It is difficult to describe shape of peritoneal cavity . That shape is very complex. Simple explanation: peritoneal cavity is like a closed bag. It is completely closed in males

Female have small holes in peritoneum. Oocytes (future babies) go from ovaries first to peritoneal cavity. The holes in peritoneum allow oocyte to go into Fallopian tubes. Fallopian tubes lead into uterus (womb in English or hyster in Latin or uterus in Greek). Organs that are covered by peritoneal cavity linings are named intra-peritoneal. There are also melo-peritoneal, extra-peritoneal or retro-peritoneal organs that covered partially or not covered at all. It looks like main function of peritoneum (peritoneal cavity) is to give some lubrication to your guts. Though there are other functions as well.

Now, take a plastic bag, pour a little bit of water or oil into it and seal. Put one hand on one side of bag, another hand - on another side of bag and rub against each other. You can see your hands slide easily. This is idea of peritoneum - you bowels slide easily against each other even when they are stretched by food and when they are pushing digested food down. When a bowel is punctured (perforated), content of bowel will go into peritoneal cavity. Colon (lower, bigger bowl) has fecal material. Fecal material consists of bacteria on 2/3 (yeah, there are so many of them). Now, that small puncture in one part of gut will cause spillage of bacteria all around that closed bag of peritoneum.

Guts on inside have several mechanisms protecting from bacteria. Peritoneal cavity doesn't' have such a protection.

Small puncture in one part of gut will cause all of you guts be inflamed on outside non-protected side (for gut it is outside, but for peritoneal cavity it is inside). This is peritonitis (diffuse). This what surgeons are afraid of. Look at you. You belly is like half of you body. So it is like half of you body is severely inflamed. Eventually it may lead to sepsis, a condition in which bacteria enter blood and infect other parts of body. This is life-threatening complication.

Sometime inflammation stays local and seals off forming an abscess. Abscess is walled off accumulation of pus. Pus is mixture of dead and alive bacteria, dead white blood cells (leukocytes; leukos = white, cyte = cell) that fought infection and honorably died, and dead tissue, that was digested partially by bacteria and partially by stuff from leukocytes. Inflamed peritoneum (the lining of peritoneal cavity is also named peritoneum) easily adhere to each other and may seal of infection - there will be local peritonitis. Any adherence may cause problems in future - guts do not slide easily anymore and food or stool sticks. Blockage of intestine may occur in acute appendicitis as well. This is partially responsible for nausea and vomiting. Sometimes, when antibiotics are used, appendicitis goes away without surgical treatment. It happens in elderly patients. The patients may come to hospital with a lump or a mass in right lower abdomen looking like tumor.

Diagnostic problem with appendicitis is that some other conditions may mimic it.

Abdominal cavity is packed with different organs. Other sources could cause pain in right lower quadrant. Females may have ovarian torsion or tuboovarian abscess or extrauterine pregnancy (this is why doctors persistently ask: when was your last menstrual period? Are you taking contraceptive hormones? Did you have vaginal bleeding?), etc. They also check your chorionic hormone, trying to find if you are pregnant.

Scrupulous doctor asks your permission to perform rectal exam. Many people refuses to do it. I can understand that. Who would like that somebody sticks fingers into his ass. I wouldn't. But rectal exam gives a lot of information. Rectum - is part of gut that is closest to back orifice. Back orifice is named anus in Latin or anal canal. Surgeons say that there are only two contra-indications for avoiding rectal exam: 1. patient does not have anus 2. Surgeon does not have fingers.

Rectal exam in appendicitis is usually unremarkable. Maybe you can cause pain by palpating side wall of rectum that is close to appendix. But rectal exam allows to distinguish other disorders. During rectal exam you may palpate hemorrhoids, uterus, nodules in prostate or enlarged prostate, you may feel fluid in lower part of peritoneal cavity, etc. You may see blood on finger telling you about internal bleeding. You may check stool for small amount of blood (named fecal occult blood test - FOBT - or Guaiac test by name of dye that turns blue in presence of blood. At last rectal exam may help in dis-impaction of rectum. That is when hard stool causes bowel obstruction.

