惡心嘔吐宣講培訓(xùn)課件

1、惡心嘔吐宣講惡心嘔吐宣講臨床診斷學(xué)上海第二醫(yī)科大學(xué)仁濟(jì)臨床醫(yī)學(xué)院 惡心嘔吐宣講2臨床診斷學(xué)上海第二醫(yī)科大學(xué)仁濟(jì)臨床醫(yī)學(xué)院 惡心嘔吐宣講2Nausea and VomitingAs the symptoms癥狀學(xué)：惡心與嘔吐惡心嘔吐宣講3Nausea and Vomiting癥狀學(xué)：惡心與嘔吐惡心GoalsBriefly defineOutline the prominent disease states associated with nausea and vomiting.Characterize Nausea and Vomiting caused by the prominent dis

2、orders Discriminate the accompanying symptoms. Suggest diagnostic strategies of the symptoms.惡心嘔吐宣講4GoalsBriefly define惡心嘔吐宣講4Definition of Nausea and VomitingNausea ：the inclination or feeling of imminent desire to vomit, usually felt in the throat or epi-gastrum. Associated with decreased activity

3、 of the stomach.Vomiting： the forceful oral expulsion of gastric contents via retro-peristalsis.Nausea-Vomiting: simultaneity or separateness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)！惡心嘔吐宣講5Definition of Nausea and VomitNausea and Vomiting惡心嘔吐宣講6Nausea and Vomiting惡心嘔吐宣講61、

4、惡心：咽部及上腹部不適，胃張力和蠕動(dòng)減弱，幽門和賁門開放。2、干嘔：胃竇部和腹壁肌肉收縮，腹壓增加，食管及咽部開放。3、嘔吐：胃和/或小腸內(nèi)容物經(jīng)食管和口腔排除體外。Definition of emesis. (Three phases)嘔吐反射過程（三個(gè)階段）1. Nausea - the inclination or feeling of imminent desire to vomit, usually felt in the throat or epigastrum. Associated with decreased activity of the stomach.2. Retchi

5、ng - 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 retroperistalsis. (Abdominal effects).惡心嘔吐宣講71、惡心：咽部及上腹部不適，胃張力和蠕動(dòng)減弱，幽門和賁門開放迷走興奮表現(xiàn)惡心干嘔嘔吐發(fā)生機(jī)制惡心嘔吐宣講8迷走興奮表現(xiàn)惡心

6、干嘔嘔吐發(fā)生機(jī)制惡心嘔吐宣講8嘔吐區(qū)別于反食嘔吐：多數(shù)情況有惡心的感覺和嘔吐反射的協(xié)調(diào)動(dòng)作。反食：無惡心的感覺和嘔吐反射的協(xié)調(diào)動(dòng)作。（兒童、飽餐）惡心嘔吐宣講9嘔吐區(qū)別于反食嘔吐：多數(shù)情況有惡心的感覺和嘔吐反射的協(xié)調(diào)動(dòng)作Mechanisms of emesis惡心嘔吐宣講10Mechanisms of emesis惡心嘔吐宣講10CTZ & Emetic Center (Vomiting center)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)（阿片嗎啡、洋地黃、代謝產(chǎn)物）Emetic Center（延髓外側(cè)網(wǎng)狀結(jié)構(gòu)背測）接受大腦皮質(zhì)、消化器官、心血管以及化學(xué)感受器觸發(fā)帶（

7、CTZ）的沖動(dòng)惡心嘔吐宣講11CTZ & Emetic Center (Vomiting CTZ & Emetic Center (Vomiting center)孤束核惡心嘔吐宣講12CTZ & Emetic Center (Vomiting Emetic Center 內(nèi)臟傳入 中腦ICP受體化學(xué)感受器觸發(fā)帶邊緣系統(tǒng)前庭系統(tǒng)嘔吐中樞（Vomiting center)ICP=Inductively Coupled Plasma 感應(yīng)耦合等離子體惡心嘔吐宣講13Emetic Center 內(nèi)臟傳入 中腦ICP受體化學(xué)感受Neurotransmitters in CTZ & Emetic Cen

