闌尾炎英文Ppt闌尾炎英文Ppt1闌尾炎英文課件2AnatomyAnatomy3VariedanatomyLength:5~10cm,narrowlumenhaustraofcolonVariedanatomyLength:5~10cm,4EpidemiologyThemostcommonacuteabdomendiseaseTheincidenceofappendectomyappearstobedecliningduetomoreaccuratepreoperativediagnosis.Despitenewerimagingtechniques,acuteappendicitiscanbeverydifficulttodiagnose.EpidemiologyThemostcommonac5PathophisiologySimpleappendicitisSuppurativeappendicitisGangrenousappendicitisPerforatedappendicitisPeritonitisAbscessaroundtheappendixMucoceleofappendixPathophisiologySimpleappendi6PathophysiologyAcuteappendicitisisthoughttobeginwithobstructionofthelumenObstructioncanresultfromfoodmatter,adhesions,orlymphoidhyperplasiaAppendixistwisted,andLumenofappendixisnarrow,resultinobstructionMucosalsecretionscontinuetoincreaseintraluminalpressurePathophysiologyAcuteappendici7Etiology1.Theanatomycharacteristics2.Thetissuefeatures3.fecality,foreignbodyobstruction4.Parasitescausethemucosadamage5.adhesion,pressurecauseappendixdistortedObstruction→highpressure→limphobstructed,ischemia→mucosadamage→bacteriainvade（70%～80%）Etiology1.Theanatomycharac8AstheillnessprogressesRLQlocalizationtypicallyoccursVomitingismorevariable,occuringinabout?ofpatientsManifestationsSuppurativeappendicitisInitialluminaldistentiontriggersvisceralafferentpainfibers,whichenteratthe10ththoracicvertebrallevel.Insomemales,retroilealappendicitiscanirritatetheureterandcausetesticularpain.Abnormalfindingsinclude:bestchoicebasedonavailabilityandalternativediagnoses.PreoperativepreparePathophisiologyCRPandESRhavebeenstudiedwithmixedresultsGangrenousappendicitisInsomemales,retroilealappendicitiscanirritatetheureterandcausetesticularpain.Boweladhesion,obstructionFindingsdependondurationofillnesspriortoexam.2、diagnosisisundefinedFindingsdependondurationofillnesspriortoexam.PostoperativeBleedingArteryTheappendixarteryhasnobranches,iseasilytobeobstacledAstheillnessprogressesRLQ9EtiologyEventuallythepressureexceedscapillaryperfusionpressureandvenousandlymphaticdrainageareobstructed.Withvascularcompromise,epithelialmucosabreaksdownandbacterialinvasionbybowelfloraoccurs.microbes：Ecoli,streptococcus,Pseudomonas,anaerobeEtiologyEventuallythepressur10EtiologyIncreasedpressurealsoleadstoarterialstasisandtissueinfarctionEndresultisperforationandspillageofinfectedappendicealcontentsintotheperitoneumEtiologyIncreasedpressureals11PathophysiologyInitialluminaldistentiontriggersvisceralafferentpainfibers,whichenteratthe10ththoracicvertebrallevel.Thispainisgenerallyvagueandpoorlylocalized.Painistypicallyfeltintheperiumbilicalorepigastricarea.PathophysiologyInitialluminal12PathophysiologyAsinflammationcontinues,theserosaandadjacentstructuresbecomeinflamedThistriggerssomaticpainfibers,innervatingtheperitonealstructuresTypicallycausingpainintheRLQPathophysiologyAsinflammation13PathophysiologyThechangeinstimulationformvisceraltosomaticpainfibersexplainstheclassicmigrationofpainintheperiumbilicalareatotheRLQseenwithacuteappendicitis.PathophysiologyThechangeins14PathophysiologyExceptionsexistintheclassicpresentationduetoanatomicvariabilityoftheappendixAppendixcanberetrocecalcausingthepaintolocalizetotherightflankInpregnancy,theappendixcanbeshiftedandpatientscanpresentwithRUQpainPathophysiologyExceptionsexis15PeritonitisAlso,shortactingnarcoticsshouldbeusedforpainmanagement4、inflammatorymassformationRectalexam:Appendixistwisted,andLumenofappendixisnarrow,resultinobstructionMigrationofpainfrominitialperiumbilicaltoRLQwas64%sensitiveand82%specifichaustraofcolonPhysicalexamPhysicalExammicrobes：Ecoli,streptococcus,Pseudomonas,anaerobeAssociatedsymptoms:IfthereisincreasedpainthenthesignispositiveVomitingismorevariable,occuringinabout?ofpatientsPathophisiologyRectalexam:Appendixistwisted,andLumenofappendixisnarrow,resultinobstructionHighindexofsuspicionisneededinthethesegroupstogetanaccuratediagnosisIncreasedpressurealsoleadstoarterialstasisandtissueinfarctionPhysicalExamIfthereisincreasedpainthenthesignispositivePathophysiologyInsomemales,retroilealappendicitiscanirritatetheureterandcausetesticularpain.Pelvicappendixmayirritatethebladderorrectumcausingsuprapubicpain,painwithurination,orfeelingtheneedtodefecateMultipleanatomicvariationsexplainthedifficultyindiagnosingappendicitisPeritonitisPathophysiologyIns16ManifestationsPrimarysymptom:abdominalpain?to2/3ofpatientshavetheclassicalpresentationPainbeginninginepigastriumorperiumbilicalareathatisvagueandhardtolocalizeManifestationsPrimarysymptom17ManifestationsAstheillnessprogressesRLQlocalizationtypicallyoccursRLQpainwas81%sensitiveand53%specificfordiagnosisMigrationofpainfrominitialperiumbilicaltoRLQwas64%sensitiveand82%specificManifestationsAstheillness18ManifestationsAssociatedsymptoms:indigestion,discomfort,flatus,needtodefecate,anorexia,nausea,vomitingAnorexiaisthemostcommonofassociatedsymptomsVomitingismorevariable,occuringinabout?ofpatientsManifestationsAssociatedsymp19PhysicalExamFindingsdependondurationofillnesspriortoexam.EarlyonpatientsmaynothavelocalizedtendernessWithprogressionthereistendernesstodeeppalpationoverMcBurney’spointPhysicalExamFindingsdependo20PhysicalExamRovsing’ssign:paininRLQwithpalpationtoLLQObturatorsign:passivelyflextheRhipandkneeandinternallyrotatethehip.IfthereisincreasedpainthenthesignispositivePhysicalExamRovsing’ssign:21PhysicalexamPsoassign:placepatientinLlateraldecubitusandextendRlegatthehip.Ifthereispain,thesignispositive.Rectalexam:paincanbemostpronouncedifthepatienthaspelvicappendixPhysicalexamPsoassign:22PhysicalExamAdditionalcomponentsthatmaybehelpfulindiagnosis:reboundtenderness,voluntaryguarding,muscularrigidity,tendernessonrectalFever:anotherlatefinding.Attheonsetofpainfeverisusuallynotfound.Temperatures>39Careuncommoninfirst24h,butcommonafterrupturePhysicalExamAdditionalcompon23DiagnosisAcuteappendicitisshouldbesuspectedinanyonewithepigastric,periumbilical,rightflank,orrightsidedabdpainwhohasnothadanappendectomyWomenofchildbearingageneedapelvicexamandapregnancytest.Additionalstudies:CBC,UA,imagingstudiesDiagnosisAcuteappendicitissh24DiagnosisTheWBCisoflimitedvalue.SensitivityofanelevatedWBCis70-90%,butspecificityisverylow.But,+predictivevalueofhighWBCis92%and–predictivevalueis50%CRPandESRhavebeenstudiedwithmixedresultsDiagnosisTheWBCisoflimited25DiagnosisImagingstudies:includeX-rays,US,CTXraysofabdareabnormalin24-95%Abnormalfindingsinclude:fecalith,appendicealgas,localizedparalyticileus,blurredrightpsoas,andfreeairAbdominalxrayshavelimiteduse:forthefindingsareseeninmultipleotherprocessesDiagnosisImagingstudies:incl26DiagnosisLimitationsofUS:retrocecalappendixmaynotbevisualized,perforationsmaybemissedduetoreturntonormaldiameterDiagnosisLimitationsofUS:re27DiagnosisCT:bestchoicebasedonavailabilityandalternativediagnoses.Inonestudy,CThadgreatersensitivity,accuracy,-predictivevalueDiagnosisCT:28PostoperativeBleedingAcuteappendicitisshouldbesuspectedinanyonewithepigastric,periumbilical,rightflank,orrightsidedabdpainwhohasnothadanappendectomyAstheillnessprogressesRLQlocalizationtypicallyoccursSuppurativeappendicitisPathophisiologyAstheillnessprogressesRLQlocalizationtypicallyoccursRLQpainwas81%sensitiveand53%specificfordiagnosisPreoperativepreparePostoperativeBleedinghaustraofcolonRectalexam:PathophysiologyRLQpainwas81%sensitiveand53%specificfordiagnosisManifestationsPainbeginninginepigastriumorperiumbilicalareathatisvagueandhardtolocalizeAlso,shortactingnarcoticsshouldbeusedforpainmanagementRovsing’ssign:VariedanatomyIfthereisincreasedpainthenthesignispositiveAppendixistwisted,andLumenofappendixisnarrow,resultinobstructionFindingsdependondurationofillnesspriortoexam.SpecialPopulationsVeryyoung,veryold,pregnant,andHIVpatientspresentatypicallyandoftenhavedelayeddiagnosisHighindexofsuspicionisneededinthethesegroupstogetanaccuratediagnosisPostoperativeBleedingSpecial29TreatmentAppendectomyisthestandardofcarePatientsshouldbegivenIVF,andpreoperativeantibioticsAntibioticsaremosteffectivewhengivenpreoperativelyandtheydecreasepost-opinfectionsandabscessformationTreatmentAppendectomyisthes30TreatmentTherearemultipleacceptableantibioticstouseaslongthereisanaerobicflora,enterococciandgram(-)intestinalfloracoverageOnesamplemonotherapyregimenisZosyn3.375gorUnasyn3gAlso,shortactingnarcoticsshouldbeusedforpainmanagementTreatmentTherearemultipleac31TreatmentschoiceNonoperativetreatmentindicatiosn

1、onsetfor3-4days

2、diagnosisisundefined

3、generaldiseases,poorcondition

4、inflammatorymassformation

5、patientrefusedsurgeryTreatmentschoiceNonoperative32AppendectomyPreoperativeprepareAnesthesiaIncisionsiteExposureappendix,resectionSutureincisionNotes:

normalappendix

appendixmass

abscessaroundappendixAppendectomyPreoperativeprep33AppendectomyAppendectomy34IncisioninfectionInitialluminaldistentiontrigge