外科学阑尾疾病.ppt

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1、 阑尾疾病目的和要求1.了解急性阑尾炎的病理和临床分类。2.熟悉急性阑尾炎的并发症及阑尾切除术并发症。3.掌握急性阑尾炎的诊断、鉴别诊断和治疗。4.了解特殊类型急性阑尾炎的临床特点和处理原则。5.了解慢性阑尾炎和阑尾肿瘤的诊断和治疗。6.了解几个与阑尾疾病相关的名词，如：Rovsing征、腰大肌征、闭孔肌征。第一节 解剖生理概要细长弯曲的盲端；粘膜下淋巴滤泡：婴幼儿很少，以后渐多，1020岁达高峰(200个)，30岁后骤降，60岁几乎无。少年期有免疫功能，成人阑尾切除后对人无影响。终末血管供血。The appendix(A)is a small worm-like pouch attached

2、 to the large bowel(B)right after the small intestine(C).The function of the appendix is uncertain and there seems to be no long-term problems in living without it.第二节 急性阑尾炎Acute Appendicitis历史背景16世纪：阑尾炎无不穿孔，普遍认为盲肠是原发病所在。Melier(1827)：这种化脓性髂窝肿块可能是阑尾的炎症所致。Fitz(1886)：明确指出“盲肠炎”的实质是阑尾炎，治疗阑尾炎需要切除阑尾。Senn(1

3、889)：首先在穿孔前明确诊断出急性阑尾炎，并进行了手术切除，治愈了该病例。McBurney(1889)：描述了急性阑尾炎的典型临床表现以及腹部压痛点，即麦氏点。人们把麦氏切口也归功于McBurney，然而，这是McArthar发明的。Charles McBurney(1845-1913)病理生理梗阻和细菌侵入(腔内侵入或血运)。阑尾解剖生理特点：细长、弯曲、盲端、蠕动慢易梗阻。淋巴组织增生、粪石、异物(食物屑、虫)、扭曲、肿瘤。终末血管易发生循环障碍易坏死穿孔。临床病理分型单纯性梗阻、腔内压、炎症由粘膜浆膜。外观：轻度肿、浆膜充血、无光泽、少量纤维素。腔内少量渗液。镜下：各层水肿、中性粒浸润

4、粘膜面小溃疡。临床：右下腹痛、压痛、反跳痛、轻度肌紧张、体温及白细胞略升。临床病理分型化脓性明显肿胀、高度充血、纤维素附着多，腔内稀薄脓液，粘膜溃疡更大，管壁各层小脓肿形成。临床：全身及腹部情况更重。临床病理分型坏疽及穿孔暗紫色、坏死、压力上升、穿孔。包裹。临床：压痛范围扩大，中毒症状。肿块、广泛腹痛。典型的阑尾位置与形态典型的急性阑尾炎（一）典型的急性阑尾炎（二）典型的急性阑尾炎（三）急性阑尾炎的组织学改变正常阑尾急性阑尾炎低倍光镜 高倍光镜临床病理分型病理转归炎症消退：(单纯近正常解剖)(化脓疤痕)单纯性及小部分化脓性近正常解剖状态，或腔变细、窄、弯曲、闭塞、壁上纤维组织增生、周围粘连。

5、穿孔：粘连阑尾脓肿；无粘连腹膜炎。感染扩散：化脓性、坏疽性细菌经门脉入全身化脓性门静脉炎，或脓毒败血症。临床表现症状腹痛：上腹或脐周(下腹、全腹)右下腹。腹痛与阑尾的位置有关。疼痛原因：阑尾蠕动阑尾腔梗阻；反射性幽门痉挛。胃肠道症状：N&V无食欲。取决于：炎性阑尾的扩张程度；病人对神经反射的敏感性。成人多厌食恶心，小儿多吐。半数人有便秘(成人)或腹泻(小儿)，盆位里急后重。临床表现症状全身症状：不适，低热38，穿孔或小儿可有高热。起病时不发热、24h内一定有发热，穿孔前不会很高。起病时体温很高，诊断可疑。脉轻度加速。持续加速示局限性腹膜炎形成，应早手术。睾丸痛：911神经受刺激，敏感性。How

6、 to feel the abdomen?Lay your hand flat on the abdomen,and keep your fingers fully extended as you feel for tenderness.Avoid the painful area,and start feeling his abdomen as far from it as you can(Dont worry if he tells you it is the wrong place!).Move towards this slowly.Where is the area of great

