《肠梗阻病例讨论》

Departmentofgeneralsurgery

BiJing-Taofrankbjt@126.com

ClinicalCase

Discussion.

A

60-year-oldfemaleisadmittedtotheemergencyroomwith

a48-hourhistoryoflowerabdominalpain,nausea,vomitingandconstipation.Thepatientdescribesthepainascrampyinearlyandnotesthatherabdomenhasbecomedistendedoverthelast12hours.Herlastbowelmovementwasthreedayspriortopresentation.CASE1.女性，60岁，“腹痛、呕吐、腹胀和肛门停止排便排气2天,加重12小时”急诊入院.Question

1.what’swrongwiththeoldwoman?

2.whatcausesit?

3.Howcanshegetwell?Operationisneedornot?.Doctorneedtoanswer:DiagnosisEtiologyTreatment.What

shouldbedonenext?.Herpastmedicalhistoryisremarkableinthatsheunderwentanappendectomyforacuteappenditistenyearsago.Sheisotherwisehealthyandtakesnomedications.Physicalexamrevealsatemperatureof38℃.Herabdomenisdistended..

ClinicalManifestationsAbdominalpainNauseaandvomitingObstipationDistention.Abdominalpain

Colickyabdominalpain

inearlyperiod

lasting

abdominalpain

later

.Nauseaandvomiting

1).Thenatureofthevomitus.

undigestedfoodparticles.

becomesbilious.

feculent.

2).Theonsetandcharacterofvomiting.

Recurrentvomitingofbile-stainedfluid

Prolongednauseaprecedesvomiting,feculent.

.

Contispationandobstipation

Theonsetofobstipation,alatedevelopmentStillpassflatus:

thedistal,unobstructedintestineempties.

partialorincompleteobstruction.Distention

Developlaterinthecourseoftheobstruction

littlebylittle.PhysicalExaminationInspectionPalpationPercussionAuscultation.Inspection

rightupperquadrantrightlowerquadrantleftupperquadrantLeftlowerquadrant.Palpation

mildtendernessinRLQbutnoguardingorrebound

Mass5cmX4cm，

Noperitonitis.Percussion

shiftingdullnessINRLQ.Auscultationnoisyandisheardasrushes.Duringattacksofcolic,thesoundsbecomeloud,high-pitchedandmetallic..Rectalexamination:Lowrectalcarcinomaandintussusceptedsegmentdon’tbepalpatedrectalexamrevealsnostoolintherectum.Knee-elbowPosition.Ahemoglobinof16,hematocrit48,whitebloodcellcount12,200with74polys.Serumelectrolytesshowthelevelofserumsodiumandpotassiumis130mol/land3.0mol/l.ArterialbloodgasanalysisrevealsthattheresultofPHis7.30.AnabdominalX-RAYrevealsmultipledilatedloopsofsmallbowelwithnumerousair-fluidlevels.ThereisnogasorstoolvisibleinthecolonAdmittinglaboratorydata.RadiologicalExaminations

2008-12-42008-12-5X-rays

Upright.SupineX-rays2008-12-52008-12-4..CTscan.B-UltraSound2008-12-4

distendedsmallintestine;

noliquidintheabdomen2008-12-5

dilatedloopsofsmallintestine;liquidinRLQ(7CMDeep).Summury

.SymptomsofthepatientsPainVomitingObstipationAbdominaldistention.SignsofthepatientsVitalSigns:temperatureof38℃Hisabdomenisdistended.Mildtendernessperiumbilicallybutnoguardingorrebound.High-pitchedbowelsoundsRectalexamrevealsnostoolintherectum.LaboratoryStudyAhemoglobinof16,hematocrit48,whichshowshemoconcentrationWhitebloodcellcount12,200,whichshowsinflammation.Serumelectrolytesareabnormal,whichshowsbodyliquidimbalancewithhyponatremiaandhypokalemia.Arterialbloodgasanalysisrevealsacidosis.RadiographyexamAnabdominalX-RAYrevealsmultipledilatedloopsofsmallbowelwithnumerousairfluidlevels.ThereisnogasorstoolvisibleinthecolonToconfirmthediagnosis:intestinalobstrution.Diagnosis

mustmakeclearthefollowingquestions:

.1.Whetherintestinalobstructionexists:

Throughsymptomsandsigns,thediagnosiscanbemadewithoutdifficulty..2.Whethertheobstructionismechanicalordynamic:

mechanicalobstruction:typicalsymptomsandsigns.

paralyticobstruction:episodicandcrampingabdominalpainisabsent;

distentionisprominent

.3.Whethertheobstructionissimpleorstrangulationobstruction:

Indicationsforstrangulation:

1).Abruptonsetwithcontinuousacuteabdominalpain,

2).Shock

3).Manifestationofperitonitis:leukocytosis,sepsis,reboundandguarding

.

4).Asymmetricaldistention,localbulge,ormasswithtenderness.

5).Hematicvomitus,

6).Conservativetreatmentinvainandnoimprovementinsymptomsandsigns.

7).Isolated,bulged,anddistendedintestinallooponabdominalplainfilm..4.Whethertheobstructionishighorlow:

Vomitinginproximalintestinalobstruction.

Distentioninlowobstruction,feculentvomitus

.5.Whethertheobstructioniscompleteorincomplete:

frequencyofvomiting,extentofdistention,

Contispationandobstipation.6.Whichcausesleadstoobstruction:

Accordingtotheage,history,symptomsandsigns.

