臨床診斷學(xué)惡心嘔吐說(shuō)課講解

健康快樂(lè)(kuàilè)每一天！第一頁(yè)，共87頁(yè)。臨床(línchuánɡ)診斷學(xué)上海第二醫(yī)科大學(xué)仁濟(jì)臨床(línchuánɡ)醫(yī)學(xué)院第二頁(yè)，共87頁(yè)。NauseaandVomitingAsthesymptoms癥狀(zhèngzhuàng)學(xué)：惡心與嘔吐第三頁(yè)，共87頁(yè)。GoalsBrieflydefineOutlinetheprominentdiseasestatesassociatedwithnauseaandvomiting.CharacterizeNauseaandVomitingcausedbytheprominentdisordersDiscriminatetheaccompanyingsymptoms.Suggestdiagnosticstrategiesofthesymptoms.第四頁(yè)，共87頁(yè)。DefinitionofNauseaandVomitingNausea：theinclinationorfeelingofimminentdesiretovomit,usuallyfeltinthethroatorepi-gastrum.Associatedwithdecreasedactivityofthestomach.Vomiting：theforcefuloralexpulsionofgastriccontentsviaretro-peristalsis.Nausea-Vomiting:simultaneityorseparateness惡心：緊迫欲吐，通常伴有上腹不適和迷走興奮的臨床征候群。嘔吐：胃和/或小腸(xiǎocháng)內(nèi)容物經(jīng)食管和口腔排除體外惡心和嘔吐常伴隨存在，也可單獨(dú)出現(xiàn)！第五頁(yè)，共87頁(yè)。NauseaandVomiting第六頁(yè)，共87頁(yè)。1、惡心：咽部及上腹部不適，胃張力和蠕動(dòng)減弱，幽門(mén)和賁門(mén)開(kāi)放。2、干嘔(ɡànǒu)：胃竇部和腹壁肌肉收縮，腹壓增加，食管及咽部開(kāi)放。3、嘔吐：胃和/或小腸內(nèi)容物經(jīng)食管和口腔排除體外。Definitionofemesis.(Threephases)嘔吐(ǒutù)反射過(guò)程（三個(gè)階段）1.Nausea-theinclinationorfeelingofimminentdesiretovomit,usuallyfeltinthethroatorepigastrum.Associatedwithdecreasedactivityofthestomach.2.Retching-thelaboredrhythmiccontractionofrespiratoryandabdominalmusculaturethatfrequentlyprecedesoraccompaniesvomiting.3.Vomiting-theforcefuloralexpulsionofgastriccontentsviaretroperistalsis.(Abdominaleffects).第七頁(yè)，共87頁(yè)。迷走興奮(xīngfèn)表現(xiàn)惡心(ěxīn)干嘔(ɡànǒu)嘔吐發(fā)生機(jī)制第八頁(yè)，共87頁(yè)。嘔吐(ǒutù)區(qū)別于反食嘔吐：多數(shù)情況有惡心(ěxīn)的感覺(jué)和嘔吐反射的協(xié)調(diào)動(dòng)作。反食：無(wú)惡心的感覺(jué)和嘔吐(ǒutù)反射的協(xié)調(diào)動(dòng)作。（兒童、飽餐）第九頁(yè)，共87頁(yè)。Mechanismsofemesis第十頁(yè)，共87頁(yè)。CTZ&EmeticCenter(Vomitingcenter)CTZ化學(xué)感受器觸發(fā)帶（第四腦室底面）：外源性或內(nèi)源性化學(xué)物質(zhì)（阿片(āpiàn)嗎啡、洋地黃、代謝產(chǎn)物）EmeticCenter（延髓外側(cè)網(wǎng)狀結(jié)構(gòu)背測(cè)）接受(jiēshòu)大腦皮質(zhì)、消化器官、心血管以及化學(xué)感受器觸發(fā)帶（CTZ）的沖動(dòng)第十一頁(yè)，共87頁(yè)。CTZ&EmeticCenter(Vomitingcenter)孤束核第十二頁(yè)，共87頁(yè)。EmeticCenter

