内科学课件：消化总论

Overview of Digestive Diseases Overview of the GI tractA muscular tube with an epithelial liningEnteric nervous systemEnteroendocrine systemGALT: the gastrointestinal-associated lymphoid systemIntestinal Microecology System肠道微生态系统（肠道微生态系统（Gut microbiome)p Bacteria、Fungus、Virus、Parasitep Bacteria 1014（100万亿）万亿） 1000，anaerobic bacteria 90% Weight 1kg，equal to the size of liver prevalence in colon ：1011-1012/mL OHara et al. EMBO Rep. 2006. 7, 688-93. 肠道微生物和胃肠道相关疾病肠道微生物和胃肠道相关疾病胃十二指肠疾病胃十二指肠疾病IBDIBS胃肠道肿瘤胃肠道肿瘤非酒精性肝病非酒精性肝病Gastroenterology. 2014 May;146(6):1500-12Gastroenterology. 2014 May;146(6):1513-24Gastroenterology. 2014 May;146(6):1534-1546Immunity. 2014 Jun 19;40(6):843-54integrationEffectEnteric nervous system器质性疾病器质性疾病食管食管：食管炎、食管癌胃胃：胃炎胃炎、消化性溃疡消化性溃疡、胃癌大肠大肠：结肠炎、炎症性肠病炎症性肠病、结肠癌小肠小肠：肠结核肠结核、克罗恩病克罗恩病肝肝：肝炎、肝硬化肝硬化、肝癌肝癌胆道胆道：结石、炎症、肿瘤胰腺胰腺: 胰腺炎胰腺炎、胰腺肿瘤功能性疾病功能性疾病肠易激综合征、功能性消化不良等肠易激综合征、功能性消化不良等Clinical Approach to GI diseasePatient HistoryPhysical examinationLab testsImaging studiesClinical approach:Patients HistoryGI symptoms (Vital) Nausea & vomiting 恶心呕吐 Abdominal pain & distension 腹痛腹胀 Constipation & diarrhea 便秘腹泻 Melena & hemorrhage 黑便呕血 Heart burn & Acid regurgitation 烧心反酸 dyspepsia, dysphagia,etc 吞咽困难消化不良GI symptoms arise from disease or dysfunction of the GI tract , the brain-gut axis , blood stream and other organs, esp. CNS.Causes of vomitingMedication: opiates, digitalis,etcGI & systemic infectionObstruction, ischemia or inflammation of GI tract or organsCNS: labyrinthine diseases; increased intracranial pressure, emotional responseMetabolic causes: uremia, DKAMiscellaneous: early pregnancy, post-operation列举？列举？Diagnostic imaging proceduresPlain film radiographyBarium studiesUltrasonographyCTMRIRadionuclide imagingVascular interventionsNon-vascular interventionsPlain film radiographyGas/fluid levels within dilated loops of bowel: obstruction or adynamic ileusSub-diagram: intraperitoneal bowel perforationAbnormal calcifications膈下游离气体右腰部结石正常腹部平片肠梗阻Barium studiesUpper GI tract: single- or double-contrastSmall bowel: follow-through study with intermittent fluoroscopic evaluation Colon: barium enemas: symptoms of colon carcinoma, diverticular disease, IBDUltrasonographyApplication: detection of gallbladder stones, obstruction of intrahepatic and extrahepatic bile ducts, evaluation of hepatic parenchyma, etcDisadvantage: inability to penetrate gas-filled structuresComputed tomographyApplication: differentiation of hepatomas from metastases from colon carcinoma, CT-angiography, virtual colonoscopy, evaluating and staging abdominal mass lesions; guide abdominal interventionsMagnetic resonance imagingAdvantages: more water a specific tissue contains, greater is its signal intensity. non-invasiveness, absence of ionizing radiationDrawback: higher cost, longer imaging timesApplication: MRCP, MR angiography, etc Diagnostic EndoscopyGastrointestinal endoscopyEndo-Ease Vista 80cm 全结肠镜全结肠镜 旋转进镜旋转进镜 Endo-Ease Discovery 115cm smalll intestine Aer-O-ScopeScreening Colonscopy微型化微型化, 自我推进式自我推进式, 有微型摄像头的内镜装置有微型摄像头的内镜装置 1. 