外科学急性阑尾炎英文教学课件

1、Acute Appendicitis急性阑尾炎IntroductionIt is the most common acute abdomen. It can occur at all ages, but most often between the ages of 10 and 30 years. Surgical AnatomyAppendix, fingerlike, lies in the right lower abdomenMcBurneys point: superficial projection anterior and superior iliac spine Appendi

2、x has mainly 6 positionsPreileal appendixPostileal appendixPelvic appendixSubcecal appendixParacecal appendixRetrocecal appendixThe radicle of Appendix is constanttaenia colicecum appendixEctopic appendix: in the upper or left abdomen, etc. The Blood Supply of AppendixAppendiceal artery: a terminal

3、artery, no branch, arising from ileocolic arterySo, when blood obstacles, appendix is easy to necroticAppendiceal arteryileocolic arteryAppendiceal vein: finally to portal vein. So, appendix inflamed,bacteria embolus pylephlebitis, liver abscessAetiology1. Obstruction of appendix lumen2. Bacterial i

4、nvasionthe opening of appendixthe lumen of appendixObstruction of lumen results from:Lymphoid hyperplasiaFecalithAdhesionsWormsTumorObstruction of appendix lumenincrease intraluminal pressure lead to blood obstacle. contribute to bacterial invasion.Pathogenesiscontinued mucus secretionCongestive, ed

5、ematousAbscessGeneralized peritonitisPurulentGangrene, perforationClinical pathologyAcute simple appendicitisAcute purulent appendicitisGangrenous and perforated appendicitisAbscess around the appendixAcute simple appendicitisAcute purulent appendicitisGangrenous and perforated appendicitisAbscess a

6、round the appendixAbscessAppendixClinical manifestation*Symptoms1. Abdominal pain Typical pain: Migratory right lower abdominal pain.Most of patients, about 70-80% The most reliable symptomInitially, the pain begins in the upper abdomen or periumbilical area.a few hours later (usually 6 to 8, no les

7、s than 2 hours) The pain moves to the right lower abdomen.The features of typical painThe initial pain: referred pain and visceral pain. Vague and poorly localized. The right lower abdominal pain: somatic pain. sharply localized, cough or sudden movement exacerbates the pain.sympathetic nerve fibres

8、 T 10,T11 Atypical pain: Pain begins in the right lower abdomen & remain there. Seldom, Pain may be located in the upper or left abdomen because of ectopic appendix. 2. Gastrointestinal SymptomsAnorexiaNauseaVomiting:ConstipationDiarrhea AnorexiaNauseaVomiting3. Systemic toxic manifestation tiredfev

9、er, approximately 38 degree, and when appendiceal perforation higher heart rate increasedSigns1. TendernessThe most common and important signs.It can even occur before the pain moves to the right lower abdomen.The location : most commonly at McBurneys point.the location of tenderness may be variable

10、 because of ectopic appendix. But we should know that wherever the location of tenderness varies, it is always fixed in the same site, which is called fixed tenderness. 2. Peritoneal irritation signsMuscular tensionRebound pain 3. A few special signs A. Rovsings sign：painB. Psoas sign：posterior exte

11、nsion of the right thigh. C. Obturator sign：flexing and internal rotation of the right hip. Laboratory TestsBlood routine examinationWBC count Proportion of neutrophil leukocytes Usually normal. When inflammation affect the bladder or ureter, a small number of RBC or WBC are examined in urine.2. Uri

12、nalysisImaging Tests Not necessary! Imaging tests can be chosen only when the diagnosis is not clear.X-rayB ultrasound CT12mmEnlarged appendixfecalithAppendical wall thickeningFecalithLaparoscopy Laparoscopy may be useful in some patients in whom the diagnosis cannot be ruled out. However, the need

13、for laparoscopy for diagnosis is quite low. Diagnosis of appendicitis is mainly made by: SymptomsSignsLaboratory testsImaging tests and Laparoscopy are not necessary unless the diagnosis is difficult.In Short Which includes: Migratory right lower abdominal pain: the most reliable symptom of acute ap