8、terNeurotransmitters 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)惡心嘔吐宣講14Neurotransmitters in CTZ & Eme惡心嘔吐宣講15惡心嘔吐宣講15惡心嘔吐宣講16惡心嘔吐宣講16Emetic Cente

9、r 1、分泌唾液中樞2、血管收縮中樞3、呼吸中樞4、中樞神經(jīng)脊神經(jīng)膈神經(jīng)迷走神經(jīng)惡心嘔吐宣講17Emetic Center 1、分泌唾液中樞脊神經(jīng)膈神經(jīng)迷走惡心嘔吐宣講18惡心嘔吐宣講18nausea and vomiting1. Reflective vomiting 反射性嘔吐2.Central vomiting 中樞性嘔吐3. Neurological vomiting 神經(jīng)性嘔吐惡心嘔吐宣講19nausea and vomiting1. ReflectiReflective vomiting （反射性嘔吐）咽部刺激胃十二指腸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?/p>

10、、泌尿、盆腔）Pharyngeal MechanismsGastrointestinal MechanismsDisease of biliary tractPeritoneal and mesenterythe five sense organsCardiovascular diseases kidneyPelvic惡心嘔吐宣講20Reflective vomiting （反射性嘔吐）咽部刺咽部刺激Pharyngal Mechanisms惡心嘔吐宣講21咽部刺激Pharyngal Mechanisms惡心嘔吐宣講Gastrointestinal Mechanisms惡心嘔吐宣講22Gastr

11、ointestinal Mechanisms惡心嘔肝、膽、胰腺惡心嘔吐宣講23肝、膽、胰腺惡心嘔吐宣講23其他惡心嘔吐宣講24其他惡心嘔吐宣講24Intra-cranial infectionCerebrovascular disordersCraniocerebral injuryEpilepsyMetabolic disorders DrugsCentral vomiting （中樞性嘔吐）顱內(nèi)感染腦血管疾病顱腦損傷癲癇全身疾?。蚨景Y、肝昏迷、糖尿病代謝紊亂）惡心嘔吐宣講25Intra-cranial infectionCentral顱內(nèi)感染（腦炎、腦膜炎）惡心嘔吐宣講26顱內(nèi)感染（腦炎

12、、腦膜炎）惡心嘔吐宣講26腦血管疾病、顱腦損傷惡心嘔吐宣講27腦血管疾病、顱腦損傷惡心嘔吐宣講27癲癇惡心嘔吐宣講28癲癇惡心嘔吐宣講28全身疾病尿毒癥肝昏迷酮癥酸中毒各種原因引起的腦水腫和顱內(nèi)壓升高代謝紊亂早孕惡心嘔吐宣講29全身疾病尿毒癥肝昏迷酮癥酸中毒各種原因引起的腦水腫和顱內(nèi)壓升Drug抗生素抗癌藥洋地黃嗎啡興奮嘔吐中樞或影響胃腸平滑肌運(yùn)動(dòng)AntibioticsAnti-carcinomaDigitalismorphia惡心嘔吐宣講30Drug抗生素興奮嘔吐中樞或影響胃腸平滑肌運(yùn)動(dòng)AntibioNeurologic & Psychogenic causesNeurologic and

13、Psychogenic causes胃腸道神經(jīng)官能癥（Gastrointestinal tract neurosis）神經(jīng)厭食癥（apositia）惡心嘔吐宣講31Neurologic & Psychogenic causeCharacteristics of Nausea and VomitingTimeTaking foodCharacteristicsCharacters of contents惡心嘔吐宣講32Characteristics of Nausea and 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或隔夜嘔吐幽門梗阻賁門失弛緩癥惡心嘔吐宣講33晨起嘔吐早

