急性阑尾炎英文课件-2

1、Acute appendicitisWangJunThe second general surgical department Peoples hospital of yuxi cityOutlinesGeneral considerationsHistorical perspectiveAnatomyPathophysiology Clinical findings DiagnosisTreatmentGeneral considerationsAbout 8% of people in Western countries have appendicitis at some time dur

2、ing their life, with a peak incidence between 10 and 30 years of age.Acute appendicitis is the most common general surgical emergency.(10%)General considerationsAcute appendicitis has protean manifestations.It may simulate almost any other acute abdominal illness and in turn may be mimicked by a var

3、iety of conditions. Progression of symptoms and signs is the rule in contrast to the fluctuating course of some other diseases.Historical perspective Willard Packard performed the first surgery in 1867.In 1886,Reginald Fitz described the characteristic,clinical findings and pathology of the disease,

4、identified the appendix as the primary cause of right lower quadrant inflammation. Fitz coined the term appendicitis and recommended early surgical treatmentHistorical perspectiveIn 1889, Chester McBurney described characteristic migratory pain as well as localization of the pain along an oblique li

5、ne from the anterior superior iliac spine to the umbilicus. In 1894, McBurney described a right lower quadrant muscle-splitting incision for removal of the appendix.Historical perspectiveIn the 1940s,the mortality rate from appendicitis improved with the widespread use of broad-spectrum antibiotics.

6、 In 1982, Laparoscopic appendectomy was first reported by the gynecologist Kurt Semm but has only gained widespread acceptance in recent years.Anatomy physiologyThe base of the appendix is located at the convergence of the taeniae(3) of colon. This anatomic relationship facilitates identification an

7、d location of the appendix at operation. Pathophysiology Obstruction of the lumen is believed to be the major cause of acute appendicitis. This may be due to lymphoid hyperplasia, inspissated stool, fecalith, vegetable matter or seeds, parasites, or a neoplasm.PathophysiologyObstruction of the appen

8、diceal lumen Bacterial overgrowth Continued secretion of mucus Intraluminal distention and increased wall pressure PathophysiologySubsequent impairment of lymphatic and venous drainage mucosal ischemia These findings in combination promote a localized inflammatory process that may progress to gangre

9、ne and perforation.PathophysiologyInflammation of the adjacent peritoneum gives rise to localized pain in the right lower quadrant.Perforation typically occurs after at least 48 hours from the onset of symptoms and is accompanied by an abscess cavity walled-off by the small intestine and omentum.Cli

10、nical findingsClinical findingshistory and symptomAppendicitis needs to be considered in the differential diagnosis of nearly every patient with acute abdominal pain The typical presentation begins with vague peri-umbilical pain followed by anorexia,nausea and vomiting. Then localizes to the right l

11、ower quadrant. history and symptomThe classic pattern of migratory pain is the most reliable symptom of acute appendicitis Fever ensues, followed by the development of leukocytosis Occasional patients have urinary symptoms or microscopic hematuriamigratory painPhysical ExaminationLow-grade fever is

12、common(38).Diminished bowel sounds Focal tenderness (commonly at McBurneys point ) -located one third of the distance along a line drawn from the anterior superior iliac spine to the umbilicus Rebound tendernessVoluntary guardingPhysical ExaminationDunphys sign -coughing cause increased pain Rovsing

13、s sign -pain in the right lower quadrant during palpation of the left lower quadrant Physical ExaminationPsoas sign -pain on extension of the right hip (retrocecal appendix) Obturator sign -pain on internal rotation of the hip (pelvic appendix) Laboratory StudiesThe average leukocyte count is 15*109

14、/L,and 90% of patient have count over 10*109/LMore than 75% neutrophils in of patients.A completely normal leukocyte count and differential is found in about 10% of patients. Imaging studiesPlain abdominal films:may be useful for the detection of ureteral calculi, small bowel obstruction, or perfora

15、ted ulcer, but such conditions are rarely confused with appendicitis.Ultrasonography and CT scan: be helpful in patients with atypical symptoms ,such as children and elderly person.A, CT scan of the abdomen demonstrates an edematous, thickened appendix (arrow) with obstructing appendicolith (arrowhe

16、ad). B, CT scan of abdomen demonstrates a perforated appendix with a complex abscess and pelvic fluid collection (arrow). BL, bladder; UT, uterus.Essentials of diagnosisAbdominal migratory pain Anorexia,nausea and vomitingLocalized abdominal tendernessLow-grade feverLeukocytosis Differential Diagnos

17、esSometimes,the diagnosis of appendicitis may be difficult.Mesenteric lymphadenitis,gastrointestinal ulcer perforationMeckels diverticulitis, ectopic pregnancy,pelvic inflammatory diseaseSpecial category of appendicitisin infants，in children，in wemen during pregnancy，in elderly people in patients infected with HIVComplicationPerforationPeritonitisAppendiceal abscesspylephlebitisTreatmentSurgical treatment : Most patients with acute appendicitis are managed by prompt surgical removal of the appendix. (Appendectomy)Non-surgical treatment: Early Stage