恶心呕吐精选PPT.ppt

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1、关于恶心呕吐第1页，讲稿共87张，创作于星期日临床诊断学临床诊断学上海第二医科大学仁济临床医学院上海第二医科大学仁济临床医学院 第2页，讲稿共87张，创作于星期日Nausea and VomitingAs the symptoms症状学：恶心与呕吐症状学：恶心与呕吐第3页，讲稿共87张，创作于星期日GoalsBriefly defineOutline the prominent disease states associated with nausea and vomiting.Characterize Nausea and Vomiting caused by the prominent d

2、isorders Discriminate the accompanying symptoms.Suggest diagnostic strategies of the symptoms.第4页，讲稿共87张，创作于星期日Definition of Nausea and VomitingnNausea：the inclination or feeling of imminent desire to vomit,usually felt in the throat or epi-gastrum.Associated with decreased activity of the stomach.n

3、Vomiting：the forceful oral expulsion of gastric contents via retro-peristalsis.nNausea-Vomiting:simultaneity or separateness恶心：紧迫欲吐，通常伴有上腹不适和迷走兴奋的临床征候群。呕吐：胃和/或小肠内容物经食管和口腔排除体外恶心和呕吐常伴随存在，也可单独出现！第5页，讲稿共87张，创作于星期日Nausea and Vomiting第6页，讲稿共87张，创作于星期日1、恶心：咽部及上腹部不适，胃张力和蠕动减弱，幽门和贲门开放。2、干呕：胃窦部和腹壁肌肉收缩，腹压增加，食管及

4、咽部开放。3、呕吐：胃和/或小肠内容物经食管和口腔排除体外。Definition of emesis.(Three phases)呕吐反射过程（三个阶段）1.Nausea-the inclination or feeling of imminent desire to vomit,usually felt in the throat or epigastrum.Associated with decreased activity of the stomach.2.Retching-the labored rhythmic contraction of respiratory and abdom

5、inal musculature that frequently precedes or accompanies vomiting.3.Vomiting-the forceful oral expulsion of gastric contents via retroperistalsis.(Abdominal effects).第7页，讲稿共87张，创作于星期日迷走兴奋表现迷走兴奋表现恶心恶心干呕干呕呕吐呕吐发生机制发生机制第8页，讲稿共87张，创作于星期日呕吐区别于反食呕吐区别于反食呕吐：多数情呕吐：多数情况有恶心的感况有恶心的感觉和呕吐反射觉和呕吐反射的协调动作。的协调动作。反食：无恶心

6、反食：无恶心的感觉和呕吐的感觉和呕吐反射的协调动反射的协调动作。（儿童、作。（儿童、饱餐）饱餐）第9页，讲稿共87张，创作于星期日Mechanisms of emesis第10页，讲稿共87张，创作于星期日CTZ&Emetic Center(Vomiting center)CTZ化学感受器触发带（第四脑室底面）：外源性或内源性化学物质（阿片吗啡、洋地黄、代谢产物）Emetic Center（延髓外侧网状结构背测）接受大脑皮质、消化器官、心血管以及化学感受器触发带（CTZ）的冲动第11页，讲稿共87张，创作于星期日CTZ&Emetic Center(Vomiting center)孤束核第12页

7、，讲稿共87张，创作于星期日Emetic Center 内脏传入 中脑ICP受体化学感受器触发带边缘系统前庭系统呕吐中枢（Vomiting center)ICP=Inductively Coupled Plasma 感应耦合等离子体第13页，讲稿共87张，创作于星期日Neurotransmitters in CTZ&Emetic CenterNeurotransmitters involved in stimulating the emetic center,chemo-receptor trigger zone and GI tract include;5-HT,acetylcholine,

8、histamine,dopamine(opiates and receptors for benzodiazepines are also found here)第14页，讲稿共87张，创作于星期日第15页，讲稿共87张，创作于星期日第16页，讲稿共87张，创作于星期日Emetic Center 1、分泌唾液中枢2、血管收缩中枢3、呼吸中枢4、中枢神经脊神经膈神经迷走神经第17页，讲稿共87张，创作于星期日第18页，讲稿共87张，创作于星期日nausea and vomiting1.Reflective vomiting 反射性呕吐反射性呕吐2.Central vomiting 中枢性呕吐中枢

