小肠疾病分类及应用SmallIntestinalDisease课件.ppt

1、小肠疾病分类和应用SmallIntestinalDisease小肠疾病分类和应用SmallIntestinalDiseaseAnatomy and PhysiologyuThe anatomy of small intestine length:35mportions blood supply：superior mesenteric a nerve：autonomic Sympathetic Parasympathetic duodenum:25cm jejunum:2/5 ileum:3/5小肠疾病分类和应用SmallIntestinalDiseaseFour layers:mucosa s

2、ubmucosa muscularis serosaPeyerpatches小肠疾病分类和应用SmallIntestinalDiseaseVillus mucosa The physiology of small intestine secrete alkaline intestinal juicedigestion and absorption endocrine and immune 小肠疾病分类和应用SmallIntestinalDisease Crohn DiseaseuEtiologyunclearuPathology occur in any segment of the pept

3、ic tractgranulomatous inflammatory lesion，involve full-thickness bowel layer小肠疾病分类和应用SmallIntestinalDiseaseuClinical manifestationoccur in any age 60%cases 50%50%小肠疾病分类和应用SmallIntestinalDiseaseTuberculosis of intestineuetiology and pathology secondary infection position：ileum-cecum ulcerative type a

4、nd proliferative type小肠疾病分类和应用SmallIntestinalDiseaseuclinical findings younglow fever,night sweat，fatigue,weightloss,poor appetitechronic abdominal paindiarrhea and constipationcomplication小肠疾病分类和应用SmallIntestinalDiseaseudiagnosisblood routine,ESR,chest film,barium meal and barium enema,coloscopyhis

5、tory and clinical manifestation小肠疾病分类和应用SmallIntestinalDiseaseutreatmentmedical therapysurgical indication complication such as obstruction、fistula、perforation、bleeding operative ways:resect the partial bowel and anastomosisperforation repairmentBy-pass小肠疾病分类和应用SmallIntestinalDiseaseIntestinal Perfo

6、ration of Typhoid Feveru etiology and pathologyinfection by bacillus typhussite:the last portion of the ileum simple perforation:80-90%小肠疾病分类和应用SmallIntestinalDiseaseclinical findings diffuse peritonitis symptomsacute severe abdominal painmuscle guardness,tenderness and rebound tendernessmajor treat

7、ment repair of the perforation小肠疾病分类和应用SmallIntestinalDiseaseAcute Hemorrhagic Enteritisuetiology:unclearmaybe related to toxin of Welch bacilusupathology the lesion localized in jejunum or ileumlocal congestion,hemorrhage,necrosis and ulceration小肠疾病分类和应用SmallIntestinalDiseaseuClinical findings occu

8、r in children and youngeracute abdominal pain accompanied by nausea,vomiting,diarrhea,hematochezia.distention,tendernesssigns of bowel of strangulationtoxic shock小肠疾病分类和应用SmallIntestinalDiseaseuTreatmentmedical treatment(main method)keep internal environment stablefasting,gastrointestinal decompress

9、ionantibioticnutritional support小肠疾病分类和应用SmallIntestinalDiseasesurgical indication obvious peritonitis bowel bleeding is difficult to controlintestinal obstructionaggravation after medical therapyDiagnosis NOT clear小肠疾病分类和应用SmallIntestinalDiseaseIntestinal Obstruction definition：a partial or complet

10、e blockage of the bowel results in the failure of the intestinal contents to pass through小肠疾病分类和应用SmallIntestinalDiseaseEtiology and Classification（一）（一）According to the obstructive cause1、Mechanical：high incidence intraluminal obstructionExtrinsic bowel tract lesionsIntrinsic bowel wall lesion 小肠疾病

11、分类和应用SmallIntestinalDisease1 1）intraluminal obstruction（1 1）胆结石胆结石（2 2）粪石粪石（3 3）毛发团毛发团（4 4）异物异物（5 5）肠减压管气囊）肠减压管气囊（6 6）寄生虫寄生虫（7 7）腔内憩室腔内憩室小肠疾病分类和应用SmallIntestinalDisease2）lesions extrinsic to the bowel（1 1）粘连：手术后；先天性；炎症后粘连：手术后；先天性；炎症后（2 2）疝：腹壁疝；腹内疝疝：腹壁疝；腹内疝（3 3）先天性：环状胰腺；腹膜包裹先天性：环状胰腺；腹膜包裹（4 4）肿瘤：肠外肿瘤；