7、est tenderness?It will be easier to find if there is no guarding,and is a useful clue to the organ involved.In his right iliac fossa?(appendicitis).In his flank?(renal suppuration).Suprapubically in a woman?(PID).Superficial induration and tenderness?(pyomyositis of the abdominal wall).Never forget

8、to examine the rectum.临床表现体征右下腹压痛(腹或直肠)：位于阑尾根部，不一定在麦氏点，局部有叩痛。盲肠区鼓音。腹膜刺激征：肌紧张、反跳痛、肠音减弱或消失壁层腹膜受炎症刺激的防御反应。肌紧张重度很紧，无呼吸运动腹膜炎，中度手触即紧，轻手深压才紧。注意病人精神紧张否？动作粗否？小、老、孕、胖、弱、盲肠后位，刺激征可不明显。右下腹包块临床表现特殊检查结肠充气试验(Rovsing sign)：腰大肌试验：闭孔内肌试验：右股内旋(膝向内、足向外)直肠指检：全身：病人怕动，小心起坐行走。实验室检查：WBC、PMN，尿WBC、RBC。闭孔内肌试验（Obturator征）腰大肌试验（P

9、soas征）WBC countWBC:10,000 per mm3 in 80 percent of all cases of acute appendicitis.Unfortunately,the WBC is elevated in up to 70%of pts with other causes of RLQ pain.An elevated WBC has a low predictive value.Serial WBC measurements(over 4 to 8 hours)in suspected cases may increase the specificityC-

10、reactive proteinC-reactive protein level:0.8 mg/dLElevated C-reactive protein level in combination with an elevated WBC count and neutrophilia are highly sensitive(97 to 100 percent).If all three of these findings are absent,the chance of appendicitis is low.UrinalysisIn patients with appendicitis,a

11、 urinalysis may demonstrate changes such as mild pyuria,proteinuria and hematuria,but the test serves more to exclude urinary tract causes of abdominal pain than to diagnose appendicitis.Imaging EvaluationThe technique of appendiceal computed tomography is more accurate than ultrasonography in confi

12、rming the diagnosis of appendicitis.Imaging EvaluationThe options for radiologic evaluation of pts with suspected appendicitis have expanded in recent years,enhancing and sometimes replacing previously used radiologic studies.Imaging EvaluationPlain radiographs,while often revealing abnormalities in

13、 acute appendicitis,lack specificity and are more helpful in diagnosing other causes of abdominal pain.Likewise,barium enema is now used infrequently because of the advances in abdominal imaging.Imaging Evaluation-USUS is appropriate in pts in which the Dx is equivocal by Hx and PE.It is especially

14、well suited in evaluating RLQ or pelvic pain in pediatric and female pts.A normal appendix(6 mm or less in diameter)must be identified to rule out appendicitis.An inflamed appendix usually measures greater than 6 mm in diameter,is noncompressible and tender with focal compression.Other RLQ condition

15、s such as IBD,cecal diverticulitis,Meckels diverticulum,endometriosis and PID can cause false-positive US results.Ultrasonogram showing longitudinal section(arrows)of inflamed appendix.Imaging Evaluation-CTCT,specifically the technique of appendiceal CT,is more accurate than US.Appendiceal CT consis

16、ts of a focused,helical,appendiceal CT after a Gastrografin-saline enema(with or without oral contrast)and can be performed and interpreted within one hour.Intravenous contrast is unnecessary.The accuracy of CT is due in part to its ability to identify a normal appendix better than US.An inflamed ap

17、pendix is greater than 6 mm in diameter,but the CT also demonstrates periappendiceal inflammatory changes.If appendiceal CT is not available,standard abdominal/pelvic CT with contrast remains highly useful and may be more accurate than US.正常阑尾阑尾周围脓肿FIG.Computed tomographic scan showing cross-section

18、 of inflamed appendix(A)with appendicolith(a).FIG.Computed tomographic scan showing enlarged and inflamed appendix(A)extending from the cecum(C).诊断右下腹疼痛+压痛!典型症状发生顺序(55%阑尾炎，1/4腹内其它病)：腹痛(上腹或脐周)恶心、呕吐右下腹痛及压痛发热WBC。非典型：开始即右下腹痛。弥散痛不转移。非典型症状发生顺序见于45%阑尾炎，在开始怀疑为阑尾炎的病人中有75%最终诊断为其它病。主要见于老人，疼痛不重，局限定位晚。1.Pain,usu