14、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嘔吐與進(jìn)食的關(guān)系（ Timing with meals）餐后即刻：神經(jīng)精神性；集體發(fā)病系食物中毒餐后1小時(shí)以上：為延遲性嘔吐：可考慮為胃張力低下排空障礙餐后較久、多餐后或隔夜：提示幽門梗阻惡心嘔吐宣講34嘔吐與進(jìn)食的關(guān)系餐后即刻：神經(jīng)精神性；集體發(fā)病系食物中毒餐后嘔吐特點(diǎn)神經(jīng)性或顱內(nèi)高壓：惡心輕、嘔吐頻；“噴射性嘔吐”嘔吐物性質(zhì)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酸腐味：賁門失遲緩癥或胃酸缺乏不含膽汁：幽門梗阻病史較長或量多：提示體液和電解質(zhì)丟失惡心嘔吐宣講35嘔吐特點(diǎn)神經(jīng)性或顱內(nèi)高壓：惡心輕、嘔吐頻；“噴射性嘔吐”嘔吐The

15、 accompanying symptoms腹痛、腹瀉：食物中毒、腸道傳染病、胃腸炎；節(jié)律性腹痛：消化性潰瘍右上腹痛，伴發(fā)熱、黃疸：膽囊炎、膽道結(jié)石、感染。頭痛、頭暈、視力異常、噴射性嘔吐：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)惡心嘔吐宣講36The accompanying symptoms腹痛、腹瀉問診要點(diǎn)起病情況：誘因、急緩、與進(jìn)食關(guān)系、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)系嘔吐物性狀、味道伴隨癥狀診療和癥狀演變情況惡心嘔吐宣講37問診要點(diǎn)起病情況：誘因、急緩、與進(jìn)食關(guān)系、腹部

16、手術(shù)史、育齡婦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 abdomen惡心嘔吐宣講38History/Backgrounda) Ageg) OdoCAUSES OF NAU

17、SEA/VOMITINGEarly pregnancyPsychogenesis vomitingBulimia(易餓病)Pyloric channel ulcerAcute gastritisGastric retention(潴留）Viral gastroenteritis（中毒性胃腸炎）Acute gastroenteritisMyocardial infarctionPeritonitis（腹膜炎）Acute obstructionNeurological emergencyDrug toxicityCancer therapyDrug withdrawal惡心嘔吐宣講39CAUSES

18、 OF NAUSEA/VOMITINGEarlyPHYSICAL EXAMVital signsSkinHEENT （head,eyes,ear,nose,throat)AbdomenNeurological惡心嘔吐宣講40PHYSICAL EXAMVital signs惡心嘔吐宣講LABORATORYRule out obstruction and peritonitisHCGUrinalysisElectrolytes, BUN, creatinine, glucoseTransaminases, amylaseEKG, head CT, upper GI &/or endoscopies

19、惡心嘔吐宣講41LABORATORYRule out obstructionBreak惡心嘔吐宣講42Break惡心嘔吐宣講42瀘沽湖黃昏惡心嘔吐宣講43瀘沽湖黃昏惡心嘔吐宣講43瀘沽湖黃昏惡心嘔吐宣講44瀘沽湖黃昏惡心嘔吐宣講44瀘沽湖摩梭女惡心嘔吐宣講45瀘沽湖摩梭女惡心嘔吐宣講45玉龍雪山雪月惡心嘔吐宣講46玉龍雪山雪月惡心嘔吐宣講46惡心嘔吐宣講47惡心嘔吐宣講47ConstipationShanghai Second Medical universityRenji clinical medical college惡心嘔吐宣講48ConstipationShanghai Second

20、MeBackground惡心嘔吐宣講49Background惡心嘔吐宣講49Constipation Is a Constellation of SymptomsMost commonly reported symptomsHard, lumpy stoolsIncreased strainingInfrequent bowel movementsSensation of incomplete evacuationBloating/fullnessChronic constipationMore persistent than intermittent or episodicSeveral m

