1. Acute Appendicitis 郭威廷 Wei-Ting KUO, M.D. Lecturer of Surgery National Yang Ming University Chia Yi Christian Hospital

2. Patient, Lee CA, a 16 y/o male, Chart no.=1350310-1 C.C: RLQ pain for 1 day P.I.: Patient began to have epgastric vague pain 2 days ago. Then, the pain shifted to RLQ 1 day after the initial epigastric pain. The RLQ pain became sharp, more localized and exacerbated. He also had anorexia and nausea. P.E.: BT= 38.5 o C tenderness, muscle guarding and rebound pain over RLQ tenderness, muscle guarding and rebound pain over RLQ Hypoactive bowel sound Hypoactive bowel sound BR: WBC=20600, N/L=89/5 UR: not remarkable CXR and KUB: not remarkable

4. Relative normal KUB with local ileus

7. Dr. Sydney Burwell, Dean of Harvard Medical School Half of what you are taught as medical students will in ten years have been shown to be wrong. And the trouble is, none of your teachers known which half.

8. How do We Actually Practice EBM? Step1. Asking answerable question Step2. Finding the best evidence Step3. Appraising the evidence Step4. Making a decision Step5. Evaluating your performance

9. 以證據模式來教導臨床醫學 使用臨床證據於病患照顧上的學習模式。 使用臨床證據於病患照顧上的學習模式。 將實證醫學觀念與其他的臨床知識結合，用於 教學上。 將實證醫學觀念與其他的臨床知識結合，用於 教學上。 整合實證醫學與其他臨床醫學知識後用於病患 身上結果的評核。 整合實證醫學與其他臨床醫學知識後用於病患 身上結果的評核。 舉例： (1) 一位下腹疼痛的病患到急診就診後， 你的診斷懷疑是急性闌尾炎；問題：你知道這 樣的疾病常發生在年輕或老年人？比例為何？ 你知道有 Alvarado score 嗎？如何使用？可以 不開刀僅使用抗生素就可以？ 舉例： (1) 一位下腹疼痛的病患到急診就診後， 你的診斷懷疑是急性闌尾炎；問題：你知道這 樣的疾病常發生在年輕或老年人？比例為何？ 你知道有 Alvarado score 嗎？如何使用？可以 不開刀僅使用抗生素就可以？

10. Asking Questions Exercise: study designs Exercise: study designs What is the question (PICO) of the study? What is the question (PICO) of the study? What is the purpose of the study? What is the purpose of the study? Intervention Intervention Frequency (incidence or prevalence) Frequency (incidence or prevalence) Diagnostic accuracy Diagnostic accuracy Prognosis (or natural history) Prognosis (or natural history) Aetiology and risk factors Aetiology and risk factors Which study type would give the highest quality evidence to answer the question? (level of evidence) Which study type would give the highest quality evidence to answer the question? (level of evidence) Which is the best study type that is also feasible? Which is the best study type that is also feasible? What is the study type used? What is the study type used?

11. Question Patient or Population: __In patients diagnosed as acute appendicitis___ Patient or Population: __In patients diagnosed as acute appendicitis___ Intervention or Indicator: __do appendectomy ___ Intervention or Indicator: __do appendectomy ___ Comparator:__conservative treatment___ Comparator:__conservative treatment___ Outcome:__hospital stay/complication ___ Outcome:__hospital stay/complication ___ Question sentence: In patients diagnosed as acute appendicitis (P), do appendectomy (I) had shorter hospital stays and less complication (O)? Question sentence: In patients diagnosed as acute appendicitis (P), do appendectomy (I) had shorter hospital stays and less complication (O)?

12. Library Searching Session Using PubMed as an example: Using PubMed as an example: Go to www.pubmed.gov and select Clinical Queries Go to www.pubmed.gov and select Clinical Querieswww.pubmed.gov Select the appropriate Category (usually “ therapy ” which is the default) Select the appropriate Category (usually “ therapy ” which is the default) Type in the most crucial single element of your PICO search (usually the I or the P) Type in the most crucial single element of your PICO search (usually the I or the P) If your search returns no articles then click the “ Broad ” scope If your search returns no articles then click the “ Broad ” scope If your search returns more than 30 articles then try adding more PICO elements, e.g, if you used only the “ I ” now try searching the I and P If your search returns more than 30 articles then try adding more PICO elements, e.g, if you used only the “ I ” now try searching the I and P Select the best single article and record why you choose the article you did. Select the best single article and record why you choose the article you did.

