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generalsurgery,Caseanalysis,personalprofile,Gender:maleAge:72-years-oldArrivedateathospital:2015-10-28marriage:bemarried,Chiefcomplaint,stomachache4days,Historyofpresentillness,ThepatienthadLowerrightabdominalpainfor4days,thepainissevereandpersistent,thenthepaintransfertothewholeabdomen.SothepatientarrivedtoYueQingsecondhospitalforConservative(保守的)treatment，butineffective.So，hetransfertoourhospital.,Pasthistory,Hedeniedhypertension,diabetesmellitus,hepatitisB,tuberculousis,andotherdiseases.Nosmokingordrinking.Intheyearof2014,hehadansurgeryofLaparoscopiccholecystectomy(LC)inTheSecondAffiliatedHospitalofWenzhouMedicalUniversity.,radiography,X-ray（2015-10-24）pneumatosis,nju:mtusisinintestine.(肠管积气)WholeAbdomenCT（2015-10-24）Asmallamountofeffusioninabdominalcavity(腹腔少量积液)，Appendixfatclearancearoundasmallamountofliquidleakage(盲肠周围脂肪间隙少量液体渗出)，Considerpossibleappendixinflammation。WholeAbdomenEnhancedCT(2015-10-27)Theupperrightabdomenandrightnexttothecolonperitoneum,pertnim、Greateromentumlimitationsinflammatorychange（右上腹及右结肠旁腹膜、网膜局限性炎症改变）.Simpleappendicitis.,pendsats,Physicalexamination,vitalsigns：Histemperatureis36.2,heartrate63bpm,respiratoryrate20timesoneminuteandbloodpressure140/89mmHg.Theabdominalmuscletension,rightlowerquadrantstomachache,andbouncepainful.Liverandspleenarenotpalpablebelowthecostalmargin,Bowelsounds5-6times/min.,Laboratoryexamination,BRT（2015-10-28）Whitebloodcell：9.8*109/L；Neutrophilpercentage：80.9%；CRP（2015-10-28）76.6mg/L。PCT（2015-10-28）2.34ng/ml。inflammationnflme()nBNP（2015-10-24）BNP42p/mlCKMB、C-TnT（2015-10-24）CKMB1.3ng/ml、C-TnT0.002ng/ml。,Diagnosis,1.Acuteperitonitis（急性腹膜炎）,pertnatsThedigestivetractperforation？消化道穿孔Acuteappendicitis？急性阑尾炎Cholecystitis？胆囊炎Ureteralcalculi？输尿管结石Acutepancreatitis？急性胰腺炎,Thedigestivetractperforation,Physicalexamination:Peritoneal,pertnilirritation(腹膜刺激征):abdominaltendernessandbouncepainful,Theabdominalmuscletension.LaboratoryexaminationBRT（2015-10-28）Whitebloodcell：9.8*109/L；Neutrophilpercentage：80.9%。CRP（2015-10-28）76.6mg/L。CT:conformtoperitonitis（腹膜炎）Wecantfindabdominalcavityfreegas？,acuteappendicitis？,Butprogressofpatientdisease：thentransfertothewholeabdominalpain.ThepatientnothadthetypicalsymptomsofMetastaticlowerabdominalpain（.转移性右下腹痛）appendicitis?,metsttk,Historyofillness：ThepatienthadLowerrightabdominalpainfor4days,thepainissevereandpersistent。CT:Simpleappendicitis.,cholecystitis,Historyofillness：Intheyearof2014,hehadansurgeryofLaparoscopiccholecystectomy(LC)inTheSecondAffiliatedHospitalofWenzhouMedicalUniversity.ThepatienthadLowerrightabdominalpainItsawrongdiagnosis,Ureteralcalculi？,WecantfindUreteralcalculiinCT.TheRoutineurineisnoabnormal.Itsawrongdiagnosis,Acutepancreatitis？,CT:Thepancreasisnoswelling,leakageThebloodamylase(2015-11-24)isnoabnormal.Itsawrongdiagnosis,急性腹膜炎待查：消化道穿孔？急性阑尾炎？,2015年10月28日TheLaparotomyoperationtime:10：0011：00Acutesuppurativeappendicitis(急性化脓性阑尾炎)perforatedappendix.（阑尾穿孔）主要手术发现：回盲部肠管结构欠清，局部粘连水肿严重，阑尾位于盲肠前位，表面可及脓苔，局部化脓性改变，阑尾根部可见穿孔。术后诊断：急性化脓性阑尾炎,surgeryrecord,主要手术发现：回盲部肠管结构欠清，局部粘连水肿严重，阑尾位于盲肠前位，表面可及脓苔，局部化脓性改变，阑尾根部可见穿孔。具体操作步骤：1.按常规消毒铺巾；2.取右腹直肌旁分离切口，逐层切开皮肤及皮下组织后逐层进腹3.找到盲肠，见回盲部肠管结构欠清，局部粘连水肿严重，予以钝性分离，4.见阑尾位于盲肠前位，表面可及脓苔，局部化脓性改变，阑尾根部可见穿孔5.在阑尾系膜根部分次钳夹、切断、结扎系膜（4号丝线双重结扎近端阑尾系膜）；6.距阑尾根部约0.5cm、切除阑尾，4号丝线结扎阑尾根部，电刀烧灼残端；7.围绕阑尾根部在盲肠壁上用1号丝线作一荷包缝合，将阑尾残端埋于盲肠壁内，8.检查无出血，留置盆腔引流管一根，清点纱布及器械无误，丝线连续缝合腹膜，清洗切口，分层缝合切口，皮肤钉钉合皮肤。,Thinking,Thepatientisnottypicalappendicitis.NotallappendicitishaveTypicalsymptomsofMetastaticlowerabdominalpainThe