阑尾炎和疝气.doc

AppendixIn infants, the appendix is a conical diverticulum at the apex of the cecum, but with differential growth and distention of the cecum, the appendix ultimately arises on the left and dorsally approximately 2.5 cm below the ileocecal valve. The aptaenia of the colon converge at thc base of the appendix, an arrangement that helps in locating this structure at operation. The appendix is fixed retrocecally in 16% of adults and is freely mobile in the remainder.The appendix in youth is characterized by a large concentration of lymphoid follicles that appear 2 weeks after birth and number about 200 or more at age 15. Thereafter, there is progressive atrophy of lymphoid tissue, concomitant with fibrosis of the wall and partial or total obliteration of the lumen.If the appendix has a physiologic function, it is probably related to the presence of lymphoid follicles. Reports of a statistical relationship between appendectomy and subsequent carcinoma of the colon and other neoplasms in humans are not supported by controlled studies.conical圆锥的; 圆锥形的diverticulum肠盲囊,小囊突,憩室 apex顶点,最高点cecum盲肠 distention膨胀; 延伸 dorsally背侧地ileocecal valve回盲瓣retrocecally盲肠后的 lymphoid follicles淋巴样滤泡,淋巴小结;progressive atrophy萎缩 concomitant伴发的,伴行的,并发的 concomitant with协同obliteration涂去, 抹消, 删除 lumen管腔,流明,腔appendectomy阑尾切除术neoplasm肿瘤ileocecal lymphoidappendicitis阑尾炎 Hernia An external hernia is an abnormal protrusion of intra-abdominal tissue or the whole or part of a viscus through an opening or fascial defect in the abdominal wall. About 75% of hernias occur in the groin (indirect inguinal, direct inguinal, femoral). Incisional and ventral hernias comprise about 10%; umbilical, 3%; and others, about 3%. Generally, a hernial mass is composed of covering tissues (skin, subcutaneous tissues, etc), a peritoneal sac, and any contained viscera. Particularly if the neck of the sac is narrow where it emerges from the abdomen, bowel protruding into the hernia may become obstructed or strangulated. If the hernia is not repaired early, normal tissues maybe compressed, the defect may enlarge, and operative repair may become more complicated. The definitive treatment of hernia is early operative repair. A reducible hernia is one in which the contents of the sac return to the abdomen spontaneously or with manual pressure when the patient is recumbent. An irreducible (incarcerated) hernia is one whose contents cannot be returned to the abdomen, usually because they are trapped by a narrow neck. The term incarceration does not imply obstruction, inflammation, or ischemia of the herniated organs, though incarceration is necessary for obstruction or strangulation to occur. Though the lumen of a segment of bowel within the hernia sac may become obstructed, there may initially be no interference with blood supply. Compromise to the blood supply of the contents of the sac (eg, omentum or intestine) results in a strangulated hernia, in which gangrene of the sac and its contents has occurred. The incidence of strangulation is higher in femoral than in inguinal hernias, but strangulation may occur in other hernias as well.1. protrusion前突,突出 2. inguinal腹股沟的 3. femoral大腿的,大腿骨的,股的,股动脉,股骨的 Incisional切入的,切开的 ventral腹部,腹侧的,腹的,腹面的 umbilical脐的2. subcutaneous皮下的 peritoneal腹膜的 sac囊; 液囊 viscera内容; 肠strangulated胀缩不均的,窒息的,绞窄的reducible可复位的,可还原的，可变形的, 可缩小的 spontaneously自发地,自然产生地 recumbent侧卧的,休息的 irreducible不能复位的 (incarcerated箝闭的,狭窄的) trapped捕集的,捕获的,收集的,截留incarceration监禁,嵌顿,箝闭 imply暗示,意指,蕴涵 ischemia局部缺血,缺血 strangulation勒颈,勒颈窒息 omentum网膜 gangrene坏疽, 疝腹外疝是腹腔内组织或部分或整个脏器通过腹壁的孔穴或筋膜缺损处所造成的不正常突出。约75的疝发生在腹股沟区(直疝、斜疝、股疝)。切口疝和腹壁疝各约占10；脐疝3，其余的约3。一般而言，疝块由覆盖组织(皮肤、皮下组织等)、腹膜囊和囊内的任何一个内脏所组成。特别是当疝囊颈部即腹腔的突出处狭小，肠管突入疝囊后可形成梗阻或绞窄。疝如不及早修复，正常组织可受压，缺损处变大、手术修复变得更为复杂。疝的根本治疗是早期手术修复。可复性疝是指疝内容可自行回纳，或在病人仰卧时用手挤入腹腔。不可复性(箝闭性)疝是指疝内容物不能回纳入腹腔，通常起因于狭窄的颈部受阻。尽管发生梗阻或绞窄前需有箝闭，然而箝闭一词并不意味被疝入的器官有梗阻，发炎或缺血。虽然疝囊内肠襻的腔可有阻塞，但开始时并不影响血液的供应。当囊内器官(姐网膜或肠管)血供受到损害就形成绞窄性疝，随即出现疝囊及疝内容的坏疽。股疝的绞窄发生率较腹股沟疝高，其他类型的疝也可发生绞窄。 