放射性直肠炎护理与相关护理措施课件.ppt

1、放射性直肠炎放射性直肠炎护理及相关措施护理及相关措施概述v放射性直肠炎放射性直肠炎是妇科恶性肿瘤男性前列腺恶性肿瘤放射治疗的主要并发症。文献报道宫颈癌体外照射结合腔内高剂量率放射治疗时，中、重度放射性直肠炎的发生率约为5.315.6%。放射性直肠炎也是盆腔放射治疗的常见并发症。它是一种自愈性疾病。如治疗和护理及时、得当，可缩短其病程，减轻患者的痛苦和经济负担，提高其生存质量。症状 一般照射总剂量在一般照射总剂量在3000cGy以下者很少发以下者很少发病。腹腔内放疗总量超病。腹腔内放疗总量超过过4000cGy时发生症状，时发生症状，若达若达7000cGy以上则发以上则发病率高达病率高达36%。症

2、状可。症状可出现在治疗早期，疗程出现在治疗早期，疗程结束后不久或治疗后数结束后不久或治疗后数月至数年。月至数年。症状 直肠流血，为鲜红或暗红色，多在排便时流出，一般是少量出血，偶尔大量出血。破溃后有坏死组织脱落排出，有臭味，肛门直肠部酸痛或灼痛，以后因括约肌受刺激而出现里急后重。症状晚期症状早期症状由于神经系统对放射线的反应，早期出现胃肠道的症状。多出现在放疗开始后12周内。恶心、呕吐、腹泻、排出粘液或血样便。累及直肠者伴有里急后重。持久便血可引起缺铁性贫血。便秘少见。偶有低热。腹痛型肠易激综合症则提示小肠受累，乙状结肠镜检查可见粘膜水肿、充血，严重者可有糜烂或溃疡。急性期的症状迁延不愈或直至

3、放疗结束6个月至数年后始有显著症状者，均提示病变延续，终将发展引起纤维化或狭窄。此期内的症状，早的可在放疗后半年，晚的可在10年后甚至30年后才发生，多与肠壁血管炎以及扣续病变有关。症状v（1）结肠、直）结肠、直肠炎肠炎 常出现于照射后618个月。症状有腹泻、便血、黏液便和里急后重、大便变细和进行性便秘或出现腹痛者提示肠道发生狭窄。严重的病损与邻近脏器形成瘘管，如直肠阴道瘘，粪便从阴道排出；直肠小肠瘘可出现食糜混于粪便中排出，也可因肠穿孔引起腹膜炎，腹腔或盆腔脓肿。由于肠道的狭窄和肠袢缠绕可发生肠梗阻。v（2）小）小肠炎肠炎 小肠受到放射线严重损伤时出现剧烈腹痛、恶心呕吐、腹胀、血样腹泻。但晚

4、期表现以消化吸收不良为主，伴有间歇性腹痛、脂肪泻、消瘦、乏力、贫血等。并发症51234诱发结、诱发结、直肠癌等直肠癌等胃肠道溃疡胃肠道溃疡和穿孔和穿孔 肠狭窄和肠梗阻肠狭窄和肠梗阻直肠阴道瘘直肠阴道瘘直肠膀胱瘘或直肠膀胱瘘或回乙结肠瘘回乙结肠瘘病因妇女宫颈癌、外阴与阴道癌及肛管直肠癌常组织也有损害，损害直肠粘膜时，可造成放射性直肠炎放射性放射性直肠炎直肠炎应用放射性镭、钴、铯等进行照射治疗，这些放射性原素诊断大便带脓血、粘液和脱落的坏死组织病理检查可见：细胞急速分裂，纤维组织肥大，血管、淋巴管扩张，管壁变性，应与恶性肿瘤鉴别。有镭照射治疗史直肠镜下可见：肠壁充血、肿胀呈赤褐色，或已浸润、变硬、

5、坏死、溃疡、穿孔，最后形成狭窄。肠粘膜充血、水肿、颗粒样改变和脆性增加肠粘膜充血、水肿、颗粒样改变和脆性增加肠道钡剂检查有助于病损范围与性质的确定肠道钡剂检查有助于病损范围与性质的确定一、直肠指诊二、内窥镜检查三、X线检查检查 包括粪便脂肪测定、维生素包括粪便脂肪测定、维生素B12及及D木糖吸收试验木糖吸收试验 可触及溃疡、狭窄或瘘道，可触及溃疡、狭窄或瘘道，3%严重严重者者直肠阴道瘘直肠阴道瘘小肠吸收功能的测定：治疗原则 1、药物保留灌肠。2、直肠狭窄，甚至梗阻，出血严重以及瘘管形成，均需手术治疗。凡已经确诊为慢性放射性直肠炎的患者，除治疗必需之外，严禁再作直肠镜检查。长期便血，出现贫血现象

6、，根据临床症状，对症处理，抗炎止血，润肠通便等。饮食以富含营养易消化，少纤维素的食物为主。必要时卧床休息减少疲劳。3、全身治疗可参照急性放射性直肠炎的处理。治疗v 1.1.一般治疗一般治疗v 急性期应卧床休息。饮食以无刺激、易消化、营养丰富、多次少餐为原则。限制纤维素摄入。腹泻严重者可采用静脉高营养疗法。v 2.2.手术治疗手术治疗v 肠狭窄、梗阻、瘘道等后期病变多需外科手术治疗。v 3.3.中医治疗中医治疗v 中医学认为，早期的胃肠反应是放射线照射后致津液耗损，胃肠蕴热。症见恶心、呕吐、食纳减少。治宜养阴和胃。药用旋覆花、代赭石降逆止呕；沙参、玉竹、芦根养阴清热；橘皮、竹茹、薏苡仁化痰和胃。

