临床诊断学：恶心呕吐呕血便血

1、 Diagnostics of Digestive System Diseases消化内科消化内科Gastroenterology Department消化系统疾病的症状消化系统疾病的症状(Symptoms)消化系统疾病的体征消化系统疾病的体征(Signs)消化系统疾病的症状消化系统疾病的症状 (Symptoms of digestive system diseases )n1、 恶心与呕吐恶心与呕吐Nausea and vomiting教学大纲教学大纲掌握：掌握：n恶心恶心、呕吐的概念，临床表现、伴随症状和问、呕吐的概念，临床表现、伴随症状和问诊诊要点要点。熟悉：熟悉：n恶心恶心、呕吐病因和

2、发病机制。、呕吐病因和发病机制。恶心与呕吐恶心与呕吐(Nausea and vomiting)n恶心恶心 (Nausea):lEpigastric discomfort and predromal sensation of vomiting accompanied with vagus activation, e.g. pale skin, sweating, salivary secretion, lowered blood pressure and bradycardia,l and followed with vomiting, but sometimes no vomiting wit

3、h only nausea, and visa versa. l恶心常为呕吐的前奏，恶心后随之呕吐，但常为呕吐的前奏，恶心后随之呕吐，但也可仅有恶心也可仅有恶心(呕吐呕吐)而无呕吐而无呕吐(恶心恶心)。 呕吐呕吐(Vomiting):lBackflow of gastric or contents of small intestines through esophagus and oral cavity out of the body. lBoth are complex reflexes and caused by many reasons. 【 Etiology】1.反射性呕吐反射性呕吐

4、(Reflex vomiting)(1)胃、十二指肠疾病胃、十二指肠疾病(Diseases of stomach and duodenum)：n急慢性胃肠炎急慢性胃肠炎 acute and chronic gastroenteritisn消化性溃疡消化性溃疡 peptic ulcern急性胃扩张或幽门梗阻急性胃扩张或幽门梗阻 pyloric obstructionn十二指肠雍滞十二指肠雍滞 duodenal stasis（2）肠道疾病）肠道疾病 Intestinal diseases：急性阑尾炎急性阑尾炎 acute appendicitis各型肠梗阻各型肠梗阻 intestinal obst

5、ruction of various types急性出血坏死性肠炎急性出血坏死性肠炎 acute hemorragic necrotic enteritis腹型过敏性紫癜腹型过敏性紫癜 allergic purpura (abdominal type)(3)咽部受到刺激咽部受到刺激(Stimulation of pharynx)：n吸烟吸烟 smoking n剧咳剧咳 severe coughn鼻咽部炎症鼻咽部炎症 naso-pharynx inflammationn溢脓溢脓 pyorrhea（4）肝胆胰疾病）肝胆胰疾病 (Heptobiliary and pancreatic disease

6、s) ：急性肝炎急性肝炎 acute hepatitis肝硬化肝硬化 liver cirrhosis肝淤血肝淤血 liver congestion、急慢性胆囊炎急慢性胆囊炎 acute and chronic cholecystitis胰腺炎胰腺炎 pancreatitis（5）腹膜及肠系膜疾病）腹膜及肠系膜疾病 (Peritoneal and mesentery diseases)：急性腹膜炎急性腹膜炎 acute peritonitis（6）其他疾病）其他疾病 (Other diseases)：l肾输尿管结石肾输尿管结石 (renal and ureter stone)l急性肾盂肾炎急性肾

7、盂肾炎 (acute pyelonephritis)l肾炎肾炎 (nephritis)l急性盆腔炎急性盆腔炎 (acute pelvic inflammatory disease)l异位妊娠破裂异位妊娠破裂 (ruptured ectopic pregnancy) l 心肌梗塞心肌梗塞 (myocardial infarction)l心力衰竭心力衰竭 (heart failure)l内耳迷路病变内耳迷路病变 (inner ear labyrinth lesions)l 青光眼青光眼 (glaucoma)l屈光不正屈光不正 (ametropia refraction error) 2.中枢性呕吐

8、中枢性呕吐 (Central vomiting)（1）颅内感染）颅内感染 (Intracranial infection)n各种脑炎各种脑炎 (encephalitis of various types)n脑膜炎脑膜炎 (meningitis)（2）脑血管疾病）脑血管疾病 (Cerebro-vascular diseases)n脑出血脑出血 (cerebral hemorrhage)n脑栓塞脑栓塞 (cerebral embolism)n脑血栓形成脑血栓形成 (cerebral thrombosis)n高血压脑病高血压脑病 (hypertensive encephalopathy)n偏头痛偏头

