急腹症的诊断与治疗.ppt

急腹症的诊断与治疗,腹部解剖,概念,急性腹痛：,急性腹痛是临床常见的一种症状，是机体受到外来或内在刺激后产生的腹部不良知觉体验，具有起病急，病情重和变化快的临床特点，涉及内外、妇、儿各科，临床统称为“急腹症”。,牵涉痛（内脏牵涉痛）是某内脏的病变引起与该内脏有一定距离，体表区域产生感觉过敏或疼痛。,牵涉痛（内脏牵涉痛）：,机制,病因,1.腹膜刺激或炎症：细菌或化学刺激引起的病变。2.空腔脏器的梗阻：肠炎症、溃疡、蛔虫、结石、肿瘤等引起。3.腹腔内空腔及实质性脏器破裂4.供血失常：栓塞、血栓、扭转或压迫性阻塞。5.支持组织的紧张与牵拉。6.腹部肌肉的损伤或炎症。,1.胸腔病变：如肺炎引起上腹部的牵涉痛。2.盆腔病变：输尿管、膀胱、生殖系。3.胸腰椎病变。,糖尿病酸中毒、尿毒症引起的腹痛。,由带状疱疹、末梢神经炎引起的腹痛。,腹腔内病变,腹外临近器官的病变,新陈代谢紊乱和各种毒素影响,神经源性疾病,医师最头痛的症状学。,处理不当最易产生纠纷,尽快作出诊断，防误诊、漏诊及误治，从而改善预后。,起病急,病因繁杂，病情多变，涉及学科广，诊断处理不当，常可造成恶果。,急性腹痛早识别早诊断的意义,患者最常见的主诉。,1,急性腹痛常规的诊断流程,迅速、细致的询问病史、详细的体格检查（重视病人的生命体征BP、HR）,2,3,4,选择作一些辅助检查,动态观察病情变化，及时扑捉新的信息,综合全面的材料分析,视诊,触诊,听诊,直肠与阴道检查,腹痛伴随症状,腹病性质：绞痛、灼热痛、酸痛、撕裂痛,起病情况：腹痛发生的时间、规则性及疼痛程度,牵涉痛,叩诊,腹痛部位：痛点范围是否固定，逐渐扩大、转移,诊断,病史,体格检查,主诉：现病史,年龄性别,既往史、个人史,辅助检查,X线检查,1.膈下游离气体提示空腔脏器破裂；2.多个液气平面或较大液气平面提示肠梗阻。,实验室检查,1.白细胞计数提示有无感染；2.红细胞、血细胞比容判断有无腹腔内出血；3.尿中大量红细胞提示泌尿系损伤或结石。,对上、下消化道出血可判断出血部位，病变性质，还可内镜下止血治疗。,CT,诊断必腹腔穿刺。,B超,对实质脏器的损伤，破裂，占位可诊断。,内镜检查,急腹症综合全面的分析,起病情况,先有发热、呕吐后出现腹痛,先有腹痛，继之发热,有无先驱症状,内科急腹症,外科急腹症,腹痛部位,全腹广泛腹痛,右上腹痛,上腹及左上腹痛,肚脐周围腹痛,右下腹痛,下腹及左下腹痛,依照腹痛位置鉴别诊断,消化性溃疡及憩室穿孔合并腹膜炎,急性胰腺炎,肠阻塞及绞死,肠缺血,4,1,2,3,全腹广泛腹痛,急性胆囊炎,急性肝炎,右肾盂炎,充血性心力衰竭,4,1,2,3,右上腹痛,5,6,高位阑尾炎,右下叶肺炎,消化性溃疡,急性胰腺炎,高位小肠阻塞,急性心肌梗塞,4,1,2,3,5,左肾盂炎,上腹及左上腹痛,便秘,急性阑尾炎,小肠阻塞,肠缺血,4,1,2,3,肚脐周围腹痛,急性阑尾炎,肠系膜淋巴炎,右肾絞痛,右睾丸扭转,4,1,2,3,5,6,克隆氏肠炎,妇科疾病,右下腹痛,憩室炎,尿液存留,泌尿道感染,大肠阻塞,4,1,2,3,5,6,左肾絞痛,左睾丸扭转,下腹及左下腹痛,7,妇科疾病,呈持续性锐痛,阵发性绞痛,强烈的绞痛或持续性痛,腹膜炎,空腔脏器梗阻或扩张,脏器扭转或破裂,中毒与代谢障碍,血管梗阻,疼痛剧烈、持续,呈持续性锐痛,腹痛的性质,腹痛的特点,诱发加剧或缓解疼痛的因素,铅绞痛时患者喜按,急性腹膜炎静卧减轻,腹壁加压或改变体位时加剧,急性胃扩张常有爆食史,胆绞痛时因脂肪餐诱发,暴力作用常是肝脾破裂,腹痛时的体位,辗转不安，腹痛喜按。