DR.İSMET PARLAKİZMİR.BOZYAKA.EĞİTİM VE ARAŞTIRMA HASTANESİ

ACİL TIP KLİNİĞİ ÖĞRETİM GÖREVLİSİ (ESKİ ACİLTIP KLİNİK ŞEFİ)

ACİL SERVİS’E BİR YIL İÇİNDE BAŞVURAN TOPLAM HASTA SAYISI: 210.221

ACİL SERVİSTEN GENEL CERRAHİYE KONSÜLTE EDİLEN TOPLAM HASTA SAYISI: 4408

KONSÜLTE EDİLEN BU HASTALARDAN GENEL CERRAHİYE YATAN HASTA SAYISI: 1798

A.APANDİSİT:484

A.KOLESİSTİT:345

İLEUS,SUBİLEUS:147

TAKİP AMAÇLI:131

A.PANKREATİT:125 HERNİLER:106 MALİGNİTE:85 KDAY:64 YANIK:58 GİS PERF.:50 ABSELER:41 AKUT BATIN:34

YÜKSEKTEN DÜŞME:29 TRAFİK KAZALARI:28 GİS KANAMALARI:16 ASY:13 HEMOROİD:11 DİVERTİKÜLİT:10 GİS FİSTÜLLERİ:8 MEZENTER İSKEMİ:5 TİROİD PAT.:4 VOLVULUS:2 NEKROTİZAN FASİİT:2

1)A.APANDİSİT2)SK ACİLLERİ3)İLEUS,SUBİLEUS4)MULTİTRAVMA5)TAKİP AMAÇLI6)A.PANKREATİT7)HERNİLER8)MALİGNİTELER9)YANIK10)GİS PERF.11)ABSELER12)AKUT BATIN13)DİĞERLERİ

RadiculitisSpinal cord or peripheral nerve tumors, Degenerative arthritis of spine Abdominal epilepsy Tabes dorsalis

Muscular contuzyon, hematoma, or tumor Narkotik çekilme sendromuAilevi akdeniz ateşiPsikiyatrik problemlerSıcak çarpması

Reproduced with permission from: Glasgow RE, Mulvihill SJ. Abdominal pain, including the acute abdomen. In: Gastrointestinal and Liver Disease, Feldman M, Scharschmidt BF, Sleisenger MH (Eds). WB Saunders, Philadelphia 1998, p.80. Copyright © 1998 W.B. Saunders.

Myocardial ischemia and infarction Myocarditis Endocarditis Heart failure Pneumonitis Pleurodynia, Bornholm's disease Pulmonary embolism and infarction Pneumothorax Empyema Esophagitis Esophageal spasm Esophageal rupture, Boerhaave's syndrom

Sickle cell anemia Hemolytic anemia Henoch-Schönlein purpura Acute leukemia

Herpes zoster Osteomyelitis Typhoid fever Miscellaneous

Uremia Diabetes mellitus Porphyria Acute adrenal insufficiency Hyperlipidemia Hyperparathyroidism Toxins Hypersensitivity reactions: insect bites, reptile venoms Lead poisoning

Parietal agrı stimulusları ağrının orgininde aynıdermatomal seviyede ve aynı taraf spesifik dorsal yol ganglionuna taşınır

Bundan dolayı ağrı çok daha belirgindir çok iyi lokalize edilir

İskemi, inflamasyon veya gerginlik parietal plevrada gerginlik oluşturur

Yansıyan ağrı ise patolojinin olduğu yerdışında ağrının hissedilmesidir (safra kesesi patolojilerinde ağtı sağ subskapular bölgede yada pertik ülser perforasyonunda ağrı periton irritasyona bağlıomuzda hissedilir)

Bunun nedeni farklı lokalizasyonlardan afferent nöronlar için ortak santral yollar bu fenomene neden olur

Abdominal visseral kaynaklı ağrılar sıklıkla embriyolojik gelişim orijine uyar

Foregut dan kaynaklananlar (proksimal deudenumdan ağıza kadar). Bu bölgeden kaynaklanan ağrılar üst abdominal bölgede hissedilir

Midgut yapılardan kaynaklanan ağrı (deudenumun distal yarısında transfer kolonun ortasına kadar olan bölge)Bu bölgeden kaynaklanan ağrılar periumblikal alanda hissedilir

Hind gut yapılar(kolonun gerikalan kısmı ve rektum) Bu bölgelerden kaynaklanan ağrılar ise alt abdomende

hissedilir

Clinicians should not base the differential diagnosis solely on the pain's location; diagnosis and pain location often do not correspond [24].

One study looking at patterns of abdominal pain found that only 60 to 70 percent of patients would be correctly diagnosed based on "typical" exam findings alone, yielding a misdiagnosis rate of 30 to 40 percent

• Başlangıcı (aniden yada tedricen)

• Arttıran veya azaltan nedenler (yemekten sonra artıyormu)

• Ağrının özelliği (küntmü, keskin batıcı, kolik veya artıp azalan şekildemi)

• Ağrının yayılımı (omuza, sırta, böğüre)

• Ağrının lokalizasyonu yeri (yaygın/diffuse veya belli bir lokalizasyon veriyormu)

• Ağrısına eşlik eden semptom varmı (ateş, kusma, ishal, kanlı dışkı, vajinal akıntı, ağrılı idrar veya nefes darlığı

• Süresi saatlerdirmi haftalardırmı ve aralıklımı veya süreklimi oluyor

Yaşlı hastalar

İmmun kompremize hastalar (HIV, chronic glucocorticoid treatment)

Alcoholism (risk of hepatitis, cirrhosis, pancreatitis)

Kardiovascular hastalık

Hipertansif hastalar

Atrial fibrillation (eg, cancer, diverticulosis, gallstones, IBD, pancreatitis, renal failure)

Önceki cerrahi veya yeni Gastrointestinal instrumentasyon

Erken yaş gebelik (risk of ectopic pregnancy)

Epigastrik Karın agrısıyla acile başvuran 31 yaş erkek hasta

Bilinen alkolizm hikayesi mevcut

Hasta akut pankreatit tanısı alıp destek tedavi sonucu alkol almaması önerileriyle birkaç gün içinde taburcu ediliyor

Hasta 10 gün sonra acile tekrar multıbl abrazyonlar ve ekimozlarla başvuruyor

Bu defa şiddetli abdominal agrısı mevcut

Hipotansiyon ve bilinç kaybı gelişiyor

Acil entübasyon resüstatif girişim yapılıyor

Yerinde akciger grf çekiliyor

Bilinç değişikliği ve genel durum bozukluğu ile acile başvuran 78 yaş bayan hasta

Vital fonksiyonlarının hepsi sınırda patolojik dikkat çeker önemli bir bulgu yok

Hastanın istenen laboratuar değerlerinin hepsi sınırın hafif üzerinde yada altında patolojik

Hastaya Beyin BT, MR ve LP yapılıyor normal Hastanın kontrol muayenesinde abdominal

yaygın hassasiyet + 37.8 ateş

Akut mezenter iskemi akut abdomenin nadir nedenidirAncak ileri yaşta görülmesi, nonspesifik klinikle başvurmaları ve bu yaş grubunun komorbit hastalıklarının olması bu hastalıgın dogası geregidir

Mezenter iskemi şu başlıklar altında değerlendirilir 1-Akut Mezenter arter embolisi 2-Akut Mezenter arter trombozu 3-Nonokluziv mezenter iskemisi 4-Mezenterik ven trombozu 5-Kolonik iskemi

