Appendicitis 英文 留学生 课件

Appendicitis

AMedicalHistoryAbstract

A28-year-oldmalepatientwasadmittedtothehospitalbecauseofacuteabdominalpainfor10hours’duration.

10hoursago,thepatientfeltanorexia&begantosufferfromabdominalpain.Thepainwascolicinnature,periumbilicalandrathersporadic,whichshiftedtotherightlowerabdomen

6hourslater

&turnedtobecontinuousinnature.Thepatienthadnausea&twoepisodesofvomitingassociatedwithhispain,butnodiarrhea.

P.E:

T37.5℃,P95/min,R18/min,BP：110/75mmHg

Mentallyclearwithdistressingfacialexpression.

Abdomenflatwithmarked

tendernessinrightlowerabdomen,

especially

overMcBurney’spoint.

Withmusclerigidity,reboundtenderness&positiveRovsing’ssign,butnegativePsoassign&Obturatorsign.Bowelsoundsdecreased.Notendernessonrectalexamination.

Laboratoryfindings:

WBC:15.6×109/LN:0.89L:0.11

Urineroutinetest

:(-)

Questions：

1.Whatisthediagnosis?

2.diagnosticcriteria?

3.therapeuticplan

?Section1

AcuteAppendicitis

Outline

Clinicalmanifestations

EtiologyandPathogenesis

DefinitionandIntroduction

Clinicalclassification

OutlineComplicationsandProcessing

Differential

diagnosis

DiagnosisPoints

TreatmentMethodsGeneralConsideration

Concept:

acutesuppurativeinflammationofappendixThemostcommonacutesurgicalemergencyoftheabdomen.

Themostcommononeofacuteabdomen.Mortalityrisk<0.1%.Theappendixisaslender,worm-shapedpouch,averaging5—10

cminlength,thatprotrudesfromthetopofthecoloninthelowerrightabdomen

L

:5~10

cm

D

:0.5~0.7

cm

Anatomyandphysiologyofappendix

LocationMcBurney’spoint:

one-third

ofthewayfromtheanterior,superioriliacspinetotheumbilicusRightiliacfossa

Location：Variedanatomy

PelvisandrightiliacfossaappendixAnteriororposteriorileumappendixRetrocecal

appendixRight

lateral

cacum

appendixbloodSupplyAppendixartery:afinalartery,fromileocolicartery.Theappendixarteryhasnobranches,iseasilytobeobstacled

AppendicealVein

——portalvein

(portalv.ofliver)(splenicv.)(superiormesentericv.)(rightcolicv.)(ileocolicv.)(appendicularv.)EtiologyofAppendicitis

appendix

obstructionBacterialinfectionNeuralreflexAcuteappendicitisEtiology1.

anatomy:

wormed-shaped

narrowplentyoflymphglands2.mechanicalreason:foodresidue,ascarid,tumor,etc.

Obstruction:obstructionoftheproximallumen，appendicitisoccurswhentheappendixbecomesblocked,oftenbystool,aforeignbody,orcancer.Blockagemayalsooccurfrominfection,sincetheappendixswellsinresponsetoanyinfectioninthebody

Obstructionofappendiceallumen

Fecalith:obstructionoflumen→normalsecretionofmucosa→distention&intraluminalpressure↑→compressA.&V.limphobstructed,ischemia→mucosadamage→bacteriainvade→gangrene

orperforation

EtiologyBacterialinvasion

Aerobic&anaerobicorfacultativebacteria

E.coli，allkindsofG-bacilusInflammationofGI

tract

Catarrhalinflammation→suppurativeinfection

Clinical

pathology

①Acutesimpleappendicitis

②Acutesuppurativeappendicitis

③Gangrenous&perforatedappendicitis

④Periappendicealabscess

Acutesimpleappendicitis

purulentappendicitisgangrenousPerforationAcutesimpleappendicitis

Acutepurulentappendicitis

Perforationandgangrenous

Gangrenous

PerforationAppendicealabscess

ClinicalclassificationAcuteappendicitisAcutesimpleappendicitis

Acutepurulentappendicitis

GangrenousAndperforatedappendicitis

Abscessaroundtheappendix

Clinicalmanifestations

（

Symptoms+Signs）

Symptoms

1：Abdominalpain.Shiftrightlowerabdominalpain

Initially,inupperabdomenorumbilicalarea&withinseveralhs(usually6to8,no＜2hs),shiftstotherightlowerabdomen,becomingrathersharplylocalized&causingdiscomfortonmoving,walkingcoughing.△Painmaybeginintherightlowerabdomen&remainthere.