,活动疼痛加剧，蜷曲侧卧痛减轻,前倾坐位或膝胸位痛减轻,胃肠道疾病,腹膜炎,胰腺疾病,腹痛拒按,肝、胆系疾病,伴随情况,恶心、呕吐反射性内脏神经受刺激所致-阑尾炎,溃疡穿孔胃肠道通过障碍呕吐-较晚较重-肠梗阻腹痛后停止排便排气机械肠梗阻腹泻或里急后重-肠炎或痢疾腹痛伴血便：绞窄性肠梗阻、肠套叠、溃疡性结肠炎、坏死性肠炎、缺血性疾病(栓塞或血栓形成),伴随情况,小儿果酱样便肠套叠绞痛伴有尿频尿急尿痛泌尿系感染或结石伴有胸闷咳嗽血痰或伴有心功能不全胸膜炎肺部炎症心绞痛肺栓塞伴寒战高热急性化脓性胆道炎症腹腔脏器脓肿、大叶性肺炎等伴黄疸急性肝胆道疾病、胰腺疾病、急性溶血等,伴随情况,伴休克急性腹腔出血、急性化脓性胆道炎症、绞窄性肠梗阻、消化性溃疡穿孔、急性胰腺炎、急性心肌梗死等伴血性腹水：腹腔内脏或异位妊娠破裂，恶性肿瘤腹腔内转移，腹膜恶性肿瘤，少数结核性渗出性腹膜炎等。脓性腹水：化脓性腹膜炎,应重点询问既往有否引起急性腹痛病史，有无类似发作史；手术史、月经生产史、外伤史及有害物接触史等。,既往史,做好诊断、鉴别诊断,判断是否全身疾病的腹部表现腹型过敏性自癜、糖尿病酮症酸中毒等判断原发病在腹腔或腹外腹外可有急性腹痛肺炎、胸膜炎、心绞痛原发病在腹腔内应区别是内科还是外科。内科急腹症常有发热或其他前驱症状，而后出现腹痛，常不能准确定位，疼痛范围不局限，缺乏固定痛点，并无腹膜刺激征，喜按。外科急腹症常先有腹痛疼痛范围局限通常有固定压痛点及，腹膜刺激征，拒按。,内科外科急性腹痛的不同特点,内科腹腔脏器疾病所致急性腹痛的特点,外科疾病所致急性腹痛的特点,腹痛可轻可重，短期内病情不恶化。症状与体征不一致，主观感觉腹痛剧烈，表情痛苦，但检查腹部体征不显著，多腹软，局部轻压痛或压痛，无反跳痛。发病短期内血象正常或稍高，无中毒血象。急诊腹透无阳性发现。,腹痛突然发作，剧烈，急剧发展，不及时处理，短期内病情常迅速恶化。表情痛苦，呻吟，大汗，面色苍白，辗转不安或蜷曲静卧。可有腹膜刺激征(腹肌紧张呈板状，压痛、反跳痛明显)及肝浊音界缩小或消失。可有内出血综合征，如头晕、心慌、多汗、面色苍白、脉细速、血压下降等。急诊腹透可见膈下游离气体、高度胀气、鼓肠或胃扩张、梯形液气平面等。发病短期内白细胞明显增高，中性及杆状核增高，中毒血象，进行性贫血等。,临床常见急腹症的特点,无诱因,先中上腹、后右下腹，后右下腹持续性痛，渐加剧。,腹钝痛、胀痛,体温升高、白细胞高、核左移，需动态观察。尤其是老年人、糖尿病、妊娠者。,诱因,腹痛部位,腹痛性质,其它,阑尾炎,肺炎、胸膜炎,呼吸道感染，急性发病上腹部偏于一侧持续性腹痛，呼吸时加剧，限制呼吸减轻上腹部可能有压痛，亦可能喜按，无肌痉挛,急性胆囊炎、胆石症,中年女性多见，多于脂餐后发作，起病突然急骤中上腹扩张至右上腹先胀痛，继之绞痛，向右肩及背部放射，右上腹明显压痛，肌痉挛，Murphy征阳性，或可触及胆囊炎性肿块、恶心、呕吐、发热、毒血症，可有轻度黄疸单纯胆结石，尤其颈部结石，可突发缓解,急性胰腺炎,暴饮暴食后急骤起病先上腹中部偏左，后可扩散持续性剧烈刀割样痛，可向左腰背放射上腹压痛，肌痉挛至严重强直，脐部及左肋部可见淤斑，转移性浊音可阳性（出血坏死）,胃、十二指肠穿孔,中年男性多见，有溃疡病史，多于食后突然发作先在中上腹，随后可扩散至全腹剧烈持续刀割样上腹压痛，肌痉挛明显呈板样强直，肝浊音消失，转移性浊音(+)，肠鸣音消失分三阶段：化学期、反应性期、化脓性感染期,异位妊娠破裂,见于育龄妇女，急性腹痛、阴道流血量少、有停经史，发病突然先一侧下腹，继扩展至全腹，但仍以下腹为显著开始可能尖锐，继而持续，伴阵发性加剧下腹部压痛伴肌紧张，有转移性浊音失血性休克征,心绞痛、心肌梗死,不典型的心绞痛、心肌梗死可产生腹部疼痛，但性质大多数为阵发性，除非有心梗，和腹部按压无关，ECG和心肌酶可帮助诊断,主动脉夹层,主动脉夹层：中年以上的高血压动脉硬化病人，发生急性剧烈腹痛，伴有休克征象而血压不降者,糖尿病酮中毒与外科急腹症鉴别,糖尿病酮中毒发生前常有多饮多尿，外科多突然发生糖尿病酮中毒先呕吐后腹痛，外科先腹痛后呕吐化验检查糖尿病酮中毒积极治疗小时后症状消逝,外科则症状继续存在,肠系膜动脉栓塞,中老年多见，有动脉硬化或心瓣病，心房纤颤史，起病急，腹中部剧烈持续性阵发加剧早期拒按，晚期有腹膜刺激征，可触到炎块，伴有肠麻痹表现呕吐频繁，呕吐物血样，血便、可出现休克。