

Coronary artery bypass grafting (CABG) is a type of surgery that improves blood flow to the heart. It’s used for people who have severe coronary heart disease (CHD), also called coronary artery disease.

CHD is a condition in which a substance called plaque (plak) builds up inside the coronary arteries. These arteries supply oxygen-rich blood to your heart. Plaque is made up of fat, cholesterol, calcium, and other substances found in the blood.

Plaque can narrow or block the coronary arteries and reduce blood flow to the heart muscle. If the blockage is severe, angina (an-JI-nuh or AN-juh-nuh), shortness of breath, and, in some cases, heart attack can occur. (Angina is chest pain or discomfort.)

CABG is one treatment for CHD. During CABG, a healthy artery or vein from the body is connected, or grafted, to the blocked coronary artery. The grafted artery or vein bypasses (that is, goes around) the blocked portion of the coronary artery.

Other Names for Coronary Artery Bypass Grafting

• Bypass surgery
• Coronary artery bypass surgery
• Heart bypass surgery

CHD isn’t always treated with CABG. Many people who have CHD can be treated other ways, such as with lifestyle changes, medicines, and a procedure calledangioplasty (AN-jee-oh-plas-tee). During angioplasty, a small mesh tube called astent may be placed in an artery to help keep it open.

CABG or angioplasty with stent placement may be options if you have severe blockages in your large coronary arteries, especially if your heart’s pumping action has already been weakened.

CABG also may be an option if you have blockages in the heart that can’t be treated with angioplasty. In this situation, CABG is considered more effective than other types of treatment.

If you’re a candidate for CABG, the goals of having the surgery include:

• Improving your quality of life and decreasing angina and other CHD symptoms
• Allowing you to resume a more active lifestyle
• Improving the pumping action of your heart if it has been damaged by a heart attack
• Lowering the risk of a heart attack (in some patients, such as those who have diabetes)
• Improving your chance of survival

You may need repeat surgery if the grafted arteries or veins become blocked, or if new blockages develop in arteries that weren’t blocked before. Taking medicines as prescribed and making lifestyle changes as your doctor recommends can lower the chance of a graft becoming blocked.

Why it’s done

Coronary bypass surgery is one treatment option if you have a blocked artery to your heart.

You and your doctor might consider it if:

• You have severe chest pain caused by narrowing of several arteries that supply your heart muscle, leaving the muscle short of blood during even light exercise or at rest.
• You have more than one diseased coronary artery, and the heart’s main pumping chamber — the left ventricle — isn’t functioning well.
• Your left main coronary artery is severely narrowed or blocked. This artery supplies most of the blood to the left ventricle.
• You have an artery blockage that can’t be treated with a procedure that involves temporarily inserting and inflating a tiny balloon to widen the artery (angioplasty).
• You’ve had a previous angioplasty or placement of a small wire mesh tube (stent) to hold the artery open that hasn’t been successful. Or you’ve had a stent placement, but the artery has narrowed again.

Coronary bypass surgery might also be performed in emergency situations, such as a heart attack, if you’re not responding to other treatments.

Even with coronary bypass surgery, you’ll need to make lifestyle changes after surgery. Medications are prescribed routinely after coronary bypass surgery to lower your blood cholesterol, reduce the risk of developing a blood clot and help your heart work as well as possible.

Physical Exam and Diagnostic Tests

To decide whether you’re a candidate for CABG, your doctor will do a physical exam. He or she will check your cardiovascular system, focusing on your heart, lungs, and pulse.

Your doctor also will ask you about any symptoms you have, such as chest pain or shortness of breath. He or she will want to know how often and for how long your symptoms occur and how severe they are.

Tests will be done to find out which arteries are clogged, how much they’re clogged, and whether there’s any heart damage.

EKG (Electrocardiogram)

An EKG is a simple test that detects and records your heart’s electrical activity. This test is used to help detect and locate the source of heart problems.

An EKG shows how fast your heart is beating and its rhythm (steady or irregular). It also records the strength and timing of electrical signals as they pass through each part of your heart.

Stress Test

Some heart problems are easier to diagnose when your heart is working hard and beating fast. During stress testing, you exercise (or are given medicine if you’re unable to exercise) to make your heart work hard and beat fast while heart tests are done.

These tests may include nuclear heart scanning, echocardiography, and magnetic resonance imaging (MRI) and positron emission tomography (PET) scanning of the heart.

Echocardiography

Echocardiography (EK-o-kar-de-OG-ra-fee), or echo, uses sound waves to create a moving picture of your heart. The test provides information about the size and shape of your heart and how well your heart’s chambers and valves are working.

The test also can identify areas of poor blood flow to the heart, areas of heart muscle that aren’t contracting normally, and previous injury to the heart muscle caused by poor blood flow.

There are several types of echo, including stress echo. This test is done both before and after a stress test. A stress echo usually is done to find out whether you have decreased blood flow to your heart, a sign of CHD.

Coronary Angiography

Coronary angiography uses dye and special x rays to show the insides of your coronary (heart) arteries. During the test, a long, thin, flexible tube called a catheter is put into a blood vessel in your arm, groin (upper thigh), or neck.

The tube is then threaded into your coronary arteries, and the dye is injected into your bloodstream. Special x rays are taken while the dye is flowing through your coronary arteries.

The dye lets your doctor study the flow of blood through your heart and blood vessels. This helps your doctor find blockages that can cause a heart attack.

Risks

Because coronary bypass surgery is an open-heart surgery, you might have complications during or after your procedure. Possible complications include:

• Bleeding
• An irregular heart rhythm
• Infections of the chest wound
• Memory loss or trouble thinking clearly, which often improves within six to 12 months
• Kidney problems
• Stroke
• Heart attack, if a blood clot breaks loose soon after surgery

Your risk of developing complications is generally low, but it depends on your health before surgery. Your risk of complications is higher if the surgery is done as an emergency procedure or if you have other medical conditions, such as emphysema, kidney disease, diabetes or blocked arteries in your legs.

How you prepare

Your doctor will give you specific instructions about activity restrictions and changes in your diet or medications that you should make before surgery.

Make arrangements for assistance after your surgery. It will take about four to six weeks for you to recover to the point where you can resume driving, return to work and perform daily chores.

What you can expect

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Before the procedure

If your coronary bypass surgery isn’t performed as emergency surgery, you’ll likely be admitted to the hospital the morning of the surgery.

During the procedure

Coronary bypass surgery generally takes between three and six hours and requires general anesthesia. The number of bypasses you need depends on where in your heart and how severe your blockages are.

For general anesthesia, a breathing tube is inserted through your mouth. This tube attaches to a ventilator, which breathes for you during and immediately after the surgery.

Most coronary bypass surgeries are done through a long incision in the chest while a heart-lung machine keeps blood and oxygen flowing through your body. This is called on-pump coronary bypass surgery.

The surgeon cuts down the center of the chest along the breastbone and spreads open the rib cage to expose the heart. After the chest is opened, the heart is temporarily stopped with medication and a heart-lung machine takes over to circulate blood to the body.

The surgeon takes a section of healthy blood vessel, often from inside the chest wall or from the lower leg, and attaches the ends above and below the blocked artery so that blood flow is redirected around the narrowed part of the diseased artery.

Other surgical techniques your surgeon might use include:

• Off-pump or beating-heart surgery. This procedure involves doing surgery on the beating heart using special equipment to stabilize the area of the heart the surgeon is working on. This type of surgery is challenging because the heart is still moving. It’s not an option for everyone.
• Minimally invasive surgery. A surgeon performs coronary bypass through small incisions in the chest, often with the use of robotics and video imaging that help the surgeon operate in a small area. Variations of minimally invasive surgery might be called port-access or keyhole surgery.

After completing the graft, the surgeon will restore your heartbeat, disconnect you from the heart-lung machine and use wire to close your chest bone. The wire will remain in your body after the bone heals.

After the procedure

Expect to spend a day or two in the intensive care unit. The breathing tube will remain in your throat until you are awake and able to breathe on your own.

Cardiac rehabilitation often begins while you’re still in the hospital. You’ll be given an exercise and education program designed to help you recover. You’ll continue with monitored programs in an outpatient setting until you can safely follow a home-based maintenance program.

Barring complications, you’ll likely be discharged from the hospital within a week. You still might have difficulty doing everyday tasks or walking a short distance. If, after returning home, you have any of the following signs or symptoms, call your doctor:

• Fever
• Rapid heart rate
• New or worsened pain around your chest wound
• Reddening around your chest wound or bleeding or other discharge from your chest wound

Expect a recovery period of about six to 12 weeks. If you have your doctor’s OK, you can return to work, begin exercising and resume sexual activity after four to six weeks.

Results

After surgery, most people feel better and might remain symptom-free for as long as 10 to 15 years. Over time, however, it’s possible that other arteries or even the new graft used in the bypass will become clogged, requiring another bypass or angioplasty.

Your results and long-term outcome will depend in part on taking your medications to prevent blood clots, lower blood pressure, lower cholesterol and help control diabetes. It’s also important to follow healthy-lifestyle recommendations, including these:

• Stop smoking.
• Follow a healthy-eating plan, such as the DASH diet.
• Achieve and maintain a healthy weight.
• Exercise regularly.
• Manage stress.

Recovery in the Hospital

After surgery, you’ll typically spend 1 or 2 days in an intensive care unit (ICU). Your heart rate, blood pressure, and oxygen levels will be checked regularly during this time.

An intravenous line (IV) will likely be inserted into a vein in your arm. Through the IV line, you may get medicines to control blood circulation and blood pressure. You also will likely have a tube in your bladder to drain urine and a tube to drain fluid from your chest.

You may receive oxygen therapy (oxygen given through nasal prongs or a mask) and a temporary pacemaker while in the ICU. A pacemaker is a small device that’s placed in the chest or abdomen to help control abnormal heart rhythms.

Your doctor may recommend that you wear compression stockings on your legs as well. These stockings are tight at the ankle and become looser as they go up the leg. This creates gentle pressure up the leg. The pressure keeps blood from pooling and clotting.

While in the ICU, you’ll also have bandages on your chest incision (cut) and on the areas where an artery or vein was removed for grafting.

After you leave the ICU, you’ll be moved to a less intensive care area of the hospital for 3 to 5 days before going home.

