外科学：阑尾炎

1、1,Appendicitis阑 尾 炎,2,Essentials of background,Appendicitis can occur at any age but is most common below 40 years, especially between the ages of 8 and 14. Acute Appendicitis is the most common acute abdomen. Appendicectomy is the most common emergency surgical operation.,3,Essentials of anatomy,Th

2、e appendix (vermiform process) is a blind-ending tube arising from the cecum at the meeting point of the three taeniae coli, just distal to the ileocecal junction.,The cecum and vermiform process, with their arteries.,4,Essentials of anatomy,This is the normal appearance of the appendix against the

3、background of the cecum (left). The colonoscopic view of the appendiceal orifice between the fork of two haustral folds in the cecum is seen (right).,5,Essentials of anatomy,6,Essentials of anatomy,The base of the appendix thus lies in the right iliac fossa, close to McBurneys point. This is two-thi

4、rds of the way along a line drawn from the umbilicus to the anterior superior iliac spine. Its position will determine the clinical presentation of the disease.,7,Acute appendicitis,8,Etiology,Appendicitis is probably initiated by obstruction of the lumen.,9,Etiology,Obstruction can result from lymp

5、hoid hyperplasia, food residue, ascarid, or tumor Mucosal secretions continue to increase intralumenal pressure Bacteria invasion: all kinds of G- bacillus,10,1. In the early stages, the mucosal inflammation extends through the submucosa to involve the muscular and serosal (peritoneal) layers, event

6、ually causing a localized peritonitis (acute simple appendicitis). 2. In a later stage, the necrotic glandular mucosa sloughs into the lumen, which becomes distended with pus (acute suppurative appendicitis).,Pathophysiology,11,Pathophysiology,3. Finally, the end-arteries supplying the appendix beco

7、me thrombosed and the infarcted appendix becomes necrotic or gangrenous (acute gangrenous appendicitis). 4. If the faecally contaminated appendiceal contents from a perforated appendix are not enveloped by omentum or adherent small bowel (appendiceal abscess), the spreading peritonitis develops.,12,

8、Results,Inflammationdisappear Inflammationlocalization Inflammationdiffusion,13,Clinical findings -Symptoms,Abdominal pain : Periumbilical or epigastric pain that migrates to right lower quadrant （7080） Pain becomes persistent and well localized. It worsens with moving, breathing deeply, coughing, s

9、neezing, walking, or being touched,14,Clinical findings -Symptoms,阑尾,Th10,阑尾炎牵涉痛 神经反射机理,15, 腹痛转移需要一定的时间； 腹痛的特点是转移，不是扩散； 转移的位置不限于右下腹，更不限于麦氏点； 并不是所有的病人都具有转移性右下腹痛；,Clinical findings -Symptoms,16,Clinical findings -Symptoms,Gastrointestinal symptoms: Anorexia, nausea, and vomiting occur after the onset

10、of pain Constipation Diarrhea Bladder and rectum stimulus symptoms,17,Clinical findings -Symptoms,General symptoms : tired fever rapid pulse SIRS (systemic inflammatory response syndrome),18,Clinical findings -Signs,Tenderness in the right lower abdomen, usually about a third of the distance from th

11、e navel to the top of the hip bone Peritoneal irritation sign : muscular rigidity rebound tenderness bowel sounds disappear,19,Clinical findings -Signs,1. 结肠充气试验（Rovsings sign）:pain in the right lower quadrant upon palpation of the left lower quadrant. 2. 腰大肌试验（Psoas sign） :pain on active elevation

12、of the legs, 其他可协助诊断的体征,20,Clinical findings -Signs,3. 闭孔内肌试验（The obturator sign）: pain on internal and external rotation of the hip 4. 直肠指检（Rectal exam）, 其他可协助诊断的体征,21,Clinical findings - Laboratory findings,Leukocytosis: 10109/L; differential neutrophils 70%. But be careful of exceptions. Urine: s

13、how a few RBCs or WBCs. Pregnancy test (women only) B-us X-ray Diagnostic abdominal puncture,22,Clinical Findings - Imaging findings,Plain film Ultrasound CT,23,Imaging findings-CT scan,Ultrasound chill, high fever, jaundice, hepatic abscess. CT scan: thrombosis and gas on the portal vein. Requires

14、vigorous antibiotics and prompt surgery.,34,Treatment,非手术治疗,手术治疗,35, 少数急性单纯性阑尾炎 阑尾周围脓肿或炎性包块有局限的趋势 不能耐受手术者,非手术治疗适应证,Treatment,36,Treatment, 体位：平卧位/半坐卧位 禁食、补充水、电解质及维生素等 抗生素应用：足量、联用（抗G-+抗厌氧菌+抗G+） 中草药治疗 对症处理：适当镇静、止痛,非手术治疗措施,37, 严密观察病情； 非手术治疗也是围手术期的治疗措施； 应作好术前准备，一旦病情需要即中转手术；,非手术治疗应注意：,Treatment,38, 大部分急性

15、单纯性阑尾炎 化脓性坏疽性及穿孔性阑尾炎 阑尾周围脓肿或炎性包块无局限的趋势者 慢性或复发性阑尾炎 不典型及特殊类型阑尾炎 非手术治疗无效者,手术适应证,Treatment,39,手术方式： 阑尾切除术 可采用 常规开腹手术 或 腹腔镜手术 脓肿引流术,手术治疗,Treatment,40,Treatment,Earlyoperation: surgicalremoval(appendectomy) Acutesimpleappendicitis:appendectomy Acutepurulentandgangrenousappendicitis: appendectomyand/ordrai

16、nage Appendicealabscess: iflocalinrightlowquadrantantibiotictherapyandgeneraltreatment ifinfectiondiffusionincisionanddrainage,41,Treatment- Appendectomy,Operative technique-1,42,Treatment- Appendectomy,Operative technique-2,43,Treatment- Appendectomy,Operative technique-3,44,Treatment- Appendectomy

17、,Operative technique-4,45,Treatment- Appendectomy,Operative technique-5,46,Pros & cons of laparoscopic appendectomy,Diagnosis with certainty. Speedier recovery and less hospital stay. Superior for obese patients. Requires general anaesthesia rather than epidural anaesthesia. Higher incidence of abdo

18、minal abscess in case of perforated appendicitis*, while an opened appendectomy could effectively handle the abscess drainage and the removal of appendix. Expensive.,47,48,*Abdomenabscess *Interorextrafistula *Phylephlebitis *Incisioninfection *Peritonitisandabdomenabscess *Bleeding *Stoolfistula *Stumpinfection *Adhesiveintestinalobstruction,Complication,49,Appendicitisin the elderly,老年人急性阑尾炎临床特点： 反应迟钝、防御功能差，临床表现与病理 变化不一致； 常合并其它器官的病变； 穿孔率、病死率高；,处理原则：及早手术，同时处理并存病。,49,50,Appendicitisin neonate,小儿急性阑尾炎临床特点： 病情发展快且重，高