大量镇痛剂、解痉剂不能缓解。,肠系膜血栓形成,有腹腔内感染或门静脉高压（肝硬化或肿瘤压迫），起病缓腹中部持续性钝痛压痛及肌紧张，肠麻痹，转移性浊音()可能触到肠段肿块伴肌痉挛可有恶心、呕吐，呕出物暗黑便臭,肾、输尿管结石,发作突然，过去可能有反复发作史，腹部两侧或腹部一侧阵发剧烈绞痛，向外生殖器放射肾区叩痛，一侧腹部自上而下沿锁骨中线压痛，无肌痉挛恶心、呕吐、尿频、尿急，一般不发热,缺血性肠病,老年人有动脉硬化病史，吃饭后12小时出现腹痛。,急性右心衰,肝郁血，迅速肿大的肝脏使其包膜紧张，右上腹痛，可放射至右肩，有时痛可很重，似急性胆囊炎,救治,基本原则：是保护生命，减轻痛苦，预防并发症，积极的对因治疗。（1）卧位：无休克的急腹症病人以半卧位或斜坡卧位，使腹腔内渗出物局限，控制感染，松弛腹肌，减轻疼痛，改善呼吸。已发生休克者，予中凹位，促进血液回流。,救治,（2）控制饮食与胃肠减压：禁食、禁水、胃肠减压（3）纠正水电解质紊乱和酸碱失衡。（4）应用抗生素控制感染。（5）对症治疗：吸氧，保肝。,救治,（6）镇静，止痛，诊断未明，处于观察期的急腹症病人，禁用麻醉镇痛剂，如吗啡、杜冷丁，必要时可用解痉剂，如阿托品，654-2等，禁腹部热敷。热敷减轻腹部疼痛掩盖病情，如有出血者，加重出血。,救治,（7）手术治疗：1）腹腔内病变严重者，如脏器破裂，穿孔绞窄性肠梗阻，炎症引起胃肠道坏死。2）进行性内出血征象，经输液、输血，止血治疗，病情不见好转或好转后迅速恶化者。,救治,3）腹腔内空腔脏器穿孔，腹膜刺激征严重或有扩大趋势者。4）肠梗阻疑有血运障碍者。5）突发性剧烈腹痛，病因不明，但有明显腹膜刺激征，经短期治疗不见缓解反而加重者。,谢谢,Contents,Clicktoaddtitleinhere,Clicktoaddtitleinhere,Clicktoaddtitleinhere,Clicktoaddtitleinhere,4,1,2,3,ThemeGalleryisaDesignDigitalContent&ContentsmalldevelopedbyGuildDesignInc.,Contents,Clicktoaddtitleinhere,Clicktoaddtitleinhere,Clicktoaddtitleinhere,Clicktoaddtitleinhere,4,1,2,3,ThemeGalleryisaDesignDigitalContent&ContentsmalldevelopedbyGuildDesignInc.,HotTip,HowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?OntheViewmenu,pointtoMaster,andthenclickSlideMasterorNotesMaster.Changeimagestotheoneyoulike,thenitwillapplytoalltheotherslides.,ImageinformationinproductTitleImage-Notetocustomers:ThisimagehasbeenlicensedtobeusedwithinthisPowerPointtemplateonly.Youmaynotextracttheimageforanyotheruse.,Clicktoedittitlestyle,Textinhere,Textinhere,Contents,Contents,ThemeGalleryisaDesignDigitalContent&ContentsmalldevelopedbyGuildDesignInc.,ThemeGalleryisaDesignDigitalContent&ContentsmalldevelopedbyGuildDesign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