9、性呕吐3.Neurological vomiting 神经性呕吐神经性呕吐第19页，讲稿共87张，创作于星期日Reflective vomiting（反射性呕吐）反射性呕吐）咽部刺激胃十二指肠疾病胆道疾病肠道疾病肝胆疾病腹膜肠系膜全身性疾病（五官、心血管、泌尿、盆腔）Pharyngeal MechanismsGastrointestinal MechanismsDisease of biliary tractPeritoneal and mesenterythe five sense organsCardiovascular diseases kidneyPelvic第20页，讲稿共87张，创

10、作于星期日咽部刺激Pharyngal Mechanisms第21页，讲稿共87张，创作于星期日Gastrointestinal Mechanisms第22页，讲稿共87张，创作于星期日肝、胆、胰腺第23页，讲稿共87张，创作于星期日其他第24页，讲稿共87张，创作于星期日Intra-cranial infectionCerebrovascular disordersCraniocerebral injuryEpilepsyMetabolic disorders DrugsCentral vomiting（中枢性呕吐）中枢性呕吐）颅内感染脑血管疾病颅脑损伤癫痫全身疾病（尿毒症、肝昏迷、糖尿病代谢

11、紊乱）第25页，讲稿共87张，创作于星期日颅内感染（脑炎、脑膜炎）第26页，讲稿共87张，创作于星期日脑血管疾病、颅脑损伤第27页，讲稿共87张，创作于星期日癫痫第28页，讲稿共87张，创作于星期日全身疾病尿毒症肝昏迷酮症酸中毒各种原因引起的脑水肿和颅内压升高代谢紊乱早孕第29页，讲稿共87张，创作于星期日Drug抗生素抗癌药洋地黄吗啡兴奋呕吐中枢或影响胃肠平滑肌运动AntibioticsAnti-carcinomaDigitalismorphia第30页，讲稿共87张，创作于星期日Neurologic&Psychogenic causesNeurologic and Psychogenic

12、causes胃肠道神经官能症（Gastrointestinal tract neurosis）神经厌食症（apositia）第31页，讲稿共87张，创作于星期日Characteristics of Nausea and Vomiting1.Time2.Taking food3.Characteristics4.Characters of contents第32页，讲稿共87张，创作于星期日晨起呕吐早孕反应功能性消化不良酒精中毒胃食管反流病鼻咽部疾患夜间或隔夜呕吐幽门梗阻贲门失弛缓症第33页，讲稿共87张，创作于星期日呕吐与进食的关系（Timing with meals）餐后即刻：神经精神性；集

13、体发病系食物中毒餐后1小时以上：为延迟性呕吐：可考虑为胃张力低下排空障碍餐后较久、多餐后或隔夜：提示幽门梗阻第34页，讲稿共87张，创作于星期日呕吐特点呕吐特点神经性或颅内高压：恶心轻、呕吐频；“喷射性呕吐”呕吐物性质呕吐物性质发酵、腐臭味：提示胃潴留粪臭味：提示较低位置的肠梗阻无酸腐味：贲门失迟缓症或胃酸缺乏不含胆汁：幽门梗阻病史较长或量多：提示体液和电解质丢失第35页，讲稿共87张，创作于星期日The accompanying symptoms腹痛、腹泻：食物中毒、肠道传染病、胃肠炎；节律性腹痛：消化性溃疡右上腹痛，伴发热、黄疸：胆囊炎、胆道结石、感染。头痛、头晕、视力异常、喷射性呕吐：颅

14、内高压性疾病、屈光不正、青光眼。伴眩晕、眼球震颤：前庭障碍育龄妇女（停经）：应排除妊娠与服药有时间关联：应想到药物反应第36页，讲稿共87张，创作于星期日问诊要点n起病情况：诱因、急缓、与进食关系、腹部手术史、育龄妇女月经史n发作时间：晨、夜、与进食、活动、体位的关系n呕吐物性状、味道n伴随症状n诊疗和症状演变情况第37页，讲稿共87张，创作于星期日History/Backgrounda)Ageb)GI history requiredc)Food intoleranced)Timing with mealse)Consistencyf)Contentg)Odorh)Frequencyi)Fe