CholecystitisCholecystitis is inflammation of the gallbladder wall, usually resulting from a gallstone obstructing the cystic duct. Acute cholecystitis is the sudden onset of inflammation of the gallbladder, resulting in severe, steady upper abdominal pain (biliary colic), which may occur repeatedly. Chronic cholecystitis is long-standing inflammation of the gallbladder characterized by repeated attacks of pain (gallbladder attacks) over a prolonged period.At least 95% of people with acute cholecystitis have gallstones. The inflammation almost always begins without infection, although infection may follow later. Rarely, acute cholecystitis occurs in a person without gallstones (acalculous cholecystitis). Acalculous cholecystitis is a serious disease. It tends to occur after major injuries, operations, burns, bodywide infections (sepsis), and critical illnessesparticularly in people receiving prolonged intravenous feedings. It can occur in young children as well, perhaps originating as an infection (viral or other).In chronic cholecystitis, the gallbladder is damaged by repeated attacks of acute inflammation, usually from gallstones, and may become thick-walled, scarred, and small. The gallbladder generally contains sludge or gallstones that often obstruct its outlet or the cystic duct.SymptomsA gallbladder attack, whether in acute or chronic cholecystitis, begins as severe, steady pain (biliary colic), usually in the right upper part of the abdomen. The person typically feels a sharp pain when a doctor presses on the upper right part of the abdomen. The pain may worsen when the person breathes deeply and often extends to the lower part of the right shoulder blade. The pain may become excruciating; nausea and vomiting are usual. The pain usually lasts more than 12 hours.Within a few hours, the abdominal muscles on the right side become rigid. Fever occurs in about one third of people but is less likely in older people. The fever tends to be slight at first, then rises gradually to above 100 F (38 C).Typically, an attack of cholecystitis subsides in 2 to 3 days and completely disappears in a week. If the attack persists, it may signal a serious complication. A high fever, chills, a marked increase in the white blood cell count, and a cessation of the normal propulsive movements of the intestine (ileus (see Emergencies: Ileus) suggest formation of an abscess (a pus-filled pocket of infection), gangrene (death of tissue), or a perforated (pierced) gallbladder.Other complications may occur. A gallbladder attack accompanied by jaundice (see Clinical Manifestations of Liver Disease: Jaundice) and other evidence of a backup of bile into the liver (cholestasis), such as passing light-colored stools, indicates that the common bile duct is obstructed (usually partially) by a stone. If blood test results reveal an increased level of a pancreatic enzyme (amylase or lipase), the person may have inflammation of the pancreas (pancreatitis) caused by a stone obstructing the pancreatic duct.In acalculous cholecystitis, typically the person has no previous symptoms or other evidence of gallbladder disease and experiences sudden, excruciating pain in the upper abdomen. Usually, the disease is very severe and can lead to gangrene or rupture of the gallbladder. If the person has other severe problems (for example, the person is in the intensive care unit), acalculous cholecystitis at first may be overlooked.DiagnosisDoctors diagnose cholecystitis, both acute and chronic, based on the persons symptoms and the results of tests that suggest gallbladder inflammation. Increased levels of white blood cells suggest inflammation or infection or both. Ultrasound scans often confirm the presence of gallstones in the gallbladder, which may be responsible for the attacks. Ultrasound scans can also show thickening of the gallbladder wall, which is typical of chronic cholecystitis.Cholescintigraphy is an imaging technique that is useful when acute cholecystitis is difficult to diagnose. In this test, a radioactive tracer is injected intravenously and its movement from the liver through the biliary tract is followed. Images are taken of the liver, bile ducts, gallbladder, and upper part of the small intestine. If the tracer does not fill the gallbladder, it is presumed that the cystic duct is obstructed by a gallstone.TreatmentA person with acute or chronic cholecystitis who experiences a gallbladder attack usually is hospitalized, is given fluids and electrolytes intravenously, and is not allowed to eat or drink. A doctor may pass a tube through the nose and into the stomach, so that suctioning can be used