19、ally epigastric or umbilical;2.Nausea or vomiting;3.Local iliac tenderness;4.Fever;5.Leucocytosis.“The symptoms occur almost without exception in the above order,and when that order varies I always question the diagnosis.”John B.MurphyJohn B.Murphy,1857-1916(President of AMA,1911-1912)鉴别诊断妇科病(2040岁)

20、宫外孕：出血症状体征，停经史，阴道不规则流血，腹痛剧突然，宫颈举痛，后穹窿饱满，穿出不凝血，附件肿块。经间痛：与宫外孕相仿、较轻。卵巢囊肿扭转：腹部肿块史、触及肿块。急性输卵管炎：脓性白带、对称痛、穹窿触痛。鉴别诊断消化溃疡穿孔：溃疡史、上腹痛剧、范围广、板状腹、肠鸣音，膈下游离气体。右输尿管结石：阵发性绞痛、向外阴放射、尿常规、X线、US。肠系膜淋巴结炎：无转移性痛、小儿、上感存在或刚退，无腹膜刺激征。鉴别诊断右肺底肺炎或右胸膜炎：刺激1012肋神经，发热38.5，胸痛、咳、啰音、呼吸弱。X线在1824h才明显。急性胃肠炎：不洁食史，吐泻频，无腹膜刺激征，肠鸣音亢，粪便脓细胞。急性胆囊炎：病

21、史、右肩牵涉痛、肿大胆囊、USMeckel憩室炎：压痛偏中，核素。治疗切口：麦氏切口，经腹直肌切口。抗生素：术前用广谱防止术后感染。术后：无并发症用24h穿孔脓肿用57天弥漫性腹膜炎 710天。手术步骤（找阑尾）手术步骤（处理系膜）手术步骤（处理阑尾根部）手术步骤（荷包缝合）手术步骤（残端包埋）手术步骤（盲肠壁水肿的处理方法）手术步骤（“8”字缝合后）Dont give him an antibiotic in the hope of cutting short early appendicitis.It will only give you and him a false sense of

22、security.The use of antibiotics in an attempt to avoid or postpone appendectomy ignores the fact that acute appendicitis begins as an obstruction.Observation until typical or definite symptoms appear is ill-advised.Exploration to discover the cause of minimal but unexplained symptoms,even in poor-ri

23、sk patients is safer than waiting.Robert E.Condon There is only one way to have a 100 per cent accurate diagnostic record for acute appendicitis,and that is to wait until they all rupture.Mark M.Ravitch Watchful waiting,however careful it may be,runs the risk of increasing both morbility and mortali

24、ty.Robert E.Condon to delay operation on acute appendicitis is to gamble with death.Mark M.Ravitch 急性阑尾炎的并发症腹腔脓肿：内、外瘘形成：门静脉炎：全身感染症状、肝大、黄疸、门静脉内气体。阑尾切除后并发症腹腔出血：切口感染：粘连性肠梗阻：阑尾残株炎：粪瘘：第三节 特殊类型阑尾炎Special Considerations一、儿童急性阑尾炎儿童阑尾解剖生理特点漏斗型、淋巴组织不发达不易梗阻。壁薄、大网膜发育差易穿孔、扩散。表达能力差，检查不合作易误诊。腹膜吸收能力大易出现中毒症状。临床特点病情重

25、高热、呕吐明显。压痛范围广，肌紧张不明显，要求动作轻柔、耐心。穿孔发生率高。二、老人急性阑尾炎老人阑尾解剖生理特点动脉硬化易栓塞穿孔。抵抗力差、反应差、症状体征比病理轻易延误诊断。临床特点可无恶心呕吐，几乎无发热及WBC，此时核左移为炎症的主要依据。注意：术前检查心、肺、麻醉选择。三、妊娠急性阑尾炎妊娠阑尾解剖生理特点阑尾位置随子宫增大向后上移位。大网膜不易包裹，炎症不易局限，穿孔后易成弥漫性。腹肌伸展，肌紧张不著。临床特点手术配合安胎治疗。切口宜偏高。操作轻柔，尽可能不用引流。Suspicion of appendicitis should lead to early surgical i

26、ntervention in all trimesters.Negative laparotomy results in minimal fetal loss,whereas a delay in diagnosis and perforation may result in a high incidence of fetal death and a relatively high incidence of maternal death.第四节 慢性阑尾炎Chronic Appendicitis病因和病理急性阑尾炎后遗纤维化(管腔狭窄、排空障碍)。异物(粪、谷、虫)、先天或粘连扭曲、滤泡增生。临床表现、诊断和治疗急性病史右下腹痛经常发作。右下腹隐痛或不适。右下腹痛和压痛。X线治疗：手术+探查。