12、肿瘤：肠外肿瘤；肠系膜肿瘤肠系膜肿瘤（5 5）炎症：腹腔内脓肿；腹腔异物炎症：腹腔内脓肿；腹腔异物（6 6）其他：肠系膜上动脉综合征；其他：肠系膜上动脉综合征；小肠疾病分类和应用SmallIntestinalDisease3）intrinsic bowel wall lesions（1 1）肠道闭锁）肠道闭锁 （2 2）炎症狭窄，肠套叠，肠扭转）炎症狭窄，肠套叠，肠扭转（3 3）肿瘤等）肿瘤等小肠疾病分类和应用SmallIntestinalDisease2、Dynamic(Paralytic ileus)1 1）麻痹性：（）麻痹性：（1 1）腹腔手术后；）腹腔手术后；（2 2）腹部创伤；）腹部

13、创伤；（3 3）急性弥漫性腹膜炎）急性弥漫性腹膜炎 2 2）痉挛性：（）痉挛性：（1 1）急性肠炎；）急性肠炎；（2 2）肠道功能紊乱；）肠道功能紊乱；（3 3）慢性铅中毒；）慢性铅中毒；小肠疾病分类和应用SmallIntestinalDisease3、Hematogenesis 血血运性肠梗阻运性肠梗阻 肠系膜血管栓塞或血栓形成致使肠管发肠系膜血管栓塞或血栓形成致使肠管发生血运障碍生血运障碍小肠疾病分类和应用SmallIntestinalDiseaseChronic illness,recurrenceHeredityImpaired motor response to bowel dist

14、entionDuodenal,colonic slow waves normalAbsence of radiogaphic findings of mechanical obstructionNon-surgical treatment小肠疾病分类和应用SmallIntestinalDisease（二）（二）According to the blood supply of the bowel wall1 1、simplesimple 只有肠内容物通过受阻，无肠管血只有肠内容物通过受阻，无肠管血 运障碍。运障碍。2 2、strangulationstrangulation 梗阻伴有肠管血运障碍

15、，例如：肠系梗阻伴有肠管血运障碍，例如：肠系膜血管栓塞膜血管栓塞小肠疾病分类和应用SmallIntestinalDisease（三）按梗阻部位（三）按梗阻部位1 1 高位梗阻：空肠及近段回肠高位梗阻：空肠及近段回肠2 2 低位梗阻：结肠及远段回肠低位梗阻：结肠及远段回肠（四）按梗阻程度（四）按梗阻程度1 1 不完全性肠梗阻不完全性肠梗阻2 2 完全性肠梗阻完全性肠梗阻（五）按病程缓急（五）按病程缓急1 1 急性肠梗阻急性肠梗阻2 2 慢性肠梗阻慢性肠梗阻（六）特殊类型：闭袢性肠梗阻（六）特殊类型：闭袢性肠梗阻 小肠疾病分类和应用SmallIntestinalDisease粘连粘连小肠疾病分类和

16、应用SmallIntestinalDisease肠套叠肠套叠小肠疾病分类和应用SmallIntestinalDisease嵌顿嵌顿小肠疾病分类和应用SmallIntestinalDisease小肠疾病分类和应用SmallIntestinalDisease蛔虫性小肠疾病分类和应用SmallIntestinalDiseasePathology and Pathophysiologypathology （acute）proximal bowel distention luminal pressure venous return hindrance congestin,edema,exudation

17、pressure artery return hindrance necrosis and perforation小肠疾病分类和应用SmallIntestinalDiseaseChronic intestinal obstruction incomplete long time bowel wall hypertrophyintestinal pattern and peristaltic waves小肠疾病分类和应用SmallIntestinalDiseasePathophysiology the loss of body fluid：water and electrolyte disord

18、er and metabolic imbalance(The intestinal tract secretes up to 8.0L/d)infection and intoxication ：the damage of intestinal barrier and bacteria translocation,toxin absorption小肠疾病分类和应用SmallIntestinalDiseaseshock：dehydration、blood concentration、hypovolemia、metabolic disorder、bacteria infection and int

