Intestinal obstruction complicating acute perforative appendicitis.

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