阑尾炎英文课件

1、阑尾炎英文阑尾炎英文阑尾炎英文课件Anatomy Anatomy Varied anatomyLength: 510 cm, narrow lumenhaustra of colonVaried anatomyLength: 510 cm,EpidemiologyThe most common acute abdomen disease The incidence of appendectomy appears to be declining due to more accurate preoperative diagnosis.Despite newer imaging techniques

2、, acute appendicitis can be very difficult to diagnose. EpidemiologyThe most common acPathophisiology Simple appendicitisSuppurative appendicitis Gangrenous appendicitisPerforated appendicitisPeritonitisAbscess around the appendixMucocele of appendixPathophisiology Simple appendiPathophysiologyAcute

3、 appendicitis is thought to begin with obstruction of the lumenObstruction can result from food matter, adhesions, or lymphoid hyperplasiaAppendix is twisted, and Lumen of appendix is narrow, result in obstructionMucosal secretions continue to increase intraluminal pressurePathophysiologyAcute appen

4、diciEtiology 1. The anatomy characteristics2. The tissue features3. fecality, foreign body obstruction4. Parasites cause the mucosa damage5. adhesion, pressure cause appendix distortedObstruction high pressure limph obstructed, ischemia mucosa damage bacteria invade（70%80%）Etiology 1. The anatomy ch

5、aracArtery The appendix artery has no branches, is easily to be obstacled Artery The appendix artery hasEtiologyEventually the pressure exceeds capillary perfusion pressure and venous and lymphatic drainage are obstructed.With vascular compromise, epithelial mucosa breaks down and bacterial invasion

6、 by bowel flora occurs.microbes：Ecoli, streptococcus, Pseudomonas, anaerobeEtiologyEventually the pressurIn pregnancy, the appendix can be shifted and patients can present with RUQ painSpecial PopulationsPerforated appendicitisTemperatures 39 C are uncommon in first 24 h, but common after ruptureIn

7、pregnancy, the appendix can be shifted and patients can present with RUQ painThis triggers somatic pain fibers, innervating the peritoneal structuresAnorexia is the most common of associated symptomsRLQ pain was 81 % sensitive and 53% specific for diagnosisAntibiotics are most effective when given p

8、reoperatively and they decrease post-op infections and abscess formationBowel adhesion, obstructionPathophysiologyAdditional studies: CBC, UA, imaging studiesLimitations of US: retrocecal appendix may not be visualized, perforations may be missed due to return to normal diameterIn one study, CT had

9、greater sensitivity, accuracy, -predictive valueAppendectomybest choice based on availability and alternative diagnoses.EtiologyIncreased pressure also leads to arterial stasis and tissue infarctionEnd result is perforation and spillage of infected appendiceal contents into the peritoneumIn pregnanc

10、y, the appendix canPathophysiologyInitial luminal distention triggers visceral afferent pain fibers, which enter at the 10th thoracic vertebral level.This pain is generally vague and poorly localized.Pain is typically felt in the periumbilical or epigastric area.PathophysiologyInitial luminalPathoph

11、ysiologyAs inflammation continues, the serosa and adjacent structures become inflamedThis triggers somatic pain fibers, innervating the peritoneal structuresTypically causing pain in the RLQPathophysiologyAs inflammationPathophysiologyThe change in stimulation form visceral to somatic pain fibers ex

12、plains the classic migration of pain in the periumbilical area to the RLQ seen with acute appendicitis.PathophysiologyThe change in sPathophysiologyExceptions exist in the classic presentation due to anatomic variability of the appendixAppendix can be retrocecal causing the pain to localize to the r

13、ight flankIn pregnancy, the appendix can be shifted and patients can present with RUQ painPathophysiologyExceptions exisPathophysiologyIn some males, retroileal appendicitis can irritate the ureter and cause testicular pain.Pelvic appendix may irritate the bladder or rectum causing suprapubic pain,

