1、健康快樂每一天！臨床診斷學(xué)上海第二醫(yī)科大學(xué)仁濟臨床醫(yī)學(xué)院NauseaVomitingAsthesymptoms癥狀學(xué)：惡心與嘔吐GoalsBrieflydefineOutlinetheprominentdiseasestatesassociatedwithnauseavomiting.acterizeNauseaVomitingcausedbytheprominentdisdersDiscriminatetheaccompanyings

2、ymptoms.Suggestdiagnosticstrategiesofthesymptoms.DefinitionofNauseaVomitingNausea：theinclinationfeelingofimminentdesiretovomitusuallyfeltinthethroatepigastrum.Associatedwithdecreasedactivityofthestomach.Vomiting：thefcefu

3、lalexpulsionofgastriccontentsviaretroperistalsis.NauseaVomiting:simultaneityseparateness惡心：緊迫欲吐，通常伴有上腹不適和迷走興奮的臨床征候群。嘔吐：胃和或小腸內(nèi)容物經(jīng)食管和口腔排除體外惡心和嘔吐常伴隨存在，也可單獨出現(xiàn)！NauseaVomiting1、惡心：咽部及上腹部不適，胃張力和蠕動減弱，幽門和賁門開放。2、干嘔：胃竇部和腹壁肌肉收縮，腹壓增加

4、，食管及咽部開放。3、嘔吐：胃和或小腸內(nèi)容物經(jīng)食管和口腔排除體外。Definitionofemesis.(Threephases)嘔吐反射過程（三個階段）1.Nauseatheinclinationfeelingofimminentdesiretovomitusuallyfeltinthethroatepigastrum.Associatedwithdecreasedactivityofthestomach.2.Retchingthel

5、abedrhythmiccontractionofrespiratyabdominalmusculaturethatfrequentlyprecedesaccompaniesvomiting.3.Vomitingthefcefulalexpulsionofgastriccontentsviaretroperistalsis.(Abdominaleffects).迷走興奮表現(xiàn)惡心干嘔嘔吐發(fā)生機制嘔吐區(qū)別于反食嘔吐：多數(shù)情況有惡心的感覺和嘔

6、吐反射的協(xié)調(diào)動作。反食：無惡心的感覺和嘔吐反射的協(xié)調(diào)動作。（兒童、飽餐）MechanismsofemesisCTZ&EmeticCenter(Vomitingcenter)CTZ化學(xué)感受器觸發(fā)帶（第四腦室底面）：外源性或內(nèi)源性化學(xué)物質(zhì)（阿片嗎啡、洋地黃、代謝產(chǎn)物）EmeticCenter（延髓外側(cè)網(wǎng)狀結(jié)構(gòu)背測）接受大腦皮質(zhì)、消化器官、心血管以及化學(xué)感受器觸發(fā)帶（CTZ）的沖動CTZ&EmeticCenter(Vomitingcenter

7、)孤束核EmeticCenter內(nèi)臟傳入中腦ICP受體化學(xué)感受器觸發(fā)帶邊緣系統(tǒng)前庭系統(tǒng)嘔吐中樞（Vomitingcenter)ICP=InductivelyCoupledPlasma感應(yīng)耦合等離子體NeurotransmittersinCTZ&EmeticCenterNeurotransmittersinvolvedinstimulatingtheemeticcenterchemorecepttriggerzoneGItractincl

8、ude5HTacetylcholinehistaminedopamine(opiatesreceptsfbenzodiazepinesarealsofoundhere)EmeticCenter1、分泌唾液中樞2、血管收縮中樞3、呼吸中樞4、中樞神經(jīng)脊神經(jīng)膈神經(jīng)迷走神經(jīng)nauseavomiting1.Reflectivevomiting反射性嘔吐2.Centralvomiting中樞性嘔吐3.Neurologicalvomiting神經(jīng)性

9、嘔吐Reflectivevomiting（反射性嘔吐）咽部刺激胃十二指腸疾病膽道疾病腸道疾病肝膽疾病腹膜腸系膜全身性疾病（五官、心血管、泌尿、盆腔…）PharyngealMechanismsGastrointestinalMechanismsDiseaseofbiliarytractPeritonealmesenterythefivesensegansCardiovulardiseaseskidneyPelvic咽部刺激Pharynga

