物诊3常见症状腹泻黄疸意识障碍

腹 泻 (Diarrhea),定 义Definition,排便次数增多、粪质稀薄，或带有粘液、脓血，或未消化的食物。如解液状便，每日3次以上，或每日排便量超过200克，含水量80。Diarrhea is commonly used to denote an increase in stool frequency or volume and an increase in the looseness of stool, or with mucus, pus and blood or undigested food, such as discharging loose stools more than three times per day, or weight of stools above 200g with containing water above 80%.,分类Classify,急性腹泻 ( acute diarrhea ) 慢性腹泻 ( chronic diarrhea ) 超过2个月 more than 2 month,急性腹泻的病因Etiology of acute diarrhea,（1）肠道疾病：感染性肠炎、急性出血坏死性肠炎（1）Intestinal diseases: infectious enteritis, acute hemorrhagic enteritis（2）急性中毒 (2) Acute poisoning（3）全身性感染: 败血症，伤寒 (3) Systemic infection: sepsis, typhoid（4）其他：变态反应性肠炎；内分泌疾病 (4) Others,慢性腹泻的病因（1）Etiology of chronic diarrhea (1),（1）消化系统疾病 digestive system diseases： 胃部疾病 stomach disorder 肠道感染 intestinal infection：肠结核、慢性菌痢、血吸虫病 肠道非感染性疾病 Non-infectious intestinal diseases： 溃疡性结肠炎 肠道肿瘤 intestinal tumor：小肠结肠恶性肿瘤 胰腺疾病 pancreatic diseases：慢性胰腺炎、胰腺癌 肝胆疾病 hepato-biliary diseases：肝硬化 (cirrhosis)、慢性胆囊炎、胆石症,慢性腹泻的病因（2）,（2）全身性疾病 systemic diseases 内分泌及代谢障碍疾病 Endocrine and metabolic disorders：甲亢、糖尿病性肠病、血管活性肠肽瘤、类癌综合征 其他系统疾病 other systemic diseases：尿毒症 (uremia)、放射性肠炎 药物副作用 adverse effects：利血平、甲状腺素、洋地黄类 神经功能紊乱 nervous dysfunction：肠易激综合征 ( irritable bowel syndrome, IBS),发病机制Mechanism,1 分 泌 性 腹 泻1 Secretory diarrhea,肠粘膜分泌过多的液体超过肠粘膜吸收能力所引起肠道非感染或感染性炎症：霍乱 (cholera) 阿米巴、细菌性、溃疡性结肠炎肠道内分泌肿瘤：胃泌素瘤 (gastrinoma),2 渗出性腹泻,渗出大量粘液、脓血，如炎症性肠病、感染性肠炎、放射性肠炎,3 渗透性腹泻3 Osmotic diarrhea,肠内容物渗透压增高，阻碍肠内水分与 电解质的吸收而引起, 常见于高渗性(hyperosmotic) 药物、高渗性食物 、胰腺病变、肝胆疾病,4 动力性腹泻4 Dynamic diarrhea,肠蠕动亢进致肠内食糜停留时间缩短，未被充分吸收；常见于肠炎，甲状腺功能亢进、糖尿病、胃肠功能紊乱hyperactive peristalsis result in short residence time of chyme without fully absorbed; it can be seen in enteritis, hyperthyroidism, diabetes, gastrointestinal dysfunction,5 吸收不良性腹泻5 Malabsorption diarrhea,由肠粘膜的吸收面积减少或吸收障碍所引起，如小肠大部切除术，吸收不良综合征Intestinal absorption area declined or absorption dysfunction, such as small Intestine resection, malabsorption syndrome,临床表现Clinical manifestation,1 起病与病程 Onset and course 起病急、病程短 rash onset, short course： 感染或中毒 infection, poisoning 起病缓慢、病程长 slow oncet, long course： 慢性感染、非特异性炎症、吸收不良、肠道肿瘤、神经功能紊乱 chronic infection, nonspecific