外科学教学课件：16阑尾炎

1、2021-7-11 Acute Appendicitis 2021-7-12 教学大纲教学大纲 目的要求：目的要求： 1、掌握急性阑尾炎的临床表现、鉴别、掌握急性阑尾炎的临床表现、鉴别 诊断和治疗原则。诊断和治疗原则。 2、了解特殊阑尾炎的临床特点和处理、了解特殊阑尾炎的临床特点和处理 原则。原则。 2021-7-13 General considerations In 1839 Bright and Addison described the symptoms of appendicitis.Surgical removal of the appendix was not performed

2、 in significant numbers until after 1880. Approximately 7% of individuals in western countries develop appendicitis at sometime during their lives, and about 200,000 appendectomies for acute appendicitis are performed annually in the USA. The appendicitis is the most common disease in acute abdomen.

3、 2021-7-14 Relevant Anatomy: The appendix, like a earthworm, is a structure connected to the cecum, its average length is 5-10 cm and it is 0.5-0.7 cm in diameter. 2021-7-15 Appendix is at the base of cecum, the meeting of three colic bands. Anterior band Cecum Ileum Appendix 2021-7-16 umbilicus Rig

4、ht anterior superior iliac spine Mcburneys point Its projection on body surface is Mcburneys point, which is a point one-third of the distance between the right anterior superior iliac spine and the umbilicus. 2021-7-17 The appendix is located in right iliac fossa (right lower quadrant) . Neighborin

5、g organs are: ovary (female) right ureter cecum ascending colon the end of the ileum 2021-7-18 Anatomic Position 1、Preileal 2、Pelvic 3、Retrocecal 4、Subcecal 5、Lateral cecal 6、Retroileal 1 2 4 5 3 6 2021-7-19 Malrotation or maldescent of the cecum is associated with abnormal location of the appendix,

6、 which may be found in anywhere between the right iliac fossa and the left subsplenic area. Such as: subhepatic area, the left lower quadrant, the pelvis. 2021-7-110 Abnormal location of the appendix 2021-7-111 The appendix runs into a serosal sheet of the peritoneum called the mesoappendix. The mes

7、oappendix carries the appendic- ular artery, which is a terminal artery of the ileocolic artery,which lies in its free border. And it has an apppendicular vein, which returns blood to the portal vein. 2021-7-112 Pathology (Etiology) According to the classic concept,the pathogenesis of acute appendic

8、itis involv- es bacterial infection distal to obstruction of the lumen. Appendicitis is due to obstruction of the appendiceal lumen from a variety of causes. 2021-7-113 Hyperplasia of submucous lymphoid follicles followed by infection (60%) The presence of fecal stasis and fecalith (35%) The presenc

9、e of no specific inciting cause， parasites, foreign bodies, tumors (5%) 2021-7-114 Hyperplasia of limphoid follicles 2021-7-115 fecalit h 2021-7-116 tumor 2021-7-117 Four stages of appendicitis 1. Acute Simple Appendicitis Mucus accumulating Intestinal bacteria multiply WBC accumulating Edema of the

10、 appendix 2021-7-118 2. Acute Suppurative Appendicitis A further rise in intraluminal pressure Venous obstruction Further edema and ischemia in the appendix Bacterial invasion through the wall of appendix The formation of pus 2021-7-119 3. Gangrenous, perforated appendicitis. Venous and arterial thr

11、ombosis The area with poorest blood supply infarcted Perforation Spilling accumulating pus Localized Peritonitis Generalized Peritonitis 2021-7-120 4、Periappendiceal abscess Generalized peritonitis Localized peritonitis Healing 2021-7-121 Diagnosis The diagnosis of acute appendicitis is made primari

12、ly on the basis of the history and the physical findings, with additional assistance from laboratory examinations. 2021-7-122 History 1. Abdominal pain 2.Gastrointestinal symptoms 3.Low fever after the other symptoms 2021-7-123 At first, patient feels vague abdominal discomfort followed by slight na

13、usea, anorexia. The pain is persistent and continuous. Within several hours, the pain shifts to the right lower quadrant, becoming rather sharply localized and causing discomfort on moving, walking or coughing. 2021-7-124 1.Abdominal pain (Typical pain and Atypical pain ) Typical pain(shifting pain)

14、(70-80%) Initial diffuse visceral pain in the epigastrium or periumbilical area. Localized somatic pain in the right lower quadrant. 2021-7-125 Atypical Pain At the onset of the appendicitis it never become localized and may remain diffuses , more be found in old patient or child. 2021-7-126 Viscera

15、l Pain It is because the appendix and the small bowel have the same visceral nerve supply, the obstruction of appendix and the accumu- lation of fluid and mucus then pus lead to higher intraluminal pressure which cause the pain, so the patient feel pain in the epi- gastrium or periumbilical area. 20

