腸梗阻教案-上海第二醫(yī)科大學(xué)附屬瑞金醫(yī)院課件

腸梗阻INTESTINALOBSTRUCTIONRuiJinhospitalZhangHaoboIntroduction

腸內(nèi)容物不能正常運(yùn)行,順利通過腸道

病因?qū)W機(jī)械性梗阻

腸腔阻塞:結(jié)石、糞塊、異物腸管受壓:粘連帶、腸扭轉(zhuǎn)、疝腸壁病變：腫瘤、炎性、先天性動(dòng)力性腸梗阻麻痹性：神經(jīng)、毒素、炎性痙攣性：腸動(dòng)力紊亂、鉛中毒血運(yùn)性腸梗阻腸系膜血管栓塞或血栓形成腸梗阻是否伴血運(yùn)障礙單純性/絞窄性腸梗阻部位高位：空腸上段低位：回腸末段結(jié)腸梗阻腸梗阻程度：不完全性/完全性發(fā)展進(jìn)程：急性/慢性病理生理病理生理ClinicalAppearance腹痛嘔吐便秘停止排氣

PhysicalExamination

視診腹脹Abdomendistention蠕動(dòng)波Peristalicwave手術(shù)疤痕Surgicalscars嵌頓疝Incarceratedhernias

觸診腹脹腹塊腹肌緊張腹膜炎PhysicalExamination腹部聽診

腸鳴音亢進(jìn)

直腸指檢LaboratoryTests血漿電解質(zhì)和PH值BloodWBCHematocrit

Serumamylase

BUN

X射線檢查

RadiologicExamination診斷正確率80~85%

平臥位

立位

側(cè)臥位

急性完全性機(jī)械性梗阻

擴(kuò)張小腸襻

氣液平倒U字型

直腸和結(jié)腸內(nèi)無氣體

RadiologicExamination小腸梗阻SmallintestinalOB

小腸黏膜呈魚刺樣

valvulae

conniventes

腸段位于腹中部

centralportions

小量/無結(jié)腸氣體

minimal/nocolonicgas結(jié)腸梗阻

ColonObstruction

結(jié)腸袋影

colonichaustralmarking

擴(kuò)張腸段位于腹部外周/盆腔

peripheryofabdomen/inthepelvic1.有否腸梗阻？

Doesthepatienthavebowelobstruction?2.梗阻在那一段腸段

Ifso,whereisit?3.病因是什么？

Whatistheanatomicandpathologicnature?4.是否存在絞榨性腸梗阻

Hasstrangulationoccurred?5.患者全身情況如何？

Whatisthegeneralconditionofthepatients?診斷

Diagnosis臨床表現(xiàn)

ClinicalAppearance腹痛Abdominalpain嘔吐Vomiting便秘Obstipation腹脹Abdominaldistention停止排氣

Failuretopassflatus

DifferentiationofpartialfromcompleteSBOPartialSBO:passflatusorliquidstoolsCompleteSBO:obstipation

DifferentiationofProximal/distalSBO:pain:epigastric/periumbilicalareavomiting:prominent/lateronsetdistention:no/predominate

鑒別近端和遠(yuǎn)端梗阻DifferentiationofProximal/distalSBO:

pain:epigastric/periumbilicalareavomiting:prominent/lateronsetdistention:no/predominate鑒別部分梗阻和完全性梗阻DifferentiationofpartialfromcompleteSBO

PartialSBO:passflatusorliquidstoolsCompleteSBO:obstipation單純性和絞榨性腸梗阻的鑒別

單純性腸梗阻腹痛陣發(fā)性輕度-中度嘔吐較少休克無，少見發(fā)熱不常見腹痛和肌衛(wèi)少見對補(bǔ)液治療有效絞榨性腸梗阻腹痛持續(xù)性重度嘔吐嚴(yán)重休克早、常見發(fā)熱明顯腹痛和肌衛(wèi)早、明顯對補(bǔ)液治療效果差治療

TreatmentofSBO保守治療和手術(shù)治療

Medicalandsurgicalmanagement三個(gè)連續(xù)的階段：觀察、治療、手術(shù)

Theoverlappingsequence:investigationresuscitationoperation手術(shù)時(shí)機(jī)的把握：Thetimingofoperationdependsonthreefactors:

病程duration重要器官的功能opportunityofvitalorganfunction絞榨的可能riskofstrangulationThetimingofoperationdependsonthreefactors:

病程duration

器官功能opportunityofvitalorganfunction

絞榨的可能riskofstrangulationMedicalmanagment胃腸減壓Nasointestinal/nasogastricintubation糾正水電解質(zhì)的紊亂Intravenousfluids/bloodplasmaadministration廣譜抗菌素的應(yīng)用Broad-spectrumantibioticsadministrationSurgicalprinciple病因

ThenatureofproblemdeterminesapproachtomanagementofSBO.腸管活性的判斷：色澤、活力、動(dòng)脈搏動(dòng)

Thecriteriaofdeterminingbowelviability:colormotilityarterialpulsation處理

Ifquestionable,releasedandplaced,re-examined.結(jié)腸梗阻

LargeBowelObstruction病因?qū)WEtiologycarcinoma55%volvulus11%diverticulitis9%extrinsiccarcinoma8%adhesions4%fecalimpaction3%Daignosis慢性梗阻Chroniccomplaints腹痛位于下腹部和臍周

Painrelatedtolowerabdomenorperiumbilicalarea.腹脹明顯Abdominaldistensionprominent隱血試驗(yàn)Guaiac-positivestools直腸指檢RectalexaminationManagement直腸乙狀結(jié)腸鏡Proctosigmoidoscopy

visualized/biopsied/decompressed結(jié)腸梗阻大多數(shù)需要手術(shù)治療

Mostlargebowelobstructionneedsurgeryexpcetforfecalimpaction閉襻性梗阻需急癥手術(shù)

Closedloopobstructionneedemergency分期手術(shù)

one/two/three-stagesurgicalprocedures腸粘連

Adhesiveobstruction形成：粘連銳角纖維束帶壓迫

surgicaltraumainfectionsbleedingintestinalischemiachemicaltraumaforeignbodies（powder）腸壞死Riskofstrangulation:9%再次手術(shù)腸排列手術(shù)(M-A管)疝源性腸梗阻外疝:

下腹痛,腹外疝好發(fā)部位腫塊,無法回納手術(shù)松解疝環(huán),疝修補(bǔ),壞死腸段切除。內(nèi)疝:

疝環(huán)為先天或手術(shù)形成腹內(nèi)間隙.

多為閉襻性,X線平片僅為一致密影.

癥狀劇烈,病情急驟,診斷困難,需急診手術(shù)

腸套疊

IntussusceptionIntussusceptumtelescopesintoanintussuscipiens(sheath)enteroenteral,ileocecal,ileocolic,colocolicchildrenrateishigh1/3casesofadultsismalignanciesresectionisnecessary(香腸狀,空虛感,粘液血便)腸扭轉(zhuǎn)