Lyrics · 完整歌詞
Appendicitis can progress from local inflammation to ischaemia and perforation,
although its clinical course is variable rather than governed by a fixed timetable.
Luminal obstruction, by a faecolith in adults,
lymphoid hyperplasia in children and tumour in the elderly,
raises intraluminal pressure and obstructs venous return.
Ischaemia, bacterial overgrowth, necrosis and finally perforation follow.
In the first twelve hours visceral afferents at T10 report only vague periumbilical pain
and nausea.
Between twelve and twenty-four hours the parietal peritoneum becomes involved,
somatic nerves localise the pain to McBurney's point and fever begins.
Beyond twenty-four to seventy-two hours perforation brings rebound tenderness,
guarding and a mass.
Migration of pain from the umbilicus to the right iliac fossa is
the most valuable feature in the history.
Signs map the position of the appendix.
Rovsing's sign, right-sided pain on left-sided palpation, indicates peritoneal irritation.
A positive psoas sign points to a retrocaecal appendix lying on the iliopsoas,
and a positive obturator sign to a pelvic appendix.
Children, pregnant women and young women are imaged first with ultrasound,
which seeks a non-compressible blind-ending tube over 6 mm with a target sign
and simultaneously examines the ovaries.
Adults are best served by CT,
whereas a plain radiograph offers only indirect signs.
Appendicitis can progress from local inflammation to ischaemia and perforation,
although its clinical course is variable rather than governed by a fixed timetable.
Laparoscopic appendicectomy is the standard treatment for uncomplicated disease.
Antibiotics alone are feasible in selected cases,
yet 25 to 40 per cent of patients require surgery within a year.
A periappendiceal abscess or phlegmon is treated with antibiotics and drainage,
with interval appendicectomy considered after six to eight weeks.
Perforation demands urgent surgery, antibiotics and peritoneal lavage.
Surgical site infection is the commonest complication,
affecting 10 to 20 per cent after perforation.
In the elderly the surgeon must think of tumour,
because carcinoid and adenocarcinoma often present as appendicitis.
Infection prevention follows fixed rules.
A single prophylactic dose is given within 60 minutes before incision,
or 120 minutes for vancomycin and fluoroquinolones.
It is repeated when the operation exceeds two half-lives of the drug
or blood loss exceeds 1500 millilitres,
and it stops within 24 hours.
Hair is clipped rather than shaved,
skin is prepared with chlorhexidine in alcohol,
and normothermia and a glucose below 200 mg/dL are maintained.
A clean wound carries a 1 to 5 per cent infection rate,
whereas a dirty wound exceeds 27 per cent
and is left for delayed primary closure.
Consent binds all of this together.
It is valid only when capacity, adequate disclosure of risks,
benefits and alternatives, and voluntariness free of manipulation coexist.
A competent adult may refuse even life-saving treatment;
the correct response is neither detention nor silent discharge but documented counselling,
a signed refusal and a clear safety net.
When a patient cannot communicate,
no proxy is available and delay threatens life, emergency implied consent applies.
A previous refusal of an elective operation does not extend to an unforeseen emergency.
Appendicitis can progress from local inflammation to ischaemia and perforation,
although its clinical course is variable rather than governed by a fixed timetable.