肠梗阻 ppt课件

肠 梗 阻,INTESTINAL OBSTRUCTIONRuiJin hospital Zhang Haobo,Introduction,肠内容物不能正常运行, 顺利通过肠道。,病 因 学,机械性梗阻 肠腔阻塞:结石、粪块、异物 肠管受压:粘连带、肠扭转、疝 肠壁病变：肿瘤、炎性、先天性动力性肠梗阻 麻痹性：神经、毒素、炎性 痉挛性：肠动力紊乱、铅中毒血运性肠梗阻 肠系膜血管栓塞或血栓形成,肠梗阻是否伴血运障碍 单纯性/绞窄性肠梗阻部位 高位：空肠上段 低位：回肠末段 结肠梗阻肠梗阻程度： 不完全性/完全性发展进程： 急性/慢性,病理生理,病理生理,Clinical Appearance,腹痛呕吐 便秘停止排气,Physical Examination,视 诊腹张Abdomen distention蠕动波Peristalic wave手术疤痕Surgical scars嵌顿疝Incarcerated hernias,触 诊腹张腹块腹肌紧张腹膜炎,Physical Examination,腹部听诊 肠鸣音亢进 直肠指检,Laboratory Tests,血浆电解质和PH值Blood WBC Hematocrit Serum amylase BUN ,X射线检查Radiologic Examination,诊断正确率 8085%平卧位 立位 侧卧位 急性完全性机械性梗阻,Radiologic Examination,小肠梗阻Small intestinal OB 小肠黏膜呈鱼刺样 valvulae conniventes 肠段位于腹中部 central portions 小量/无结肠气体 minimal /no colonic gas,结肠梗阻 Colon Obstruction 结肠袋影 colonic haustral marking 扩张肠段位于腹部外周/盆腔 periphery of abdomen/in the pelvic,1.有否肠梗阻？ Does the patient have bowel obstruction?2.梗阻在那一段肠段 If so , where is it?3.病因是什么？ What is the anatomic and pathologic nature ?4.是否存在绞榨性肠梗阻 Has strangulation occurred?5.患者全身情况如何？ What is the general condition of the patients?,诊 断 Diagnosis,临床表现Clinical Appearance,腹痛 Abdominal pain 呕吐 Vomiting便秘 Obstipation腹张 Abdominal distention停止排气 Failure to pass flatus,鉴别近端和远端梗阻Differentiation of Proximal / distal SBO: pain: epigastric / periumbilical area vomiting: prominent / later onset distention: no / predominate,鉴别部分梗阻和完全性梗阻Differentiation of partial from complete SBO Partial SBO: pass flatus or liquid stools Complete SBO: obstipation,单纯性和绞榨性肠梗阻的鉴别,单纯性肠梗阻腹痛 阵发性 轻度-中度呕吐 较少休克 无，少见发热 不常见腹痛和肌卫 少见对补液治疗 有效,绞榨性肠梗阻腹痛 持续性 重度呕吐 严重休克 早、常见发热 明显腹痛和肌卫 早、明显对补液治疗效果 差,治 疗Treatment of SBO,保守治疗和手术治疗 Medical and surgical management三个连续的阶段：观察、治疗、手术 The overlapping sequence :investigation resuscitation operation手术时机的把握：The timing of operation depends on three factors: 病程 duration 重要器官的功能opportunity of vital organ function绞榨的可能 risk of strangulation,The timing of operation depends on three factors: 病程 duration 器官功能 opportunity of vital organ function 绞榨的可能 risk of strangulation,Medical managment,胃肠减压Nasointestinal /nasogastric intubation 纠正水电解质的紊乱Intravenous fluids /blood plasma administration广谱抗菌素的应用Broad-spectrum antibiotics administration,Surgical principle,病因 The nature of problem determines approach to management of SBO.肠管活性的判断：色泽、活力、动脉搏动 The criteria of determining bowel viability: color motility arterial pulsation处理 If questionable , released and placed ,re-examined.,结肠梗阻Large Bowel Obstruction,病因学 Etiologycarcinoma 55%volvulus 11%diverticulitis 9%extrinsic carcinoma 8%adhesions 4%fecal impaction 3%,Daignosis,慢性梗阻 Chronic complaints腹痛位于下腹部和脐周 Pain related to lower abdomen or periumbilical area.腹胀明显 Abdominal distension prominent隐血试验 Guaiac-positive stools直肠指检 Rectal examination,Management,直肠乙状结肠镜 Proctosigmoidoscopy visualized/biopsied/decompressed结肠梗阻大多数需要手术治疗 Most large bowel obstruction need surgery expcet for fecal impaction闭襻性梗阻需急症手术 Closed loop obstruction need emergency分期手术 one/two/three -stage surgical procedures,肠粘连 Adhesive obstruction,形成： 粘连锐角 纤维束带压迫 surgical trauma infections bleeding intestinal ischemia chemical trauma foreign bodies （powder）肠坏死 Risk of strangulation: 9%再次手术 肠排列手术 ( M-A管),疝源性肠梗阻,外疝: 下腹痛, 腹外疝好发部位肿块 ,无法回纳 手术松解疝环, 疝修补, 坏死肠段切除。内疝: 疝环为先天或手术形成腹内间隙. 多为闭襻性, X线平片仅为一致密影 . 症状剧烈, 病情急骤, 诊断困难, 需急诊手术,肠套叠Intussusception,Intussusceptum telescopes into an intussuscipiens(sheath)enteroenteral ,ileocecal,ileocolic ,colocolic children rate is high1/3 cases of adults is malignancies resection is necessary( 香肠状, 空虚感, 粘液血便),肠扭转Volvulus,Most patient are elderly mensigmoid 60%70%psychiatric disorders an