外科学教学课件：Acute Appendicitis

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1、Introduction It is the most common acute abdomen.It can occur at all ages,but most often between the ages of 10 and 30 years.Surgical AnatomynAppendix,fingerlike,lies in the right lower abdomenMcBurneys point:superficial projection anterior and superior iliac spine nAppendix has mainly 6 positionsPr

2、eileal appendixPostileal appendixPelvic appendixSubcecal appendixParacecal appendixRetrocecal appendixnThe radicle of Appendix is constanttaenia colicecum appendixnEctopic appendix:in the upper or left abdomen,etc.The Blood Supply of AppendixAppendiceal artery:a terminal artery,no branch,arising fro

3、m ileocolic arterySo,when blood obstacles,appendix is easy to necroticAppendiceal arteryileocolic arteryAppendiceal vein:finally to portal vein.So,appendix inflamed,bacteria embolus pylephlebitis,liver abscessAetiology1.Obstruction of appendix lumen2.Bacterial invasionthe opening of appendixthe lume

4、n of appendixObstruction of lumen results from:Lymphoid hyperplasiaFecalithAdhesionsWormsTumorObstruction of appendix lumenincrease intraluminal pressure lead to blood obstacle.contribute to bacterial invasion.Pathogenesiscontinued mucus secretion Congestive,edematousAbscessGeneralized peritonitisPu

5、rulentGangrene,perforationClinical pathology Acute simple appendicitis Acute purulent appendicitis Gangrenous and perforated appendicitis Abscess around the appendixAcute simple appendicitisAcute purulent appendicitisGangrenous and perforated appendicitisAbscess around the appendixAbscessAppendixCli

6、nical manifestation*Symptoms1.Abdominal pain Typical pain:Migratory right lower abdominal pain.Most of patients,about 70-80%The most reliable symptomThe features of typical painsympathetic nerve fibres T 10,T11 2.Gastrointestinal SymptomsAnorexiaNauseaVomiting:ConstipationDiarrhea AnorexiaNauseaVomi

7、ting3.Systemic toxic manifestation tired fever,approximately 38 degree,and when appendiceal perforation higher heart rate increasedSigns1.Tenderness The most common and important signs.It can even occur before the pain moves to the right lower abdomen.The location:most commonly at McBurneys point.th

8、e location of tenderness may be variable because of ectopic appendix.But we should know that wherever the location of tenderness varies,it is always fixed in the same site,which is called fixed tenderness.2.Peritoneal irritation signsMuscular tensionRebound pain 3.A few special signspainposterior ex

9、tension of the right thigh.flexing and internal rotation of the right hip.Laboratory Tests1.Blood routine examinationWBC count Proportion of neutrophil leukocytesl Usually normal.l When inflammation affect the bladder or ureter,a small number of RBC or WBC are examined in urine.2.UrinalysisImaging T

10、ests Not necessary!Imaging tests can be chosen only when the diagnosis is not clear.X-ray B ultrasound CT12mmEnlarged appendixfecalithAppendical wall thickeningFecalithLaparoscopyl Laparoscopy may be useful in some patients in whom the diagnosis cannot be ruled out.l However,the need for laparoscopy

11、 for diagnosis is quite low.Diagnosis of appendicitis is mainly made by:vSymptomsvSignsvLaboratory testsvImaging tests and Laparoscopy are not necessary unless the diagnosis is difficult.In Short Which includes:Migratory right lower abdominal pain:the most reliable symptom of acute appendicitis.Fixe

12、d tenderness of right lower abdomen:even occur before the pain moves to the right lower abdomen WBC and neutrophil increases1.Gastric or duodenal ulcer Perforation History of peptic ulcer.Sudden onset and not a shifting pain.Pain:rarely in the right lower abdomen.Signs:peritonitis marked in upper ab

13、domen.X-ray is helpful:free air under diaphragm.Differential Diagnosis2.Right ureteral stone Sudden severe colic pain.Signs is not obvious.A number of RBC in urine.B type ultrasound or X-ray is helpful:stone in urinary tract.3.Gynecologic disorders A:Ruptured ectopic pregnancy Menolipsis,irregular v