內(nèi)臟(nèizàng)傳入中腦(zhōngnǎo)ICP受體化學(xué)(huàxué)感受器觸發(fā)帶邊緣系統(tǒng)前庭系統(tǒng)嘔吐中樞（Vomitingcenter)ICP=InductivelyCoupledPlasma感應(yīng)耦合等離子體第十三頁(yè)，共87頁(yè)。NeurotransmittersinCTZ&EmeticCenterNeurotransmittersinvolvedinstimulatingtheemeticcenter,chemo-receptortriggerzoneandGItractinclude;5-HT,acetylcholine,histamine,dopamine(opiatesandreceptorsforbenzodiazepinesarealsofoundhere)第十四頁(yè)，共87頁(yè)。第十五頁(yè)，共87頁(yè)。第十六頁(yè)，共87頁(yè)。EmeticCenter

1、分泌唾液中樞2、血管收縮(shōusuō)中樞3、呼吸中樞4、中樞神經(jīng)脊神經(jīng)膈神經(jīng)(shénjīng)迷走神經(jīng)(mízǒu-shéngjīng)第十七頁(yè)，共87頁(yè)。第十八頁(yè)，共87頁(yè)。nauseaandvomiting1.Reflectivevomiting反射性嘔吐(ǒutù)2.Centralvomiting中樞性嘔吐(ǒutù)3.Neurologicalvomiting神經(jīng)性嘔吐(ǒutù)第十九頁(yè)，共87頁(yè)。Reflectivevomiting（反射性嘔吐(ǒutù)）咽部刺激胃十二指腸(shíèrzhǐcháng)疾病膽道疾病腸道疾病肝膽疾病腹膜腸系膜全身性疾?。ㄎ骞佟⑿难?、泌尿、盆腔…）PharyngealMechanismsGastrointestinalMechanismsDiseaseofbiliarytractPeritonealandmesenterythefivesenseorgansCardiovasculardiseaseskidneyPelvic第二十頁(yè)，共87頁(yè)。咽部刺激(cìjī)PharyngalMechanisms第二十一頁(yè)，共87頁(yè)。GastrointestinalMechanisms第二十二頁(yè)，共87頁(yè)。肝、膽、胰腺(yíxiàn)第二十三頁(yè)，共87頁(yè)。其他(qítā)第二十四頁(yè)，共87頁(yè)。Intra-cranialinfectionCerebrovasculardisordersCraniocerebralinjuryEpilepsyMetabolicdisordersDrugsCentralvomiting（中樞性嘔吐(ǒutù)）顱內(nèi)感染腦血管疾病顱腦(lúnǎo)損傷癲癇全身疾?。蚨景Y、肝昏迷、糖尿病代謝紊亂）第二十五頁(yè)，共87頁(yè)。顱內(nèi)感染(gǎnrǎn)（腦炎、腦膜炎）第二十六頁(yè)，共87頁(yè)。腦血管疾病(jíbìng)、顱腦損傷第二十七頁(yè)，共87頁(yè)。癲癇(diānxián)第二十八頁(yè)，共87頁(yè)。全身(quánshēn)疾病尿毒癥肝昏迷(hūnmí)酮癥酸中毒各種原因引起(yǐnqǐ)的腦水腫和顱內(nèi)壓升高代謝紊亂早孕第二十九頁(yè)，共87頁(yè)。Drug抗生素抗癌藥洋地黃嗎啡(mafēi)興奮(xīngfèn)嘔吐中樞或影響胃腸平滑肌運(yùn)動(dòng)AntibioticsAnti-carcinomaDigitalismorphia第三十頁(yè)，共87頁(yè)。Neurologic&PsychogeniccausesNeurologicandPsychogeniccauses胃腸道神經(jīng)(shénjīng)官能癥（Gastrointestinaltractneurosis）神經(jīng)(shénjīng)厭食癥（apositia）第三十一頁(yè)，共87頁(yè)。CharacteristicsofNauseaandVomitingTimeTakingfoodCharacteristicsCharactersofcontents第三十二頁(yè)，共87頁(yè)。晨起嘔吐早孕反應(yīng)功能性消化不良酒精中毒胃食管反流病鼻咽部疾患夜間(yèjiān)或隔夜嘔吐幽門(mén)(yōumén)梗阻賁門(mén)(bēnmén)失弛緩癥第三十三頁(yè)，共87頁(yè)。嘔吐與進(jìn)食(jìnshí)的關(guān)系（Timingwithmeals）餐后即刻：神經(jīng)精神性；集體發(fā)病(fābìng)系食物中毒餐后1小時(shí)以上：為延遲性嘔吐：可考慮為胃張力(zhānglì)低下排空障礙餐后較久、多餐后或隔夜：提示幽門(mén)梗阻第三十四頁(yè)，共87頁(yè)。