Recovery at Home

Your doctor will give you specific instructions for recovering at home, especially concerning:

• How to care for your healing incisions
• How to recognize signs of infection or other complications
• When to call the doctor right away
• When to make followup appointments

You also may get instructions on how to deal with common side effects from surgery. Side effects often go away within 4 to 6 weeks after surgery, but may include:

• Discomfort or itching from healing incisions
• Swelling of the area where an artery or vein was removed for grafting
• Muscle pain or tightness in the shoulders and upper back
• Fatigue (tiredness), mood swings, or depression
• Problems sleeping or loss of appetite
• Constipation
• Chest pain around the site of the chest bone incision (more frequent with traditional CABG)

Full recovery from traditional CABG may take 6 to 12 weeks or more. Less recovery time is needed for nontraditional CABG.

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role of physiotherapy

Cardiac rehabilitation program

Cardiac rehabilitation programs aim to limit the psychological and physiological stresses of CVD, reduce the risk of mortality secondary to CVD, and improve cardiovascular function to help patients achieve their highest quality of life possible. Accomplishing these goals is the result of improving overall cardiac function and capacity, halting or reversing the progression of atherosclerotic disease, and increasing the patient’s self-confidence through gradual conditioning

CR ere the process by which patients with cardiac disease, in partnership with a multidisciplinary team of health professionals are encouraged to support and achieve and maintain optimal physical and psychosocial health. The involvement of partners, other family members, and carers is also important”

They require a team approach, including a multidisciplinary the multidisciplinary team including:

• Cardiologist/Physician and co-coordinator to lead cardiac rehabilitation
• Clinical Nurse Specialist
• Physiotherapist
• Clinical nutritionist/Dietitian
• Occupational Therapist
• Pharmacist
• Psychologist
• Smoking cessation counselor/nurse
• Social worker
• Vocational counselor
• Clerical Administration

It is essential that all cardiac rehabilitation staff have appropriate training, qualifications, skills, and competencies to practice within their scope of practice and recognise and respect the professional skills of all other disciplines involved in providing comprehensive cardiac rehabilitation. The cardiac rehabilitation team should actively engage and effectively link with the general practitioner and practice nurses, sports and leisure industry where phase IV is conducted, community pharmacists and other relevant bodies to create a long-term approach to CVD management.

Indication

Cardiac rehabilitation should be offered to all cardiac patients who would benefit:

• Recent myocardial infarction
• Acute coronary artery syndrome
• Chronic stable angina
• Congestive heart failure
• After coronary artery bypass surgery
• After a percutaneous coronary intervention
• Valvular surgery
• Cardiac transplantation

CR begins as soon as possible in intensive care units (only if the patient is in stable medical condition). Intensity of rehabilitation depends on the patient’s condition and complications in the acute phase of disease. Randomized controlled trials and systematic analysis show that early mobilization improved physical function (distance walked during the 6-min walking test improved by 54 m) at the discharge in patients after cardiac surgery. Another prospective randomized clinical trial improved postoperative functional capacity (6-minute walk test) shorten the duration of mechanical ventilation, dependence on oxygen therapy, and reduced the time of hospital stay in patients who underwent elective Coronary artery bypass graft surgery.

Goals of Cardiac Rehabilitation

Comprehensive cardiac rehabilitation program should contain specific core components.

These components should optimize cardiovascular risk reduction, reduce disability, encourage active and healthy lifestyle changes, and help maintain those healthy habits after rehabilitation is complete. Cardiac rehabilitation programs should focus on:

• Patient assessment nutritional counseling
• Weight management
• Blood pressure management
• Lipid management
• Diabetes management
• Tobacco cessation
• Psychosocial management
• Physical activity counseling
• Exercise training

Individual Risk Assessment

CR can be tailored to meet individual needs thus a thorough assessment and evaluation of the CV risk factor profile of the patient should be undertaken at the beginning of the programme. This should be accompanied by ongoing assessment and reassessment throughout and upon completion of the programme.

Phases of Cardiac Rehabilitation

Cardiac rehabilitation consists of 3 phases.

Phase I: Clinical phase

This phase begins in the inpatient setting soon after a cardiovascular event or completion of an intervention. It begins by assessing the patient’s physical ability and motivation to tolerate rehabilitation. Therapists and nurses may start by guiding patients through non-strenuous exercises in the bed or at the bedside, focusing on a range of motion and limiting hospital deconditioning. The rehabilitation team may also focus on activities of daily living (ADLs) and educate the patient on avoiding excessive stress. Patients are encouraged to remain relatively rested until completion of treatment of comorbid conditions, or post-operative complications. The rehabilitation team assesses patient needs such as assistive devices, patient and family education, as well as discharge planning.

Phase II: Outpatient cardiac rehab

Once a patient is stable and cleared by cardiology, outpatient cardiac rehabilitation may begin. Phase II typically lasts three to six weeks though some may last up to up to twelve weeks. Initially, patients have an assessment with a focus on identifying limitations in physical function, restrictions of participation secondary to comorbidities, and limitations to activities. A more rigorous patient-centered therapy plan is designed, comprising three modalities: information/advice, tailored training program, and a relaxation program. The treatment phase intends to promote independence and lifestyle changes to prepare patients to return to their lives at home.

Phase III: Post-cardiac rehab. Maintenance

This phase involves more independence and self-monitoring. Phase III centers on increasing flexibility, strengthening, and aerobic conditioning.

Goal: facilitate long term maintenance of lifestyle changes, monitoring risk factor changes and secondary prevention.

Options:

• Educational sessions
• Support groups
• Telephone follow up
• Review in clinics
• Outreach programmes
• Exercise program organised by qualified phase IV gym instructor
• Links with GP and primary health care team
• Ongoing involvement of partners/spouses/family

A randomized controlled study shows positive outcomes with the internet-based remote home-based cardiac rehabilitation program

NB There is also a pre-surgery phase, where the patient starts cardiovascular rehabilitation. A small number of studies demonstrate that the post-surgical pathway is better tolerated by patients.

Warm-Up

Purpose: Prepare the body for exercise by raising the pulse rate in a graduated and safe way

Effects:

• redistributes blood to active tissues
• increases muscle temperature and speed of muscle action and relaxation
• prepares the mind
• prepares the muscle for the ROM involved for the conditioning period

Should include pulse raising activities (5 minutes) eg) marching on the spot, walking, low-level cycle followed by stretching of the major muscle groups (5 mins) followed by more pulse raising activity.

NB: should try to keep feet moving at all times to maintain HR and body temp and avoid pooling.

Main Class

For group rehab circuit training seems most popular. Depending on CV status and functional capacity patients may adopt an interval or continuous approach to the circuit.

Separate stations are set out and participants spend a fixed amount of time at each aerobic station (30secs-2mins) before moving onto the next station which may be rest or active recovery in the form of resistance work targeted at specific muscle groups.

Resistance work as set out by ACSM 2006 – 10-15 reps to moderate fatigue of 8-10 exercises.

Individualisation of the CV component can be achieved by varying; duration spent at each CV station, intensity (increase resistance, speed or ROM), period of rest, overall duration of the class

Cool Down

10 minutes at the end

Goal: bring the body back to its resting state

Should incorporate movements of diminishing intensity and passive stretching of the major muscle groups.

Necessary because of;

• Increased risk of hypotension
• Older hearts take longer to return to resting levels
• Raised sympathetic activity during exercise increases the risk of arrhythmias immediately post exercise.

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“Surgery” means a procedure performed for the purpose of structurally altering the human body by incision or destruction of tissues and is part of the practice of medicine for the diagnostic or therapeutic treatment of conditions or disease processes.

• Surgery can be done by any instruments causing localized alteration or transportation of live human tissue, which include lasers, ultrasound, ionizing radiation, scalpels, probes, and needles.
• During surgery the tissue can be cut, burned, vaporized, frozen, sutured, probed, or manipulated by closed reduction for major dislocation and fractures, or otherwise altered by any mechanical, thermal, light-based, electromagnetic, or chemical means.
• Injection of diagnostic or therapeutic substances into body cavities, internal organs, joints, sensory organs, and the central nervous system is also considered to be surgery

Anaesthetics

An anaesthetic is a drug or agent that produces a complete or partial loss of feeling. There are three kinds of anaesthetic: general, regional and local.

General Anaesthetic

A qualified anaesthetist administers the general anaesthetic (intravenously or by gas mask, or both).

• After a few seconds the client becomes unconscious.
• The anaesthetist then inserts a small tube connected to a ventilator into the airway (an endotracheal tube is usually used) or a laryngeal mask.
• The anaesthetist controls the length of time patient is asleep, and constantly monitors pulse, breathing and blood pressure.
• If necessary, the anaesthetist will administer intravenous fluids before, during and after surgery.
• Once the surgery is over other drugs may be injected that will reverse the effect of the anaesthetic and any other drugs used during the operation (such as muscle relaxant).

Complications from general anaesthetic are rare. It is estimated that around one in every 10,000 people undergoing general anaesthetic die from an unforeseen complication, such as an allergic reaction or a heart attack.

Regional and Local Anaesthetics

Depending on the type of surgery, alternatives to general anaesthetic can include:

1. Regional anaesthetic – or ‘nerve block’. eg, a woman giving birth by caesarean section may have an epidural (an injection into the spine that numbs the body from the waist down).
2. Local anaesthetic – anaesthetic is injected into the immediate area to be operated on.eg a dentist may inject local anaesthetic into the gum before removing a tooth.

Surgical Epidemiology

Surgical approaches are receiving increasing attention as a way to solve many global public health problems. Surgery can play a vital role in helping countries meet their Millennium Development Goals 4, 5 and 6.3

What is surgical epidemiology? Unfortunately, there is not yet an agreed definition for this field. Definitional issues and challenges are greater in developing countries, where WHO wish to encourage the debate on surgical epidemiology. To improve the evidence base for surgery as a cost-effective intervention in developing countries, epidemiologists and surgeons must work together to agree upon a vocabulary and set of definitions. As the saying goes, the eye cannot see what the mind does not know.

Why Physical Therapy Is Important Before You Have Surgery?

It is easy to see why physical therapy is important after surgery. Not only can it help minimize the development of scar tissue around the wound, it can also help a person heal faster and return to full mobility. It may be a little more difficult to see why you need physical therapy before surgery, but participating in it before going under the knife may be even more beneficial in the long run.

Pre-Operative Physical Therapy Reduces Recovery Time

A recent study revealed that pre-operative physical therapy reduces post-operative care by as much as 29 percent in patients who have a total knee or total hip replacement. Not only does this translate to a significant cost savings, it also means recovery time is shortened. Best part? You can see results in as few as one to two pre-operative physical therapy sessions.