14、pain with urination, or feeling the need to defecateMultiple anatomic variations explain the difficulty in diagnosing appendicitisPathophysiologyIn some males, pain can be most pronounced if the patient has pelvic appendixManifestationsPathophysiologyIf there is increased pain then the sign is posit

15、iveImaging studies: include X-rays, US, CTPhysical ExamRLQ pain was 81 % sensitive and 53% specific for diagnosisAs the illness progresses RLQ localization typically occursEnd result is perforation and spillage of infected appendiceal contents into the peritoneum5、patient refused surgeryPrimary symp

16、tom:375g or Unasyn 3gThe incidence of appendectomy appears to be declining due to more accurate preoperative diagnosis.appendix massPhysical ExamIn one study, CT had greater sensitivity, accuracy, -predictive valuePathophisiologyRovsings sign:Preoperative prepareManifestations Primary symptom: abdom

17、inal pain to 2/3 of patients have the classical presentationPain beginning in epigastrium or periumbilical area that is vague and hard to localize pain can be most pronounced ifManifestations As the illness progresses RLQ localization typically occursRLQ pain was 81 % sensitive and 53% specific for

18、diagnosisMigration of pain from initial periumbilical to RLQ was 64% sensitive and 82% specificManifestations As the illness Manifestations Associated symptoms: indigestion, discomfort, flatus, need to defecate, anorexia, nausea, vomitingAnorexia is the most common of associated symptomsVomiting is

19、more variable, occuring in about of patientsManifestations Associated sympPhysical ExamFindings depend on duration of illness prior to exam.Early on patients may not have localized tendernessWith progression there is tenderness to deep palpation over McBurneys pointPhysical ExamFindings depend oPhys

20、ical ExamRovsings sign: pain in RLQ with palpation to LLQObturator sign: passively flex the R hip and knee and internally rotate the hip. If there is increased pain then the sign is positivePhysical ExamRovsings sign: Physical examPsoas sign: place patient in L lateral decubitus and extend R leg at

21、the hip. If there is pain, the sign is positive.Rectal exam: pain can be most pronounced if the patient has pelvic appendixPhysical examPsoas sign: Physical ExamAdditional components that may be helpful in diagnosis: rebound tenderness, voluntary guarding, muscular rigidity, tenderness on rectalFeve

22、r: another late finding.At the onset of pain fever is usually not found. Temperatures 39 C are uncommon in first 24 h, but common after rupturePhysical ExamAdditional componDiagnosisAcute appendicitis should be suspected in anyone with epigastric, periumbilical, right flank, or right sided abd pain

23、who has not had an appendectomyWomen of child bearing age need a pelvic exam and a pregnancy test.Additional studies: CBC, UA, imaging studiesDiagnosisAcute appendicitis shAnorexia is the most common of associated symptomsIn pregnancy, the appendix can be shifted and patients can present with RUQ pa

24、inpain in RLQ with palpation to LLQAlso, short acting narcotics should be used for pain managementPathophysiologyPatients should be given IVF, and preoperative antibioticsAbnormal findings include:Acute appendicitis should be suspected in anyone with epigastric, periumbilical, right flank, or right

25、sided abd pain who has not had an appendectomyEarly on patients may not have localized tendernessDespite newer imaging techniques, acute appendicitis can be very difficult to diagnose.fecality, foreign body obstructionPhysical ExamAppendix is twisted, and Lumen of appendix is narrow, result in obstr

26、uctionfecalith, appendiceal gas, localized paralytic ileus, blurred right psoas, and free airPathophysiologyThe incidence of appendectomy appears to be declining due to more accurate preoperative diagnosis.Temperatures 39 C are uncommon in first 24 h, but common after rupturePathophysiologypain can

27、be most pronounced if the patient has pelvic appendixRLQ pain was 81 % sensitive and 53% specific for diagnosisIn pregnancy, the appendix can be shifted and patients can present with RUQ painDiagnosisThe WBC is of limited value. Sensitivity of an elevated WBC is 70-90%, but specificity is very low.B

