1、Acute appendicitis WangJun The second general surgical department Peoples hospital of yuxi city Outlines ?General considerations ?Historical perspective ?Anatomy ?Pathophysiology ?Clinical findings ?Diagnosis ?Treatment General considerations ?About 8% of people in Western countries have appendiciti
2、s at some time during their life, with a peak incidence between 10 and 30 years of age. ?Acute appendicitis is the most common general surgical emergency.(10%) General considerations ?Acute appendicitis has protean manifestations. ?It may simulate almost any other acute abdominal illness and in turn
3、 may be mimicked by a variety of conditions. ?Progression of symptoms and signs is the rule in contrast to the fluctuating course of some other diseases. Historical perspective ?Willard Packard performed the first surgery in 1867. ?In 1886,Reginald Fitz described the characteristic,clinical findings
4、 and pathology of the disease,identified the appendix as the primary cause of right lower quadrant inflammation. ?Fitz coined the term appendicitis and recommended early surgical treatment Historical perspective ?In 1889, Chester McBurney described characteristic migratory pain as well as localizati
5、on of the pain along an oblique line from the anterior superior iliac spine to the umbilicus. ?In 1894, McBurney described a right lower quadrant muscle-splitting incision for removal of the appendix. Historical perspective ?In the 1940s,the mortality rate from appendicitis improved with the widespr
6、ead use of broad-spectrum antibiotics. ?In 1982, Laparoscopic appendectomy was first reported by the gynecologist Kurt Semm but has only gained widespread acceptance in recent years. Anatomy physiology ?The base of the appendix is located at the convergence of the taeniae(3) of colon. ?This anatomic
7、 relationship facilitates identification and location of the appendix at operation. Pathophysiology ?Obstruction of the lumen is believed to be the major cause of acute appendicitis. ?This may be due to lymphoid hyperplasia, inspissated stool, fecalith, vegetable matter or seeds, parasites, or a neo
8、plasm. Pathophysiology ?Obstruction of the appendiceal lumen ?Bacterial overgrowth ?Continued secretion of mucus ?Intraluminal distention and increased wall pressure Pathophysiology ?Subsequent impairment of lymphatic and venous drainage ?mucosal ischemia ?These findings in combination promote a loc
9、alized inflammatory process that may progress to gangrene and perforation. Pathophysiology ?Inflammation of the adjacent peritoneum gives rise to localized pain in the right lower quadrant. ?Perforation typically occurs after at least 48 hours from the onset of symptoms and is accompanied by an absc
10、ess cavity walled-off by the small intestine and omentum. ?Clinical findings Clinical findings history and symptom ?Appendicitis needs to be considered in the differential diagnosis of nearly every patient with acute abdominal pain ?The typical presentation begins with vague peri-umbilical pain foll
11、owed by anorexia,nausea and vomiting. Then localizes to the right lower quadrant. history and symptom ?The classic pattern of migratory pain is the most reliable symptom of acute appendicitis ?Fever ensues, followed by the development of leukocytosis ?Occasional patients have urinary symptoms or mic
12、roscopic hematuria migratory pain Physical Examination ?Low-grade fever is common(38). ?Diminished bowel sounds ?Focal tenderness (commonly at McBurney s point ) -located one third of the distance along a line drawn from the anterior superior iliac spine to the umbilicus ?Rebound tenderness ?Volunta
13、ry guarding Physical Examination ?Dunphys sign -coughing cause increased pain ?Rovsings sign -pain in the right lower quadrant during palpation of the left lower quadrant Physical Examination ?Psoas sign -pain on extension of the right hip (retrocecal appendix) ?Obturator sign -pain on internal rota
14、tion of the hip (pelvic appendix) Laboratory Studies ?The average leukocyte count is 15*109/L,and 90% of patient have count over 10*109/L ?More than 75% neutrophils in ? of patients. ?A completely normal leukocyte count and differential is found in about 10% of patients. Imaging studies ?Plain abdom
15、inal films: may be useful for the detection of ureteral calculi, small bowel obstruction, or perforated ulcer, but such conditions are rarely confused with appendicitis. ?Ultrasonography and CT scan: be helpful in patients with atypical symptoms ,such as children and elderly person. ?A, CT scan of t
16、he abdomen demonstrates an edematous, thickened appendix (arrow) with obstructing appendicolith (arrowhead). ?B, CT scan of abdomen demonstrates a perforated appendix with a complex abscess and pelvic fluid collection (arrow). BL, bladder; UT, uterus. Essentials of diagnosis ?Abdominal migratory pai
17、n ?Anorexia,nausea and vomiting ?Localized abdominal tenderness ?Low-grade fever ?Leukocytosis Differential Diagnoses ?Sometimes,the diagnosis of appendicitis may be difficult. ?Mesenteric lymphadenitis, ?gastrointestinal ulcer perforation ?Meckels diverticulitis, ?ectopic pregnancy, ?pelvic inflamm
18、atory disease Special category of appendicitis ?in infants， ?in children， ?in wemen during pregnancy， ?in elderly people ?in patients infected with HIV Complication ?Perforation ?Peritonitis ?Appendiceal abscess ?pylephlebitis Treatment ?Surgical treatment : Most patients with acute appendicitis are
19、 managed by prompt surgical removal of the appendix. (Appendectomy) ?Non-surgical treatment: Early Stage, Objective conditions are not allowed, Serious organic disease.(antibiotics) Treatment ?Laparoscopic appendectomy offers the advantage of: diagnostic laparoscopy shorter recovery less conspicuous incisions Subjective to think ?What s the Essentials of diagnosis about acute appendicitis?
