双语教学查房胆囊结石课件

双语教学查房BWR- 胆囊结石Cholecystolithiasis,:,一、病 史 Course of Disease,主诉:反复发作的右上腹疼痛半年余，再发三天 患者:张运友，男，49岁,诉进食油腻食物后出现右上腹痛，呈持续性胀痛，向腰背部放射，无发热 、恶心、呕吐、腹胀、腹泻、黄疸，无尿频、尿急、尿痛等症状，患者自发病以来，精神、饮食、睡眠尚可。,2013-7-10到我院检查，B超提示：胆囊结石，收住我科。 入院时：T:36.4 P:60次分 R：19次/分 BP：11070mmHg 体重：70Kg。,腹部检查：腹软不胀，无压痛、反跳痛，墨菲氏征（+），腹式呼吸存在。肝肾区无叩痛，肠鸣音4次分，无血管杂音。 既往史：既往健康，家中无特殊病史，无外伤史、过敏史，预防接种不详。无饮酒嗜好，抽烟30年。,The Case: The patient has a right upper abdominal pain again and again more than six months, has terrible pain three days. Zhang Yunyou, male,49 years old, the patient complain of right upper quadrant abdominal pain witch radiate to back.and remaining persistent pain after eating high fat food. He has no fever, nausea, vomiting, abdominal distension, diarrhea, jaundice, no frequent micturition, urgency,dysuria symptoms, since attack this disease . His sprite ,diet ,sleep is well. The B ultrasound exam in the hospital in 10.july.2013 is cholecystolithiasis,Temprature is 36.4 .Pulse is 60 times per minute. Respration is 19 times per minute. The Blood pressure is 110 to 70 minimigh. The body weight is 70 kilogram. Abdominal examination: the abdomen is soft,has no expansion, no tenderness, rebound tenderness. The Murphys sign is positive.He has the abdominal breathing. Percussion pain without hepatorenal area, bowel sound is 4 times per minute, no vascular murmur.Previous health status is good, no special history of relationship, trauma and allergic. The vaccination is unknown. He had no behaviour of drink and smok about 30 years.,Physical Examination,二、体格检查,胆囊结石的定义是什么? The definition of the cholecystolithiasis,三、相关知识Relevant Knowledge,胆囊结石cholecystolithiasis： 指发生在胆囊内的结石，主要为胆固醇结石或以胆固醇为主的混合型结石，常用急性胆囊炎并存。女性多见。,（一）病因Etiology,形成结石的常见原因有：,长期三高饮食,胆固醇,胆固醇过饱和,胆盐的丧失,胆汁潴留时间过长,胆囊收缩功能减退,胆道感染,其他（溶血，胆汁淤滞,胆囊排空延迟.）,Long-term high-protein, high-fat, high-calorie diet the loss of bile salts bile stay in the gallbladder too long biliary infection Long-term fasting,intravenous nutrition Others(gastrectomy,vagus nerve axotomy surgery),胆结石,（二）病理生理pathophysiology,实质上,所有胆结石都 是在胆囊内形成的,但在 由于胆汁淤积所致的胆 囊管狭窄处后端和胆囊 切除后的胆管内亦可形 成结石.,胆汁中胆固醇的过度饱和 是胆固醇结石形成的必要 条件,但并不是唯一原因. 因为在没有胆结石的禁食 者,其胆固醇往往也呈过度 饱和状态.其他决定胆结石 形成的关键因素包括胆石 形成的最初过程,Cholesterols over saturation of bile is a necessary condition for the formation of gallstones,but not the only reason. Because the fasting havent gallstones,the cholesterol ofen is over saturated.So other key factors of gall-stones formation also include the initial process of gall-stone formation.thats the regulation of individual crytral formation. It includes some proteins or aplipoproteins, gallbladder mucin and gallbladder bile stasis role.,In fact, all gall-stones are formed in the gallbladder, but due to bile stasis induced cystic ductstenosis and after resection of gallbladders cystic duct also can formed stones.,？