10、lMechanismsGastrointestinalMechanisms肝、膽、胰腺其他IntracranialinfectionCerebrovulardisdersCraniocerebralinjuryEpilepsyMetabolicdisdersDrugsCentralvomiting（中樞性嘔吐）顱內(nèi)感染腦血管疾病顱腦損傷癲癇全身疾?。蚨景Y、肝昏迷、糖尿病代謝紊亂）顱內(nèi)感染（腦炎、腦膜炎）腦血管疾病、顱腦損傷癲癇全身疾病

11、尿毒癥肝昏迷酮癥酸中毒各種原因引起的腦水腫和顱內(nèi)壓升高代謝紊亂早孕Drug抗生素抗癌藥洋地黃嗎啡興奮嘔吐中樞或影響胃腸平滑肌運動AntibioticsAnticarcinomaDigitalismphiaNeurologic&PsychogeniccausesNeurologicPsychogeniccauses胃腸道神經(jīng)官能癥（Gastrointestinaltractneurosis）神經(jīng)厭食癥（apositia）acteristi

12、csofNauseaVomitingTimeTakingfoodacteristicsactersofcontents夜間或隔夜嘔吐幽門梗阻賁門失弛緩癥嘔吐與進食的關(guān)系（Timingwithmeals）餐后即刻：神經(jīng)精神性；集體發(fā)病系食物中毒餐后1小時以上：為延遲性嘔吐：可考慮為胃張力低下排空障礙餐后較久、多餐后或隔夜：提示幽門梗阻嘔吐特點神經(jīng)性或顱內(nèi)高壓：惡心輕、嘔吐頻；“噴射性嘔吐”嘔吐物性質(zhì)發(fā)酵、腐臭味：提示胃潴留糞臭味：提示較低

13、位置的腸梗阻無酸腐味：賁門失遲緩癥或胃酸缺乏不含膽汁：幽門梗阻病史較長或量多：提示體液和電解質(zhì)丟失Theaccompanyingsymptoms腹痛、腹瀉：食物中毒、腸道傳染病、胃腸炎；節(jié)律性腹痛：消化性潰瘍右上腹痛，伴發(fā)熱、黃疸：膽囊炎、膽道結(jié)石、感染。頭痛、頭暈、視力異常、噴射性嘔吐：顱內(nèi)高壓性疾病、屈光不正、青光眼。伴眩暈、眼球震顫：前庭障礙育齡婦女（停經(jīng)）：應(yīng)排除妊娠與服藥有時間關(guān)聯(lián)：應(yīng)想到藥物反應(yīng)問診要點起病情況：誘因、急緩、

14、與進食關(guān)系、腹部手術(shù)史、育齡婦女月經(jīng)史發(fā)作時間：晨、夜、與進食、活動、體位的關(guān)系嘔吐物性狀、味道伴隨癥狀診療和癥狀演變情況HistyBackgrounda)Ageb)GIhistyrequiredc)Foodintoleranced)Timingwithmealse)Consistencyf)Contentg)Odh)Frequencyi)Feverj)Weightlossk)Precipitatingfactsl)Myalgias（肌

15、痛）visualdisturbancesheadachepainoutsideabdomenCAUSESOFNAUSEAVOMITINGEarlypregnancyPsychogenesisvomitingBulimia(易餓病)PylicchannelulcerAcutegastritisGastricretention(潴留）Viralgastroenteritis（中毒性胃腸炎）AcutegastroenteritisMyocar

16、dialinfarctionPeritonitis（腹膜炎）AcuteobstructionNeurologicalemergencyDrugtoxicityCancertherapyDrugwithdrawalPHYSICALEXAMVitalsignsSkinHEENT（headeyesearnosethroat)AbdomenNeurologicalLABATYRuleoutobstructionperitonitisHCGUri

17、nalysisElectrolytesBUNcreatinineglucoseTransaminasesamylaseEKGheadCTupperGI&endoscopiesBreak瀘沽湖黃昏瀘沽湖黃昏瀘沽湖?摩梭女玉龍雪山?雪月47ConstipationShanghaiSecondMedicaluniversityRenjiclinicalmedicalcollegeBackgroundConstipationIsaConstel