Mortalitesi %60-85 Erken cerrahi iskemik barsak ansının rezeksiyonu ve embolektomi mortalitenin en önemli belirleyicisidirOnedenle mümkün olduğunca erken anjiografi veya laboratomi yapılmalıdırTanıda ilk olarak BT anjio düşünülmelidir ve yaşlı ve karın ağrısı olan bir hastada ilk olarak bu tanı ekarte edilmelidir

Korean J Gastroenterol. 2011 Apr;57(4):243-8. Chirurg. 2011 Oct;82(10):863-70)

Barsaklar bütün seviyelerde çok iyi kollateral beslenmeye sahiptir

Mezenter kan akımının %75 azaldığı durumda bile 12 saate kadar ciddi iskemi oluşmaz

Eur J Radiol. 2011 Dec;80(3):e582-7. Epub 2011 Oct 10. Role of multidetector CT angiography in the evaluation of suspected mesenteric ischemia. Barmase M, Kang M, Wig J, Kochhar R, Gupta R, Khandelwal N. Source Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and

Research, Chandigarh 160012, India. Abstract OBJECTIVE: To assess the role of multidetector CT angiography (MDCTA) in the diagnosis of acute mesenteric

ischemia (AMI) and to compare the diagnostic utility of axial images with reconstructed images. MATERIALS AND METHODS: In this Institute Review Board approved prospective study, MDCTA was performed on 31 patients

who presented with the clinical suspicion of AMI (25M; 6F, age range: 16-73 years). Axial and reconstructed images of each patient were evaluated independently by two radiologists for evidence of bowel wall thickening, abnormal mucosal enhancement, bowel dilatation or obstruction, mesenteric stranding, ascites, solid organ infarcts, pneumatosis intestinalis or porto-mesenteric gas, and mesenteric arterial or venous occlusion. MDCT findings were correlated with the surgical findings and clinical outcome. Patients were later divided into two groups: a study group of patients with proven AMI and a control group of patients with an alternate diagnosis, for the purpose of statistical analysis.

RESULTS: AMI was correctly diagnosed in all 16 patients on MDCTA (100% sensitivity and specificity) of

whom nine patients underwent surgical exploration. Three patients expired before surgery and the remaining 5 patients were proven based on positive clinical and laboratory findings. Mesenteric arterial occlusion was seen in 7 patients while 5 patients had portomesenteric venous thrombosis. Reconstructed images using minimum intensity projection, volume rendering and multiplanar volume reconstruction were found to perform better for the detection of vascular abnormalities and improved the diagnostic confidence of both radiologists in the evaluation of bowel and mesenteric abnormalities.

CONCLUSION: MDCTA is an effective non-invasive modality for the diagnosis of mesenteric ischemia.

Role of multidetector CT angiography in the evaluation of suspected mesenteric ischemia

Eur J Radiol. 2011 Dec;80(3):e582-7. Epub 2011 Oct 10.

Mezenter iskeminin hepsinin ortalama mortalite oranı %71 (59-93%)

Cerrahiye alınma ve tanısı uzadıkça mortalite %90-%100 kadar çıkar

• İleri yaş

• Aterosikleroz

• Kalp yetmezliği

• Atrial fibrilasyon gibi kardiak aritmiler

• Şiddetli kapak hastalığı olanlar

• Yeni myokardial enfarktüs geçirme

• İntraabdominal malignansiler

Figure 1. Skipping areas of intestinal ischemia of the distendedloops of the involved jejunum.

Fig. 10Fig. 10——Sagittal reformatted 64Sagittal reformatted 64--MDCTMDCTimage obtained in arterial phase inimage obtained in arterial phase in8484--yearyear--old woman with chronic atrialold woman with chronic atrialfibrillation. Patient was receivingfibrillation. Patient was receivingcoumadin and had subtherapeuticcoumadin and had subtherapeuticinternational normalized ratio of 1.2 andinternational normalized ratio of 1.2 andacute abdominal pain. Filling defectacute abdominal pain. Filling defect((arrowarrow) is visible in superior mesenteric) is visible in superior mesentericartery and is well depicted on thisartery and is well depicted on thispostprocessed image.postprocessed image.

Çok geniş etyolojik ve geniş bir ayırıcı tanı profiline sahiptir

Sorun bir çok intraabdominal ve extraabdominal hastalıklardan kaynaklanabilir

Bening bir etyolojik faktörden yada hayati tehdit eden bir nedendende kaynaklanabilir

Spesifik semptom ve bulgu eksikliği

Atipik prezentasyon ve geç başvuru

Yaşlı, immunkompremize, doğurganlık çağındaki kadınlar

Ensık neden bilier hastalıklar (26%)

Acute appendicitis (18%)

Gastrointestinal cancer (11%)

Incarcerated hernia (10%)

Bu hastaların 29’u (13%) postoperatif birinci ayda ex

Ölümün ensık nedeni GİS kanaması idi (24%) ve iskemik kalb hastalığı (14%) idi

Ann Chir Gynaecol. 1996;85(1):11-5.

Yaşlı hastalarda önemli ayırıcı tanılardan birininde akut batın bulguları ile başvuran Rektus Sheat hematom olabilicegini unutma

Akut karın bulguları ile başvuran pulmoner embolisi olan çocuk ve genç bir hasta olabileceğini

Cerrahi batın gibi acile başvuran dalak enfarktı yada renal enfark

Akut batın gibi prezente olan sezaryan skar endometriozis

Geriatr Gerontol Int. 2009 Jun;9(2):200-2. Am J Emerg Med. 2009 May;27(4):514.e1-5. Ann Ital Chir. 2007 Nov-Dec;78(6):529-32 Arch Gynecol Obstet. 2008 Feb;277(2):167-9

Akut apandisit

Mezenter iskemi

Abdominal aort rüptürü yada diseksiyonu

Dış gebelik rüptürü ve over torsiyonu

Testis torsiyonu

Strangüle herniler

Abstract Background Intestinal fatty acid-binding protein (I-FABP) is a low-molecular-mass (15 kDa) cytosolic

protein found exclusively in the epithelial cells of the small bowel mucosa. We aimed to evaluate the clinical usefulness of serum I-FABP measurement for the diagnosis of ischemic small bowel disease.

Methods Patients with a clinical diagnosis of acute abdomen were recruited for this multicenter trial at

one university hospital and nine city hospitals over a 13-month period. Serum I-FABP levels were measured in 361 eligible patients by an enzyme-linked immunosorbent assay using a specific monoclonal antibody.

Results Of the 361 patients, 242 underwent surgery, and small bowel ischemia was diagnosed in 52

patients. The mean serum I-FABP level in the patients with small bowel ischemia was 40.7 ± 117.9 ng/ml, which was significantly higher than that in patients with non-ischemic small bowel disease (5.8 ± 15.6 ng/ml) and those with non-small bowel disease (1.8 ± 1.7 ng/ml). The serum I-FABP cutoff level for the diagnosis of small bowel ischemia was 3.1 ng/ml. Serum I-FABP was more efficient than conventional biochemical markers, in terms of sensitivity and positive and negative predictive values, in the diagnosis of small bowel ischemia. However, its specificity was slightly lower than that of creatinine phosphokinase or lactate dehydrogenase. The positive and negative likelihood ratios of serum I-FABP were 3.01 and 0.29, respectively.