19、oxication respiratory and circulation dysfunction：abdominal pressure increasedabdominal compartment hypertension小肠疾病分类和应用SmallIntestinalDisease痛、呕、胀、闭痛、呕、胀、闭小肠疾病分类和应用SmallIntestinalDisease痛痛小肠疾病分类和应用SmallIntestinalDisease呕呕小肠疾病分类和应用SmallIntestinalDisease胀胀小肠疾病分类和应用SmallIntestinalDiseaseuClinical Man

20、ifestation Abdominal pain Vomiting Distention Failure to pass gas and stool小肠疾病分类和应用SmallIntestinalDisease单纯性机械性肠梗阻单纯性机械性肠梗阻 反复发作的、节律性的、阵发性腹部绞痛反复发作的、节律性的、阵发性腹部绞痛绞窄性肠梗阻绞窄性肠梗阻 腹痛间歇不断缩短腹痛间歇不断缩短 持续性腹痛持续性腹痛 疼痛程度不断加重疼痛程度不断加重麻痹性肠梗阻麻痹性肠梗阻 持续性胀痛持续性胀痛小肠疾病分类和应用SmallIntestinalDisease VomitingEarly reflectivityP

21、aralysis overflowHigh position early and frequentlyLow position late and few 小肠疾病分类和应用SmallIntestinalDiseaseDistention 高位高位-不明显不明显 低位低位-显著，遍及全腹显著，遍及全腹 闭袢性闭袢性(closed loop)(closed loop)小肠疾病分类和应用SmallIntestinalDisease小肠疾病分类和应用SmallIntestinalDiseaseuExaminationAbdominal signs：Abdominal bulge,gastrointes

22、tinal patterns and peristaltic waves,tenderness and rebound tenderness,positive shift dullness,high pitched bowel sound or bowel silence in late stage and bowel paralysis Digital rectal examination小肠疾病分类和应用SmallIntestinalDisease Lab test：the results with the change of the primary disease itself Earl

23、y stage:normal or slight abnormal Late stage:disorder of many serum markers小肠疾病分类和应用SmallIntestinalDiseaseX-ray：Supine and upright abdominal radiographs with stepladder pattern of air-fluid levels and no colonic gas note:The barium enema is need if the intussusceptions,sigmoid rotation or colon tumo

24、r are suspicious.小肠疾病分类和应用SmallIntestinalDisease In small-bowel obstruction,radiologic evaluation has several goals.It is carried out to confirm the diagnosis,distinguish between simple and strangulating obstruction,differentiate the various causes of obstruction,estimate the degree of obstruction,a

25、nd exclude the possibility of colonic obstruction or paralytic ileus 小肠疾病分类和应用SmallIntestinalDisease小肠疾病分类和应用SmallIntestinalDisease小肠疾病分类和应用SmallIntestinalDisease小肠疾病分类和应用SmallIntestinalDisease小肠疾病分类和应用SmallIntestinalDiseaseuDiagnosis is it intestinal obstruction?history clinical findings X-ray exam

26、ination is it mechanical or dynamic？history X-ray findings小肠疾病分类和应用SmallIntestinalDiseaseSimple or Strangulation（Very Important）Acute and persistent severe abdominal painEmergently and early shock Severe peritoneal irritation signAsymmetric distention，palpable massBleeding content of vomitus,dischar

27、ge and abdominal paracentesisX-ray shows isolated ansa interstinalis Medical treatment failure小肠疾病分类和应用SmallIntestinalDisease小肠疾病分类和应用SmallIntestinalDisease小肠疾病分类和应用SmallIntestinalDiseaseThe Obstructive Site:Low or HighHigh:vomitting occur in early stage and show slight abdominal distentionLow:sever

28、e abdominal distentionX-ray findings小肠疾病分类和应用SmallIntestinalDiseaseComplete or Incompletecomplete:severe and acuteincomplete:chronic and slightThe Cause of ObstructionAlways very difficult to identificateHistory is very important小肠疾病分类和应用SmallIntestinalDiseaseTreatmentPrinciples：Correct the systemic