嘔吐(ǒutù)特點(diǎn)神經(jīng)性或顱內(nèi)高壓(gāoyā)：惡心輕、嘔吐頻；“噴射性嘔吐”嘔吐物性質(zhì)(xìngzhì)發(fā)酵、腐臭味：提示胃潴留糞臭味：提示較低位置的腸梗阻無(wú)酸腐味：賁門(mén)失遲緩癥或胃酸缺乏不含膽汁：幽門(mén)梗阻病史較長(zhǎng)或量多：提示體液和電解質(zhì)丟失第三十五頁(yè)，共87頁(yè)。Theaccompanyingsymptoms腹痛、腹瀉：食物中毒、腸道傳染病、胃腸炎；節(jié)律(jiélǜ)性腹痛：消化性潰瘍右上腹痛，伴發(fā)熱、黃疸(huángdǎn)：膽囊炎、膽道結(jié)石、感染。頭痛、頭暈、視力異常、噴射性嘔吐(ǒutù)：顱內(nèi)高壓性疾病、屈光不正、青光眼。伴眩暈、眼球震顫：前庭障礙育齡婦女（停經(jīng)）：應(yīng)排除妊娠與服藥有時(shí)間關(guān)聯(lián)：應(yīng)想到藥物反應(yīng)第三十六頁(yè)，共87頁(yè)。問(wèn)診要點(diǎn)(yàodiǎn)起病情況：誘因、急緩、與進(jìn)食關(guān)系(guānxì)、腹部手術(shù)史、育齡婦女月經(jīng)史發(fā)作時(shí)間：晨、夜、與進(jìn)食、活動(dòng)、體位的關(guān)系(guānxì)嘔吐物性狀、味道伴隨癥狀診療和癥狀演變情況第三十七頁(yè)，共87頁(yè)。History/Backgrounda)Ageb)GIhistoryrequiredc)Foodintoleranced)Timingwithmealse)Consistencyf)Contentg)Odorh)Frequencyi)Feverj)Weightlossk)Precipitatingfactorsl)Myalgias（肌痛）,visualdisturbances,headache,painoutsideabdomen第三十八頁(yè)，共87頁(yè)。CAUSESOFNAUSEA/VOMITINGEarlypregnancyPsychogenesisvomitingBulimia(易餓病)PyloricchannelulcerAcutegastritisGastricretention(潴留(zhūliú)）Viralgastroenteritis（中毒性胃腸炎）AcutegastroenteritisMyocardialinfarctionPeritonitis（腹膜炎）AcuteobstructionNeurologicalemergencyDrugtoxicityCancertherapyDrugwithdrawal第三十九頁(yè)，共87頁(yè)。PHYSICALEXAMVitalsignsSkinHEENT（head,eyes,ear,nose,throat)AbdomenNeurological第四十頁(yè)，共87頁(yè)。LABORATORYRuleoutobstructionandperitonitisHCGUrinalysisElectrolytes,BUN,creatinine,glucoseTransaminases,amylaseEKG,headCT,upperGI&/orendoscopies第四十一頁(yè)，共87頁(yè)。Break第四十二頁(yè)，共87頁(yè)。瀘沽湖黃昏(huánghūn)第四十三頁(yè)，共87頁(yè)。瀘沽湖黃昏(huánghūn)第四十四頁(yè)，共87頁(yè)。瀘沽湖?摩梭女第四十五頁(yè)，共87頁(yè)。玉龍雪山(yùlónɡxuěshān)?雪月第四十六頁(yè)，共87頁(yè)。第四十七頁(yè)，共87頁(yè)。47ConstipationShanghaiSecondMedicaluniversityRenjiclinicalmedicalcollege第四十八頁(yè)，共87頁(yè)。Background第四十九頁(yè)，共87頁(yè)。ConstipationIsaConstellationofSymptomsMostcommonlyreportedsymptomsHard,lumpystoolsIncreasedstrainingInfrequentbowelmovementsSensationofincompleteevacuationBloating/fullnessChronicconstipationMorepersistentthanintermittentorepisodicSeveralmonthsdurationC第五十頁(yè)，共87頁(yè)。SandlerRS,etal.DigDisSci.1987;32:841-845.n=1128ConstipationIsMoreThanJustInfrequentPassageofStool53Constipationsymptomsreportedmostoften第五十一頁(yè)，共87頁(yè)。ReducedStoolFrequencyIsNotthe

