恶心呕吐.课件

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,健康快乐每一天！,1,健康快乐每一天！1,临床诊断学,上海第二医科大学仁济临床医学院,2,临床诊断学上海第二医科大学仁济临床医学院 2,Nausea and Vomiting,As the symptoms,症状学：恶心与呕吐,3,Nausea and Vomiting症状学：恶心与呕吐3,Goals,Briefly define,Outline the prominent disease states associated with nausea and vomiting.,Characterize Nausea and Vomiting caused by the prominent disorders,Discriminate the accompanying symptoms.,Suggest diagnostic strategies of the symptoms.,4,GoalsBriefly define4,Definition of Nausea and Vomiting,Nausea ：the inclination or feeling of imminent desire to vomit, usually felt in the throat or epi-gastrum. Associated with decreased activity of the stomach.,Vomiting： the forceful oral expulsion of gastric contents via retro-peristalsis.,Nausea-Vomiting: simultaneity or separateness,恶心：紧迫欲吐，通常伴有上腹不适和迷走兴奋的临床征候群。,呕吐：胃和/或小肠内容物经食管和口腔排除体外,恶心和呕吐常伴随存在，也可单独出现！,5,Definition of Nausea and Vomit,Nausea and Vomiting,6,Nausea and Vomiting6,1、恶心：咽部及上腹部不适，胃张力和蠕动减弱，幽门和贲门开放。,2、干呕：胃窦部和腹壁肌肉收缩，腹压增加，食管及咽部开放。,3、呕吐：胃和/或小肠内容物经食管和口腔排除体外。,Definition of emesis. (Three phases),呕吐反射过程（三个阶段）,1.,Nausea,- the inclination or feeling of imminent desire to vomit, usually felt in the throat or epigastrum. Associated with decreased activity of the stomach.,2.,Retching,- the labored rhythmic contraction of respiratory and abdominal musculature that frequently precedes or accompanies vomiting.,3.,Vomiting,- the forceful oral expulsion of gastric contents via retroperistalsis. (Abdominal effects).,7,1、恶心：咽部及上腹部不适，胃张力和蠕动减弱，幽门和贲门开放,迷走兴奋表现,恶心,干呕,呕吐,发生机制,8,迷走兴奋表现恶心干呕呕吐发生机制8,呕吐区别于反食,呕吐：多数情况有恶心的感觉和呕吐反射的协调动作。,反食：无恶心的感觉和呕吐反射的协调动作。（儿童、饱餐）,9,呕吐区别于反食呕吐：多数情况有恶心的感觉和呕吐反射的协调动作,Mechanisms of emesis,10,Mechanisms of emesis10,CTZ & Emetic Center,(Vomiting center),CTZ,化学感受器触发带,（,第四脑室底面）：外源性或内源性化学物质（阿片吗啡、洋地黄、代谢产物）,Emetic Center,（,延髓外侧网状结构背测）,接受大脑皮质、消化器官、心血管以及化学感受器触发带（,CTZ）,的冲动,11,CTZ & Emetic Center (Vomiting,CTZ & Emetic Center,(Vomiting center),孤束核,12,CTZ & Emetic Center (Vomiting,Emetic Center,内脏传入,中脑,ICP,受体,化学感受器触发带,边缘系统,前庭系统,呕吐中枢（,Vomiting center),ICP=Inductively Coupled Plasma,感应耦合等离子体,13,Emetic Center 内脏传入 中脑ICP受体化学感受,Neurotransmitters in CTZ & Emetic Center,Neurotransmitters involved in stimulating the emetic center, chemo-receptor trigger zone and GI tract include;,5-HT, acetylcholine, histamine, dopamine (opiates and receptors for benzodiazepines are also found here),14,Neurotransmitters in CTZ & Eme,15,15,16,16,Emetic Center,1、分泌唾液中枢,2、血管收缩中枢,3、呼吸中枢,4、中枢神经,脊神经,膈神经,迷走神经,17,Emetic Center 1、分泌唾液中枢脊神经膈神经迷走,18,18,nausea and vomiting,1.,Reflective vomiting,反射性呕吐,2.Central vomiting,中枢性呕吐,3.,Neurological vomiting,神经性呕吐,19,nausea and vomiting1. Reflecti,Reflective vomiting （,反射性呕吐）,咽部刺激,胃十二指肠疾病,胆道疾病,肠道疾病,肝胆疾病,腹膜肠系膜,全身性疾病（五官、心血管、泌尿、盆腔）,Pharyngeal Mechanisms,Gastrointestinal Mechanisms,Disease of biliary tract,Peritoneal and mesentery,the five sense organs,Cardiovascular