英語(yǔ)查房預(yù)習(xí)資料課件

AcuteAppendicitis2012.8Epidemiology(流行病學(xué)）ThemostcommonacuteabdomendiseaseTheincidenceofappendectomyappearstobedecliningduetomoreaccuratepreoperativediagnosis.Despitenewerimagingtechniques,acuteappendicitiscanbeverydifficulttodiagnose.Etiology（病因）Eventuallythepressureexceedscapillary（毛細(xì)血管）perfusionpressureandvenousandlymphaticdrainageareobstructed.Withvascularcompromise,epithelial（上皮）mucosabreaksdownandbacterialinvasionbybowelflora（腸道菌群）occurs.Pathophisiology（病理生理）SimpleappendicitisSuppurative（化膿的）appendicitisGangrenous（壞疽的）appendicitisPerforated（穿孔的）appendicitisPeritonitis（腹膜炎）Abscess（膿腫）aroundtheappendixMucocele（粘液囊腫）ofappendixPathophysiology（病理生理）Acuteappendicitisisthoughttobeginwithobstructionofthelumen（內(nèi)腔）Obstructioncanresultfromfoodmatter,adhesions,orlymphoidhyperplasia（增生）Appendixistwisted,andLumenofappendixisnarrow,resultinobstructionMucosalsecretionscontinuetoincreaseintraluminal（管腔內(nèi)的）pressurePathophysiology（病理生理）Initialluminaldistentiontriggersvisceralafferentpainfibers（疼痛內(nèi)臟輸入纖維）,whichenteratthe10ththoracicvertebrallevel.Thispainisgenerallyvagueandpoorlylocalized.Painistypicallyfeltintheperiumbilical（臍周的）orepigastric（上腹部）area.Pathophysiology（病理生理）Asinflammationcontinues,theserosa（漿膜）andadjacentstructuresbecomeinflamedThistriggerssomatic（軀體的）painfibers,innervating（刺激）theperitonealstructuresTypicallycausingpainintheRightLowerQuadrant(右下象限）Manifestations（臨床表現(xiàn)）AstheillnessprogressesRLQlocalizationtypicallyoccursRLQpainwas81%sensitiveand53%specificfordiagnosisMigrationofpainfrominitialperiumbilicaltoRLQwas64%sensitiveand82%specificManifestations（臨床表現(xiàn)）Associatedsymptoms:indigestion,discomfort,flatus（脹氣）,needtodefecate（排便）,anorexia（厭食）,nausea,vomitingAnorexia

isthemostcommonofassociatedsymptomsVomitingismorevariable,occurringinabout?ofpatientsPhysicalExam（體格檢查）Findingsdependondurationofillnesspriortoexam.EarlyonpatientsmaynothavelocalizedtendernessWithprogressionthereistendernesstodeeppalpation（觸診）overMcBurney’spointPhysicalExam（體格檢查）Rovsing’ssign:paininRLQwithpalpationtoLLQObturator（閉孔）sign:passivelyflextheRhipandkneeandinternallyrotatethehip.IfthereisincreasedpainthenthesignispositivePhysicalexam（體格檢查）Psoas（腰大?。﹕ign:placepatientinLlateraldecubitus（臥位）andextendRlegatthehip.Ifthereispain,thesignispositive.Rectal（直腸）exam:paincanbemostpronouncedifthepatienthaspelvicappendixDiagnosisAcuteappendicitisshouldbesuspectedinanyonewithepigastric,periumbilical,rightflank（側(cè)面）,orrightsidedabdpainwhohasnothadanappendectomyWomenofchildbearingageneedapelvicexamandapregnancytest.Additionalstudies:CBC,UA,imagingstudiesDiagnosisTheWBCisoflimitedvalue.SensitivityofanelevatedWBCis70-90%,butspecificityisverylow.But,+predictivevalueofhighWBCis92%and–predictivevalueis50%C-reactiveproteinhavebeenstudiedwithmixedresultsDiagnosisImagingstudies:includeX-rays,CTXraysofabdareabnormalin24-95%Abnormalfindingsinclude:Fecalith(糞石）,appendicealgas,localizedparalyticileus（麻痹性腸梗阻）,blurred（模糊）rightpsoas（腰大?。?andfreeairDiagnosisCT:Bestchoicebasedonavailabilityandalternativediagnoses.Inonestudy,CThadgreatersensitivity,accuracy,-predictivevalueTreatmentAppendectomyisthestandardofcarePatientsshouldbegivenIVF（靜脈輸液）,andpreoperativeantibioticsAntibioticsaremosteffectivewhengivenpreoperativelyandtheydecreasepost-opinfectionsandabscessformationTreatmentschoiceNo