肠疾病的肠梗阻与阑尾炎医学PPT.ppt

IntestineDiseases 1 医药交流PPT ReviewofAnatomyandPhysiology I SmallIntestineMacroscopicanatomyTreitzileocecalvalve 2 5jejunum 3 5ileumMesentery fat bloodvessels lymphatics andnerves superiormesenteryarteryandveinMicroscopicanatomy4layers mucosa submucosa muscularis andserosa 2 Physiologyofthesmallintestine1 Digestiondigestsandabsorbsnutrientsfromingestedfood 2 SecretionAlkalinemucusandsomegastroenteralhormones3 MotilityThemovementiscomposedofsegmentalcontractionandperistalsis short weak propulsive 3 II LargeIntestineMacroscopicanatomy1 5mlong endofileumrectum Rightcolon cecum ascendingcolon hepaticflexure andproximaltransversecolonLeftcolon thedistaltransversecolon splenicflexure descendingcolon andsigmoidcolon Bloodsupply Superiormesenteryarterytherightcolon Inferiormesenteryarterytheleftcolon Microscopicanatomy4layers mucosa submucosa muscularis andserosa 4 Physiologyoflargeintestine1 Digestionelectrolytesandwaterfromtheilealfluid2 SecretionAlkalinemucusandsomegastroenteralhormones3 MotilityRetrogradeperistalsis dominatesintherightcolon Segmentalcontraction inthetransverseanddescendingcolon Massmovement astrongringcontractionoverlongdistanceinthetransverseanddescendingcolon 5 6 MajorContents Inflammatoryboweldiseases IBD IntestineObstructionVascularlesionsofmesenteryShortbowelsyndromePolypsTumorCongenitaldiseases 7 Inflammatoryboweldiseases IBD 1 intestinetuberculosis2 typhoidperforation3 amoebicperforation4 nonspecificinflammatorydiseases Crohn sDiseases ulcerativecolitis Surgicalinterventionperforation obstruction orhemorrhage bleeding 8 Vascularlesionsofmesentery vascularocclusionorischemia MesentricarterialembolismorthrombosiscardiacdiseasesMesentericvenousthrombosisHepaticcirrhosisandhaemaldiseasesCharacter symptomsevere signlightDiagnosis angiographyTreatment operation 9 Shortbowelsyndrome Etiologyintestineresectionnotlongenough 100cm digestiveandabsorptiondisfunctionTreatment1 nutritionsupport TPN 1 2yearhalfcompensationrecover2 intestinetransplantationimmunerejectionproblem 10 Polypsandpolyposis Difference 100ornotPlace anywhere butcommonincolonPresentation1 changeofdefecation2 rectalbleeding3 ileus obstruction TreatmentEndoscopicelectrocauterysnareOpenoperation 11 Congenitaldiseases Classification atresia stenosis andmalrotationEtiology abnormalgrowthDiagnosis 1 newborn2 intestinalobstruction3 uppergastrointestinalseriesorbariumenemaevidenceTreatmentoperation 12 ObstructionofIntestine Bowelileus EtiologyandclassificationI MechanicalObstructioninside outsidethelumen orintestinewalllesions II Adynamic paralytic ileusoperationoracuteperitonitis bloodsupply simpleorstrangulatedileus 13 Changeinphysiology 1 Lossofbodyfluid Metabolicacidosis lower distal obstructionMetabolicalkalosis high proximal obstruction2 InfectionandtoxicsymptomsEndogenousinfectionbybacteriainsidethelumen3 ShockSeverelossofliquidorinfection 4 RespirationandcirculationbarrierCausedbythedistensionofintestine 14 Clinicalfindings Symptoms1 Abdominalpain variable crampingperi umbilicalpain2 Vomitingespeciallyinproximal high 3 Abdominaldistension middleordistalbowelobstruction andparalytic adynamic obstruction4 Difficultyofdefecationandgasexpelling variesaccordingtoitiscompleteornot 15 Signs1 GenerallyDehydration andshockatthelatestage2 LocallyInspection Peristalsisindilatedloopsmaybevisibleinthinpatients Palpation mildtendernessAuscultation Peristalticrushes gurgles andhighpitchedtinklesareaudible Incarceratedhernia 16 Adjuvantexamination Laboratoryfindingsearlynormallatehemoconcentration leukocytosiselectrolyteabnormalities Serumamylaseisoftenelevated X rayfindingsPlainfilmsladderlikepatternofdilatedsmallbowelloopswithair fluidlevels Contrastmediaorallyorbyanasogastrictube proximalBariumenemadistal 17 diagnosisandquestions Diagnosis basedaboveclinicalfindingsandadjuvantexaminationQuestions 1 isornot 2 Mechanicalorparalytic adynamic 3 Simpleorstrangulated 4 highorlower 5 completeornot 6 thereasonofobstruction 18 Indicationofstrangulation 1 severecolicpain2 shock3 peritonitis4 visibleorpalpabledilatedintestineloops5 bowelbleeding6 medicaltreatmentisnotsuccessful7 X rayshowsdistendedbowelloopsthatisnotchangewithtime 19 Treatment 1 Conservativetherapy1 