上海交大外科学肠梗阻PBL

肠 梗 阻,上海交通大学医学院附属瑞金医院普外科 马迪 PBL教学,Intestinal Obstruction,肠梗阻是急诊最常见的外科急腹症之一，也是外科医生最不愿碰到的，最头痛的外科急腹症之一。诊断有时比较困难临床病情发展较快需要密切临床观察严密把握手术时机,Case one(scene1),Male , age: 65, “Paraxymal abdominal pain 48h with nausea and vomiting one day”, you are the doctor on duty.,Q1. According to the chief complaint, which kind of information you should collect during ask the history?,Main point of the history,1:Abdominal painThe position、level、kind of pain, with or without radiation ,the relationship between bowel sound and pain, paroxymal or continuing.2:Nausea and vomitingThe kind、volumn、color and smell of vomitus, the relationship between vomiting and pain.3:Abdominal distentionTime,level and position 4:Failure to pass flatus and fecesThe kind、quantity of feces and the relationship between it and pain,if the pain relieve after pass flatus and feces.5:Past history,Case one(scene1),Q2：To make a definite diagnosis，which kind of information we should pay attention to in the next Physical Examination and Auxiliary Examination?,Main point of the physical examination,General Examination： T:37.2 HR:96bpm R:22bpm BP:130/70mmhg No dehydration, no anemia, no jaundice,Abdominal Examination： Inspection：Distended abdomen, no peristaltic waves can be observed,previous scar in the upper abdomen. Palpation: Mild abdominal tenderness, no rebound,no guarding,no mass, no incarcerated hernia in the groin. Percussion：Tympany.,Auscultation：Hyperactive bowel sounds , 6-8bpm.,Rectal Examination：Negative,Local pathophysiology of intestinal obstruction,肠蠕动增加,1.各类刺激,长时间强蠕动,肠麻痹,2.肠腔膨胀、积气积液,吞咽下的气体，以氮气为主，不易向血液内弥散,长时间梗阻，肠腔内液体不再回流入血，而仍有液体自血液流入肠腔,3.肠壁水肿、通透性增加,梗阻近段肠腔压力升高，静脉回流受阻。,细胞缺氧，能量代谢障碍，肠壁通透性增加。,Q3: What is your diagnosis?,Case one(scene1),Definition & Classification,Definition:Intestinal contents can not pass successfully,which cause many pathophysiology and clinical symptoms. Classification:按照梗阻发生基本原因可分为三类：1. Mechanical Obstruction 2. Dynamic Obstruction3. Vascular Obstrucion,Mechanical obstruction include：Intraluminal obstructionExtraluminal obstruction Obstruction intrinsic to the bowel wall,Reasons of the intraluminal obstruction:Foreign bodiesGallstonesAscarid and etc.,蛔虫引起小肠梗阻 胆囊十二指肠内瘘引起胆石性肠梗阻,CT scan show the stone in the intestine,Reason of the extraluminal obstruction :AdhesionsIncarceration herniaVolvulus and etc.,图中圆圈处显示束带压迫小肠引起梗阻 腹股沟斜疝嵌顿引起肠梗阻,Reason of the obstruction intrinsic to the bowel wall:,盲肠菜花样肿瘤导致肠梗阻 炎症性肠病导致肠壁炎性狭窄,TumorInflammatory bowel disease and etc.,Paralytic ileus Drug indusedMetabolicNeurogenic InfectionsSpastic ileus,Dynamic obstruction include:,Plain Abdominal radiographs reveal ： Distended small bowel as well as large bowel loops,Vascular