恶心呕吐精品课件

1、关于恶心呕吐第一张，PPT共八十七页，创作于2022年6月临床诊断学上海第二医科大学仁济临床医学院 第二张，PPT共八十七页，创作于2022年6月Nausea and VomitingAs the symptoms症状学：恶心与呕吐第三张，PPT共八十七页，创作于2022年6月GoalsBriefly defineOutline the prominent disease states associated with nausea and vomiting.Characterize Nausea and Vomiting caused by the prominent disorders Di

2、scriminate the accompanying symptoms. Suggest diagnostic strategies of the symptoms.第四张，PPT共八十七页，创作于2022年6月Definition of Nausea and VomitingNausea ：the inclination or feeling of imminent desire to vomit, usually felt in the throat or epi-gastrum. Associated with decreased activity of the stomach.Vom

3、iting： the forceful oral expulsion of gastric contents via retro-peristalsis.Nausea-Vomiting: simultaneity or separateness恶心：紧迫欲吐，通常伴有上腹不适和迷走兴奋的临床征候群。呕吐：胃和/或小肠内容物经食管和口腔排除体外恶心和呕吐常伴随存在，也可单独出现！第五张，PPT共八十七页，创作于2022年6月Nausea and Vomiting第六张，PPT共八十七页，创作于2022年6月1、恶心：咽部及上腹部不适，胃张力和蠕动减弱，幽门和贲门开放。2、干呕：胃窦部和腹壁肌肉收

4、缩，腹压增加，食管及咽部开放。3、呕吐：胃和/或小肠内容物经食管和口腔排除体外。Definition of emesis. (Three phases)呕吐反射过程（三个阶段）1. Nausea - the inclination or feeling of imminent desire to vomit, usually felt in the throat or epigastrum. Associated with decreased activity of the stomach.2. Retching - the labored rhythmic contraction of re

5、spiratory and abdominal musculature that frequently precedes or accompanies vomiting.3. Vomiting - the forceful oral expulsion of gastric contents via retroperistalsis. (Abdominal effects).第七张，PPT共八十七页，创作于2022年6月迷走兴奋表现恶心干呕呕吐发生机制第八张，PPT共八十七页，创作于2022年6月呕吐区别于反食呕吐：多数情况有恶心的感觉和呕吐反射的协调动作。反食：无恶心的感觉和呕吐反射的协调动

6、作。（儿童、饱餐）第九张，PPT共八十七页，创作于2022年6月Mechanisms of emesis第十张，PPT共八十七页，创作于2022年6月CTZ & Emetic Center (Vomiting center)CTZ化学感受器触发带（第四脑室底面）：外源性或内源性化学物质（阿片吗啡、洋地黄、代谢产物）Emetic Center（延髓外侧网状结构背测）接受大脑皮质、消化器官、心血管以及化学感受器触发带（CTZ）的冲动第十一张，PPT共八十七页，创作于2022年6月CTZ & Emetic Center (Vomiting center)孤束核第十二张，PPT共八十七页，创作于202

7、2年6月Emetic Center 内脏传入 中脑ICP受体化学感受器触发带边缘系统前庭系统呕吐中枢（Vomiting center)ICP=Inductively Coupled Plasma 感应耦合等离子体第十三张，PPT共八十七页，创作于2022年6月Neurotransmitters in CTZ & Emetic CenterNeurotransmitters involved in stimulating the emetic center, chemo-receptor trigger zone and GI tract include; 5-HT, acetylcholine

8、, histamine, dopamine (opiates and receptors for benzodiazepines are also found here)第十四张，PPT共八十七页，创作于2022年6月第十五张，PPT共八十七页，创作于2022年6月第十六张，PPT共八十七页，创作于2022年6月Emetic Center 1、分泌唾液中枢2、血管收缩中枢3、呼吸中枢4、中枢神经脊神经膈神经迷走神经第十七张，PPT共八十七页，创作于2022年6月第十八张，PPT共八十七页，创作于2022年6月nausea and vomiting1. Reflective vomiting 反

9、射性呕吐2.Central vomiting 中枢性呕吐3. Neurological vomiting 神经性呕吐第十九张，PPT共八十七页，创作于2022年6月Reflective vomiting （反射性呕吐）咽部刺激胃十二指肠疾病胆道疾病肠道疾病肝胆疾病腹膜肠系膜全身性疾病（五官、心血管、泌尿、盆腔）Pharyngeal MechanismsGastrointestinal MechanismsDisease of biliary tractPeritoneal and mesenterythe five sense organsCardiovascular diseases kid