14、pendicitis. Fixed tenderness of right lower abdomen: even occur before the pain moves to the right lower abdomen WBC and neutrophil increases1. Gastric or duodenal ulcer Perforation History of peptic ulcer. Sudden onset and not a shifting pain. Pain: rarely in the right lower abdomen. Signs: periton

15、itis marked in upper abdomen. X-ray is helpful: free air under diaphragm.Differential Diagnosis2. Right ureteral stone Sudden severe colic pain. Signs is not obvious. A number of RBC in urine. B type ultrasound or X-ray is helpful: stone in urinary tract.3. Gynecologic disorders A: Ruptured ectopic

16、pregnancy Menolipsis,irregular vaginal bleeding history. Acute hemorrhage symptoms & intra-abdominal bleeding signs Culdocentesis: non-clotting blood. HCG: (+)B: Ovarian follicles or luteal cyst rupture Clinical manifestation is similar to ectopic pregnancy but not very severe. Occurs after the ovul

17、ation and the middle of a menstrual period. C: Acute Salpingitis or pelvic inflammation Occur at the end of a menstrual period. Pain: bilateral in the lower abdomen. Leukorrhea: suppurative. D: Ovarian cyst torsion Obvious and severe pain. Palpable mass on abdominal or pelvic examination. Ultrasound

18、 is helpful for the diagnosis.4. Acute mesenteric adenitis Often in children. Upper respiratory tract infection history. Pain & tenderness: not sharply localized Usually no muscle rigidity.5. Acute gastroenteritis Profuse diarrhea, nausea & vomiting. Abdominal signs absent: No fixed tenderness or pe

19、ritoneal irritation. Treatment1. Surgical treatment If appendicitis is diagnosed or strongly suspected, the best treatment is surgical removal called appendectomy because treatment delay increases mortality.Open appendectomyLaparoscopic appendectomy2. non-surgical treatmentOnly simple and early stag

20、e of appendicitis.With severe organic disease contraindication to surgery.Its measures include effective antibiotics and rehydration therapy.Techniques of open appendectomyA. incision:McBurney incision.A McBurney incisionB. search appendix:By tracing the taenia of the colon until the cecum.C. deal w

21、ith mesoappendix:D. purse-string suture:E. resection of appendix:cut the appendix.F. inversion of stump:invert the stump.G. Closure of abdomen:Laparoscopic appendectomy1. Appendicitis in child Quick progressionHigh fever and vomiting earlyNon-typical tenderness at right lower abdomenHigh rate of per

22、forationHigh mortalityMore complicationsSpecial types of appendicitisTreatment:Early operationTransfusion and correct dehydrationBroadspectrum antibiotics2. Appendicitis in the elderlyLess well-defined symptoms and signsSevere pathologic typeError diagnosis easilyEarly perforationFrequently complica

23、ted with the senile illnessOnce diagnosed, appendectomy 3. Appendicitis during pregnancyelevation of abdominal wallTenderness site upper shift appendix displaced superiorlyUnobvious oftenderness rebound tendernessmuscle rigidityWithout adherent blanket of omentum Peritonitis diffusionUterus enlargem

24、entTreatment: Appendectomy Late pregnancy: operated earlier Superior Incision Gentle operation No drainage Broadspectrum antibiotics Chronic appendicitis 1. Clinical feature:Most arise from acute inflammation, but some start as a chronic process.Recurrent right lower abdominal pain with attack histo

25、ry of acute appendicitis.Fixed tenderness at right lower abdomen.2. Barium enemaAppendix no filled or only partially filled with irregular lumen.Barium still remain in the lumen more than 72h.3. Treatment: Once diagnosed, appendectomy A Case Discussion 1. Medical History Abstract: A 28-year-old male patient was admitted to the hospital because of acute abdominal pain for 10 hours duration. 10 hours ago, the patient felt poor