Acute Appedicitis-謝宏仁
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Transcript of Acute Appedicitis-謝宏仁
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Acute Appendicitis
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Epidemiology
It affects 6~7 % of the population.
Peak incidence in adolescents and young
adults, with a slight male predominance
in this age group.
Infants, elderly, pregnant women and
immunocompromised patients tend to
have atypical presentations and have
higher morbidity and mortality.
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Pathophysiology
Obstruction-most commonly secondary to
fecalith in adults and lymphoid hyperplasia
in children.
Continued mucosal secretion.
Worsened edema, high luminal pressure and
bacterial proliferation.
Transmural necrosis and bacterial
penetration.
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Clinical presentation Classical presentation occurs in only 50 %
of patients.
Pain begins in peri-umbilical or epigastric
region, due to appendiceal distension andreferred pain.
Pain localizes to the RLO as the parietal
peritoneum in the area becomes irritated.
Anorexia and nausea occur almost
uniformly after the pain.
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Physical examination
Mild fever may be present.
Mc-Burneys point
Rovsings sign
Psoas sign & Obturator sign
Rectal examination
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Laboratory and Imaging Findings
WBC elevation from 10000 to 18000/mm3
Abdominal radiograph may show a fecalith
in the RLQ, loss of the psoas shadow and/or
a few dilated loops of the bowel.
Ultrasonography reveals a non-compressible,
aperistalic appedix larger than 6 mm in
diameter.
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Treatment
Immediate operative treatment is indicated.
In the case of a perforated appedix with
phlegmon formation, an interval
appedectomy is usually performed with
drains left and skin & subcutaneous tissue
open for weeks.
Peri-operative antibiotics have been shown
to lower the infectious complications.
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Prognosis
The mortality of appedicitis is the mortality
ofdelay.
Most surgeons are therefore believed that a
certain number of negative explorations are
necessary to avoid a high incidence of
perforation and its sequelae.
Can negative laparotomy be lowered
without a concomitant rise in perforation
rates?
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The value of99mTc HMPAO labeled
white blood cell scintigraphyin
acute appendicitis patients
with an equivocal clinical presentation
Eur J Nucl Med (2001) 28:575-580
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Introduction
Up to 30% of patients with proved
appendicitis are misdiagnosed and
discharged.
The rate of normal appendectomy averages
16%, with females comprising 68% of these
patients.
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Materials and methods
This study was designed as a prospective
clinical trial.Forty-one patients (24 females and 17 males,
aged 7-70 years) were included. The inclusion
criteria were acute right lower quadrantabdominal pain with a clinical presentation
equivocal for acute appendicitis, as
determined by the surgeons.
A WBC count of greater than 3000/mm3
was required for cell labeling.
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Labeling of WBCs
Imaging
The anterior abdomen and pelvis were
imaged under a camera (Toshiba GCA 602)
equipped with a low-energy all-purpose
collimator starting at 30 min following the
injection of 125-300 MBq99mTc-HMPAO
WBCs.
Imaging was repeated at 1, 2, and 4 h.
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Interpretation
Negative:
Absence of abnormal intra-abdominal
localization through 4 h of imaging.
Positive:
Focal accumulation of99mTc-HMPAO
WBCs in the right lower quadrant.
Decision on surgical intervention was made
on the basis of consensus between the twosurgeons.
Non-operated patients was followed
for a minimum of 1 month.
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Results
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Discussion
There were no false-positive or false-
negativeresults in this study.* We believe that as the number of the patients
studied increases, we may encounter false-
positive results due to other diseases whichcause right lower quadrant inflammation.
False-negative results can result when the
activity of the appendix superimposed with
the background, such as iliac vascular
activity. This can be prevented by an oblique
imaging technique.
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In our group of patients with presentationsequivocal for acute appendicitis, the
negative laparotomy rate was only 5.8%.
Fasting reduce the enterohepatic circulation
of the by-products of HMPAO metabolism
and that this increased the specificity of
the test.
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Conclusion
99mTc-HMPAO is a rapid and accurate
method for detecting acute appendicitis
in patients with an equivocal clinicalpresentation, which may reduce the
hospital stay and lower unnecessary
laparotomy rate.
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