10、neyPelvic第二十张，PPT共八十七页，创作于2022年6月咽部刺激Pharyngal Mechanisms第二十一张，PPT共八十七页，创作于2022年6月Gastrointestinal Mechanisms第二十二张，PPT共八十七页，创作于2022年6月肝、胆、胰腺第二十三张，PPT共八十七页，创作于2022年6月其他第二十四张，PPT共八十七页，创作于2022年6月Intra-cranial infectionCerebrovascular disordersCraniocerebral injuryEpilepsyMetabolic disorders DrugsCentra

11、l vomiting （中枢性呕吐）颅内感染脑血管疾病颅脑损伤癫痫全身疾病（尿毒症、肝昏迷、糖尿病代谢紊乱）第二十五张，PPT共八十七页，创作于2022年6月颅内感染（脑炎、脑膜炎）第二十六张，PPT共八十七页，创作于2022年6月脑血管疾病、颅脑损伤第二十七张，PPT共八十七页，创作于2022年6月癫痫第二十八张，PPT共八十七页，创作于2022年6月全身疾病尿毒症肝昏迷酮症酸中毒各种原因引起的脑水肿和颅内压升高代谢紊乱早孕第二十九张，PPT共八十七页，创作于2022年6月Drug抗生素抗癌药洋地黄吗啡兴奋呕吐中枢或影响胃肠平滑肌运动AntibioticsAnti-carcinomaDigi

12、talismorphia第三十张，PPT共八十七页，创作于2022年6月Neurologic & Psychogenic causesNeurologic and Psychogenic causes胃肠道神经官能症（Gastrointestinal tract neurosis）神经厌食症（apositia）第三十一张，PPT共八十七页，创作于2022年6月Characteristics of Nausea and VomitingTimeTaking foodCharacteristicsCharacters of contents第三十二张，PPT共八十七页，创作于2022年6月晨起呕吐

13、早孕反应功能性消化不良酒精中毒胃食管反流病鼻咽部疾患夜间或隔夜呕吐幽门梗阻贲门失弛缓症第三十三张，PPT共八十七页，创作于2022年6月呕吐与进食的关系（ Timing with meals）餐后即刻：神经精神性；集体发病系食物中毒餐后1小时以上：为延迟性呕吐：可考虑为胃张力低下排空障碍餐后较久、多餐后或隔夜：提示幽门梗阻第三十四张，PPT共八十七页，创作于2022年6月呕吐特点神经性或颅内高压：恶心轻、呕吐频；“喷射性呕吐”呕吐物性质发酵、腐臭味：提示胃潴留粪臭味：提示较低位置的肠梗阻无酸腐味：贲门失迟缓症或胃酸缺乏不含胆汁：幽门梗阻病史较长或量多：提示体液和电解质丢失第三十五张，PPT共八

14、十七页，创作于2022年6月The accompanying symptoms腹痛、腹泻：食物中毒、肠道传染病、胃肠炎；节律性腹痛：消化性溃疡右上腹痛，伴发热、黄疸：胆囊炎、胆道结石、感染。头痛、头晕、视力异常、喷射性呕吐：颅内高压性疾病、屈光不正、青光眼。伴眩晕、眼球震颤：前庭障碍育龄妇女（停经）：应排除妊娠与服药有时间关联：应想到药物反应第三十六张，PPT共八十七页，创作于2022年6月问诊要点起病情况：诱因、急缓、与进食关系、腹部手术史、育龄妇女月经史发作时间：晨、夜、与进食、活动、体位的关系呕吐物性状、味道伴随症状诊疗和症状演变情况第三十七张，PPT共八十七页，创作于2022年6月Hi

15、story/Backgrounda) Ageb) GI history requiredc) Food intoleranced) Timing with mealse) Consistencyf) Contentg) Odorh) Frequencyi) Feverj) Weight lossk) Precipitating factorsl) Myalgias（肌痛）, visual disturbances, headache, pain outside abdomen第三十八张，PPT共八十七页，创作于2022年6月CAUSES OF NAUSEA/VOMITINGEarly preg

16、nancyPsychogenesis vomitingBulimia(易饿病)Pyloric channel ulcerAcute gastritisGastric retention(潴留）Viral gastroenteritis（中毒性胃肠炎）Acute gastroenteritisMyocardial infarctionPeritonitis（腹膜炎）Acute obstructionNeurological emergencyDrug toxicityCancer therapyDrug withdrawal第三十九张，PPT共八十七页，创作于2022年6月PHYSICAL EX