In cases of a total knee or total hip replacement, pre-operative physical therapy sessions tend to focus less on building muscle or improving flexibility and more on training on walkers, planning for recovery and teaching patients basic exercises they will perform after surgery.

Pre-Operative Physical Therapy Can Shorten Hospitalization

Patients who are prone to complications after surgery or who are at a high probability for transfer to an acute care rehabilitation facility can shorten the length of their stay with pre-operative physical therapy. From joint replacement to cardio-thoracic surgery, low intensity exercise, under the guidance of a physical therapist, improves circulation which in turn speeds the body’s healing response.

Likewise, patients who build muscle in their core, arms, legs, and back are less likely to experience large amounts of atrophy during their recovery. Such atrophy often delays a patient’s return home even if they are healing well. Even a patient’s balance can be improved before surgery, diminishing the likelihood of falling afterward, which could result in longer hospital stays. 

Pre-Operative Physical Therapy May Prevent Surgery Altogether

Even though pre-operative physical therapy meets a different objective than post-operative physical therapy, working with a therapist before surgery may yield a shocking result. You may not need surgery. While this is not the case with patients who are planning for total joint replacement, physical therapy may help soft tissue injuries heal while restoring function without going under the knife. People tend to think of PT as something you do after surgery.

In reality, physical therapists are experts in restoring movement and function throughout the body, with or without surgical intervention. If you are planning to have surgery on any soft tissues in your body, give pre-operative physical therapy a try first. You may be surprised by your results.

From improving recovery times and shortening hospital stays to improving function and healing of soft tissue injuries, pre-operative physical therapy is a vital key to returning you to activity. If you are in the process of scheduling elective surgery.

Why is Physical Therapy Important After Surgery?

We may not always realize it, but any kind of major surgery is a big deal. It can leave patients weak, immobilized, in pain, and sometimes depressed. Everyone’s goal is to recover quickly and completely, so that they can get back to the meaningful activities they love. More and more, doctors and patients are realizing that physical therapy is one of the most important parts of a healthy and successful outcome after surgery.

What Are The Benefits Of Physical Therapy After Surgery?

The benefits of physical therapy after surgery are increasingly backed up by scientific studies. Getting patients moving is key to a healthy recovery. Physical therapy helps patients regain mobility and recover faster, and it ensures that any replacements or repairs made during surgery heal properly.  Physical therapy is also an excellent option for managing pain and helps many patients avoid or limit opioid medications.

Getting Moving After Surgery Is Key

A National Institutes of Health (NIH) study specifically looking at seniors showed that lack of movement after surgery causes loss of function, muscle weakness, and increases postoperative complications. When patients stay in bed following surgery, they lose muscle strength and heart and lung capacity because of a lack of physical activity. One of the best solutions to this problem is a carefully planned and supervised physical therapy program.

Physical therapy helps patients regain strength and return to daily activity sooner by pushing them to move in a safe environment with the assistance of trained professionals. In the case of seniors, this can help them stay independent and even live longer,

Physical therapy also helps patients manage pain safely, without turning to opioids. And physical activity can have a positive effect on patients’ emotional and psychological state. Exercise does, after all, release endorphins that help create a sense of well being while enhancing your overall mood.

Who Are Candidates For Post-Surgery Physical Therapy?

Physical therapy is a post-surgery boost following many procedures, including:

• Joint replacement surgery: For knee, hip and shoulder replacement surgeries, the NIH recommends early and intense physical therapy tailored to the patient’s needs under the supervision of a trained therapist. This helps patients regain mobility faster and get back to their routine.
• ACL and Meniscus repair: Physical therapy is a must following repair to the ACL knee ligament (often a problem for athletes) along with tears to the meniscal cartilage. Studies show that patients can heal faster and avoid re-injury by building quadriceps and hamstring strength.
• Back surgery: Because of the especially delicate nature of a spinal fusion or disk surgery, this is one case where supervised physical therapy is essential. Your therapist will help you with gentle stretches and exercises to get the blood flowing and gradually work up to daily activities.
• Heart attack/bypass surgery: Physical therapy can prevent cardiopulmonary complications by giving patients a safe opportunity to move. The ability to get supervised low-impact, gradual exercise improves health and can reduce the length of the patient’s hospital stay.

What Should I Expect From Physical Therapy After Surgery?

Most doctors are now recommending that physical therapy start immediately after surgery. You’ll begin with simple exercises involving flexing and stretching and move on to more intense exercise as you recover. Part of your therapist’s job is to safely push you to make progress even when you don’t think you can! Some of the most common types of physical therapy techniques include:

• Range of motion exercises including knee extensions, moving from sitting to standing and circling joints
• Strengthening exercises including leg raises, hamstring and quadriceps contractions, squats using a chair
• Stretching exercises in both a seated and standing position
• Walking and other low-impact cardiovascular exercises, including using an exercise bike. Sometimes after major surgery, just taking a few steps is a big deal, and the sense of accomplishment patients feel as they progress goes a long way in moving recovery forward.

Advances in Surgery

• Lasers became widely used to destroy tumours and other pigmented lesions, some of which are inaccessible by conventional surgery. They are also used to surgically weld detached retinas back in place and to coagulate blood vessels to stop them from bleeding. 
• Stereotaxic surgery uses a three-dimensional system of coordinates obtained by X-ray photography to accurately focus high-intensity radiation, cold, heat, or chemicals on tumours located deep in the brain that could not otherwise be reached. 
• Cryosurgery uses extreme cold to destroy warts and precancerous and cancerous skin lesions and to remove cataracts
• Some traditional techniques of open surgery were replaced by the use of a thin flexible fibre-optic tube equipped with a light and a video connection; the tube, or endoscope, is inserted into various bodily passages and provides views of the interior of hollow organs or vessels. Accessories added to the endoscope allow small surgical procedures to be executed inside the body without making a major incision.

Major Categories of Surgery

There are four major categories of surgery:

1. Wound treatment: centred on procuring good healing and the avoidance of infection
2. Extirpative surgery: involves the removal of diseased tissue or organs. Cancer surgery usually falls into this category, with mastectomy, cholecystectomy (removal of the gallbladder), and hysterectomy among the most frequent procedures.
3. Reconstructive surgery: deals with the replacement of lost tissues, whether from fractures, burns, or degenerative-disease processes, and is especially prominent in the practice of plastic surgery and orthopedic surgery eg the use of metal in reconstructing hip joints (THR) and the use of plastic valves to replace heart valves.
4. Transplantation surgery: the use of organs transplanted from other bodies to replace diseased organs in patients. Kidneys are the most commonly transplanted organs

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An anal fissure is a small tear in the thin, moist tissue (mucosa) that lines the anus. An anal fissure may occur when you pass hard or large stools during a bowel movement. Anal fissures typically cause pain and bleeding with bowel movements. You also may experience spasms in the ring of muscle at the end of your anus (anal sphincter).

Anal fissures are very common in young infants but can affect people of any age. Most anal fissures get better with simple treatments, such as increased fiber intake or sitz baths. Some people with anal fissures may need medication or, occasionally, surgery.

An anal fissure is a small cut or tear in the lining of the anus. The crack in the skin causes severe pain and some bright red bleeding during and after bowel movements. At times, the fissure can be deep enough to expose the muscle tissue underneath.

An anal fissure usually isn’t a serious condition. It can affect people of all ages, and it’s often seen in infants and young children since constipation is a common problem in these age groups.

In most cases, the tear heals on its own within four to six weeks. In cases where the fissure persists beyond eight weeks, it’s considered chronic.

Certain treatments can promote healing and help relieve discomfort, including stool softeners and topical pain relievers.

If an anal fissure doesn’t improve with these treatments, you may need surgery. Or your doctor may need to look for other underlying disorders that can cause anal fissures.

causes

An anal fissure most often occurs when passing large or hard stools. Chronic constipation or frequent diarrhea can also tear the skin around your anus. Other common causes include:

• straining during childbirth or bowel movements
• inflammatory bowel disease (IBD), such as Crohn’s disease
• decreased blood flow to the anorectal area
• overly tight or spastic anal sphincter muscles

In rare cases, an anal fissure may develop due to:

• anal cancer
• HIV
• tuberculosis
• syphilis
• herpes

Symptoms

Signs and symptoms of an anal fissure include:

• Pain, sometimes severe, during bowel movements
• Pain after bowel movements that can last up to several hours
• Bright red blood on the stool or toilet paper after a bowel movement
• A visible crack in the skin around the anus
• A small lump or skin tag on the skin near the anal fissure

When to see a doctor

See your doctor if you have pain during bowel movements or notice blood on stools or toilet paper after a bowel movement.

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Risk factors

Factors that may increase your risk of developing an anal fissure include:

• Constipation. Straining during bowel movements and passing hard stools increase the risk of tearing.
• Childbirth. Anal fissures are more common in women after they give birth.
• Crohn’s disease. This inflammatory bowel disease causes chronic inflammation of the intestinal tract, which may make the lining of the anal canal more vulnerable to tearing.
• Anal intercourse.
• Age. Anal fissures can occur at any age, but are more common in infants and middle-aged adults.

Complications

Complications of anal fissure can include:

• Failure to heal. An anal fissure that fails to heal within eight weeks is considered chronic and may need further treatment.
• Recurrence. Once you’ve experienced an anal fissure, you are prone to having another one.
• A tear that extends to surrounding muscles. An anal fissure may extend into the ring of muscle that holds your anus closed (internal anal sphincter), making it more difficult for your anal fissure to heal. An unhealed fissure can trigger a cycle of discomfort that may require medications or surgery to reduce the pain and to repair or remove the fissure.

diagnosis

A doctor can usually diagnose an anal fissure simply by examining the area around the anus. However, they may want to perform a rectal exam to confirm the diagnosis.

During this exam, the doctor may insert an anoscope into your rectum to make it easier to see the tear. This medical instrument is a thin tube that allows doctors to inspect the anal canal.

Using an anoscope may also help your doctor find other causes of anal or rectal pain such as hemorrhoids. In some cases of rectal pain, you may need an endoscopy for better evaluation of your symptoms.

treatment

Most anal fissures don’t require extensive treatment. However, certain home remedies can help promote healing and relieve uncomfortable symptoms. You can treat an anal fissure at home by:

• using over-the-counter stool softeners
• drinking more fluids
• taking fiber supplements and eating more fibrous foods, such as raw fruits and vegetables
• taking a sitz bath to relax the anal muscles, relieve irritation, and increase blood flow to the anorectal area
• applying a nitroglycerin ointment to promote blood flow to the area or a hydrocortisone cream, such as Cortizone 10, to help with inflammation
• applying topical pain relievers, such as lidocaine, to the anus to ease discomfort

If your symptoms aren’t relieved within two weeks of treatment, see your doctor for further evaluation. Your doctor can make sure you have the correct diagnosis and can recommend other treatments.