diseases,kidney,Pelvic,20,Reflective vomiting （反射性呕吐）咽部刺,咽部刺激,Pharyngal Mechanisms,21,咽部刺激Pharyngal Mechanisms21,Gastrointestinal Mechanisms,22,Gastrointestinal Mechanisms22,肝、胆、胰腺,23,肝、胆、胰腺23,其他,24,其他24,Intra-cranial infection,Cerebrovascular disorders,Craniocerebral injury,Epilepsy,Metabolic disorders,Drugs,Central vomiting （,中枢性呕吐）,颅内感染,脑血管疾病,颅脑损伤,癫痫,全身疾病,（,尿毒症、肝昏迷、糖尿病代谢紊乱）,25,Intra-cranial infectionCentral,颅内感染（脑炎、脑膜炎）,26,颅内感染（脑炎、脑膜炎）26,脑血管疾病、颅脑损伤,27,脑血管疾病、颅脑损伤27,癫痫,28,癫痫28,全身疾病,尿毒症,肝昏迷,酮症酸中毒,各种原因引起的脑水肿和颅内压升高,代谢紊乱,早孕,29,全身疾病尿毒症肝昏迷酮症酸中毒各种原因引起的脑水肿和颅内压升,Drug,抗生素,抗癌药,洋地黄,吗啡,兴奋呕吐中枢或影响胃肠平滑肌运动,Antibiotics,Anti-carcinoma,Digitalis,morphia,30,Drug抗生素兴奋呕吐中枢或影响胃肠平滑肌运动Antibio,Neurologic & Psychogenic causes,Neurologic and Psychogenic causes,胃肠道神经官能症（,Gastrointestinal tract neurosis）,神经厌食症（,apositia）,31,Neurologic & Psychogenic cause,Characteristics of,Nausea and Vomiting,Time,Taking food,Characteristics,Characters of contents,32,Characteristics of Nausea and,晨起呕吐,早孕反应,功能性消化不良,酒精中毒,胃食管反流病,鼻咽部疾患,夜间或隔夜呕吐,幽门梗阻,贲门失弛缓症,33,晨起呕吐早孕反应功能性消化不良酒精中毒胃食管反流病鼻咽部疾患,呕吐与进食的关系,（,Timing with meals）,餐后即刻：,神经精神性；集体发病系食物中毒,餐后1小时以上：,为延迟性呕吐：可考虑为胃张力低下排空障碍,餐后较久、多餐后或隔夜：,提示幽门梗阻,34,呕吐与进食的关系餐后即刻：神经精神性；集体发病系食物中毒餐后,呕吐特点,神经性或颅内高压：,恶心轻、呕吐频；“喷射性呕吐”,呕吐物性质,发酵、腐臭味：,提示胃潴留,粪臭味：,提示较低位置的肠梗阻,无酸腐味：,贲门失迟缓症或胃酸缺乏,不含胆汁：,幽门梗阻,病史较长或量多：,提示体液和电解质丢失,35,呕吐特点神经性或颅内高压：恶心轻、呕吐频；“喷射性呕吐”呕吐,The accompanying symptoms,腹痛、腹泻：,食物中毒、肠道传染病、胃肠炎；节律性腹痛：消化性溃疡,右上腹痛，伴发热、黄疸：,胆囊炎、胆道结石、感染。,头痛、头晕、视力异常、喷射性呕吐：,颅内高压性疾病、屈光不正、青光眼。,伴眩晕、眼球震颤：,前庭障碍,育龄妇女（停经）：,应排除妊娠,与服药有时间关联：,应想到药物反应,36,The accompanying symptoms腹痛、腹泻,问诊要点,起病情况：,诱因、急缓、与进食关系、腹部手术史、育龄妇女月经史,发作时间,：晨、夜、与进食、活动、体位的关系,呕吐物性状、味道,伴随症状,诊疗和症状演变情况,37,问诊要点起病情况：诱因、急缓、与进食关系、腹部手术史、育龄妇,History/Background,a) Age,b) GI history required,c) Food intolerance,d) Timing with meals,e) Consistency,f,) Content,g) Odor,h) Frequency,i) Fever,j) Weight loss,k) Precipitating factors,l) Myalgias（,肌痛）, visual disturbances, headache, pain outside abdomen,38,History/Backgrounda) Ageg) Odo,CAUSES OF NAUSEA/VOMITING,Early pregnancy,Psychogenesis vomiting,Bulimia(,易饿病),Pyloric channel ulcer,Acute gastritis,Gastric retention(,潴留）,Viral gastroenteritis（,中毒性胃肠炎）,Acute gastroenteritis,Myocardial infarction,Peritonitis（,腹膜炎）,Acute obstruction,Neurological emergency,Drug toxicity,Cancer therapy,Drug withdrawal,39,CAUSES OF NAUSEA/VOMITINGEarly,PHYSICAL EXAM,Vital signs,Skin,HEENT （head,eyes,ear,nose,throat),Abdomen,Neurological,40,PHYSICAL EXAMVital signs40,LABORATORY,Rule out obstruction and peritonitis,HCG,Urinalysis,Electrolytes, BUN, creatinine, glucose,Transaminases, amylase,EKG, head CT, upper GI &/or endoscopies,41,LABORATORYRule out obstruction,Break,42,Break42,泸沽湖黄昏,43,泸沽湖黄昏43,泸沽湖黄昏,44,泸沽湖黄昏44,2024/9/1,45,2023/9/745,泸沽湖摩梭女,46,泸沽湖摩梭女46,玉龙雪山雪月,47,玉龙雪山雪月47,48,48,Constipation,Shanghai Second Medical university,Renji clinical medical college,49,ConstipationShanghai Second Me,Background,50,Background50,Constipation Is a