Journal of Gastroenterology Volume 46, Number 4, 492-500, DOI: 10.1007/s00535-011-0373-2

Serum I-FABP konvansiyonal biomarkırlardan daha sensitif, pozitif ve negatif prediktif değeri daha yüksektir

Ancak spesifitesi kreatinin kinaz ve laktat dehidrogenezdan daha düşüktür

Can J Surg, Vol. 54, No. 1, February 2011

70 yaş erkek hasta Hikaye; Hipertansiyon ve ürolotiazis Geliş şikayeti; karın agrısı, fenalaşma, aynı

şikayetle 6 saat öncede acile başvurmuş

Vital fonsiyonları: TA:180/100 mmHg, Nb:120/dk, SS:20, SpO2: %95, Ateş:37 C

Genel Durum: Bilinç açık, oryante koopere, huzursuz ve terli görülüyor

Fizik muayenede batında yaygın hassasiyet dışında pozitif bir bulgu yok

Yanlış tanı alan hastaların başlangıç fizik muayene bulguları; %70 abdominal ağrı, %57 şok ve %50 sinde sırt ağrısı mevcuttur

AAA olan hastaların %72 sinde batında pulsatil kitle doğru tanıya götürürken %26 pulsatil kitle tanısal değilmiş

Abdominal aort rüptüre olan ve olmayanın mortaliteleri birbirine yakın (%44-%58)

Doğru tanı alan hastaların mortalitesi %58 iken yanlış tanı alanların %44 dür (p:0.34)

HT

Sigara

Vasküler hastalık

İleri yaş ( özellikle 65 yaş üstü)

Erkek cinsiyet

Aile hikayesi

KOAH

J Emerg Med. 2007 Feb;32(2):191-6. Epub 2007 Jan 22. The diagnosis of aortic dissection by emergency medicine

ultrasound. Fojtik JP, Costantino TG, Dean AJ. SourceDepartment of Emergency Medicine, Drexel University

College of Medicine, Philadelphia, Pennsylvania 19140, USA.

Abstract A series of five cases of aortic dissection are presented that were

diagnosed by emergency physicians using ultrasound to search the abdominal and thoracic aorta for pathology. Aortic dissection is a vascular emergency with a high morbidity and mortality, yetits presentation can be varied and subtle. This article reports the use of Emergency ultrasound in a series of five aortic dissections discovered with a limited, yet timely viewing of the aorta and heart by emergency physicians

Acil de ultrason ve eko kullanmanın önemi vurgulanıyor

Özellikle aort diseksiyonun erken teşhisinde hastalarının mortalitesinin azaltılabileceği vurgulanıyor

J Emerg Med. 2010 May;38(4):490-3. Epub 2008 Nov 26. Ultrasound diagnosis of type a aortic dissection. Perkins AM, Liteplo A, Noble VE. SourceDepartment of Emergency Medicine, Massachusetts General Hospital, Boston,

Massachusetts 02114, USA.

Abstract BACKGROUND: An aortic dissection is a life-threatening process that must be diagnosed

and treated expeditiously. Imaging modalities used for diagnosis in the emergency department include computed tomography, magnetic resonance imaging, and trans-esophageal echocardiography. There are significant limitations to these studies, including patient contraindications (intravenous contrast dye allergies, renal insufficiency, metal-containing implants, hemodynamic instability) and the length of time required for study completion and interpretation by a radiologist or cardiologist.

OBJECTIVES: A case is presented that demonstrates how emergency physicians can use trans-thoracic and abdominal bedside ultrasound to diagnose a type A aortic dissection.

CASE REPORT: A 72-year-old woman presented with chest pain radiating to her neck and back that was concerning for aortic dissection. This was subsequently confirmed and further classified as a type A dissection by bedside emergency physician-performed ultrasound. The images showed a clear intimal flap in the abdominal aorta, a dilatated aortic root, and extension of the intimal flap into the left common carotid artery. With prompt diagnosis, the patient was able to have emergent surgical consultation, confirmatory imaging, and intervention before further complication occurred.

CONCLUSION: This case provides an example of how emergency trans-thoracic and abdominal ultrasound can be used to promptly diagnose a type A aortic dissection and expedite further consultation and prompt management.

Copyright (c) 2010 Elsevier Inc. All rights reserved.

Bu abstrak ise acil hekiminin transtorasik ve transabdominal aort diseksiyonunun erken teşhisinin önemi anlatılmaktadır

Types DeBakey Type I Involves entire aorta DeBakey Type II Least common Ascending aorta only DeBakey Type III Most common Descending aorta only

Stanford Type A Ascending aorta involved Over half develop aortic regurgitation Stanford Type B Ascending aorta NOT involved

DeBakey Classification

Stanford Classification

Portion of Aorta Involved Common causes RX

DeBakey Type I Stanford Type A(ascending aorta

involved)

Involves entire aorta

HypertensionAtherosclerosis Usually surgically*

DeBakey Type II(least common)

Stanford Type A(ascending aorta

involved)

Ascending aorta only

Cystic medial necrosis

e.g.Marfan’s Ehlers-Danlos

Usually surgically*

DeBakey Type III(most common) Stanford Type B Descending aorta

onlyHypertension

Atherosclerosis

Usually medically*Goal is to prevent backward involvement of the aortic valve or rupture into pericardium

Aort diseksiyonlarının başlangıç değerlendirilmesinden sonra %38 i atlanmaktadır

Otopsilerde %28 e kadar rastlanmaktadır

Geleneksel olarak ağrısız aort diseksiyonu nadiren düşünülür

Artık son zamanlardaki yayınlarda vurgulanan bildiğimiz tipik semptomlarının sıklıkla olmadığı (Yırtılır tarzda sırta ve karnına vuran ağrı)

Hastaların %90 klasik ağrı semptomları ile başvurmaktadır

Hastaların %10 u atipik semptomlarla acile başvurmaktadır

senkop, serebro vasküler atak, dispne, hipovolemik şok, myokart enfarktüsü, fasial şişlik (vena kava sendromunu taklit

eden) parapleji, akut periferal iskemi ve hemipleji

28 yaş erkek Epigastrik ağrı Bulantı Hikayede bir özellik yok Vitalleri stabil Muayenede epigastrik hassasiyet dışında bir

problem yok

Tabiki peptik ulkus ve hemen ilahi üçlü tedavisi yapılıyor !!!

Ama hasta maalesef rahatlamıyor

Ne yapalım Neler isteyelim

ABD de her yıl 300 000, Avrupa ülkelerinde ise 700 000 insan appendektomi olmaktadır

Hayatları boyunca akut appendisit olma olasılığıkadınlarda %25 erkeklerde %12

1> üzerindeki çocuklarda enyaygın nontravmatik karın ağrısı etyolojisini oluşturur

Hamilelerde ensık nonobstetrik cerrahi acil durumdur

Hem akut appendisitin atlanması hemde negatif laparotomi oranı bunca ilerlemelere rağmen az değildir

Am J Emerg Med. 2010 Sep;28(7):766-70. Epub 2010 Mar 25. The accuracy of emergency medicine and surgical residents in the diagnosis of acute appendicitis. Jo YH, Kim K, Rhee JE, Kim TY, Lee JH, Kang SB, Kim DW, Kim YH, Lee KH, Kim SY, Lee CC, Singer AJ. Source Department of Emergency Medicine, Seoul National University Bundang Hospital, Gyeonggi-do 463-707, Korea. Abstract OBJECTIVE: This study was conducted to compare the diagnostic accuracy for acute appendicitis between emergency

medicine residents (EMRs) and surgical residents (SRs). METHODS: We conducted a prospective cohort study of adult patients with right lower quadrant pain. Each patient was

evaluated by an EMR and an SR, and physicians predicted the probability of appendicitis into 4 groups from highest (group 1) to lowest (group 4). The diagnostic accuracies of EMR and SR for the diagnosis of appendicitis were compared by constructing receiver operating characteristics curves. In each case, an Alvarado score was calculated and a computed tomography (CT) scan of the abdomen and pelvis was performed, and their diagnostic accuracies were also compared with the predicted probabilities.