Usually a rectal exam is more or less normal. But every surgeon will tell you a war story about how once in while, once in five years he found something significant on rectal exam, something that every other doctor missed. Just by putting finger into butt. I saw how a surgeon put a finger into an old, demented women and pulled out a pessarium. It was an apple-size pink plastic membrane , that should go into vagina, but somebody (at home?) put it (by mistake?) into rectum of that woman. You really need to push hard to get such big object into anus. The poor lady suffered bowel obstruction for a week and would probably die if it stayed long enough.

OK, lets return to appendicitis. So, doctors will check you White Blood Cell Count Any infection or inflammation may cause this count to be abnormally high. It is not specific for appendicitis, but it confirms other findings.

Next, doctors check Urinalysis - microscopic examination of urine. That detects red blood cells, white blood cells and bacteria in urine. When there is inflammation or stones in kidneys or bladder, urinalysis is abnormal. A normal urinalysis is more characteristic to appendicitis.

Next they try to image what is going on in your belly. An abdominal x-ray may detect fecalith as cause of appendicitis (5%). Free air due to perforation can might be seen on plain film.

A barium enema may be used. It is an x-ray test where liquid contrast is used from anus to fill colon. Sometimes it show an impression on colon in area of inflamed appendix. Barium enema also can exclude other intestinal problems that mimic appendicitis.

Here are guidelines that need to be followed. grade 1st concussion 2nd concussion grade 1: transient confusion, no loss of consciousness or mental status abnormalities on exam. symptoms resolve in 15 minutes or less. return to play when asymptomatic for 1 minutes return to play when asymptomatic for 1 week. if 2nd during same game must not return to same activity that day. grade 2, similar to grade 1 but symptoms resolve in more than 15 minutes return to lay when asmptymatic for 1 week. return to play after 2 weeks of being asymptomatic. grade 3, any loss of consciousness transport to hospital. return to play when asymptomatic for 1 week. if loss of consciousness > than a few seconds must be asymptomatic for 2 weeks. terminate for season, discourage return to sport.

Dr Bob's Take:As parents we need to remember that an athlete who suffers a concussion has up to 4 times risk of getting another. Cumulative concussions may cause cognitive (learning) disabilities.

Holidays Seasons and Snacks

As much as I hate to admit it holiday season is coming up real fast. With holiday season it seems to me that our eating habits change as well. Yes, some of us have been or are on diets and a question that frequently comes up is "what about snacks?".

First off, we should not waste our times on "wasted calories". These are calories that are primarily made up of sugars including one called "high fructose". Look at ingredient list if sugars are near top of list that means those ingredients make up highest percentage of ingredients.

The good snacks should be balanced with fat making up less 33% and sugars are not near top of ingredients. Occasionally we all get urges for that "cookie". And it's ok to give in to these but do it sparingly. Eat a couple of cookies but not 4 or 5.

One hundred calorie snacks can really help you when you just need something to carry you over. This will not blow your diet. Here are some ways to estimate size of portions when you are on run.

The palm of your hand generally represents about 3 ounces. The last part of your thumb is about 1 tablespoon. The length of your forefinger equals to about ounce.

Here are some 100 calorie snacks for you to try: half an apple and 2 tsp of peanut butter an orange and a few dry roasted nuts 10 cashews 10 almonds 2 oz of lean roast beef half a small avocado 3 oz of whole grained noodles, with 1 fresh tomato and 1/2 oz hard cheese 1 seven grain Belgian waffle 4 mini rice cakes with 2 tbsp of low fat cottage cheese !/2 cup of frozen orange juice eaten as a sorbet 2 large graham cracker squares with 1 tsp of peanut butter 3 handfuls of unbuttered popcorn seasoned with herbs

Dr Bob's Take: with holiday season fast approaching we need to be more careful not to over-indulge. These snacks provide a wonderful to way to satisfy our "hunger pains".

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