18、lationofSymptomsMostcommonlyreptedsymptomsHardlumpystoolsIncreasedstrainingInfrequentbowelmovementsSensationofincompleteevacuationBloatingfullnessChronicconstipationMepersistentthanintermittentepisodicSeveralmonthsdurati

19、onCSlerRSetal.DigDisSci.198732:841845.n=1128ConstipationIsMeThanJustInfrequentPassageofStool53ConstipationsymptomsreptedmostoftenReducedStoolFrequencyIsNottheMostCommonlyReptedSymptominConstipationEPOC=Epidemiologyofcons

20、tipationBM=Bowelmovement.1.StewartWFetal.AmJGastroenterol.199994:35303540.2.ParPetal.AmJGastroenterol.200196:31303137.Stewart(EPOC)19991Par20012n=1476n=1149ConstipationsymptomsreptedmostoftenCPrevalenceintheGeneralPopula

21、tion1.StewartWFetal.AmJGastroenterol.199994:35303540.2.DrossmanDAetal.DigDisSci.199338:15691580.3.HarrisInteractiveStudyWave2.Dataonfile.4.ParPetal.AmJGastroenterol.200196:31303137.53EpidemiologyChronicconstipationiscomm

22、onSlightlymecommoninwomenFMratio=range1.3to2.5(China=4:1)AffectsallagegroupsStewartWFetal.AmJGastroenterol.199994:35303540.ParPetal.AmJGastroenterol.200196:31303137.SlerRSetal.DigDisSci.198732:841845.CConstipationAffects

23、AllAgeGroups53Canadianpopulation.ParPetal.AmJGastroenterol.200196:31303137.N=1149n=378n=367n=217n=187ProfileofaTypicalChronicConstipationPatientinMyPracticeGenerallyfemaleSymptomaticf10yrMajityhavetriedlifestylechangesfi

24、berOTClaxativespritoseekingcareManagesconditionwithmultipletherapiesMostoftenreferredbyaprimarycarephysicianCopeswithconditionbutisnotcompletelysatisfiedCConstipationCanHaveaNegativeImpactonQualityofLifePeoplewithCCrepte

25、dsignificantimpairmentinQoLonSF36scale(n=126)1InCanadapeoplewithselfreptedRomeIIconstipationhadsignificantlywseSF36scesthanthenmalpopulation(n=472)2InAustraliapeoplewithconstipationhadsignificantlywseSF12scesonbothmental

26、physicalscales(n=227)31.O’KeefeEAetal.JGerontolABiolSciMedSci.199550:M184M189.2.IrvineEJetal.AmJGastroenterol.200297:19861993.3.KoloskiNAetal.AmJGastroenterol.200095:6771.CConstipationSignificantlyImpactsHealthcareUtiliz

27、ation5.7millionconstipationrelatedoutpatientvisitsannually124.1millionphysicianofficebasedvisits991000emergencyroomvisits587000hospitaloutpatientvisits$2752patientftertiarycareevaluation31.NationalAmbulatyMedicalCareSurv

28、ey2001.www.cdc.gov2.NationalHospitalAmbulatyCareSurvey2001.www.cdc.gov3.RantisPCJretal.DisColonRectum.199740:280286.CComplicationsrelatedwithconstipationColonicrectalcarcinomaOthercolonrectalanusdisdershepaticcomaacutemy

29、ocardialinfarctionmammarygldisderspreseniledementia(早老性癡呆）psychoproblemsappearanceDefinition:CausesofChronicConstipationSecondaryDruginducedMetabolicfactsCombidconditionsPrimaryImpairedcolonictransitmotilityAlteredneuroe

30、ntericfunctionreflexesFailureofmuscularapparatusIneffectivedefecation(functionaloutletobstruction)PelvicdyssynergiaanismusNmaltransitconstipationPresentationObjectivesDefineconstipationThepathophysiologicalmechanismsEtio

31、logiesofconstipationacterizemanifestationDiscriminatetheaccompanyingsymptoms.Suggestdiagnosticstrategiesofthesymptoms.CWhatisConstipationPassageofharddrylumpystoolsInfrequentbowelmovementsusuallyfewerthanthreetimesaweekS

