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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    Thanks for your attention!