《腸梗阻病例討論》

Departmentofgeneralsurgery

BiJing-Taofrankbjt@126.com

ClinicalCase

Discussion精選ppt

A

60-year-oldfemaleisadmittedtotheemergencyroomwith

a48-hourhistoryoflowerabdominalpain,nausea,vomitingandconstipation.Thepatientdescribesthepainascrampyinearlyandnotesthatherabdomenhasbecomedistendedoverthelast12hours.Herlastbowelmovementwasthreedayspriortopresentation.CASE1精選ppt女性，60歲，“腹痛、嘔吐、腹脹和肛門停止排便排氣2天,加重12小時(shí)”急診入院精選pptQuestion

1.what’swrongwiththeoldwoman?

2.whatcausesit?

3.Howcanshegetwell?Operationisneedornot?精選pptDoctorneedtoanswer:DiagnosisEtiologyTreatment精選pptWhat

shouldbedonenext?精選pptHerpastmedicalhistoryisremarkableinthatsheunderwentanappendectomyforacuteappenditistenyearsago.Sheisotherwisehealthyandtakesnomedications.Physicalexamrevealsatemperatureof38℃.Herabdomenisdistended.精選ppt

ClinicalManifestationsAbdominalpainNauseaandvomitingObstipationDistention精選pptAbdominalpain

Colickyabdominalpain

inearlyperiod

lasting

abdominalpain

later

精選pptNauseaandvomiting

1).Thenatureofthevomitus.

undigestedfoodparticles.

becomesbilious.

feculent.

2).Theonsetandcharacterofvomiting.

Recurrentvomitingofbile-stainedfluid

Prolongednauseaprecedesvomiting,feculent.

精選ppt

Contispationandobstipation

Theonsetofobstipation,alatedevelopmentStillpassflatus:

thedistal,unobstructedintestineempties.

partialorincompleteobstruction精選pptDistention

Developlaterinthecourseoftheobstruction

littlebylittle精選pptPhysicalExaminationInspectionPalpationPercussionAuscultation精選pptInspection

rightupperquadrantrightlowerquadrantleftupperquadrantLeftlowerquadrant精選pptPalpation

mildtendernessinRLQbutnoguardingorrebound

Mass5cmX4cm，

Noperitonitis精選pptPercussion

shiftingdullnessINRLQ精選pptAuscultationnoisyandisheardasrushes.Duringattacksofcolic,thesoundsbecomeloud,high-pitchedandmetallic.精選pptRectalexamination:Lowrectalcarcinomaandintussusceptedsegmentdon’tbepalpatedrectalexamrevealsnostoolintherectum.Knee-elbowPosition精選pptAhemoglobinof16,hematocrit48,whitebloodcellcount12,200with74polys.Serumelectrolytesshowthelevelofserumsodiumandpotassiumis130mol/land3.0mol/l.ArterialbloodgasanalysisrevealsthattheresultofPHis7.30.AnabdominalX-RAYrevealsmultipledilatedloopsofsmallbowelwithnumerousair-fluidlevels.ThereisnogasorstoolvisibleinthecolonAdmittinglaboratorydata精選pptRadiologicalExaminations

2008-12-42008-12-5X-rays

Upright精選pptSupineX-rays2008-12-52008-12-4精選ppt精選pptCTscan精選pptB-UltraSound2008-12-4

distendedsmallintestine;

noliquidintheabdomen2008-12-5

dilatedloopsofsmallintestine;liquidinRLQ(7CMDeep)精選pptSummury

精選pptSymptomsofthepatientsPainVomitingObstipationAbdominaldistention精選pptSignsofthepatientsVitalSigns:temperatureof38℃Hisabdomenisdistended.Mildtendernessperiumbilicallybutnoguardingorrebound.High-pitchedbowelsoundsRectalexamrevealsnostoolintherectum精選pptLaboratoryStudyAhemoglobinof16,hematocrit48,whichshowshemoconcentrationWhitebloodcellcount12,200,whichshowsinflammation.Serumelectrolytesareabnormal,whichshowsbodyliquidimbalancewithhyponatremiaandhypokalemia.Arterialbloodgasanalysisrevealsacidosis精選pptRadiographyexamAnabdominalX-RAYrevealsmultipledilatedloopsofsmallbowelwithnumerousairfluidlevels.ThereisnogasorstoolvisibleinthecolonToconfirmthediagnosis:intestinalobstrution精選pptDiagnosis

mustmakeclearthefollowingquestions:

