肠梗阻病例讨论ppt课件

DepartmentofgeneralsurgeryBiJing-TaoClinicalCaseDiscussion肠梗阻病例讨论ClinicalCaseDiscussion肠梗阻病1A60-year-oldfemaleisadmittedtotheemergencyroomwitha48-hourhistoryoflowerabdominalpain,nausea,vomitingandconstipation.Thepatientdescribesthepainascrampyinearlyandnotesthatherabdomenhasbecomedistendedoverthelast12hours.Herlastbowelmovementwasthreedayspriortopresentation.CASE1肠梗阻病例讨论A60-year-oldfemaleisad2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”急诊入院肠梗阻病例讨论女性，60岁，“腹痛、呕吐、腹胀和肛门停止排便排气2天,加重3Question1.whatswrongwiththeoldwoman?2.whatcausesit?3.Howcanshegetwell?Operationisneedornot?肠梗阻病例讨论Question肠梗阻病例讨论4Doctorneedtoanswer:DiagnosisEtiologyTreatment肠梗阻病例讨论Doctorneedtoanswer:Diagnosi5Whatshouldbedonenext?肠梗阻病例讨论Whatshouldbedonenext?肠梗阻6Herpastmedicalhistoryisremarkableinthatsheunderwentanappendectomyforacuteappenditistenyearsago.Sheisotherwisehealthyandtakesnomedications.nPhysicalexamrevealsatemperatureof38.Herabdomenisdistended.肠梗阻病例讨论Herpastmedicalhistoryisre7ClinicalManifestationsAbdominalpainNauseaandvomitingObstipationDistention肠梗阻病例讨论ClinicalManifestations肠梗阻病例讨8Abdominalpain Colickyabdominalpain in early period lasting abdominalpain later 肠梗阻病例讨论AbdominalpainColickyabdo9Nauseaandvomiting1).Thenatureofthevomitus.undigestedfoodparticles.becomesbilious.feculent.2).Theonsetandcharacterofvomiting.Recurrentvomitingofbile-stainedfluidProlongednauseaprecedesvomiting,feculent.肠梗阻病例讨论Nauseaandvomiting1).Then10Contispationandobstipation Theonsetofobstipation,alatedevelopmentStillpassflatus:thedistal,unobstructedintestineempties.partialorincompleteobstruction肠梗阻病例讨论Contispationandobstipation11DistentionDeveloplaterinthecourseoftheobstructionlittlebylittle肠梗阻病例讨论DistentionDeveloplaterint12PhysicalExaminationInspectionPalpationPercussionAuscultation肠梗阻病例讨论PhysicalExaminationInspection13Inspectionright upper quadrantright lower quadrantleft upper quadrantLeft lower quadrant肠梗阻病例讨论Inspectionrightupperquadran14PalpationmildtendernessinRLQbutnoguardingorreboundMass5cmX4cm，Noperitonitis肠梗阻病例讨论Palpationmildtendernessin15PercussionshiftingdullnessINRLQ肠梗阻病例讨论PercussionshiftingdullnessI16Auscultationnoisyandisheardasrushes.Duringattacksofcolic,thesoundsbecomeloud,high-pitchedandmetallic.肠梗阻病例讨论Auscultationnoisyandisheard17Rectalexamination:Lowrectalcarcinomaandintussusceptedsegmentdontbepalpatedrectalexamrevealsnostoolintherectum.Knee-elbowPosition肠梗阻病例讨论Rectalexamination:Lowrectal18Ahemoglobinof16,hematocrit48,whitebloodcellcount12,200with74polys.Serumelectrolytesshowthelevelofserumsodiumandpotassiumis130mol/land3.0mol/l.ArterialbloodgasanalysisrevealsthattheresultofPHis7.30.AnabdominalX-RAYrevealsmultipledilatedloopsofsmallbowelwithnumerousair-fluidlevels.ThereisnogasorstoolvisibleinthecolonAdmittinglaboratorydata肠梗阻病例讨论Ahemoglobinof16,hematocrit19RadiologicalExaminations2008-12-42008-12-5X-raysUpright肠梗阻病例讨论RadiologicalExaminations20020SupineX-rays2008-12-52008-12-4肠梗阻病例讨论SupineX-rays2008-12-52008-12-421CTscan肠梗阻病例讨论CTscan肠梗阻病例讨论22B-UltraSound2008-12-4distendedsmallintestine;noliquidintheabdomen2008-12-5dilatedloopsofsmallintestine;liquidinRLQ(7CMDeep)肠梗阻病例讨论B-UltraSound2008-12-4distende23Summury肠梗阻病例讨论Summury肠梗阻病例讨论24SymptomsofthepatientsPainVomitingObstipationAbdominaldistention肠梗阻病例讨论SymptomsofthepatientsPain肠梗25SignsofthepatientsVitalSigns:temperatureof38Hisabdomenisdistended.Mildtendernessperiumbilicallybutnoguardingorrebound.High-pitchedbowelsoundsRectalexamrevealsnostoolintherectum肠梗阻病例讨论SignsofthepatientsVitalSig26LaboratoryStudyAhemoglobinof16,hematocrit48,whichshowshemoconcentrationWhitebloodcellcount12,200,whichshowsinflammation.Serumelectrolytesareabnormal,whichshowsbodyliquidimbalancewithhyponatremiaandhypokalemia.Arterialbloodgasanalysisrevealsacidosis肠梗阻病例讨论LaboratoryStudyAhemoglobino27RadiographyexamAnabdominalX-RAYrevealsmultipledilatedloopsofsmallbowelwithnumerousairfluidlevels.ThereisnogasorstoolvisibleinthecolonToconfirmthediagnosis:intestinalobstrution肠梗阻病例讨论RadiographyexamAnabdominalX28Diagnosismustmakeclearthefollowingquestions:肠梗阻病例讨论Diagnosismustmakeclearthe291.Whetherintestinalobstructionexists:Throughsymptomsandsigns,thediagnosiscanbemadewithoutdifficulty.肠梗阻病例讨论1.Whetherintestinalobstructi302.Whethertheobstructionismechanicalordynamic:mechanicalobstruction:typicalsymptomsandsigns.paralyticobstruction:episodicandcrampingabdominalpainisabsent;distentionisprominent肠梗阻病例讨论2.Whethertheobstructionism313.Whethertheobstructionissimpleorstrangulationobstruction:Indicationsforstrangulation:1).Abruptonsetwithcontinuousacuteabdominalpain,2).Shock3).Manifestationofperitonitis:leukocytosis,sepsis,reboundandguarding肠梗阻病例讨论3.Whethertheobstructioniss324).Asymmetricaldistention,localbulge,ormasswithtenderness.5).Hematicvomitus,6).Conservativetreatmentinvainandnoimprovementinsymptomsandsigns.7).Isolated,bulged,anddistendedintestinallooponabdominalplainfilm.肠梗阻病例讨论4).Asymmetricaldistention,334.Whethertheobstructionishighorlow:Vomitinginproximalintestinalobstruction.Distentioninlowobstruction,feculentvomitus肠梗阻病例讨论4.Whethertheobstructionish345.Whethertheobstructioniscompleteorincomplete:frequencyofvomiting,extentofdistention,Contispationandobstipation肠梗阻病例讨论5.Whethertheobstructionisc356.Whichcausesleadstoobstruction:Accordingtotheage,history,symptomsandsigns.Postoperativeadhesions;postinflammatoryHeniasCongenitalmalformationsIntestinalintussusceptionObstructionofparasiteoriginCarcinomasanddryfeces.