15、verj)Weight lossk)Precipitating factorsl)Myalgias（肌痛）,visual disturbances,headache,pain outside abdomen第38页，讲稿共87张，创作于星期日CAUSES OF NAUSEA/VOMITINGnEarly pregnancynPsychogenesis vomitingnBulimia(易饿病易饿病)nPyloric channel ulcernAcute gastritisnGastric retention(潴留）潴留）nViral gastroenteritis（中毒性胃肠炎）中毒性胃肠炎

16、）nAcute gastroenteritisnMyocardial infarctionnPeritonitis（腹膜炎）nAcute obstructionnNeurological emergencynDrug toxicitynCancer therapynDrug withdrawal第39页，讲稿共87张，创作于星期日PHYSICAL EXAMnVital signsnSkinnHEENT（head,eyes,ear,nose,throat)nAbdomennNeurological第40页，讲稿共87张，创作于星期日LABORATORYnRule out obstruction

17、and peritonitisnHCGnUrinalysisnElectrolytes,BUN,creatinine,glucosenTransaminases,amylasenEKG,head CT,upper GI&/or endoscopies第41页，讲稿共87张，创作于星期日Break第42页，讲稿共87张，创作于星期日泸沽湖黄昏泸沽湖黄昏第43页，讲稿共87张，创作于星期日泸沽湖黄昏泸沽湖黄昏第44页，讲稿共87张，创作于星期日泸沽湖泸沽湖摩梭女摩梭女第45页，讲稿共87张，创作于星期日玉龙雪山玉龙雪山雪月雪月第46页，讲稿共87张，创作于星期日47第47页，讲稿共87张，创作于星

18、期日ConstipationShanghai Second Medical universityRenji clinical medical college第48页，讲稿共87张，创作于星期日Background第49页，讲稿共87张，创作于星期日Constipation Is a Constellation of SymptomsnMost commonly reported symptomsnHard,lumpy stoolsnIncreased strainingnInfrequent bowel movementsnSensation of incomplete evacuationn

19、Bloating/fullnessnChronic constipationnMore persistent than intermittent or episodicnSeveral months durationC第50页，讲稿共87张，创作于星期日Sandler RS,et al.Dig Dis Sci.1987;32:841-845.n=1128Constipation Is More Than Just Infrequent Passage of Stool53Constipation symptoms reported most often第51页，讲稿共87张，创作于星期日Red

20、uced Stool Frequency Is Not the Most Commonly Reported Symptom in ConstipationEPOC=Epidemiology of constipation;BM=Bowel movement.1.Stewart WF,et al.Am J Gastroenterol.1999;94:3530-3540.2.Par P,et al.Am J Gastroenterol.2001;96:3130-3137.Stewart(EPOC)19991Par 20012n=1476n=1149Constipation symptoms re

21、ported most oftenC第52页，讲稿共87张，创作于星期日Prevalence in the General Population1.Stewart WF,et al.Am J Gastroenterol.1999;94:3530-3540.2.Drossman DA,et al.Dig Dis Sci.1993;38:1569-1580.3.Harris Interactive Study,Wave 2.Data on file.4.Par P,et al.Am J Gastroenterol.2001;96:3130-3137.53PopulationnCriteriaPre

22、valence,n(%)US110,018 Rome I 461(4.6)US25430 Rome I 195(3.6)US315,183 Rome II2429(16)Canada41149 Rome II 171(14.9)China(18-70ys)?RomeII?(6.07)China(60ys)?RomeII?(15-20)第53页，讲稿共87张，创作于星期日EpidemiologynChronic constipation is commonnSlightly more common in women nF/M ratio=range 1.3 to 2.5(China=4:1)nA