A calcium channel blocker ointment can relax the sphincter muscles and allow the anal fissure to heal.

Another possible treatment is Botox injections into the anal sphincter. The injections will prevent spasms in your anus by temporarily paralyzing the muscle. This allows the anal fissure to heal while preventing new fissures from forming.

If your anal fissure fails to respond to other treatments, your doctor may recommend an anal sphincterotomy. This surgical procedure involves making a small incision in the anal sphincter to relax the muscle. Relaxing the muscle allows the anal fissure to heal.

Not all anal fissures are a sign of low-fiber diets and constipation. Poorly healing fissures or those located in a position other than the posterior and midline portion of your anus may indicate an underlying condition.

prevention

An anal fissure can’t always be prevented, but you can reduce your risk of getting one by taking the following preventive measures:

• keeping the anal area dry
• cleansing the anal area gently with mild soap and warm water
• drinking plenty of fluids, eating fibrous foods, and exercising regularly to avoid constipation
• treating diarrhea immediately
• changing infants’ diapers frequently

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Epidermoid cysts are small, lumps that develop under the skin. However, this isn’t the correct term for these types of growths. They don’t cause other symptoms and are never cancerous.

Epidermoid cysts are often found on the head, neck, back, or genitals. They range in size from very small (millimeters) to inches across. They look like a small bump, and the overlying skin can be skin-colored, whitish, or yellowish in color.

They’re filled with cheesy-like, white keratin debris. They’re typically painless. Although, they can become inflamed and irritated. They don’t require removal unless bothersome or the diagnosis is in question.

Dermoid cysts (also called epidermoid cysts or dermal/epidermal inclusion cysts) are masses, in children and adults, most commonly found in the:

• Head
• Face
• Neck
• Upper chest

Dermoid cysts are the most common orbital/periorbital tumors found in the pediatric population. They are slow growing, cystic masses, lined by skin and filled with oil and old skin cells.

The term dermoid cysts is used to describe:

• Simple, skin-lined cysts under the skin
• Cysts with hair follicles
• Deeper neck cysts with similar contents of oil, skin, and/or hair follicles

The term dermoid cyst is also sometimes used to describe more complex cystic tumors found in the ovaries of women (teratomas) which are a completely different medical condition not treated in Interventional Radiology.

causes of epidermoid cysts

Buildup of trapped keratin usually causes epidermoid cysts. Keratin is a protein that occurs naturally in skin cells. Cysts develop when the protein is trapped below the skin because of disruption to the skin or to a hair follicle.

These cysts may develop for a number of reasons, but trauma to the skin is typically thought to be the main cause. When numerous, an underlying genetic disorder such as Gardner syndrome may be the cause.

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How are epidermoid cysts diagnosed?

To diagnose epidermoid cysts, your healthcare provider will examine the bump and surrounding skin, as well as request your medical history. They’ll ask for details on how long the bump has been present and whether it has changed over time.

Healthcare providers can usually diagnose an epidermoid cyst by examination only, but sometimes an ultrasound or a referral to a dermatologist is needed to confirm the diagnosis.

What are the Symptoms of a Dermoid Cyst?

A dermoid cyst usually presents as a painless “mass,” or lump, that is felt in the affected area. Dermoid cysts near the eye may produce pressure on the eyeball resulting in pain and visual problems.

The easiest way to think of a dermoid cyst is “skin being trapped” under the surface in the affected area during fetal development. Just like skin elsewhere in the body that normally produces oil and sheds old cells, the skin trapped in a dermoid continues to make these things which collect and form a cyst or “bubble” under the surface.

Very slowly more oil and old skin cells accumulate within the cyst and the dermoid cyst enlarges. If a dermoid cyst grows into the bone (most often the skull), the hole in the affected bone also grows as the cyst enlarges.

How are epidermoid cysts treated?

Epidermoid cysts typically don’t go away completely on their own, although they may shrink to an unnoticeable size and then grow again. Thus, a dermatologist’s surgical intervention is needed to resolve the condition.

Since epidermoid cysts aren’t dangerous, they don’t pose a health risk. Many are never treated.

If the cyst becomes red, swollen, or painful, changes in size or character, or becomes infected, treatment may be desired. In such cases, treatment options typically include antibiotics. Sometimes the cyst may also be drained or injected with a steroid solution.

If you want complete resolution of the cyst, you’ll typically need to have it surgically removed. Usually, this is delayed to a later date if the cyst is currently inflamed.

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Boils are bacterial infections that form under your skin at a hair follicle. A carbuncle is a cluster of boils that have multiple pus “heads.” They’re tender and painful, and cause a severe infection which could leave a scar. A carbuncle is also called a staph skin infection.

A boil is a painful, pus-filled bump that forms under your skin when bacteria infect and inflame one or more of your hair follicles. A carbuncle is a cluster of boils that form a connected area of infection under the skin.

Boils (furuncles) usually start as red, tender bumps. The bumps quickly fill with pus, growing larger and more painful until they rupture and drain. Areas most likely to be affected are the face, back of the neck, armpits, thighs and buttocks.

You can usually care for a single boil at home. But don’t attempt to prick or squeeze it — that may spread the infection.

A skin abscess happens when pus collects in hair follicles, skin tissues, or under the skin. A furuncle, also known as a boil, is a painful infection that forms around a hair follicle and contains pus.

A carbuncle is collection of boils that develop under the skin. When bacteria infect hair follicles, the follicles can swell and turn into boils and carbuncles.

A furuncle starts as a red lump. It may be tender. The lump rapidly fills with pus, and as it grows it may burst.

Furuncles, boils, and carbuncles typically affect the thighs, armpits, buttocks, face, and neck.

Individuals with weakened immune systems, adolescents, and young adults are more susceptible to furuncles than younger children or older adults.

causes

S. aureus, also known as staph bacteria, live on the skin and inside the nose and throat.

Usually, the body’s immune system keeps them under control, but sometimes they enter the skin through a hair follicle, or through a cut or graze in the skin.

When the skin becomes infected, the immune system responds by sending white blood cells to the affected area to destroy the bacteria. Pus is an accumulation of dead bacteria, dead white blood cells, and dead skin.

The following conditions increase the risk of developing furuncles:

• Diabetes: High levels of blood sugar, or glucose, can reduce the immune system’s ability to respond to infection.
• Medications: Some medications weaken the immune system.
• HIV and some other diseases: Certain conditions weaken the immune systems
• Skin conditions: Psoriasis, eczema, and acne increase susceptibility.

Obesity also increases the risk.

Often, the normal bacteria in a person’s nose or on their skin can lead to an abscess. Sometimes, however, the infection can spread when people share space, materials, or devices, such as clothing and whirlpool footbaths.

Symptoms

Boils

Boils can occur anywhere on your skin, but appear mainly on the face, back of the neck, armpits, thighs and buttocks — hair-bearing areas where you’re most likely to sweat or experience friction. Signs and symptoms of a boil usually include:

• A painful, red bump that starts out small and can enlarge to more than 2 inches (5 centimeters)
• Red, swollen skin around the bump
• An increase in the size of the bump over a few days as it fills with pus
• Development of a yellow-white tip that eventually ruptures and allows the pus to drain out

Carbuncles

A carbuncle is a cluster of boils that form a connected area of infection. Compared with single boils, carbuncles cause a deeper and more severe infection and are more likely to leave a scar. People who have a carbuncle often feel unwell in general and may experience a fever and chills.

When to see a doctor

You usually can care for a single, small boil yourself. But see your doctor if you have more than one boil at a time or if a boil:

• Occurs on your face or affects your vision
• Worsens rapidly or is extremely painful
• Causes a fever
• Gets bigger despite self-care
• Hasn’t healed in two weeks
• Recurs

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Risk factors

Although anyone — including otherwise healthy people — can develop boils or carbuncles, the following factors can increase your risk:

• Close contact with a person who has a staph infection. You’re more likely to develop an infection if you live with someone who has a boil or carbuncle.
• Diabetes. This disease can make it more difficult for your body to fight infection, including bacterial infections of your skin.
• Other skin conditions. Because they damage your skin’s protective barrier, skin problems, such as acne and eczema, make you more susceptible to boils and carbuncles.
• Compromised immunity. If your immune system is weakened for any reason, you’re more susceptible to boils and carbuncles.

Complications

Rarely, bacteria from a boil or carbuncle can enter your bloodstream and travel to other parts of your body. The spreading infection, commonly known as blood poisoning (sepsis), can lead to infections deep within your body, such as your heart (endocarditis) and bone (osteomyelitis).

diagnosis

Your doctor can usually diagnose a carbuncle by looking at your skin. A pus sample may also be taken for lab analysis.

It’s important to keep track of how long you’ve had the carbuncle. Tell your doctor if it’s lasted longer than two weeks. You should also mention if you’ve had the same symptoms before.

If you keep developing carbuncles, it may be a sign of other health issues, such as diabetes. Your doctor may want to run urine or blood tests to check your overall health.

Prevention

It’s not always possible to prevent boils, especially if you have a weakened immune system. But the following measures may help you avoid staph infections:

• Wash your hands regularly with mild soap. Or use an alcohol-based hand rub often. Careful hand-washing is your best defense against germs.
• Keep wounds covered. Keep cuts and abrasions clean and covered with sterile, dry bandages until they heal.
• Avoid sharing personal items. Don’t share towels, sheets, razors, clothing, athletic equipment and other personal items. Staph infections can spread via objects, as well as from person to person. If you have a cut or sore, wash your towels and linens using detergent and hot water with added bleach, and dry them in a hot dryer.

Lifestyle and home remedies

For small boils, these measures may help the infection heal more quickly and prevent it from spreading:

• Warm compresses. Apply a warm washcloth or compress to the affected area several times a day, for about 10 minutes each time. This helps the boil rupture and drain more quickly.
• Never squeeze or lance a boil yourself. This can spread the infection.
• Prevent contamination. Wash your hands thoroughly after treating a boil. Also, launder clothing, towels or compresses that have touched the infected area, especially if you have recurrent infections.