肠梗阻病例讨论6.Whichcausesleadstoobstru36Etiology肠梗阻病例讨论Etiology 肠梗阻病例讨论37EtiologyformechanicalIntestinalobstruction1.Obstructionarisingfromextraluminalcauses2.Obstructionintrinsictothebowelwall3.Intraluminalobturatorobstruction肠壁外因素肠壁因素肠腔内因素outsideoninside肠梗阻病例讨论EtiologyformechanicalInte38Outside:Adhesions Volvulus Hernias Tumor肠梗阻病例讨论Outside:AdhesionsVolvulus39On:TumorIntussusception肠梗阻病例讨论On:TumorIntussusception肠梗40Inside:fecalimpaction 肠梗阻病例讨论Inside:fecalimpaction肠梗阻41Intestinalobstruction肠梗阻病例讨论Intestinalobstruction肠梗阻病例讨论42Classification1Mechanicalobstruction机械性肠梗阻 2 Paralyticileus动力性肠梗阻 3Strangulatingobstruction血运性肠梗阻 4原因不明的假性肠梗阻肠梗阻病例讨论Classification1Mechanical43others：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肠梗阻病例讨论others：肠梗阻病例讨论44Diagnosis1.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急性粘连性小肠低位完全梗阻肠梗阻病例讨论Diagnosis1.老年女性，急性病程急性粘连性小肠低位45DoesStrangulatingobstructionexist？MechanicalobstructionParalyticileusStrangulatingobstruction肠梗阻病例讨论DoesStrangulatingobstruction46DifferentialDiagnosisuppergastrointestinalperforationacutepancreatitisacutecholecystisisacutecholangitis肠梗阻病例讨论DifferentialDiagnosisupperga47TreatmentTheprinciple:correctionofsystemicdisturbancereductionofobstruction.肠梗阻病例讨论Treatment肠梗阻病例讨论48Conservativetreatment1).Gastrointestinaldecompression:Nasogastricsuction2).Correctionofwater-electrolyticdisturbance,acid-baseimbalance3).Preventionandtreatmentofinfectionandtoxemia:Antibiotics肠梗阻病例讨论Conservativetreatment1).Gas49Surgicalintervention1)Lysisofadhesion,reductionofintussusception,2)Enterectomyandanastomosis.3)Bypassprocedurefornonresectablelesions.4)Enterostomyandexteriorizationofintestine.肠梗阻病例讨论Surgicalintervention1)Lysiso50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肠梗阻病例讨论本病例治疗方案：病人腹痛逐渐加重，且呕吐频繁，保守无效lap51Inoperationpostoperation肠梗阻病例讨论Inoperationpostoperation肠梗阻病52Case2Marry is an 87-year-old woman with a 3-day history of intermittent abdominal pain,abdominal bloating,nausea and vomiting.Marry moved from Italy to join her grandson and his family only 2 months ago,and she speaks little English.All information was obtained through her grandson.肠梗阻病例讨论Case2Marryisan87-year-old53Past medical history(PMH)includes colectomy for colon cancer 6 years ago and femoral hernia repair 2 years ago.She has no history of coronary artery disease(CAD),diabetes mellitus(DM),or pulmonary disease.She takes no drugs.Allergies include Penicillin drugs and Dolantin.肠梗阻病例讨论Pastmedicalhistory(PMH)inc54Marrys tentative diagnosis is small bowel obstruction(SBO)secondary to adhesion.Marry is being admitted to your floor for diagnostic work-up.Her vital signs are stable,she has an IV of with 20 mmol KCI at 100 ml/hr,and 3 L oxygen by nasal cannula(O2/NC).肠梗阻病例讨论Marrystentativediagnosisis551.Basedonthenursesreport,whatsignsofbowelobstructiondidMarrymanifest?QUESTION肠梗阻病例讨论1.Basedonthenursesreport,56IntermittentabdominalpainmostSBOcausewavesofcrampingabdominalpainaroundtheperiumbilicalarea.Abdominalbloating-Blockagesmaycausebloatinginthelowerabdomen.Youmayalsoheargurglingsoundscomingfromyourbelly.Withacompleteobstruction,yourdoctormayhearhigh-pitchedsoundswhenlisteningwithastethoscope.Thesoundsdecreaseasmovementofthebowelslows.