惡心嘔吐宣講

健康快樂每一天！第1頁臨床診斷學(xué)上海第二醫(yī)科大學(xué)仁濟(jì)臨床醫(yī)學(xué)院

第2頁NauseaandVomitingAsthesymptoms癥狀學(xué)：惡心與嘔吐第3頁GoalsBrieflydefineOutlinetheprominentdiseasestatesassociatedwithnauseaandvomiting.CharacterizeNauseaandVomitingcausedbytheprominentdisordersDiscriminatetheaccompanyingsymptoms.Suggestdiagnosticstrategiesofthesymptoms.第4頁DefinitionofNauseaandVomitingNausea：theinclinationorfeelingofimminentdesiretovomit,usuallyfeltinthethroatorepi-gastrum.Associatedwithdecreasedactivityofthestomach.Vomiting：theforcefuloralexpulsionofgastriccontentsviaretro-peristalsis.Nausea-Vomiting:simultaneityorseparateness惡心：急迫欲吐，一般伴有上腹不適和迷走興奮旳臨床征候群。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隨著存在，也可單獨(dú)浮現(xiàn)！第5頁NauseaandVomiting第6頁1、惡心：咽部及上腹部不適，胃張力和蠕動(dòng)削弱，幽門和賁門開放。2、干嘔：胃竇部和腹壁肌肉收縮，腹壓增長，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。Definitionofemesis.(Threephases)嘔吐反射過程（三個(gè)階段）1.Nausea-theinclinationorfeelingofimminentdesiretovomit,usuallyfeltinthethroatorepigastrum.Associatedwithdecreasedactivityofthestomach.2.Retching-thelaboredrhythmiccontractionofrespiratoryandabdominalmusculaturethatfrequentlyprecedesoraccompaniesvomiting.3.Vomiting-theforcefuloralexpulsionofgastriccontentsviaretroperistalsis.(Abdominaleffects).第7頁迷走興奮體現(xiàn)惡心干嘔嘔吐發(fā)生機(jī)制第8頁嘔吐區(qū)別于反食嘔吐：多數(shù)狀況有惡心旳感覺和嘔吐反射旳協(xié)調(diào)動(dòng)作。反食：無惡心旳感覺和嘔吐反射旳協(xié)調(diào)動(dòng)作。（小朋友、飽餐）第9頁Mechanismsofemesis第10頁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)（阿片嗎啡、洋地黃、代謝產(chǎn)物）EmeticCenter（延髓外側(cè)網(wǎng)狀構(gòu)造背測）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（CTZ）旳沖動(dòng)第11頁CTZ&EmeticCenter(Vomitingcenter)孤束核第12頁EmeticCenter

內(nèi)臟傳入中腦ICP受體化學(xué)感受器觸發(fā)帶邊沿系統(tǒng)前庭系統(tǒng)嘔吐中樞（Vomitingcenter)ICP=InductivelyCoupledPlasma感應(yīng)耦合等離子體第13頁NeurotransmittersinCTZ&EmeticCenterNeurotransmittersinvolvedinstimulatingtheemeticcenter,chemo-receptortriggerzoneandGItractinclude;5-HT,acetylcholine,histamine,dopamine(opiatesandreceptorsforbenzodiazepinesarealsofoundhere)第14頁第15頁第16頁EmeticCenter

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)第17頁第18頁nauseaandvomiting1.Reflectivevomiting