23、ffects all age groupsStewart WF,et al.Am J Gastroenterol.1999;94:3530-3540.Par P,et al.Am J Gastroenterol.2001;96:3130-3137.Sandler RS,et al.Dig Dis Sci.1987;32:841-845.C第54页，讲稿共87张，创作于星期日Constipation Affects All Age Groups53Canadian population.Par P,et al.Am J Gastroenterol.2001;96:3130-3137.N=1149

24、n=378n=367n=217n=187第55页，讲稿共87张，创作于星期日Profile of a Typical Chronic Constipation Patient in My PracticenGenerally femalenSymptomatic for 10 yrnMajority have tried lifestyle changes,fiber,and OTC laxatives prior to seeking carenManages condition with multiple therapiesnMost often referred by a primary

25、 care physician nCopes with condition,but is not completely satisfiedC第56页，讲稿共87张，创作于星期日Constipation Can Have a Negative Impact on Quality of LifenPeople with CC reported significant impairment in QoL on SF-36 scale(n=126)1nIn Canada,people with self-reported or Rome II constipation had significantl

26、y worse SF-36 scores than the normal population(n=472)2nIn Australia,people with constipation had significantly worse SF-12 scores on both mental and physical scales(n=227)31.OKeefe EA,et al.J Gerontol A Biol Sci Med Sci.1995;50:M184-M189.2.Irvine EJ,et al.Am J Gastroenterol.2002;97:1986-1993.3.Kolo

27、ski NA,et al.Am J Gastroenterol.2000;95:67-71.C第57页，讲稿共87张，创作于星期日Constipation Significantly Impacts Healthcare Utilizationn5.7 million constipation-related outpatient visits annually1,2n4.1 million physician office-based visits n991,000 emergency room visitsn587,000 hospital outpatient visitsn$2752/

28、patient for tertiary care evaluation31.National Ambulatory Medical Care Survey,2001.www.cdc.gov2.National Hospital Ambulatory Care Survey,2001.www.cdc.gov3.Rantis PC Jr,et al.Dis Colon Rectum.1997;40:280-286.C第58页，讲稿共87张，创作于星期日Complications related with constipationvColonic and rectal carcinomavOthe

29、r colon-rectal-anus disordersvhepatic coma vacute myocardial infarctionvmammary gland disordersvpresenile dementia(早老性痴呆）vpsycho-problemsvappearance第59页，讲稿共87张，创作于星期日Definition:Causes of Chronic ConstipationnSecondarynDrug induced nMetabolic factorsnComorbid conditionsnPrimarynImpaired colonic trans

30、it/motility nAltered neuroenteric function and reflexesnFailure of muscular apparatusnIneffective defecation(functional outlet obstruction)nPelvic dyssynergia and anismusnNormal transit constipation第60页，讲稿共87张，创作于星期日Presentation ObjectivesnDefine constipationnThe pathophysiological mechanisms nEtiol

31、ogies of constipation nCharacterize manifestationnDiscriminate the accompanying symptoms.nSuggest diagnostic strategies of the symptoms.C第61页，讲稿共87张，创作于星期日What is Constipation?nPassage of hard,dry,lumpy stools;Infrequent bowel movements,usually fewer than three times a weeknSymptoms:npainful bowel m

32、ovements nstrainingnUncomfortable（Sensation of incomplete evacuation）nbloatednsluggish第62页，讲稿共87张，创作于星期日Rome II Defines Functional Constipation Based on Multiple SymptomsRome II diagnostic criteria for functional constipationnAt least 12 wk,which need not be consecutive,over the past 12 months of 2

33、or more of nStraining*nLumpy or hard stools*nSensation of incomplete evacuation*nSensation of anorectal obstruction/blockage*nManual maneuvers to facilitate defecation*n 1/4 of defecations.Drossman DA,et al.In:Rome II:The Functional Gastrointestinal Disorders.2000:382-391.C第63页，讲稿共87张，创作于星期日Normal m

34、etabolismnAs food moves through your intestines,it absorbs water while forming waste products nMuscles contract in the colon,pushing the stool toward the rectum第64页，讲稿共87张，创作于星期日Defecation ProcessnYield awareness of defecation nAnal intra-and extra-sphincter RelaxationnAbdominal effects第65页，讲稿共87张，创