肠梗阻病例讨论Intermittentabdominalpain57Nauseaandvomiting-Thevomitisusuallygreeniftheobstructionisintheuppersmallintestineandbrownifitisinthelowersmallintestine.肠梗阻病例讨论Nauseaandvomiting-Thevom582.ArethereothersignsandsymptomsthatyoushouldobserveforwhileMarryisinyourcare?肠梗阻病例讨论2.Arethereothersignsandsy59Continuousseverepaininoneareacanmeanthattheblockagehascutoffthebowelsbloodsupply.Thisiscalledabowelstrangulationandrequiresemergencytreatment.肠梗阻病例讨论Continuousseverepaininone60Constipation(latefinding)andinabilitytopassgasarecommonsignsofabowelobstruction.However,whenthebowelispartiallyblocked,youmayhavediarrhea(earlyfinding)andpasssomegas.Ifyouhaveacompleteobstruction,youmayhaveabowelmovementifthereisstoolbelowtheobstruction.Feverandtachycardialatesign;mayberelatedtostrangulation肠梗阻病例讨论Constipation(latefinding)a61PeritonealsignsAbdominaldistentionHyperactivebowelsoundsoccurearlyasGIcontentsattempttoovercometheobstruction;hypoactivebowelsoundsoccurlateGrossoroccultblood-latestrangulationormalignancyMasses-obturatorhernia肠梗阻病例讨论PeritonealsignsAbdominald623.Marryandhergrandsonarriveonyourunit.YouadmitMarrytoherroomandintroduceyourselfashernurse.Ashergrandsoninterpretsforher,shepatsyourhand.Youknowthatyouneedtocompleteaphysicalexaminationandtakeahistory.Whatwillyoudofirst?肠梗阻病例讨论3.Marryandhergrandsonarriv63Builduparelationshipoftrust;attempttoobtainpatientscooperation肠梗阻病例讨论Builduparelationshipoftr644.Thegrandson,anattorney,tellsyouelderlyItalianwomenareextremelymodestandmaynotanswerquestionscompletely.Howmightyougatherinfointhiscase?肠梗阻病例讨论4.Thegrandson,anattorney,t65Explainingtothepatientthattheinfoshegiveswillbetreatedasconfidential,andmaintainingthisconfidentialityGivethepatientanunderstandingofherproblemBenon-judgmental肠梗阻病例讨论Explainingtothepatienttha665.Whatkeyquestionsmustyouaskthispatientwhileyouhavetheuseofaninterpreter?肠梗阻病例讨论5.Whatkeyquestionsmustyou67Askaboutthelocation,duration,intensity,andfrequencyofabdominalpainOnset,frequency,color,odor,andamountofvomitusBowelandrenalfunctioningNutritional/dietHealth/medicalhistoryAnyotherallergies?Datesandtypeofimmunizationsreceived肠梗阻病例讨论Askaboutthelocation,dura686.Howwouldthedescriptionofpaindifferifshehasasmallversuslargebowelobstruction?肠梗阻病例讨论6.Howwouldthedescriptionof69SBOpainiscolicky,cramp-like,andintermittentLBOpainislow-grade,crampingabdominalpain肠梗阻病例讨论SBOpainiscolicky,cramp-li70SummaryEtiologyManifestationsDiagnosisTreatment肠梗阻病例讨论SummaryEtiology 肠梗阻病例讨论71Reference吴阶平，裘法祖主编黄家驷外科学（第六版）人民卫生出版社黄志强，黎鳌，张肇祥主编外科手术学（第二版）人民卫生出版社SabistonTextbookofSurgery,18thed肠梗阻病例讨论Reference肠梗阻病例讨论72肠梗阻病例讨论Thankyou!肠梗阻病例讨论73