上海交大外科学肠梗阻pbl

肠肠 梗梗 阻阻上海交通大学医学院附属瑞金医院上海交通大学医学院附属瑞金医院上海交通大学医学院附属瑞金医院上海交通大学医学院附属瑞金医院普外科普外科普外科普外科 马迪马迪马迪马迪 PBLPBLPBLPBL教学教学教学教学Intestinal Obstruction 肠梗阻肠梗阻是急诊是急诊最常见最常见的外科急腹的外科急腹症之一，也是外科医生症之一，也是外科医生最不愿碰到的，最不愿碰到的，最头痛最头痛的外科急腹症之一。的外科急腹症之一。诊断有时比较困难诊断有时比较困难临床病情发展较快临床病情发展较快需要密切临床观察需要密切临床观察严密把握手术时机严密把握手术时机Case one(scene1)Male,age:65,“Paraxymal abdominal pain 48h with nausea and vomiting one day”,you are the doctor on duty.Q1.According to the chief complaint,which kind of information you should collect during ask the history?Main point of the history1:1:Abdominal painThe positionThe position、levellevel、kind of pain,with or without radiation,the kind of pain,with or without radiation,the relationship between bowel sound and pain,paroxymal or relationship between bowel sound and pain,paroxymal or continuing.continuing.2:Nausea and vomiting2:Nausea and vomitingThe kind、volumn、color and smell of vomitus,the relationship between vomiting and pain.3:Abdominal distention3:Abdominal distentionTime,level and position 4:Failure to pass flatus and fecesThe kind、quantity of feces and the relationship between it and pain,if the pain relieve after pass flatus and feces.5:Past historyCase one(scene1)Q2：To make a definite diagnosis，which kind of information we should pay attention to in the next Physical Examination and Auxiliary Examination?Main point of the physical examinationGeneral Examination：T:37.2 HR:96bpm R:22bpm BP:130/70mmhg No dehydration,no anemia,no jaundice Abdominal Examination：Inspection：Distended abdomen,no peristaltic waves can be observed,previous scar in the upper abdomen.Palpation:Mild abdominal tenderness,no rebound,no guarding,no mass,no incarcerated hernia in the groin.Percussion：Tympany.Auscultation：Hyperactive bowel sounds,6-8bpm.Rectal Examination：Negative Local pathophysiology of intestinal obstruction肠蠕动增加肠蠕动增加1.1.各类刺激各类刺激各类刺激各类刺激长时间强蠕动长时间强蠕动肠麻痹肠麻痹2.肠腔膨胀、积气积液肠腔膨胀、积气积液吞咽下的气体，以氮气为主，不易吞咽下的气体，以氮气为主，不易向血液内弥散向血液内弥散长时间梗阻，肠腔内液体不再回流入长时间梗阻，肠腔内液体不再回流入血，而仍有液体自血液流入肠腔血，而仍有液体自血液流入肠腔3.3.肠壁水肿、通透性增加肠壁水肿、通透性增加梗阻近段肠腔压力升高，静脉回梗阻近段肠腔压力升高，静脉回流受阻。