35、作于星期日Mechanical stimulation1.Yield awareness of defecation第66页，讲稿共87张，创作于星期日2.Anal intra-and extra-sphincter Relaxationintra-sphincterextra-sphincterLevator ani muscle第67页，讲稿共87张，创作于星期日2.Abdominal effectsgastric contents via anus第68页，讲稿共87张，创作于星期日What Causes Constipation?nEating too little fiber nNo

36、t drinking enough liquidsnLack of exercise/physical activity第69页，讲稿共87张，创作于星期日What Causes Constipation?nChange in routinentravelnOlder agenSlower metabolismnFrequent use of laxativesnCertain diseases or conditions第70页，讲稿共87张，创作于星期日What Causes Constipation?nCertain diseases or conditionsnRectal and A

37、nal disordersnColonic disordersnSystemic diseases or conditions第71页，讲稿共87张，创作于星期日What Causes Constipation?npain(narcotics麻药)nantacids containing aluminumnantidepressantsniron supplementsndiuretics(“water”pills)Medications第72页，讲稿共87张，创作于星期日Classification of etiologiesnEating too little fiber nNot dri

38、nking enough liquidsnLack of exercise/physical activitynChange in routinenTravelnpsycho-relatednOlder agenSlower metabolismnFrequent use of laxativesntediously long ColonnMedicationsnTravelnpain(narcotics麻药麻药)nantacids containing aluminumnantidepressantsniron supplementsndiuretics(“water”pills)Funct

39、ional etiologies第73页，讲稿共87张，创作于星期日psycho-related第74页，讲稿共87张，创作于星期日Tediously long Colon结肠冗长第75页，讲稿共87张，创作于星期日 Organic constipation(certain diseases or conditions cause constipation)Classification of etiologiesnRectal and Anal disordersnBenign or malignancy tumornTumor or mass outsidenSystemic disease

40、s or conditions(e.g.disorders make dyscinesia:spasm and paralysis）第76页，讲稿共87张，创作于星期日Rectal and Anal disordersCancerNevusanal fissureanal fistulaProctoptosis(直肠脱垂）第77页，讲稿共87张，创作于星期日intestinal obstruction第78页，讲稿共87张，创作于星期日Benign or malignancy tumorPolypCancer第79页，讲稿共87张，创作于星期日Outside tumor or mass第80页

41、，讲稿共87张，创作于星期日Systemic diseases or conditionsGastro-paresisDiabetes mellitus;DMUremiaMyasthenia gravisHypothyroidismHematoporphyriaLead poisoning胃轻瘫糖尿病尿毒症重症肌无力甲状腺机能低下血卟啉病铅中毒第81页，讲稿共87张，创作于星期日Characteristics of manifestation急性便秘常伴随原发病的表现：腹痛、腹胀、恶心呕吐、排气停止，见于各种原因的肠梗阻。慢性便秘可有消化不良症状：便秘型IBS：大便形状：1.散粒2.团粒3.柱

42、粒4.条形5.堆6.片7.水第82页，讲稿共87张，创作于星期日Accompanying symptoms1。呕吐、腹胀、肠绞痛，提示肠梗阻2。伴包块：提示肿瘤、肠结核、Crohn病3。便秘腹泻交替：肠结核、IBS、UC4。继发于生活、环境改变：功能性Intestinal obstructionTumor,TB,Crhons diseaseTB,IBS,UCFunctional constipation1.Vomiting,abdominal distention,Intestinal colic2.Mass3.With diarrhea alternatively4.Change in ro

43、utine第83页，讲稿共87张，创作于星期日第84页，讲稿共87张，创作于星期日第85页，讲稿共87张，创作于星期日Important information for etiological diagnosisa)Ageb)GI history requiredc)Food habitd)Condition related(living,working,communicating,psychology)e)Consistency f)course of diseasesg)Frequency h)form,texture,Odor,Content,i)Increased straining,Sensation of incomplete j)Weight lossk)Precipitating factorsl)Medicationsm)Disorders outside gastroenterology第86页，讲稿共87张，创作于星期日感谢大家观看第87页，讲稿共87张，创作于星期日