阑尾炎英文课件

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,Central-South University,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,Central-South University,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,Central-South University,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,Central-South University,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,Central-South University,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,Central-South University,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,Central-South University,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,Central-South University,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,阑尾炎英文Ppt,阑尾炎英文Ppt,1,阑尾炎英文课件,2,Anatomy,Anatomy,3,Varied anatomy,Length: 510 cm, narrow lumen,haustra of colon,Varied anatomyLength: 510 cm,4,Epidemiology,The most common acute abdomen disease,The incidence of appendectomy appears to be declining due to more accurate preoperative diagnosis.,Despite newer imaging techniques, acute appendicitis can be very difficult to diagnose.,EpidemiologyThe most common ac,5,Pathophisiology,Simple appendicitis,Suppurative appendicitis,Gangrenous appendicitis,Perforated appendicitis,Peritonitis,Abscess around the appendix,Mucocele of appendix,Pathophisiology Simple appendi,6,Pathophysiology,Acute appendicitis is thought to begin with obstruction of the lumen,Obstruction can result from food matter, adhesions, or lymphoid hyperplasia,Appendix is twisted, and Lumen of appendix is narrow, result in obstruction,Mucosal secretions continue to increase intraluminal pressure,PathophysiologyAcute appendici,7,Etiology,1. The anatomy characteristics,2. The tissue features,3. fecality, foreign body obstruction,4. Parasites cause the mucosa damage,5. adhesion, pressure cause appendix distorted,Obstruction,high pressure,limph obstructed, ischemia,mucosa damage,bacteria invade,（,70%,80%,）,Etiology 1. The anatomy charac,8,Artery,The appendix artery has no branches, is easily to be obstacled,Artery The appendix artery has,9,Etiology,Eventually the pressure exceeds capillary perfusion pressure and venous and lymphatic drainage are obstructed.,With vascular compromise, epithelial mucosa breaks down and bacterial invasion by bowel flora occurs.,microbes,：,Ecoli, streptococcus, Pseudomonas, anaerobe,EtiologyEventually the pressur,10,Migration of pain from initial periumbilical to RLQ was 64% sensitive and 82% specific,Pathophysiology,There are multiple acceptable antibiotics to use as long there is anaerobic flora, enterococci and gram(-) intestinal flora coverage,End result is perforation and spillage of infected appendiceal contents into the peritoneum,Abscess around the appendix,3、general diseases, poor condition,As inflammation continues, the serosa and adjacent structures become inflamed,Manifestations,1、onset for 3-4 days,Primary symptom:,Appendectomy is the standard of care,With progression there is tenderness to deep palpation over McBurneys point,Associated symptoms:,Also, short acting narcotics should be used for pain management,indigestion, discomfort, flatus, need to defecate, anorexia, nausea, vomiting,This triggers somatic pain fibers, innervating the peritoneal structures,Etiology,Increased pressure also leads to arterial stasis and tissue infarction,End result is perforation and spillage of infected appendiceal contents into the peritoneum,Migration of pain from initial,11,Pathophysiology,Initial luminal distention triggers visceral afferent pain fibers, which enter at the 10,th,thoracic vertebral level.,This pain is generally vague and poorly localized.,Pain is typically felt in the periumbilical or epigastric area.,PathophysiologyInitial luminal,12,Pathophysiology,As inflammation continues, the serosa and adjacent structures become inflamed,This triggers somatic pain fibers, innervating the peritoneal structures,Typically causing pain in the RLQ,PathophysiologyAs inflammation,13,Pathophysiology,The change in stimulation form visceral to somatic pain fibers explains the classic migration of pain in the periumbilical area to the RLQ seen with acute appendicitis.,PathophysiologyThe change in s,14,Pathophysiology,Exceptions exist in the classic presentation due to anatomic variability of the appendix,Appendix can be retrocecal causing the pain to localize to the right flank,In pregnancy, the appendix can be shifted and patients can present with RUQ pain,PathophysiologyExceptions exis,15,Pathophysiology,In some males, retroileal appendicitis can irritate the ureter