Medical treatment

Your doctor will use one or more of the following medical treatments to heal your carbuncle:

• Antibiotics. These are taken orally or applied to your skin.
• Pain relievers. Over-the-counter medications are typically sufficient.
• Antibacterial soaps. These may be suggested as part of your daily cleaning regimen.
• Surgery. Your doctor may drain deep or large carbuncles with a scalpel or needle.

You should never try to drain a carbuncle yourself. There’s a risk that you’ll spread the infection. You could also end up infecting your bloodstream.

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Burns are one of the most common household injuries, especially among children. The term “burn” means more than the burning sensation associated with this injury. Burns are characterized by severe skin damage that causes the affected skin cells to die.

Most people can recover from burns without serious health consequences, depending on the cause and degree of injury. More serious burns require immediate emergency medical care to prevent complications and death.

Burns are tissue damage that results from heat, overexposure to the sun or other radiation, or chemical or electrical contact. Burns can be minor medical problems or life-threatening emergencies.

The treatment of burns depends on the location and severity of the damage. Sunburns and small scalds can usually be treated at home. Deep or widespread burns need immediate medical attention. Some people need treatment at specialized burn centers and monthslong follow-up care.

Burn levels

There are three primary types of burns: first-, second-, and third-degree. Each degree is based on the severity of damage to the skin, with first-degree being the most minor and third-degree being the most severe. Damage includes:

• first-degree burns: red, nonblistered skin
• second-degree burns: blisters and some thickening of the skin
• third-degree burns: widespread thickness with a white, leathery appearance

There are also fourth-degree burns. This type of burn includes all of the symptoms of a third-degree burn and also extends beyond the skin into tendons and bones.

Burns have a variety of causes, including:

• scalding from hot, boiling liquids
• chemical burns
• electrical burns
• fires, including flames from matches, candles, and lighters
• excessive sun exposure

The type of burn is not based on the cause of it. Scalding, for example, can cause all three burns, depending on how hot the liquid is and how long it stays in contact with the skin.

Chemical and electrical burns warrant immediate medical attention because they can affect the inside of the body, even if skin damage is minor.

First-degree burn

First-degree burns cause minimal skin damage. They are also called “superficial burns” because they affect the outermost layer of skin. Signs of a first-degree burn include:

• redness
• minor inflammation, or swelling
• pain
• dry, peeling skin occurs as the burn heals

Since this burn affects the top layer of skin, the signs and symptoms disappear once the skin cells shed. First-degree burns usually heal within 7 to 10 days without scarring.

You should still see your doctor if the burn affects a large area of skin, more than three inches, and if it’s on your face or a major joint, which include:

• knee
• ankle
• foot
• spine
• shoulder
• elbow
• forearm

First-degree burns are usually treated with home care. Healing time may be quicker the sooner you treat the burn. Treatments for a first-degree burn include:

• soaking the wound in cool water for five minutes or longer
• taking acetaminophen or ibuprofen for pain relief
• applying lidocaine (an anesthetic) with aloe vera gel or cream to soothe the skin
• using an antibiotic ointment and loose gauze to protect the affected area

Make sure you don’t use ice, as this may make the damage worse. Never apply cotton balls to a burn because the small fibers can stick to the injury and increase the risk of infection. Also, avoid home remedies like butter and eggs as these are not proven to be effective.

Second-degree burn

Second-degree burns are more serious because the damage extends beyond the top layer of skin. This type burn causes the skin to blister and become extremely red and sore.

Some blisters pop open, giving the burn a wet or weeping appearance. Over time, thick, soft, scab-like tissue called fibrinous exudate may develop over the wound.

Due to the delicate nature of these wounds, keeping the area clean and bandaging it properly is required to prevent infection. This also helps the burn heal quicker.

Some second-degree burns take longer than three weeks to heal, but most heal within two to three weeks without scarring, but often with pigment changes to the skin.

The worse the blisters are, the longer the burn will take to heal. In some severe cases, skin grafting is required to fix the damage. Skin grafting takes healthy skin from another area of the body and moves it to the site of the burned skin.

As with first-degree burns, avoid cotton balls and questionable home remedies. Treatments for a mild second-degree burn generally include:

• running the skin under cool water for 15 minutes or longer
• taking over-the-counter pain medication (acetaminophen or ibuprofen)
• applying antibiotic cream to blisters

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However, seek emergency medical treatment if the burn affects a widespread area, such as any of the following:

• face
• hands
• buttocks
• groin
• feet

Third-degree burn

Excluding fourth-degree burns, third-degree burns are the most severe. They cause the most damage, extending through every layer of skin.

There is a misconception that third-degree burns are the most painful. However, with this type of burn the damage is so extensive that there may not be any pain because of nerve damage.

Depending on the cause, the symptoms third-degree burns can exhibit include:

• waxy and white color
• char
• dark brown color
• raised and leathery texture
• blisters that do not develop

Without surgery, these wounds heal with severe scarring and contracture. There is no set timeline for complete spontaneous healing for third-degree burns.

Causes

Burns are caused by:

• Fire
• Hot liquid or steam
• Hot metal, glass or other objects
• Electrical currents
• Radiation, such as that from X-rays
• Sunlight or other sources of ultraviolet radiation, such as a tanning bed
• Chemicals such as strong acids, lye, paint thinner or gasoline
• Abuse

Symptoms

Burn symptoms vary depending on how deep the skin damage is. It can take a day or two for the signs and symptoms of a severe burn to develop.

• 1st-degree burn. This minor burn affects only the outer layer of the skin (epidermis). It may cause redness and pain.
• 2nd-degree burn. This type of burn affects both the epidermis and the second layer of skin (dermis). It may cause swelling and red, white or splotchy skin. Blisters may develop, and pain can be severe. Deep second-degree burns can cause scarring.
• 3rd-degree burn. This burn reaches to the fat layer beneath the skin. Burned areas may be black, brown or white. The skin may look leathery. Third-degree burns can destroy nerves, causing numbness.

When to see a doctor

Seek emergency medical assistance for:

• Burns that cover the hands, feet, face, groin, buttocks, a major joint or a large area of the body
• Deep burns, which means burns affecting all layers of the skin or even deeper tissues
• Burns that cause the skin to look leathery
• Burns that appear charred or have patches of black, brown or white
• Burns caused by chemicals or electricity
• Difficulty breathing or burns to the airway

Complications

Complications of deep or widespread burns can include:

• Bacterial infection, which may lead to a bloodstream infection (sepsis)
• Fluid loss, including low blood volume (hypovolemia)
• Dangerously low body temperature (hypothermia)
• Breathing problems from the intake of hot air or smoke
• Scars or ridged areas caused by an overgrowth of scar tissue (keloids)
• Bone and joint problems, such as when scar tissue causes the shortening and tightening of skin, muscles or tendons (contractures)

Prevention

To reduce the risk of common household burns:

• Never leave items cooking on the stove unattended.
• Turn pot handles toward the rear of the stove.
• Don’t carry or hold a child while cooking at the stove.
• Keep hot liquids out of the reach of children and pets.
• Keep electrical appliances away from water.
• Check the temperature of food before serving it to a child. Don’t heat a baby’s bottle in the microwave.
• Never cook while wearing loosefitting clothes that could catch fire over the stove.
• If a small child is present, block his or her access to heat sources such as stoves, outdoor grills, fireplaces and space heaters.
• Before placing a child in a car seat, check for hot straps or buckles.
• Unplug irons and similar devices when not in use. Store them out of reach of small children.
• Cover unused electrical outlets with safety caps. Keep electrical cords and wires out of the way so that children can’t chew on them.
• If you smoke, never smoke in bed.
• Be sure you have working smoke detectors on each floor of your home. Check them and change their batteries at least once a year.
• Keep a fire extinguisher on every floor of your house.
• When using chemicals, always wear protective eyewear and clothing.
• Keep chemicals, lighters and matches out of the reach of children. Use safety latches. And don’t use lighters that look like toys.
• Set your water heater’s thermostat to below 120 F (48.9 C) to prevent scalding. Test bath water before placing a child in it.

Also be alert to burn risks outside the home, especially if you are in places with open flames, chemicals or superheated materials

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A wound infection occurs when germs, such as bacteria, grow within the damaged skin of a wound. Symptoms can include increasing pain, swelling, and redness. More severe infections may cause nausea, chills, or fever.

A person may be able to treat minor wound infections at home. However, people with more severe or persistent wound infections should seek medical attention.

An infected wound is a localized defect or excavation of the skin or underlying soft tissue in which pathogenic organisms have invaded into viable tissue surrounding the wound. Infection of the wound triggers the body’s immune response, causing inflammation and tissue damage, as well as slowing the healing process. Many infections will be self-contained and resolve on their own, such as a scratch or infected hair follicle. Other infections, if left untreated, can become more severe and require medical intervention.

The skin is the body’s first line of defense, the surface of which is protected by a thin, acid film produced by the sebaceous glands called the acid mantle. This acid mantle is a dynamic barrier that regulates the skin’s pH and maintains microorganisms called the normal flora that help prevent pathogens from entering the body. Pathogens will often displace some of the normal flora and colonize certain locations, but most of the time this does not lead to infection and does not stimulate an immune response. However, when the skin is broken or if the immune system becomes compromised, any of the microorganisms colonizing the skin or introduced to the wound can cause an infection. The microorganisms likely to infect a wound depend predominantly on what microorganisms are present on the skin, as well as the depth and location of the wound.

Etiology

Most infected wounds are caused by bacterial colonization, originating either from the normal flora on the skin, or bacteria from other parts of the body or the outside environment. The most common infection-causing bacteria is Staphylococcus aureus and other types of staphylococci.

Wound infections are caused by the deposition and multiplication of microorganisms in the surgical site of a susceptible host. There are a number of ways microorganisms can get into wounds.

• Direct contact – transfer from surgical equipment or the hands of the surgeons or nurses
• Airborne dispersal – surrounding air contaminated with micro-organisms that deposit onto the wound
• Self-contamination – physical migration of the patient’s own endogenous flora which is present on the skin, mucous membranes or gastrointestinal tract to the surgical site.

What defines a surgical wound infection?

A surgical wound/site infection is defined by the following criteria. Infection must occur within 30 days of the surgical operation, and at least one of the following must occur:

• Purulent discharge from the surgical site
• Purulent discharge from wound or drain placed in the wound
• Organisms isolated from the aseptically obtained wound culture
• Must be at least one of the signs and symptoms of infection – pain or tenderness, localised swelling, or redness/heat.