反射性嘔吐2.Centralvomiting中樞性嘔吐3.Neurologicalvomiting神經(jīng)性嘔吐第19頁Reflectivevomiting（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?、心血管、泌尿、盆腔…）PharyngealMechanismsGastrointestinalMechanismsDiseaseofbiliarytractPeritonealandmesenterythefivesenseorgansCardiovasculardiseaseskidneyPelvic第20頁咽部刺激PharyngalMechanisms第21頁GastrointestinalMechanisms第22頁肝、膽、胰腺第23頁其他第24頁Intra-cranialinfectionCerebrovasculardisordersCraniocerebralinjuryEpilepsyMetabolicdisordersDrugsCentralvomiting（中樞性嘔吐）顱內(nèi)感染腦血管疾病顱腦損傷癲癇全身疾病（尿毒癥、肝昏迷、糖尿病代謝紊亂）第25頁顱內(nèi)感染（腦炎、腦膜炎）第26頁腦血管疾病、顱腦損傷第27頁癲癇第28頁全身疾病尿毒癥肝昏迷酮癥酸中毒多種因素引起旳腦水腫和顱內(nèi)壓升高代謝紊亂早孕第29頁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第30頁Neurologic&PsychogeniccausesNeurologicandPsychogeniccauses胃腸道神經(jīng)官能癥（Gastrointestinaltractneurosis）神經(jīng)厭食癥（apositia）第31頁CharacteristicsofNauseaandVomitingTimeTakingfoodCharacteristicsCharactersofcontents第32頁晨起嘔吐早孕反映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第33頁嘔吐與進(jìn)食旳關(guān)系（Timingwithmeals）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：提示幽門梗阻第34頁嘔吐特點(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：提示較低位置旳腸梗阻無酸腐味：賁門失緩慢癥或胃酸缺少不含膽汁：幽門梗阻病史較長或量多：提示體液和電解質(zhì)丟失第35頁Theaccompanyingsymptoms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)想到藥物反映第36頁問診要點(diǎn)起病狀況：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)、體位旳關(guān)系嘔吐物性狀、味道隨著癥狀診斷和癥狀演變狀況第37頁History/Backgrounda)Ageb)GIhistoryrequiredc)Foodintoleranced)Timingwithmealse)Consistencyf)Contentg)Odorh)Frequencyi)Feverj)Weightlossk)Precipitatingfactorsl)Myalgias（肌痛）,visualdisturbances,headache,painoutsideabdomen第38頁CAUSESOFNAUSEA/VOMITINGEarlypregnancyPsychogenesisvomitingBulimia(易餓病)PyloricchannelulcerAcutegastritisGastricretention(潴留）Viralgastroenteritis（中毒性胃腸炎）AcutegastroenteritisMyocardialinfarctionPeritonitis（腹膜炎）AcuteobstructionNeurologicalemergencyDrugtoxicityCancertherapyDrugwithdrawal第39頁P(yáng)HYSICALEXAMVitalsignsSkinHEENT（head,eyes,ear,nose,throat)AbdomenNeurological第40頁LABORATORYRuleoutobstructionandperitonitisHCGUrinalysisElectrolytes,BUN,creatinine,glucoseTransaminases,amylaseEKG,headCT,upperGI&/orendoscopies第41頁Break第42頁瀘沽湖傍晚第43頁瀘沽湖傍晚第44頁瀘沽湖?摩梭女第45頁玉龍雪山?雪月第46頁47第47頁ConstipationShanghaiSecondMedicaluniversityRenjiclinicalmedicalcollege第48頁Background第49頁ConstipationIsaConstellationofSymptomsMostcommonlyreportedsymptomsHard,lumpystoolsIncreasedstrainingInfrequentbowelmovementsSensationofincompleteevacuationBloating/fullnessChronicconstipationMorepersistentthanintermittentorepisodicSeveralmonthsdurationC第50頁SandlerRS,etal.DigDisSci.1987;32:841-845.n=1128ConstipationIsMoreThanJustInfrequentPassageofStool53Constipationsymptomsreportedmostoften第51頁ReducedStoolFrequencyIsNotthe

MostCommonlyReportedSymptominConstipationEPOC=Epidemiologyofconstipation;BM=Bowelmovement.1.StewartWF,etal.AmJGastroenterol.1999;94:3530-3540.2.ParéP,etal.AmJGastroenterol.2023;96:3130-3137.Stewart(EPOC)19991Paré20232n=1476n=1149ConstipationsymptomsreportedmostoftenC第52頁P(yáng)revalenceintheGeneralPopulation1.StewartWF,etal.AmJGastroenterol.1999;94:3530-3540.2.DrossmanDA,etal.DigDisSci.1993;38:1569-1580.3.HarrisInteractiveStudy,Wave2.Dataonfile.

4.ParéP,etal.AmJGastroenterol.2023;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53頁EpidemiologyChronicconstipationiscommonSlightlymorecommoninwomenF/Mratio=range1.3to2.5(China=4:1)AffectsallagegroupsStewartWF,etal.AmJGastroenterol.1999;94:3530-3540.ParéP,etal.AmJGastroenterol.2023;96:3130-3137.SandlerRS,etal.DigDisSci.1987;32:841-845.C第54頁ConstipationAffectsAllAgeGroups53Canadianpopulation.ParéP,etal.AmJGastroenterol.2023;96:3130-3137.N=1149n=378n=367n=217n=187第55頁P(yáng)rofileofaTypicalChronicConstipationPatientinMyPracticeGenerallyfemaleSymptomaticfor>10yrMajorityhavetriedlifestylechanges,fiber,andOTClaxativespriortoseekingcareManagesconditionwithmultipletherapiesMostoftenreferredbyaprimarycarephysicianCopeswithcondition,butisnotcompletelysatisfiedC第56頁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.2023;97:1986-1993.

