闌尾炎英文演示文稿

闌尾炎英文演示文稿當前第1頁\共有35頁\編于星期五\13點當前第2頁\共有35頁\編于星期五\13點Anatomy當前第3頁\共有35頁\編于星期五\13點VariedanatomyLength:5~10cm,narrowlumenhaustraofcolon當前第4頁\共有35頁\編于星期五\13點EpidemiologyThemostcommonacuteabdomendiseaseTheincidenceofappendectomyappearstobedecliningduetomoreaccuratepreoperativediagnosis.Despitenewerimagingtechniques,acuteappendicitiscanbeverydifficulttodiagnose.當前第5頁\共有35頁\編于星期五\13點PathophisiologySimpleappendicitisSuppurativeappendicitisGangrenousappendicitisPerforatedappendicitisPeritonitisAbscessaroundtheappendixMucoceleofappendix當前第6頁\共有35頁\編于星期五\13點PathophysiologyAcuteappendicitisisthoughttobeginwithobstructionofthelumenObstructioncanresultfromfoodmatter,adhesions,orlymphoidhyperplasiaAppendixistwisted,andLumenofappendixisnarrow,resultinobstructionMucosalsecretionscontinuetoincreaseintraluminalpressure當前第7頁\共有35頁\編于星期五\13點Etiology1.Theanatomycharacteristics2.Thetissuefeatures3.fecality,foreignbodyobstruction4.Parasitescausethemucosadamage5.adhesion,pressurecauseappendixdistortedObstruction→highpressure→limphobstructed,ischemia→mucosadamage→bacteriainvade（70%～80%）當前第8頁\共有35頁\編于星期五\13點ArteryTheappendixarteryhasnobranches,iseasilytobeobstacled當前第9頁\共有35頁\編于星期五\13點EtiologyEventuallythepressureexceedscapillaryperfusionpressureandvenousandlymphaticdrainageareobstructed.Withvascularcompromise,epithelialmucosabreaksdownandbacterialinvasionbybowelfloraoccurs.microbes：Ecoli,streptococcus,Pseudomonas,anaerobe當前第10頁\共有35頁\編于星期五\13點EtiologyIncreasedpressurealsoleadstoarterialstasisandtissueinfarctionEndresultisperforationandspillageofinfectedappendicealcontentsintotheperitoneum當前第11頁\共有35頁\編于星期五\13點PathophysiologyInitialluminaldistentiontriggersvisceralafferentpainfibers,whichenteratthe10ththoracicvertebrallevel.Thispainisgenerallyvagueandpoorlylocalized.Painistypicallyfeltintheperiumbilicalorepigastricarea.當前第12頁\共有35頁\編于星期五\13點PathophysiologyAsinflammationcontinues,theserosaandadjacentstructuresbecomeinflamedThistriggerssomaticpainfibers,innervatingtheperitonealstructuresTypicallycausingpainintheRLQ當前第13頁\共有35頁\編于星期五\13點PathophysiologyThechangeinstimulationformvisceraltosomaticpainfibersexplainstheclassicmigrationofpainintheperiumbilicalareatotheRLQseenwithacuteappendicitis.當前第14頁\共有35頁\編于星期五\13點PathophysiologyExceptionsexistintheclassicpresentationduetoanatomicvariabilityoftheappendixAppendixcanberetrocecalcausingthepaintolocalizetotherightflankInpregnancy,theappendixcanbeshiftedandpatientscanpresentwithRUQpain當前第15頁\共有35頁\編于星期五\13點PathophysiologyInsomemales,retroilealappendicitiscanirritatetheureterandcausetesticularpain.Pelvicappendixmayirritatethebladderorrectumcausingsuprapubicpain,painwithurination,orfeelingtheneedtodefecateMultipleanatomicvariationsexplainthedifficultyindiagnosingappendicitis當前第16頁\共有35頁\編于星期五\13點ManifestationsPrimarysymptom:abdominalpain?to2/3ofpatientshavetheclassicalpresentationPainbeginninginepigastriumorperiumbilicalareathatisvagueandhardtolocalize當前第17頁\共有35頁\編于星期五\13點ManifestationsAstheillnessprogressesRLQlocalizationtypicallyoccursRLQpainwas81%sensitiveand53%specificfordiagnosisMigrationofpainfrominitialperiumbilicaltoRLQwas64%sensitiveand82%specific當前第18頁\共有35頁\編于星期五\13點ManifestationsAssociatedsymptoms:indigestion,discomfort,flatus,needtodefecate,anorexia,nausea,vomitingAnorexiaisthemostcommonofassociatedsymptomsVomitingismorevariable,occuringinabout?ofpatients當前第19頁\共有35頁\編于星期五\13點PhysicalExamFindingsdependondurationofillnesspriortoexam.EarlyonpatientsmaynothavelocalizedtendernessWithprogressionthereistendernesstodeeppalpationoverMcBurney’spoint當前第20頁\共有35頁\編于星期五\13點PhysicalExamRovsing’ssign:paininRLQwithpalpationtoLLQObturatorsign:passivelyflextheRhipandkneeandinternallyrotatethehip.Ifthereisincreasedpainthenthesignispositive當前第21頁\共有35頁\編于星期五\13點PhysicalexamPsoassign:placepatientinLlateraldecubitusandextendRlegatthehip.Ifthereispain,thesignispositive.Rectalexam:paincanbemostpronouncedifthepatienthaspelvicappendix當前第22頁\共有35頁\編于星期五\13點PhysicalExamAdditionalcomponentsthatmaybehelpfulindiagnosis:reboundtenderness,voluntaryguarding,muscularrigidity,tendernessonrectalFever:anotherlatefinding.Attheonsetofpainfeverisusuallynotfound.Temperatures>39Careuncommoninfirst24h,butcommonafterrupture當前第23頁\共有35頁\編于星期五\13點DiagnosisAcuteappendicitisshouldbesuspectedinanyonewithepigastric,periumbilical,rightflank,orrightsidedabdpainwhohasnothadanappendectomyWomenofchildbearingageneedapelvicexamandapregnancytest.Additionalstudies:CBC,UA,imagingstudies當前第24頁\共有35頁\編于星期五\13點DiagnosisTheWBCisoflimitedvalue.SensitivityofanelevatedWBCis70-90%,butspecificityisverylow.But,+predictivevalueofhighWBCis92%and–predictivevalueis50%CRPandESRhavebeenstudiedwithmixedresults當前第25頁\共有35頁\編于星期五\13點DiagnosisImagingstudies:includeX-rays,US,CTXraysofabdareabnormalin24-95%Abnormalfindingsinclude:fecalith,appendicealgas,localizedparalyticileus,blurredrightpsoas,andfreeairAbdominalxrayshavelimiteduse:forthefindingsareseeninmultipleotherprocesses當前第26頁\共有35頁\編于星期五\13點DiagnosisLimitationsofUS:retrocecalappendixmaynotbevisualized,perforationsmaybemissedduetoreturntonormaldiameter當前第27頁\共有35頁\編于星期五\13點DiagnosisCT:bestchoicebasedonavailabilityandalternativediagnoses.Inonestudy,CThadgreatersensitivity,accuracy,-predictivevalue當前第28頁\共有35頁\編于星期五\13點SpecialPopulationsVeryyoung,veryold,pregnant,andHIVpatientspresentatypicallyandoftenhavedelayeddiagnosisHighindexofsuspicionisneededinthethesegroupstogetanaccuratediagnosis當前第29頁\共有35頁\編于星期五\13點TreatmentAppendectomyisthestandardofcarePatientsshouldbegivenIVF,andpreoperativeantibioticsAntibioticsaremosteffectivewhengivenpreoperativelyandtheydecreasepost-opinfectionsandabscessformation當前第30頁\共有35頁\編于星期五\13點TreatmentTherearemultipleacceptableantibioticstouseaslongthereisanaerobicflora,enterococciandgram(-)intestinalfloracoverageOnesamplemonotherapyregimenisZosyn3.375gorUnasyn3gAlso,shortactingnarcoticsshoul