inflammation, malabsorption, intestinal tumor, nervous dysfunction,临床表现,2 腹泻次数与粪便性质2 Diarrhea times and stool properties急性感染性腹泻 acute infectious diarrhea: several times or even dozens of times per day; paste or watery stools慢性腹泻 chronic diarrhea: several times per day; loose stools阿米巴痢疾 amoebic dysentery: dark red or like jam 肠易激综合征 irritable bowel syndrome (IBS): stools with mucus and without pathological changes,临床表现,3 腹泻与腹痛的关系 relationship with abdomen pain急性腹泻常有腹痛，以感染性腹泻为明显Acute diarrhea usually has abdomen pain, and infective diarrhea is the most obvious.小肠疾病的腹泻疼痛常在脐周，便后腹痛缓解不明显The pain of intestinal disease diarrhea is always around navel, and it relieves un-obviously after defecate.结肠疾病疼痛多在下腹，且便后疼痛常可缓解The pain of colon lesions diarrhea is always in the lower abdomen, and it relieves obviously after defecate.分泌性腹泻往往无明显腹痛The pain of secretory diarrhea is not obvious.,伴随症状 Accompanied symptom,1 发热 fever：痢疾(dysentery)、伤寒(typhoid)、肠结核(intestinal tuberculosis)2 里急后重 tenesmus：colonic diseases, rectal diseases 提示直肠和乙状结肠病变3 消瘦 thin：小肠病变 intestine diseases4 皮疹、皮下出血 skin rash, subcutaneous hemorrhage：败血症(sepsis)、伤寒(typhoid),伴随症状,5 腹部包块 abdominal mass：胃肠道肿瘤Gastric or intestinal carcinoma 6 重度失水 severe dehydration：霍乱 cholera 7 关节痛、关节肿胀 joint pain, joint swelling： Crohn diseases, ulcerative colitis 见于Crohn病、溃疡性结肠炎、肠结核、SLE等。,问诊要点,腹泻的起病大便的性状及臭味同食者群集发病的历史地区和家族中的发病情况腹泻加重、缓解的因素病后一般情况变化,20,黄 疸 (Jaundice),21,定 义Definition,血清中胆红素(bilirubin)升高致使皮肤、粘膜和巩膜发黄的症状和体征。Jaundice is both symptom and sign of becoming yellow in the skin, mucosa and sclera due to increase of bilirubin in serum.正常值 normal value：总胆红素 ( total bilirubin, TB ) 1.7 17.1 mol/L结合胆红素 ( conjugated bilirubin, CB ) 0 3.42 mol/L非结合胆红素 ( unconjugated bilirubin, UCB ) 1.7 13.68 mol/L,22,胆红素升高 increase of bilirubin隐性黄疸 No visible jaundice： bilirubin 17.1 34.2 umol/L可见黄疸 Visible jaundice： bilirubin 34.2 umol/L,23,24,胆红素的正常代谢（1）,体内胆红素的代谢： 血循环中衰老的红细胞单核巨噬细胞系统 血红蛋白血红素 血红素加氧酶 胆绿素 胆绿素还原酶 非结合胆红素（UCB）,红细胞生成的血红蛋白：7.5g/d生成胆红素 250 mg /d占总胆红素的 8085,组织蛋白酶,25,胆红素的正常代谢（2）,骨髓幼稚红细胞的血红蛋白 肝内含亚铁血红素的蛋白质（过氧化氢酶、过氧化物酶、细胞色素氧化酶、肌红蛋白）旁路胆红素（bypass bilirubin) 10 30 mg / d 占1520,26,27,分 类Classification,Based on etilolgy（病因）溶血性黄疸 Hemolytic Jaudice肝细胞性黄疸 Hepatic Jaudice胆汁淤积性黄疸 Cholestasis