流受阻。细胞缺氧，能量代谢障碍，肠细胞缺氧，能量代谢障碍，肠壁通透性增加。壁通透性增加。Q3:What is your diagnosis?Case one(scene1)Definition&ClassificationDefinition:Intestinal contents can not pass successfully,which cause many pathophysiology and clinical symptoms.Classification:按照梗阻发生基本原因可分为三类：按照梗阻发生基本原因可分为三类：1.Mechanical Obstruction 2.Dynamic Obstruction3.Vascular ObstrucionMechanical obstruction include：l lIntraluminal obstructionIntraluminal obstructionl lExtraluminal obstruction Extraluminal obstruction l lObstruction intrinsic to the bowel wallObstruction intrinsic to the bowel wall Reasons of the intraluminal obstruction:1.1.Foreign bodiesForeign bodies2.2.GallstonesGallstones3.3.Ascarid and etc.Ascarid and etc.蛔虫引起小肠梗阻蛔虫引起小肠梗阻 胆囊十二指肠内瘘引起胆石性肠梗阻胆囊十二指肠内瘘引起胆石性肠梗阻CT scan show the stone in the intestineReason of the extraluminal obstruction:1.1.AdhesionsAdhesions2.2.Incarceration herniaIncarceration hernia3.3.Volvulus and etc.Volvulus and etc.图中圆圈处显示束带压迫小肠引起梗阻图中圆圈处显示束带压迫小肠引起梗阻 腹股沟斜疝嵌顿引起肠梗阻腹股沟斜疝嵌顿引起肠梗阻Reason of the obstruction intrinsic to the bowel wall:盲肠菜花样肿瘤导致肠梗阻盲肠菜花样肿瘤导致肠梗阻 炎症性肠病导致肠壁炎性狭窄炎症性肠病导致肠壁炎性狭窄1.1.TumorTumor2.2.Inflammatory bowel disease and etc.Inflammatory bowel disease and etc.lParalytic ileus 1.Drug indused2.Metabolic3.Neurogenic 4.InfectionslSpastic ileusDynamic obstruction include:Plain Abdominal radiographs reveal：Distended small bowel as well as large bowel loops Vascular Obstrucion Caution：In the early stage of vascular obstruction,patients often have obvious chief complaint but without abdominal sign.But in the late stage,besides the obvious chief complaint,patients will have peritoneal irritation sign and bloody stool.按照有无血运障碍分为：按照有无血运障碍分为：1:Simple Obstruction 1:Simple Obstruction 2:Strangulating Obstruction 2:Strangulating Obstruction 其他分类：其他分类：Proximal obstruction-Proximal obstruction-Distal obstructionDistal obstructionComplete obstruction-Incomplete obstructionComplete obstruction-Incomplete obstructionClosed-loop Obstruction :V Volvulus Colonic obstruction Internal herniaCase one(scene2)Discussion：Please list your therapeutic-schedule.Case one(scene3)见附页见附页2General pathophysiology of intestinal obstruction消化液的回吸收停止、消化液的回吸收停止、液体仍向肠腔渗出液体仍向肠腔渗出大量呕吐、禁食大量呕吐、禁食1.