醫(yī)學(xué)教程 急性化膿性腹膜炎

急性化膿性腹膜炎(AcuteSuppurativePeritonitis)[??kju:t's?pju?r?tiv

,perit?u'naitis]

重慶醫(yī)科大學(xué)附屬第一醫(yī)院普外科孔令泉

腹膜Peritoneum

[?perit?u'ni?m]

壁腹膜ParietalPeritoneum[p?'raiitl?perit?u'ni?m]

臟腹膜

VisceralPeritoneum['vis?r?l?perit?u'ni?m]

腹腔

PeritonealCavity

[,perit?u'ni:?l'k?viti]大腹腔

PeritonealCavity

小腹腔

LesserPeritonealCavity

神經(jīng)支配（NerveSupply）壁腹膜ParietalPeritoneum

[p?'raiitl?perit?u'ni?m]

軀體神經(jīng)SomaticN[s?u'm?tik

n?:v]

對(duì)刺激敏感，疼痛定位準(zhǔn)確→銳痛sharppain

[?ɑ:p

pein]

※

腹膜炎體征Peritonealsigns

[,perit?u'ni:?l

sainz]

﹡

壓痛Tenderness['tend?nis]

﹡反跳痛ReboundTenderness[ri'baund'tend?nis]

﹡腹肌緊張Involuntarymusclespasm[in?v?l?nt?ri'm?sl'sp?z?m

]

rigidity

[ri'd?id?ti]

臟腹膜VisceralPeritoneum

['vis?r?l?perit?u'ni?m]

自主神經(jīng)AutomaticN

[,?:t?'m?tik

n?:v]

對(duì)牽引、張力、炎癥刺激敏感，定位差（poorlylocalizedpain）→鈍痛Dullpain[d?l

pein]

消化道癥狀：惡心nausea['n?:sj?]

嘔吐Vomiting['v?miti?]

腹膜結(jié)構(gòu)和功能

StructureandFunctionofthePeritoneum）

結(jié)構(gòu)（Structure）一層扁平的間皮細(xì)胞Mesothelium

[,mes(z)?u'θi:lj?m]

面積約1.8m2雙向的半透性膜。

功能（Function）

分泌功能Secretion[si'kri:??n]

吸收功能Absorption

[?b's?:p??n]

防御功能defense[di'fens]

修復(fù)功能Repair[ri'p??]

病因（Etiology）原發(fā)性腹膜炎PrimaryPeritonitis['praim?ri,perit?u'naitis]

(無(wú)原發(fā)病灶)Spontaneous～[sp?n'teinj?s,perit?u'naitis]

1.血行播散Hematogenousinvasion[,he(i:)m?'t?d?in?s

in'vei??n]

溶血性鏈球菌streptococcus

[,strept?u'k?k?s]

肺炎雙球菌

pneumococcus

[,nju:m?'k?k?s]

2.生殖、泌尿系感染擴(kuò)散urogenitalinfection

[,ju?r?u'd?enitl

in'fek??n

]

genitourinaryinfection

[,d?enit?u'ju?rin?ri

in'fek??n]

3.

肝硬化腹水、腎病等，

腸道細(xì)菌易位

BacterialTranslocation

[b?k'ti?ri?l

,tr?nsl?u'kei??n]

Bacteriaenterperitonealcavityvia4portals:

★1)Bloodstream

★2)Ascendinginfection

★3)Transmuralinfection

★4)Directinvasion繼發(fā)性腹膜炎SecondaryPeritonitis['sek?nd?ri,perit?u'naitis]

1、臟器穿孔化學(xué)性腹膜炎（ChemicalPeritonitis）細(xì)菌性腹膜炎（BacterialPeritonitis）2、炎癥擴(kuò)散inflammation

[,infl?'mei??n]

3、損傷Injury4、壞死necrosis

[ne'kr?usis]

5、手術(shù)污染Contamination

[k?n,t?mi'nei??n]

吻合口漏

anastomosis

Leakage

[??n?st?'m?usis'li:kid?

]病理生理

Pathophysiology

[,p?θ?u,fizi'?l?d?i]

[,perit?u'ni:?l

?d'hi:??n]

臨床表現(xiàn)（ClinicalManifestations）

癥狀

Symptoms

腹痛AbdominalPain

惡心Nausea、嘔吐Vomiting

腹脹AbdominalDistension

全身癥狀systemicsymptoms腹部體征（Abdominalsigns）望診（Inspection）腹脹（AbdominalDistention），腹式呼吸減弱或消失觸診（Palpation）

壓痛

Tenderness['tend?nis]

反跳痛

ReboundTenderness[ri'baund'tend?nis]

肌緊張

MuscleSpasm['m?sl'sp?z?m

]

肌衛(wèi)

MuscleGuarding

['m?sl

ga:di?]