Jaudice先天性非溶血性黄疸 Congenital unhemolytic Jaudice,Based on quality of bilirubin（胆红素性质）以UCB增高为主的黄疸Unconjugated hyperbilirubinemia以CB增高为主的黄疸Conjugated hyperbilirubinemia,28,病因、发生机制和临床表现Etiology, pathogenesis and clinical occurrence,29,溶血性黄疸 Hemolytic Juandice,定义 凡能引起红细胞大量破坏而产生溶血的疾病都可产生溶血性黄疸Definition Hemolytic juandice is caused by hemolysis with too much erythrocytes destroyed.,30,常见疾病,先天性 Congenital: 遗传性球形红细胞增多症 hereditary spherocytosis 后天性 Acquired: 自身免疫性溶血autoimmune hemolysis, 新生儿溶血 newborn hemolysis, 异型输血后的溶血 hemolysis after blood transfusion due to different blood groups,31,溶血性黄疸代谢图,破坏,32,大量RBC破坏 Hb UCB ，超过肝细胞的摄取、结合能力 UCB ；This is usually caused by hemolysis producing UCB at a rate exceeding the maximal rate of liver uptake, conjugation and excretion.缺氧和红细胞破坏产物对肝细胞的毒性作用 肝细胞受损 处理胆红素能力下降 UCB 。Hypoxia and erythrocyte destruction product have toxic effect to liver cell The liver cell suffers injury Processing bilirubin ability drops.,溶血性黄疸发生机制Pathogenesis of hemolytic juandice,33,溶血性黄疸 Hemolytic Juandice,临床表现 clinical occurrence：黄疸较轻，呈浅柠檬色，不伴皮肤搔痒，其它症状为原发病的表现 The jaundice is light, appears the shallow citrine, not accompanied by skin titillation, other symptoms are primary diseases performance. 急性溶血时：发热、寒战、腰痛、头痛 呕吐、Hb尿 急性肾功能衰竭 慢性溶血：多为先天性，贫血，脾肿大,34,溶血性黄疸 Hemolytic Juandice,实验室检查： 血TB 以UCB 为主，CB基本正常，CB/TB20% 尿胆原和粪胆原 、尿中无胆红素,35,肝细胞性黄疸 Hepatocellular Juandice,定义 各种肝脏疾病使肝细胞发生弥漫性 损害而引起黄疸。,36,肝细胞性黄疸代谢图,受损,37,肝细胞性黄疸,肝细胞受损 肝细胞处理胆红素的能力下降 血中UCB增加；未受损的肝细胞仍能将UCB CB，部分CB经受损细胞或坏死细胞反流入血、胆汁排泄受阻使CB返流入血 血中CB增加。,38,常见疾病,病因 病毒性肝炎、肝硬化 中毒性肝炎、败血症,39,肝细胞性黄疸 Hepatocellular Juandice,临床表现 皮肤、粘膜浅黄至深黄色 可伴有轻度皮肤搔痒 肝脏原发病的表现：乏力、食欲减退 严重者可有出血倾向,40,肝细胞性黄疸 Hepatocellular Juandice,实验室检查 血中CB与UCB均增加，CB/TB 20-50% 黄疸型肝炎时，CB增加幅度高于UCB 不同程度的肝功能异常,41,胆汁淤积性黄疸Cholestasis Juandice,分类 肝内性 肝内阻塞性胆汁淤积：肝内泥沙样结石、癌栓 肝内胆汁淤积：毛细胆管型病毒性肝炎 原发性胆汁性肝硬化 药物性胆汁淤积 肝外性 胆总管结石、狭窄、炎性水肿、 肿瘤等阻塞所引起,42,胆汁淤积性黄疸代谢图,43,胆汁淤积性黄疸 Cholestasis Juandice,发病机制胆道阻塞其上方的压力升高小胆管与毛细胆管破裂胆汁中的胆红素反流入血 肝内胆汁淤积有些并非是机械因素引起，而是由于胆汁分泌功能障碍，毛细胆管通透性增加，胆汁浓缩而流量减少，导致胆道内胆盐沉淀和胆栓形成。