Postoperativeadhesions;postinflammatory

Henias

Congenitalmalformations

Intestinalintussusception

Obstructionofparasiteorigin

Carcinomasanddryfeces..Etiology.Etiologyfor

mechanicalIntestinal

obstruction1.

Obstructionarisingfromextraluminalcauses2.

Obstructionintrinsictothebowelwall3.

Intraluminalobturatorobstruction肠壁外因素肠壁因素肠腔内因素outsideoninside.Outside:Adhesions

Volvulus

Hernias

Tumor

.On:Tumor

Intussusception

.Inside:

fecalimpaction

.Intestinalobstruction

.

Classification

1

Mechanicalobstruction机械性肠梗阻

2

Paralyticileus动力性肠梗阻

3Strangulating

obstruction血运性肠梗阻

4原因不明的假性肠梗阻

.others：根据有无血运障碍：单纯性Simpleobstruction,

绞窄性strangulationobstruction

梗阻部位：高位Proximalintestinal

低位distalintestinal

大肠largebowel

小肠

smallbowel

梗阻程度:

不完全性Incompleteobstruction

完全性

completeobstruction

发展过程:

急性Acuteobstruction

慢性chronicobstruction.Diagnosis

1.老年女性，急性病程2.典型临床表现：痛、呕、闭、胀3.腹部体征4.X-Rays和腹部CT表现5.既往腹部手术病史急性粘连性小肠低位完全梗阻.DoesStrangulatingobstructionexist？MechanicalobstructionParalyticileusStrangulatingobstruction.DifferentialDiagnosisuppergastrointestinalperforationacutepancreatitisacutecholecystisisacutecholangitis.TreatmentTheprinciple:

correctionofsystemicdisturbance

reductionofobstruction..Conservativetreatment

1).Gastrointestinaldecompression:

Nasogastricsuction

2).Correctionofwater-electrolytic

disturbance,acid-baseimbalance

3).Preventionandtreatmentofinfectionandtoxemia:Antibiotics.Surgical

intervention1)Lysisofadhesion,reductionofintussusception,

2)Enterectomyandanastomosis.3)Bypassprocedurefornonresectablelesions.4)Enterostomyandexteriorizationofintestine..本病例治疗方案：病人腹痛逐渐加重，且呕吐频繁，保守无效体温从36.5度升高至38度查体：腹胀加重，右下腹压痛明显，肠鸣音变弱腹穿：有血性液化验：WBC及中性粒细胞均升高超过正常X-rays:可见固定肠袢，肠管扩张明显，加重laparetomy.Inoperationpostoperation.Case2Marryisan87-year-oldwomanwitha3-dayhistoryofintermittentabdominalpain,abdominalbloating,nauseaandvomiting.MarrymovedfromItalytojoinhergrandsonandhisfamilyonly2monthsago,andshespeakslittleEnglish.Allinformationwasobtainedthroughhergrandson.

.Pastmedicalhistory(PMH)includescolectomyforcoloncancer6yearsagoandfemoralherniarepair2yearsago.Shehasnohistoryofcoronaryarterydisease(CAD),diabetesmellitus(DM),orpulmonarydisease.Shetakesnodrugs.AllergiesincludePenicillindrugsandDolantin..Marry’stentativediagnosisissmallbowelobstruction(SBO)secondarytoadhesion.Marryisbeingadmittedtoyourfloorfordiagnosticwork-up.Hervitalsignsarestable,shehasanIVofwith20mmolKCIat100ml/hr,and3Loxygenbynasalcannula(O2/NC)..1.Basedonthenurse’sreport,whatsignsofbowelobstructiondidMarrymanifest?

QUESTION.·Intermittentabdominalpain–mostSBOcausewavesofcrampingabdominalpainaroundtheperiumbilicalarea.

·Abdominalbloating-Blockagesmaycausebloatinginthelowerabdomen.Youmayalsoheargurglingsoundscomingfromyourbelly.Withacompleteobstruction,yourdoctormayhearhigh-pitchedsoundswhenlisteningwithastethoscope.Thesoundsdecreaseasmovementofthebowelslows.

.·Nauseaandvomiting-Thevomitisusuallygreeniftheobstructionisintheuppersmallintestineandbrownifitisinthelowersmallintestine..2.ArethereothersignsandsymptomsthatyoushouldobserveforwhileMarryisinyourcare?

.·Continuousseverepaininoneareacanmeanthattheblockagehascutoffthebowel'sbloodsupply.Thisiscalledabowelstrangulationandrequiresemergencytreatment.

.·Constipation(latefinding)andinabilitytopassgasarecommonsignsofabowelobstruction.However,whenthebowelispartiallyblocked,youmayhavediarrhea(earlyfinding)andpasssomegas.Ifyouhaveacompleteobstruction,youmayhaveabowelmovementifthereisstoolbelowtheobstruction.

·Feverandtachycardia–latesign;mayberelatedtostrangulation

.·Peritonealsigns

·Abdominaldistention

·HyperactivebowelsoundsoccurearlyasGIcontentsattempttoovercometheobstruction;hypoactivebowelsoundsoccurlate

·Grossoroccultblood-latestrangulationormalignancy

·Masses-obturatorhernia.3.Marryandhergrandsonarriveonyourunit.YouadmitMarrytoherroomandintroduceyourselfashernurse.Ashergrandsoninterpretsforher,shepatsyourhand.Youknowthatyouneedtocompleteaphysicalexaminationandtakeahistory.Whatwillyoudofirst?

.·Builduparelationshipoftrust;attempttoobtainpatient’scoope