MostCommonlyReportedSymptominConstipationEPOC=Epidemiologyofconstipation;BM=Bowelmovement.1.StewartWF,etal.AmJGastroenterol.1999;94:3530-3540.2.ParéP,etal.AmJGastroenterol.2001;96:3130-3137.Stewart(EPOC)19991Paré20012n=1476n=1149ConstipationsymptomsreportedmostoftenC第五十二頁(yè)，共87頁(yè)。PrevalenceintheGeneralPopulation1.StewartWF,etal.AmJGastroenterol.1999;94:3530-3540.2.DrossmanDA,etal.DigDisSci.1993;38:1569-1580.3.HarrisInteractiveStudy,Wave2.Dataonfile.

4.ParéP,etal.AmJGastroenterol.2001;96:3130-3137.53PopulationnCriteriaPrevalence,n(%)US110,018RomeI461(4.6)US25430RomeI195(3.6)US315,183RomeII2429(16)Canada41149RomeII171(14.9)China(18-70ys)?RomeII?(6.07)China(>60ys)?RomeII?(15-20)第五十三頁(yè)，共87頁(yè)。EpidemiologyChronicconstipationiscommonSlightlymorecommoninwomenF/Mratio=range1.3to2.5(China=4:1)AffectsallagegroupsStewartWF,etal.AmJGastroenterol.1999;94:3530-3540.ParéP,etal.AmJGastroenterol.2001;96:3130-3137.SandlerRS,etal.DigDisSci.1987;32:841-845.C第五十四頁(yè)，共87頁(yè)。ConstipationAffectsAllAgeGroups53Canadianpopulation.ParéP,etal.AmJGastroenterol.2001;96:3130-3137.N=1149n=378n=367n=217n=187第五十五頁(yè)，共87頁(yè)。ProfileofaTypicalChronicConstipationPatientinMyPracticeGenerallyfemaleSymptomaticfor>10yrMajorityhavetriedlifestylechanges,fiber,andOTClaxativespriortoseekingcareManagesconditionwithmultipletherapiesMostoftenreferredbyaprimarycarephysicianCopeswithcondition,butisnotcompletelysatisfiedC第五十六頁(yè)，共87頁(yè)。ConstipationCanHaveaNegativeImpactonQualityofLifePeoplewithCCreportedsignificantimpairmentinQoLonSF-36scale(n=126)1InCanada,peoplewithself-reportedorRomeIIconstipationhadsignificantlyworseSF-36scoresthanthenormalpopulation(n=472)2InAustralia,peoplewithconstipationhadsignificantlyworseSF-12scoresonbothmentalandphysicalscales(n=227)31.O’KeefeEA,etal.JGerontolABiolSciMedSci.1995;50:M184-M189.

2.IrvineEJ,etal.AmJGastroenterol.2002;97:1986-1993.

3.KoloskiNA,etal.AmJGastroenterol.2000;95:67-71.C第五十七頁(yè)，共87頁(yè)。ConstipationSignificantlyImpactsHealthcareUtilization5.7millionconstipation-relatedoutpatientvisitsannually1,24.1millionphysicianoffice-basedvisits991,000emergencyroomvisits587,000hospitaloutpatientvisits$2752/patientfortertiarycareevaluation31.NationalAmbulatoryMedicalCareSurvey,2001.2.NationalHospitalAmbulatoryCareSurvey,2001.3.RantisPCJr,etal.DisColonRectum.1997;40:280-286.C第五十八頁(yè)，共87頁(yè)。Complicationsrelated