精選ppt1.Whetherintestinalobstructionexists:

Throughsymptomsandsigns,thediagnosiscanbemadewithoutdifficulty.精選ppt2.Whethertheobstructionismechanicalordynamic:

mechanicalobstruction:typicalsymptomsandsigns.

paralyticobstruction:episodicandcrampingabdominalpainisabsent;

distentionisprominent

精選ppt3.Whethertheobstructionissimpleorstrangulationobstruction:

Indicationsforstrangulation:

1).Abruptonsetwithcontinuousacuteabdominalpain,

2).Shock

3).Manifestationofperitonitis:leukocytosis,sepsis,reboundandguarding

精選ppt

4).Asymmetricaldistention,localbulge,ormasswithtenderness.

5).Hematicvomitus,

6).Conservativetreatmentinvainandnoimprovementinsymptomsandsigns.

7).Isolated,bulged,anddistendedintestinallooponabdominalplainfilm.精選ppt4.Whethertheobstructionishighorlow:

Vomitinginproximalintestinalobstruction.

Distentioninlowobstruction,feculentvomitus

精選ppt5.Whethertheobstructioniscompleteorincomplete:

frequencyofvomiting,extentofdistention,

Contispationandobstipation精選ppt6.Whichcausesleadstoobstruction:

Accordingtotheage,history,symptomsandsigns.

Postoperativeadhesions;postinflammatory

Henias

Congenitalmalformations

Intestinalintussusception

Obstructionofparasiteorigin

Carcinomasanddryfeces.精選pptEtiology精選pptEtiologyfor

mechanicalIntestinal

obstruction1.

Obstructionarisingfromextraluminalcauses2.

Obstructionintrinsictothebowelwall3.

Intraluminalobturatorobstruction腸壁外因素腸壁因素腸腔內(nèi)因素outsideoninside精選pptOutside:Adhesions

Volvulus

Hernias

Tumor

精選pptOn:Tumor

Intussusception

精選pptInside:

fecalimpaction

精選pptIntestinalobstruction

精選ppt

Classification

1

Mechanicalobstruction機(jī)械性腸梗阻

2

Paralyticileus動(dòng)力性腸梗阻

3Strangulating

obstruction血運(yùn)性腸梗阻

4原因不明的假性腸梗阻

精選pptothers：根據(jù)有無(wú)血運(yùn)障礙：?jiǎn)渭冃許impleobstruction,

絞窄性strangulationobstruction

梗阻部位：高位Proximalintestinal

低位distalintestinal

大腸largebowel

小腸

smallbowel

梗阻程度:

不完全性Incompleteobstruction

完全性

completeobstruction

發(fā)展過程:

急性Acuteobstruction

慢性chronicobstruction精選pptDiagnosis

1.老年女性，急性病程2.典型臨床表現(xiàn)：痛、嘔、閉、脹3.腹部體征4.X-Rays和腹部CT表現(xiàn)5.既往腹部手術(shù)病史急性粘連性小腸低位完全梗阻精選pptDoesStrangulatingobstructionexist？MechanicalobstructionParalyticileusStrangulatingobstruction精選pptDifferentialDiagnosisuppergastrointestinalperforationacutepancreatitisacutecholecystisisacutecholangitis精選pptTreatmentTheprinciple:

correctionofsystemicdisturbance

reductionofobstruction.精選pptConservativetreatment

1).Gastrointestinaldecompression:

Nasogastricsuction

2).Correctionofwater-electrolytic

disturbance,acid-baseimbalance

3).Preventionandtreatmentofinfectionandtoxemia:Antibiotics精選pptSurgical

intervention1)Lysisofadhesion,reductionofintussusception,

2)Enterectomyandanastomosis.3)Bypassprocedurefornonresectablelesions.4)Enterostomyandexteriorizationofintestine.精選ppt本病例治療方案：病人腹痛逐漸加重，且嘔吐頻繁，保守?zé)o效體溫從36.5度升高至38度查體：腹脹加重，右下腹壓痛明顯，腸鳴音變?nèi)醺勾河醒砸夯?yàn)：WBC及中性粒細(xì)胞均升高超過正常X-rays:可見固定腸袢，腸管擴(kuò)張明顯，加重laparetomy精選pptInoperationpostoperation精選pptCase2Marryisan87-year-oldwomanwitha3-dayhistoryofintermittentabdominalpain,abdominalbloating,nauseaandvomiting.MarrymovedfromItalytojoinhergrandsonandhisfamilyonly2monthsago,andshespeakslittleEnglish.Allinformationwasobtainedthroughhergrandson.

精選pptPastmedicalhistory(PMH)includescolectomyforcoloncancer6yearsagoandfemoralherniarepair2yearsago.Shehasnohistoryofcoronaryarterydisease(CAD),diabetesmellitus(DM),orpulmonarydisease.Shetakesnodrugs.AllergiesincludePenicillindrugsandDolantin.精選pptMarry’stentativediagnosisissmallbowelobstruction(SBO)secondarytoadhesion.Marryisbeingadmittedtoyourfloorfordiagnosticwork-up.Hervitalsignsarestable,shehasanIVofwith20mmolKCIat100ml/hr,and3Loxygenbynasalcannula(O2/NC).精選ppt1.Basedonthenurse’sreport,whatsignsofbowelobstructiondidMarrymanifest?

QUESTION精選ppt·Intermittentabdominalpain–mostSBOcausewavesofcrampingabdominalpainaroundtheperiumbilicalarea.

·Abdominalbloating-Blockagesmaycausebloatinginthelowerabdomen.Youmayalsoheargurglingsoundscomingfromyourbelly.Withacompleteobstruction,yourdoctormayhearhigh-pitchedsoundswhenlisteningwithastethoscope.Thesoundsdecreaseasmovementofthebowelslows.

精選ppt·Nauseaandvomiting-Thevomitisusuallygreeniftheobstructionisintheuppersmallintestineandbrownifitisinthelowersmallintestine.精選ppt2.ArethereothersignsandsymptomsthatyoushouldobserveforwhileMarryisinyourcare?

精選ppt·Continuousseverepaininoneareacanmeanthattheblockagehascutoffthebowel'sbloodsupply.Thisiscalledabowelstrangulationandrequiresemergencytreatment.

精選ppt·Constipation(latefinding)andinabilitytopassgasarecommonsignsofabowelobstruction.However,whenthebowelispartiallyblocked,youmayhavediarrhea(earlyfinding)andpasssomegas.Ifyouhaveacompleteobstruction,youmayhaveabowelmovementifthereisstoolbelowtheobstruction.

·Feverandtachycardia–latesign;mayberelatedtostrangulation

精選ppt·Peritonealsigns

·Abdominaldistention

·HyperactivebowelsoundsoccurearlyasGIcontentsattempttoovercometheobstruction;hypoactivebowelsoundsoccurlate

·Grossoroccultblood-latestrangulationormalignancy

·Masses-obturatorhernia精選ppt3.Marryandhergrandsonarriveonyourunit.YouadmitMarrytoherroomandintroduceyourselfashernurse.Ashergrandsoninterpretsforher,shepatsyourhand.Youknowthatyouneedtocompleteaphysicalexaminationandtakeahistory.Whatwillyoudofirst?

精選ppt·Builduparelationshipoftrust;attempttoobtainpatient’scooperation

精選