RESULTS: Of a total 191 patients, 120 underwent surgery, and the negative appendectomy rate was 6.8%. There was a

significant correlation between the predicted probabilities of EMR and SR. The areas under the curve for EMR and SR were 0.698 and 0.657, which were not statistically different. The areas under the curve of the Alvarado score and the CT were 0.735 and 0.978, respectively. The diagnostic accuracy of the CT scan was significantly higher than those of the Alvarado score and the resident-predicted probabilities.

CONCLUSION: In patients with right lower quadrant abdominal pain who have already been evaluated by EMR, consultation

evaluation by SR does not appear to improve clinical diagnostic accuracy, and routine performance of CT before surgical consultation should be considered for these patients.

Copyright © 2010 Elsevier Inc. All rights reserved.

Çalışmanın özeti Düşünüyorsan vakitli BT iste çünkü zaman kaybı ve

hastanın mortalitesini azaltabileceği vurgulanıyor

Am J Emerg Med. 2010 Sep;28(7):766-70. Epub 2010 Mar 25.

Am J Emerg Med. 2009 Mar;27(3):320-7. Reappraisal of radiographic signs of pneumoperitoneum at emergency department. Chiu YH, Chen JD, Tiu CM, Chou YH, Yen DH, Huang CI, Chang CY. Source Department of Emergency Medicine, Taipei Veterans General Hospital, Taiwan, ROC. Abstract PURPOSE: This study aimed to evaluate the sensitivities of the reported free air signs on supine chest and

abdominal radiographs of hollow organ perforation. We also verified the value of supine radiographic images as compared with erect chest and decubitus abdominal radiographs in detection of pneumoperitoneum.

METHODS: Two hundred fifty cases with surgically proven hollow organ perforation were included. Five hundred

twenty-seven radiographs were retrospectively reviewed on the picture archiving and communication system. Medical charts were reviewed for operative findings of upper gastrointestinal tract, small bowel, or colon perforations. The variable free air signs on both supine abdominal radiographs (KUB) and supine chest radiographs (CXR) were evaluated and determined by consensus without knowledge of initial radiographic reports or final diagnosis. Erect CXR and left decubitus abdominal radiographs were evaluated for subphrenic free air or air over nondependent part of the right abdomen.

RESULT: Upper gastrointestinal tract perforation was proven in 91.2%; small bowel perforation, in 6.8%; and

colon perforation, in 2.0%. The positive rate of free air was 80.4% on supine KUB, 78.7% on supine CXR, 85.1% on erect CXR, and 98.0% on left decubitus abdominal radiograph. Anterior superior oval sign was the most common radiographic sign on supine KUB (44.0%) and supine CXR (34.0%). Other free air signs ranged from 0% to 30.4%.

CONCLUSIONS: Most free air signs on supine radiographs are located over the right upper abdomen. Familiarity with

free air signs on supine radiographs is very important to emergency physicians and radiologists for detection of hollow organ perforation.

Comment in• Am J Emerg Med. 2010 Jan;28(1):109-10.

Ensık neden bir fekalitin vermiform appendisitin bir fekalitle tıkanması olarak suçlanır

Lenfatik dokular tarafından oluşturulan obstrüksiyon

Gallstone/safra taşı Tümor Parazitler Devam eden sekresyon artışı sonrası lümen

içi obstrüksiyon daha artar ve dolaşım dahada bozulur ve bakterlerin artışı olur

Hastalığın erken döneminde oluşan visseral ağrıya baglı sessiz gizli ve iyi lokalize edilemeyen ağrıgenellikle periumblikal ve santral yerleşimlidir

Bu durum genellikle hastalığın erken döneminde olur

Daha sonra enflamasyonun ilerlemesiyle somatik ağrıoluşmaya başlar çünkü artık parietal periton enflame olmuştur

Böylece ağrı sağ alt kadrana lokalize olur ve McBurney hassasiyeti belirir

Anteriyor süperiyor iliac spinden umblikusa uzanan mesafenin 1/3 lük bölümün üst kısmına lokalize olur yani

52 hastanın 34’ü (%65,4) AA olarak değerlendirilirken 18’inde (%34) AA yönünden patoloji bulunmadı

AA olarak değerlendirilen 34 hastanın 31’inde (%91,2) ameliyat ve patoloji bulgularına göre AA saptandı,3 olguda ise (%8,2) saptanmadı

BT’de AA olarak değerlendirilmeyen18 olgunun 15’inde (%83,3) ameliyat ve patoloji bulgularında AA saptanmazken, 3 olguda ise saptandı

Bu çalışmada AA tanısında BT’nin duyarlılığı %91,2

Özgüllüğü %83,3 olarak bulundu.Ulus Travma Acil Cerrahi Derg 2010;16 (5):445-448

Acil laparotomi gereken hastalarda bu testin duyarlığı %95,7 iken lökosit sayısınınki ise %74,8 olarak saptandı.

Ulus Travma Acil Cerrahi Derg 2010;16 (1):22Ulus Travma Acil Cerrahi Derg 2010;16 (1):22--2626

Hala bir çok klinisyen muayene bulgularının daha önemli olduğunu söylesede bu metaanalizde negatif laparatomi oranının azaltıldığı vurgulanmaktadır (%8.7- %16.7)

Perforasyon oranlarında bir fark yok

Erken cerrahiye girişim oranı 5 çalışmada belirtilmiş

Sonuç olarak vurgulanan tüm hastalara tomografi çektirmenin morbititeyi azaltacağı ve negatif laparatomi oranını azaltacağıbelirtiliyor

Ancak BT çekimi sırasında zaman kaybına dikkat çekiliyor

Doğurganlık çağındaki kadınlardaki negatif laboratomi oranı % 40 bulmaktadır

Genelde bu oran %10-20 olarak bildirilmektedir

A recent systematic review showed that CT is a very accurate diagnostic tool in appendicitis,with an overall sensitivity and specificity of 94% and 95%, respectively.6

Önce halsizlik iştahsızlık sonra sindrim bozuklukları ve barsak düzensizlikleri olur

Daha sonra ishal konstipasyon hatta ileus bile gelişebilir

Kusmalı yada kusmasız bulantı olur ancak bu herzaman agrıyla eşzamanlıdır

Hastanın agrısının aniden kesilmesi yada hafiflemesi perforasyon oldugunu düşündürür

Rovsing sign inen kolonun palpasyonu ile sağ alt kadranda ağrının provake olması demektir

Psoas sign hastanın sol tarafına yatırılarak sag bacağıextensiyona getirilmesi sonucu agrı oluşması

Obturator sign ise sağ femurun internal ve external rotasyon sonucu ağrı oluşması

Patients with acute cholecystitis typically complain of abdominal pain, most commonly in the right upper quadrant or epigastrium.

The pain may radiate to the right shoulder or back. Pain is often steady and severe. Associated complaints may include nausea,

vomiting, and anorexia. There is often a history of fatty food ingestion about

one hour or more before the onset of pain. Patients are usually ill appearing, febrile, and tachycardic, with tenderness in the right upper abdomen.

Murphy's sign may be present, although the test's sensitivity can be diminished in the elderly

Acute pancreatitis almost always presents with acute upper abdominal pain.

The pain is steady and may be in the midepigastrium, right upper quadrant, diffuse, or, infrequently, confined to the left side. Band-like radiation to the back is common.

Pain often reaches maximum intensity within 10 to 20 minutes of onset, but can persist for days. Nausea and vomiting is common.

