课件：小肠疾病PPT课件.ppt

Small Intestinal Disease 中南大学湘雅医院胃肠外科 裴海平 2010.9.9,Anatomy and Physiology The anatomy of small intestine length: 35m portions blood supply：superior mesenteric a nerve：autonomic,Sympathetic Parasympathetic,duodenum:25cm jejunum :2/5 ileum:3/5,Four layers : mucosa submucosa muscularis serosa Peyerpatches,Villus mucosa The physiology of small intestine secrete alkaline intestinal juice digestion and absorption endocrine and immune,Inflammatory Bowel Disease,Crohn Disease Etiology unclear Pathology occur in any segment of the peptic tract granulomatous inflammatory lesion ，involve full-thickness bowel layer,Clinical manifestation occur in any age 60% cases40y intermittent abdominal complaint or pain digestive symptom:diarrhea others low fever fatigue poor appetite anemia and weight loss,complications intestinal obstruction 中毒性巨结肠 perforation hemorrhage carcinogenesis,diagnosis history and clinical findings barium meal and barium enema coloscopy differential diagnosis bowel tuberculosis ulcerative colitis appendicitis,treatment major therapy: medicine surgical indications: complication because its higher recurrence rate 50%,Tuberculosis of intestine etiology and pathology secondary infection position：ileum-cecum ulcerative type and proliferative type,clinical findings young low fever, night sweat，fatigue, weightloss,poor appetite chronic abdominal pain diarrhea and constipation complication,diagnosis blood routine,ESR,chest film,barium meal and barium enema,coloscopy history and clinical manifestation,treatment medical therapy surgical indication complication such as obstruction 、 fistula 、 perforation、bleeding operative ways: resect the partial bowel and anastomosis perforation repairment By-pass,Intestinal Perforation of Typhoid Fever etiology and pathology infection by bacillus typhus site: the last portion of the ileum simple perforation:80-90%,clinical findings diffuse peritonitis symptoms acute severe abdominal pain muscle guardness, tenderness and rebound tenderness major treatment repair of the perforation,Acute Hemorrhagic Enteritis etiology:unclear maybe related to toxin of Welch bacilus pathology the lesion localized in jejunum or ileum local congestion, hemorrhage,necrosis and ulceration,Clinical findings occur in children and younger acute abdominal pain accompanied by nausea, vomiting ,diarrhea , hematochezia. distention , tenderness signs of bowel of strangulation toxic shock,Treatment medical treatment (main method) keep internal environment stable fasting, gastrointestinal decompression antibiotic nutritional support,surgical indication obvious peritonitis bowel bleeding is difficult to control intestinal obstruction aggravation after medical therapy Diagnosis NOT clear,Intestinal Obstruction definition：a partial or complete blockage of the bowel results in the failure of the intestinal contents to pass through,Etiology and Classification （一）According to the obstructive cause 1、 Mechanical ：high incidence intraluminal obstruction Extrinsic bowel tract lesions Intrinsic bowel wall lesion,1） intraluminal obstruction （1） 胆结石 （2） 粪石 （3） 毛发团 （4） 异物 （5 ）肠减压管气囊 （6） 寄生虫 （7） 腔内憩室,2）lesions extrinsic to the bowel （1） 粘连：手术后；先天性；炎症后 （2） 疝：腹壁疝；腹内疝 （3） 先天性：环状胰腺；腹膜包裹 （4） 肿瘤：肠外肿瘤； 肠系膜肿瘤 （5） 炎症：腹腔内脓肿；腹腔异物 （6） 其他：肠系膜上动脉综合征；,3）intrinsic bowel wall lesions （1）肠道闭锁 （2）炎症狭窄，肠套叠，肠扭转 （3）肿瘤等,2、Dynamic (Paralytic ileus) 1）麻痹性：（1）腹腔手术后； （2）腹部创伤； （3）急性弥漫性腹膜炎 2）痉挛性：（1）急性肠炎； （2）肠道功能紊乱； （3）慢性铅中毒；,3、Hematogenesis 血运性肠梗阻 肠系膜血管栓塞或血栓形成致使肠管发生血运障碍,4、 Idiopathic Intestinal Pseudo-Obstruction,Chronic illness, recurrence Heredity Impaired motor response to bowel distention Duodenal,colonic slow waves normal Absence of radiogaphic findings of mechanical obstruction Non-surgical treatment,（二） According to the blood supply of the bowel wall 1、simple 只有肠内容物通过受阻，无肠管血 运障碍。 