Nasogastricsuction 2 Fluidandelectrolyteresuscitation 3 Antibioticsusedbeforeoperation 4 TraditionalChinesemedicinetherapy 20 2 Operation removingthecauseofobstructionintestineresectionbypassoperation intestinestoma 21 IntestineTumor I SmallIntestineTumorsIntroduction1 Themorbidityisrare occupiednearly2 ofthetumorsingastrointestinaltract 2 Most 3 4 aremalignancies 3 Thediagnosisbeforeoperationisdifficult sothetreatmentisoftendelayed 22 Clinicalfindings nottypical1 abdominalpain discomfort dullpain orcolicpain2 hemorrhage bleeding fromdigestivetract 3 intestineobstruction4 abdominalmass5 intestineperforation6 carcinoidsyndrome presentation cutaneousflushing diarrhea asthma andcardicvalvulardiseaseReason activesubstancessecretedbycarcinoids suchashistamine bradykinin andprostaglandins 23 DiagnosisBesidesclinicalfindings followingexaminationsarehelpful Uppergastrointestinalseries abariumswallowexaminationEndoscopyexamination duedenoscopy intestinoscopyAngiographyUrinarylevelsof5 hydroxyindoleaceticacid 5 HIAA ametaboliteof5 hydroxytryptophan Operativeexploration 24 TreatmentFirstchoice resectionoftumor Ifitiscannotberesected bypassoperationbowelobstruction Adjuvanttherapy chemotherapyandradiotherapy 25 IILargeIntestineTumorsIntroductioncommoninmalesat41 50ages Etiologyisnotclear familialpolyposis ulcerativecolitis colonadenoma andcolorectalpolyps PathologyandClassificationMacroscopicallyMicroscopicallyPolypoid mass 1 adenocarcinomaspreadingtype2 mucouscarcinomaulceratingtype3 undifferentiatedcarcinoma 26 Stage DukesclassificationAccordingtheinvasionextentoflumenwall lymphnodes anddistantmetastasis itisclassifiedasstageA insidetheintestinewallB outsidetheintestinewallbutlymphnode C outsidetheintestinewalllymphnode D distantmetastasis 27 ClinicalfindingsChangeinbowelhabits themostearlysymptom frequency constipationandgrossblood Leftcolon Abdominaldiscomfortorpain Leftandrightcolon Palpableabdominalmass Rightcolon Obstructivesymptoms Leftcolon Unexplainedweaknessoranemia Rightcolon 28 SpecialexaminationsFlexiblecolonscopyorrigidsigmoidscopy biopsy BariumenemaCTscanandultrasonography todetectthelymphnodeinvasionandhepaticmetastasis Carcinoembryonicantigen CEA atumormarker usefulindiagnosis prognosis orevaluationofresponsetotreatment 29 TreatmentSurgicalresectionoflesionanditsregionallymphaticnodesthefirstchoice secondchoicecolostomyorbypassoperation2 Adjuvanttherapy chemotherapy radiotherapyimmunotherapy traditionalChinesemedicine 30 3 TreatmentofcomplicationA ObstructionRightcolon carcinomacanberesectedandanastomosedinasinglestageinmostcases Leftcolon surgicaldecompression colostomy followedlaterbyelectiveresection BPerforationTheinvolvedsegmentofcolonisresectedifpossible colostom secondaryanastomosisisperformedafterinflammationsubsides 31 Appendicitis Anatomyaseparatemesoappendixwithanappendiculararteryandveinthatarethebranchesoftheileocolicvessels linedwithcolonicepitheliumcharacterizedbymanylymphfollicles McBurneypoint 5 10cminlength 0 5 0 7cmindiameter atanypositiononaclockwiserotationfromthebaseofthececum 32 PathophysiologyHyperplasiaofthelymphoidfollicles 60 fecalith 35 obstruction bacteriamultiply endotoxinsAepitheliumdamageexotoxinsmucosaulceratedinflammatoryprocessischemia necrosis perforation peritonitis 33 PathologicalClassificationofacuteappendicitis acutesimpleappendicitis acutepurulentappendicitis gangrenousorperforatedappendicitis peri appendixabscess 34 ClinicalDiagnosisofacuteappendicitisdiagnosis1 historyandthephysicalfindings2 labrartoryexaminations WBCTypicalsymptomsandsigns 1 generalizedabdominalpainfollowedbynauseaepigastriumumbilicustherightlowerquadrant 2 Temperature spasm tendernessandreboundtendernessintheMacBurneypoint 35 Assistantphysicalexaminations1 Rovsingsign colonairfillingtest 2 Obturatorsign3 Psoassign4 Rectalexamination 36 Differentialdiagnosis1 1 Pepticulcerperforation2 2 Ureteralstones3 3 GynecologicalandobstetricdiseasesEctopicpregnancy rupturedovariancystorfollicleacutesalpingitis wistedovariancyst4 4 acutemesentericlymphadenitis55 Others acutegastroenteritis cholecystitis childrenintussusception cecumtumor 37 TreatmentFirstchoice appendectomyIncisionselectionfinditcutandligatemesoappendixpursestringsutureresectitandresidue