In severe cases, patients can present in shock or coma. Physical findings vary with severity. In mild disease, the epigastrium may be minimally tender; in severe episodes, upper abdominal distention, tenderness, and guarding are common.

• alcoholism,• biliary tract disease, • trauma, penetrating ulcer, • infection,• hypertriglyceridemia,• drug reactions (eg, NSAIDS, furosemide,

thiazides, sulfonamides, tetracycline, erythromycin, acetaminophen, corticosteroids, estrogens),

• hypercalcemia,• carbon monoxide exposure, and • hypothermia.

The presentation of diverticulitis depends upon the severity of inflammation and the presence of complications.

Left lower quadrant pain is the most common complaint. Pain is often present for several days prior to

presentation. Many patients have had one or more similar past episodes. Nausea and vomiting or a change in bowel habits occurs

often. Examination usually reveals abdominal tenderness in the

left lower quadrant. Elderly patients are at increased risk for developing

diverticula and their complications, which can include diverticulitis, perforation, obstruction, and hemorrhage

Approximately 10 percent of patients with PID go on to develop perihepatitis (Fitz-Hugh Curtis Syndrome).

Since these patients present with right upper quadrant pain and tenderness, the syndrome can mimic cholecystitis, pneumonia, or pulmonary embolus

• Testicular torsion usually presents with the sudden onset of severe pain following vigorous activity or testicular trauma

• Examination often reveals an asymmetrically high-riding, transversely oriented testis on the affected side and loss of the cremasteric reflex.

• Testicular salvage rates are over 80 percent if treatment is initiated within six hours of symptoms, but fall significantly thereafter

The administration of IV contrast material is critical for CT assessment of end-organ perfusion and vascular patency. The simultaneous use of positive IV and positive oral contrast materials has limited usefulness

because the high-density enteric contents prevent any meaningful assessment of mural enhancement and often obscure distinctions between the bowel wall and lumen. Neutraldensity contrast agents, such as water, sorbitol, and polyethylene glycol solutions, are useful alternatives

Radiology 2006; 238:87–95

However, the endogenous bowel content is often sufficient for depiction of the bowel lumen, and an urgent study should not be delayed purely for administration of oral contrast media.

This approach also reflects the increasingly widespread view that IV contrast material alone issufficient for CT evaluation of the acute abdomen

Radiological Society of North America scientific assembly and annual meeting program. Oak Ridge, IL: RSNA, 2007:396–397

Focal small-bowel dilatation in acute mesenteric ischemia results from interruption of normal peristaltic activity

The most frequent CT finding in mesenteric ischemia is bowel wall thickening greater than 3 mm

However, in most reports, no distinction is made between smalland large-bowel ischemia

The highest incidence of bowel wall thickening is observed in cases of colonic ischemia or venous occlusion,

Whereas pronounced luminal dilation without wall thickening is often seen in fullblown small-bowel transmural infarction

Pneumatosis is seen in up to 30% of patients who have acute mesenteric ischemiam

The simultaneous presence of portomesenteric venous gas is more likely to indicate transmural infarction

Patients with acute nontraumatic abdominal pain in the setting of atrial fibrillation should be evaluated for underlying intraabdominal thromboembolic or hemorrhagic complications

When CT is the imaging technique, scans should ideally be obtained with positive IV and neutral oral contrast material

Melena or hematochezia occurs in 15% of cases, and occult blood is detected in approximately 50% of patients.

Nonocclusive ischemia

The causes of nonocclusive mesenteric ischemia include all of the causes of splanchnic vasoconstriction including hypovolemia, cardiac shock, sepsis, alpha-agonism, ergots, cocaine, and digitalis.

Acta Chir Belg. 2011 Jul-Aug;111(4):219-22. Is C-reactive protein helpful for early diagnosis of acute appendicitis? Jangjoo A, Varasteh AR, Bahar MM, Meibodi NT, Aliakbarian M, Hoseininejad M, Esmaili H, Amouzeshi A. SourceSurgical Oncology Research Center, Imam Reza Hospital, Faculty of Medicine, Mashhad University of

Medical Sciences, Mashhad, Iran.

Abstract PURPOSE: Appendectomy is one of the most common surgical procedures all over the world. Although various

laboratory tests and imaging studies are available to improve the accuracy of diagnosis, the rate of negative appendectomy is still about 15-30%. This study was designed to assess the diagnostic value of quantitative C-reactive protein (CRP) in patients suspected to acute appendicitis.

MATERIALS AND METHODS: In a prospective study, blood samples of 102 patients were collected before appendectomy. CRP was measured by immunoturbidimetry and the data were compared with the final histopathologic reports. Diagnostic accuracy of the CRP test was analyzed by ROC curve.

RESULTS: In histopathology, 83 patients (81/4%) had acute appendicitis and 19 (18/6%) had normal appendices. Considering 14 mg/lit as the cut-off point, this test shows 59% (95% CI, 48-69%) sensitivity and 68% (95% CI, 47-88%) specificity. The positive and negative predictive values were 89% (95% CI, 80-97%) and 27% (95% CI, 14-39%), respectively.

CONCLUSIONS: The measurement of CRP levels is not an ideal diagnostic tool for ruling out or determination of acute appendicitis.

Ulus Travma Acil Cerrahi Derg. 2010 Sep;16(5):445-8. The role of computerized tomography in the diagnosis of acute appendicitis in patients with negative

ultrasonography findings and a low Alvarado score. Cağlayan K, Günerhan Y, Koç A, Uzun MA, Altınlı E, Köksal N. Source Bozok University Faculty of Medicine, Yozgat, Turkey. Abstract BACKGROUND: We aimed to identify the role of computerized tomography (CT) in the differential diagnosis of acute appendicitis

in patients with a low Alvarado score and negative ultrasonography findings. METHODS: Fifty-two cases who underwent appendectomy (December 2004-September 2008) were included. All patients

had an Alvarado score of 4-6 together with negative ultrasonography findings; preoperative abdominal CT examination results were available in all patients. CT results were compared with intraoperative and pathological findings.

RESULTS: The mean age of the cases was 31±4 years (range 11 to 71 years). The mean Alvarado score was 4.9. CT results

were in favor of acute appendicitis in 34 of 52 cases. Of these 34 patients, acute appendicitis was confirmed by pathological findings in 31, whereas acute appendicitis could not be confirmed in the remaining three cases (8.2%). In 15 of 18 cases without CT findings of appendicitis, intraoperative and pathological findings were also in agreement; however, the remaining three cases had acute appendicitis. Based on the results of the recent studies, sensitivity and specificity of CT in the diagnosis of acute appendicitis were 91.2% and 83.3%, respectively.

CONCLUSION: To avoid unnecessary appendectomies in suspected acute appendicitis cases with a low Alvarado score and

negative ultrasonography findings, CT may be used as a complementary diagnostic tool.

Eur Radiol. 2011 Apr;21(4):768-75. Epub 2010 Oct 6. Utility of diffusion-weighted imaging in the diagnosis of acute appendicitis. Inci E, Kilickesmez O, Hocaoglu E, Aydin S, Bayramoglu S, Cimilli T. Source Department of Radiology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey.

ercan@inci.com Abstract OBJECTIVES: To evaluate the value of diffusion-weighted MRI (DWI) in the diagnosis of acute appendicitis. METHODS: 119 patients with acute appendicitis and 50 controls were enrolled in this prospective study. DWI was obtained

with b factors 0, 500 and 1000 s/mm² and were assessed with a visual scoring system by two radiologists followed by quantitative evaluation of the DW images and ADC maps.

