便秘和肠梗阻的姑息性处理课件

便秘和肠梗阻的姑息性处理目的讨论姑息关怀领域便秘的病因和处理通过使用一个病例来阐明继发于晚期癌症的肠梗阻的内科处理ManagementofconstipationandbowelobstructioninpalliativecareDr.CharlieBond.SirmichaelSobellHouse.oxfordAimsToconsiderthecausesandmanagementofconstipationinpalliativecareTodemonstrate,throughtheuseofacaseexample,themedicalmanagementofbowelobstructionsecondarytoadvancedcancer便秘和肠梗阻的姑息性处理便秘和肠梗阻的姑息性处理目的讨论姑息关怀领域便秘的病因和处理通过使用一个病例来阐明继发于晚期癌症的肠梗阻的内科处理ManagementofconstipationandbowelobstructioninpalliativecareDr.CharlieBond.SirmichaelSobellHouse.oxfordAimsToconsiderthecausesandmanagementofconstipationinpalliativecareTodemonstrate,throughtheuseofacaseexample,themedicalmanagementofbowelobstructionsecondarytoadvancedcancer便秘一病因药物阿片类药物(引起过多分节)抗毒蕈碱类药物虚弱制动脱水癌症高钙血症瘤旁内脏神经病Constipation-causesDrugsOpioids(causehypersegmentation)AntimuscarinicsDebilityInactivityDehydrationancerHypercalcaemiaParaneoplasticvisceralneuropath缓泻剂刺激剂-增加蠕动例如:番泻叶,便塞停渗透性药物-增加水的含量&软化氢氧化镁,乳果糖表面润湿剂-例如:多库酯钠润滑剂一液体石蜡(矿物油)LaxativesStimulant-increaseperistalsisSenna,BisacodylOsmotic-increasewatercontentsoftenMagnesiumhydroxideLactuloseSurfacewettingagentse.gdocusatesodiumLubricantsLiquidParaffin(mineraloil便秘和肠梗阻的姑息性处理便秘和肠梗阻的姑息性处理便秘和肠梗阻1便秘一病因药物阿片类药物(引起过多分节)抗毒蕈碱类药物虚弱制动脱水癌症高钙血症瘤旁内脏神经病Constipation-causesDrugsOpioids(causehypersegmentation)AntimuscarinicsDebilityInactivityDehydrationancerHypercalcaemiaParaneoplasticvisceralneuropath便秘一病因2缓泻剂刺激剂-增加蠕动例如:番泻叶,便塞停渗透性药物-增加水的含量&软化氢氧化镁,乳果糖表面润湿剂-例如:多库酯钠润滑剂一液体石蜡(矿物油)LaxativesStimulant-increaseperistalsisSenna,BisacodylOsmotic-increasewatercontentsoftenMagnesiumhydroxideLactuloseSurfacewettingagentse.gdocusatesodiumLubricantsLiquidParaffin(mineraloil缓泻剂3Orallaxativeclassification口服缓泻剂的分类PredominantlyLiquidParaffin(mineraloil)Softening液体石蜡(矿物油)以软化为主Bulk-forminglaxativese.gMethylcellulose,ispaghula容积性缓泻剂,例如甲基纤维素,Polyethyleneglycol聚乙二醇DocusateSodium多库酯钠Lactulose乳果糖PredominantlyMagnesiumHydroxide氢氧化镁peristalsisSennaanddanthronStimulating番泻叶和丹蒽醌以刺激蠕动为主Bisacodyl,sodiumpicosulphate便塞停(吡沙可啶),匹可硫酸钠Orallaxativeclassification4便秘的处理纠正可逆转的因素:脱水;高钙血症;药物非药物治疗:液体;饮食-果汁,纤维素;腹部按摩;针灸药物治疗:刺激性缓泻剂+/-软化性缓泻剂;栓剂/灌肠剂ManagementofConstipationCorrectthecorrectableDehydrationHypercalcaemiaNondrugtreatmentfluidsDiet-fruitAbdominalmassageAcupunctureDrugtreatmentStimulantlaxative+/softeninglaxatiSuppositories/enemas便秘的处理5便秘的处理如果直肠内大便