,44,胆汁淤积性黄疸 Cholestasis Juandice,临床表现 皮肤呈暗黄色、黄绿色 伴有皮肤搔痒 尿色深 大便颜色变浅或呈白陶土色,45,胆汁淤积性黄疸Cholestasis Juandice,实验室检查 血清CB增加 尿胆原和粪胆素减少或缺如 血清碱性磷酸酶和总胆固醇增高,46,三种黄疸实验室检查的区别,项目 溶血性 肝细胞性 胆汁淤积性TB CB 正常 CB/TB 20% 2050% 50%尿胆红素 尿胆原 轻度 或消失ALT、AST 正常 ALP 正常 r-GT 正常 PT 正常 延长 延长,47,先天性非溶血性黄疸Congenital Unhemolytic JuandiceInherent Jaundice,Gilbert Syndrom Dubin-Johnson SyndromCrigle-Najjar Syndrom Rotor Syndrom,48,Gilbert 综合征：病因： 肝细胞摄取UCB障碍 葡萄糖醛酸转移酶不足 肝细胞摄取UCB障碍 UCB转化成CB障碍 血中UCB升高 肝活组织检查无异常,49,Dubin-Johnson综合征病因： 肝细胞排泄CB障碍 CB向毛细胆管排泄障碍 血中CB增高 肝脏外观呈绿黑色，活检见肝细胞内有特异的棕褐色素颗粒,50,Crigler-Najjar 综合征病因： 葡萄糖醛酸转移酶缺乏肝细胞不能将UCB转化成CB 血中UCB明显升高 核黄疸的产生,51,Roter 综合征,肝细胞摄取非结合胆红素障碍肝细胞排泄结合胆红素障碍非结合、结合胆红素均增高肝活组织检查正常,52,辅助检查,B超 观察肝胆脾胰的大小、形态，及有无占位， 有无结石X线检查 腹部平片可发现胆道钙化结石 胆道造影可发现胆道结石影 并可判断胆囊收缩功能及胆管有无扩张ERCP（经十二指肠镜逆行胰胆管造影） 区分肝内或肝外胆管阻塞部位 直接观察壶腹部、乳头部、胰腺有无病变,53,54,辅助检查,PTC（经皮肝穿刺胆管造影） 区分肝外胆管阻塞与肝内胆汁淤积性黄疸， 对胆管阻塞部位、程度及范围有所了解放射性核素检查 198金，99锝，131碘-玫瑰红上腹部CT扫描 鉴别肝、胆、胰等疾病引起的黄疸MRI（磁共振成像) 对良性肿瘤的鉴别比CT为优肝穿刺活检及腹腔镜 对疑难黄疸病例的诊断,55,黄疸伴随症状,伴发热急性胆管炎、肝脓肿；病毒性肝炎或急性溶血可先有发热、后出现黄疸伴上腹剧烈疼痛胆道结石、胆道蛔虫病；右上腹剧痛、寒战高热、黄疸为夏科（Charcot）三联征，急性化脓性胆管炎伴肝肿大，持续性钝痛或胀痛 病毒性肝炎、原发性肝癌伴胆囊肿大胆总管梗阻，胰头壶腹癌、胆总管癌等伴脾大、腹水肝硬化失代偿期、肝癌等,56,小 结,1. 黄疸的概念。2. 溶血性、肝细胞性、胆汁淤积性黄疸的 特点。3. 三大黄疸的鉴别。,57,意识障碍Disturbance of consciousness,定义Definition,意识障碍：是指人对周围环境及自身状态的识别和觉察能力出现障碍。Disturbance of consciousness is dysfunction of the ability that allow an individual to perceive, comprehend and act on the internal and external environments.,病因Etiology,1 重症急性感染：败血症，肺炎，痢疾、伤寒、颅脑感染1 Severe acute infection: sepsis, pneumonia, dysentery, typhoid, brain infection2 颅脑非感染性疾病：脑血管病，脑占位性疾病，颅脑损伤，癫痫2 Brain non-infectious diseases: cerebrovascular diseases, brain tumor diseases, brain injury, epilepsy 3 内分泌与代谢障碍：尿毒症，肝性脑病，肺性脑病，糖尿病性昏迷3 Endocrine and metabolic disorders: uremia, hepatic encephalopathy, pulmonary encephalopathy, diabetic coma 4 心血管疾病：重度休克，重度心律失常，阿-斯综合征4 Cardiovascular diseases: Severe shock, severe arrythmia, Adams-Stokes syndrome,病因Etiology,5 水电解质平衡紊乱 water factor and electrolyte imbalance: 水中毒，低钠血症 water intoxication, hyponatremia 6 外源性中毒 Exogenous poisoning: 酒精中毒alcoholic intoxication7 物理性及缺氧性损害 physical and anoxic damages：中暑，触电 heat shock, electric shock,发生机制,意识内容：大脑皮质功能活动“开关”系统：特异性上行投射系统（经典感觉传导路径）非特异性上行投射系统（脑干网状结构）由于脑部缺氧、缺血、葡萄糖供给不足、酶代谢异常等因素致脑代谢紊乱,Consciousness refers to a set of neural processes that allow an individual to perceive, comprehend, and act on the internal and external environments. It consists of two components: awareness