32、ymptoms:painfulbowelmovementsstrainingUncomftable（Sensationofincompleteevacuation）bloatedsluggishRomeIIDefinesFunctionalConstipationBasedonMultipleSymptomsRomeIIdiagnosticcriteriaffunctionalconstipationAtleast12wkwhichne

33、ednotbeconsecutiveoverthepast12monthsof2meofStrainingLumpyhardstoolsSensationofincompleteevacuationSensationofanectalobstructionblockageManualmaneuverstofacilitatedefecation3defecationswkLoosestoolsnotpresentInsufficient

34、criteriafIBS14ofdefecations.DrossmanDAetal.In:RomeII:TheFunctionalGastrointestinalDisders.2000:382391.CNmalmetabolismAsfoodmovesthroughyourintestinesitabsbswaterwhilefmingwasteproductsMusclescontractinthecolonpushingthes

35、tooltowardtherectumDefecationProcessYieldawarenessofdefecationAnalintraextrasphincterRelaxationAbdominaleffectsMechanicalstimulation1.Yieldawarenessofdefecation2.AnalintraextrasphincterRelaxationintrasphincterextrasphinc

36、terLevatanimuscle2.AbdominaleffectsgastriccontentsviaanusWhatCausesConstipationEatingtoolittlefiberNotdrinkingenoughliquidsLackofexercisephysicalactivityWhatCausesConstipationChangeinroutinetravelOlderageSlowermetabolism

37、FrequentuseoflaxativesCertaindiseasesconditionsWhatCausesConstipationCertaindiseasesconditionsRectalAnaldisdersColonicdisdersSystemicdiseasesconditionsWhatCausesConstipationpain(narcotics麻藥)antacidscontainingaluminumanti

38、depressantsironsupplementsdiuretics(“water”pills)MedicationsClassificationofetiologiesEatingtoolittlefiberNotdrinkingenoughliquidsLackofexercisephysicalactivityChangeinroutineTravelpsychorelatedOlderageSlowermetabolismFr

39、equentuseoflaxativestediouslylongColonMedicationsTravelpain(narcotics麻藥)antacidscontainingaluminumantidepressantsironsupplementsdiuretics(“water”pills)FunctionaletiologiespsychorelatedTediouslylongColon結(jié)腸冗長ganicconstipat

40、ion(certaindiseasesconditionscauseconstipation)ClassificationofetiologiesRectalAnaldisdersBenignmalignancytumTummassoutsideSystemicdiseasesconditions(e.g.disdersmakedyscinesia:spasmparalysis）RectalAnaldisdersCancerNevusa

41、nalfissureanalfistulaProctoptosis(直腸脫垂）intestinalobstructionBenignmalignancytumPolypCancerOutsidetummassSystemicdiseasesconditionsGastroparesisDiabetesmellitusDMUremiaMyastheniagravisHypothyroidismHematopphyriaLeadpoison

42、ing胃輕癱糖尿病尿毒癥重癥肌無力甲狀腺機能低下血卟啉病鉛中毒acteristicsofmanifestation急性便秘常伴隨原發(fā)病的表現(xiàn)：腹痛、腹脹、惡心嘔吐、排氣停止，見于各種原因的腸梗阻。慢性便秘可有消化不良癥狀：便秘型IBS：大便形狀：1.散粒2.團粒3.柱粒4.條形5.堆6.片7.水Accompanyingsymptoms1。嘔吐、腹脹、腸絞痛，提示腸梗阻2。伴包塊：提示腫瘤、腸結(jié)核、Crohn病3。便秘腹瀉交替：腸結(jié)核、I

43、BS、UC4。繼發(fā)于生活、環(huán)境改變：功能性IntestinalobstructionTumTBCrhon’sdiseaseTBIBSUCFunctionalconstipationImptantinfmationfetiologicaldiagnosisa)Ageb)GIhistyrequiredc)Foodhabitd)Conditionrelated(livingwkingcommunicatingpsychology…)e)Con

44、sistencyf)courseofdiseasesg)Frequencyh)fmtextureOdContenti)IncreasedstrainingSensationofincompletej)Weightlossk)Precipitatingfactsl)Medicationsm)Disdersoutsidegastroenterology今天告訴你的事情可要記牢吆?。?！人有了知識，就會具備各種分析能力，明辨是非的能力。所以我們