abdomen急腹症（英文）（课件）

11/98,,1,Acute Abdomen,Stuart Danovitch, MD Washington VA Medical Center,11/98,,2,Acute Abdomen - Conundrum,If I operate and the problem is not surgical, patient exposed to unnecessary risk, anesthetic, etc. Risks greater with concomitant illness, older age If I do not operate and problem is surgical, patient at risk because of wrong therapy. Again the older patient is under greater burden.,11/98,,3,A Caricature - Surgery,Acute pain Septic & toxic Board-like abdomen Absent bowel sounds WBC 25,000 Free air under diaphragm,11/98,,4,A Caricature - No Surgery,Trivial pain Robust appearance Soft abdomen with no guarding Normal bowel sounds Normal WBC Normal pain and upright films of abdomen,11/98,,5,Acute Abdominal Pain Non-surgical Emergencies,Mesenteric Adenitis Acute Enteric Infections Acute Enteric Poisonings Inflammatory Bowel Disease Pancreatitis (usually),11/98,,6,Acute Abdominal Pain Metabolic Causes,Diabetic Ketoacidosis Heavy Metal Poisoning Acute Porphyria Tabes Sickle Cell Crisis,11/98,,7,Acute Abdominal Pain Clinical Phenomena,2/3 of attacks typical, 1/3 atypical Acute cholecystitis and perforated DU are rare, 20 years Acute diverticulitis rate, 30 years 80% of patients with bowel obstruction had previous surgery 75% of patients with cholecystitis had previous attacks,11/98,,8,Acute Abdominal Pain Confounding Clinical Features,Perforated duodenal ulcer 50% of patients had no previous pain 50% of patients had bowel sounds Diverticulitis 40% of patients vomited 30% of patients have upper pain Obstruction 40% of patients have no distension,11/98,,9,Acute Abdominal Pain Ancillary Diagnostic Studies,CBC Urine Amylase Plain abdominal films Paracentesis and lavage Radionuclide Scans,11/98,,10,Acute Abdominal Pain The WBC in 570 patients,Diagnosis Sensitivity % Specificity % Appendicitis () 91 21 Cholecystitis () 78 11 Obstruction () 56 8 Gastroenteritis (N) 49 11 Other Non-surgical (N) 62 82 Predictive value of WBC for surgical condition 29% Predictive value of WBC for non-surgical cond 93%,11/98,,11,Acute Abdominal Pain Sensitivity of Roentgen Findings - 249 Patients,% Abnormal Appendicitis 48 Cholecystitis 64 Pancreatitis 60 Intestinal Obstruction 98 Perforated Ulcer 60,11/98,,12,Acute Abdominal Pain Specificity of Roentgen Findings - 249 Patients,Diagnostic 24 % Helpful 18 % Not Helpful 57 % Misleading 1 %,11/98,,13,Diagnosis of Pancreatitis Amylase - Whats Right,Cheap Quick Non-invasive A decent first approximation,11/98,,14,Diagnosis of Pancreatitis Amylase - Lack of Specificity,Organ non-specific Disease non-specific,11/98,,15,Diagnosis of Pancreatitis Heterogeneity of Serum Amylase,40% pancreatic 60% salivary If total activity doubles due to pancreatitis, p-isoenzyme must 3.5 x.,11/98,,16,Diagnosis of Pancreatitis Timing of Enzyme Measurement,% Activity Days Trypsin Lipase P-amylase T-amylase 0 100 100 100 100 1-2 100 100 100 75 3-4 100 85 70 35 5-7 55 55 35 15,Eckenfeld, Arch Path Lab Med, 1986,11/98,,17,Acute Abdominal Pain The Serum Amylase in 37 Patients,Amylase Amylase NL Pancreatitis (23) 17 6 No pancreatitis (14) 7 7 Sensitivity Specificity +PV -PV 74 50 71 54,11/98,,18,Acute Abdominal Pain Frequency of Diagnoses in 1000 Patients,Unknown 41% Cholecystis 4% Urinary Tract 9% Intestinal Obst 2.5% Gastroenteritis 7% Constipation 2% PID 7% Misc 7%,11/98,,19,Acute Abdominal Pain Diagnostic Errors - 1000 Patients,False+ Assessment Pre-op -20 Patients Pre-op Post-op Appendicitis - 7 Mesenteric Adenitis - 1 Ectopic Pregnancy - 5 PID - 5 “Acute” Abdomen - 5 Nothing - 13 Diverticulitis - 2 Pyelonephritis - 1 Tubp-ovarian Abscess - 3,11/98,,20,Acute Abdominal Pain Diagnostic Errors - 1000 Patients,False- Assessment Pre-op -11 Patients Initial Dx Post-op Endometriosis - 1 Appendicitis - 8 Gastroenteritis - 4 Obstruction - 3 UTI - 1 Uncertain - 5,11/98,,21,Acute Abdominal Pain Saga of 1190 Admissions,Etiology % Nonspecific 35 Appendicitis 17 Intestinal Obstruction 15 GU 6 GB 5 Diverticulitis 4 PUD 3 Pancreatitis 2 Miscellaneous 13,11/98,,22,Acute Abdominal Pain Saga of 1190 Admissions,Effect of Age 60 (40%) 60 (60%) Nonspecific 23 43 Appendicitis 4 25 Intestinal Obstruction 28 6 GU 3 8 IB 9 3 Diverticulitis 9 1 PUD 4 1 Pancreatitis 4 2 Miscellaneous 16 11,11/98,,23,Computer-Aided Diagnosis of Acute Appendicitis,Favoring Dx Against Dx WBC Normal WBC RLQ location Other sites Pain 48 hrs Vomiting No Nausea Rebound, Guarding Female,11/98,,24,Computer-Aided Diagnosis of Acute Appendicitis,Reliability of Decision Rules % Negative Lap Rate 15 Sensitivity 90 Specificity 91 + Predictive Value 80 - Predictive Value 95,11/98,,25,Decision Analysis in Management of Acute Abdominal Pain,% Error - lap + lap Computer Surgery 13 0 0 No surgery 5 2 11 Uncertain 11 0 31 Lap contraind 4 5 20,11/98,,26,Diagnosis Small Bowel Obstruction,Attribute Relative Risk Hx Previous surgery 12.1 Colicky Pain 2.5 Distension on PE 13.1 Abnormal Bowel Sounds 9.0,11/98,,27,Acute Pancreatitis - Pathogenesis,Bernards Dictum No enzymes, No Pancreatitis,11/98,,28,Acute Pancreatitis - Pathogenesis Mechanisms Limiting Intrapancreatic Enzyme Activation,Storage and secretion as proenzymes Pancreatic trypsin inhibitors pH (8-9.5); Ca ( 1mM) abet degradation Mesotryptic digestion of enzymes Plasma anti-trypsins,11/98,,29,Acute Pancreatitis - Pathogenesis Hypothesis for Intrapancreatic Enzyme Activation,Activation Activation by thrombin, plasmin Lysosomal cathepsin Enterokinase,11/98,,30,Acute Pancreatitis - Pathogenesis In Vivo Enzyme Activation,Ascites and surgical findings phospholipase elastase lysosomal enzymes ;as,a amto-tryptic activity Blood enzymes - active and inactive,11/98,,31,Etiology of Acute Pancreatitis,Cause % Gallstones 40 EtOH 40 Hyperlipemia, Drugs, 10 Trauma, Tumor, Infection Idiopathic 10,11/98,,32,Drugs Associated with Acute Pancreatitis,Azathioprine L-Asparaginase Diuretics -methyldopa Pentamidine Captopril Sulfonamides Procaninamide 6-MP Nitrofurantoin,11/98,,33,Diagnosis of Pancreatitis,Problems Symptoms non-specific Laboratory non-specific No gold standard,11/98,,34,Diagnosis of Pancreatitis,Appropriate clinical circumstance 3-fold amylase activity Return to normal in one week No gut perforation or infarction trypsiongen, lipase, pancreatic isoamylase,11/98,,35,DDx of Pancreatitis,Perforated viscus Intestinal obstruction Mesenteric vascular events Acute cholecystitis PID,11/98,,36,DDx of Pancreatitis,Clue that amylase is not due to pancreatitis in sick patients renal failure early bacteremia normal calcium deterioration in pt with calcified gland rising amylase after 48 hrs,11/98,,37,Diagnosis of Pancreatitis Pancreatic Imaging,Sensitivity Ultrasound 35 CT 65 CT (Severe) 95-100,11/98,,38,Diagnosis of Pancreatitis % Concordance of Amylase and Imaging,Amylase 200U Normal CT 12 20 Abn CT 20