16、21-7-127 Somatic Pain Inflammation stimulate the peritonium , leading to localized peritonitis, because the peritoneum has somatic nerve supply, so the painful area can be exactly pointed (McBurney point). 2021-7-128 2.Gastrointestinal symptoms Anorexia Nausea Vomiting Diarrhea or constipation 3.Low

17、er fever 2021-7-129 The most specific physical finding: 1. localized tenderness in RLQ. 2. Rebound tenderness, muscular guarding. 3.A tenderness mass in RLQ . 4.Rovsing sign, obturator sign, psoas sign . Physical Examination: 2021-7-130 Rovsing sign 2021-7-131 psoas sign 2021-7-132 obturator sign 20

18、21-7-133 White Blood Cell Count It can be normal in early stage, always has a elevation of the white blood cell count .90% of patients have counts over 10,000/L. In three-fourths of patients,the differential white count shows more than 8090% neutrophils. Lab test 2021-7-134 Urinalysis The urine is u

19、sually normal,but a few leukocytes and erythrocytes may be noted, particularly in retrocecal or pelvic appendicitis. It exclude problems such as urinary infections or kidney stones, which at times can be confused with appendicitis Abdominal X-Ray It may detect a fecalith 2021-7-135 2021-7-136 Ultras

20、ound If the appendix is enlarged, the diagnosis is strongly suggested. It excludes painful conditions involving the ovaries, fallopian tubes and uterus. CT Laparoscopy The appendix can be directly visualized. 2021-7-137 2021-7-138 Essentials of Diagnosis 1. abdominal pain (shifting pain) 2. gastroin

21、testinal symptoms (Anorexia, nausea and vomiting). 3. Localized abdominal tenderness in RLQ( most important) 4. Lower fever 5.Leukocytosis 2021-7-139 Differential Diagnosis: The essential differential diagnosis is to eliminate those illness that do not need operative therapy and to decided suitable

22、operation for those that need operative therapy. 2021-7-140 1.Acute gastroduodenal ulcer perforation An ulcer history The most painful area is at epigastrium . Tenderness and guarding are more severe . Air under diaphragm is detected by x-ray. 2021-7-141 2021-7-142 2.Ureteral stone Suddenly sharp ex

23、treme pain Less tenderness and guarding The pain may spreads to the groin Red blood cells were detected in the urine (microscopic hematuria) B-ultrasound show dilation of ureter 2021-7-143 3.Gynecologic diseases Pelvic inflammatory disease (PID) (acute salpingitis输卵管炎输卵管炎 , endometritis子宫内膜炎子宫内膜炎 )

24、relationship to the last menstrual period no nausea and vomiting more often with bilateral tenderness culdocentesis（后穹隆穿刺）（后穹隆穿刺） yield pus . 2021-7-144 Ruptured Ectopic Pregnancy Menolipsis（停经）（停经） Symptoms relate to blood loss A palpable tubal mass on pelvic examination Culdocentesis（后穹窿穿刺术）（后穹窿穿刺

25、术） yield noncoltting blood intermenstrual pain or mittelschmerz (排卵痛）排卵痛） Onset in midmenstrual cycle Symptom spontaneously subside in few hours 2021-7-145 Ruptured ectopic pregnancy 2021-7-146 2021-7-147 4.Acute mesenteric adenitis It often happened in children or young patients, have respiratory i

26、nfec- tion history, abdominal tenderness is not localized. 2021-7-148 5.The others Gastroenteritis, Diverticulitis Acute cholecystitis , Perforating cecal carcinoma, Torsion of An Ovarian Cyst 2021-7-149 If appendicitis is diagnosed or strongly suspected, the best treatment is surgical removal of th

27、e appendix. Treatment 2021-7-150 1. An incision is made in the skin over the area of the appendix in the right lower abdomen (McBurney incision). 2021-7-151 2. The muscles are spread and the abdomen is entered . 3. The large bowel or cecum is located and followed to its end where the appendix is fou

28、nd. 2021-7-152 4. The appendix is pulled up through the incision . 2021-7-153 5. The mesoappendix is separated off of the appendix, clamped and tied off. 2021-7-154 6. The appendix is then tied off at its base next to the cecum . 7. The remainder of the appendix is lamped, cut and removed. 2021-7-15

29、5 8. Care is taken to prevent spillage of bacteria from the cut end. 9. If the appendix has ruptured, a drainage is placed in the region of the appendix to allow bacteria to drain out . The drainage are removed when the infection is cleared. 2021-7-156 complications Complications of appendicitis abd

30、omen abscess fecal fistula pylephlebitis-Chills, high fever,low-grade jaundice, and hepatic abscess. Complications of appendectomy bleeding wound infection Intestinal obstruction Fecal fistula 2021-7-157 APPENDICITIS IN INFANTS AND CHILDREN 2021-7-158 Accuracy of early diagnosis of appendi- citis in infants and children is not so easy. Appendicitis is infrequent in infants. Acute nonspecific abdominal pains are common in infants and children. Unable to give a history of the present illness. 2021-7-159 The inciden