阑尾炎(英文).ppt

surgery,AcuteAppendicitis,Anatomy,Variedanatomy,Length:510cm,narrowlumen,haustraofcolon,Epidemiology,ThemostcommonacuteabdomendiseaseTheincidenceofappendectomyappearstobedecliningduetomoreaccuratepreoperativediagnosis.Despitenewerimagingtechniques,acuteappendicitiscanbeverydifficulttodiagnose.,Pathophisiology,SimpleappendicitisSuppurativeappendicitisGangrenousappendicitisPerforatedappendicitisPeritonitisAbscessaroundtheappendixMucoceleofappendix,Pathophysiology,AcuteappendicitisisthoughttobeginwithobstructionofthelumenObstructioncanresultfromfoodmatter,adhesions,orlymphoidhyperplasiaAppendixistwisted,andLumenofappendixisnarrow,resultinobstructionMucosalsecretionscontinuetoincreaseintraluminalpressure,Etiology,1.Theanatomycharacteristics2.Thetissuefeatures3.fecality,foreignbodyobstruction4.Parasitescausethemucosadamage5.adhesion,pressurecauseappendixdistortedObstructionhighpressurelimphobstructed,ischemiamucosadamagebacteriainvade（70%80%）,Artery,Theappendixarteryhasnobranches,iseasilytobeobstacled,Etiology,Eventuallythepressureexceedscapillaryperfusionpressureandvenousandlymphaticdrainageareobstructed.Withvascularcompromise,epithelialmucosabreaksdownandbacterialinvasionbybowelfloraoccurs.microbes：Ecoli,streptococcus,Pseudomonas,anaerobe,Etiology,IncreasedpressurealsoleadstoarterialstasisandtissueinfarctionEndresultisperforationandspillageofinfectedappendicealcontentsintotheperitoneum,Pathophysiology,Initialluminaldistentiontriggersvisceralafferentpainfibers,whichenteratthe10ththoracicvertebrallevel.Thispainisgenerallyvagueandpoorlylocalized.Painistypicallyfeltintheperiumbilicalorepigastricarea.,Pathophysiology,Asinflammationcontinues,theserosaandadjacentstructuresbecomeinflamedThistriggerssomaticpainfibers,innervatingtheperitonealstructuresTypicallycausingpainintheRLQ,Pathophysiology,ThechangeinstimulationformvisceraltosomaticpainfibersexplainstheclassicmigrationofpainintheperiumbilicalareatotheRLQseenwithacuteappendicitis.,Pathophysiology,ExceptionsexistintheclassicpresentationduetoanatomicvariabilityoftheappendixAppendixcanberetrocecalcausingthepaintolocalizetotherightflankInpregnancy,theappendixcanbeshiftedandpatientscanpresentwithRUQpain,Pathophysiology,Insomemales,retroilealappendicitiscanirritatetheureterandcausetesticularpain.Pelvicappendixmayirritatethebladderorrectumcausingsuprapubicpain,painwithurination,orfeelingtheneedtodefecateMultipleanatomicvariationsexplainthedifficultyindiagnosingappendicitis,Manifestations,Primarysymptom:abdominalpainto2/3ofpatientshavetheclassicalpresentationPainbeginninginepigastriumorperiumbilicalareathatisvagueandhardtolocalize,Manifestations,AstheillnessprogressesRLQlocalizationtypicallyoccursRLQpainwas81%sensitiveand53%specificfordiagnosisMigrationofpainfrominitialperiumbilicaltoRLQwas64%sensitiveand82%specific,Manifestations,Associatedsymptoms:indigestion,discomfort,flatus,needtodefecate,anorexia,nausea,vomitingAnorexiaisthemostcommonofassociatedsymptomsVomitingismorevariable,occuringinaboutofpatients,PhysicalExam,Findingsdependondurationofillnesspriortoexam.EarlyonpatientsmaynothavelocalizedtendernessWithprogressionthereistendernesstodeeppalpationoverMcBurneyspoint,PhysicalExam,Rovsingssign:paininRLQwithpalpationtoLLQObturatorsign:passivelyflextheRhipandkneeandinternallyrotatethehip.Ifthereisincreasedpainthenthesignispositive,Physicalexam,Psoassign:placepatientinLlateraldecubitusandextendRlegatthehip.Ifthereispain,thesignispositive.Rectalexam:paincanbemostpronouncedifthepatienthaspelvicappendix,PhysicalExam,Additionalcomponentsthatmaybehelpfulindiagnosis:reboundtenderness,voluntaryguarding,muscularrigidity,tendernessonrectalFever:anotherlatefinding.Attheonsetofpainfeverisusuallynotfound.Temperatures39Careuncommoninfirst24h,butcommonafterrupture,Diagnosis,Acuteappendicitisshouldbesuspectedinanyonewithepigastric,periumbilical,rightflank,orrightsidedabdpainwhohasnothadanappendectomyWomenofchildbearingageneedapelvicexamandapregnancytest.Additionalstudies:CBC,UA,imagingstudies,Diagnosis,TheWBCisoflimitedvalue.SensitivityofanelevatedWBCis70-90%,butspecificityisverylow.But,+predictivevalueofhighWBCis92%andpredictivevalueis50%CRPandESRhavebeenstudiedwithmixedresults,Diagnosis,Imagingstudies:includeX-rays,US,CTXraysofabdareabnormalin24-95%Abnormalfindingsinclude:fecalith,appendicealgas,localizedparalyticileus,blurredrightpsoas,andfreeairAbdominalxrayshavelimiteduse:forthefindingsareseeninmultipleotherprocesses,Diagnosis,LimitationsofUS:retrocecalappendixmaynotbevisualized,perforationsmaybemissedduetoreturntonormaldiameter,Diagnosis,CT:bestchoicebasedonavailabilityandalternativediagnoses.Inonestudy,CThadgreatersensitivity,accuracy,-predictivevalue,SpecialPopulations,Veryyoung,veryold,pregnant,andHIVpatientspresentatypicallyandoftenhavedelayeddiagnosisHighindexofsuspicionisneededinthethesegroupstogetanaccuratediagnosis,Treatment,AppendectomyisthestandardofcarePatientsshouldbegivenIVF,andpreoperativeantibioticsAntibioticsaremosteffectivewhengivenpreoperativelyandtheydecreasepost-opinfectionsandabscessformation,Treatment,Therearemultipleacceptableantibioticstouseaslongthereisanaerobicflora,enterococciandgram(-)intestinalfloracoverageOnesamplemonotherapyregimenisZosyn3.375gorUnasyn3gAlso,shortactingnarcoticsshouldbeusedforpainmanagement,Treatmentschoice,Nonoperativetreatmentindicatiosn1、onsetfor3-4days2、diagnosisisundefined3、generaldiseases,poorcondition4、inflammatorymassformation5、patientrefusedsurgery,Appendectomy,PreoperativeprepareAnesthesiaInc