1、阑尾炎英文PptAnatomy Varied anatomyLength:510 cm,narrow lumenhaustra of colonEpidemiologyThe most common acute abdomen disease The incidence of appendectomy appears to be declining due to more accurate preoperative diagnosis.Despite newer imaging techniques,acute appendicitis can be very difficult to dia
2、gnose.Pathophisiology Simple appendicitisSuppurative appendicitis Gangrenous appendicitisPerforated appendicitisPeritonitisAbscess around the appendixMucocele of appendixPathophysiologyAcute appendicitis is thought to begin with obstruction of the lumenObstruction can result from food matter,adhesio
3、ns,or lymphoid hyperplasiaAppendix is twisted,and Lumen of appendix is narrow,result in obstructionMucosal secretions continue to increase intraluminal pressureEtiology 1.The anatomy characteristics2.The tissue features3.fecality,foreign body obstruction4.Parasites cause the mucosa damage5.adhesion,
4、pressure cause appendix distortedObstruction high pressure limph obstructed,ischemia mucosa damage bacteria invade（70%80%）Artery The appendix artery has no branches,is easily to be obstacled EtiologyEventually the pressure exceeds capillary perfusion pressure and venous and lymphatic drainage are ob
5、structed.With vascular compromise,epithelial mucosa breaks down and bacterial invasion by bowel flora occurs.microbes：Ecoli,streptococcus,Pseudomonas,anaerobeMigration of pain from initial periumbilical to RLQ was 64%sensitive and 82%specificPathophysiologyThere are multiple acceptable antibiotics t
6、o use as long there is anaerobic flora,enterococci and gram(-)intestinal flora coverageEnd result is perforation and spillage of infected appendiceal contents into the peritoneumAbscess around the appendix3、general diseases,poor conditionAs inflammation continues,the serosa and adjacent structures b
7、ecome inflamedManifestations1、onset for 3-4 daysPrimary symptom:Appendectomy is the standard of careWith progression there is tenderness to deep palpation over McBurneys pointAssociated symptoms:Also,short acting narcotics should be used for pain managementindigestion,discomfort,flatus,need to defec
8、ate,anorexia,nausea,vomitingThis triggers somatic pain fibers,innervating the peritoneal structuresEtiologyIncreased pressure also leads to arterial stasis and tissue infarctionEnd result is perforation and spillage of infected appendiceal contents into the peritoneumPathophysiologyInitial luminal d
9、istention 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.PathophysiologyAs inflammation continues,the serosa and adjacent structures become inflam
10、edThis triggers somatic pain fibers,innervating the peritoneal structuresTypically causing pain in the RLQPathophysiologyThe change in stimulation form visceral to somatic pain fibers explains the classic migration of pain in the periumbilical area to the RLQ seen with acute appendicitis.Pathophysio
11、logyExceptions exist in the classic presentation due to anatomic variability of the appendixAppendix can be retrocecal causing the pain to localize to the right flankIn pregnancy,the appendix can be shifted and patients can present with RUQ painPathophysiologyIn some males,retroileal appendicitis ca
12、n irritate the ureter and cause testicular pain.Pelvic appendix may irritate the bladder or rectum causing suprapubic pain,pain with urination,or feeling the need to defecateMultiple anatomic variations explain the difficulty in diagnosing appendicitisPatients should be given IVF,and preoperative an
13、tibioticsPathophisiologyAnorexia is the most common of associated symptomsPhysical examPrimary symptom:Bowel fistula1、onset for 3-4 daysTreatments choiceAdditional studies:CBC,UA,imaging studiesThe WBC is of limited value.Gangrenous appendicitisRemained abscessThere are multiple acceptable antibioti
14、cs to use as long there is anaerobic flora,enterococci and gram(-)intestinal flora coveragePhysical Exampassively flex the R hip and knee and internally rotate the hip.Incision infectionbest choice based on availability and alternative diagnoses.Imaging studies:include X-rays,US,CTPhysical examManif
15、estations Primary symptom:abdominal pain to 2/3 of patients have the classical presentationPain beginning in epigastrium or periumbilical area that is vague and hard to localize Manifestations As the illness progresses RLQ localization typically occursRLQ pain was 81%sensitive and 53%specific for di
16、agnosisMigration of pain from initial periumbilical to RLQ was 64%sensitive and 82%specificManifestations Associated symptoms:indigestion,discomfort,flatus,need to defecate,anorexia,nausea,vomitingAnorexia is the most common of associated symptomsVomiting is more variable,occuring in about of patien
17、tsPhysical 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 ExamRovsings sign:pain in RLQ with palpation to LLQObturator sign:passively flex the R hip and kn
18、ee and internally rotate the hip.If there is increased pain then the sign is positivePhysical examPsoas sign:place patient in L lateral decubitus and extend R leg at the hip.If there is pain,the sign is positive.Rectal exam:pain can be most pronounced if the patient has pelvic appendixPhysical ExamA
19、dditional components that may be helpful in diagnosis:rebound tenderness,voluntary guarding,muscular rigidity,tenderness on rectalFever: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 ruptureDiagnosisAcute appendiciti
20、s should be suspected in anyone with epigastric,periumbilical,right flank,or right sided abd pain who has not had an appendectomyWomen of child bearing age need a pelvic exam and a pregnancy test.Additional studies:CBC,UA,imaging studiesIn some males,retroileal appendicitis can irritate the ureter a