△

painmayvarywiththeabnormallocationofappendix(inrarecases)

Symptoms2:Symptomsofgastrointestinaltract

Poorappetite&nausea(anorexia)Vomiting；

Symptoms3:Systemictoxicmanifestations:

fatigue,pyrexia,tachycardia

abdominalpain

MetastaticrightlowerquadrantpainClinicalmanifestations

——Symptoms

--------------------------TypicalSymptoms

Gastrointestinalsymptoms

Nausea

、vomit

wholebodySymptomsFever

、Generalfatigue

，Bodyweakness，orheadache

、dizziness

SignsTendernessintherightlowerabdomen,usuallyabouta

thirdofthedistancefromthenaveltothetopofthehipbone

1)Tendernessofrightlowerabdomen

Fixedtendernessinrightlowerabdomen

(usuallyatMcBurney’spoint)

2)Peritonealirritation

♠

Tenderness

♠Rebound

tenderness

♠Musclerigidity

3)Massofrightlowerabdomen

Distension&afixedtender

masswithunclearmargin

4)Othersigns

A:Rovsing’ssign:

B:Psoassign:

iliopsoasmuscle.

﹡Positivewhenextensionproducespain

﹡Retrocecalappendicitisorinflamedappendix

inadeepposition&nearthemuscle

C:Obturatorsign:

﹡Lowinpelvicornearthemuscle

D:Rectalexamination:

Tendernessoramass

overanteriorrectalwall

incaseofpelvicappendicitisClinicalmanifestations

——Signs

Rightlowerquadranttenderness

StimulateperitonealSymptomsRightlowerquadrantmassmaybereached

Themostcommon,themostimportant

SignsReboundpain、MuscletensionOthersigns

Inflatablecolontest

LumbarmuscletestObturatormuscletestdigitalrectalexamination

LaboratoryTestsAhighwhitebloodcellcountDehydrationElectrolytedisordersUrinalysis:

ruleoutaurinarytractinfectionLabtestB-usX-rayDiagnosticabdominalpunctureImagingTestsXraysUltrasound&CTLaparoscope

diagnosticmethod,therapy

5.Diagnosis

Mainlymadeby:

♠SymptomaticHistory&symptoms

♠P.E

♠LaboratoryFindingsDiagnosis

PeriumbilicalorepigastricpainthatmigratestorightlowerquadrantShiftrightlower

abdominalpain

&differentdegreeofGItractsymptoms:

poorappetitenausea

&/orvomiting

Diagnosis

Tendernessintherightlowerabdomen,usuallyaboutathirdofthedistancefromthenaveltothetopofthehipboneFixedtendernessofrightlowerabdomenLeukocytosiswithleftshiftofdifferential.DiagnosisPointsMetastaticrightlowerquadrantpainFixedrightlowerquadranttendernessandStimulateperitonealSymptoms

Thenecessaryexamination

laboratoryBloodWBCNImaging

AbdominalplainfilmUltrasonographyCTLaparoscopic

Differentialdiagnosis

①Perforatedpepticulcer

♠

Historyofpepticulcer

♠

Suddenattackofsevereabdominalpain

♠

Signsofperitonitismarkedinupperabdomen

(board-likerigidity)

♠PlainabdominalX-ray:

subdiaphragmaticpneumoperitoneum

(freeairunderdiaphragm)

Rightureteralstone

♠

colicpain

referredtoperineum

♠

Hematuria:grossorurinalysis

♠BtypeultrasoundorX-ray

③Gynecologicdisorders

A:Rupturedectopicpregnancy

♠

Menolipsis

(≠amenorrhea;menopause）

orirregular

vaginalbleedinghistory

♠

Acutehemorrhagesymptoms

&intra-abdominalbleedingsigns

♠

Palpabletubalmassonpelvicexamination

♠

HCG:(+)

♠

Culdocentesis:non-clottingblood

③Gynecologicdisorders

B:Salpingitisorpelvicinflammation

♠

Pain:bilateral,lowerintheabdomen

♠Symptomsoccurattheendofamenstrualperiod

♠

Suppurative

leukorrhea

♠Rectalexamination:

symmetrical

pelvictenderness

Sonographyishelpfulfortheabovediagnosis④Acutemesentericadenitis

♠

Inchildren.

♠

Upperrespiratoryinfection

history.

♠

Pain&tenderness:notsharplylocalized

♠

usuallynomuscle

rigidity

⑤Others

Acutegastroenteritis

♠

Profusediarrhea,nausea&vomiting,

♠

NofixedtendernessorperitonealirritationDifferentialdiagnosisperforationofgastroduodenalulcer

rightureteralstoneMaternitydiseaseAcutemesentericlymphadenitis

otherHighFever

，awiderangeofabdominal

rightsidetubalpregnancy

Torsionofovariancyst

ovarianfolliclerupture

Acuteannexitis

Treatment

Earlyoperation:

Appendicitisisamedicalemergencythatrequirespromptsurgerytoremovetheappendix.surgicalremoval(appendectomy)TreatmentLeftuntreated,aninflamedappendixwilleventuallyburst,orperforate,spillinginfectiousmaterialsintotheabdominalcavity.Thiscanleadtoperitonitis,aseriousinflammationoftheabdominalcavity'slining(theperitoneum)thatcanbefatalunlessitistreatedquicklywithstrongantibiotics.TreatmentAcutesimpleappendicitis