9、痛 (hemicrania)（3）颅脑损伤）颅脑损伤 (Craniocerebral injury)n脑挫裂伤脑挫裂伤 (contusion and laceration of brain)n颅内血肿颅内血肿 (intracranial hematoma)（4）癫痫病）癫痫病 Epilepsy, especially in persistent state.（5）其他疾病）其他疾病 Other diseases 尿毒症尿毒症 (uremia) 肝昏迷肝昏迷 (hepatic coma) 糖尿病酮症酸中毒糖尿病酮症酸中毒 (diabetic ketoacidosis) 低血糖低血糖 (hypog

10、lycemia) 引起脑水肿、颅压升高等而致呕吐引起脑水肿、颅压升高等而致呕吐 causing cerebral edema, increased intracranial pressure and leading to nausea and vomiting. （6）药物）药物 (Drugs) 抗生素抗生素 (antibiotics) 抗癌药抗癌药 (anti-cancer drugs) 洋地黄洋地黄 (digitalis) 吗啡吗啡 (morphine) etc. 可因兴奋呕吐中枢而致呕吐。可因兴奋呕吐中枢而致呕吐。 May activate the vomiting center and

11、 cause vomiting. 3. 神经性呕吐神经性呕吐 (Psychogenic vomiting) 胃肠神经症胃肠神经症 (gastrointestinal neurosis) 神经性厌食神经性厌食 (anorexia nervosa) VOMITING CENTRE 1.呕吐的时间呕吐的时间 Vomiting timenMorning vomiting: early pregnancy in child bearing period , uremia , chronic alcohol intoxication or functional dyspepsia；nAlso seen i

12、n patients with naso-sinusitis in whom pus may flows back through choana leading to stimulation of the pharynx. nEvening or midnight vomiting: seen in pyloric obstruction（晚上或夜间呕吐见于幽门梗阻）晚上或夜间呕吐见于幽门梗阻） 【Clinical manifestation】2.呕吐与进食的关系呕吐与进食的关系 Relationship between vomiting and food intakenFood poison

13、ing: after food intake, especially in group attack. nPsychogenic vomiting: immediately after food intake. nProlonged vomiting: one hour after food intake, seen in prolonged gastric emptying or decreased gastric tension.nPyloric obstruction: long after food intake.（餐餐后后较久或数餐后呕吐，见于较久或数餐后呕吐，见于幽门梗阻）。幽门梗

14、阻）。3.呕吐的特点呕吐的特点 characteristic of vomitingnPsychogenic vomiting: no prodromal nausea or mild;nIntra-cranial vomiting: caused by increased intra-cranial pressure and projectile vomiting is seen.（精神性或颅内精神性或颅内高压性呕吐，恶心很轻或缺如，后者以喷高压性呕吐，恶心很轻或缺如，后者以喷射状呕吐为其特点。）射状呕吐为其特点。） 4.呕吐物的性质呕吐物的性质 Features of vomitusnSm

15、ell of fermentation and putrefaction: gastric retention;nFoul smell: distal obstruction of the small intestine;nNo bile content: obstruction is above duodenal papilla; Bile content: obstruction is below duodenal papilla;nLarge amount of acidic content: duodenal ulcer or gastrinoma; nNo acidic taste:

16、 cardiac stenosis or achalasia. 【Accompany symptoms】nAbdominal pain, diarrhea: acute enteritis, food poisoning, cholera;nPain, jaundice, fever: cholecystitis, biliary stone;nHeadache, projectile vomiting: intra-cranial high pressure, glaucoma青光眼青光眼;nTaking anti-cancer medications: side effects;nMarr

17、ied women: early pregnancy;呕吐的起病；呕吐的时间，晨起还是夜呕吐的起病；呕吐的时间，晨起还是夜间，间歇或持续，与饮食、活动等有无间，间歇或持续，与饮食、活动等有无关系；呕吐物性状、特点、量等。根据关系；呕吐物性状、特点、量等。根据是否有酸味可区别胃潴留与贲门失弛缓；是否有酸味可区别胃潴留与贲门失弛缓；是否有胆汁，可区分十二指肠乳头平面是否有胆汁，可区分十二指肠乳头平面上、下之梗阻等；上、下之梗阻等；发作的诱因，如体位、进食、咽部刺激等诱因。发作的诱因，如体位、进食、咽部刺激等诱因。伴随的症状。伴随的症状。诊治情况，如是否作诊治情况，如是否作X线钡餐、胃镜、腹部线钡餐