to keep the stomach empty and reduce fluid accumulating in the intestines, which do not work properly because of the inflammation of the abdominal cavity. Antibiotics usually are given.In acute cholecystitis, if the diagnosis is certain and the risk of surgery is small, the gallbladder usually is removed during the first day or two of the illness. If necessary, gallbladder removal may be delayed; if the attack subsides, removal may wait 6 weeks or more. If a complication such as an abscess, gangrene, or perforation of the gallbladder is suspected, immediate surgery is necessary.In chronic cholecystitis, treatment generally involves surgical removal of the gallbladder, usually by laparoscopic cholecystectomy, once the acute episode subsides.In acalculous cholecystitis, immediate surgery is necessary to remove the diseased gallbladder.After gallbladder removal for cholecystitis with gallstones, a small percentage of people develop new or recurring episodes of pain that feel like gallbladder attacks even though they no longer have a gallbladder. The cause of these episodes is not known, but episodes may result from an abnormal function of the sphincter of Oddi, the opening at the base of the bile duct that controls the release of bile into the small intestine. Pain is believed to result from increased pressure in the ducts caused by resistance to the flow of bile or pancreatic secretions. In some people, small gallstones remaining after surgery may cause pain. A doctor can use endoscopic retrograde cholangiopancreatography to widen (by cutting) the sphincter of Oddi. This procedure usually relieves symptoms in people who have a recognizable abnormality of the sphincter. In many others, the pain is caused by another problem, such as the irritable bowel syndrome or even peptic ulcer disease.gallbladder胆囊 upper abdominal pain上腹痛 （右下right lower）腹痛abdominal pain biliary胆道的,胆的,胆汁的colic绞痛, 疝痛, 疝气acalculous cholecystitis无结石胆囊炎sepsis败血症,脓毒症intravenous静脉内的,静脉注射静originate发起,开始,创造,发明Acute gallstone cholecystitis in the elderly: treatment with emergency ultrasonographic percutaneous cholecystostomy and interval laparoscopic cholecystectomy.Macri A, Scuderi G, Saladino E, Trimarchi G, Terranova M, Versaci A, Famulari C.Emergency Surgery Unit, University of Messina, Messina 98125, Italy. amacriunime.itBACKGROUND: The treatment of acute cholecystitis in the elderly is still a subject of debate, particularly with reference to the timing of surgery and the role of laparoscopy. PATIENTS: From January 1994 to June 2002 we observed 27 patients aged over 70 years with acute calcolous cholecystitis. The patients were submitted to ultrasonographic percutaneous cholecystostomy within 12 h of the acute attack. For two patients (7.4%) at high operative risk, we chose a conservative treatment. Twenty-five patients (92.6%) were submitted, in 15 cases (60%) within 5 days and in 10 patients (40%) within 8 days, to a laparoscopic cholecystectomy. Statistical significance was accepted when the value of p was less than 0.05. RESULTS: Ultrasonographic percutaneous cholecystostomy was performed successfully in all patients, without major morbidity or mortality, and complete resolution of clinical symptoms was obtained within 48 h. The conversion rate of laparoscopy was 20% (13.3% in patients submitted to surgery within 5 days and 30% in the group submitted within 8 days-p 0.05). The postoperative morbidity rate was 24%; it was higher (40% versus 15%) in patients converted to laparotomy (p 0.05); mortality was 4%. The period of hospitalization was 11 days in patients operated laparoscopically and 21 days in those converted to open cholecystectomy (p 0.001). CONCLUSIONS: The more rational treatment of acute calcolous cholecystitis in elderly patients is represented by ultrasonographic percutaneous cholecystostomy followed, within 5 days, by laparoscopic cholecystectomy using an abdominal insufflation maximum to 12 mmHg and a limited 10-15 degrees head-up tilt.Percutaneous cholecystostomy for high-risk patients with acute cholecystitis.Welschbillig-Meunier K, Pessaux P, Lebigot J, Lermite E, Aube Ch, Brehant O, Hamy A, Arnaud JP.Department of Visceral Surgery, Chu Angers, 4 rue Larrey, 49033, Angers Cedex, France.BACKGROUND: Cholecystectomy remains the best treatment for a