and arousal.Awareness refers to the higher-level integration of multiple sensory inputs that permit meaningful understanding self and environment, residing in the cerebral cortex.Arousal refers to an “on-off switch” for the cortical awareness system by ascending reticular activating system (ARAS), residing in the brainstem.Any injuries involving both bilateral diffuse cerebral cortex and/or brainstem can cause disturbance of consciousness.,发生机制Pathophysiology,临床表现Clinical manifestation,Disturbances of consciousness can be classified according to degree, from minor to severe:1 嗜睡 somnolence: 最轻的意识障碍，病理性倦睡，可唤醒，正确回答和反应，停止刺激则入睡 Its the lightest disturbances of consciousness, pathology tired sleep, can be awaken, can give the correct reply and response, but go to sleep after stoping the stimulation,临床表现Clinical manifestation,2 意识模糊 confusion: 患者保持简单的精神活动，但对时间，地点，人物的定向力发生障碍。 The patient maintains the simple spiritual activity, but has the disturbances to the orientation of time, place and person.3 昏睡 stupor: 患者处于熟睡状态，不易唤醒，虽在强烈刺激下可被唤醒，但很快又在入睡。醒时答话含糊或答非所问。The patient is at deep sleep condition, not easy to be awaken, although awaken under the intense stimulation and with ambiguous or irrelevantly replies, but going to sleep very quickly.,4 昏迷 coma：严重的意识障碍，意识持续的中断或完全丧失 Its the serious disturbances of consciousness, consciousness retains interrupted or even loses completely. (1) 轻度昏迷 mild coma：无自主活动，对声光刺激无反应，对疼痛刺激有痛苦表情或肢体退缩等防御性反应；生理反射可存在。 Its no spontaneous activity, no response to the sound-optic stimulation, having the defensive responses (painful expression or withdrawal limbs) to the ache stimulation, the physiological reflection may exist.,(2) 中度昏迷 moderate coma ：对周围事物及各种刺激均无反应，对于剧烈刺激或可出现防御性反射，各种生理反射减弱或迟钝，眼球无转动。 It has no response to the surroundings and all kinds of stimulation, or may present the defensive reflex regarding the fierce stimulation, each physiological reflection is weaken or slow, the eyeball does not have the rotation. (3) 深度昏迷 deep coma：全身肌肉松弛，刺激无反应，深浅反射均消失The whole body muscle is relaxation, no response to any stimulation, nor shallow reflection and deep reflection.,谵妄 delirium: 意识模糊,定向力丧失,感觉错乱,躁动不安,言语杂乱 a speical disturbance of consciousness with increased excitability. For