18、、胃镜、腹部B型超声、型超声、血糖、尿素氮等检查。血糖、尿素氮等检查。 【Important notes of history taking】呕呕 血血Hematemesis快！快！快！快！快！快！教学大纲教学大纲掌握掌握： n呕血呕血的概念，临床表现，问诊的概念，临床表现，问诊要点要点n便血便血概念（注意与呕血定义中出血范围的区别概念（注意与呕血定义中出血范围的区别）；临床表现；问诊要点。）；临床表现；问诊要点。熟悉熟悉：n呕血呕血病因病因，伴随，伴随症状症状n便血概念、病因和伴随症状便血概念、病因和伴随症状。nHematemesis is referred to acute upper d

19、igestive tract bleeding caused by diseases of the organs above Triz ligament( including esophagus, stomach, duodenum, liver, biliary tract and pancreas) and by systematic diseases. nBleeding from nasal cavity, oral cavity and throat or from respiratory tract is not regarded as hematemesis. 【 Etiolog

20、y】 1.食管疾病食管疾病Diseases of esophagus n食管静脉曲张破裂食管静脉曲张破裂rupture of esophageal varicesn食管炎食管炎 esophagitisn食管憩室炎食管憩室炎 esophageal diverticulitis n食管癌食管癌 esophageal cancern食管异物食管异物 foreign bodies in esophagusn食管贲门粘膜撕裂食管贲门粘膜撕裂 esophageal cardiac mucosa （Mallory-Weiss综合征）综合征） lacerationn食管裂孔疝食管裂孔疝 esophageal

21、hiatal hernia nmassive bleeding usually is caused by ruptured esophageal varices in portal hypertension.大量呕血常由大量呕血常由门脉高压门脉高压导致导致的的食管静脉曲张破裂食管静脉曲张破裂所致所致 nPerforation of aorta by esophageal foreign body may cause life threatening massive hematemesis.食管异物戳穿主动食管异物戳穿主动脉可造成大量呕血，常危及生命。脉可造成大量呕血，常危及生命。n 2.胃及十

22、二指肠疾病胃及十二指肠疾病 Gastro-duodenal diseases l消化性溃疡消化性溃疡 peptic ulcer 最常见最常见 包括胃及十二指肠溃疡包括胃及十二指肠溃疡 gastric and duodenal ulcerl慢性胃炎慢性胃炎 chronic gastritis l非甾类抗炎药非甾类抗炎药 non-steroid anti-inflammatory drugs （如阿司匹林（如阿司匹林aspirin）l应激所引起的应激所引起的急性胃粘膜病变急性胃粘膜病变 acute gastric mucosa lesions( AGML)l胃癌胃癌 gastric cancerl

23、胃粘膜脱垂症胃粘膜脱垂症 prolapse of gastric mucosal血管异常如血管异常如 恒径动脉破裂综合征恒径动脉破裂综合征 (Dieulafoy disease) 3.肝、胆道疾病肝、胆道疾病 Hepato-biliary diseases n肝硬化门静脉高压可引起食管和胃底静脉曲张破裂出血；肝硬化门静脉高压可引起食管和胃底静脉曲张破裂出血；nBleeding from ruptured esophageal and gastric varices caused by portal hypertension of liver cirrhosisn肝恶性肿瘤肝恶性肿瘤 hepat

24、ic malignant tumorsn肝癌肝癌 liver cancern肝脓肿肝脓肿 liver abscessn肝动脉瘤破裂出血肝动脉瘤破裂出血 bleeding of ruptured liver angioman胆囊结石胆囊结石 gall bladder stonen胆道结石胆道结石 biliary tract stonen胆道寄生虫胆道寄生虫 biliary parasite diseasesn蛔虫蛔虫 ascaridn胆囊癌胆囊癌 cancer of gall bladdern胆管癌胆管癌 biliary cancer n壶腹癌壶腹癌 ampulla cancer 4.胰腺疾病胰