28、ut, +predictive value of high WBC is 92% and predictive value is 50%CRP and ESR have been studied with mixed resultsAnorexia is the most common ofDiagnosisImaging studies: include X-rays, US, CTX rays of abd are abnormal in 24-95%Abnormal findings include: fecalith, appendiceal gas, localized paraly

29、tic ileus, blurred right psoas, and free airAbdominal xrays have limited use:for the findings are seen in multiple other processesDiagnosisImaging studies: inclDiagnosisLimitations of US: retrocecal appendix may not be visualized, perforations may be missed due to return to normal diameterDiagnosisL

30、imitations of US: reDiagnosisCT: best choice based on availability and alternative diagnoses.In one study, CT had greater sensitivity, accuracy, -predictive value DiagnosisCT: Special PopulationsVery young, very old, pregnant, and HIV patients present atypically and often have delayed diagnosisHigh

31、index of suspicion is needed in the these groups to get an accurate diagnosisSpecial PopulationsVery young,TreatmentAppendectomy is the standard of carePatients should be given IVF, and preoperative antibiotics Antibiotics are most effective when given preoperatively and they decrease post-op infect

32、ions and abscess formationTreatmentAppendectomy is the sTreatmentThere are multiple acceptable antibiotics to use as long there is anaerobic flora, enterococci and gram(-) intestinal flora coverageOne sample monotherapy regimen is Zosyn 3.375g or Unasyn 3gAlso, short acting narcotics should be used

33、for pain management TreatmentThere are multiple acTreatments choiceNon operative treatment indicatiosn 1、onset for 3-4 days 2、diagnosis is undefined 3、general diseases, poor condition 4、inflammatory mass formation 5、patient refused surgeryTreatments choiceNon operativeAppendectomy Preoperative prepa

34、reAnesthesiaIncision siteExposure appendix, resectionSuture incisionNotes: normal appendix appendix mass abscess around appendixAppendectomy Preoperative prepAppendectomy Appendectomy Abnormal findings include:abdominal painEnd result is perforation and spillage of infected appendiceal contents into

35、 the peritoneumpassively flex the R hip and knee and internally rotate the hip.Pain is typically felt in the periumbilical or epigastric area.fecalith, appendiceal gas, localized paralytic ileus, blurred right psoas, and free airAppendectomyGangrenous appendicitisThe appendix artery has no branches,

36、 is easily to be obstacledfecality, foreign body obstructionBowel adhesion, obstructionPathophysiology5、patient refused surgeryAdditional studies: CBC, UA, imaging studiesEarly on patients may not have localized tendernessThis triggers somatic pain fibers, innervating the peritoneal structuresAssoci

37、ated symptoms:Additional studies: CBC, UA, imaging studiesRovsings sign:This pain is generally vague and poorly localized.In one study, CT had greater sensitivity, accuracy, -predictive valueappendix masshaustra of colonPathophisiologyThere are multiple acceptable antibiotics to use as long there is

38、 anaerobic flora, enterococci and gram(-) intestinal flora coverageRLQ pain was 81 % sensitive and 53% specific for diagnosisEnd result is perforation and spillage of infected appendiceal contents into the peritoneumPathophysiologyPhysical ExamAntibiotics are most effective when given preoperatively

39、 and they decrease post-op infections and abscess formationSpecial Populationsabscess around appendixAppendectomy375g or Unasyn 3gIn one study, CT had greater sensitivity, accuracy, -predictive valuefecalith, appendiceal gas, localized paralytic ileus, blurred right psoas, and free airLimitations of

40、 US: retrocecal appendix may not be visualized, perforations may be missed due to return to normal diameterindigestion, discomfort, flatus, need to defecate, anorexia, nausea, vomitingIncreased pressure also leads to arterial stasis and tissue infarctionThe incidence of appendectomy appears to be declining due to more accurate preoperative diagnosis