恶心呕吐讲诉.ppt

健康快乐每一天！,临床诊断学,上海第二医科大学仁济临床医学院,Nausea and Vomiting As the symptoms,症状学：恶心与呕吐,Goals,Briefly define Outline the prominent disease states associated with nausea and vomiting. Characterize Nausea and Vomiting caused by the prominent disorders Discriminate the accompanying symptoms. Suggest diagnostic strategies of the symptoms.,Definition of Nausea and Vomiting,Nausea ：the inclination or feeling of imminent desire to vomit, usually felt in the throat or epi-gastrum. Associated with decreased activity of the stomach. Vomiting： the forceful oral expulsion of gastric contents via retro-peristalsis. Nausea-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！,Nausea and Vomiting,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 abdominal musculature that frequently precedes or accompanies vomiting. 3. Vomiting - the forceful oral expulsion of gastric contents via retroperistalsis. (Abdominal effects).,迷走兴奋表现,恶心,干呕,呕吐,发生机制,呕吐区别于反食,呕吐：多数情况有恶心的感觉和呕吐反射的协调动作。,反食：无恶心的感觉和呕吐反射的协调动作。（儿童、饱餐）,Mechanisms of emesis,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,CTZ & Emetic Center (Vomiting center),孤束核,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,Neurotransmitters in CTZ & Emetic Center,Neurotransmitters involved in stimulating the emetic center, chemo-receptor trigger zone and GI tract include; 5-HT, acetylcholine, histamine, dopamine (opiates and receptors for benzodiazepines are also found here),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,nausea and vomiting,1. Reflective vomiting 反射性呕吐 2.Central vomiting 中枢性呕吐 3. Neurological vomiting 神经性呕吐,Reflective vomiting （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 Mechanisms Gastrointestinal Mechanisms Disease of biliary tract Peritoneal and mesentery the five sense organs Cardiovascular diseases kidney Pelvic,咽部刺激,Pharyngal Mechanisms,Gastrointestinal Mechanisms,肝、胆、胰腺,其他,Intra-cranial infection Cerebrovascular disorders Craniocerebral injury Epilepsy Metabolic disorders Drugs,Central vomiting （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、糖尿病代谢紊乱）,颅内感染（脑炎、脑膜炎）,脑血管疾病、颅脑损伤,癫痫,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,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,Antibiotics Anti-carcinoma Digitalis morphia,Neurologic & Psychogenic causes,Neurologic and Psychogenic causes,胃肠道神经官能症（Gastrointestinal tract neurosis） 神经厌食症（apositia）,Characteristics of Nausea and Vomiting,Time Taking food Characteristics Characters of contents,夜间或隔夜呕吐,幽门梗阻,贲门失弛缓症,呕吐与进食的关系 （ Timing with meals）,餐后即刻：神经精神性；集体发病系食物中毒,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,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,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,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,问诊要点,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 发作时间：晨、夜、与进食、活动、体位的关系 呕吐物性状、味道 伴随症状 诊疗和症状演变情况,History/Background,a) Age b) GI history required c) Food intolerance d) Timing with meals e) Consistency f) Content,g) Odor h) Frequency i) Fever j) Weight loss k) Precipitating factors l) Myalgias（肌痛）, visual disturbances, headache, pain outside abdomen,CAUSES OF NAUSEA/VOMITING,Early pregnancy Psychogenesis vomiting Bulimia(易饿病) Pyloric channel ulcer Acute gastritis Gastric retention(潴留） Viral gastroenteritis（中毒性胃肠炎） Acute gastroenteritis,Myocardial infarction Peritonitis（腹膜炎） Acute obstruction Neurological emergency Drug toxicity Cancer therapy Drug withdrawal,PHYSICAL EXAM,Vital signs Skin HEENT （head,eyes,ear,nose,throat) Abdomen Neurological,LABORATORY,Rule out obstruction and peritonitis HCG Urinalysis Electrolytes, BUN, creatinine, glucose Transaminases, amylase EKG, head CT, upper GI &/or endoscopies,Break,泸沽湖黄昏,泸沽湖黄昏,泸沽湖摩梭女,玉龙雪山雪月,47,Constipation,Shanghai Second Medical university Renji clinical medical college,Background,Constipation Is a Constellation of Symptoms,Most commonly reported symptoms Hard, lumpy stools Increased straining Infrequent bowel movements Sensation of incomplete evacuation Bloating/fullness Chronic constipation More persistent than intermittent or episodic Several months duration,C,Sandler RS, et al. Dig Dis Sci. 1987;32:841-845.,n = 1128,Constipation Is More Than Just Infrequent Passage of Stool,53,Constipation symptoms reported most often,Reduced Stool Frequency Is Not the Most Commonly Reported Symptom in Constipation,EPOC = 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) 19991,Par 20012,n = 1476,n = 1149,Constipation symptoms reported most often,C,Prevalence in the General Population,1. 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.,53,Epidemiology,Chronic constipation is common Slightly more common in women F/M ratio = range 1.3 to 2.5 (China=4:1) Affects all age groups,Stewart 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,Constipation Affects All Age Groups,53,Canadian population. Par P, et al. Am J Gastroenterol. 