3.KoloskiNA,etal.AmJGastroenterol.2023;95:67-71.C第57頁ConstipationSignificantlyImpactsHealthcareUtilization5.7millionconstipation-relatedoutpatientvisitsannually1,24.1millionphysicianoffice-basedvisits991,000emergencyroomvisits587,000hospitaloutpatientvisits$2752/patientfortertiarycareevaluation31.NationalAmbulatoryMedicalCareSurvey,2023.2.NationalHospitalAmbulatoryCareSurvey,2023.3.RantisPCJr,etal.DisColonRectum.1997;40:280-286.C第58頁Complicationsrelated

withconstipationColonicandrectalcarcinomaOthercolon-rectal-anusdisordershepaticcomaacutemyocardialinfarctionmammaryglanddisorderspreseniledementia(早老性癡呆）psycho-problemsappearance第59頁Definition:CausesofChronicConstipationSecondaryDruginducedMetabolicfactorsComorbidconditionsPrimaryImpairedcolonictransit/motilityAlteredneuroentericfunctionandreflexesFailureofmuscularapparatusIneffectivedefecation(functionaloutletobstruction)PelvicdyssynergiaandanismusNormaltransitconstipation第60頁P(yáng)resentationObjectivesDefineconstipationThepathophysiologicalmechanismsEtiologiesofconstipationCharacterizemanifestationDiscriminatetheaccompanyingsymptoms.Suggestdiagnosticstrategiesofthesymptoms.C第61頁WhatisConstipation?Passageofhard,dry,lumpystools;Infrequentbowelmovements,usuallyfewerthanthreetimesaweekSymptoms:painfulbowelmovementsstrainingUncomfortable（Sensationofincompleteevacuation）bloatedsluggish第62頁RomeIIDefinesFunctionalConstipationBasedonMultipleSymptomsRomeIIdiagnosticcriteriaforfunctionalconstipationAtleast12wk,whichneednotbeconsecutive,overthepast12monthsof2ormoreofStraining*Lumpyorhardstools*Sensationofincompleteevacuation*Sensationofanorectalobstruction/blockage*Manualmaneuverstofacilitatedefecation*<3defecations/wkLoosestoolsnotpresentInsufficientcriteriaforIBS*>1/4ofdefecations.DrossmanDA,etal.In:RomeII:TheFunctionalGastrointestinalDisorders.2023:382-391.C第63頁NormalmetabolismAsfoodmovesthroughyourintestines,itabsorbswaterwhileformingwasteproductsMusclescontractinthecolon,pushingthestooltowardtherectum第64頁DefecationProcessYieldawarenessofdefecationAnalintra-andextra-sphincterRelaxationAbdominaleffects第65頁Mechanicalstimulation1.Yieldawarenessofdefecation第66頁2.Analintra-andextra-sphincterRelaxationintra-sphincterextra-sphincterLevatoranimuscle第67頁2.Abdominaleffectsgastriccontentsviaanus第68頁WhatCausesConstipation?EatingtoolittlefiberNotdrinkingenoughliquidsLackofexercise/physicalactivity第69頁WhatCausesConstipation?ChangeinroutinetravelOlderageSlowermetabolismFrequentuseoflaxativesCertaindiseasesorconditions第70頁WhatCausesConstipation?CertaindiseasesorconditionsRectalandAnaldisordersColonicdisordersSystemicdiseasesorconditions第71頁WhatCausesConstipation?pain(narcotics麻藥)antacidscontainingaluminumantidepressantsironsupplementsdiuretics(“water”pills)

Medications第72頁ClassificationofetiologiesEatingtoolittlefiberNotdrinkingenoughliquidsLackofexercise/physicalactivityChangeinroutineTravelpsycho-relatedOlderageSlowermetabolismFrequentuseoflaxativestediouslylongColonMedicationsTravelpain(narcotics麻藥)antacidscontainingaluminumantidepressantsironsupplementsdiuretics(“water”pills)Functionaletiologies第73頁psycho-related第74頁TediouslylongColon結(jié)腸冗長第75頁Organicconstipation(certaindiseasesorconditionscauseconstipation)ClassificationofetiologiesRectalandAnaldisordersBenignormalignancytumorTumorormassoutsideSystemicdiseasesorconditions(e.g.disordersmakedysci