急性腹痛英文ppt课件

11 98 1 AcuteAbdomen StuartDanovitch MDWashingtonVAMedicalCenter 11 98 2 AcuteAbdomen Conundrum IfIoperateandtheproblemisnotsurgical patientexposedtounnecessaryrisk anesthetic etc Risksgreaterwithconcomitantillness olderageIfIdonotoperateandproblemissurgical patientatriskbecauseofwrongtherapy Againtheolderpatientisundergreaterburden 11 98 3 ACaricature Surgery AcutepainSeptic toxicBoard likeabdomenAbsentbowelsoundsWBC25 000Freeairunderdiaphragm 11 98 4 ACaricature NoSurgery TrivialpainRobustappearanceSoftabdomenwithnoguardingNormalbowelsoundsNormalWBCNormalpainanduprightfilmsofabdomen 11 98 5 AcuteAbdominalPainNon surgicalEmergencies MesentericAdenitisAcuteEntericInfectionsAcuteEntericPoisoningsInflammatoryBowelDiseasePancreatitis usually 11 98 6 AcuteAbdominalPainMetabolicCauses DiabeticKetoacidosisHeavyMetalPoisoningAcutePorphyriaTabesSickleCellCrisis 11 98 7 AcuteAbdominalPainClinicalPhenomena 2 3ofattackstypical 1 3atypicalAcutecholecystitisandperforatedDUarerare 20yearsAcutediverticulitisrate 30years80 ofpatientswithbowelobstructionhadprevioussurgery75 ofpatientswithcholecystitishadpreviousattacks 11 98 8 AcuteAbdominalPainConfoundingClinicalFeatures Perforatedduodenalulcer50 ofpatientshadnopreviouspain50 ofpatientshadbowelsoundsDiverticulitis40 ofpatientsvomited30 ofpatientshaveupperpainObstruction40 ofpatientshavenodistension 11 98 9 AcuteAbdominalPainAncillaryDiagnosticStudies CBCUrineAmylasePlainabdominalfilmsParacentesisandlavageRadionuclideScans 11 98 10 AcuteAbdominalPainTheWBCin570patients DiagnosisSensitivity Specificity Appendicitis 9121Cholecystitis 7811Obstruction 568Gastroenteritis N 4911OtherNon surgical N 6282Predictivevalueof WBCforsurgicalcondition29 Predictivevalueof WBCfornon surgicalcond93 11 98 11 AcuteAbdominalPainSensitivityofRoentgenFindings 249Patients AbnormalAppendicitis48Cholecystitis64Pancreatitis60IntestinalObstruction98PerforatedUlcer60 11 98 12 AcuteAbdominalPainSpecificityofRoentgenFindings 249Patients Diagnostic24 Helpful18 NotHelpful57 Misleading1 11 98 13 DiagnosisofPancreatitisAmylase What sRight CheapQuickNon invasiveAdecentfirstapproximation 11 98 14 DiagnosisofPancreatitisAmylase LackofSpecificity Organnon specificDiseasenon specific 11 98 15 DiagnosisofPancreatitisHeterogeneityofSerumAmylase 40 pancreatic60 salivaryIftotalactivitydoublesduetopancreatitis p isoenzymemust 3 5x 11 98 16 DiagnosisofPancreatitisTimingofEnzymeMeasurement ActivityDaysTrypsinLipaseP amylaseT amylase01001001001001 2100100100753 41008570355 755553515 Eckenfeld ArchPathLabMed 1986 11 98 17 AcuteAbdominalPainTheSerumAmylasein37Patients Amylase AmylaseNLPancreatitis 23 176Nopancreatitis 14 77SensitivitySpecificity PV PV74507154 11 98 18 AcuteAbdominalPainFrequencyofDiagnosesin1000Patients Unknown41 Cholecystis4 UrinaryTract9 IntestinalObst2 5 Gastroenteritis7 Constipation2 PID7 Misc7 11 98 19 AcuteAbdominalPainDiagnosticErrors 1000Patients False AssessmentPre op 