大量体液丧失和酸碱失调大量体液丧失和酸碱失调肠内容物淤积，毒素产生肠内容物淤积，毒素产生肠壁通透性增加，细菌毒肠壁通透性增加，细菌毒素移位素移位2.感染与中毒感染与中毒3.休克休克肠腔压力升高，横膈抬高肠腔压力升高，横膈抬高4.呼吸困难，心肺功能障碍呼吸困难，心肺功能障碍 复查平片如下图复查平片如下图Case one(scene3)（Strangulated intestinal obstruction,internalhernia）患者即刻完善术前准备后行剖腹探查，术中见患者即刻完善术前准备后行剖腹探查，术中见Treitz ligment 远端远端2 2m处小肠与腹部原切口下方粘连成角梗阻，并有远端小肠钻处小肠与腹部原切口下方粘连成角梗阻，并有远端小肠钻入其中形成内疝。入其中形成内疝。Q4:What should we pay attention to during the operation?Q5:Whats your suggestion when the patient discharge?腹部立卧位平片腹部立卧位平片造影剂检查对于肠梗阻也是重要诊断方法造影剂检查对于肠梗阻也是重要诊断方法CT不是首选不是首选 但有时会有意外发现但有时会有意外发现Case two(scene1)见附页见附页3Case two(scene1)Q1:What is your primary diagnosis?To prove your diagnosis,which kind of examination do you need?Case two(scene1)Supine&upright radiographs of the patientCase two(scene1)Case two(scene1)Water-soluble contrast enemaCase two(scene1)Admitting diagnosis:Colonic obstruction.Q2:What is the treatment?Operation or Conservation？Case two(scene2)见附页见附页4 4Case two(scene2)Q3：What is the special preparation before the operation？Case two(scene2)患者完善肠道准备后，于入院第患者完善肠道准备后，于入院第患者完善肠道准备后，于入院第患者完善肠道准备后，于入院第9 9 9 9天行剖腹探查天行剖腹探查天行剖腹探查天行剖腹探查术，术中见腹腔内无明显肿瘤，乙结肠部分冗长扩术，术中见腹腔内无明显肿瘤，乙结肠部分冗长扩术，术中见腹腔内无明显肿瘤，乙结肠部分冗长扩术，术中见腹腔内无明显肿瘤，乙结肠部分冗长扩张，内有肛管支撑，乙结肠系膜较短，降结肠无明张，内有肛管支撑，乙结肠系膜较短，降结肠无明张，内有肛管支撑，乙结肠系膜较短，降结肠无明张，内有肛管支撑，乙结肠系膜较短，降结肠无明显充血水肿，内无明显肠内容物，行冗长部分乙结显充血水肿，内无明显肠内容物，行冗长部分乙结显充血水肿，内无明显肠内容物，行冗长部分乙结显充血水肿，内无明显肠内容物，行冗长部分乙结肠切除术，并行一期吻合。患者恢复顺利，术后第肠切除术，并行一期吻合。患者恢复顺利，术后第肠切除术，并行一期吻合。患者恢复顺利，术后第肠切除术，并行一期吻合。患者恢复顺利，术后第10101010天出院。天出院。天出院。天出院。Discussion：Please compare case 1 with case 2.1：History2：Clinical manifestation3：Auxiliary examination4：Treatment请从以上两个病例讨论肠梗阻的诊断流程请从以上两个病例讨论肠梗阻的诊断流程腹痛腹胀伴恶心呕吐入院腹痛腹胀伴恶心呕吐入院详细询问病史和体格检查详细询问病史和体格检查 有痛吐胀闭共同特点，考虑肠梗阻有痛吐胀闭共同特点，考虑肠梗阻有正常排气排便，暂时排出肠梗阻有正常排气排便，暂时排出肠梗阻根据病史特点及体检选择相关检查根据病史特点及体检选择相关检查（血常规，（血常规，B B超，腹部平片及超，腹部平片及CTCT等）等）排除消化道穿孔，胰腺炎，阑尾炎，排除消化道穿孔，胰腺炎，阑尾炎，胆道疾病等外科常见急腹症胆道疾病等外科常见急腹症必要时请相关科室会诊，排除尿必要时请相关科室会诊，排除尿路梗阻，卵巢扭转，胃肠炎等疾路梗阻，卵巢扭转，胃肠炎等疾病病 首选腹部立卧位平片检查首选腹部立卧位平片检查针对病史，体检及辅检对各类型肠梗针对病史，体检及辅检对各类型肠梗阻进行诊断（腹部阻进行诊断（腹部CT，造影剂口服，造影剂口服/灌肠摄片均是临床常用检查）灌肠摄片均是临床常用检查）选择治疗方案（保守选择治疗方案（保守/手术）手术）机械性机械性/动力性、完全性动力性、完全性/非完全性，非完全性，单纯性单纯性/绞窄性、小肠绞窄性、小肠/结肠梗阻。