17、AMVital signsSkinHEENT （head,eyes,ear,nose,throat)AbdomenNeurological第四十张，PPT共八十七页，创作于2022年6月LABORATORYRule out obstruction and peritonitisHCGUrinalysisElectrolytes, BUN, creatinine, glucoseTransaminases, amylaseEKG, head CT, upper GI &/or endoscopies第四十一张，PPT共八十七页，创作于2022年6月Break第四十二张，PPT共八十七页，创作于2

18、022年6月泸沽湖黄昏第四十三张，PPT共八十七页，创作于2022年6月泸沽湖黄昏第四十四张，PPT共八十七页，创作于2022年6月泸沽湖摩梭女第四十五张，PPT共八十七页，创作于2022年6月玉龙雪山雪月第四十六张，PPT共八十七页，创作于2022年6月47第四十七张，PPT共八十七页，创作于2022年6月ConstipationShanghai Second Medical universityRenji clinical medical college第四十八张，PPT共八十七页，创作于2022年6月Background第四十九张，PPT共八十七页，创作于2022年6月Constipat

19、ion Is a Constellation of SymptomsMost commonly reported symptomsHard, lumpy stoolsIncreased strainingInfrequent bowel movementsSensation of incomplete evacuationBloating/fullnessChronic constipationMore persistent than intermittent or episodicSeveral months durationC第五十张，PPT共八十七页，创作于2022年6月Sandler

20、RS, et al. Dig Dis Sci. 1987;32:841-845.n = 1128Constipation Is More Than Just Infrequent Passage of Stool53Constipation symptoms reported most often第五十一张，PPT共八十七页，创作于2022年6月Reduced Stool Frequency Is Not the Most Commonly Reported Symptom in ConstipationEPOC = Epidemiology of constipation; BM = Bow

21、el movement.1. Stewart WF, et al. Am J Gastroenterol. 1999;94:3530-3540.2. Par P, et al. Am J Gastroenterol. 2001;96:3130-3137.Stewart (EPOC) 19991Par 20012n = 1476n = 1149Constipation symptoms reported most oftenC第五十二张，PPT共八十七页，创作于2022年6月Prevalence in the General Population1. Stewart WF, et al. Am

22、J Gastroenterol. 1999;94:3530-3540.2. Drossman DA, et al. Dig Dis Sci. 1993;38:1569-1580.3. Harris Interactive Study, Wave 2. Data on file. 4. Par P, et al. Am J Gastroenterol. 2001;96:3130-3137.53PopulationnCriteriaPrevalence, n (%)US110,018Rome I 461 (4.6)US25430Rome I 195 (3.6)US315,183Rome II242

23、9 (16)Canada41149Rome II 171 (14.9)China (18-70ys)?RomeII?(6.07)China(60ys)?RomeII?(15-20)第五十三张，PPT共八十七页，创作于2022年6月EpidemiologyChronic constipation is commonSlightly more common in women F/M ratio = range 1.3 to 2.5 (China=4:1)Affects all age groupsStewart WF, et al. Am J Gastroenterol. 1999;94:3530

24、-3540.Par P, et al. Am J Gastroenterol. 2001;96:3130-3137.Sandler RS, et al. Dig Dis Sci. 1987;32:841-845. C第五十四张，PPT共八十七页，创作于2022年6月Constipation Affects All Age Groups53Canadian population.Par P, et al. Am J Gastroenterol. 2001;96:3130-3137.N = 1149n = 378n = 367n = 217n = 187第五十五张，PPT共八十七页，创作于2022

25、年6月Profile of a Typical Chronic Constipation Patient in My PracticeGenerally femaleSymptomatic for 10 yrMajority have tried lifestyle changes, fiber, and OTC laxatives prior to seeking careManages condition with multiple therapiesMost often referred by a primary care physician Copes with condition,

26、but is not completely satisfiedC第五十六张，PPT共八十七页，创作于2022年6月Constipation Can Have a Negative Impact on Quality of LifePeople with CC reported significant impairment in QoL on SF-36 scale (n = 126)1In Canada, people with self-reported or Rome II constipation had significantly worse SF-36 scores than the

27、 normal population (n = 472)2In Australia, people with constipation had significantly worse SF-12 scores on both mental and physical scales (n = 227)31. OKeefe EA, et al. J Gerontol A Biol Sci Med Sci. 1995;50:M184-M189.2. Irvine EJ, et al. Am J Gastroenterol. 2002;97:1986-1993. 3. Koloski NA, et al

28、. Am J Gastroenterol. 2000;95:67-71. C第五十七张，PPT共八十七页，创作于2022年6月Constipation Significantly Impacts Healthcare Utilization5.7 million constipation-related outpatient visits annually1,24.1 million physician office-based visits 991,000 emergency room visits587,000 hospital outpatient visits$2752/patient

