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#31
08.09.2005, 21:53
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Очень интересная полнотекстовая статья по аппендициту. Очень хорошие примеры УЗИ и КТ, есть информация по лечению. Говорится о необходимости опер лечения.
[Ссылки доступны только зарегистрированным пользователям ] Abstract Acute appendicitis is a common clinical problem. Accurate and prompt diagnosis is essential to minimize morbidity. While the clinical diagnosis may be straightforward in patients who present with classic signs and symptoms, atypical presentations may result in diagnostic confusion and delay in treatment. Helical computed tomography (CT) and graded compression color Doppler ultrasonography (US) are highly accurate means of establishing the diagnosis. These imaging modalities have now assumed critical roles in the treatment of patients suspected to have appendicitis. The purpose of this article is threefold: to provide an update on new information regarding the pathophysiology, clinical diagnosis, and laparoscopic treatment of acute appendicitis; to describe the state-of-the art use of CT and US in diagnosing this disease entity; and to address the role of medical imaging in this patient population. Index terms: Appendicitis, 751.291 • Appendix, CT, 751.12112, 751.12115 • Appendix, US, 751.12983 • State of the Art Appendicitis is the most common cause of acute abdominal pain that requires surgical intervention in the Western world (1). Patients with the disease may present with a wide variety of clinical manifestations, and the diagnosis may elude even the most experienced clinicians (2). Prompt diagnosis is essential to minimize morbidity, which remains substantial if perforation occurs. The advent of antibiotics and effective surgical management have substantially reduced appendicitis-related mortality; however, deaths from appendicitis still occur, particularly in the elderly. Appendicitis was rare in the past and remains so in underdeveloped countries (3). There appears to be no record of early physicians, from Hippocrates to Moses Maimonides, recognizing this disease entity (3). Although the anatomy of the appendix was well known by the 18th century, it was not until this time that it was recognized that the appendix could become inflamed, with possibly fatal consequences (4). Early reports of perityphlitis and typhlitis in the 19th century appeared to describe a new clinical phenomenon (3,4). Confusion over this right-lower-quadrant entity existed until Reginald H. Fitz presented his landmark article in 1886, in which he coined the term "appendicitis" and correctly classified this disease by describing the appendix as the primary source of inflammation in acute typhlitis (5). Fitz described the signs and symptoms of acute and perforated appendicitis, outlined the progression from acute right-lower-quadrant inflammation through peritonitis and iliac fossa abscess formation, and recommended early appendectomy if there were signs of spreading peritonitis or of clinical deterioration. Shortly thereafter, Charles McBurney and other pioneering surgeons began to intervene early in acute appendicitis (6,7). These clinicians advocated prompt clinical diagnosis and surgical intervention. Their surgical aim was to operate in a timely fashion before appendiceal perforation and peritonitis developed. The goal of modern surgical management essentially is the same and focuses on a balance between the rate of false-negative laparotomy and the rate of perforation at the time of surgical exploration (8–10). It is tradition that surgeons have diagnosed appendicitis on the basis of patient history and physical examination results. The relatively recent introduction of new imaging technology—in particular, graded compression color Doppler US and helical computed tomography (CT)—potentially has changed "the rules of the game." The purpose of this article is to document recent advances in our understanding of appendicitis and to define the role of medical imaging in patients with this condition. 
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#32
08.09.2005, 21:57
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[Ссылки доступны только зарегистрированным пользователям ]
Рассказывается о стратегии консервативной терапии перфор. аппендицита с последующей интервальной аппендэктомией.
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#33
08.09.2005, 22:03
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Сообщение от doctor101
Ну и, господа коллеги, учитывать нужно еще несколько факторов -профессия пациента.Если моряк, летчик, шахтер и т.п.то чаша весов склоняется в сторону операции/так нас учили во ВМОЛА /. Нельзя рисковать выпуская в полет или отправляя в плавание человека, которому решили "отложить операцию до следующего раза". -место проживания пациента, с точки зрения удаленности от стационара. Ну понятно же, что городской житель хоть ежедневно может попасть в приемный покой больницы, в отличии от с трудом добравшегося до нее. //Ни в одном руководстве/статье я не встретил одобрения рутинной аппендэктомии... Я не то читаю? С жёлчной горечью...// Речь не о рутинной аппендектомии, а об учете вышеупомянутых важных факторов при принятии решения.Или это не имеет никакого значения? Cчитаю и уверен что это обосновано и верно. Ошибка-не принимать во внимание возможность пациента, отпущенного домой,назавтра сесть в кресло пилота и в 9 часовом перелете или более того в море оказаться без возможности получить квалифицированную помощь.