Constellation of Symptoms,Most commonly reported symptoms,Hard, lumpy stools,Increased straining,Infrequent bowel movements,Sensation of incomplete evacuation,Bloating/fullness,Chronic constipation,More persistent than intermittent or episodic,Several months duration,C,51,Constipation Is a Constellatio,Sandler RS, et al.,Dig Dis Sci.,1987;32:841-845.,n = 1128,Constipation Is More Than Just Infrequent Passage of Stool,53,Constipation symptoms reported most often,52,Sandler RS, et al. Dig Dis Sci,Reduced Stool Frequency Is Not the Most Commonly Reported Symptom in Constipation,EPOC = Epidemiology of constipation; BM = Bowel movement.,1. Stewart WF, et al.,Am J Gastroenterol,. 1999;94:3530-3540.,2. Par P, et al.,Am J Gastroenterol,. 2001;96:3130-3137.,Stewart (EPOC) 1999,1,Par,2001,2,n = 1476,n = 1149,Constipation symptoms reported most often,C,53,Reduced Stool Frequency Is Not,Prevalence in the General Population,1. Stewart WF, et al.,Am J Gastroenterol,. 1999;94:3530-3540.,2.,Drossman DA, et al.,Dig Dis Sci.,1993;38:1569-1580.,3. Harris Interactive Study, Wave 2. Data on file. 4. Par P, et al.,Am J Gastroenterol.,2001;96:3130-3137.,53,Population,n,Criteria,Prevalence, n (%),US,1,10,018,Rome I,461 (4.6),US,2,5430,Rome I,195 (3.6),US,3,15,183,Rome II,2429 (16),Canada,4,1149,Rome II,171 (14.9),China (18-70ys),?,RomeII,?(6.07),China(60ys),?,RomeII,?(15-20),54,Prevalence in the General Popu,Epidemiology,Chronic constipation is common,Slightly more common in women,F/M ratio = range 1.3 to 2.5,(China=4:1),Affects all age groups,Stewart WF, et al.,Am J,Gastroenterol,. 1999;94:3530-3540.,Par P, et al.,Am J Gastroenterol,. 2001;96:3130-3137.,Sandler RS, et al.,Dig Dis Sci,. 1987;32:841-845.,C,55,EpidemiologyChronic constipati,Constipation Affects All Age Groups,53,Canadian population.,Par P, et al.,Am J Gastroenterol,. 2001;96:3130-3137.,N = 1149,n = 378,n = 367,n = 217,n = 187,56,Constipation Affects All Age G,Profile of a Typical Chronic Constipation Patient in My Practice,Generally female,Symptomatic for 10 yr,Majority have tried lifestyle changes, fiber, and OTC laxatives prior to seeking care,Manages condition with multiple therapies,Most often referred by a primary care physician,Copes with condition, but is not completely satisfied,C,57,Profile of a Typical Chronic C,Constipation Can Have a Negative Impact on Quality of Life,People with CC reported significant impairment in QoL on SF-36 scale (n = 126),1,In Canada, people with self-reported or Rome II constipation had significantly worse SF-36 scores than the normal population (n = 472),2,In Australia, people with constipation had significantly worse SF-12 scores on both mental and physical scales (n = 227),3,1.,OKeefe EA, et al.,J Gerontol A Biol Sci Med Sci,. 1995;50:M184-M189.2. Irvine EJ, et al.,Am J Gastroenterol,. 2002;97:1986-1993. 3. Koloski NA, et al.,Am J Gastroenterol,. 