29、 pathophysiologic disorder Relieve obstruction。小肠疾病分类和应用SmallIntestinalDiseaseBasic TreatmentNaso-gastric suctionCorrect body fluid disorderPrevent infection and intoxicationGeneral treatment:sedation,spasmolysis小肠疾病分类和应用SmallIntestinalDiseaseRemove the ObstructionSurgeryIndications：strangulation、ca

30、used by tumor and congenital bowel malformation,can not relieved by medical therapyAims：utility the simplest methods to remove the obstruction and recover the continuity of the bowel in the shortest time小肠疾病分类和应用SmallIntestinalDiseaseMethodsRemove the cause：Such as adhesion remove,foreign body taken

31、 out、replacement of intussusception and volvulusIntestinal resection and anastomosis:tumor,stenosis,necrosis 小肠疾病分类和应用SmallIntestinalDiseaseHow to judge the intestinal necrosis in the operation?$The bowel wall is black$No peristaltic capability and tension$No pulsation of mesenteric terminal arterio

32、le小肠疾病分类和应用SmallIntestinalDisease Bypass operation:The lesion is difficult to remove Enterostomy or Intestinal exteriorization The patients condition cannot tolerance the complicated operation or the obstructive lesion is difficult to treat 小肠疾病分类和应用SmallIntestinalDisease手术方式 A.解除梗阻原因的术式 如粘连松解术小肠疾病分

33、类和应用SmallIntestinalDisease如肠切开取异物，肠扭转复位术。小肠疾病分类和应用SmallIntestinalDiseaseB.B.肠切除肠吻合术肠切除肠吻合术 C.C.短路手术短路手术小肠疾病分类和应用SmallIntestinalDiseaseD.D.肠造口和肠外置术肠造口和肠外置术小肠疾病分类和应用SmallIntestinalDiseaseMedical treatment Indications：simple adhesive obstruction,paralysis or dynamic ileus、obstruction because of ascarid

34、 or stoolmass,inflammatory obstruction and early stage of intussusceptionNotes：The state of illness should be monitor closedly during medical treatment小肠疾病分类和应用SmallIntestinalDiseaseCommon typesAdhesive Obstruction（40%60%）Obstruction due to adhesions小肠疾病分类和应用SmallIntestinalDiseaseuEtiology and patho

35、logyCongenital Secondary uDiagnosisMechanical obstruction+history of abdominal operation,infection or trauma*如何区分广泛粘连梗阻与局部束带梗如何区分广泛粘连梗阻与局部束带梗 阻？阻？小肠疾病分类和应用SmallIntestinalDiseaseuProphylaxis:more significance减少组织损伤，减轻组织炎症反应减少组织损伤，减轻组织炎症反应 uTreatment:usimple,incomplete medical therapyustrangulation su

36、rgical therapy 小肠疾病分类和应用SmallIntestinalDisease小肠疾病分类和应用SmallIntestinalDisease小肠疾病分类和应用SmallIntestinalDisease小肠疾病分类和应用SmallIntestinalDisease小肠疾病分类和应用SmallIntestinalDiseaseIntestinal Volvulus(3600)Obstruction due to volvulus小肠疾病分类和应用SmallIntestinalDiseaseuEtiologyAnatomic factors:Excessive long mesent

37、erium AdhesionPhysical factors:Enteric bodyDynamic factors:Abnormal bowel motivation Alter the body position suddentlySlight4800小肠疾病分类和应用SmallIntestinalDiseaseuClinical findingsclosed loop：acute /severeSmall bowel:younger,motion after meal pain in the periumbilicus Sigmoid:aged,constipation habitsuT

38、reatment:It is a severe mechanical obstruction emergent operation 小肠疾病分类和应用SmallIntestinalDiseaseuObstruction by foreign body（肠蛔虫、粪（肠蛔虫、粪块等）块等）A simple mechanical bowel obstruction 蛔虫成团蛔虫成团+肠管痉挛肠管痉挛Treatment:medical therapy and necessary surgery 小肠疾病分类和应用SmallIntestinalDiseaseChildren,countrysideMed