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#34
08.09.2005, 22:04
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[Ссылки доступны только зарегистрированным пользователям ]
The Need for Interval Appendectomy after Resolution of an Appendiceal Mass Questioned Paul J. Willemsena, Lidewij E. Hoorntjeb, Eric-Hans Eddesb, Rutger J. Ploega aDepartment of Surgery, University Hospital Groningen, and bDepartment of Surgery, Deventer Ziekenhuis, Deventer, The Netherlands Address of Corresponding Author Digestive Surgery 2002;19:216-222 (DOI: 10.1159/000064216) Abstract Background: Our current treatment of an appendiceal mass is initially conservative, followed by an interval appendectomy. The necessity of this routine interval appendectomy is debatable. A study was conducted to evaluate whether surgical factors and pathological features of the excised appendices support interval appendectomy. Methods: We performed a retrospective study at the University Hospital Groningen and the Deventer Ziekenhuis. All patients diagnosed with an appendiceal mass in the period January 1991 to January 1997 were identified using the hospital database. The medical records of all these patients (n = 233, 108 M, 125 F) were reviewed. The clinical course of the appendiceal mass patients was split up into three distinct episodes: initial diagnosis and treatment of the appendiceal mass, the interval period and the interval appendectomy. Presenting symptoms, findings at clinical examination and additional imaging (ultrasound) were registered, as well as the course of the primary hospitalisation, the interval period, and the interval appendectomy. Results of histological examination of all resected specimens were reviewed. Results: It was found that clinical findings alone were not specific enough to diagnose an appendiceal mass; 47% had a palpable abdominal mass and the median temperature was 38.2°C ranging from 36 to 40.5°C. Ultrasound examination was done in 69% of patients and showed an appendiceal mass in 72%. During the interval period, 4 patients presented with an appendiceal mass needing drainage, and 3 with acute appendicitis requiring emergency appendectomy. At interval appendectomy, histological examination of resection specimen showed a normal appendix without signs of previous inflammation in 30% of cases. In addition, complications due to interval appendectomy were seen in 18% of patients, including sepsis, bowel perforation, small bowel ileus, and various wound abscesses. Conclusions: We conclude that when causes for the appendiceal mass other than appendicitis are excluded, interval appendectomy seems unnecessary in patients who respond well to initial conservative treatment. Статья о консервативном лечении аппендикулярных образований (инфильтрат, абсцесс). Говорится об отсутствии необходиимости интервальной аппендэктомии.
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#35
08.09.2005, 22:07
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Позвольте подвести итоги (на 2005 год):
1. Острый аппендицит требует оперативного лечения. В случае консервативной терапии частота рецидивов может достигать 38% 2. Аппендикулярный абсцесс и инфильтрат лечится консервативно (или интервенционная радиология) с последующей интервальной аппендэктомией. 3. Интервальная аппендэктомия - дискутабельный вопрос и некоторые авторы выступают против ее проведения. Спасибо за внимание.
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#36
08.09.2005, 22:11
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Цитата:
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#42
08.09.2005, 23:06
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Я конечно жутко извиняюсь, что опять помяну гинекологов, но хочу рассказать случай. Молодую женщину в поселковой больнице недели две лечили бешеными дозами вицефа с метрогилом от чего-то так женского, женщина толстая, ничего не пальпируется, прислали к нам. Наши гинекологи в свою очередь нашли на УЗИ образование справа, но больной вроде лучше, дальше антибиотики, еще недели две, температура 39 - 38 - 37 - комнатная (шутка). Вылечили. У больной большая пупочная грыжа, перевели в хирургию. Ну мы на грыжесечении поболе разрез сделали - интересно же посмотреть. На куполе слепой кишки на месте отростка бугорок с пол-сантиметра и все. Спаек почти нет. Консервативная терапия?
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Линейный вид