Obstrucion Caution： In the early stage of vascular obstruction, patients often have obvious chief complaint but without abdominal sign. But in the late stage, besides the obvious chief complaint, patients will have peritoneal irritation sign and bloody stool.,按照有无血运障碍分为：1: Simple Obstruction 2: Strangulating Obstruction 其他分类：Proximal obstruction- Distal obstructionComplete obstruction- Incomplete obstructionClosed-loop Obstruction : Volvulus Colonic obstruction Internal hernia,Case one(scene2),Discussion： Please list your therapeutic-schedule.,Case one(scene3)见附页2,General pathophysiology of intestinal obstruction,消化液的回吸收停止、液体仍向肠腔渗出,大量呕吐、禁食,1.大量体液丧失和酸碱失调,肠内容物淤积，毒素产生,肠壁通透性增加，细菌毒素移位,2.感染与中毒,3.休克,肠腔压力升高，横膈抬高,4.呼吸困难，心肺功能障碍,复查平片如下图,Case one(scene3) （Strangulated intestinal obstruction, internalhernia）,患者即刻完善术前准备后行剖腹探查，术中见Treitz ligment 远端2m处小肠与腹部原切口下方粘连成角梗阻，并有远端小肠钻入其中形成内疝。,Q4: What should we pay attention to during the operation?,Q5: Whats your suggestion when the patient discharge?,腹部立卧位平片,造影剂检查对于肠梗阻也是重要诊断方法,CT不是首选,但有时会有意外发现,Case two(scene1) 见附页3,Case two(scene1),Q1: What is your primary diagnosis? To prove your diagnosis,which kind of examination do you need?,Case two(scene1),Supine & upright radiographs of the patient,Case two(scene1),Case two(scene1),Water-soluble contrast enema,Case two(scene1),Admitting diagnosis: Colonic obstruction.Q2: What is the treatment? Operation or Conservation ？,Case two(scene2)见附页4,Case two(scene2),Q3：What is the special preparation before the operation？,Case two(scene2),患者完善肠道准备后，于入院第9天行剖腹探查术，术中见腹腔内无明显肿瘤，乙结肠部分冗长扩张，内有肛管支撑，乙结肠系膜较短，降结肠无明显充血水肿，内无明显肠内容物，行冗长部分乙结肠切除术，并行一期吻合。患者恢复顺利，术后第10天出院。,Discussion：Please compare case 1 with case 2.1：History2：Clinical manifestation3：Auxiliary examination4：Treatment,请从以上两个病例讨论肠梗阻的诊断流程,腹痛腹胀伴恶心呕吐入院,详细询问病史和体格检查,有痛吐胀闭共同特点，考虑肠梗阻,有正常排气排便，暂时排出肠梗阻,根据病史特点及体检选择相关检查（血常规，B超，腹部平片及CT等）排除消化道穿孔，胰腺炎，阑尾炎，胆道疾病等外科常见急腹症,必要时请相关科室会诊，排除尿路梗阻，卵巢扭转，胃肠炎等疾病,首选腹部立卧位平片检查,针对病史，体检及辅检对各类型肠梗阻进行诊断（腹部CT，造影剂口服/灌肠摄片均是临床常用检查）,选择治疗方案（保守/手术）,机械性/动力性、完全性/非完全性，单纯性/绞窄性、小肠/结肠梗阻。,肠梗阻诊断流程,请归纳肠梗阻的治疗方案,肠梗阻的治疗方案,基础治疗,（任何肠梗阻无论手术或非手术均需要基础治疗）,胃肠减压，纠正水电解质酸碱失衡，适当解痉，抗感染治疗,非手术治疗（需要观察哪些事项?）,（禁食，石蜡油胃管注入，腹部按摩，皮硝外敷，大承气汤攻下等）,单纯性机械性不全小肠梗阻,麻痹性肠梗阻,正常排气排便，腹痛腹胀缓解。,非手术治疗成功,正规保守治疗 24-48小时后症状无缓解或加重,绞窄性肠梗阻,完全性小肠梗阻,结肠梗阻,手术治疗,最简单的方法解除梗阻和恢复肠道功能,手术的方式根据梗阻的性质、部位、患者的全身情况决定。,肠梗阻诊疗过程中几个注意点,1: 肠梗阻病因不一，临床表现多样，诊疗有一定困难，有 较高死亡率。,2: 体格检查中切勿遗漏腹股沟部位和直肠指检。,3: 病史中即使有少量排气排便也不可完全排除肠梗阻。,4: 肠梗阻患者症状与体征不符合时，应考虑到血运性肠梗阻可 能。,5: 单纯性不全性肠梗阻治疗过程中可能随时变成绞窄性肠梗 阻，需要密切观察。,思考题,1：请简述肠梗阻的临床表现，常用诊断 方法。2：如何把握肠梗阻的手术时机？3：粘连性肠梗阻，肠扭转，血运性肠梗 阻的临床特点和处理原则。,参考文献及书籍,1: Lau KC, Miller BJ, Schache DJ, et al. A study of large-bowel volvulus in urban Australia. Can J Surg, 2006; 49(3): 203-7. 2: Attard JA,