临床诊断学恶心呕吐.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,NauseaandVomitingAsthesymptoms,症状学：恶心与呕吐,Goals,BrieflydefineOutlinetheprominentdiseasestatesassociatedwithnauseaandvomiting.CharacterizeNauseaandVomitingcausedbytheprominentdisordersDiscriminatetheaccompanyingsymptoms.Suggestdiagnosticstrategiesofthesymptoms.,DefinitionofNauseaandVomiting,Nausea：theinclinationorfeelingofimminentdesiretovomit,usuallyfeltinthethroatorepi-gastrum.Associatedwithdecreasedactivityofthestomach.Vomiting：theforcefuloralexpulsionofgastriccontentsviaretro-peristalsis.Nausea-Vomiting:simultaneityorseparateness,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！,NauseaandVomiting,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。,Definitionofemesis.(Threephases)呕吐反射过程（三个阶段）,1.Nausea-theinclinationorfeelingofimminentdesiretovomit,usuallyfeltinthethroatorepigastrum.Associatedwithdecreasedactivityofthestomach.2.Retching-thelaboredrhythmiccontractionofrespiratoryandabdominalmusculaturethatfrequentlyprecedesoraccompaniesvomiting.3.Vomiting-theforcefuloralexpulsionofgastriccontentsviaretroperistalsis.(Abdominaleffects).,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）,Mechanismsofemesis,CTZ5-HT,acetylcholine,histamine,dopamine(opiatesandreceptorsforbenzodiazepinesarealsofoundhere),EmeticCenter,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,nauseaandvomiting,1.Reflectivevomiting反射性呕吐2.Centralvomiting中枢性呕吐3.Neurologicalvomiting神经性呕吐,Reflectivevomiting（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）,PharyngealMechanismsGastrointestinalMechanismsDiseaseofbiliarytractPeritonealandmesenterythefivesenseorgansCardiovasculardiseaseskidneyPelvic,咽部刺激,PharyngalMechanisms,GastrointestinalMechanisms,肝、胆、胰腺,其他,Intra-cranialinfectionCerebrovasculardisordersCraniocerebralinjuryEpilepsyMetabolicdisordersDrugs,Centralvomiting（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,AntibioticsAnti-carcinomaDigitalismorphia,Neurologic32:841-845.,n=1128,ConstipationIsMoreThanJustInfrequentPassageofStool,53,Constipationsymptomsreportedmostoften,ReducedStoolFrequencyIsNottheMostCommonlyReportedSymptominConstipation,EPOC=Epidemiologyofconstipation;BM=Bowelmovement.1.StewartWF,etal.AmJGastroenterol.1999;94:3530-3540.2.ParP,etal.AmJGastroenterol.2001;96:3130-3137.,Stewart(EPOC)19991,Par20012,n=1476,n=1149,Constipationsymptomsreportedmostoften,C,PrevalenceintheGeneralPopulation,1.StewartWF,etal.AmJGastroenterol.1999;94:3530-3540.2.DrossmanDA,etal.DigDisSci.1993;38:1569-1580.3.HarrisInteractiveStudy,Wave2.Dataonfile.4.ParP,etal.AmJGastroenterol.2001;96:3130-3137.,53,Epidemiology,ChronicconstipationiscommonSlightlymorecommoninwomenF/Mratio=range1.3to2.5(China=4:1)Affectsallagegroups,StewartWF,etal.AmJGastroenterol.1999;94:3530-3540.ParP,etal.AmJGastroenterol.2001;96:3130-3137.SandlerRS,etal.DigDisSci.1987;32:841-845.,C,ConstipationAffectsAllAgeGroups,53,Canadianpopulation.ParP,etal.AmJGastroenterol.2001;96:3130-3137.,N=1149,n=378,n=367,n=217,n=187,ProfileofaTypicalChronicConstipationPatientinMyPractice,GenerallyfemaleSymptomaticfor10yrMajorityhavetriedlifestylechanges,fiber,andOTClaxativespriortoseekingcareManagesconditionwithmultipletherapiesMostoftenreferredbyaprimarycarephysicianCopeswithcondition,butisnotcompletelysatisfied,C,ConstipationCanHaveaNegativeImpactonQualityofLife,PeoplewithCCreportedsignificantimpairmentinQoLonSF-36scale(n=126)1InCanada,peoplewithself-reportedorRomeIIconstipationhadsignificantlyworseSF-36scoresthanthenormalpopulation(n=472)2InAustralia,peoplewithconstipationhadsignificantlyworseSF-12scoresonbothmentalandphysicalscales(n=227)3,1.OKeefeEA,etal.JGerontolABiolSciMedSci.1995;50:M184-M189.2.IrvineEJ,etal.AmJGastroenterol.2002;97:1986-1993.3.KoloskiNA,etal.AmJGastroenterol.2000;95:67-71.,C,ConstipationSignificantlyImpactsHealthcareUtilization,5.7millionconstipation-relatedoutpatientvisitsannually1,24.1millionphysicianoffice-basedvisits991,000emergencyroomvisits587,000hospitaloutpatientvisits$2752/patientfortertiarycareevaluation3,1.NationalAmbulatoryMedicalCareSurvey,2001.2.NationalHospitalAmbulatoryCareSurvey,2001.3.RantisPCJr,etal.DisColonRectum.1997;40:280-286.,C,Complicationsrelatedwithconstipation,ColonicandrectalcarcinomaOthercolon-rectal-anusdisordershepaticcomaacutemyocardialinfarctionmammaryglanddisorderspreseniledementia(早老性痴呆）psycho-problemsappearance,Definition:CausesofChronicConstipation,SecondaryDruginducedMetabolicfactorsComorbidconditionsPrimaryImpairedcolonictransit/motilityAlteredneuroentericfunctionandreflexesFailureofmuscularapparatusIneffectivedefecation(functionaloutletobstruction)PelvicdyssynergiaandanismusNormaltransitconstipation,PresentationObjectives,DefineconstipationThepathophysiologicalmechanismsEtiologiesofconstipationCharacterizemanifestationDiscriminatetheaccompanyingsymptoms.Suggestdiagnosticstrategiesofthesymptoms.,C,WhatisConstipation?,Passageofhard,dry,lumpystools;Infrequentbowelmovements,usuallyfewerthanthreetimesaweekSymptoms:painfulbowelmovementsstrainingUncomfortable（Sensationofincompleteevacuation）bloatedsluggish,RomeIIDefinesFunctionalConstipationBasedonMultipleSymptoms,RomeIIdiagnosticcriteriaforfunctionalconstipationAtleast12wk,whichneednotbeconsecutive,overthepast12monthsof2ormoreofStraining*Lumpyorhardstools*Sensationofincompleteevacuation*Sensationofanorectalobstruction/blockage*Manualmaneuverstofacilitatedefecation*1/4ofdefecations.DrossmanDA,etal.In:RomeII:TheFunctionalGastrointestinalDisorders.2000:382-391.,C,Normalmetabolism,Asfoodmovesthroughyourintestines,itabsorbswaterwhileformingwasteproductsMusclescontractinthecolon,pushingthestooltowardtherectum,DefecationProcess,YieldawarenessofdefecationAnalintra-andextra-sphincterRelaxationAbdominaleffects,Mechanicalstimulation,1.Yieldawarenessofdefecation,2.Analintra-andextra-sphincterRelaxation,intra-sphincter,extra-sphincter,Levatoranimuscle,2.Abdominaleffects,gastriccontentsviaanus,WhatCausesConstipation?,EatingtoolittlefiberNotdrinkingenoughliquidsLackofexercise/physicalactivity,WhatCausesConstipation?,ChangeinroutinetravelOlderageSlowermetabolismFrequentuseoflaxativesCertaindiseasesorconditions,WhatCausesConstipation?,CertaindiseasesorconditionsRectalandAnaldisordersColonicdisordersSystemicdiseasesorconditions,WhatCausesConstipation?,pain(narcotics麻药)antacidscontainingaluminumantidepressantsironsupplementsdiuretics(“water”pills),Medications,Classificationofetiologies,EatingtoolittlefiberNotdrinkingenoughliquidsLackofexercise/physicalactivityChangeinroutineTravelpsycho-relatedOlderageSlowermetabolism,FrequentuseoflaxativestediouslylongColonMedicationsTravelpain(narcotics麻药)antacidscontainingaluminumantidepressantsironsupplementsdiuretics(“water”pills),Functionaletiologies,psycho-related,TediouslylongColon,结肠冗长,Organicconstipation(certaindiseasesorconditionscauseconstipation),Classificationofetiologies,RectalandAnaldisordersBenignormalignancytumorTumorormassoutsideSystemicdiseasesorconditions(e.g.disordersmakedyscinesia:spasmandparalysis）,RectalandAnaldisorders,CancerNevusanalfissureanalfistulaProctoptosis(直肠脱垂）,intestinalobstruction,Benignormalignancytumor,Polyp,Cancer,Outsidetumo