2000;95:67-71.,C,58,Constipation Can Have a Negati,Constipation Significantly Impacts Healthcare Utilization,5.7,million constipation-related outpatient visits annually,1,2,4.1 million physician office-based visits,991,000 emergency room visits,587,000 hospital outpatient visits,$2752/patient for tertiary care evaluation,3,1.,National Ambulatory Medical Care Survey, 2001. www.cdc.gov,2. National Hospital Ambulatory Care Survey, 2001. www.cdc.gov,3. Rantis PC Jr, et al.,Dis Colon Rectum,. 1997;40:280-286.,C,59,Constipation Significantly Imp,Complications related,with constipation,Colonic and rectal carcinoma,Other colon-rectal-anus disorders,hepatic coma,acute myocardial infarction,mammary gland disorders,presenile dementia(,早老性痴呆）,psycho-problems,appearance,60,Complications related with con,Definition: Causes of Chronic Constipation,Secondary,Drug induced,Metabolic factors,Comorbid conditions,Primary,Impaired colonic transit/motility,Altered neuroenteric function and reflexes,Failure of muscular apparatus,Ineffective defecation (functional outlet obstruction),Pelvic dyssynergia and anismus,Normal transit constipation,61,Definition: Causes of Chronic,Presentation Objectives,Define constipation,The pathophysiological mechanisms,Etiologies of constipation,Characterize manifestation,Discriminate the accompanying symptoms.,Suggest diagnostic strategies of the symptoms.,C,62,Presentation ObjectivesDefine,What is Constipation?,Passage of hard, dry, lumpy stools; Infrequent bowel movements, usually,fewer than three times a week,Symptoms:,painful bowel movements,straining,Uncomfortable（,Sensation of incomplete evacuation）,bloated,sluggish,63,What is Constipation?Passage o,Rome II Defines Functional Constipation Based on Multiple Symptoms,Rome II diagnostic criteria for functional constipation,At least 12 wk, which need not be consecutive, over the past 12 months of 2 or more of,Straining*,Lumpy or hard stools*,Sensation of incomplete evacuation*,Sensation of anorectal obstruction/blockage*,Manual maneuvers to facilitate defecation*, 1/4,of defecations.,Drossman DA, et al. In:,Rome II: The Functional Gastrointestinal Disorders,. 2000:382-391.,C,64,Rome II Defines Functional Con,Normal metabolism,As food moves through your intestines, it absorbs water while forming waste products,Muscles contract in the colon, pushing the stool toward the rectum,65,Normal metabolismAs food moves,Defecation Process,Yield awareness of defecation,Anal intra- and extra-sphincter Relaxation,Abdominal effects,66,Defecation ProcessYield awaren,Mechanical stimulation,1.,Yield awareness of defecation,67,Mechanical stimulation1. Yield,2. Anal intra- and extra-sphincter Relaxation,intra- sphincter,extra-sphincter,Levator ani muscle,68,2. Anal intra- and extra-sphin,2. Abdominal effects,gastric contents via anus,69,2. Abdominal effectsgastric co,What Causes Constipation?,Eating too little