光学透明顶盖光学透明顶盖 2. 镜头架镜头架 3.镜头镜头 4. 照明用发光二极管（照明用发光二极管（LED） 5. 互补金属氧化物半导体检互补金属氧化物半导体检CMOS） 6. 电池电池 7. 特定用途集成电路（特定用途集成电路（ASIC）发送装置）发送装置 8. 天线天线Wireless capsule endoscopePolyp of small intestineCrohn diseaseAdenoma of small Intestine空肠远端环行溃疡伴狭窄空肠远端环行溃疡伴狭窄内镜新技术-二代胶囊结肠内镜视角更宽广：172拍照频率更高：35帧/秒但仍需肠道准备Surg Endosc. 2014 Feb;28(2):570-5Endoscopy. 2014 Jun;46(6):485-92Parasite of bile ductERCPEndoscopic retrograde cholangiopancreatographyIndications: 1.Suspected biliary pathology: stones & tumors of bile duct, sclerosing cholangitis 2. Pancreatic diseases: pancreatic cancer, chronic ´ pancreatitis.Therapeutic Endoscopy胃镜检查：距门齿胃镜检查：距门齿31cm31cm处食管中段一条索状处食管中段一条索状异物，其两端分别插入食管壁内异物，其两端分别插入食管壁内处理？处理？A: 知情同意后，尽快胃知情同意后，尽快胃镜下取出异物镜下取出异物B: 询问病史，根据误食询问病史，根据误食种类而定种类而定C: 作胸部作胸部CT检查，与检查，与胸外科商量胸外科商量D: 采用超声胃镜，了解采用超声胃镜，了解深度深度AOLPAV(AO:主动脉；LPA：左肺动脉；V：胸椎椎体；箭头：指向异物）鼠齿钳钳夹取出异物后摄片,异物穿透处明显糜烂、充血.异物: 鳖骨硬化剂止血治疗硬化剂止血治疗Emergency Endoscopy After 5 days Esophageal varices食管静脉套扎治疗食管静脉套扎治疗2013.11.14 第一次套扎2013.12.27第二次套扎2014.12.9复查2015.3.20复查妹妹妹妹姐姐姐姐重度重度EV预防套扎预防套扎两姐妹EVL 治疗 胃癌术后门脉高压反复出血 早期胃癌早期胃癌ESD（内镜下胃黏膜切除术）（内镜下胃黏膜切除术） N Engl J Med, 2005WHO Fact sheet , 2011中国肿瘤登记年报中国肿瘤登记年报, 2010恶性肿瘤是第一死因，占所有死因的恶性肿瘤是第一死因，占所有死因的22.32%22.32%胃、肝、结肠和食管癌在我国发病率和死亡率高胃、肝、结肠和食管癌在我国发病率和死亡率高胃胃肺肺肝脏肝脏结肠结肠食管食管 740,000 410,0001400,000700,000610,000 Inflammation and GI cancerCopyright from Houghton J. in AACR HK 2008Reflux esophagitis Barrett esophagusesophageal adenocaricinomaH.pylori infection Atrophic gastritisgastric cancerUlcerative colitis Dysplasiacolon cancerVirus hepatitis Liver cirrhosisliver cancerHPV infection Rectal cancer，nasopharyngeal carcinoma 全世界慢性全世界慢性乙肝乙肝流行的地域分布流行的地域分布HBsAg+的的地域分布地域分布 8% - 高高 ( (占全世界人口占全世界人口45%) )2%7% - 中中 ( (占全世界人口占全世界人口43%) ) 2% - 低低 ( (占全世界人口占全世界人口70%克拉霉素的耐药率20%阿莫西林的耐药率为2.7%四环素,阿莫西林,呋喃唑酮和铋剂耐药少 序贯治疗序贯治疗 （Sequential therapy） 概念：概念：2002年意大利年意大利De Francesco首次提首次提出出第一个第一个5 5天天 诱导期诱导期 PPI 常规剂量，常规剂量，bid阿莫西林阿莫西林 1000 mg，bid随后随后5 5天天 PPI 常规剂量，常规剂量，bid替硝唑替硝唑 500 mg ,bid 克拉霉素克拉霉素 500 mg，bidGU 6-8 weeksDU 4-6 weeksMaintenance therapy Symptomatic self-controlTake home pointsEtiology of acute and chronic gastritisThe difference of Type A and B atrophic gastritisEtiology of peptic ulcerThe definition of special ulcerThe complications of peptic ulcerThe diagnostic methods of Hp infectionThe principle of the treatment of peptic ulcerThank you ! W