恶心呕吐临床诊断学

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 CTZ EmeticCenter Vomitingcenter 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 EmeticCenter 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 EmeticCenter Vomitingcenter 孤束核 EmeticCenter 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 Vomitingcenter ICP InductivelyCoupledPlasma感应耦合等离子体 NeurotransmittersinCTZ EmeticCenter Neurotransmittersinvolvedinstimulatingtheemeticcenter chemo receptortriggerzoneandGItractinclude 5 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 Neurologic Psychogeniccauses NeurologicandPsychogeniccauses 胃肠道神经官能症 Gastrointestinaltractneurosis 神经厌食症 apositia CharacteristicsofNauseaandVomiting TimeTakingfoodCharacteristicsCharactersofcontents 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 Timingwithmeals 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 Theaccompanyingsymptoms 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 Ageb GIhistoryrequiredc Foodintoleranced Timingwithmealse Consistencyf Content g Odorh Frequencyi Feverj Weightlossk Precipitatingfactorsl Myalgias 肌痛 visualdisturbances headache painoutsideabdomen CAUSESOFNAUSEA VOMITING EarlypregnancyPsychogenesisvomitingBulimia 易饿病 PyloricchannelulcerAcutegastritisGastricretention 潴留 Viralgastroenteritis 中毒性胃肠炎 Acutegastroenteritis MyocardialinfarctionPeritonitis 腹膜炎 AcuteobstructionNeurologicalemergencyDrugtoxicityCancertherapyDrugwithdrawal PHYSICALEXAM VitalsignsSkinHEENT head eyes ear nose throat AbdomenNeurological LABORATORY RuleoutobstructionandperitonitisHCGUrinalysisElectrolytes BUN creatinine glucoseTransaminases amylaseEKG headCT upperGI orendoscopies 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 ShanghaiSecondMedicaluniversityRenjiclinicalmedicalcollege Background ConstipationIsaConstellationofSymptoms MostcommonlyreportedsymptomsHard lumpystoolsIncreasedstrainingInfrequentbowelmovementsSensationofincompleteevacuationBloating fullnessChronicconstipationMorepersistentthanintermittentorepisodicSeveralmonthsduration C SandlerRS etal DigDisSci 1987 32 841 845 n 1128 ConstipationIsMoreThanJustInfrequentPassageofStool 53 Constipationsymptomsreportedmostoften ReducedStoolFrequencyIsNottheMostCommonlyReportedSymptominConstipation EPOC Epidemiologyofconstipation BM Bowelmovement 1 StewartWF etal AmJGastroenterol 1999 94 3530 3540 2 Par P etal AmJGastroenterol 2001 96 3130 3137 Stewart EPOC 19991 Par 20012 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 Par P etal AmJGastroenterol 2001 96 3130 3137 53 Epidemiology ChronicconstipationiscommonSlightlymorecommoninwomenF Mratio range1 3to2 5 China 4 1 Affectsallagegroups StewartWF etal AmJGastroenterol 1999 94 3530 3540 Par P etal AmJGastroenterol 2001 96 3130 3137 SandlerRS etal DigDisSci 1987 32 841 845 C ConstipationAffectsAllAgeGroups 53 Canadianpopulation Par P etal AmJGastroenterol 2001 96 3130 3137 N 1149 n 378 n 367 n 217 n 187 ProfileofaTypicalChronicConstipationPatientinMyPractice GenerallyfemaleSymptomaticfor 10yrMajorityhavetriedlifestylechanges fiber andOTClaxativespriortoseekingcareManagesconditionwithmultipletherapiesMostoftenreferredbyaprimarycarephysicianCopeswithcondition butisnotcompletelysatisfied C ConstipationCanHaveaNegativeImpactonQualityofLife PeoplewithCCreportedsignificantimpairmentinQoLonSF 36scale n 126 1InCanada peoplewithself reportedorRomeIIconstipationhadsignificantlyworseSF 36scoresthanthenormalpopulation n 472 2InAustralia peoplewithconstipationhadsignificantlyworseSF 12scoresonbothmentalandphysicalscales n 227 3 1 O KeefeEA 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 www cdc gov2 NationalHospitalAmbulatoryCareSurvey 2001 www cdc gov3 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 3defecations wkLoosestoolsnotpresentInsufficientcriteriaforIBS 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 RectalandAnaldisordersBenignormalignancytumorTumorormassouts