急性闌尾炎(講稿)

急性闌尾炎AcuteAppendicitisOutlinesIncidenceAnatomy&PhysiologyEtiology&PathogenesisEssentialsofDiagnosisComplicationsDifferentialDiagnosisTreatment2IncidenceThemostcommonacutesurgicalconditionofabdomen.

(Occursin6%oftheUSpopulation.)Mostfrequentlyin10~30years.Sexratio=1:1.

(In15-25yearsM:F=2:1)3Anatomy&PhysiologyAnatomyPositionoftheappendix:

constantontheleftanddorsallytothececum,2.5cmbelowtheileocecalvalve.Freeend-pelvic,retrocecal,retroileal,L/Rlowerquadrant.Landmark:

Threetaeniaecoliconvergeatthebaseoftheappendix.

5體表定位6AnatomyPositionVariation7AnatomyVascularsupply:

Appendixartery-

branchofileo-colicartery.89PhysiologyLymphoidtissue.Apartofthegut-associatedlymphoidtissues(GALT).10Etiology&PathogenesisEtiologyObstruction:

fecaliths,foreignbody(barium,vegetableandfruitseeds,intestinalworms-ascarids),truecalculi,gallstone,cecumCa,primarytumor,adhesionorhypertrophyoflymphoidtissue.Bacteriology:

anaerobes,aerobes,orfacultativebacteria.12Etiology&PathogenesisClosedloopobstructionBacterialinfection

mucosasecretionDistension&dilationCapillariesoccludedvenulesoccludedGangrene&perforationPeritonitis(LocalizedorGeneralized)13臨床病理分型1.急性單純性闌尾炎2.急性化膿性闌尾炎3.壞疽性及穿孔性闌尾炎4.闌尾周圍膿腫14EssentialsofDiagnosis

ClinicalManifestations.Laboratory&ImagingFindings.15ClinicalManifestationsSymptoms:

1.Abdominalpain.

2.Anorexia,nauseaandvomiting.Signs:3.Localizedabdominaltenderness.

4.Muscularresistanceandreflexrigidity.

5.Low-gradefever.16Laboratory&ImagingFindings1.Leukocytosis.10,000~18,000/mm32.Plainfilm:localizedair-fluidlevers.3.Chestfilm,bariumenema&CT.4.Ultrasound:Specificdiagnostictechnique.5.Laparoscopy:

distinguishgynecologicdiseaseandileitisfromappendicitis.17AcuteAppendicitisRefineYourResults(pubmed?-20091207All8415Review(582)

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US,CT,MRdiagnosisPathobacteriaandAntibioticsLapvs.OpenappendectomySuspectedandseverepatients(neonatal/old/pregnancy/SLE/TB/DM/Complicationstreatment181920右下腹解剖（B超）21探頭腹壁腰大肌闌尾22闌尾的B超表現(xiàn)2324ComplicatedappendicitisPerforation,Peritonitis.Abscess.Fistula.Pylephlebitis.25DifferentialDiagnosis1.Acutemesentericadenitis(淋巴結(jié)炎).2.Acutegastroenteritis.3.Femalepelvicdisorders:

(Rupturedovarianfollicle,Pelvicinflammatorydisease,Twistedovariancyst,Estopicpregnancy.)4.GenitourinaryDiseases:

(Ureteralorrenalcalculi,pyelonephritis.)5.Otheracuteemergencies:

(perforatedulcer,acutecholecystitis,pancreatitis,diverticulitis,intestinalabstruction,Meckle’sdiverticlitis,perforatedcarcinoma)6.Systemicdiseases.26內(nèi)科外科婦科急性胃腸炎消化道潰瘍穿孔異位妊娠破裂急性腸系膜淋巴結(jié)炎腸梗阻卵巢囊腫扭轉(zhuǎn)Meckel憩室炎急性膽囊炎卵巢濾泡或黃體破裂局限性回腸炎急性胰腺炎急性盆腔炎心胸疾病輸尿管結(jié)石急性附件炎其他泌尿系感染其他其他鑒別診斷27常見急腹癥問診查體輔助檢查消化道穿孔潰瘍病史、發(fā)病突然腹肌緊張強直立位腹平片腸梗阻排氣排便情況立位腹平片急性胰腺炎膽囊結(jié)石病史左上腹壓痛血AMY泌尿系結(jié)石腰痛、會陰放射痛腎區(qū)叩痛尿常規(guī)，泌尿系超聲婦科疾病月經(jīng)史尿HCG，婦科超聲必要時請相關(guān)科室會診！鑒別診斷28鑒別診斷胃穿孔合并不全腸梗阻29鑒別診斷卵巢囊腫孕12周合并右側(cè)卵巢黃體囊腫破裂30闌尾類癌31TreatmentOperation-Appendectomy:1.Acuteappendicitis.2.Rupturedappendixwithlocalperitonitisorphlegmon(蜂窩織炎)formation.3.RupturedappendixwithspreadingperitonitisAntibiotics.Intervetionaltherapy:AbscessSupportivetreatment:BowelFistula323334特殊類型闌尾炎Infantandchildren.PregnancyTheElderly35急性單純性闌尾炎（B超）36急性單純性闌尾炎37急性化膿性闌尾炎（B超）38急性化膿性闌尾炎39壞疽穿孔性闌尾炎40壞疽性闌尾炎41亞急性闌尾炎42慢性闌尾炎43THREATMENTLAPAROSCOPICSURGERYSIGNODSTOMY44Oneofthemostcommonconditionsinchildrenandadults.Patientsusuallypresentwithperiumbilicalpainthatlaterlocalizestotherightlowerquadrant(RLQ)atMcBurney'spoint.Inmostcases,painisaccompaniedbymildanorexiaandnauseaorvomiting.Inmostsituations,signsandsymptomscanestablishthediagnosisreliably.Thecombinationofabdominalpainandtendernessaccompaniedbyleukocytosis>12,000cells/mm3hadthehighestpredictivevalueforacuteappendicitisAppendicitis454.Insomepatientsthereisadelayindiagnosisresultinginincreasedriskofperforation,sepsis,andevendeath.Inarecentseriesofchildhoodappendicitis,all10patients<10yrshadaperforatedappendixatthetimeofoperation.In35childrenbetween1-5yrswithappendicitisperforationrateof69%.19.8%morbidityrateamongptswithperforatedappendicitis.Thesurgicalliterature:25%ofpatientsundergoingthenegativeappendectomyrate.

46Thegoalwouldbethreefold:Todiagnoseappendicitispromptly