RESULTS: Histopathology revealed appendicitis in 79/92 patients (78%) who had undergone surgery. On visual evaluation,

except for one patient with histopathologically proven appendicitis all inflamed appendixes were hyperintense on DWI (98.7%). Quantitative evaluation with DW signal intensities and ADC values revealed a significant difference with normal and inflamed appendixes (p < 0.001). The best discriminative parameter was signal intensity (b 500). With a cut-off value of 56 for the signal intensity the ratio had a sensitivity of 99% and a specificity of 97%. The cut-off ADC value at 1.66 mm²/s had a sensitivity of 97% and a specificity of 99%.

CONCLUSION: DWI is a valuable technique for the diagnosis of acute appendicitis with both qualitative and quantitative

evaluation. DWI increases the conspicuity of the inflamed appendix. We recommend using DWI to diagnose acute appendicitis.

Turk J Gastroenterol. 2011 Feb;22(1):101-3. Patent vitelline duct as a cause of acute abdomen: Case report of an adult patient. Alevli F, Akbulut S, Dolek Y, Cakabay B, Sezgın A. Source Department of Surgery, Diyarbakir Education and Research Hospital, Diyarbakir,

Turkey. Abstract A patent vitelline duct is an uncommon condition. Diagnosis is based on clinical

and radiological findings. Complications include prolapse, intestinal obstruction, hemorrhage, and perforation. Here, we report the case of a 23-year-old man with patent vitelline duct who presented with umbilical discharge, severe abdominal pain, fever of 38.5°C, no gas/feces passage, and nausea and vomiting for three days. Laparotomy with midline incision was performed because of acute abdomen. A patent vitelline duct from the terminal ileum to the umbilicus was observed. Meckel's diverticulitis and ileus were also noted. En bloc resection of the umbilicus, patent vitelline duct and a 15 cm ileal segment was performed. The patient was discharged five days after the operation.

Can J Surg. 2011 Feb;54(1):43-53. Impact of computed tomography of the abdomen on clinical outcomes in patients with acute right lower quadrant pain: a meta-analysis. Krajewski S, Brown J, Phang PT, Raval M, Brown CJ. Source Department of Surgery, University of British Columbia, Vancouver, BC. Abstract BACKGROUND: Clinical evaluation alone is still considered adequate by many clinicians who treat patients with appendicitis. The impact of computed

tomography (CT) on clinical outcomes remains unclear, and there is no consensus regarding the appropriate use of CT in these patients. We sought to evaluate the impact of abdominal CT on the clinical outcomes of patients presenting with suspected appendicitis.

METHODS: We conducted a systematic review of the literature to identify studies that examined clinical outcomes related to the use of abdominal CT

in the diagnosis of acute appendicitis. Inclusion criteria were studies of adult patients with suspected appendicitis that evaluated the impact of abdominal CT on negative appendectomy rates, perforation rates or time to surgery. Two independent investigators reviewed all titles and abstracts and extracted data from 28 full-text articles. Statistical analysis was conducted using Review Manager 5.0.10 software.

RESULTS: The negative appendectomy rate was 8.7% when using CT compared with 16.7% when using clinical evaluation alone (p < 0.001). There

was also a significantly lower negative appendectomy rate during the CT era compared with the pre-CT era (10.0% v. 21.5%, p < 0.001). Time to surgery was evaluated in 10 of the 28 studies, 5 of which demonstrated a significant increase in the time to surgery with the use of CT. Appendiceal perforation rates were unchanged by the use of CT (23.4% in the CT group v. 16.7% in the clinical evaluation group, p = 0.15). Similarly, the perforation rate during the CT era was not significantly different than that during the pre-CT era (20.0% v. 19.6%, p = 0.74).

CONCLUSION: This meta-analysis supports the hypothesis that the use of preoperative abdominal CT is associated with lower negative appendectomy

rates. The use of CT in the absence of an expedited imaging protocol may delay surgery, but this delay is not associated with increased appendiceal perforation rates. Routine CT in all patients presenting with suspected appendicitis could reduce the rate of unnecessary surgery without increasing morbidity.

J Pediatr Surg. 2011 Jan;46(1):192-6. An evidence-based clinical protocol for diagnosis of acute appendicitis decreased the use of computed

tomography in children. Adibe OO, Amin SR, Hansen EN, Chong AJ, Perger L, Keijzer R, Muensterer OJ, Georgeson KE, Harmon CM. Source Division of Pediatric Surgery, The Children's Hospital of Alabama, Birmingham, AL 35233, USA. Abstract PURPOSE: The increased use of computed tomography (CT) to diagnose appendicitis in children has led to a concern for

the possibility of increased CT-related cancer morbidity. We designed a clinical protocol for the diagnosis and treatment of appendicitis in children in an attempt to decrease the use of CT scans at our institution.

METHODS: Patients who had surgical consultation for suspected appendicitis were placed on the clinical protocol. Data

concerning diagnosis and treatment were collected prospectively. Retrospective data from patients admitted to our institution with acute appendicitis before the clinical protocol were collected as historical controls.

RESULTS: One hundred twelve patients were diagnosed and treated by our protocol between June and November 2009. Of

these, 100 patients underwent an appendectomy for acute appendicitis. They were compared with 146 patients from 2007. In-house CT use decreased from 71.2% to 51.7% (P = .01). Preoperative ultrasound use increased from 2.7% to 21% (P < .001). The negative appendectomy rate increased (6.8% vs 11%, P = .25).

CONCLUSIONS: Our findings suggest that the implementation of an evidence-based clinical protocol for the diagnosis and

treatment of acute appendicitis in children may safely decrease the use of CT scans and increase the use of ultrasound.

Emerg Med Australas. 2004 Oct-Dec;16(5-6):410-6. Radiological imaging to improve the emergency department diagnosis of acute appendicitis. Rosengren D, Brown AF, Chu K. Source Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.

david_rosengren@health.qld.gov.au Abstract OBJECTIVES: To determine the institution's current non-therapeutic (negative) appendicectomy rate; the frequency of clinical

predictors for appendicitis in patients who underwent appendicectomy; and the utilization and accuracy of ultrasound scans (USS) and computed tomography (CT) in the diagnosis of appendicitis.

METHODS: A retrospective chart review was conducted in an adult, metropolitan teaching hospital. Patients who presented

to the ED and underwent an appendicectomy over a 12-month period were analysed. Symptoms and signs predictive of appendicitis, results of USS and CT scans if performed, and histopathology findings were abstracted from patient records.

RESULTS: Two hundred and forty patients had appendicectomies, 147 (61%) were male and the median age was 25 years

(range 14-78 years). The negative appendicectomy rate was 14.3% (95% CI 9.1-21.0%) and 18.3% (95% CI 11.0-26.7%) in males and females, respectively. Abdominal pain shifting to the right iliac fossa (RIF), anorexia and RIF rebound tenderness were found more frequently in patients with positive than negative appendicectomies (P < 0.05). USS and CT scans were performed in 68 (28%) and 15 (9.5%) patients, respectively. The likelihood ratio for appendicitis in patients with a normal USS or a normal CT scan was 0.83 (95% CI 0.56-1.24) and 0.08 (95% CI 0.01-0.60), respectively. There were no false positive CT scan results.

CONCLUSION: Computed tomoraphy scanning should play an increasing role in the ED management of suspected appendicitis.

Our negative appendicectomy rate could potentially be halved by the introduction of CT scans in the diagnostic work up of these patients.

Conclusion: Five of 13 patients with CT fi ndings of appendicitis and

reassuring clinical evaluation results in whom immediate

treatment was deferred ultimately returned with appendicitis.

