acuteappendicits - Acute Appendicitis Acute Epidemiology...

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Acute Appendicitis Acute Appendicitis
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Epidemiology Epidemiology The incidence of appendectomy appears to be declining due to more accurate preoperative diagnosis. Despite newer imaging techniques, acute appendicitis can be very difficult to diagnose.
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Pathophysiology Pathophysiology Acute appendicitis is thought to begin with obstruction of the lumen Obstruction can result from food matter, adhesions, or lymphoid hyperplasia Mucosal secretions continue to increase intraluminal pressure
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Pathophysiology Pathophysiology Eventually the pressure exceeds capillary perfusion pressure and venous and lymphatic drainage are obstructed. With vascular compromise, epithelial mucosa breaks down and bacterial invasion by bowel flora occurs.
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Pathophysiology Pathophysiology Increased pressure also leads to arterial stasis and tissue infarction End result is perforation and spillage of infected appendiceal contents into the peritoneum
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Pathophysiology Pathophysiology Initial luminal distention triggers visceral afferent pain fibers, which enter at the 10 th thoracic vertebral level. This pain is generally vague and poorly localized. Pain is typically felt in the periumbilical or epigastric area.
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Pathophysiology Pathophysiology As inflammation continues, the serosa and adjacent structures become inflamed This triggers somatic pain fibers, innervating the peritoneal structures. Typically causing pain in the RLQ
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Pathophysiology Pathophysiology The change in stimulation form visceral to somatic pain fibers explains the classic migration of pain in the periumbilical area to the RLQ seen with acute appendicitis.
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Pathophysiology Pathophysiology Exceptions exist in the classic presentation due to anatomic variability of the appendix Appendix can be retrocecal causing the pain to localize to the right flank In pregnancy, the appendix ca be shifted and patients can present with RUQ pain
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Pathophysiology Pathophysiology In some males, retroileal appendicitis can irritate the ureter and cause testicular pain. Pelvic appendix may irritate the bladder or rectum causing suprapubic pain, pain with urination, or feeling the need to defecate Multiple anatomic variations explain the difficulty in diagnosing appendicitis
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History History Primary symptom: abdominal pain ½ to 2/3 of patients have the classical presentation Pain beginning in epigastrium or periumbilical area that is vague and hard to localize
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History History Associated symptoms: indigestion, discomfort, flatus, need to defecate, anorexia, nausea, vomiting As the illness progresses RLQ localization typically occurs RLQ pain was 81 % sensitive and 53% specific for diagnosis
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History History Migration of pain from initial periumbilical to RLQ was 64% sensitive and 82% specific Anorexia is the most common of associated symptoms Vomiting is more variable, occuring in about ½ of patients
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Physical Exam Physical Exam
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