恶心呕吐临床诊断学.ppt

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1、临床诊断学临床诊断学Nausea and VomitingAs the symptoms症状学：恶心与呕吐症状学：恶心与呕吐GoalsBriefly defineOutline 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 sym

2、ptoms.Definition of Nausea and VomitingnNausea：the inclination or feeling of imminent desire to vomit,usually felt in the throat or epi-gastrum.Associated with decreased activity of the stomach.nVomiting：the forceful oral expulsion of gastric contents via retro-peristalsis.nNausea-Vomiting:simultane

3、ity 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！Nausea and Vomiting1、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 vomi

4、t,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 retroperis

5、talsis.(Abdominal effects).迷走兴奋表现迷走兴奋表现恶心恶心干呕干呕呕吐呕吐发生机制发生机制呕吐区别于反食呕吐区别于反食呕吐：多数情呕吐：多数情况有恶心的感况有恶心的感觉和呕吐反射觉和呕吐反射的协调动作。的协调动作。反食：无恶心反食：无恶心的感觉和呕吐的感觉和呕吐反射的协调动反射的协调动作。（儿童、作。（儿童、饱餐）饱餐）Mechanisms of emesisCTZ&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）

6、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CTZ&Emetic Center(Vomiting center)孤束核孤束核孤束核Emetic Center Midbrain Chemoreceptor Limbic Vestibular ICP Receptor Trigger Zone System system Visceral afferents 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Neurotra

7、nsmitters in CTZ&Emetic CenterNeurotransmitters 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)Emetic Center Emetic Center 1.Salivary center 2.Vasomotor cen

8、ter 3.Respiratory center 4.Cranial nerves Spinal nerve phrenic nerve vagus nerve Abdominal DiaphragmStomach Esophagus muscles 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nausea and vomiting1.Reflective vomiting 反射性呕吐反射性呕吐2.Central vomiting 中枢性呕吐中枢性呕吐3.Neurological vomiting 神经性呕吐神经性呕吐Reflective vomiting（反射

9、性呕吐）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 MechanismsGastrointestinal MechanismsDisease of biliary tractPeritoneal and mesenterythe five sense organsCardiovascular diseases kidneyPelvic咽部刺激Pharyngal MechanismsGastrointestinal Mechanisms肝、胆、胰腺其他Intra-cranial infectionCerebrov

10、ascular disordersCraniocerebral injuryEpilepsyMetabolic disorders DrugsCentral vomiting（中枢性呕吐）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）颅内感染（脑炎、脑膜炎）脑血管疾病、颅脑损伤癫痫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AntibioticsAnti-carcinomaDigitalismorphiaNeurologic&Psychogenic causesNe

11、urologic and Psychogenic causes胃肠道神经官能症（Gastrointestinal tract neurosis）神经厌食症（apositia）Characteristics of Nausea and Vomiting1.Time2.Taking food3.Characteristics4.Characters of contents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

12、力低下排空障碍餐后较久、多餐后或隔夜：提示幽门梗阻呕吐特点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：应想到药物反应问诊要点n起

13、病情况：诱因、急缓、与进食关系、腹部手术史、育龄妇女月经史n发作时间：晨、夜、与进食、活动、体位的关系n呕吐物性状、味道n伴随症状n诊疗和症状演变情况History/Backgrounda)Ageb)GI history requiredc)Food intoleranced)Timing with mealse)Consistencyf)Contentg)Odorh)Frequencyi)Feverj)Weight lossk)Precipitating factorsl)Myalgias（肌痛）,visual disturbances,headache,pain outside abdom

14、enCAUSES OF NAUSEA/VOMITINGnEarly pregnancynPsychogenesis vomitingnBulimia(易饿病易饿病)nPyloric channel ulcernAcute gastritisnGastric retention(潴潴留）留）nViral gastroenteritis（中毒性胃肠炎）中毒性胃肠炎）nAcute gastroenteritisnMyocardial infarctionnPeritonitis（腹膜炎）nAcute obstructionnNeurological emergencynDrug toxicitynC

15、ancer therapynDrug withdrawalPHYSICAL EXAMnVital signsnSkinnHEENT（head,eyes,ear,nose,throat)nAbdomennNeurologicalLABORATORYnRule out obstruction and peritonitisnHCGnUrinalysisnElectrolytes,BUN,creatinine,glucosenTransaminases,amylasenEKG,head CT,upper GI&/or endoscopies泸沽湖黄昏泸沽湖黄昏泸沽湖黄昏泸沽湖黄昏泸沽湖泸沽湖摩梭女摩

16、梭女玉龙雪山玉龙雪山雪月雪月46ConstipationShanghai Second Medical universityRenji clinical medical collegeBackgroundConstipation Is a Constellation of SymptomsnMost commonly reported symptomsnHard,lumpy stoolsnIncreased strainingnInfrequent bowel movementsnSensation of incomplete evacuationnBloating/fullnessnChronic constipationnMore persistent than intermittent or episodicnSeveral months durationC52524444343432322020191911110 0101020203030404050506060StrainingStraining Hard Hard stoolsstools Want to Want to