※腹膜炎體征（Peritonealsigns)[,perit?u'ni:?l

sainz]叩診

Percussion

[p?:'k???n]

鼓音Tympany

移動(dòng)性濁音ShiftingDullness聽(tīng)診

Auscultation[,?:sk?l'tei??n]

腸鳴音BowelSounds減弱Diminished

消失Disappear直腸、陰道檢查

Rectal&VaginalExaminations

盆腔感染PelvicInfection

盆腔膿腫PelvicAbscess輔助檢查AccessoryExamination

[?k'ses?ri

iɡ,z?mi'nei??n

]

血象Hemogram

['hi:m?gr?m]

WBC↑伴核左移

leukocytosiswithleftshiftofdifferential[,lju:k?sai't?usis

w?eleft?ift

?v,dif?'ren??l]

腹部立位平片AbdominalPlainfilm

膈下游離氣體FreeAirbeneaththeDiaphragm

['dai?fr?m]

腹腔穿刺AbdominalParacentesis

[?b'd?minl,p?r?sen'ti:sis]

B超

CT診斷

Diagnosis

病史History

體格檢查PhysicalExamination

※腹膜炎體征

PeritonealSigns[,perit?u'ni:?l

sainz]

壓痛

Tenderness['tend?nis]

反跳痛

ReboundTenderness[ri'baund'tend?nis]

肌緊張

MuscleSpasm['m?sl'sp?z?m

]

輔助檢查（AccessoryExamination）目的在于鑒別原發(fā)病和腹膜炎的類(lèi)型治療（Treatment）非手術(shù)治療（NonoperativeTreatment）

1、體位Posture['p?st??]

半臥位semisupineposition

[semi-sju:'pain/'sju:pain

p?'zi??n]

2、禁食、胃腸減壓fasting,gastrointestinaldecompression

['fɑ:sti?][?ɡ?str?uin'testinl,di:k?m'pre??n]

3、糾正水電解質(zhì)紊亂FluidandElectrolyteImbalance

['flu(:)id

?nd

i'lektr?ulait

im'b?l?n

]

4、抗生素治療AntibioticTherapy5、營(yíng)養(yǎng)支持NutritionalSupport[nju(:)'tri??nl

s?'p?:t]手術(shù)治療（OperativeTreatment）1.去除病因（Removingthecause）

剖腹探查explorativelaparotomy

[ik'spl?r?tiv

l?p?'r?t?mi]

2.清理腹腔（CleaningtheAbdominalCavity）

(1)清潔腹腔Cleaning(2)腹腔灌洗

lavage[l?'vɑ:d?]

3.充分引流Drainage['dreinid?]

4.術(shù)后處理PostoperativeManagement

半臥位semi-supinepositionPeritonealabscess[,perit?u'ni:?l

'?bsis]

※腹腔膿腫膈下膿腫subphrenic[s?b'frenik'?bsis]

盆腔膿腫

PelvicAbscess

['pelvik'?bsis]腸間膿腫

InterloopAbscess

[int?'lu:p'?bsis]

Fever,pain,ileus&sometimesa

palpablemass

Diarrhea,tenderness&fullnessincaseofpelvicabsess

膈下膿腫

SubphrenicAbscess

[s?b'frenik'?bsis]

臨床表現(xiàn)

ClinicalManifestations

全身癥狀：不明原因持續(xù)發(fā)熱UnexplainedPersistentFever

toxicsymptoms['t?ksik'simpt?m

]

fever&abdominalpainreoccurseveraldays

afterrecoveryof★acuteperitonitis

★infectionofintra-abdominalviscus

★abdominaloperation

局部癥狀：不典型，可有疼痛（腹痛、胸痛、肩痛）呃逆hiccup/hiccough

['h?k?p/'h?k?p]

診斷

Diagnosis

B超引導(dǎo)診斷性穿刺

CT

治療Treatment

1、經(jīng)皮穿刺插管引流術(shù)PercutaneousAbscessDrainage,PAD

[,p?:kju(:)'teinj?s'?bsis

'dreinid?]