21、onths durationC惡心嘔吐宣講50Constipation Is a ConstellatioSandler RS, et al. Dig Dis Sci. 1987;32:841-845.n = 1128Constipation Is More Than Just Infrequent Passage of Stool53Constipation symptoms reported most often惡心嘔吐宣講51Sandler RS, et al. Dig Dis SciReduced Stool Frequency Is Not the Most Commonly Rep

22、orted Symptom in ConstipationEPOC = Epidemiology of constipation; BM = Bowel movement.1. Stewart WF, et al. Am J Gastroenterol. 1999;94:3530-3540.2. Par P, et al. Am J Gastroenterol. 2001;96:3130-3137.Stewart (EPOC) 19991Par 20012n = 1476n = 1149Constipation symptoms reported most oftenC惡心嘔吐宣講52Redu

23、ced Stool Frequency Is NotPrevalence in the General Population1. Stewart WF, et al. Am J Gastroenterol. 1999;94:3530-3540.2. Drossman DA, et al. Dig Dis Sci. 1993;38:1569-1580.3. Harris Interactive Study, Wave 2. Data on file. 4. Par P, et al. Am J Gastroenterol. 2001;96:3130-3137.53PopulationnCrite

24、riaPrevalence, n (%)US110,018Rome I 461 (4.6)US25430Rome I 195 (3.6)US315,183Rome II2429 (16)Canada41149Rome II 171 (14.9)China (18-70ys)?RomeII?(6.07)China(60ys)?RomeII?(15-20)惡心嘔吐宣講53Prevalence in the General PopuEpidemiologyChronic constipation is commonSlightly more common in women F/M ratio = r

25、ange 1.3 to 2.5 (China=4:1)Affects all age groupsStewart WF, et al. Am J Gastroenterol. 1999;94:3530-3540.Par P, et al. Am J Gastroenterol. 2001;96:3130-3137.Sandler RS, et al. Dig Dis Sci. 1987;32:841-845. C惡心嘔吐宣講54EpidemiologyChronic constipatiConstipation Affects All Age Groups53Canadian populati

26、on.Par P, et al. Am J Gastroenterol. 2001;96:3130-3137.N = 1149n = 378n = 367n = 217n = 187惡心嘔吐宣講55Constipation Affects All Age GProfile of a Typical Chronic Constipation Patient in My PracticeGenerally femaleSymptomatic for 10 yrMajority have tried lifestyle changes, fiber, and OTC laxatives prior

27、to seeking careManages condition with multiple therapiesMost often referred by a primary care physician Copes with condition, but is not completely satisfiedC惡心嘔吐宣講56Profile of a Typical Chronic CConstipation Can Have a Negative Impact on Quality of LifePeople with CC reported significant impairment

28、 in QoL on SF-36 scale (n = 126)1In Canada, people with self-reported or Rome II constipation had significantly worse SF-36 scores than the normal population (n = 472)2In Australia, people with constipation had significantly worse SF-12 scores on both mental and physical scales (n = 227)31. OKeefe E

29、A, et al. J Gerontol A Biol Sci Med Sci. 1995;50:M184-M189.2. Irvine EJ, et al. Am J Gastroenterol. 2002;97:1986-1993. 3. Koloski NA, et al. Am J Gastroenterol. 2000;95:67-71. C惡心嘔吐宣講57Constipation Can Have a NegatiConstipation Significantly Impacts Healthcare Utilization5.7 million constipation-rel

30、ated outpatient visits annually1,24.1 million physician office-based visits 991,000 emergency room visits587,000 hospital outpatient visits$2752/patient for tertiary care evaluation31. National Ambulatory Medical Care Survey, 2001. 2. National Hospital Ambulatory Care Survey, 2001. 3. Rantis PC Jr,

31、et al. Dis Colon Rectum. 1997;40:280-286.C惡心嘔吐宣講58Constipation Significantly ImpComplications related with constipationColonic and rectal carcinomaOther colon-rectal-anus disordershepatic coma acute myocardial infarctionmammary gland disorderspresenile dementia(早老性癡呆）psycho-problemsappearance惡心嘔吐宣講5