2001;96:3130-3137.,N = 1149,n = 378,n = 367,n = 217,n = 187,Profile of a Typical Chronic Constipation Patient in My Practice,Generally female Symptomatic for 10 yr Majority have tried lifestyle changes, fiber, and OTC laxatives prior to seeking care Manages condition with multiple therapies Most often referred by a primary care physician Copes with condition, but is not completely satisfied,C,Constipation Can Have a Negative Impact on Quality of Life,People with CC reported significant impairment in QoL on SF-36 scale (n = 126)1 In Canada, people with self-reported or Rome II constipation had significantly worse SF-36 scores than the normal population (n = 472)2 In Australia, people with constipation had significantly worse SF-12 scores on both mental and physical scales (n = 227)3,1. 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. Koloski NA, et al. Am J Gastroenterol. 2000;95:67-71.,C,Constipation Significantly Impacts Healthcare Utilization,5.7 million constipation-related outpatient visits annually1,2 4.1 million physician office-based visits 991,000 emergency room visits 587,000 hospital outpatient visits $2752/patient for tertiary care evaluation3,1. National Ambulatory Medical Care Survey, 2001. 2. National Hospital Ambulatory Care Survey, 2001. 3. Rantis PC Jr, et al. Dis Colon Rectum. 1997;40:280-286.,C,Complications related with constipation,Colonic and rectal carcinoma Other colon-rectal-anus disorders hepatic coma acute myocardial infarction mammary gland disorders presenile dementia(早老性痴呆） psycho-problems appearance,Definition: Causes of Chronic Constipation,Secondary Drug induced Metabolic factors Comorbid conditions Primary Impaired colonic transit/motility Altered neuroenteric function and reflexes Failure of muscular apparatus Ineffective defecation (functional outlet obstruction) Pelvic dyssynergia and anismus Normal transit constipation,Presentation Objectives,Define constipation The pathophysiological mechanisms Etiologies of constipation Characterize manifestation Discriminate the accompanying symptoms. Suggest diagnostic strategies of the symptoms.,C,What is Constipation?,Passage of hard, dry, lumpy stools; Infrequent bowel movements, usually fewer than three times a week Symptoms: painful bowel movements straining Uncomfortable（Sensation of incomplete evacuation） bloated sluggish,Rome II Defines Functional Constipation Based on Multiple Symptoms,Rome II diagnostic criteria for functional constipation At least 12 wk, which need not be consecutive, over the past 12 months of 2 or more of Straining* Lumpy or hard stools* Sensation of incomplete evacuation* Sensation of anorectal obstruction/blockage* Manual maneuvers to facilitate defecation* 3 defecations/wk Loose stools not present Insufficient criteria for IBS,* 1/4 of defecations. Drossman DA, et al. In: Rome II: The Functional Gastrointestinal Disorders. 2000:382-391.,C,Normal metabolism,As food moves through your intestines, it absorbs water while forming waste products Muscles contract in the colon, pushing the stool toward the rectum,Defecation Process,Yield awareness of defecation Anal intra- and extra-sphincter Relaxation Abdominal effects,Mechanical stimulation,1. Yield awareness of defecation,2. Anal intra- and extra-sphincter Relaxation,intra- sphincter,extra-sphincter,Levator ani muscle,2. Abdominal effects,gastric contents via anus,What Causes Constipation?,Eating too little fiber Not drinking enough liquids Lack of exercise/physical activity,What Causes Constipation?,Change in routine travel Older age Slower metabolism Frequent use of laxatives Certain diseases or conditions,What Causes Constipation?,Certain diseases or conditions Rectal and Anal disorders Colonic disorders Systemic diseases or conditions,What Causes Constipation?,pain (narcotics麻药) antacids containing aluminum antidepressants iron supplements diuretics (“water” pills),Medications,Classification of etiologies,Eating too little fiber Not drinking enough liquids Lack of exercise/physical activity Change in routine Travel psycho-related Older age Slower metabolism,Frequent use of laxatives tediously long Colon Medications Travel pain (narcotics麻药) antacids containing aluminum antidepressants iron supplements diuretics (“water” pills),Functional etiologies,psycho-related,Tediously long Colon,结肠冗长,Organic constipation (certain diseases or conditions cause constipation),Classification of etiologies,Rectal and Anal disorders Benign or malignancy tumor Tumor or mass outside Systemic diseases or conditions (e.g. disorders make dyscinesia: spasm and paralysis）,Rectal and Anal disorders,Cancer Nevus anal fissure an