1、Acute appendicitisWangJunThe second general surgical department Peoples hospital of yuxi cityOutlinesnGeneral considerationsnHistorical perspectivenAnatomynPathophysiology nClinical findings nDiagnosisnTreatmentGeneral considerationsnAbout 8%of people in Western countries have appendicitis at some t
2、ime during their life,with a peak incidence between 10 and 30 years of age.nAcute appendicitis is the most common general surgical emergency.(10%)General considerationsnAcute appendicitis has protean manifestations.nIt may simulate almost any other acute abdominal illness and in turn may be mimicked
3、 by a variety of conditions.nProgression of symptoms and signs is the rule in contrast to the fluctuating course of some other diseases.Historical perspective nWillard Packard performed the first surgery in 1867.nIn 1886,Reginald Fitz described the characteristic,clinical findings and pathology of t
4、he disease,identified the appendix as the primary cause of right lower quadrant inflammation.nFitz coined the term appendicitis and recommended early surgical treatmentHistorical perspectivenIn 1889,Chester McBurney described characteristic migratory pain as well as localization of the pain along an
5、 oblique line from the anterior superior iliac spine to the umbilicus.nIn 1894,McBurney described a right lower quadrant muscle-splitting incision for removal of the appendix.Historical perspectivenIn the 1940s,the mortality rate from appendicitis improved with the widespread use of broad-spectrum a
6、ntibiotics.nIn 1982,Laparoscopic appendectomy was first reported by the gynecologist Kurt Semm but has only gained widespread acceptance in recent years.Anatomy physiologynThe base of the appendix is located at the convergence of the taeniae(3)of colon.nThis anatomic relationship facilitates identif
7、ication and location of the appendix at operation.Pathophysiology nObstruction of the lumen is believed to be the major cause of acute appendicitis.nThis may be due to lymphoid hyperplasia,inspissated stool,fecalith,vegetable matter or seeds,parasites,or a neoplasm.PathophysiologynObstruction of the
8、 appendiceal lumen nBacterial overgrowth nContinued secretion of mucus nIntraluminal distention and increased wall pressure PathophysiologynSubsequent impairment of lymphatic and venous drainage nmucosal ischemia nThese findings in combination promote a localized inflammatory process that may progre
9、ss to gangrene and perforation.PathophysiologynInflammation of the adjacent peritoneum gives rise to localized pain in the right lower quadrant.nPerforation typically occurs after at least 48 hours from the onset of symptoms and is accompanied by an abscess cavity walled-off by the small intestine a
10、nd omentum.nClinical findingsClinical findingshistory and symptomnAppendicitis needs to be considered in the differential diagnosis of nearly every patient with acute abdominal pain nThe typical presentation begins with vague peri-umbilical pain followed by anorexia,nausea and vomiting.Then localize
11、s to the right lower quadrant.history and symptomnThe classic pattern of migratory pain is the most reliable symptom of acute appendicitis nFever ensues,followed by the development of leukocytosis nOccasional patients have urinary symptoms or microscopic hematuriamigratory painPhysical ExaminationnL
12、ow-grade fever is common(38).nDiminished bowel sounds nFocal tenderness(commonly at McBurneys point)-located one third of the distance along a line drawn from the anterior superior iliac spine to the umbilicus nRebound tendernessnVoluntary guardingPhysical ExaminationnDunphys sign -coughing cause in
13、creased pain nRovsings sign -pain in the right lower quadrant during palpation of the left lower quadrant Physical ExaminationnPsoas sign -pain on extension of the right hip(retrocecal appendix)nObturator sign -pain on internal rotation of the hip (pelvic appendix)Laboratory StudiesnThe average leuk
14、ocyte count is 15*109/L,and 90%of patient have count over 10*109/LnMore than 75%neutrophils in of patients.nA completely normal leukocyte count and differential is found in about 10%of patients.Imaging studiesnPlain abdominal films:may be useful for the detection of ureteral calculi,small bowel obst
15、ruction,or perforated ulcer,but such conditions are rarely confused with appendicitis.nUltrasonography and CT scan:be helpful in patients with atypical symptoms,such as children and elderly person.nA,CT scan of the abdomen demonstrates an edematous,thickened appendix(arrow)with obstructing appendico
16、lith(arrowhead).nB,CT scan of abdomen demonstrates a perforated appendix with a complex abscess and pelvic fluid collection(arrow).BL,bladder;UT,uterus.Essentials of diagnosisnAbdominal migratory pain nAnorexia,nausea and vomitingnLocalized abdominal tendernessnLow-grade fevernLeukocytosis Different
17、ial DiagnosesnSometimes,the diagnosis of appendicitis may be difficult.nMesenteric lymphadenitis,ngastrointestinal ulcer perforationnMeckels diverticulitis,nectopic pregnancy,npelvic inflammatory diseaseSpecial category of appendicitisnin infants，nin children，nin wemen during pregnancy，nin elderly p
18、eople nin patients infected with HIVComplicationnPerforationnPeritonitisnAppendiceal abscessnpylephlebitisTreatmentnSurgical treatment:Most patients with acute appendicitis are managed by prompt surgical removal of the appendix.(Appendectomy)nNon-surgical treatment:Early Stage,Objective conditions are not allowed,Serious organic disease.(antibiotics)TreatmentnLaparoscopic appendectomy offers the advantage of:diagnostic laparoscopy shorter recovery less conspicuous incisionsSubjective to thinknWhats the Essentials of diagnosis about acute appendicitis?