39、ical therapy小肠疾病分类和应用SmallIntestinalDiseaseObstruction due to intussusception小肠疾病分类和应用SmallIntestinalDiseaseuEtiology anatomy:cecum too free pathological factors:polyp,tumor abnormality of intestineuTypes intestine-intestine intestine-colon colon-colon小肠疾病分类和应用SmallIntestinalDiseaseuClinical finding

40、s80%,2y childrenAbdominal pain,currant-jelly stool,sausage-shaped massCoil-spring signAir or Barium enema Reduction小肠疾病分类和应用SmallIntestinalDiseaseuTreatment:Gas or barium enema(youngers).Operation:manual reduction bowel resection小肠疾病分类和应用SmallIntestinalDisease肠系膜血管缺血性疾病肠系膜血管缺血性疾病uetiology and pathol

41、ogy1.superior mesenteric artery embolus2.superior mesenteric arterial thrombosis3.superior mesenteric venous thrombosis4.others:non-mesenteric vascular ischemiaischemia necrosis小肠疾病分类和应用SmallIntestinalDiseaseuClinical manifestationhistory of coronary heart disease or atrial fibrillationacute abdomin

42、al crampsevere symptom and slight abdominal sign in the early stageuDiagnosisabdominal film,angiography(DSA)小肠疾病分类和应用SmallIntestinalDiseaseuTreatment:Key point:Early diagnosis and reasonable therapyVasodilating agentSurgical therapy Embolectomy Vascular bypass Intestinal resection and anastomosis小肠疾

43、病分类和应用SmallIntestinalDiseaseCase1:Male,25 years old,complains of abdominal pain and distention for 2 days.PE:P 80,abdominal bulge,intestinal patterns and peristaltic waves,high-pitched bowel sound.Past history:He underwent appendectomy 3 month ago.Diagnosis and treatment?小肠疾病分类和应用SmallIntestinalDise

44、aseCase2:male,68 years old,complains of abdominal bowel motion for 3month,abdominal distention and stop pass gas and feces for 2 days.PE:P 90,Bp 130/70mmHg,abdominal bulge,intestinal patterns and peristaltic waves,high-pitched bowel sound.Diagnosis and treatment?Which examintation should be undergon

45、e for diagnosis?小肠疾病分类和应用SmallIntestinalDiseaseShort Bowel SyndromeDefinition:Short Bowel Syndrome(SBS)is defined as malabsorption resulting from anatomical or functional loss of a significant length of the small intestine.小肠疾病分类和应用SmallIntestinalDiseaseuPathophysiologyThe majority of carbohydrate,p

46、rotein,fats,vitamins,bile salts absorption takes place in the small bowel.100cm severe influencebody fluid disorder and malnutrition 小肠疾病分类和应用SmallIntestinalDiseaseuClinical findings First symptom:diarrhea,the severity relates to the length of residual bowel Weight loss,fatigue,malnutrition,body flu

47、id disorder小肠疾病分类和应用SmallIntestinalDiseaseuTreatmentCorrect imbalance of metabolism and electrolyte Nutritional support total parenteral nutrition partial parenteral nutrition enteral nutrtion小肠疾病分类和应用SmallIntestinalDiseaseThe first stage(2month)TPN and correct the fluid disorderThe second stage(12y

48、)PPN+ENThe third stage EN or PPN+EN May be sustain one life小肠疾病分类和应用SmallIntestinalDisease It need long-term regular nutrition monitoring to prevent problems associated with fluid,macro-and micro-nutrient malabsorption.Since they are at high risk for dehydration and bacterial overgrowth,they need pr

49、ompt medical attention any time they have symptoms of gastroenteritis.小肠疾病分类和应用SmallIntestinalDiseaseIntestinal Tumoru小肠肿瘤小肠肿瘤Lower incidence（5%in the gastrointestinal tumor）But malignancy 3/4小肠疾病分类和应用SmallIntestinalDiseaseuClinical Findings:Abdominal pain Intestinal bleeding Intestinal obstructionI

50、ntraabdominal massIntestinal perforationCarcinoid syndrome小肠疾病分类和应用SmallIntestinalDiseaseuDiagnosis Clinical findings+X-ray Barium meal Gastroscopyintestinal endoscopy Laparoscopy uTreatment Surgical operation小肠疾病分类和应用SmallIntestinalDisease definition:there is abnormal tract between bowel and other