阑尾炎(英文)课件

surgeryAcuteAppendicitis阑尾炎(英文)阑尾炎(英文)Anatomy阑尾炎(英文)VariedanatomyLength:5~10cm,narrowlumenhaustraofcolon阑尾炎(英文)EpidemiologyThemostcommonacuteabdomendiseaseTheincidenceofappendectomyappearstobedecliningduetomoreaccuratepreoperativediagnosis.Despitenewerimagingtechniques,acuteappendicitiscanbeverydifficulttodiagnose.阑尾炎(英文)PathophisiologySimpleappendicitisSuppurativeappendicitisGangrenousappendicitisPerforatedappendicitisPeritonitisAbscessaroundtheappendixMucoceleofappendix阑尾炎(英文)PathophysiologyAcuteappendicitisisthoughttobeginwithobstructionofthelumenObstructioncanresultfromfoodmatter,adhesions,orlymphoidhyperplasiaAppendixistwisted,andLumenofappendixisnarrow,resultinobstructionMucosalsecretionscontinuetoincreaseintraluminalpressure阑尾炎(英文)Etiology1.Theanatomycharacteristics2.Thetissuefeatures3.fecality,foreignbodyobstruction4.Parasitescausethemucosadamage5.adhesion,pressurecauseappendixdistortedObstruction→highpressure→limphobstructed,ischemia→mucosadamage→bacteriainvade（70%～80%）阑尾炎(英文)ArteryTheappendixarteryhasnobranches,iseasilytobeobstacled阑尾炎(英文)EtiologyEventuallythepressureexceedscapillaryperfusionpressureandvenousandlymphaticdrainageareobstructed.Withvascularcompromise,epithelialmucosabreaksdownandbacterialinvasionbybowelfloraoccurs.microbes：Ecoli,streptococcus,Pseudomonas,anaerobe阑尾炎(英文)EtiologyIncreasedpressurealsoleadstoarterialstasisandtissueinfarctionEndresultisperforationandspillageofinfectedappendicealcontentsintotheperitoneum阑尾炎(英文)PathophysiologyInitialluminaldistentiontriggersvisceralafferentpainfibers,whichenteratthe10ththoracicvertebrallevel.Thispainisgenerallyvagueandpoorlylocalized.Painistypicallyfeltintheperiumbilicalorepigastricarea.阑尾炎(英文)PathophysiologyAsinflammationcontinues,theserosaandadjacentstructuresbecomeinflamedThistriggerssomaticpainfibers,innervatingtheperitonealstructuresTypicallycausingpainintheRLQ阑尾炎(英文)PathophysiologyThechangeinstimulationformvisceraltosomaticpainfibersexplainstheclassicmigrationofpainintheperiumbilicalareatotheRLQseenwithacuteappendicitis.阑尾炎(英文)PathophysiologyExceptionsexistintheclassicpresentationduetoanatomicvariabilityoftheappendixAppendixcanberetrocecalcausingthepaintolocalizetotherightflankInpregnancy,theappendixcanbeshiftedandpatientscanpresentwithRUQpain阑尾炎(英文)PathophysiologyInsomemales,retroilealappendicitiscanirritatetheureterandcausetesticularpain.Pelvicappendixmayirritatethebladderorrectumcausingsuprapubicpain,painwithurination,orfeelingtheneedtodefecateMultipleanatomicvariationsexplainthedifficultyindiagnosingappendicitis阑尾炎(英文)ManifestationsPrimarysymptom:abdominalpain½to2/3ofpatientshavetheclassicalpresentationPainbeginninginepigastriumorperiumbilicalareathatisvagueandhardtolocalize阑尾炎(英文)ManifestationsAstheillnessprogressesRLQlocalizationtypicallyoccursRLQpainwas81%sensitiveand53%specificfordiagnosisMigrationofpainfrominitialperiumbilicaltoRLQwas64%sensitiveand82%specific阑尾炎(英文)ManifestationsAssociatedsymptoms:indigestion,discomfort,flatus,needtodefecate,anorexia,nausea,vomitingAnorexiaisthemostcommonofassociatedsymptomsVomitingismorevariable,occuringinabout½ofpatients阑尾炎(英文)PhysicalExamFindingsdependondurationofillnesspriortoexam.EarlyonpatientsmaynothavelocalizedtendernessWithprogressionthereistendernesstodeeppalpationoverMcBurney’spoint阑尾炎(英文)PhysicalExamRovsing’ssign:paininRLQwithpalpationtoLLQObturatorsign:passivelyflextheRhipandkneeandinternallyrotatethehip.Ifthereisincreasedpainthenthesignispositive阑尾炎(英文)PhysicalexamPsoassign:placepatientinLlateraldecubitusandextendRlegatthehip.Ifthereispain,thesignispositive.Rectalexam:paincanbemostpronouncedifthepatienthaspelvicappendix阑尾炎(英文)PhysicalExamAdditionalcomponentsthatmaybehelpfulindiagnosis:reboundtenderness,voluntaryguarding,muscularrigidity,tendernessonrectalFever:anotherlatefinding.Attheonsetofpainfeverisusuallynotfound.Temperatures>39Careuncommoninfirst24h,butcommonafterrupture阑尾炎(英文)DiagnosisAcuteappendicitisshouldbesuspectedinanyonewithepigastric,periumbilical,rightflank,orrightsidedabdpainwhohasnothadanappendectomyWomenofchildbearingageneedapelvicexamandapregnancytest.Additionalstudies:CBC,UA,imagingstudies阑尾炎(英文)DiagnosisTheWBCisoflimitedvalue.SensitivityofanelevatedWBCis70-90%,butspecificityisverylow.But,+predictivevalueofhighWBCis92%and–predictivevalueis50%CRPandESRhavebeenstudiedwithmixedresults阑尾炎(英文)DiagnosisImagingstudies:includeX-rays,US,CTXraysofabdareabnormalin24-95%Abnormalfindingsinclude:fecalith,appendicealgas,localizedparalyticileus,blurredrightpsoas,andfreeairAbdominalxrayshavelimiteduse:forthefindingsareseeninmultipleotherprocesses阑尾炎(英文)DiagnosisLimitationsofUS:retrocecalappendixmaynotbevisualized,perforationsmaybemissedduetoreturntonormaldiameter阑尾炎(英文)DiagnosisCT:bestchoicebasedonavailabilityandalternativediagnoses.Inonestudy,CThadgreatersensitivity,accuracy,-predictivevalue阑尾炎(英文)SpecialPopulationsVeryyoung,veryold,pregnant,andHIVpatientspresentatypicallyandoftenhavedelayeddiagnosisHighindexofsuspicionisneededinthethesegroupstogetanaccuratediagnosis阑尾炎(英文)TreatmentAppendectomyisthestandardofcarePatientsshouldbegivenIVF,andpreoperativeantibioticsAntibioticsaremosteffectivewhengivenpreoperativelyandtheydecreasepost-opinfectionsandabscessformation阑尾炎(英文)TreatmentTherearemultipleacceptableantibioticstouseaslongthereisanaerobicflora,enterococciandgram(-)intestinalfloracoverageOnesamplemonotherapyregimenisZosyn3.375gorUnasyn3gAlso,shortactingnarcoticsshouldbeusedf