and cause testicular pain.,Pelvic appendix may irritate the bladder or rectum causing suprapubic pain, pain with urination, or feeling the need to defecate,Multiple anatomic variations explain the difficulty in diagnosing appendicitis,PathophysiologyIn some males,16,Patients should be given IVF, and preoperative antibiotics,Pathophisiology,Anorexia is the most common of associated symptoms,Physical exam,Primary symptom:,Bowel fistula,1、onset for 3-4 days,Treatments choice,Additional studies: CBC, UA, imaging studies,The WBC is of limited value.,Gangrenous appendicitis,Remained abscess,There are multiple acceptable antibiotics to use as long there is anaerobic flora, enterococci and gram(-) intestinal flora coverage,Physical Exam,passively flex the R hip and knee and internally rotate the hip.,Incision infection,best choice based on availability and alternative diagnoses.,Imaging studies: include X-rays, US, CT,Physical exam,Manifestations,Primary symptom:,abdominal pain,to 2/3 of patients have the classical presentation,Pain beginning in epigastrium or periumbilical area that is vague and hard to localize,Patients should be given IVF,17,Manifestations,As the illness progresses RLQ localization typically occurs,RLQ pain was 81 % sensitive and 53% specific for diagnosis,Migration of pain from initial periumbilical to RLQ was 64% sensitive and 82% specific,Manifestations As the illness,18,Manifestations,Associated symptoms:,indigestion, discomfort, flatus, need to defecate, anorexia, nausea, vomiting,Anorexia is the most common of associated symptoms,Vomiting is more variable, occuring in about of patients,Manifestations Associated symp,19,Physical Exam,Findings depend on duration of illness prior to exam.,Early on patients may not have localized tenderness,With progression there is tenderness to deep palpation over McBurneys point,Physical ExamFindings depend o,20,Physical Exam,Rovsings sign:,pain in RLQ with palpation to LLQ,Obturator sign:,passively flex the R hip and knee and internally rotate the hip. If there is increased pain then the sign is positive,Physical ExamRovsings sign:,21,Physical exam,Psoas sign:,place patient in L lateral decubitus and extend R leg at the hip. If there is pain, the sign is positive.,Rectal exam:,pain can be most pronounced if the patient has pelvic appendix,Physical examPsoas sign:,22,Physical Exam,Additional components that may be helpful in diagnosis:,rebound tenderness, voluntary guarding, muscular rigidity, tenderness on rectal,Fever:,another late finding.,At the onset of pain fever is usually not found.,Temperatures 39 C are uncommon in first 24 h, but common after rupture,Physical ExamAdditional compon,23,Diagnosis,Acute appendicitis should be suspected in anyone with epigastric, periumbilical, right flank, or right sided abd pain who has not had an appendectomy,Women of child bearing age need a pelvic exam and a pregnancy test.,Additional studies: CBC, UA, imaging studies,DiagnosisAcute appendicitis sh,24,In some males, retroileal appendicitis can irritate the ureter and cause testicular pain.,Peritonitis,abdominal pain,3、general diseases, poor condition,Mucocele of appendix,Epidemiology,Epidemiology,At the onset of pain fever is usually not found.,Typically causing pain in the RLQ,Incision infection,Abdominal xrays have limited use:,Abnormal findings include:,Obturator sign:,The change in stimulation form visceral to somatic pain fibers explains the classic migration of pain in the periumbilical area to the RLQ seen with acute appendicitis.,End result is perforation and spillage of infected appendiceal contents into the peritoneum,passively flex the R hip and knee and internally rotate the hip.,Imaging studies: include X-rays, US, CT,Treatments choice,Obstruction high pressure limph obstructed, ischemia mucosa damage bacteria invade（70%80%）,375g or Unasyn 3g,place patient in L lateral decubitus and extend R leg at the hip.,Diagnosis,The WBC is of limited value.,Sensitivity of an elevated WBC is 70-90%, but specificity is very low.,But, +predictive value of high WBC is 92% and predictive value is 50%,CRP and ESR have been studied with mixed results,In some males, retroileal appe,25,Diagnosis,Imaging studies: include X-rays, US, CT,X rays of abd are abnormal in 24-95%,Abnormal findings include:,fecalith, appendiceal gas, localized paralytic ileus, blurred right psoas, and free air,Abdominal xrays have limited use:,for the findings are seen in multiple other processes,DiagnosisImaging studies: incl,26,Diagnosis,Limitations of US: retrocecal appendix may not be visualized, perforations may be missed due to return to normal diameter,DiagnosisLimitations of US: re,27,Diagnosis,CT:,best choice based on availability and alternative diagnoses.,In one study, CT had greater sensitivity, accuracy, -predictive value,DiagnosisCT:,28,Special Populations,Very young, very old, pregnant, and HIV patients present atypically and often have delayed diagnosis,High index of suspicion is needed in the these groups to get an accurate diagnosis,Special PopulationsVery young,29,Treatment,Appendectomy is the standard of care,Patients should be given IVF, and preoperative antibiotics,Antibiotics are most effective when given preoperatively and they decrease post-op infections and abscess formation,TreatmentAppendectomy is the s,30,Treatment,There are multiple acceptable antibiotics to use as long there is anaerobic flora, enterococci and gram(-) intestinal flora coverage,One sample monotherapy regimen is Zosyn 3.375g or Unasyn 3g,Also, short acting narcotics should be used for pain management,TreatmentThere are multiple ac,31,Treatments choice,Non operative treatment indicatiosn,1,、,onset for 3-4 days,2,、,diagnosis is undefined,3,、,general diseases, poor condition,4,、,inflammatory mass formation,5,、,patient refused surgery,Treatments choiceNon operative,32,Appendectomy,Preoperative prepare,Anesthesia,Incision site,Exposure appendix, resection,Suture incision,Notes:,normal appendix,appendix mass,abscess around appendix,Appendectomy Preoperative prep,33,Appendectomy,Appendectomy,34,End result is perforation and spillage of infected appendiceal contents into the peritoneum,Appendectomy is the standard of care,pain in RLQ with palpation to LLQ,Multiple anatomic variations explain the difficulty in diagnosing appendicitis,Gangrenous appendicitis,Increased pressure also leads to arterial stasis and tissue infarction,Abdominal xrays have limited use:,Migration of pain from initial periumbilical to RLQ was 64% sensitive and 82% specific,Mucosal secretions continue to increase intraluminal pressure,Increased pressure also leads to arterial stasis and tissue infarction,abdominal pain,Epidemiology,pain in RLQ with palpation to LLQ,Pain beginning in epigastrium or periumbilical area that is vague and hard to localize,Pathophysiology,Simple appendicitis,Physical Exam,Pain beginning in epigastrium or periumbilical area that is vague and hard to localize,Typically causing pain in the RLQ,Pathophysiology,Increased pressure also leads to arterial stasis and tissue infarction,Bowel fistula,Abdominal xrays have limited use:,Abscess around the appendix,Acute appendicitis is thought to begin with obstruction of the lumen,abscess around appendix,Vomiting is more variable, occuring in about of patients,In some males, retroileal appendicitis can irritate the ureter and cause testicular pain.,Physical Exam,Increased pressure also leads to arterial stasis and tissue infarction,In one study, CT had greater sensitivity, accuracy, -predictive value,There are multiple acceptable antibiotics to use as long there is anaerobic flora, enterococci and gram(-) intestinal flora coverage,Remained abscess,Varied anatomy,Simple appendicitis,X rays of abd are abnormal in 24-95%,5、patient refused surgery,There are multiple acceptable antibiotics to use as long there is anaerobic flora, enterococci and gram(-) intestinal flora coverage,375g or Unasyn 3g,Incision infection,Physical exam,Incision infection,The appendix artery has no branches, is easily to be obstacled,Primary symptom:,Increased pressure also leads to arterial stasis and tissue infarction,Multiple anatomic variations explain the difficulty in diagnosing appendicitis,Obturator sign:,Pain beginning in epigastrium or periumbilical area that is vague and hard to localize,Rovsings sign:,Imaging studies: include X-rays, US, CT,375g or Unasyn 3g,There are multiple acceptable antibiotics to use as long there is anaerobic flora, enterococci and gram(-) intestinal flora coverage,Epidemiology,Abscess around the appendix,In some males, retroileal appendicitis can irritate the ureter and cause testicular pain.,The appendix artery has no branches, is easily to be obstacled,Abnormal findings include:,Physical Exam,appendix mass,Obstruction high pressure limph obstructed, ischemia mucosa damage bacteria invade（70%80%）,Complications,Incision infection,Remained abscess,Bowel fistula,Post operative Bleeding,Bowel adhesion, obstruction,Incisional hernia,Pylephlebitis (,门静脉炎,),、,liver abscess,End result is perforation and,35,