withconstipationColonicandrectalcarcinomaOthercolon-rectal-anusdisordershepaticcomaacutemyocardialinfarctionmammaryglanddisorderspreseniledementia(早老性癡呆(chīdāi)）psycho-problemsappearance第五十九頁(yè)，共87頁(yè)。Definition:CausesofChronicConstipationSecondaryDruginducedMetabolicfactorsComorbidconditionsPrimaryImpairedcolonictransit/motilityAlteredneuroentericfunctionandreflexesFailureofmuscularapparatusIneffectivedefecation(functionaloutletobstruction)PelvicdyssynergiaandanismusNormaltransitconstipation第六十頁(yè)，共87頁(yè)。PresentationObjectivesDefineconstipationThepathophysiologicalmechanismsEtiologiesofconstipationCharacterizemanifestationDiscriminatetheaccompanyingsymptoms.Suggestdiagnosticstrategiesofthesymptoms.C第六十一頁(yè)，共87頁(yè)。WhatisConstipation?Passageofhard,dry,lumpystools;Infrequentbowelmovements,usuallyfewerthanthreetimesaweekSymptoms:painfulbowelmovementsstrainingUncomfortable（Sensationofincompleteevacuation）bloatedsluggish第六十二頁(yè)，共87頁(yè)。RomeIIDefinesFunctionalConstipationBasedonMultipleSymptomsRomeIIdiagnosticcriteriaforfunctionalconstipationAtleast12wk,whichneednotbeconsecutive,overthepast12monthsof2ormoreofStraining*Lumpyorhardstools*Sensationofincompleteevacuation*Sensationofanorectalobstruction/blockage*Manualmaneuverstofacilitatedefecation*<3defecations/wkLoosestoolsnotpresentInsufficientcriteriaforIBS*>1/4ofdefecations.DrossmanDA,etal.In:RomeII:TheFunctionalGastrointestinalDisorders.2000:382-391.C第六十三頁(yè)，共87頁(yè)。NormalmetabolismAsfoodmovesthroughyourintestines,itabsorbswaterwhileformingwasteproductsMusclescontractinthecolon,pushingthestooltowardtherectum第六十四頁(yè)，共87頁(yè)。DefecationProcessYieldawarenessofdefecationAnalintra-andextra-sphincterRelaxationAbdominaleffects第六十五頁(yè)，共87頁(yè)。Mechanicalstimulation1.Yieldawarenessofdefecation第六十六頁(yè)，共87頁(yè)。2.Analintra-andextra-sphincterRelaxationintra-sphincterextra-sphincterLevatoranimuscle第六十七頁(yè)，共87頁(yè)。2.Abdominaleffectsgastriccontentsviaanus第六十八頁(yè)，共87頁(yè)。WhatCausesConstipation?EatingtoolittlefiberNotdrinkingenoughliquidsLackofexercise/physicalactivity第六十九頁(yè)，共87頁(yè)。WhatCausesConstipation?ChangeinroutinetravelOlderageSlowermetabolismFrequentuseoflaxativesCertaindiseasesorconditions第七十頁(yè)，共87頁(yè)。WhatCausesConstipation?CertaindiseasesorconditionsRectalandAnaldisordersColonicdisordersSystemicdiseasesorconditions第七十一頁(yè)，共87頁(yè)。WhatCausesConstipation?pain(narcotics麻藥(máyào))antacidscontainingaluminumantidepressantsironsupplementsdiuretics(“water”pills)

Medications第七十二頁(yè)，共87頁(yè)。ClassificationofetiologiesEatingtoolittlefiberNotdrinkingenoughliquidsLackofexercise/physicalactivityChangeinroutineTravelpsycho-relatedOlderageSlowermetabolismFrequentuseoflaxativestediouslylongColonMedicationsTravelpain(narcotics麻藥(máyào))antacidscontainingaluminumantidepressantsironsupplementsdiuretics(“water”pills)Functionaletiologies第七十三頁(yè)，共87頁(yè)。psycho-related第七十四頁(yè)，共87頁(yè)。TediouslylongColon結(jié)腸(jiécháng)冗長(zhǎng)第七十五頁(yè)，共87頁(yè)。Organicconstipation(certaindiseasesorconditionscauseconstipation)ClassificationofetiologiesRectalandAnaldisordersBenignormalignancytumorTumorormassoutsideSystemicdiseasesorconditions(e.g.disordersmakedyscinesia:spasmandpar