Other signs of wound infection include:

• Delayed healing not previously anticipated.
• Discolouration of tissues both within and at the wound margins.
• Abnormal smell coming from the wound site.
• Friable, bleeding granulation tissue despite appropriate care and management.
• Lymphangitis, a red line originating from the wound and leading to swollen tender lymph glands draining the affected area.

Surgical site infections do not include a stitch abscess, episiotomy infection, newborn circumcision scar, or infected thermal burn wound.

Symptoms of Infected Wounds

People can usually safely treat small wounds, such as minor cuts and scratches, at home. With proper care, most small wounds will gradually get better until they fully heal.

If a wound becomes infected, however, it can get worse instead of better. Any pain, redness, and swelling will typically increase in intensity.

Wound infections can also lead to other symptoms, such as:

• warm skin around the wound
• yellow or green discharge coming from the wound
• the wound giving off an unpleasant odor
• red streaks on the skin around the wound
• fever and chills
• aches and pains
• nausea
• vomiting

Risk factors

Cuts, grazes, and other breaks in the skin can become infected when bacteria enter the wound and begin to multiply. The bacteria may come from the surrounding skin, the external environment, or the object that caused the injury.

It is important to clean and protect the wound properly to reduce the risk of infection.

The risk of wound infection is higher if:

• the wound is large, deep, or has a jagged edge
• dirt or foreign particles entered the wound
• the cause of the wound was a bite from an animal or another person
• the cause of the wound was an injury involving a dirty, rusty, or contaminated object

Certain health conditions and environmental factors can also increase the risk of infection. These include:

• diabetes
• poor blood circulation
• a weakened immune system, such as in people living with HIV or those taking immunosuppressant medications
• lack of mobility, for example, in people who spend most of their time in bed
• advancing age — older adults are more at risk of wound infection
• nutrient and vitamin deficiencies

Rarely, incision wounds from surgical procedures can also become infected.

Complications

If a person does not receive treatment for a wound infection, it can spread to other parts of the body, which may lead to serious complications, including:

• Cellulitis is an infection of the deeper layers and tissues of the skin, and it can cause swelling, redness, and pain in the affected area. Other symptoms can include fever, dizziness, and nausea and vomiting.
• Osteomyelitis is a bacterial infection of the bone, and symptoms include pain, redness, and swelling around the infected area. Fatigue and fever are other symptoms that may affect those with osteomyelitis.
• Sepsis is an extreme immune reaction that can sometimes occur when an infection enters the bloodstream. Sepsis can lead to multiple organ failure and is life-threatening. According to the CDCTrusted Source, nearly 270,000 people in the U.S. die each year due to sepsis.
• Necrotizing fasciitis is a rare condition that occurs when a bacterial infection spreads into a tissue called the fascial lining that lies deep beneath the skin. Necrotizing fasciitis is a medical emergency that causes severe skin damage and pain and can spread throughout the body.

When to see a doctor

A person with a wound should seek medical attention if:

• the wound is large, deep, or has jagged edges
• the edges of the wound do not stay together
• symptoms of infection occur, such as fever, increasing pain or redness, or discharge from the wound
• it is not possible to clean the wound properly or remove all debris, such as glass or gravel
• the cause of the wound was a bite or an injury from a dirty, rusty, or contaminated object

Seek urgent medical attention if blood is spurting from the wound or if applying pressure to the wound does not stop the bleeding.

Diagnostic Studies

• Bacterial culture
• Gram stain
• Antimicrobial susceptibility
• Fungal culture
• Blood culture

Treatments & Interventions for Infected Wounds

The following precautions can help minimize the risk of developing infected wounds in at-risk patients and to minimize complications in patients already exhibiting symptoms:

• Prompt and proper wound cleansing to reduce bioburden
• Maintaining proper nutrition and hydration

Approaches to treatment can be broken down by whether the infection is systemic or localized just to the wound area. Systemic treatment often will call for oral antibiotics, the specific type determined by microbiological investigation and local infection control protocols.

Localized infections can often be treated with topical antibiotics. Drainage or debridement may be necessary to remove slough and devitalized tissue, as these slow wound healing and can affect the efficiency of topical antibiotics. Antimicbrobial dressings, including those that use silver technology, may be used to help reduce bioburden. Antibiotics, whether topical or systemic, should only be used under the explicit direction of a physician.

How are wound infections prevented?

The goal of wound infection management is to prevent or minimise the risk of infection. The following factors or methods external to the patient are used to prevent infection.

Theatre environment and care of instruments

• Maintain positive pressure ventilation of operating theatre
• Laminar airflow in high-risk areas
• Sterilisation of surgical instruments, sutures etc according to guidelines

Surgical team members educated in aseptic technique

• Staff with infections excluded from duty
• Scrubbing up followed by appropriate sterile attire

Techniques applied to the patient to prevent wound infections include:

• Skin preparation
• Wound cleansing
• Antibiotic prophylaxis
• Good surgical technique.

Antiseptic wound cleansers are adequate for clean wounds or lightly contaminated wounds. Antibiotic prophylaxis may be indicated for clean-contaminated wounds and is usually recommended for contaminated wounds. Antibiotics for dirty wounds are part of the treatment because the infection is already established. When deciding on a prophylactic antibiotic consider the following:

• Use an antibiotic based on likely bacteria to cause infection
• An antibiotic should have good tissue penetration to reach wound involved
• Timing and duration of antibiotic – it is important that therapeutic concentrations are reached at the time of the incision, throughout the surgical procedure and ideally a few hours postoperatively.

Wound infection can complicate illness, cause anxiety, increase patient discomfort and lead to death. It is estimated that surgical wound infections result in an increased length of hospital stay by about 7–10 days. Hence the prevention and management of wound infection have a major impact on both patient health and health economics.

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A skin ulcer is an open wound that develops on the skin as a result of injury, poor circulation, or pressure.

Skin ulcers can take a very long time to heal. If left untreated, they can become infected and cause other medical complications.

These ulcers can form on any area of the skin. Depending on the type, they are especially common on the legs, mouth or lips, hips, and bottom.

A skin ulcer is an open sore caused by poor blood flow.

Good blood flow is necessary for wound healing. But if you have blood circulation problems, minor injuries can’t heal properly. Over time, an injury can turn into a skin ulcer.

If an ulcer becomes infected, it should be treated quickly. Infected sores are serious because the infection can spread throughout the body.

Often, skin ulcers affect the legs. Up to 3 in 1,000 peopleTrusted Source have active leg ulcers. They can also show up on the feet, back, and hips. Skin ulcers are more common in older people.

Your symptoms, treatment, and recovery will depend on the specific cause of your ulcer.

Types of skin ulcer

People can develop the following types of skin ulcer:

Venous skin ulcers

Venous skin ulcers are shallow, open sores that develop in the skin of the lower leg as a result of poor blood circulation.

Damage to the valves inside leg veins prevents blood from returning to the heart. Instead, blood collects in the lower legs, causing them to swell. This swelling puts pressure on the skin, which can cause ulcers.

Arterial (ischemic) skin ulcers

Arterial ulcers occur when the arteries fail to deliver enough oxygen-rich blood to the lower limbs. Without a steady supply of oxygen, the tissues die and an ulcer develops.

Arterial ulcers can form on the outside of the ankle, feet, and toes.

Neuropathic skin ulcers

Neuropathic skin ulcers are a common complication of uncontrolled diabetes. Over time, elevated blood glucose levels can cause nerve damage, which results in a reduced or total loss of feeling in the hands and feet.

This condition is called neuropathy, and it occurs in approximately 60–70 percentTrusted Source of people with diabetes.

Neuropathic skin ulcers develop from smaller wounds, such as blisters or small cuts. A person with diabetes-associated neuropathy might not realize that they have an ulcer until it starts leaking fluid or becomes infected, in which case they may notice a distinct odor.

Bedsores or pressure ulcers

Decubitus ulcers, also called pressure sores or bedsores, occur as a result of constant pressure or friction on the skin.

Skin tissues can withstand a maximum pressure of 30–32 millimeters of mercuryTrusted Source. Any increase in pressure beyond this range can lead to poor circulation, tissue death, and eventually ulcer formation.

If left untreated, decubitus ulcers can cause damage to tendons, ligaments, and muscles tissue.

Buruli ulcer

Buruli ulcer is a medical condition caused by the Mycobacterium ulcerans bacteria. An infection with this bacteria can form large ulcers on the arms and legs.

If left untreated, Buruli ulcer can result in permanent physical damage and disability.

Stasis dermatitis

Stasis dermatitis, or gravitational dermatitis, is a condition that causes inflammation, irritated skin, and ulcers on the legs. It is the result of fluid buildup due to poor circulation.

According to the National Eczema Association, stasis dermatitis is more common in women than men and people over the age of 50.

causes

Skin ulcers happen when there’s a problem with blood circulation. Causes of poor blood flow include:

Diabetes

Diabetes is a disease that causes high blood sugar. Over time, high blood sugar can lead to nerve damage called peripheral neuropathy. You may lose sense of touch in your feet and legs.

Since you can’t feel pain or pressure, you won’t feel injuries on your legs or feet. High blood sugar also slows down wound healing.

If left untreated, injuries can turn into skin ulcers.

Atherosclerosis

Atherosclerosis, or arteriosclerosis, occurs when the arteries become narrow due to fat buildup called plaque.

Normally, the arteries deliver blood throughout the body. But when the arteries narrow, they can’t properly circulate blood.

If part of your body doesn’t get enough blood, the skin tissue breaks down and forms a sore.

You’re more likely to develop atherosclerosis if you have diabetes.

Pressure

If you stay in one position for too long, the constant pressure will squeeze your blood vessels.

This blocks blood flow to skin tissue. Eventually, the skin dies and develops an ulcer.

Venous insufficiency

Venous insufficiency occurs when your veins can’t send blood from your legs to your heart. Blood collects in your leg veins, which leads to swelling.

If the swelling is severe, it can put pressure on your skin and cause ulcers.

Causes of venous insufficiency include varicose veins and blood clots.

symptoms

Skin ulcers look like round, open sores. They range in severity and are usually minor injuries on the skin.

In severe cases, ulcers can become deep wounds that extend through muscle tissue, leaving bones and joints exposed.