In patients with CT results positive for appendicitis

and benign or atypical clinical fi ndings, a diagnosis of

chronic or recurrent appendicitis may be considered.

Results: Overall, 516 (23%) of 2283 patients had CT fi ndings of

probable or defi nite appendicitis. Thirteen (3%) of 516 patients did not receive immediate treatment for

appendicitis. Of these, fi ve (38%; 95% confi dence interval: 18%, 65%) underwent later appendectomy with proved

appendicitis after a mean interval of 118 days (range, 5–443 days). Seven (54%) of 13 patients never developed

appendicitis across a mean follow-up of 583 days (range, 14–1460 days). One (8%) of 13 had a normal appendix at eventual surgery

Surg Clin North Am. 2011 Feb;91(1):141-54. Update on imaging for acute appendicitis. Parks NA, Schroeppel TJ. Source Department of Surgery, University of Tennessee Health Science Center,

910 Madison Avenue, Suite 220, Memphis, TN 38163, USA. Abstract Acute appendicitis is a common surgical emergency and the diagnosis

can often be made clinically; however, many patients present with atypical findings. For these patients, there are multiple imaging modalities available to aid in the diagnosis of suspected appendicitis in an effort to avoid a negative appendectomy. Computed tomography is the test of choice in most patients in whom the diagnosis is not certain. Ultrasonography is particularly useful in children and pregnant women. Magnetic resonance imaging is recommended when ultrasonography is inconclusive. Appropriate use of these imaging studies avoids delays in treatment, prolonged hospitalization, and unnecessary surgery.

World J Surg. 2010 Oct;34(10):2278-85. Routine ultrasound and limited computed tomography for the diagnosis of acute appendicitis. Toorenvliet BR, Wiersma F, Bakker RF, Merkus JW, Breslau PJ, Hamming JF. Source Department of Surgery, Leiden University Medical Centre, P.O. Box 9600, 2300 RC, Leiden, The Netherlands.

br.toorenvliet@tiscali.nl Abstract BACKGROUND: Acute appendicitis continues to be a challenging diagnosis. Preoperative radiological imaging using ultrasound

(US) or computed tomography (CT) has gained popularity as it may offer a more accurate diagnosis than classic clinical evaluation. The optimal implementation of these diagnostic modalities has yet to be established. The aim of the present study was to investigate a diagnostic pathway that uses routine US, limited CT, and clinical re-evaluation for patients with acute appendicitis.

METHODS: A prospective analysis was performed of all patients presenting with acute abdominal pain at the emergency

department from June 2005 until July 2006 using a structured diagnosis and management flowchart. Daily practice was mimicked, while ensuring a valid assessment of clinical and radiological diagnostic accuracies and the effect they had on patient management.

RESULTS: A total of 802 patients were included in this analysis. Additional radiological imaging was performed in 96.3% of

patients with suspected appendicitis (n = 164). Use of CT was kept to a minimum (17.9%), with a US:CT ratio of approximately 6:1. Positive and negative predictive values for the clinical diagnosis of appendicitis were 63 and 98%, respectively; for US 94 and 97%, respectively; and for CT 100 and 100%, respectively. The negative appendicitis rate was 3.3%, the perforation rate was 23.5%, and the missed perforated appendicitis rate was 3.4%. No (diagnostic) laparoscopies were performed.

CONCLUSIONS: A diagnostic pathway using routine US, limited CT, and clinical re-evaluation for patients with acute abdominal

pain can provide excellent results for the diagnosis and treatment of appendicitis.

J Invest Surg. 2010 Aug;23(4):218-23. The role of d-lactate in differential diagnosis of acute appendicitis. Filiz AI, Aladag H, Akin ML, Sucullu I, Kurt Y, Yucel E, Uluutku AH. Source Department of General Surgery, Gulhane Military Medical Academy, Haydarpasa Teaching Hospital, Istanbul

34668, Turkey. Abstract INTRODUCTION: Early diagnosis of acute appendicitis, known as the most frequent cause of acute surgical abdominal

pathologies, dramatically decreases the related complications. D-lactate, produced by intestinal bacteria as a fermentation product, may be useful in diagnosing acute abdominal pathologies. The aim of this study was to investigate whether the presence of d-lactate would be a significant indicator in the early diagnosis of acute appendicitis.

METHODS: Eighty consecutive patients were prospectively included in this study. The patients were divided into four

groups: acute appendicitis (group 1), perforated acute appendicitis (group 2), nonspecific abdominal pain (group 3), and acute abdomen other than acute appendicitis (group 4). For the control group, blood samples were taken in the same manner from 20 healthy subjects.

RESULTS: There was no significant difference in blood d-lactate levels between the simple acute appendicitis and acute

perforated appendicitis groups (p > .05). The blood d-lactate levels in groups 1 and 2 were significantly higher than those in groups 3 and 4, and the control group (p < .001). The reliability of d-lactate was determined as 97% sensitivity, 93% specificity, 90% positive predictive and 95% negative predictive values, and 95% accuracy.

CONCLUSIONS: Based on findings in this study, blood d-lactate level may be a valuable diagnostic marker for the diagnosis of

acute appendicitis.

Am J Emerg Med. 2011 Mar;29(3):256-60. Epub 2010 Mar 25. A pilot study on potential new plasma markers for diagnosis of acute appendicitis. Thuijls G, Derikx JP, Prakken FJ, Huisman B, van Bijnen Ing AA, van Heurn EL, Buurman WA, Heineman E. Source NUTRIM School for Nutrition, Toxicology and Metabolism, Department of Surgery, Maastricht University Medical

Centre, 6229 ER, Maastricht, The Netherlands. Abstract BACKGROUND: Diagnosis of acute appendicitis (AA) remains a surgical dilemma, with negative appendectomy rates of 5% to

40% and perforation suggestive for late operative intervention in 5% to 30%. The aim of this study is to evaluate new plasma markers, representing early neutrophil activation, to improve diagnostic accuracy in patients suspected for AA.

MATERIALS AND METHODS: Fifty-one patients who underwent surgery for AA were included (male-female = 28:23), and blood was sampled.

Plasma concentrations of 2 neutrophil proteins were measured: lactoferrin (LF) and calprotectin (CP). Controls consisted of 27 healthy volunteers. C-reactive protein (CRP) and white blood cell count (WBC) concentrations were measured for routine patient care.

RESULTS: Median plasma concentrations for LF and CP were significantly higher in 51 patients with proven AA (665 and

766 ng/mL, respectively) than in 27 healthy volunteers (198 and 239 ng/mL, respectively, P < .001). No clinically relevant correlation exists between the plasma levels of LF and CP and the conventional laboratory tests for CRP and WBC.

CONCLUSIONS: Circulating LF and CP levels are significantly elevated in patients with appendicitis and are detectable in plasma

using relatively simple and low-cost enzyme-linked immunosorbent assays. Furthermore, plasma levels of LF and CP give additional information to conventional markers WBC and CRP, making them potential new markers for AA diagnosis

Ann R Coll Surg Engl. 2011 Apr;93(3):213-7. The value of hyperbilirubinaemia in the diagnosis of acute appendicitis. Emmanuel A, Murchan P, Wilson I, Balfe P. Source Department of Surgery, St. Luke's Hospital, Kilkenny, Ireland. arhemmanuel@gmail.com Abstract INTRODUCTION: No reliably specific marker for acute appendicitis has been identified. Although recent studies have shown hyperbilirubinaemia to be a

useful predictor of appendiceal perforation, they did not focus on the value of bilirubin as a marker for acute appendicitis. The aim of this study was to determine the value of hyperbilirubinaemia as a marker for acute appendicitis.

