急腹症病例分析课件

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,2016-11-9,#,The diagnosis,and treatment of,acute,abdomen,Dai hao,Spine and Trauma department of Guanghua hospital Shanghai,是一类以急性腹痛为突出,表现,，,需要,早期诊断和及时处理的腹部疾病,Acute abdomen,Characteristic of acute abdomen,Acute,Rapid,Critical,Change,ARCC,WHEN YOU FACE AN EMERGENCY PATIENT.,Acute abdominal pain,54 yrs Male,Acute upper abdominal pain 3 hours(30 mins after meal),the,pain transferred to the Right lower,abdomen 2 hours ago,and now,full,abdominal pain,.,T:38.1,P,：,113/min R,：,31/min,Bp,：,87/60mmHg,What is your judge?How to judge?judge by what?,What is your final decision?,Your action?,CLINICAL DIAGNOSIS,1指出病变的性质 2认定病变的器官,性质：,1、急性炎症(Acute inflammation),2、急性穿孔(Acute perforation),3、急性出血(Acute hemorrhage),4、腔道急性梗阻(Acute obstruction of bore),5、脏器急性绞窄(Acute strangulation of viscera),6、血管急性栓塞Acute embolism of blood vessel,First aid,1“MONITOR,3“TUBES,1“FORBIDEN,What kinds of Imformation do you need?,How to get it?,Investigation,History demand,physical examination,Assist examination,Get the clues step by step,History,demand,-,Episode condition,诱因、起病的缓急、病症出现的先后主次和演变过程等,餐后腹痛：胃、十二指肠溃疡穿孔、胆囊炎、胰腺炎,伤后腹痛：内出血/脏器破裂,动后腹痛：肠扭转或尿路结石,热后腹痛：内科病,由,轻到重，,腹痛,局限,：,炎症,病变,突发,剧痛，迅速扩散：,腔,道的,穿孔,、,梗阻,和脏器的破裂、,扭转、出血,History,demand,-,Character of abdomen pain,持续性,钝痛或,隐痛：,炎症,或出血刺激腹膜的,表现,阵发性的,绞痛：,管道,阻塞后痉挛收缩的结果,持续腹痛阵,发,加剧：,炎症,和梗阻并存,，互,为,因果,History,demand,-,Degree of abdomen pain,急性,炎症：,较,轻，可以,忍受,管道梗阻：,绞痛通常都较剧烈,穿孔,：,出血性胰腺炎：,疼痛剧烈,伴,休克,History,demand,-,Locus of abdomen pain,History,demand,-,Transfer or radiating pain in special site,R,History,demand,-,Gastrointestinal tract symptom,反射性呕吐,(Reflectivity vomiting),高位肠梗阻,(High intestinal,obstruction),一般呕吐之后频繁呕吐,低位,梗阻,(Low intestinal obstruction,),呕吐,出现较晚，不如高位梗阻频繁但可吐粪样物,根据呕吐性质及味道判断部位,喷射性呕吐 Projectile vomiting？,History,demand,-,Stool state,便秘：,腹,内炎症,(abdominal inflammation,),频数粘液便：,盆腔脓肿,(pelvic abscess),无排便排气：,完全性梗阻,(complete obstruction),粘液血便：,肠套叠,(intussusception),颜 色？,History,demand,-,Other condition,溃疡穿孔：,过去,有长期溃疡病史突发上腹部剧痛,胆囊炎,：,右,上腹反复发作疼痛史,粘连性肠梗阻：,有腹部手术、外伤、炎症史,寒战、高热：,化脓性病变,尿频尿急、排尿困难或血尿：,泌尿系,病变,追问病史,餐后半小时突发中上腹绞痛，剧痛难忍，进行性加重。,10,分钟后疼痛转移至右下腹，出现局部持续性钝痛，转移后中上腹疼痛无缓解，半小时后疼痛转为全腹痛，为持续性剧痛，间歇性加剧。疼痛无放射，呕吐,6,次，开始为胃内容物，后为清澈液体，末次呕吐为入院前半小时，清澈液体内有鲜红色液体混杂，呕吐后无口苦，大便,2,次，第一次为黑褐色咖啡样，量约,300g,，第二次为咖啡样加鲜红色液体量约,400ml,，继而出现乏力、心悸、视物模糊、全身汗出。既往有餐后中上腹疼痛史。,Physical,examination,察言观色 Common condition,生命体征 Vital signs,腹部检查Abdomen examination,压痛最剧点most tenderness,腹膜刺激征Peritoneal irritation sings,移动性浊音 Shifting dullness,肠鸣音 Bowel sounds,肛指检查 Digital rectal inspection,体格检查,面色苍白，神志冷淡，对答切题，查体合作。屈膝、辗转体位，不能平卧。全腹压痛，板样腹，反跳痛；最剧压痛点位于中上腹。移动性浊音阳性，肠鸣音减弱2次/分，未及金属音、未及气过水声。肛指检查：未及肿块，未及痔疮，指套末端带有鲜红色血性液体。,Assist examination,Chemical,analysis,X-ray,examination,B-ultrasound,examination,CT scan(Computer,tomography,),Endoscope,Artero-radiography,Diagnostic,abdominal,paracentesis,Laparoscopy,辅助检查,血常规：白细胞-14.3，中性87%.HB:8.9 g/L,RBC:2.3,平均血红蛋白浓度正常，平均红细胞体积正常。血、尿淀粉酶正常。粪便隐血+，呕吐物隐血+。,ANY MORE?,分,析 鉴 别,(,Analysis differentiation),1、首先鉴别是否确为外科急腹症,外科急腹症腹痛大都是最先出现的或最主要的病症,内儿科疾病即使有急性腹痛，一般也不是最早出现,或最突出的表现，或者至少尚有其他同样,突出的病症存在,兼有腹痛和发热:先有腹痛而后发热的是外科病,而先发热后有腹痛的是内科病,心绞痛:上腹或“心窝部疼痛外，常有明显的心脏病体征，警惕下壁心梗。,肺炎或胸膜炎：除上腹痛以外，常有咳嗽、气促及肺部罗音等病症,急腹症的危急病变,急性出血坏死性胰腺炎,急性化脓性梗阻性胰腺炎,肝脾破裂,急性绞榨性肠梗阻,空腔脏器穿孔,生命支持,2.,尽快,明确诊断，针对病因采取治疗措施。,3.,诊断,不明禁用强效止痛剂。,4.,诊断,不能明确时剖腹探查指征：,脏器有血运障碍，如肠坏死；,腹膜炎不能局限且有扩散倾向；,腹腔活动性内出血；,非手术治疗病情无改善或恶化。,急腹症的处理原那么,(treatment principle of acute abdomen),叫上级医生,Case,THANK YOU FOR YOUR ATTENTION,