20PatientsPre opPost opAppendicitis 7MesentericAdenitis 1EctopicPregnancy 5PID 5 Acute Abdomen 5Nothing 13Diverticulitis 2Pyelonephritis 1Tubp ovarianAbscess 3 11 98 20 AcuteAbdominalPainDiagnosticErrors 1000Patients False AssessmentPre op 11PatientsInitialDxPost opEndometriosis 1Appendicitis 8Gastroenteritis 4Obstruction 3UTI 1Uncertain 5 11 98 21 AcuteAbdominalPainSagaof1190Admissions Etiology Nonspecific35Appendicitis17IntestinalObstruction15GU6GB5Diverticulitis4PUD3Pancreatitis2Miscellaneous13 11 98 22 AcuteAbdominalPainSagaof1190Admissions EffectofAge 60 40 60 60 Nonspecific2343Appendicitis425IntestinalObstruction286GU38IB93Diverticulitis9 1PUD41Pancreatitis42Miscellaneous1611 11 98 23 Computer AidedDiagnosisofAcuteAppendicitis FavoringDxAgainstDx WBCNormalWBCRLQlocationOthersitesPain48hrsVomitingNoNauseaRebound GuardingFemale 11 98 24 Computer AidedDiagnosisofAcuteAppendicitis ReliabilityofDecisionRules NegativeLapRate15Sensitivity90Specificity91 PredictiveValue80 PredictiveValue95 11 98 25 DecisionAnalysisinManagementofAcuteAbdominalPain Error lap lapComputerSurgery1300Nosurgery5211Uncertain11031Lapcontraind4520 11 98 26 DiagnosisSmallBowelObstruction AttributeRelativeRiskHxPrevioussurgery12 1ColickyPain2 5DistensiononPE13 1AbnormalBowelSounds9 0 11 98 27 AcutePancreatitis Pathogenesis Bernard sDictumNoenzymes NoPancreatitis 11 98 28 AcutePancreatitis PathogenesisMechanismsLimitingIntrapancreaticEnzymeActivation StorageandsecretionasproenzymesPancreatictrypsininhibitors pH 8 9 5 Ca 1mM abetdegradationMesotrypticdigestionofenzymesPlasmaanti trypsins 11 98 29 AcutePancreatitis PathogenesisHypothesisforIntrapancreaticEnzymeActivation ActivationActivationbythrombin plasminLysosomalcathepsinEnterokinase 11 98 30 AcutePancreatitis PathogenesisInVivoEnzymeActivation Ascitesandsurgicalfindings phospholipase elastase lysosomalenzymes as aamto trypticactivityBlood enzymes activeandinactive 11 98 31 EtiologyofAcutePancreatitis Cause Gallstones40EtOH40Hyperlipemia Drugs 10Trauma Tumor InfectionIdiopathic10 11 98 32 DrugsAssociatedwithAcutePancreatitis AzathioprineL AsparaginaseDiuretics methyldopaPentamidineCaptoprilSulfonamidesProcaninamide6 MPNitrofurantoin 11 98 33 DiagnosisofPancreatitis ProblemsSymptomsnon specificLaboratorynon specificNogoldstandard 11 98 34 DiagnosisofPancreatitis Appropriateclinicalcircumstance3 fold amylaseactivityReturntonormalinoneweekNogutperforationorinfarction trypsiongen lipase pancreaticisoamylase 11 98 35 DDxofPancreatitis PerforatedviscusIntestinalobstructionMesentericvasculareventsAcutecholecystitisPID 11 98 36 DDxofPancreatitis Cluethat amylaseisnotduetopancreatitisinsickpatientsrenalfailureearlybacteremianormalcalciumdeteriorationinptwithcalcifiedglandrisingamylaseafter48hrs 11 98 37 DiagnosisofPancreatitisPancreaticImaging SensitivityUltrasound35CT65CT Severe 95 100 11 98 38 DiagnosisofPancreatitis ConcordanceofAmylaseandImaging Amylase200UNormalCT1220AbnCT20