13. World J Surg.World J Surg. 2010 Feb;34(2):199-209. Antibiotic therapy versus appendectomy for acute appendicitis: a meta-analysis. Varadhan KKVaradhan KK, Humes DJ, Neal KR, Lobo DN.Humes DJNeal KRLobo DN Source Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre NIHR Biomedical Research Unit, Nottingham University Hospitals, Queen's Medical Centre, Nottingham, NG7 2UH, United Kingdom. Abstract BACKGROUND: Antibiotic treatment has been shown to be effective in treating selected patients with acute appendicitis, and three randomized controlled trials (RCTs) have compared the efficacy of antibiotic therapy alone with that of surgery for acute appendicitis. The purpose of this meta-analysis of RCTs was to assess the outcomes with these two therapeutic modalities.

14. METHODS: All RCTs comparing antibiotic therapy alone with surgery in patients over 18 years of age with suspected acute appendicitis were included. Patients with suspected perforated appendix or peritonitis, and those with an allergy to antibiotics had been excluded in the RCTs. The outcome measures studied were complications, length of hospital stay, and readmissions. RESULTS: Meta-analysis of RCTs of antibiotic therapy versus surgery showed a trend toward a reduced risk of complications in the antibiotic-treated group [RR (95%CI): 0.43 (0.16, 1.18) p = 0.10], without prolonging the length of hospital stay [mean difference (inverse variance, random, 95% CI): 0.11 (-0.22, 0.43) p = 0.53]. Of the 350 patients randomized to the antibiotic group, 238 (68%) were treated successfully with antibiotics alone and 38 (15%) were readmitted. The remaining 112 (32%) patients randomized to antibiotic therapy crossed over to surgery for a variety of reasons. At 1 year, 200 patients in the antibiotic group remained asymptomatic. CONCLUSIONS: This meta-analysis suggests that although antibiotics may be used as primary treatment for selected patients with suspected uncomplicated appendicitis, this is unlikely to supersede appendectomy at present. Selection bias and crossover to surgery in the RCTs suggest that appendectomy is still the gold standard therapy for acute appendicitis.

17. Appendicolith

19. Ruptured appendicitis with abscess formation

20. Ruptured appendicitis with peritonitis

22. Mesenteric adenitis

23. Lymphadnopathy

24. Appendicolith

26. Appendicitis 1736 Claudius Amyand-1st appendectomy 1736 Claudius Amyand-1st appendectomy (from hernia sac) (from hernia sac) 1824 Louer-Villermay report appendicitis by 1824 Louer-Villermay report appendicitis by autopsy report autopsy report 1889 Charles McBurney – early laparotomy for appendicitis treatment 1889 Charles McBurney – early laparotomy for appendicitis treatment

27. Appendicitis 1886 Fitz -Appendicitis associated mortality 67% without surgical therapy. 1886 Fitz -Appendicitis associated mortality 67% without surgical therapy.

28. Appendicitis The lifetime rate of appendectomy is 12% for men and 25% of female. The lifetime rate of appendectomy is 12% for men and 25% of female. Approximately 7% of all people undergoing appendectomy for Acute appendicitis. Approximately 7% of all people undergoing appendectomy for Acute appendicitis. Textbook of Schwartz ’ s surgery, 8th ed. p1120

29. Appendicitis It is generally agreed that 10% - 15% false positive rate in the diagnosis of acute appendicitis. It is generally agreed that 10% - 15% false positive rate in the diagnosis of acute appendicitis. Pathogenesis is obstruction of the appendiceal lumen — 60% by marked hyperplasia of the lymphoid follicles; 35% by a appendicolith, and neoplasms, parasites and foreign bodies- 5% -6 %. Pathogenesis is obstruction of the appendiceal lumen — 60% by marked hyperplasia of the lymphoid follicles; 35% by a appendicolith, and neoplasms, parasites and foreign bodies- 5% -6 %. Textbook of Surgery, 15 th ed. pp964-970