,胆囊结石有什么 症状和体征呢,胆绞痛 The biliary colic,（四）临床表现Clinical Manifestation,胆绞痛 The biliary colic,典型症状 右上腹、后上腹部 阵痛或持续性阵发性加重，可放射 饱餐、食油腻食物或体位改变,classical symptom,Upper abdomen 、 right upperquadrant Labor pains or persistent paroxysmal increase Feast, eating rich food, or position change,上腹隐痛 The upper abdomen ache,食油腻食物、紧张、疲劳 饱胀不适、嗳气、呃逆 Full bilge unwell, belching, hiccups,胆囊积液 The gallbladder effusion,长期嵌顿或阻塞未合并感染，胆囊黏膜吸收胆汁中的胆色素。分泌黏液性物质，形成胆囊积液，积液呈透明无色，又称为白胆汁。,体征sign,1.压痛、反跳痛和肌紧张 Tenderness, rebound tenderness and muscle tension 2.黄疸 jaundice,胆囊结石的主要辅助检查有哪些？ What are the main auxiliary of gallstones,1、首选B超：可见强回声团伴声影，随体位移动 2、CT,MRI,胆囊结石的治疗Treatment,最佳选择是胆囊切除术 手术方式：腹腔镜胆囊切除术（LC） 开腹胆囊切除术（OC） 小切口胆囊切除术（OM） 综合患者的病情和辅助检查等各方面情况，决定行腹腔镜胆囊切除术。,The treatment of gallbladder stones: the bestchoice is cholecystectomy, asymptomatic gallstones without active surgical treatment, Operation method: laparoscopic cholecystectomy(LC) open cholecystectomy(OC) open mini-cholecystectomy(OM).,与结石突然嵌顿，胆汁排空受阻致胆囊强烈收缩或激发感染有关,与不能进 食和手 术前后需要 禁食有关,与继发胆囊 感染有关,与发热， 食欲不振 有关,Nursing measures,护 理 措 施,术前护理,术后护理,疼痛护理,合理饮食,术前准备,体位,LC术后护理,T管的护理,并发症,（一）疼痛护理 Pain therapy,评估疼痛Pain therapy 了解诱因及缓解因素 消炎利胆、解痉镇痛药物 Anti-inflammatory and cholagogic, spasmolysis analgesic drugs,（二）合理饮食 the care of diet,低脂Low fat 防诱发急性胆囊炎而影响手术,To prevent induced acute cholecystitis and surgery specially to preoparation of LC,（二）术前的特殊准备,皮肤准备 （1）清洗脐部 Skin preparation 呼吸道准备 （1）呼吸功能锻炼 （2）避免感冒 （3）戒烟,Avoid cold quit smoking,（三）体位 position,舒适体位：协助病人取舒适体位，有节律的呼吸，达到放松和减轻疼痛的效果。 深呼吸 Assist the patient to comfortable postures, rhythmic breathing, to achieve the effect of relax and relieve pain,（四）术后护理 the nursing care of LC,饮食指导 Diet guide ： 术后禁食小时。术后小时内饮食以无脂流质、半流质为主，逐渐过渡至低脂饮食。 高碳酸血症的护理 Hypercapnia care： 予低流量吸氧，鼓励病人深呼吸，有效咳嗽,高碳酸血症的表现: 呼吸浅慢、 二氧化碳分压升高。,并发症的观察与护理,生命体征 腹部体征 引流情况 若病人出现发热、腹胀和腹痛等腹膜炎表现，或腹腔引流液呈黄绿色胆汁样，常提示发生胆瘘。一旦发生，及时报告医师并协助处理。,Observating vital signs, signs of abdomen, and drainage. If the patients fever, abdominal pain and abdominal distention peritonitis, or abdominal drainage fluid was yellow-green bile samples, often hint biliary fistula. Once happened, timely report the doctor and assist processing.,T管的护理-T tube cares,妥善固定 Fixed properly 保持有效引流 Maintain effective drainage 观察并记录引流液的颜色、量和性状 预防感染 To prevent infection 拔管 Tube drawing,平卧时引流管的高度不能高于腋中线，站立或 活动时应低于腹部切口，以防止胆汁逆流引起 感染。若引流袋的位置太低，可使胆汁流出过 量，影响脂肪的消化和吸收。T管不可受压、 扭曲、折叠，经常予以挤捏，保持引流通畅。,the hypothesis when the height of the drainage tube can not be higher than that of the middle route of t