fiber,Not drinking enough liquids,Lack of exercise/physical activity,70,What Causes Constipation?Eatin,What Causes Constipation?,Change in routine,travel,Older age,Slower metabolism,Frequent use of laxatives,Certain diseases or conditions,71,What Causes Constipation?Chang,What Causes Constipation?,Certain diseases or conditions,Rectal and Anal disorders,Colonic disorders,Systemic diseases or conditions,72,What Causes Constipation?Certa,What Causes Constipation?,pain (narcotics,麻药),antacids containing aluminum,antidepressants,iron supplements,diuretics (“water” pills),Medications,73,What Causes Constipation?pain,Classification of etiologies,Eating too little fiber,Not drinking enough liquids,Lack of exercise/physical activity,Change in routine,Travel,psycho-related,Older age,Slower metabolism,Frequent use of laxatives,tediously long Colon,Medications,Travel,pain (narcotics,麻药),antacids containing aluminum,antidepressants,iron supplements,diuretics (“water” pills),Functional etiologies,74,Classification of etiologiesEa,psycho-related,75,psycho-related75,Tediously long Colon,结肠冗长,76,Tediously long Colon结肠冗长76,Organic constipation,(certain diseases or conditions cause constipation),Classification of etiologies,Rectal and Anal disorders,Benign or malignancy tumor,Tumor or mass outside,Systemic diseases or conditions (e.g. disorders make dyscinesia: spasm and paralysis）,77,Organic constipation Classifi,Rectal and Anal disorders,Cancer,Nevus,anal fissure,anal fistula,Proctoptosis (,直肠脱垂）,78,Rectal and Anal disordersCance,intestinal obstruction,79,intestinal obstruction79,Benign or malignancy tumor,Polyp,Cancer,80,Benign or malignancy tumorPoly,Outside tumor or mass,81,Outside tumor or mass81,Systemic diseases or conditions,Gastro-paresis,Diabetes mellitus; DM,Uremia,Myasthenia gravis,Hypothyroidism,Hematoporphyria,Lead poisoning,胃轻瘫,糖尿病,尿毒症,重症肌无力,甲状腺机能低下,血卟啉病,铅中毒,82,Systemic diseases or condition,Characteristics of manifestation,急性便秘常伴随原发病的表现：腹痛、腹胀、恶心呕吐、排气停止，见于各种原因的肠梗阻。,慢性便秘可有消化不良症状：,便秘型,IBS：,大便形状：,1.散粒2.团粒3.柱粒4.条形5.堆6.片7.水,83,Characteristics of manifestati,Accompanying symptoms,1。呕吐、腹胀、肠绞痛，提示肠梗阻,2。伴包块：提示肿瘤、肠结核、,Crohn,病,3。便秘腹泻交替：肠结核、,IBS、UC,4。继发于生活、环境改变：功能性,Intestinal obstruction,Tumor,TB,Crhons disease,TB,IBS,UC,Functional constipation,Vomiting, abdominal distention, Intestinal colic,Mass,With diarrhea alternatively,Change in routine,84,Accompanying symptoms1。呕吐、腹胀、,85,85,86,86,Important information for etiological diagnosis,a) Age,b) GI history required,c) Food habit,d) Condition related (living,working, communicating, psychology),e) Consistency,f,) course of diseases,g) Frequency,h) form, texture, Odor, Content,i) Increased straining, Sensation of incomplete,j) Weight loss,k) Precipitating factors,l) Medications,m) Disorders outside gastroenterology,87,Important information for etio,今天告诉你的事情可要记牢吆！,88,今天告诉你的事情可要记牢吆！88,2024/9/1,89,2023/9/789,