30. Clinical diagnosis of acute appendicitis History: epigastric/periumbilical vague pain  anorexia and nausea/vomiting. Then, the pain finally moves toward and becomes localized to RLQ (McBurney ’ s point). The BT is usually mildly elevated ( around 38 o C). History: epigastric/periumbilical vague pain  anorexia and nausea/vomiting. Then, the pain finally moves toward and becomes localized to RLQ (McBurney ’ s point). The BT is usually mildly elevated ( around 38 o C). High fever, toxic or generalized peritonitis always mean ruptured appendicitis. High fever, toxic or generalized peritonitis always mean ruptured appendicitis. Textbook of Surgery, 15 th ed. pp964-970

31. Physical Examinations & Lab. Data for Acute Appendicitis “ Hand Scan ” is the most rapid and important dignostic tool!!! Inspection: not remarkable Palpation: Local peritoneal signs over RLQ Rovsing ’ s sign Rovsing ’ s sign Psoas sign Psoas sign Obturator sign Obturator sign Rectodigital exam.: tenderness, right Rectodigital exam.: tenderness, right Ausculataion: Hypoactive BS Percussion: not remarkable BR: Leukocytosis (10000 – 20000) or a shift to the left in the DC. Ultrasound, CT scan and laparoscopy are usually unnecessary and should not be overemphasized. Textbook of Surgery, 15 th ed. pp964-970

32. Differential Diagnosis of Acute Appendicitis 1. AGE 2. URI with mesenteric adenitis 3. Gyn. Conditions: Rupture ovarian cyst, Ovarian torsion Mittelschmerz syndrome, Endometrisos Mittelschmerz syndrome, Endometrisos Ectopic/normal pregnancy, PID Ectopic/normal pregnancy, PID 4. GU conditions: Right renal/ureteral stone, APN, Cystitis Testicular torsion, Epididymitis Testicular torsion, Epididymitis 5. PPU 6. Cholecystitis 7. Intussusception 8. Meckel ’ s diverticulitis 9. Right side colon cancer 10. Others … Textbook of Surgery, 15 th ed. pp964-970

33. Clinical Presentation Order of Acute Appendicitis 1. Pain, usually epigastric or umbilical 2. Anorexia, nausea, or vomiting 3. Tenderness — somewhere in the abdomen or pelvis 4. Fever 5. Leukocytosis

34. Textbook of Surgery, 15 th ed. pp964-970 Location of appendix: Retrocecal-65.28% Pelvic-31.01% Subcecal-2.26% Preileal-1% Right paracolic and postileal-0.4% --Maingot’s Abdominal opertions.10 th ed. MaBurney incision Appendectomy

35. Laparoscopic Appendectomy All patients are begun on antibiotics preoperatively and maintained postoperatively as needed. If the appendix is unruptured and not gangreneous,antibiotics can be discontinued after 24 hours. Localized ruptured appendicitis or appendiceal abscess without diffuse peritonitis or toxic signs can be treated with antibiotics+/- drainage, followed by interval appendectomy in 6 weeks to 3 months. Textbook of Surgery, 15 th ed. pp964-970

36. Delayed Diagnosis of Acute Appendicitis Reasons why patients come to attention late: 1.The patient may think that the symptoms are not serious enough to need medical advice. 2.The medical adviser may think that the syptoms are not typical of appendicitis or not serious enough to demand operation. 3.There is over-reliance on blood tests or misleading radiological evaluations. Cope’s Early Diagnosis of the Acute Abdomen. 21 th ed. Revised by Silen W. 2005

37. Conclusion-1 Appendectomy remains the standard treatment for acute appendicitis.Antibiotic treatment might be used as an alternative treatment in a good quality RCT or in specific patients or conditions were surgery is contraindicated. Appendectomy versus antibiotic treatment for acute appendicitis. Wilms IM, de Hoog DE, de Visser DC, Janzing HM. Cochrane Database Syst Rev. 2011 Nov 9;11

39. Conclusion-2 Localized ruptured appendicitis or appendiceal abscess without diffuse peritonitis or toxic signs can be treated with antibiotics+/- drainage, followed by interval appendectomy in 6 weeks to 3 months. Textbook of Surgery, 15 th ed. pp964-970