硬结经直肠处理以软化大便例如:甘油栓剂或十二烷酸灌肠首先使用软化性缓泻剂如果直肠内为软便:刺激性缓泻剂+/-栓剂如果直肠内没有或只有少量大便刺激性缓泻剂+/-软化性缓泻剂,栓剂/灌肠ManagementofConstipationIfrectumimpactedwithhardfaecesRectalmeasurestosoftene.gglycerinesuppositoriesorarachisoilenemaUsesofteninglaxativesfirstIfrectumisloadedwithsoftfaecesStimulantlaxatives+/-suppositoriesIfthereislittleornostoolinrectum:Stimulantlaxatives+/-softeninglaxativeSuppositories/enemas便秘的处理6阿片类药物诱发的便秘90%接受阿片类药物的患者需要一种缓泻剂阿片类药物增强结肠环收缩,导致“分节过多”刺激性缓泻剂松弛结肠环的收缩用于阿片类药物诱发的便秘的缓泻剂:刺激剂+/-软化剂Opioidinducedconstipation:90%ofpatientsonmorphineneedalaxative.OpioidsenhanceringcontractionsleadingtoHypersegmentationStimulantlaxativesrelaxringcontractionsLaxativesforopioidinducedconstipationStimulant+/softener阿片类药物诱发的便秘7晚期癌症消化道梗阻的病因梗阻性肿瘤团块癌症引起的炎症/水肿内脏神经病便秘CausesofgastrointestinalobstructioninadvancedcancerObstructingtumourmassInflammation/oedemafromcancerVisceralneuropathyConstipation晚期癌症消化道梗阻的病因8肠梗阻-5个问题梗阻的平面(节段)?单个或多个部位?器质性或功能性?部分的或完全的?过性或持续的Bowelobstruction-5questionsLevelofobstructionSingleormultiplesites?Organicorfunctional?Partialorcomplete?Transientorpersistent肠梗阻-5个问题9肠梗阻:治疗的选择“滴注和吸吮”-鼻胃管+静脉内输液外科手术:切除和吻合,支架,“分流手术”,穿孔胃造口术内科治疗BowelobstructionManagementoptions“Dripandsuck”-Nasogastrictube+ivfluidsSurgeryExcisionandanastamosisStentBypassStomaformationVentinggastrostomyMedicalmanagement肠梗阻:治疗的选择10便秘和肠梗阻的姑息性处理课件11便秘和肠梗阻的姑息性处理课件12便秘和肠梗阻的姑息性处理课件13便秘和肠梗阻的姑息性处理课件14便秘和肠梗阻的姑息性处理课件15便秘和肠梗阻的姑息性处理课件16便秘和肠梗阻的姑息性处理课件17便秘和肠梗阻的姑息性处理课件18便秘和肠梗阻的姑息性处理课件19便秘和肠梗阻的姑息性处理课件20便秘和肠梗阻的姑息性处理课件21便秘和肠梗阻的姑息性处理课件22便秘和肠梗阻的姑息性处理课件23便秘和肠梗阻的姑息性处理课件24便秘和肠梗阻的姑息性处理目的讨论姑息关怀领域便秘的病因和处理通过使用一个病例来阐明继发于晚期癌症的肠梗阻的内科处理ManagementofconstipationandbowelobstructioninpalliativecareDr.CharlieBond.SirmichaelSobellHouse.oxfordAimsToconsiderthecausesandmanagementofconstipationinpalliativecareTodemonstrate,throughtheuseofacaseexample,themedicalmanagementofbowelobstructionsecondarytoadvancedcancer便秘和肠梗阻的姑息性处理便秘和肠梗阻的姑息性处理目的讨论姑息关怀领域便秘的病因和处理通过使用一个病例来阐明继发于晚期癌症的肠梗阻的内科处理ManagementofconstipationandbowelobstructioninpalliativecareDr.CharlieBond.SirmichaelSobellHouse.oxfordAimsToconsiderthecausesandmanagementofconstipationinpalliativecareTodemonstrate,throughtheuseofacaseexample,themedicalmanagementofbowelobstructionsecondarytoadvancedcancer便秘一病因药物阿片类药物(引起过多分节)抗毒蕈碱类药物虚弱制动脱水癌症高钙血症瘤旁内脏神经病Constipation-causesDrugsOpioids(causehypersegmentation)AntimuscarinicsDebilityInactivityDehydrationancerHypercalcaemiaParaneoplasticvisceralneuropath缓泻剂刺激剂-增加蠕动例如:番泻叶,便塞停渗透性药物-增加水的含量&软化氢氧化镁,乳果糖表面润湿剂-例如:多库酯钠润滑剂一液体石蜡(矿物油)LaxativesStimulant-increaseperistalsisSenna,BisacodylOsmotic-increasewatercontentsoftenMagnesiumhydroxideLactuloseSurfacewettingagentse.gdocusatesodiumLubricantsLiquidParaffin(mineraloil便秘和肠梗阻的姑息性处理便秘和肠梗阻的姑息性处理便秘和肠梗阻25便秘一病因药物阿片类药物(引起过多分节)抗毒蕈碱类药物虚弱制动脱水癌症高钙血症瘤旁内脏神经病Constipation-causesDrugsOpioids(causehypersegmentation)AntimuscarinicsDebilityInactivityDehydrationancerHypercalcaemiaParaneoplasticvisceralneuropath便秘一病因26缓泻剂刺激剂-增加蠕动例如:番泻叶,便塞停渗透性药物-增加水的含量&软化氢氧化镁,乳果糖表面润湿剂-例如:多库酯钠润滑剂一液体石蜡(矿物油)LaxativesStimulant-increaseperistalsisSenna,BisacodylOsmotic-increasewatercontentsoftenMagnesiumhydroxideLactuloseSurfacewettingagentse.gdocusatesodiumLubricantsLiquidParaffin(mineraloil缓泻剂27Orallaxativeclassification口服缓泻剂的分类PredominantlyLiquidParaffin(mineraloil)Softening液体石蜡(矿物油)以软化为主Bulk-forminglaxativese.gMethylcellulose,ispaghula容积性缓泻剂,例如甲基纤维素,Polyethyleneglycol聚乙二醇DocusateSodium多库酯钠Lactulose乳果糖PredominantlyMagnesiumHydroxide氢氧化镁peristalsisSennaanddanthronStimulating番泻叶和丹蒽醌以刺激蠕动为主Bisacodyl,sodiumpicosulphate便塞停(吡沙可啶),匹可硫酸钠Orallaxativeclassification28便秘的处理纠正可逆转的因素:脱水;高钙血症;药物非药物治疗:液体;饮食-果汁,纤维素;腹部按摩;针灸药物治疗:刺激性缓泻剂+/-软化性缓泻剂;栓剂/灌肠剂ManagementofConstipationCorrectthecorrectableDehydrationHypercalcaemiaNondrugtreatmentfluidsDiet-fruitAbdominalmassageAcupunctureDrugtreatmentStimulantlaxative+/softeninglaxatiSuppositories/enemas便秘的处理29便秘的处理如果直肠内大便硬结经直肠处理以软化大便例如:甘油栓剂或十二烷酸灌肠首先使用软化性缓泻剂如果直肠内为软便:刺激性缓泻剂+/-栓剂如果直肠内没有或只有少量大便刺激性缓泻剂+/-软化性缓泻剂,栓剂/灌肠ManagementofConstipationIfrectumimpactedwithhardfaecesRectalmeasurestosoftene.gglycerinesuppositoriesorarachisoilenemaUsesofteninglaxativesfirstIfrectumisloadedwithsoftfaecesStimulantlaxatives+/-suppositoriesIfthereislittleornostoolinrectum:Stimulantlaxatives+/-softeninglaxativeSuppositories/enemas便秘的处理30阿片类药物诱发的便秘90%接受阿片类药物的患者需要一种缓泻剂阿片类药物增强结肠环收缩,导致“分节过多”刺激性缓泻剂松弛结肠环的收缩用于阿片类药物诱发的便秘的缓泻剂:刺激剂+/-软化剂Opioidinducedconstipation:90%ofpatientsonmorphineneedalaxative.OpioidsenhanceringcontractionsleadingtoHypersegmentationStimulantlaxativesrelaxringcontractionsLaxativesforopioidinducedconstipationStimulant+/softener阿片类药物诱发的便秘31晚期癌症消化道梗阻的病因梗阻性肿瘤团块癌症引起的炎症/水肿内脏神经病便秘Causesofgastrointestinal