discuss appendicitic andappen disectomy
Answers
Answer:
The diagnosis of acute appendicitis is predominantly a clinical one; many patients present with a typical history and examination findings. The cause of acute appendicitis is unknown but is probably multifactorial; luminal obstruction and dietary and familial factors have all been suggested.1 Appendicectomy is the treatment of choice and is increasingly done as a laparoscopic procedure. This article reviews the presentation, investigation, treatment, and complications of acute appendicitis and appendicectomy.
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How common is appendicitis?
Appendicitis is the most common abdominal emergency and accounts for more than 40 000 hospital admissions in England every year.2 Appendicitis is most common between the ages of 10 and 20 years, but no age is exempt.3 A male preponderance exists, with a male to female ratio of 1.4:1; the overall lifetime risk is 8.6% for males and 6.7% for females in the United States.3 Since the 1940s the incidence of hospital admission for acute appendicitis has been falling, but the reason for this decline is not clear.w1
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How do I diagnose it?
Diagnosis of acute appendicitis relies on a thorough history and examination.w2
History
Abdominal pain is the primary presenting complaint of patients with acute appendicitis. The diagnostic sequence of colicky central abdominal pain followed by vomiting with migration of the pain to the right iliac fossa was first described by Murphy but may only be present in 50% of patients.4 Typically, the patient describes a peri-umbilical colicky pain, which intensifies during the first 24 hours, becoming constant and sharp, and migrates to the right iliac fossa. The initial pain represents a referred pain resulting from the visceral innervation of the midgut, and the localised pain is caused by involvement of the parietal peritoneum after progression of the inflammatory process. Loss of appetite is often a predominant feature, and constipation and nausea are often present. Profuse vomiting may indicate development of generalised peritonitis after perforation but is rarely a major feature in simple appendicitis. A meta-analysis of the symptoms and signs associated with a presentation of acute appendicitis was unable to identify any one diagnostic finding but showed that a migration of pain was associated with a diagnosis of acute appendicitis.5
Sources and selection criteria
We reviewed the Cochrane database for articles relating to acute appendicitis. We searched Medline for the past two years (up to June 2006) to find any recent meta-analyses, systematic reviews, or randomised controlled trials relating to appendicitis that JS had not included in the latest Clinical Evidence review. We also included important historical articles
Summary points
Appendicitis is the most common abdominal surgical emergency
Not all patients present in a typical manner
Patients at the extremes of age have increased mortality because of late presentation or subtle signs
Specialist investigations should not delay definitive treatment
Computed tomography scanning is more sensitive and specific than ultrasonography when diagnosing acute appendicitis
Laparoscopic appendicectomy is becoming increasingly common, and clinical evidence suggests that it has some advantages over open surgery
Wound infections can be decreased with the use of perioperative antibiotics
This classic presentation can be influenced by the age of the patient and anatomical position of the appendix (box 1).w3 Patients at the extremes of the age spectrum can present diagnostic difficulty because of non-specific presentation, often with subtle clinical signs. Infants and young children often seem withdrawn, and elderly people may present with confusion. A high index of suspicion for acute appendicitis is needed in such patients.
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Answer:
Abstract
Right lower quadrant pain after a lumbar discectomy is a rare condition. We report on a 29-year-old man who developed right lower quadrant pain 12 h after lumbar discectomy due to the formation and rupture of a right iliac artery pseudoaneurysm. The diagnostic laparoscopy was done under the impression of acute appendicitis but showed a retroperitoneal hematoma. An emergency abdominal computed tomography confirmed a right iliac artery pseudoaneurysm rupture. We performed a transarterial embolization with multiple metallic coils in the aneurysm cavity and connected the proximal and distal right internal iliac artery because his hemodynamics became progressively unstable. In this article, in addition to presenting the clinical course of an unusual case, we also wanted to emphasize that patients with right lower quadrant pain could be presenting an early sign of pseudoaneurysm formation and rupture after a lumbar discectomy.
Explanation:Introduction
Lumbar disectomy is a common and relatively safe procedure in spinal surgery.
However, vascular injury is occasionally reported.[1,2,3,4,5,6,7] Without prompt diagnosis, the prognosis is dismal, even fetal.[2] Here, we report a patient with right lower quadrant pain that was caused by internal iliac artery injury after lumbar discectomy mimicking appendicitis
A 29-year-old man had received an L4–L5 laminectomy and discectomy surgery 3 years prior to his admission to our ward complaining of low back pain radiating to the right lower leg for 3 months. He underwent an L45S1 laminectomy + L4/5 and L5/S1 discectomy operation. Twelve hours later, he developed right lower quadrant pain, with suspicion of acute appendicitis. The diagnostic laparoscopy showed a retroperitoneal hematoma and no acute appendicitis. An emergency abdominal computed tomography showed the rupture of a pseudoaneurysm from the right internal iliac artery. His hemodynamic status became unstable, so we performed a transarterial embolization with multiple metallic coils in the aneurysm cavity and connected the proximal and distal right internal iliac artery after angiography diagnos. After the embolization and a massive fluid and blood transfusion, his hemodynamic status stabilized.