The symptoms of skin ulcers include:

• discoloration of the skin
• itching
• scabbing
• swelling of the skin near the ulcer
• dry or flaky skin around the ulcer
• pain or tenderness near the affected area
• clear, bloody, or pus-filled discharge from the ulcer
• a foul odor coming from the area
• hair loss near the ulcer

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diagnosis

A doctor can perform different tests to diagnose your sore. This might include:

• Medical history. This information can help your doctor better understand your symptoms.
• Physical exam. Your doctor will examine the size and depth of your sore, and look for blood, fluid, or pus.
• Blood test. If your ulcer is infected, a blood panel will show how your body is fighting the infection. A blood test can also show underlying problems.
• Tissue or fluid culture. This test can determine what kind of bacteria is causing your infection so your doctor can prescribe the right antibiotics.
• Imaging tests. An X-ray, CT scan, or MRI helps your doctor look at the tissue and bone under the sore.

Complications

If a person does not receive treatment, skin ulcers can progress into chronic wounds or dangerous infections.

Some complications of untreated skin ulcers include:

• cellulitis, a bacterial infection affecting deep layers of skin and soft tissue
• septicemia, or blood poisoning from a bacterial infection
• infections in the bone of joints
• gangrene, which is tissue death as a result of poor blood supply

Risk factors of skin ulcers

You’re more likely to get skin ulcers if you have certain risk factors. These include:

• Pregnancy. During pregnancy, hormonal changes and increased blood volume may cause leg vein problems.
• Cigarette smoking. Tobacco smoke hardens your arteries and disrupts proper blood flow.
• Limited mobility. Being bedridden, paralyzed, or using a wheelchair puts your skin under constant pressure. Leg injuries and arthritis can limit your movement.
• Increasing age. Age is linked to atherosclerosis and venous insufficiency.
• High blood pressure. Hypertension, or high blood pressure, damages the arteries and disrupts blood flow.
• High blood cholesterol. High cholesterol increases narrowing and oxidative stress in the arteries, which disrupts blood flow.
• Obesity. Obesity raises your risk for diabetes, atherosclerosis, and increased pressure in your leg veins.
• History of blood clots. If you’re prone to blood clots, you’re more likely to have blood flow issues.

Skin ulcers treatment

The goal of skin ulcer treatment is to heal the wound, reduce pain, and treat any infection. Your treatment may include:

Dressing

Dressings protect the wound and keep it clean. This promotes healing and prevents infection.

The type of dressing depends on your ulcer and your doctor’s preference. Examples include moist dressings, hydrogels, hydrocolloids, collagen wound dressings, and antimicrobial dressings.

Always follow your doctor’s instructions. They’ll explain how to clean the ulcer and change the dressing.

Antibiotics

If your ulcer is infected, you’ll need antibiotic ointment. If the infection has reached deeper tissue or bone, you’ll receive oral antibiotics.

Your doctor may prescribe antibiotics even if your ulcer isn’t infected. The antibiotics will reduce the risk of infection.

Pain medication

At first, changing the dressing will be painful. A doctor can prescribe medication to control the pain. The ulcer will be less painful as it gets better.

If you can’t feel pain or pressure, you likely won’t need pain medication.

Surgery

Typically, noninfected skin ulcers don’t need surgery.

If other treatments don’t work, or if you have a large sore, you might need a skin graft. This will close the wound and help proper healing.

Surgery may also be done to remove pressure by shaving away bone.

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Appendicitis happens when your appendix becomes inflamed. It can be acute or chronic.

In the United States, appendicitis is the most common cause of abdominal pain resulting in surgery. Over 5 percent of Americans experience it at some point in their lives.

If left untreated, appendicitis can cause your appendix to burst. This can cause bacteria to spill into your abdominal cavity, which can be serious and sometimes fatal.

Read on to learn more about the symptoms, diagnosis, and treatment for appendicitis.

Appendicitis is an inflammation of the appendix, a finger-shaped pouch that projects from your colon on the lower right side of your abdomen.

Appendicitis causes pain in your lower right abdomen. However, in most people, pain begins around the navel and then moves. As inflammation worsens, appendicitis pain typically increases and eventually becomes severe.

Although anyone can develop appendicitis, most often it occurs in people between the ages of 10 and 30. Standard treatment is surgical removal of the appendix.

Causes

In many cases, the exact cause of appendicitis is unknown. Experts believe it develops when part of the appendix becomes obstructed, or blocked.

Many things can potentially block your appendix, including:

• a buildup of hardened stool
• enlarged lymphoid follicles
• intestinal worms
• traumatic injury
• tumors

When your appendix becomes blocked, bacteria can multiply inside it. This can lead to the formation of pus and swelling, which can cause painful pressure in your abdomen.

Other conditions can also cause abdominal pain. Click here to read about other potential causes of pain in your lower right abdomen.

Symptoms

Signs and symptoms of appendicitis may include:

• Sudden pain that begins on the right side of the lower abdomen
• Sudden pain that begins around your navel and often shifts to your lower right abdomen
• Pain that worsens if you cough, walk or make other jarring movements
• Nausea and vomiting
• Loss of appetite
• Low-grade fever that may worsen as the illness progresses
• Constipation or diarrhea
• Abdominal bloating
• Flatulence

The site of your pain may vary, depending on your age and the position of your appendix. When you’re pregnant, the pain may seem to come from your upper abdomen because your appendix is higher during pregnancy.

When to see a doctor

Make an appointment with a doctor if you or your child has worrisome signs or symptoms. Severe abdominal pain requires immediate medical attention

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Complications

Appendicitis can cause serious complications, such as:

• A ruptured appendix. A rupture spreads infection throughout your abdomen (peritonitis). Possibly life-threatening, this condition requires immediate surgery to remove the appendix and clean your abdominal cavity.
• A pocket of pus that forms in the abdomen. If your appendix bursts, you may develop a pocket of infection (abscess). In most cases, a surgeon drains the abscess by placing a tube through your abdominal wall into the abscess. The tube is left in place for about two weeks, and you’re given antibiotics to clear the infection. Once the infection is clear, you’ll have surgery to remove the appendix. In some cases, the abscess is drained, and the appendix is removed immediately.

Diagnosis

Diagnosing appendicitis can be tricky. Symptoms  are often unclear or similar to those of other illnesses, including gallbladder problems, bladder or urinary tract infection, Crohn’s disease, gastritis, kidney stones, intestinal infection, and ovary problems.

These tests can help diagnose appendicitis:

• Examination of your abdomen to look for inflammation
• Urine (pee) test to rule out a urinary tract infection
• Rectal exam
• Blood test to see whether your body is fighting an infection
• CT scans
• Ultrasound

Tests for appendicitis

If your doctor suspects you might have appendicitis, they will perform a physical exam. They will check for tenderness in the lower right part of your abdomen and swelling or rigidity.

Depending on the results of your physical exam, your doctor may order one or more tests to check for signs of appendicitis or rule out other potential causes of your symptoms.

There’s no single test available to diagnose appendicitis. If your doctor can’t identify any other causes of your symptoms, they may diagnose the cause as appendicitis.

Complete blood count

To check for signs of infection, your doctor may order a complete blood count (CBC). To conduct this test, they will collect a sample of your blood and send it to a lab for analysis.

Appendicitis is often accompanied by bacterial infection. An infection in your urinary tract or other abdominal organs may also cause symptoms similar to those of appendicitis.

Urine tests

To rule out urinary tract infection or kidney stones as a potential cause of your symptoms, your doctor may use urinalysis. This is also known as a urine test.

Your doctor will collect a sample of your urine that will be examined in a lab.

Pregnancy test

Ectopic pregnancy can be mistaken for appendicitis. It happens when a fertilized egg implants itself in a fallopian tube, rather than the uterus. This can be a medical emergency.

If your doctor suspects you might have an ectopic pregnancy, they may perform a pregnancy test. To conduct this test, they will collect a sample of your urine or blood. They may also use a transvaginal ultrasound to learn where the fertilized egg has implanted.

Pelvic exam

If you’re female, your symptoms might be caused by pelvic inflammatory disease, an ovarian cyst, or another condition affecting your reproductive organs.

To examine your reproductive organs, your doctor may perform a pelvic exam.

During this exam, they will visually inspect your vagina, vulva, and cervix. They will also manually inspect your uterus and ovaries. They may collect a sample of tissue for testing.

Abdominal imaging tests

To check for inflammation of your appendix, your doctor might order imaging tests of your abdomen. This can also help them identify other potential causes of your symptoms, such as an abdominal abscess or fecal impaction.

Your doctor may order one or more of the following imaging tests:

• abdominal ultrasound
• abdominal X-ray
• abdominal CT scan
• abdominal MRI scan

In some cases, you might need to stop eating food for a period of time before your test. Your doctor can help you learn how to prepare for it.

Chest imaging tests

Pneumonia in the lower right lobe of your lungs can also cause symptoms similar to appendicitis.

If your doctor thinks you might have pneumonia, they will likely order a chest X-ray. They may also order a CT scan to create detailed images of your lungs

Treatment

Appendicitis is almost always treated as an emergency.  Surgery to remove the appendix, which is called an appendectomy, is the standard treatment for almost all cases of appendicitis.

Generally, if your doctor suspects that you have appendicitis, they will quickly remove it to avoid a rupture. If you have an abscess, you may get two procedures: one to drain the abscess of pus and fluid, and a later one to take out the appendix. But some research shows that treating acute appendicitis with antibiotics may help you avoid surgery.

Depending on your condition, your doctor’s recommended treatment plan for appendicitis may include one or more of the following:

• surgery to remove your appendix
• needle drainage or surgery to drain an abscess
• antibiotics
• pain relievers
• IV fluids
• liquid diet

In rare cases, appendicitis may get better without surgery. But in most cases, you will need surgery to remove your appendix. This is known as an appendectomy.

If you have an abscess that hasn’t ruptured, your doctor may treat the abscess before you undergo surgery. To start, they will give you antibiotics. Then they will use a needle to drain the abscess of pus.

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Surgery for appendicitis

To treat appendicitis, your doctor may use a type of surgery known as appendectomy. During this procedure, they will remove your appendix. If your appendix has burst, they will also clean out your abdominal cavity.

In some cases, your doctor may use laparoscopy to perform minimally invasive surgery. In other cases, they may have to use open surgery to remove your appendix.

Like any surgery, there are some risks associated with appendectomy. However, the risks of appendectomy are smaller than the risks of untreated appendicitis.

Acute appendicitis

Acute appendicitis is a severe and sudden case of appendicitis. The symptoms tend to develop quickly over the course of one to two daysTrusted Source.

It requires immediate medical treatment. If left untreated, it can cause your appendix to rupture. This can be a serious and even fatal complication.