21、nd cause testicular pain.Peritonitisabdominal pain3、general diseases,poor conditionMucocele of appendixEpidemiologyEpidemiologyAt the onset of pain fever is usually not found.Typically causing pain in the RLQIncision infectionAbdominal xrays have limited use:Abnormal findings include:Obturator sign:
22、The change in stimulation form visceral to somatic pain fibers explains the classic migration of pain in the periumbilical area to the RLQ seen with acute appendicitis.End result is perforation and spillage of infected appendiceal contents into the peritoneumpassively flex the R hip and knee and int
23、ernally rotate the hip.Imaging studies:include X-rays,US,CTTreatments choiceObstruction high pressure limph obstructed,ischemia mucosa damage bacteria invade（70%80%）375g or Unasyn 3gplace patient in L lateral decubitus and extend R leg at the hip.DiagnosisThe WBC is of limited value.Sensitivity of a
24、n elevated WBC is 70-90%,but specificity is very low.But,+predictive value of high WBC is 92%and predictive value is 50%CRP and ESR have been studied with mixed resultsDiagnosisImaging studies:include X-rays,US,CTX rays of abd are abnormal in 24-95%Abnormal findings include:fecalith,appendiceal gas,
25、localized paralytic ileus,blurred right psoas,and free airAbdominal xrays have limited use:for the findings are seen in multiple other processesDiagnosisLimitations of US:retrocecal appendix may not be visualized,perforations may be missed due to return to normal diameterDiagnosisCT:best choice base
26、d on availability and alternative diagnoses.In one study,CT had greater sensitivity,accuracy,-predictive value Special PopulationsVery young,very old,pregnant,and HIV patients present atypically and often have delayed diagnosisHigh index of suspicion is needed in the these groups to get an accurate
27、diagnosisTreatmentAppendectomy is the standard of carePatients should be given IVF,and preoperative antibiotics Antibiotics are most effective when given preoperatively and they decrease post-op infections and abscess formationTreatmentThere are multiple acceptable antibiotics to use as long there i
28、s anaerobic flora,enterococci and gram(-)intestinal flora coverageOne sample monotherapy regimen is Zosyn 3.375g or Unasyn 3gAlso,short acting narcotics should be used for pain management Treatments choiceNon operative treatment indicatiosn 1、onset for 3-4 days 2、diagnosis is undefined 3、general dis
29、eases,poor condition 4、inflammatory mass formation 5、patient refused surgeryAppendectomy Preoperative prepareAnesthesiaIncision siteExposure appendix,resectionSuture incisionNotes:normal appendix appendix mass abscess around appendixAppendectomy End result is perforation and spillage of infected app
30、endiceal contents into the peritoneumAppendectomy is the standard of carepain in RLQ with palpation to LLQMultiple anatomic variations explain the difficulty in diagnosing appendicitisGangrenous appendicitisIncreased pressure also leads to arterial stasis and tissue infarctionAbdominal xrays have li
31、mited use:Migration of pain from initial periumbilical to RLQ was 64%sensitive and 82%specificMucosal secretions continue to increase intraluminal pressureIncreased pressure also leads to arterial stasis and tissue infarctionabdominal painEpidemiologypain in RLQ with palpation to LLQPain beginning i
32、n epigastrium or periumbilical area that is vague and hard to localizePathophysiologySimple appendicitisPhysical ExamPain beginning in epigastrium or periumbilical area that is vague and hard to localizeTypically causing pain in the RLQPathophysiologyIncreased pressure also leads to arterial stasis
33、and tissue infarctionBowel fistulaAbdominal xrays have limited use:Abscess around the appendixAcute appendicitis is thought to begin with obstruction of the lumenabscess around appendixVomiting is more variable,occuring in about of patientsIn some males,retroileal appendicitis can irritate the urete
34、r and cause testicular pain.Physical ExamIncreased pressure also leads to arterial stasis and tissue infarctionIn one study,CT had greater sensitivity,accuracy,-predictive valueThere are multiple acceptable antibiotics to use as long there is anaerobic flora,enterococci and gram(-)intestinal flora c
35、overageRemained abscessVaried anatomySimple appendicitisX rays of abd are abnormal in 24-95%5、patient refused surgeryThere are multiple acceptable antibiotics to use as long there is anaerobic flora,enterococci and gram(-)intestinal flora coverage375g or Unasyn 3gIncision infectionPhysical examIncis
36、ion infectionThe appendix artery has no branches,is easily to be obstacledPrimary symptom:Increased pressure also leads to arterial stasis and tissue infarctionMultiple anatomic variations explain the difficulty in diagnosing appendicitisObturator sign:Pain beginning in epigastrium or periumbilical
37、area that is vague and hard to localizeRovsings sign:Imaging studies:include X-rays,US,CT375g or Unasyn 3gThere are multiple acceptable antibiotics to use as long there is anaerobic flora,enterococci and gram(-)intestinal flora coverageEpidemiologyAbscess around the appendixIn some males,retroileal
38、appendicitis can irritate the ureter and cause testicular pain.The appendix artery has no branches,is easily to be obstacledAbnormal findings include:Physical Examappendix massObstruction high pressure limph obstructed,ischemia mucosa damage bacteria invade（70%80%）Complications Incision infectionRemained abscessBowel fistulaPost operative BleedingBowel adhesion,obstructionIncisional herniaPylephlebitis(门静脉炎门静脉炎)、liver abscess