MATERIALS AND METHODS: A retrospective analysis of appendicectomies performed in two hospitals (n=472). Data collected included laboratory and histological

results. Patients were grouped according to histology findings and comparisons were made between the groups. RESULTS: The mean bilirubin levels were higher for patients with simple appendicitis compared to those with a non-inflamed appendix (p<0.001).

More patients with simple appendicitis had hyperbilirubinaemia on admission (30% vs 12%) and the odds of these patients having appendicitis were over three times higher (odds ratio: 3.25, p<0.001). Hyperbilirubinaemia had a specificity of 88% and a positive predictive value of 91% for acute appendicitis. Patients with appendicitis who had a perforated or gangrenous appendix had higher mean bilirubin levels (p=0.01) and were more likely to have hyperbilirubinaemia (p<0.001). The specificity of hyperbilirubinaemia forperforation or gangrene was 70%. The specificities of white cell count and C-reactive protein were less than hyperbilirubinaemia for simple appendicitis (60% and 72%) and perforated or gangrenous appendicitis (19% and 36%).

CONCLUSIONS: Hyperbilirubinaemia is a valuable marker for acute appendicitis. Patients with hyperbilirubinaemia are also more likely to have

appendiceal perforation or gangrene. Bilirubin should be included in the assessment of patients with suspected appendicitis.

Beyaz küre sayısı yüksek olması anlamlı ancak normal olması hatta lokopeni olabilecegini unutmayalım

Hem Beyaz küre yüksekliği hemde CPR yüksekliğinin sensivitesi ve spesifitesi %98 lerde

Ultrason kullanıcı bağımlı ve bazı durumlarda hastaya ilişkin durumlarda yalancı negatif olabilmektedir( örn; retroçökal appendisit olması, hastanın gazlı olması, hamile ..)

Ayırıcı tanılar açısından faydalı olabilir kolay ucuz noninvaziv

Nonkontrast BT nin sensivitesi %92.7 spesifitesi %96 olarak bildiriliyor

Hamilelerde ilk Trimesterde MR dan yararlanılabilir ancak 2 ve 3. trimesterde BT hala daha çok tercih edilmektedir

Mülti detektör BT nin sensivitesi %93.3 ve spesifitesi %95.9

Risk factors for cecal volvulus include adhesions, recent surgery, congenital bands, and prolonged constipation

Mortality for cecal volvulus ranges from 12 to 17 percent; mortality in the elderly can be as high as 65 percent

Sigmoid volvulus accounts for the majority of volvulus cases

• The abdomen is usually distended and tympanitic

• Risk factors include excessive use of laxatives, tranquilizers, anticholinergic medications, ganglionic blocking agents, and medications for Parkinsonism

Clinicians must consider the diagnosis of ectopic pregnancy in any female of childbearing age with abdominal pain and should obtain a human chorionic gonadotropin (hCG) test in all such patients.

Risk factors include a history of pelvic inflammatory disease, previous tubal pregnancy, previous tubal surgery, history of endometriosis, and an indwelling intrauterine device.

Although symptoms of ectopic pregnancy classically include amenorrhea, abdominal pain, and vaginal bleeding, up to 30 percent of patients do not have vaginal bleeding.

The pelvic examination is often nondiagnostic transvaginal ultrasonography is performed to make the diagnosis

An acute, clinical abruption classically presents with painful vaginal bleeding, abdominal or back pain, and uterine contractions.

The uterus may be rigid and tender. The amount of vaginal bleeding correlates poorly

with the degree of placental separation. In the presence of a severe abruption (≥50

percent placental separation), both fetal and maternal compromise may occur, and acute disseminated intravascular coagulation (DIC) can develop

• In approximately 10 to 20 percent of cases, a woman with placental abruption will present with only preterm labor and no vaginal bleeding.

• Therefore, even small amounts of vaginal bleeding in the setting of abdominal pain and uterine contractions should prompt close maternal and fetal evaluation.

• Maternal hypertension is the most common cause of abruption, occurring in 44 percent of cases

• Other risk factors include• cocaine use,• alcohol consumption, • cigarette smoking,• trauma, and • advanced maternal age.

• Previous upper or lower abdominal surgery increases the risk for obstruction.

• Causes of SBO include: adhesions (50 percent to 70 percent), incarcerated hernias (15 percent), and neoplasms (15 percent)

• Gallstone ileus is the cause in up to 20 percent of cases among elderly patients

• Patients with Crohn's disease frequently present with obstruction.

Ann R Coll Surg Engl. 2011 May;93(4):e1-2. Isolated right testicular pain for six days: an

unusual presentation of occult abdominal aortic aneurysm leak.

Forsythe RO, Lavin V, Fraser SC, McNeill A.

Am J Emerg Med. 2008 Feb;26(2):202-5. Ischemia-modified albumin in the diagnosis

of acute mesenteric ischemia: a preliminary study.

Gunduz A, Turedi S, Mentese A, Karahan SC, Hos G, Tatli O, Turan I, Ucar U, Russell RM, Topbas M.

Source Department of Emergency Medicine, Karadeniz Technical University

Faculty of Medicine, 61080 Trabzon, Turkey.

Karın ağrısı ishal şikayeti ile acile gelen 35 yaş hamileliginin 8 ayında bayan hasta başvuruyor

Vital fonksiyonları normal olan hastadan hemogram, biokimya ve ultrason isteniyor

Kadın doğum konsultasyonu sonucu taburcu ediliyor

Hasta zaten kadındoğumcusunun kontrolünden geliyor ve patolojinin kadın doğum dışı bir patolojiden kaynaklandığınısöylemesi üzerine acile geliyor

Acile karın ağrısı ile gelen 40 yaş obes bayan hastanın muayenesinde vital fonksiyonları normal olarak değerlendiriliyor

Muayene ve muayeden sonra arada kolik vasıflıağrıdan dolayı çığlık şeklinde bağırıyor

Hastanın istenen hemogram biokimyasında özellik yok

Ultrasonda böbreklerde kalsifikasyon vs acil bir patoloji düşünülmüyor

Kontrastlı Batın BT çekiliyor ordada acil patoloji yok

Cerrahi konsultasyonu sonucu hasta izlem amaçlıyatırılıyor

Sonra ne oluyor sizce!!!Sonra ne oluyor sizce!!! Hasta ikinci kere gelmişse çok dikkatli ol Hasta üçüncü kere gelmişse asla çıkarma En iyi hasta yakını hastanın doktorudur (Hasta yakını ilgisizse ve/veya bakıcısı ile

yaşıyorsa dikka)t Çok ilgili yada ilgisiz hasta yakınlarına aman dikkat Hasta ve hasta yakını çıkmak istemiyorsa mümkünse çıkarma Hasta çıkmak istiyorsa mutlaka istek formunu imzalat Yaşlı karın ağrısı ve ateş yatar Gecenin geç saatlerinde gelen karın ağrısı ile sabah mesaide geleni bir tutma izle

izle Anemnez bilgilerini güvenilir enaz iki kişiden mümkünse al Ölecek hasta bağırmaz Yaşlı hasta ölüyorum doktor diyorsa ölür Yaşlı hasta acilde oteldeki gibi davranıyorsa dikkat Acilde uyuyan yaşlı hastalara dikkat et Hastalarınızı yürüterek gönderin Oral aldığını görmeden kimseyi taburcu etmeyin Yaptığını yaz yada yazmadığını yapma Bazen neyazarsan yaz seni kimse kurtaramaz Acile başvuran herhasta acildir Ben çok acilim diyen acil değildir