32、9Complications related with conDefinition: Causes of Chronic ConstipationSecondaryDrug induced Metabolic factorsComorbid conditionsPrimaryImpaired colonic transit/motility Altered neuroenteric function and reflexesFailure of muscular apparatusIneffective defecation (functional outlet obstruction)Pel

33、vic dyssynergia and anismusNormal transit constipation惡心嘔吐宣講60Definition: Causes of Chronic Presentation ObjectivesDefine constipationThe pathophysiological mechanisms Etiologies of constipation Characterize manifestationDiscriminate the accompanying symptoms. Suggest diagnostic strategies of the sy

34、mptoms.C惡心嘔吐宣講61Presentation ObjectivesDefine What is Constipation?Passage of hard, dry, lumpy stools; Infrequent bowel movements, usually fewer than three times a weekSymptoms:painful bowel movements strainingUncomfortable（Sensation of incomplete evacuation）bloatedsluggish惡心嘔吐宣講62What is Constipati

35、on?Passage oRome II Defines Functional Constipation Based on Multiple SymptomsRome II diagnostic criteria for functional constipationAt least 12 wk, which need not be consecutive, over the past 12 months of 2 or more of Straining*Lumpy or hard stools*Sensation of incomplete evacuation*Sensation of a

36、norectal obstruction/blockage*Manual maneuvers to facilitate defecation* 1/4 of defecations.Drossman DA, et al. In: Rome II: The Functional Gastrointestinal Disorders. 2000:382-391.C惡心嘔吐宣講63Rome II Defines Functional ConNormal metabolismAs food moves through your intestines, it absorbs water while f

37、orming waste products Muscles contract in the colon, pushing the stool toward the rectum惡心嘔吐宣講64Normal metabolismAs food movesDefecation ProcessYield awareness of defecation Anal intra- and extra-sphincter RelaxationAbdominal effects惡心嘔吐宣講65Defecation ProcessYield awarenMechanical stimulation1. Yiel

38、d awareness of defecation惡心嘔吐宣講66Mechanical stimulation1. Yield2. Anal intra- and extra-sphincter Relaxationintra- sphincterextra-sphincterLevator ani muscle惡心嘔吐宣講672. Anal intra- and extra-sphin2. Abdominal effectsgastric contents via anus惡心嘔吐宣講682. Abdominal effectsgastric coWhat Causes Constipati

39、on?Eating too little fiber Not drinking enough liquidsLack of exercise/physical activity惡心嘔吐宣講69What Causes Constipation?EatinWhat Causes Constipation?Change in routinetravelOlder ageSlower metabolismFrequent use of laxativesCertain diseases or conditions惡心嘔吐宣講70What Causes Constipation?ChangWhat Ca

40、uses Constipation?Certain diseases or conditionsRectal and Anal disordersColonic disordersSystemic diseases or conditions惡心嘔吐宣講71What Causes Constipation?Certa惡心嘔吐宣講培訓(xùn)課件Classification of etiologiesEating too little fiber Not drinking enough liquidsLack of exercise/physical activityChange in routineT

41、ravelpsycho-relatedOlder ageSlower metabolismFrequent use of laxativestediously long ColonMedicationsTravelpain (narcotics麻藥)antacids containing aluminumantidepressantsiron supplementsdiuretics (“water” pills)Functional etiologies惡心嘔吐宣講73Classification of etiologiesEapsycho-related惡心嘔吐宣講74psycho-rel

42、ated惡心嘔吐宣講74Tediously long Colon結(jié)腸冗長惡心嘔吐宣講75Tediously long Colon結(jié)腸冗長惡心嘔吐宣講 Organic constipation (certain diseases or conditions cause constipation)Classification of etiologiesRectal and Anal disordersBenign or malignancy tumorTumor or mass outsideSystemic diseases or conditions (e.g. disorders make dyscinesia: spasm and paralysis）惡心嘔吐宣講76 Organic constipation ClassifiRectal and Anal disordersCancerNevusanal fissur