14、aginal bleeding history.Acute hemorrhage symptoms&intra-abdominal bleeding signs Culdocentesis:non-clotting blood.HCG:(+)B:Ovarian follicles or luteal cyst rupture Clinical manifestation is similar to ectopic pregnancy but not very severe.Occurs after the ovulation and the middle of a menstrual peri

15、od.C:Acute Salpingitis or pelvic inflammation Occur at the end of a menstrual period.Pain:bilateral in the lower abdomen.Leukorrhea:suppurative.D:Ovarian cyst torsion Obvious and severe pain.Palpable mass on abdominal or pelvic examination.Ultrasound is helpful for the diagnosis.4.Acute mesenteric a

16、denitis Often in children.Upper respiratory tract infection history.Pain&tenderness:not sharply localized Usually no muscle rigidity.5.Acute gastroenteritis Profuse diarrhea,nausea&vomiting.Abdominal signs absent:No fixed tenderness or peritoneal irritation.Treatment1.Surgical treatment If appendici

17、tis is diagnosed or strongly suspected,the best treatment is surgical removal called appendectomy because treatment delay increases mortality.Open appendectomyLaparoscopic appendectomy2.non-surgical treatment Only simple and early stage of appendicitis.With severe organic disease contraindication to

18、 surgery.Its measures include effective antibiotics and rehydration therapy.Techniques of open appendectomyA.incision:McBurney incision.A McBurney incisionB.search appendix:By tracing the taenia of the colon until the cecum.C.deal with mesoappendix:D.purse-string suture:E.resection of appendix:cut t

19、he appendix.F.inversion of stump:invert the stump.G.Closure of abdomen:Laparoscopic appendectomy1.Appendicitis in child Quick progression High fever and vomiting early Non-typical tenderness at right lower abdomen High rate of perforation High mortality More complicationsSpecial types of appendiciti

20、sTreatment:Early operation Transfusion and correct dehydration Broadspectrum antibiotics2.Appendicitis in the elderly Less well-defined symptoms and signs Severe pathologic type Error diagnosis easily Early perforation Frequently complicated with the senile illness Once diagnosed,appendectomy 3.Appe

21、ndicitis during pregnancyelevation of abdominal wallTenderness site upper shift appendix displaced superiorlyUnobvious oftenderness rebound tendernessmuscle rigidityWithout adherent blanket of omentum Peritonitis diffusionUterus enlargementTreatment:Appendectomy Late pregnancy:operated earlier Super

22、ior Incision Gentle operation No drainage Broadspectrum antibioticsChronic appendicitis1.Clinical feature:Most arise from acute inflammation,but some start as a chronic process.Recurrent right lower abdominal pain with attack history of acute appendicitis.Fixed tenderness at right lower abdomen.2.Ba

23、rium enema Appendix no filled or only partially filled with irregular lumen.Barium still remain in the lumen more than 72h.3.Treatment:Once diagnosed,appendectomyA Case Discussion1.Medical History Abstract:A 28-year-old male patient was admitted to the hospital because of acute abdominal pain for 10

24、 hours duration.10 hours ago,the patient felt poor appetite&began to suffer from abdominal pain.The pain was sporadic in periumbilical area,which shifted to the right lower abdomen 6 hours later&turned to be continuous.The patient had nausea&two episodes of vomiting associated with his pain,but no d

25、iarrhea.2.P.E.:T37.5,P95/min,R18/min,BP110/75mmHg Mentally clear with distressing facial expression.Heart and lungs not abnormal.Abdomen flat with marked tenderness in right lower abdomen,especially over McBurneys point.With muscle rigidity,rebound tenderness&positive Rovsings sign,but negative Psoas sign&Obturator sign.Bowel sounds decreased.No tenderness or mass on rectal examination.3.Laboratory findings:WBC:15.6109/L,N:0.89,L:0.11 Urinary routine test:(-)What is the diagnosis,diagnosis criteria&differential diagnosis&therapeutic plan?Thank you!Thank you!