2、切開(kāi)引流術(shù)OpenTransabdominal

incisionanddrainage

[,tr?ns?b'd?minl

in'si??n

?nd'dreinid?]

※預(yù)防

preventionrelativelylowspaceinsupineposition

半臥位semi-supineposition盆腔膿腫

PelvicAbscess

['pelvik'?bsis

]

臨床表現(xiàn)（Chinical

Manifestions）

全身癥狀：toxicsymptoms['t?ksik'simpt?m

]

直腸刺激癥狀I(lǐng)rritationoftherectum

[?iri'tei??n

'rekt?m]

里急后重rectal

tenesmus

['rekt?l

ti'nezm?s]

尿路刺激癥狀urinary

irritation

['ju?rin?ri?iri'tei??n

]

診斷Diagnosis

※直腸或陰道檢查Rectal，VaginalExam

tenderness&fullness

B超&

CT治療Treatment

antibiotic,hotsitzbath,warmsalineenema

[w?:m

'seilain

'enim?]

盆腔引流PelvicDrainage['pelvik

'dreinid?

]腸間膿腫

InterloopAbscess

[int?'lu:p'?bsis]

單發(fā)膿腫（SingleAbscess）多發(fā)膿腫（MultipleAbscess）癥狀體征不典型toxicsymptoms['t?ksik'simpt?m

]

Fever,pain,abdominaldistention

ileus

&sometimesapalpablemass粘連性腸梗阻intestinalobstructionduetoadhesions[in'testinl

?b'str?k??n

dju:tu

?d'hi:??n]

診斷Diagnosis

B超&

CT治療：surgicalintervention※預(yù)防

prevention半臥位semi-supinepositionAbstractofaMedicalHistory

Amalepatientof30wasadmitted,complainingofintermittentabdominalpainfor10yearswhichwasmoremarkedinthepast6hours.Tenyearsago,hebegantohaveepisodesofpainovertheepigastriumpersistedfordaysorevenweeksateachtime&oftenassociatedwithdietaryindiscretion.Sometimeshehadnocturnalabdominalpain,severeenoughtowakeuphimfromsleepattimes,butbothfood&alkalinemedicinesmayrelievethepain.Suchepisodesoccurredalmostonceayear.6hoursago,hesuddenlysufferedfromsevereupperabdominalpainwhichspreadtothewholeabdomen,accompaniedwithnausea&vomiting.

P.E:T38.5℃,P105/min,R21/min,BP120/80mmHg

Normallydeveloped&mentallyclearbutacutelyill-looking.Nojaundiceonskinorsclerae.Superficiallymphnodesnotpalpable.Necksoftandsupple.Tracheainmidline.Thyroidnotenlarged.Heart&lungsnotabnormal.Abdomenflat&board-likerigidwithmarkedtenderness&reboundtendernessespeciallyinepigastrium,togetherwithdecreasedliverdullness.Spleennotpalpable.Bowelsoundsdecreased.Nopathologicalreflexesfound.

X-ray&Laboratoryfindingsreveal:

1.X-ray:

freeairunderdiaphragm

2.Bloodpicture:

Hb98g/l,WBC15.6×109/LN0.89,L0.11

Discussthediagnosis,criteria&thrapeuticplan?

AbstractofaMedicalHistory

Amalepatientof30wasadmitted,complainingofintermittentabdominalpainfor10yearswhichwasmoremarkedinthepast6hours.Tenyearsago,hebegantohaveepisodesofpainovertheepigastriumpersistedfordaysorevenweeksateachtime&oftenassociatedwithdietaryindiscretion.Sometimeshehadnocturnalabdominalpain,severeenoughtowakeuphimfromsleepattimes,butbothfood&alkalinemedicinesmayrelievethepain.Suchepisodesoccurredalmostonceayear.6hoursago,hesuddenlysufferedfromsevereupperabdominalpainwhichspreadtothewholeabdomen,accompaniedwithnausea&vomiting.

P.E:T38.5℃,P105/min,R21/min,BP120/80mmHg

Normallydeveloped&mentallyclearbutacutelyill-looking.Nojaundiceonskinorsclerae.Superficiallymphnodesnotpalpable.Necksoftandsupple.Tracheainmidline.Thyroidnotenlarged.Heart&lungsnotabnormal.Abdomenflat&board-likerigidwithmarkedtenderness&reboundtendernessespecial