Acute appendicitis is more common than chronic appendicitis.

Chronic appendicitis

Chronic appendicitis is less common than acute appendicitis. In chronic cases of appendicitis, the symptoms may be relatively mild. They may disappear before reappearing again over a period of weeks, months, or even years.

This type of appendicitis can be challenging to diagnose. Sometimes, it’s not diagnosed until it develops into acute appendicitis.

Chronic appendicitis can be dangerous.

Appendicitis in kids

An estimated 70,000 children experience appendicitis every year in the United States. Although it’s most common in people between the ages of 15 and 30 years old, it can develop at any age.

In children and teenagers, appendicitis often causes a stomachache near the navel. This pain may eventually become more severe and move to the lower right side of your child’s abdomen.

Your child may also:

• lose their appetite
• develop a fever
• feel nauseous
• vomit

If your child develops symptoms of appendicitis, contact their doctor right away.

Recovery time for appendicitis

Your recovery time for appendicitis will depend on multiple factors, including:

• your overall health
• whether or not you develop complications from appendicitis or surgery
• the specific type of treatments you receive

If you have laparoscopic surgery to remove your appendix, you may be discharged from the hospital a few hours after you finish surgery or the next day.

If you have open surgery, you will likely need to spend more time in the hospital to recover afterward. Open surgery is more invasive than laparoscopic surgery and typically requires more follow-up care.

Before you leave the hospital, your healthcare provider can help you learn how to care for your incision sites. They may prescribe antibiotics or pain relievers to support your recovery process. They may also advise you to adjust your diet, avoid strenuous activity, or make other changes to your daily habits while you heal.

It may take several weeks for you to fully recover from appendicitis and surgery. If you develop complications, your recovery may take longer.

Appendicitis in pregnancy

Acute appendicitis is the most common non-obstetric emergency requiring surgery during pregnancy. It affects an estimated 0.04 to 0.2 percent of pregnant women.

The symptoms of appendicitis may be mistaken for routine discomfort from pregnancy. Pregnancy may also cause your appendix to shift upward in your abdomen, which can affect the location of appendicitis-related pain. This can make it harder to diagnose.

Treatment options during pregnancy might include one or more of the following:

• surgery to remove your appendix
• needle drainage or surgery to drain an abscess
• antibiotics

Delayed diagnosis and treatment may increase your risk of complications, including miscarriage.

Potential complications of appendicitis

Appendicitis can cause serious complications. For example, it may cause a pocket of pus known as an abscess to form in your appendix. This abscess may leak pus and bacteria into your abdominal cavity.

Appendicitis can also lead to a ruptured appendix. If your appendix ruptures, it can spill fecal matter and bacteria into your abdominal cavity.

If bacteria spill into your abdominal cavity, it can cause the lining of your abdominal cavity to become infected and inflamed. This is known as peritonitis, and it can be very serious, even fatal.

Bacterial infections can also affect other organs in your abdomen. For example, bacteria from a ruptured abscess or appendix may enter your bladder or colon. It may also travel through your bloodstream to other parts of your body.

To prevent or manage these complications, your doctor may prescribe antibiotics, surgery, or other treatments. In some cases, you might develop side effects or complications from treatment. However, the risks associated with antibiotics and surgery tend to be less serious than the potential complications of untreated appendicitis.

Preventing appendicitis

There’s no sure way to prevent appendicitis. But you might be able to lower your risk of developing it by eating a fiber-rich diet. Although more research is needed on the potential role of diet, appendicitis is less common in countries where people eat high-fiber diets.

Foods that are high in fiber include:

• fruits
• vegetables
• lentils, split peas, beans, and other legumes
• oatmeal, brown rice, whole wheat, and other whole grains

Your doctor may also encourage you to take a fiber supplement.

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Perianal abscess is a superficial infection that appears as a tender red lump under the skin near the anus. The infection occurs when bacteria gets trapped in the crypt glands that line the anal canal. The bacteria and fluid (pus) build up and becomes a lump that is red and painful (like a “pimple”). This type of abscess happens most often in male babies under a year of age. It may drain pus on its own and then heal and disappear.

An anal, or rectal, abscess occurs when a cavity in the anus becomes filled with pus. It causes extreme pain, fatigue, rectal discharge, and fever. In some cases, anal abscesses can result in painful anal fistulas. This occurs when the abscess doesn’t heal and breaks open on the surface of the skin. If an anal abscess doesn’t heal, it can cause a lot of pain and may require surgery.

Pathophysiology

Anorectal abscess are though to be caused by plugging of the anal ducts, the ducts that drain the anal glands in the anal wall, helping to ease the passage of faecal matter through mucus secretion.

Blockage of an anal duct results in fluid stasis, which will lead to infection. Common causative organisms include E. coli, Bacteriodes spp., and Enterococcus spp..

The anal glands are located in the intersphincteric space (between the internal and external anal sphincters), therefore infection from the glands here spreads to adjacent areas. Anorectal abscesses are thus categorised by the area (Fig. 1) in which they occur: (1) Perianal* (2) Ischiorectal (3) Intersphincteric (4) Supralevator

causes

A blocked anal gland, a sexually transmitted infection (STI), or an infected anal fissure can cause anal abscesses. Some other risk factors include:

• Crohn’s disease or ulcerative colitis, which are inflammatory bowel diseases that cause the body to attack healthy tissue
• diabetes
• a compromised immune system due to illnesses like HIV or AIDS
• anal sex, which can increase the risk of anal abscesses in both men and women
• use of the medication prednisone or other steroids
• current or recent chemotherapy
• constipation
• diarrhea

Toddlers or children that have a history of anal fissures (tears in the anal sphincter) are also at a higher risk for developing anal abscesses later on. Such anal fissures might occur in children who have a history of constipation.

What is a fistula?

Perianal and perirectal abscesses can be associated with fistula development.  Fistula is a tube-like connection between the space inside the anus (anal canal or rectum) and the skin outside the anus.  Once a fistula forms, bacteria from the intestine becomes trapped and causes the infection to return. Fistula that forms from perianal abscess is superficial. Fistula that forms from perirectal abscess is deep and can track through the different layers of the pelvic floor muscle and anal sphincter muscle complex.

symptoms 

hrobbing and constant pain in the anal area is probably one of the most common and immediately noticeable symptoms of anal abscess. The pain is usually accompanied by swelling in the anal area and greater pain during bowel movements.

Other common signs of an anal abscess include:

• constipation
• rectal discharge or bleeding
• swelling or tenderness of the skin surrounding the anus
• fatigue

Some people may be able to feel a nodule or lump that’s red, swollen, and tender at the rim of the anus. Fever and chills can result from the infection. You may also have rectal bleeding or urinary symptoms such as difficulty urinating.

Anal abscesses may also occur deeper in the rectum, most often in those who have inflammatory bowel diseases. This can result in some pain or discomfort in the abdominal area.

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In toddlers, there typically aren’t many symptoms other than signs of discomfort or pain, which may cause a child to become irritable. A lump or nodule may also be visible or felt around the anal area.

Clinical Features

Anorectal abscesses present with pain in the perianal region, which becomes exacerbated when sat down. Other symptoms include localised swelling, itching, or discharge. Severe abscesses may present with systemic features* such as fever, rigors, general malaise, or features of sepsis.

On examination, there will be a erythematous, fluctuant, tender perianal mass (Fig. 1), which may be discharging pus or have surrounding cellulitis.

Deeper abscesses may not have any obvious external signs, however produce severe tenderness on digital rectal exam, therefore require a further examination under anaesthesia for full assessment.

Complicated, unclear, or chronic disease may require additional imaging, either a CT or MRI scan.

diagnosis

Anal abscesses are most often diagnosed through a physical exam where your doctor checks the area for characteristic nodules. You doctor will also check for pain, redness, and swelling in the anal area.

In some people, there may not be any visible signs of the abscess on the surface of the skin around their anus. You doctor will instead use an instrument called an endoscope to look inside the anal canal and lower rectum. Sometimes the abscess may be deeper than a physical exam can find. Then, you doctor may order an MRI or ultrasound to get a better look.

Further tests may be necessary to make sure Crohn’s disease isn’t a contributing factor. In these cases, a blood test, imaging, and a colonoscopy may be required. During a colonoscopy, your doctor will use a lighted, flexible scope to examine your colon.

treatment

Location and size of the perirectal abscess determines what needs to be done to the treat the infection. When the abscess is small, antibiotics alone are enough to treat the infection.  However, when the abscess is large, in addition to antibiotics, the infection will need to be drained.  Drainage procedure can be done by radiologist who will place a drain (small plastic tube) into the abscess to drain the pus.  The infection can also be drained by the pediatric surgeon in the operating room. 

The type of procedure that is done will depend on the location of the abscess.  Both types of procedure are done with your child under general anesthesia.  After the procedure, your child will be admitted to the hospital for a few days until the infection has resolved.  Sometimes, patients are discharged home with drain in the place, which can be removed in the clinic.  

Perirectal abscess can be associated with fistula. The fistula can be identified on the CT or MRI scan that was used to diagnose the perirectal abscess.  If perirectal abscess or fistula is identified, your child will need to be seen by pediatric gastroenterologist to be evaluated for inflammatory bowel disease. If your child is diagnosed with inflammatory bowel disease, medications will be prescribed to treat the inflammation and allow the fistula to heal.  In some occasions, the fistula stays open and continues to cause abscess formation.  

To prevent future abscess, your child’s pediatric surgeon may recommend an operation to place a Seton (thin rubber band) through the fistula to prevent bacteria and pus from building up.  After this operation, your child can go home the same day or may need to be admitted in the hospital for a few days depending on the extent and how deep the fistula is located.  The Seton can remain in place for few months.

The decision to remove the Seton is determined by your child’s pediatric gastroenterologist and pediatric surgeon.  When the Seton needs to be removed, removal can be done in clinic.  

Management

Patients should be started on antibiotic therapy, as guided by local protocol, and provided with sufficient analgesia.

The main management for anorectal abscesses is with an incision and drainage procedure, which should always be performed under general anaesthetic. These can be left to heal by secondary intention.

Once drained, proctoscopy should be performed to check for the presence of any identifiable fistula-in-ano. If a fistula is identified, the insertion of a seton can be considered by experienced surgeons, however this should only be performed if the tract is clearly identifiable with minimal probing.

Limited data has suggested that use of post-operative antibiotics following drainage of anorectal abscess may lower the risk of fistula formation.

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