29、 for tertiary care evaluation31. National Ambulatory Medical Care Survey, 2001. 2. National Hospital Ambulatory Care Survey, 2001. 3. Rantis PC Jr, et al. Dis Colon Rectum. 1997;40:280-286.C第五十八张，PPT共八十七页，创作于2022年6月Complications related with constipationColonic and rectal carcinomaOther colon-rectal

30、-anus disordershepatic coma acute myocardial infarctionmammary gland disorderspresenile dementia(早老性痴呆）psycho-problemsappearance第五十九张，PPT共八十七页，创作于2022年6月Definition: Causes of Chronic ConstipationSecondaryDrug induced Metabolic factorsComorbid conditionsPrimaryImpaired colonic transit/motility Altere

31、d neuroenteric function and reflexesFailure of muscular apparatusIneffective defecation (functional outlet obstruction)Pelvic dyssynergia and anismusNormal transit constipation第六十张，PPT共八十七页，创作于2022年6月Presentation ObjectivesDefine constipationThe pathophysiological mechanisms Etiologies of constipati

32、on Characterize manifestationDiscriminate the accompanying symptoms. Suggest diagnostic strategies of the symptoms.C第六十一张，PPT共八十七页，创作于2022年6月What is Constipation?Passage of hard, dry, lumpy stools; Infrequent bowel movements, usually fewer than three times a weekSymptoms:painful bowel movements stra

33、iningUncomfortable（Sensation of incomplete evacuation）bloatedsluggish第六十二张，PPT共八十七页，创作于2022年6月Rome II Defines Functional Constipation Based on Multiple SymptomsRome II diagnostic criteria for functional constipationAt least 12 wk, which need not be consecutive, over the past 12 months of 2 or more o

34、f Straining*Lumpy or hard stools*Sensation of incomplete evacuation*Sensation of anorectal obstruction/blockage*Manual maneuvers to facilitate defecation* 1/4 of defecations.Drossman DA, et al. In: Rome II: The Functional Gastrointestinal Disorders. 2000:382-391.C第六十三张，PPT共八十七页，创作于2022年6月Normal meta

35、bolismAs food moves through your intestines, it absorbs water while forming waste products Muscles contract in the colon, pushing the stool toward the rectum第六十四张，PPT共八十七页，创作于2022年6月Defecation ProcessYield awareness of defecation Anal intra- and extra-sphincter RelaxationAbdominal effects第六十五张，PPT共八

36、十七页，创作于2022年6月Mechanical stimulation1. Yield awareness of defecation第六十六张，PPT共八十七页，创作于2022年6月2. Anal intra- and extra-sphincter Relaxationintra- sphincterextra-sphincterLevator ani muscle第六十七张，PPT共八十七页，创作于2022年6月2. Abdominal effectsgastric contents via anus第六十八张，PPT共八十七页，创作于2022年6月What Causes Consti

37、pation?Eating too little fiber Not drinking enough liquidsLack of exercise/physical activity第六十九张，PPT共八十七页，创作于2022年6月What Causes Constipation?Change in routinetravelOlder ageSlower metabolismFrequent use of laxativesCertain diseases or conditions第七十张，PPT共八十七页，创作于2022年6月What Causes Constipation?Certa

38、in diseases or conditionsRectal and Anal disordersColonic disordersSystemic diseases or conditions第七十一张，PPT共八十七页，创作于2022年6月What Causes Constipation?pain (narcotics麻药)antacids containing aluminumantidepressantsiron supplementsdiuretics (“water” pills) Medications第七十二张，PPT共八十七页，创作于2022年6月Classificatio

39、n of etiologiesEating too little fiber Not drinking enough liquidsLack of exercise/physical activityChange in routineTravelpsycho-relatedOlder ageSlower metabolismFrequent use of laxativestediously long ColonMedicationsTravelpain (narcotics麻药)antacids containing aluminumantidepressantsiron supplemen

40、tsdiuretics (“water” pills)Functional etiologies第七十三张，PPT共八十七页，创作于2022年6月psycho-related第七十四张，PPT共八十七页，创作于2022年6月Tediously long Colon结肠冗长第七十五张，PPT共八十七页，创作于2022年6月 Organic constipation (certain diseases or conditions cause constipation)Classification of etiologiesRectal and Anal disordersBenign or malignancy tumorTumor or mass outsideSystemic diseases or conditions (e.g. disorders make dyscinesia: spasm and paralysis）第七十六张，PPT共八十七页，创作于2022年6月Rectal and