25、腺疾病 (Pancreatic diseases) n急性胰腺炎合并脓肿或囊肿急性胰腺炎合并脓肿或囊肿 acute pancreatitis complicated with abscess or cystn胰腺癌破裂出血胰腺癌破裂出血 bleeding from ruptured pancreatic cancer5.血液疾病血液疾病 （Hematological disorders) n血小板减少性紫癜血小板减少性紫癜 idiopathic thrombocytopenic purpura ITPn过敏性紫癜过敏性紫癜 allergic purpuran白血病白血病 leukemian血友

26、病血友病 hemophilian霍奇金病霍奇金病 Hodgkin diseasen遗传性毛细血管扩张症遗传性毛细血管扩张症 Hereditary telangiectasian弥散性血管内凝血弥散性血管内凝血 disseminated intra-vascular coagulation (DIC)6. 急性传染病急性传染病 Acute infectious diseasesl 流行性出血热流行性出血热 epidemic hemorrhagic feverl钩端螺旋体病钩端螺旋体病 leptospirosis l登革热登革热 Dengue feverl暴发型肝炎暴发型肝炎 fulminate

27、hepatitis7. 其他其他 Othersl尿毒症尿毒症 uremia l呼吸功能衰竭呼吸功能衰竭 respiratory failure lPeptic ulcer消化性溃疡消化性溃疡 is the most common cause lruptured esophageal and gastric varices 食管或胃底静脉曲张破裂食管或胃底静脉曲张破裂lacute gastric mucosa lesion 急性胃粘膜病变急性胃粘膜病变lgastric cancer 胃癌胃癌 常见病因常见病因 【Clinical manifestation】nEpi-gastric discom

28、fort and nausea usually proceed hematomesis, followed by bloody vomiting.nIf blood vomitus stays in the stomach short, and large in quantity, and bleeding from esophagus, then the vomitus is fresh red or with clot or dark red.nIf bleeding is small and stays longer time in stomach, hemoglobin is conv

29、erted into hematin by way of gastric acid, the vomitus is coffee-like咖啡咖啡渣样物渣样物：酸化正铁血红蛋白：酸化正铁血红蛋白nand the stool becomes black in color (melena). tarry stool黑便、柏油便黑便、柏油便 失血的表现失血的表现 (Manifestation of blood loss)n急性失血的表现急性失血的表现nBleeding is 10-15% of blood volume, dizziness, chill, no blood pressure and

30、 pulse changenBleeding is 20% of blood volume, heartbeat fast, rapid pulse, chillnOver 30%, peripheral circulation failure, weak pulse, low blood pressure, rapid respiration and shock.出出血量达血量达30%30%以上：急性周围循环衰竭的表现，脉以上：急性周围循环衰竭的表现，脉搏细速，血压下降，休克搏细速，血压下降，休克n Accompanying symptoms 1. Epi-gastric pain nYou

31、ng and middle aged man with chronic pain: peptic ulcer；nmiddle and old man with weight loss: gastric cancer;2. Liver and spleen enlargement nLiver palm, spider angioma, abdominal wall varices or ascites: portal hypertension; npain in liver region, un-smooth enlarged liver and AFP positive: liver can

32、cer; 3. JaundicenJaundice, chill, fever with epi-gastric pain: biliary diseasenJaundice, fever, bleeding tendency of skin and mucosa: infectious diseases，septicemia, leptospirosis钩端螺旋体病钩端螺旋体病;4. skin and mucosa bleeding nBlood system diseases5. others lNSAID, burn, brain surgery, cerebro-vascular di

33、sease, trauma, AGML; Severe vomiting, esophageal cardiac laceration; 6. dizziness , thirsty, cold sweatinglInsufficient blood volume, shock; Important note of history taking 1. 确定是否呕血确定是否呕血 应注意排除鼻咽部出血和咯血。应注意排除鼻咽部出血和咯血。2. 呕血的诱因呕血的诱因 有否饮食不节、大量饮酒、毒物或特有否饮食不节、大量饮酒、毒物或特殊药物摄入史。殊药物摄入史。3. 呕血的颜色呕血的颜色 可以帮助推测出血