结肠梗阻。肠梗阻诊断流程肠梗阻诊断流程请归纳肠梗阻的治疗方案请归纳肠梗阻的治疗方案肠梗阻的治疗方案肠梗阻的治疗方案基础治疗基础治疗（任何肠梗阻无论手术或非手术均需要基础治疗）（任何肠梗阻无论手术或非手术均需要基础治疗）胃肠减压，纠正水电解质酸碱失衡，适当解痉，抗感染治疗胃肠减压，纠正水电解质酸碱失衡，适当解痉，抗感染治疗非手术治疗（非手术治疗（需要观察哪些事项需要观察哪些事项?）（禁食，石蜡油胃管注入，腹部按（禁食，石蜡油胃管注入，腹部按摩，皮硝外敷，大承气汤攻下等）摩，皮硝外敷，大承气汤攻下等）单纯性机械性不全小肠梗阻单纯性机械性不全小肠梗阻麻痹性肠梗阻麻痹性肠梗阻正常排气排便，正常排气排便，腹痛腹胀缓解。腹痛腹胀缓解。非手术治疗成功非手术治疗成功正规保守治疗正规保守治疗 24-4824-48小时后症小时后症状无缓解或加重状无缓解或加重绞窄性肠梗阻绞窄性肠梗阻 完全性小肠梗阻完全性小肠梗阻结肠梗阻结肠梗阻手术治疗手术治疗最简单的方法解除梗阻和恢复肠道功能最简单的方法解除梗阻和恢复肠道功能手术的方式根据梗阻的性质、手术的方式根据梗阻的性质、部位、患者的全身情况决定。部位、患者的全身情况决定。肠梗阻诊疗过程中几个注意点肠梗阻诊疗过程中几个注意点1:1:肠梗阻病因不一，临床表现多样，诊疗有一定困难，有肠梗阻病因不一，临床表现多样，诊疗有一定困难，有 较高死亡率。较高死亡率。2:2:体格检查中切勿遗漏腹股沟部位和直肠指检。体格检查中切勿遗漏腹股沟部位和直肠指检。3:3:病史中即使有少量排气排便也不可完全排除肠梗阻。病史中即使有少量排气排便也不可完全排除肠梗阻。4:4:肠梗阻患者症状与体征不符合时，应考虑到血运性肠梗阻可肠梗阻患者症状与体征不符合时，应考虑到血运性肠梗阻可 能。能。5:5:单纯性不全性肠梗阻治疗过程中可能随时变成绞窄性肠梗单纯性不全性肠梗阻治疗过程中可能随时变成绞窄性肠梗 阻，需要密切观察。阻，需要密切观察。思考题1：请简述肠梗阻的临床表现，常用诊断请简述肠梗阻的临床表现，常用诊断 方法。方法。2：如何把握肠梗阻的手术时机？如何把握肠梗阻的手术时机？3：粘连性肠梗阻，肠扭转，血运性肠梗：粘连性肠梗阻，肠扭转，血运性肠梗 阻的临床特点和处理原则。阻的临床特点和处理原则。参考文献及书籍1:1:Lau KC,Miller BJ,Schache DJ,et al.A study of large-bowel Lau KC,Miller BJ,Schache DJ,et al.A study of large-bowel volvulus in urban Australia.Can J Surg,2006;49(3):203-7.volvulus in urban Australia.Can J Surg,2006;49(3):203-7.2:2:Attard JA,Maclean AR.Adhesive small bowel obstruction:epi-Attard JA,Maclean AR.Adhesive small bowel obstruction:epi-demiology,biology and prevention.Can J Surg,2007;50(4):291-demiology,biology and prevention.Can J Surg,2007;50(4):291-300.300.3:3:杜晓辉，李荣，梁发启。急性血运性肠梗阻的诊治（附杜晓辉，李荣，梁发启。急性血运性肠梗阻的诊治（附杜晓辉，李荣，梁发启。急性血运性肠梗阻的诊治（附杜晓辉，李荣，梁发启。急性血运性肠梗阻的诊治（附3535例报例报例报例报告）。中国现代医学杂志，告）。中国现代医学杂志，告）。中国现代医学杂志，告）。中国现代医学杂志，2006;16(5):765-7662006;16(5):765-766。4:Sabiston Textbook of Surgery,174:Sabiston Textbook of Surgery,17thth ed.&ed.&黄家驷外科学黄家驷外科学黄家驷外科学黄家驷外科学 教学大纲教学大纲l熟悉肠梗阻常见病因和病理生理。熟悉肠梗阻常见病因和病理生理。l熟悉不同原因肠梗阻的处理原则。熟悉不同原因肠梗阻的处理原则。l掌握肠梗阻的临床表现，诊断和治疗掌握肠梗阻的临床表现，诊断和治疗原则。原则。