阑尾炎(英文)PPT课件.ppt

surgery AcuteAppendicitis 2020 3 19 1 2020 3 19 2 Anatomy 2020 3 19 3 Variedanatomy Length 5 10cm narrowlumen haustraofcolon 2020 3 19 4 Epidemiology ThemostcommonacuteabdomendiseaseTheincidenceofappendectomyappearstobedecliningduetomoreaccuratepreoperativediagnosis Despitenewerimagingtechniques acuteappendicitiscanbeverydifficulttodiagnose 2020 3 19 5 Pathophisiology SimpleappendicitisSuppurativeappendicitisGangrenousappendicitisPerforatedappendicitisPeritonitisAbscessaroundtheappendixMucoceleofappendix 2020 3 19 6 Pathophysiology AcuteappendicitisisthoughttobeginwithobstructionofthelumenObstructioncanresultfromfoodmatter adhesions orlymphoidhyperplasiaAppendixistwisted andLumenofappendixisnarrow resultinobstructionMucosalsecretionscontinuetoincreaseintraluminalpressure 2020 3 19 7 Etiology 1 Theanatomycharacteristics2 Thetissuefeatures3 fecality foreignbodyobstruction4 Parasitescausethemucosadamage5 adhesion pressurecauseappendixdistortedObstruction highpressure limphobstructed ischemia mucosadamage bacteriainvade 70 80 2020 3 19 8 Artery Theappendixarteryhasnobranches iseasilytobeobstacled 2020 3 19 9 Etiology Eventuallythepressureexceedscapillaryperfusionpressureandvenousandlymphaticdrainageareobstructed Withvascularcompromise epithelialmucosabreaksdownandbacterialinvasionbybowelfloraoccurs microbes Ecoli streptococcus Pseudomonas anaerobe 2020 3 19 10 Etiology IncreasedpressurealsoleadstoarterialstasisandtissueinfarctionEndresultisperforationandspillageofinfectedappendicealcontentsintotheperitoneum 2020 3 19 11 Pathophysiology Initialluminaldistentiontriggersvisceralafferentpainfibers whichenteratthe10ththoracicvertebrallevel Thispainisgenerallyvagueandpoorlylocalized Painistypicallyfeltintheperiumbilicalorepigastricarea 2020 3 19 12 Pathophysiology Asinflammationcontinues theserosaandadjacentstructuresbecomeinflamedThistriggerssomaticpainfibers innervatingtheperitonealstructuresTypicallycausingpainintheRLQ 2020 3 19 13 Pathophysiology ThechangeinstimulationformvisceraltosomaticpainfibersexplainstheclassicmigrationofpainintheperiumbilicalareatotheRLQseenwithacuteappendicitis 2020 3 19 14 Pathophysiology ExceptionsexistintheclassicpresentationduetoanatomicvariabilityoftheappendixAppendixcanberetrocecalcausingthepaintolocalizetotherightflankInpregnancy theappendixcanbeshiftedandpatientscanpresentwithRUQpain 2020 3 19 15 Pathophysiology Insomemales retroilealappendicitiscanirritatetheureterandcausetesticularpain Pelvicappendixmayirritatethebladderorrectumcausingsuprapubicpain painwithurination orfeelingtheneedtodefecateMultipleanatomicvariationsexplainthedifficultyindiagnosingappendicitis 2020 3 19 16 Manifestations Primarysymptom abdominalpain to2 3ofpatientshavetheclassicalpresentationPainbeginninginepigastriumorperiumbilicalareathatisvagueandhardtolocalize 2020 3 19 17 Manifestations AstheillnessprogressesRLQlocalizationtypicallyoccursRLQpainwas81 sensitiveand53 specificfordiagnosisMigrationofpainfrominitialperiumbilicaltoRLQwas64 sensitiveand82 specific 2020 3 19 18 Manifestations Associatedsymptoms indigestion discomfort flatus needtodefecate anorexia nausea vomitingAnorexiaisthemostcommonofassociatedsymptomsVomitingismorevariable occuringinabout ofpatients 2020 3 19 19 PhysicalExam Findingsdependondurationofillnesspriortoexam EarlyonpatientsmaynothavelocalizedtendernessWithprogressionthereistendernesstodeeppalpationoverMcBurney spoint 2020 3 19 20 PhysicalExam Rovsing ssign paininRLQwithpalpationtoLLQObturatorsign passivelyflextheRhipandkneeandinternallyrotatethehip Ifthereisincreasedpainthenthesignispositive 2020 3 19 21 Physicalexam Psoassign placepatientinLlateraldecubitusandextendRlegatthehip Ifthereispain thesignispositive Rectalexam paincanbemostpronouncedifthepatienthaspelvicappendix 2020 3 19 22 PhysicalExam Additionalcomponentsthatmaybehelpfulindiagnosis reboundtenderness voluntaryguarding muscularrigidity tendernessonrectalFever anotherlatefinding Attheonsetofpainfeverisusuallynotfound Temperatures 39Careuncommoninfirst24h butcommonafterrupture 2020 3 19 23 Diagnosis Acuteappendicitisshouldbesuspectedinanyonewithepigastric periumbilical rightflank orrightsidedabdpainwhohasnothadanappendectomyWomenofchildbearingageneedapelvicexamandapregnancytest Additionalstudies CBC UA imagingstudies 2020 3 19 24 Diagnosis TheWBCisoflimitedvalue SensitivityofanelevatedWBCis70 90 butspecificityisverylow But predictivevalueofhighWBCis92 and predictivevalueis50 CRPandESRhavebeenstudiedwithmixedresults 2020 3 19 25 Diagnosis Imagingstudies includeX rays US CTXraysofabdareabnormalin24 95 Abnormalfindingsinclude fecalith appendicealgas localizedparalyticileus blurredrightpsoas andfreeairAbdominalxrayshavelimiteduse forthefindingsareseeninmultipleotherprocesses 2020 3 19 26 Diagnosis LimitationsofUS retrocecalappendixmaynotbevisualized perforationsmaybemissedduetoreturntonormaldiameter 2020 3 19 27 Diagnosis CT bestchoicebasedonavailabilityandalternativediagnoses Inonestudy CThadgreatersensitivity accuracy predictivevalue 2020 3 19 28 SpecialPopulations Veryyoung veryold pregnant andHIVpatientspresentatypicallyandoftenhavedelayeddiagnosisHighindexofsuspicionisneededinthethesegroupstogetanaccuratediagnosis 2020 3 19 29 Treatment AppendectomyisthestandardofcarePatientsshouldbegivenIVF andpreoperativeantibioticsAntibioticsaremosteffectivewhengivenpreoperativelyandtheydecreasepost opinfectionsandabscessformation 2020 3 19 30 Treatment Therearemultipleacceptableantibioticstouseaslongthereisanaerobicflora enterococciandgram intestinalfloracoverageOnesamplemonotherapyregimenisZosyn3 375gorUnasyn3gAlso shortactingnarcoti