急性闌尾炎 Acute appendicitis

PATHOPHYSIOLOGY Lumen obstruction Necrosis, Luminal pressure↑ Perforation Fecalith, lymphoid follicles Bacterial growth, Venous obstruction Arterial compromised

History Periumbilical or epigastric pain Right lower quadrant pain Lumen obstruction → Visceral pain Anorexia (90%), nausea & vomiting (70%), diarrhea (10%) Right lower quadrant pain Transmural inflammation → Parietal pain Peritoneal irritation, pain on movement, fever, tachycardia Diffused tenderness Ruptured appendicitis with peritonitis

Physical examination McBurney’s point tenderness Rovsing’s sign RLQ pain resulting from palpation in the left lower quadrant

Lab & Radiologic exam Lab Radiologic exam CBC U/A Electrolytes, BUN, creatinine Pregnancy test Radiologic exam X-ray: rarely helpful Ultrasound: operator dependent CT scan: most common, sensitivity 94%, specificity 95% MRI: for pregnant patient

Alvarado Score for Acute Appendicitis (MANTRELS) Abdominal pain that Migrates to the right iliac fossa (2pts) Anorexia (loss of appetite) or ketones in the urine Nausea or vomiting Tenderness in the right iliac fossa Rebound tenderness Fever of 37.3 °C or more (Elevated temperature) Leukocytosis, (>10000 WBC/mL) (2pts) Neutrophilia, or Shift of neutrophils to the left Total score <5 Unlikely 5 or 6 Possible 7 or 8 Likely 9 or 10 Highly likely

Treatment Antibiotics therapy Appendectomy Broad-spectrum gram-negative and anaerobic coverage Appendectomy Open appendectomy Conventional procedure Laparoscopic appendectomy Reduce pain, hospital stay Quicker return to work Lower risk of wound infection Benefit in obese and woman