2 、strangulation 梗阻伴有肠管血运障碍，例如：肠系膜血管栓塞,（三）按梗阻部位 1 高位梗阻：空肠及近段回肠 2 低位梗阻：结肠及远段回肠 （四）按梗阻程度 1 不完全性肠梗阻 2 完全性肠梗阻 （五）按病程缓急 1 急性肠梗阻 2 慢性肠梗阻 （六）特殊类型：闭袢性肠梗阻,粘连,肠套叠,嵌顿,扭转、粪性,蛔虫性,Pathology and Pathophysiology pathology （acute） proximal bowel distention luminal pressure venous return hindrance congestin,edema, exudation pressure artery return hindrance necrosis and perforation,Chronic intestinal obstruction incomplete long time bowel wall hypertrophy intestinal pattern and peristaltic waves,Pathophysiology the loss of body fluid：water and electrolyte disorder and metabolic imbalance (The intestinal tract secretes up to 8.0L/d ) infection and intoxication ：the damage of intestinal barrier and bacteria translocation, toxin absorption,shock：dehydration、blood concentration、hypovolemia 、metabolic disorder、bacteria infection and intoxication respiratory and circulation dysfunction：abdominal pressure increased abdominal compartment hypertension,临床表现症状,痛、呕、胀、闭,痛,呕,胀,Clinical Manifestation Abdominal pain Vomiting Distention Failure to pass gas and stool,单纯性机械性肠梗阻 反复发作的、节律性的、阵发性腹部绞痛 绞窄性肠梗阻 腹痛间歇不断缩短 持续性腹痛 疼痛程度不断加重 麻痹性肠梗阻 持续性胀痛,Vomiting Early reflectivity Paralysis overflow High position early and frequently Low position late and few,Distention 高位-不明显 低位-显著，遍及全腹 闭袢性(closed loop),腹周膨胀 结肠闭袢,腹胀不对称 肠扭转,Failure to pass gas and stool 完全性肠梗阻 停止排便排气 高位肠梗阻 早期梗阻以下的残留气体和粪便仍可排出 肠套叠和血运性肠梗阻（绞窄） 可排出血性或果酱样便,Examination Abdominal signs： Abdominal bulge, gastrointestinal patterns and peristaltic waves, tenderness and rebound tenderness, positive shift dullness, high pitched bowel sound or bowel silence in late stage and bowel paralysis Digital rectal examination,Lab test：the results with the change of the primary disease itself Early stage: normal or slight abnormal Late stage: disorder of many serum markers,X-ray： Supine and upright abdominal radiographs with stepladder pattern of air-fluid levels and no colonic gas note: The barium enema is need if the intussusceptions ,sigmoid rotation or colon tumor are suspicious.,In small-bowel obstruction, radiologic evaluation has several goals. It is carried out to confirm the diagnosis, distinguish between simple and strangulating obstruction, differentiate the various causes of obstruction, estimate the degree of obstruction, and exclude the possibility of colonic obstruction or paralytic ileus,2019/4/20,57,可编辑,Diagnosis is it intestinal obstruction? history clinical findings X-ray examination is it mechanical or dynamic？ history X-ray findings,Simple or Strangulation （Very Important） Acute and persistent severe abdominal pain Emergently and early shock Severe peritoneal irritation sign Asymmetric distention ，palpable mass Bleeding content of vomitus , discharge and abdominal paracentesis X-ray shows isolated ansa interstinalis Medical treatment failure,The Obstructive Site: Low or High High:vomitting occur in early stage and show slight abdominal distention Low: severe abdominal distention X-ray findings,Complete or Incomplete complete: severe and acute incomplete: chronic and slight The Cause of Obstruction Always very difficult to identificate History is very important,Treatment Principles： Correct the systemic pathophysiologic disorder Relieve obstruction。,Basic Treatment Naso-gastric suction Correct body fluid disorder Prevent infection and intoxication General treatment:sedation,spasmolysis,Remove the Obstruction Surgery Indications：strangulation、caused by tumor and congenital bowel malformation, can not relieved by medical therapy Aims：utility the simplest methods to remove the obstruction and recover the continuity of the bowel in the shortest time,Methods Remove the cause ： Such as adhesion remove,foreign body taken out、replacement of intussusception and volvulus Intestinal resection and anastomosis: tumor,stenosis,necrosis,How to judge the intestinal necrosis in the operation ? The bowel wall is black No peristaltic capability and tension No pulsation of mesenteric terminal arteriole,Bypass operation: The lesion is difficult to remove Enterostomy or Intestinal exteriorization The patients condition cannot tolerance the complicated operation or the obstructive lesion is difficult to treat,手术方式 A.