上海交大外科学肠梗阻pblppt课件

肠肠 梗梗 阻阻 上海交通大学医学院附属瑞金医院上海交通大学医学院附属瑞金医院 普外科普外科 马迪马迪 PBL教学教学 Intestinal Obstruction 肠梗阻肠梗阻 是急诊是急诊 最常见最常见 的外科急腹的外科急腹 症之一，也是外科医生症之一，也是外科医生 最不愿碰到的，最不愿碰到的， 最头痛最头痛 的外科急腹症之一。的外科急腹症之一。 诊断有时比较困难诊断有时比较困难 临床病情发展较快临床病情发展较快 需要密切临床观察需要密切临床观察 严密把握手术时机严密把握手术时机 Case one(scene1) Male , age: 65, “Paraxymal abdominal pain 48h with nausea and vomiting one day”, you are the doctor on duty. Q1. According to the chief complaint, which kind of information you should collect during ask the history? Main point of the history 1:Abdominal pain The position、 level、 kind of pain, with or without radiation ,the relationship between bowel sound and pain, paroxymal or continuing. 2:Nausea and vomiting The kind、 volumn、 color and smell of vomitus, the relationship between vomiting and pain. 3:Abdominal distention Time,level and position 4:Failure to pass flatus and feces The kind、 quantity of feces and the relationship between it and pain, if the pain relieve after pass flatus and feces. 5:Past history Case one(scene1) Q2： To make a definite diagnosis， which kind of information we should pay attention to in the next Physical Examination and Auxiliary Examination? Main point of the physical examination General Examination： T:37.2 HR:96bpm R:22bpm BP:130/70mmhg No dehydration, no anemia, no jaundice Abdominal Examination： Inspection： Distended abdomen, no peristaltic waves can be observed,previous scar in the upper abdomen. Palpation: Mild abdominal tenderness, no rebound,no guarding,no mass, no incarcerated hernia in the groin. Percussion： Tympany. Auscultation： Hyperactive bowel sounds , 6-8bpm. Rectal Examination： Negative Local pathophysiology of intestinal obstruction 肠蠕动增加1.各类刺激各类刺激 长时间强蠕动 肠麻痹 2.肠腔膨胀、积气积液 吞咽下的气体，以氮气为主，不易 向血液内弥散 长时间梗阻，肠腔内液体不再回流入 血，而仍有液体自血液流入肠腔 3.肠壁水肿、通透性增加 梗阻近段肠腔压力升高，静脉回 流受阻。 细胞缺氧，能量代谢障碍，肠 壁通透性增加。 Q3: What is your diagnosis? Case one(scene1) Definition 49(3): 203-7. 2: Attard JA, Maclean AR. Adhesive small bowel obstruction:epi- -demiology,biology and prevention. Can J Surg, 2007;50(4):291- 300. 3: 杜晓辉，李荣，梁发启。急性血运性肠梗阻的诊治（附杜晓辉，李荣，梁发启。急性血运性肠梗阻的诊治（附 35例报例报 告）。中国现代医学杂志，告）。中国现代医学杂志， 2006;16(5):765-766。 4: Sabiston Textbook of Surgery,17th ed.&黄家驷外科学黄家驷外科学