34、的部位和速度。可以帮助推测出血的部位和速度。4. 呕血量呕血量 5.患者的一般情况患者的一般情况6.过去有否上腹疼痛、反酸、嗳气、消化不良史，有过去有否上腹疼痛、反酸、嗳气、消化不良史，有否肝病和长期药物摄入史。否肝病和长期药物摄入史。便便 血血hematocheziaHematochezia nHematochezia means bleeding from digestive tract. The colour of the stool may vary from fresh red, dark red to black.nLittle bleeding may result in no

35、colour change of the stool. And it is determined by occult blood test隐血试验隐血试验. 【 Etiology】1. Diseases of upper digestive tract .有呕血一定有黑便有呕血一定有黑便2.小肠疾病小肠疾病 Diseases of small intestinesn肠结核肠结核 intestinal TB n肠伤寒肠伤寒 intestinal typhoid n急性出血性坏死性肠炎急性出血性坏死性肠炎 acute hemorrhagic necrotic enteritisn钩虫病钩虫病 ho

36、okworm disease n小肠肿瘤小肠肿瘤 small intestine tumors nCrohn 病病 Crohns disease n小肠血管瘤小肠血管瘤 small intestinal angioman空肠憩室炎或溃疡空肠憩室炎或溃疡 diverticulitis or ulcer of jejunumnMeckel憩室炎或溃疡憩室炎或溃疡 Meckel diverticulitis or ulcern肠套叠肠套叠 Intussusception3. 结肠疾病结肠疾病 Diseases of colon 急性细菌性痢疾急性细菌性痢疾 bacillary dysentery 阿

37、米巴痢疾阿米巴痢疾 amebic dysentery血吸虫病血吸虫病 schistosomiasis 溃疡性结肠炎溃疡性结肠炎 ulcerative colitis 结肠憩室炎结肠憩室炎 colon diverticulitis 结肠癌结肠癌 colon cancer结肠息肉结肠息肉 polyp of colon 缺血性结肠炎缺血性结肠炎 ischemic colitis 4.直肠肛管疾病直肠肛管疾病 Rectum and anal diseases q直肠肛管损伤直肠肛管损伤 rectum and anal injuryq非特异性直肠炎非特异性直肠炎 non-specific proctit

38、isq直肠息肉直肠息肉 polyp q直肠癌直肠癌 rectum cancerq痔痔 hemorrhoidq肛裂肛裂 anal fissureq肛瘘肛瘘 anal fistulan 5. 全身性疾病全身性疾病 Systematic diseases 白血病白血病 leukemia血小板减少性紫癜血小板减少性紫癜 ITP血友病血友病 hemophilia遗传性毛细血管扩张症遗传性毛细血管扩张症 hereditary telangiectasis维生素维生素C及及K缺乏症缺乏症 Vitamin C and D deficiency肝脏疾病肝脏疾病 liver diseases流行性出血热流行性出血

39、热 epidemic hemorrhagic fever败血症败血症 septicemia 【Manifestation】 nThe color of the stool may vary with the location, amount and the duration of stay of the blood in the intestines . nLower GI bleeding: big amount fresh, stay longer-dark red, may be mixed with the stool.Fresh red and not mixed with stoo

40、l, adhere to the surface or blood drop or projection after defecation- anal or rectum diseases or rectum cancer.肛门或肛管疾病出血，如痔、肛裂或肛门或肛管疾病出血，如痔、肛裂或直肠肿瘤直肠肿瘤If bleeding is from upper GI or small intestines and stays longer time in the intestines, hemoglobin combines with sulphide forming ferrous sulphide

41、 and the stool becomes black in color and shining appearance known as tarry stool柏油便柏油便.n阿米巴痢疾的粪便多为暗红色果酱样的脓血便阿米巴痢疾的粪便多为暗红色果酱样的脓血便 nAmebic dysentery jam-like stooln急性细菌性疾病多有粘液脓性鲜血便急性细菌性疾病多有粘液脓性鲜血便nAcute bacterial dysentery mucus-pus-bloody stooln急性出血性坏死性肠炎可排出洗肉水样血便，并有急性出血性坏死性肠炎可排出洗肉水样血便，并有特殊的腥臭味。特殊的腥臭味。nAcute hemorrhagic necrotic enteritis meat washing watery stool with especial foul odor. 【 Accompanying symptoms】 1. abdominal painnChronic epigastric pain, relieved after bleeding：peptic ulcer;nEpigastric pain with jaundice：hepatic or biliary ble