解除梗阻原因的术式 如粘连松解术,如肠切开取异物，肠扭转复位术。,B.肠切除肠吻合术 C.短路手术,D.肠造口和肠外置术,Medical treatment Indications： simple adhesive obstruction, paralysis or dynamic ileus、obstruction because of ascarid or stoolmass,inflammatory obstruction and early stage of intussusception Notes： The state of illness should be monitor closedly during medical treatment,Common types Adhesive Obstruction（40%60%） Obstruction due to adhesions,Etiology and pathology Congenital Secondary Diagnosis Mechanical obstruction+ history of abdominal operation, infection or trauma *如何区分广泛粘连梗阻与局部束带梗 阻？,Prophylaxis: more significance 减少组织损伤，减轻组织炎症反应 Treatment: simple, incomplete medical therapy strangulation surgical therapy,Intestinal Volvulus(3600) Obstruction due to volvulus,Etiology Anatomic factors: Excessive long mesenterium Adhesion Physical factors: Enteric body Dynamic factors: Abnormal bowel motivation Alter the body position suddently Slight4800,Clinical findings closed loop： acute / severe Small bowel: younger, motion after meal pain in the periumbilicus Sigmoid: aged, constipation habits Treatment: It is a severe mechanical obstruction emergent operation,Obstruction by foreign body（肠蛔虫、粪块等） A simple mechanical bowel obstruction 蛔虫成团+肠管痉挛 Treatment :medical therapy and necessary surgery,Bowl Ascariasis,Children,countryside Medical therapy,Intussusception,Obstruction due to intussusception,Etiology anatomy:cecum too free pathological factors:polyp ,tumor abnormality of intestine Types intestine-intestine intestine-colon colon-colon,Clinical findings 80%,2y children Abdominal pain ,currant-jelly stool, sausage-shaped mass Coil-spring sign Air or Barium enema Reduction,Treatment: Gas or barium enema(youngers). Operation :manual reduction bowel resection,肠系膜血管缺血性疾病 etiology and pathology 1.superior mesenteric artery embolus 2.superior mesenteric arterial thrombosis 3.superior mesenteric venous thrombosis 4.others: non-mesenteric vascular ischemia ischemia necrosis,Clinical manifestation history of coronary heart disease or atrial fibrillation acute abdominal cramp severe symptom and slight abdominal sign in the early stage Diagnosis abdominal film, angiography (DSA),Treatment: Key point: Early diagnosis and reasonable therapy Vasodilating agent Surgical therapy Embolectomy Vascular bypass Intestinal resection and anastomosis,Case1: Male,25 years old, complains of abdominal pain and distention for 2 days. PE: P 80, abdominal bulge, intestinal patterns and peristaltic waves, high-pitched bowel sound. Past history: He underwent appendectomy 3 month ago. Diagnosis and treatment?,Case2: male,68 years old, complains of abdominal bowel motion for 3month,abdominal distention and stop pass gas and feces for 2 days. PE: P 90, Bp 130/70mmHg, abdominal bulge, intestinal patterns and peristaltic waves, high-pitched bowel sound. Diagnosis and treatment? Which examintation should be undergone for diagnosis?,Short Bowel Syndrome Definition: Short Bowel Syndrome (SBS) is defined as malabsorption resulting from anatomical or functional loss of a significant length of the small intestine .,Pathophysiology The majority of carbohydrate , protein ,fats, vitamins, bile salts absorption takes place in the small bowel. 100cm severe influence body fluid disorder and malnutrition,Clinical findings First symptom:diarrhea,the severity relates to the length of residual bowel Weight loss, fatigue, malnutrition ,body fluid disorder,Treatment Correct imbalance of metabolism and electrolyte Nutritional support,total parenteral nutrition partial parenteral nutrition enteral nutrtion,The first stage (2month) TPN and correct the fluid disorder The second stage (12y) PPN+EN The third stage EN or PPN+EN May be sustain one life,It need long-term regular nutrition monitoring to prevent problems associated with fluid, macro- and micro-nutrient malabsorption . Since they are at high risk for dehydration and bacterial overgrowth, they need prompt medical attention any time they have symptoms of gastroenteritis.,Intestinal