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,IntestinalObstruction,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,Caseone(scene1),Male,age:65,“Paraxymalabdominalpain48hwithnauseaandvomitingoneday”,youarethedoctoronduty.,Q1.Accordingtothechiefcomplaint,whichkindofinformationyoushouldcollectduringaskthehistory?,Mainpointofthehistory,1:AbdominalpainTheposition、level、kindofpain,withorwithoutradiation,therelationshipbetweenbowelsoundandpain,paroxymalorcontinuing.2:NauseaandvomitingThekind、volumn、colorandsmellofvomitus,therelationshipbetweenvomitingandpain.3:AbdominaldistentionTime,levelandposition4:FailuretopassflatusandfecesThekind、quantityoffecesandtherelationshipbetweenitandpain,ifthepainrelieveafterpassflatusandfeces.5:Pasthistory,Caseone(scene1),Q2：Tomakeadefinitediagnosis，whichkindofinformationweshouldpayattentiontointhenextPhysicalExaminationandAuxiliaryExamination?,Mainpointofthephysicalexamination,GeneralExamination：T:37.2HR:96bpmR:22bpmBP:130/70mmhgNodehydration,noanemia,nojaundice,AbdominalExamination：Inspection：Distendedabdomen,noperistalticwavescanbeobserved,previousscarintheupperabdomen.Palpation:Mildabdominaltenderness,norebound,noguarding,nomass,noincarceratedherniainthegroin.Percussion：Tympany.,Auscultation：Hyperactivebowelsounds,6-8bpm.,RectalExamination：Negative,Localpathophysiologyofintestinalobstruction,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:Whatisyourdiagnosis?,Caseone(scene1),Definition49(3):203-7.2:AttardJA,MacleanAR.Adhesivesmallbowelobstruction:epi-demiology,biologyandprevention.CanJSurg,2007;50(4):291-300.3:杜晓辉，李荣，梁发启。急性血运性肠梗阻的诊治（附35例报告）。中国现代医学杂志，2006;16(5):765-766。4:Sabiston