7、另外还可配合针刺内关、足三里等穴位。v 放射性小肠炎的预后较放射性结肠、直肠炎为差。2/3轻症患者可在418个月内好转或痊愈。有人认为广泛的盆腔手术如再放疗则病变组织血供更中不良，其预后常较差。治疗v 4.内科治疗内科治疗v（1）收敛解痉）收敛解痉:可用巅茄合剂、复方樟脑酊、石榴皮煎剂（石榴皮30g加水200300ml煎制50ml，每日1次口服）。阿司匹林可有效地控制放射性肠炎的早期腹泻，可能与抑制前列腺素的合成有关。v（2）局部镇痛剂和粪便软化剂）局部镇痛剂和粪便软化剂:有显著里急后和疼痛者，可用2%苯唑卡因棉籽油保留灌肠。用温石蜡油保留灌肠或温水坐浴。v（3）激素灌肠）激素灌肠:琥珀酰氢化

8、可的松50mg加200ml温盐水保留灌肠，特别是里急后重者有效。v（4）骶前封闭疗法）骶前封闭疗法:0.5%的普鲁卡因40ml、维生素B6100mg、维生素B1200mg、糜蛋白酶25mg、链霉素0.5g，可使疼痛减轻。v（5）止血）止血:低位肠出血可在内镜直视下压迫止血或使用止血剂或出血点做“8”字缝合止血。但不能做烧灼止血。部位较高的出血点可用去甲肾上腺素或新福林稀释于200ml温盐水中保留灌肠，或用凝血酶加入200ml温盐水中保留灌肠，一般在13分钟内即可止血。大量难以控制的高位出血需做外科处理。v（6）抗感染）抗感染:有继发性感染时，需用抗生素。v（7）2巨球蛋白巨球蛋白:国内已试用2

9、巨球蛋白治疗放射性肠炎，效果良好。用药后黏膜出血和疼痛明显好转。溃疡趋向愈合。它是通过制血浆激肽释放酶，使之减少，从而减轻毛细血管渗出和疼痛。饮食指导v 1.高热能、高蛋白质以补偿长期腹泻而导致的营养消耗，可根据病人消化吸收耐受情况循序渐进地提高供给量。一般热能按每日每公斤体重40千卡供给。蛋白质每日每公斤体重1.5克，其中优质蛋白占50%为好。热量的单位：大卡 1大卡=1000卡 v 2.维生素无机盐要充足以补偿腹泻引起的营养丢失。饮食指导3.限制脂肪和膳食纤维：腹泻常伴有脂肪吸收不良，严重者伴有脂肪泻。因此膳食脂肪量要限制，应采用少油的食物和少油的烹调方法。对伴有脂肪泻者，可采用中链脂肪酸

10、油脂。避免食用含刺激性和纤维高的食物，如辛辣食物、白薯、萝卜、芹菜、生蔬菜、水果以及带刺激性的葱、姜、蒜和粗杂粮、干豆类等。4.少食多餐：为减轻肠道负担，以少食多餐方式补充营养摄入量。饮食指导v5.膳食安排:v1）急性发作或手术前后采用流食或少渣半流食，食物内容:米汤、蒸蛋、藉粉、牛奶一般不主张采用。必须禁用蔬菜水果。可将之制成菜水、菜泥、果汁、果泥、果冻等食用。少渣半流可选用含优质蛋白的鱼肉、瘦肉、蛋类制成软而少油的食物，如氽鱼丸、芙蓉粥、鸡丝龙须面及面包类;v2）对病情严重不能口服者可用管饲要素膳或静脉营养支持，待营养状况改善后逐渐增加口服自然食物。相关护理措施v1、避免进食纤维素多或对肠

11、壁有刺激的食物，宜食用少渣、低脂及产气少的食物。如胡萝卜、菠菜等，既润肠又补充维生素。v2、保持肛门及会阴部清洁，穿宽松内裤。症状明显者，可在肛门、会阴部热敷以减轻症状，口服或经肛门应用消炎药物。v3、有出血者可用消炎药。腹泻明显者，可用止泻药。v4、疼痛明显者，可用消炎痛栓。症状严重者，可暂停放疗，并大剂量应用维生素、输液补充各种静脉营养及应用肾上腺皮质激素、抗生素，以减轻局部炎症反应，促进恢复。相关护理措施相关护理措施v（1）病人出现腹痛、腹泻、里急后重等肠道刺激症状，甚至直肠充血、溃疡而导致血便。应配合医生拟定个体放疗计划，通过适当调整，使子宫位置前移。进行腔内治疗时要保持直肠空虚，有利

12、于阴道填塞，减少直肠的辐射受量。v（2）对急性直肠炎应立即停止放疗，用消化道黏膜保护剂：思密达，口服，3次/d，或每晚保留灌肠；腹泻次数多，口服易蒙停，抑制肠蠕动，延长肠内容物的滞留时间。v（3）严密观察大便的性状、腹痛的性质，防止水电解质紊乱；了解贫血程度，贫血严重者应少量多次输血，并加强全身支持治疗。DiagramThemeGallery is a Design Digital Content&Contents mall developed by Guild Design Inc.ThemeGallery is a Design Digital Content&Contents mall

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