:appendectomyAcutepurulentandgangrenousappendicitis:appendectomyand/ordrainageTreatmentAppendicealabscess:iflocalinrightlowquadrant(antibiotictherapyandgeneraltreatment)ifinfectiondiffusion(incisionanddrainage)

abcAppendectomyOperationIncision:incisionoverthepointofmaximaltenderness,generallyatMcBurnypoint3—6cmlong切开腹壁各层寻找阑尾

Thetaeniaofthecolonarefollowedtothebaseoftheappendixmesoappendixisdividedbetweenclampsandligated切断根部切断根部包埋残端关腹TreatmentAntibioticthearpyantibiotics:broadspectrumantibioticsampicillin-sulbactamgentamycintriaddrugsMetronidazol3rdgenerationcefotideslaparoscopyappendectomynon-surgicaltreatment

TreatmentMethodssurgicaltherapy

InitialTherapyAnti-BacterialTherapy

acupuncturechinesemedicinetreatment

preoperativepreparation

surgicalmethods

Managementafteroperation

ComplicationAcuteappendicitis:AbdomenabscessInterorextrafistulaPhylephlebitisComplications

①intra-abdominalabscess

♠sites:appendicealfossa

pelvicspace

sub-hepaticspace

betweenloopsofintestine

♠Fever,pain,ileus&sometimesa

palpablemass

♠Diarrhea,tenderness&fullness

incaseofpelvicabsess

②Pylephlebitis

♠jaundice

♠chills

♠highfever

Septicemiaofportalsystem

Usuallyassociatedwith

gangrenousor

perforatedappendicitis

(portalv.ofliver)(splenicv.)(superiormesentericv.)(rightcolicv.)(ileocolicv.)(appendicularv.)ComplicationOperation:IncisioninfectionPeritonitisandabdomenabscessBleedingStoolfistulaStumpinfectionAdhesiveintestinalobstructionWoundinfection

fecalfistula

adhesiveintestinalobstruction

abscessofpelvic

InternalBleeding

acommoncomplication

Section2.

AppendicitisofSpecialType.

1.Appendicitisininfants&youngchildren

.

♠

Difficultdiagnosis

.unabletoprovidehistory

.acutenonspecificabdominalpain

.infrequentforconicalconfiguration

♠

Significantmortalityrate

.rapidprogressiontorupture

.underdevelopedgreateromentum

SpecialCasesInfants:WithoutaclearhistorySymptomsvarywidelyLeadingtotheperforationeasilyAppendicitisinneonateSeldomNon-specificclinicalmanifestationAnorexia,nausea,andvomitingdiarrheadehydrationDifficultinearlydiagnosisHighrateofperforationHighmortalityAppendicitisinneonateDiagnosis&TreatmentCarefullyphysicalexamEarlyoperationAppendicitisinchildQuickonsetandseverehighfeverandvomitingpresentearlyNon-typicaltendernessatrightlowquadrantHighrateofperforationHighmortalityMorecomplicationAppendicitisinchildTreatment:EarlyoperationTransfusionandcorrectdehydrationBroadspectrumantibiotics

2.Appendicitisintheelderly

Morbidity:↑

Lesspronounced

♠insensitivitytopain,

♠weaknessofabdominalmuscle

♠lowereddefensefunction

(noobvious↑ofT&leukocytosis)

Earlyperforation:

impairedbloodsupply

structuralweaknessSpecialCasesTheelderly:AslightfeverandabdominalpainWorsebodyconditionMoretimetorecover

AppendictisintheelderlyLesswell-definedsymptomsandsignsSeverepathologictypeErrordiagnosiseasilyHighrateofperforationPayattentiontotumor

3.Appendicitisduringpregnancy

Difficultdiagnosis

♠displacedlaterally&superiorly

♠noteasilycontainedbygreateromentum

♠lessfrequentreboundtenderness&

muscleguarding(laxityoftheabdominalwall)

Ultrasoud

Appendicitisinpregnancy

Uterusenlargement

elevationofabdominalwallTendernesssiteuppershiftappendixdisplacedsuperiorlyInconspicuousoftendernessreboundtendernessmuscularrigidityWithoutadherentblanketofomentum

PeritonitisdiffusionAppendicitisinpregnancyTreatment:Operation:appendectomyTolatepregancy:earlyoperationSuperiorIncisionNodrainageBroadspectrumantibioticsParturientwithperforation:cesareansectionandappendectomySpecialCasesPregnantwomen:DonotexperiencetheclassicsymptomsTheappendixtipisrotatedmediallybythegraviduterus

Section3

ChronicAppendicitis

ChronicappendicitisEtiologyandpathologyClinicfeatureanddiagnosisrightlowquadrantpainlocaltendernessx-rayTreatappendectomy♠

FromAAwithlumennarrow

irregular

evenblocked

♠

Recurrentrightlowerabdominalpainwith

attackhistoryofAA

♠PE:fixedtenderness

♠

Bariumenemaexam

△nofilledoronlypartiallyfilledwithirregularlumen

△stillremaininthelumenmorethan72hrsAppendectomyAMedicalHistoryAbstract

A28-year-oldmalepatientwasadmittedtothehospitalbecauseofacuteabdominalpainfor10hours’duration.10hoursago