1、肠梗阻病例讨论肠梗阻病例讨论 A 60-year-old female is admitted to the emergency room with a 48- hour history of lower abdominal pain, nausea, vomiting and constipation. The patient describes the pain as crampy in early and notes that her abdomen has become distended over the last 12 hours. Her last bowel movement
2、was three days prior to presentation.CASE 1n女性，女性，60岁，岁，“腹痛、呕吐、腹胀腹痛、呕吐、腹胀和肛门停止排便排气和肛门停止排便排气2天天,加重加重12小小时时” 急诊入院急诊入院Question 1.whats wrong with the old woman? 2.what causes it? 3.How can she get well? Operation is need or not? nHer past medical history is remarkable in that she underwent an appendect
3、omy for acute appenditis ten years ago. She is otherwise healthy and takes no medications.nPhysical exam reveals a temperature of 38. Her abdomen is distended.Abdominal painNausea and vomitingObstipationDistention Colicky abdominal painlasting abdominal pain 1).The nature of the vomitus. undigested
4、food particles. becomes bilious. feculent. 2).The onset and character of vomiting. Recurrent vomiting of bile-stained fluid Prolonged nausea precedes vomiting, feculent.nThe onset of obstipation, a late developmentStill pass flatus: the distal, unobstructed intestine empties. partial or incomplete o
5、bstruction Develop later in the course of the obstructionlittle by littleInspectionPalpationPercussionAuscultation right upper quadrantright lower quadrantleft upper quadrantLeft lower quadrant mild tenderness in RLQ but no guarding or rebound Mass 5cmX4cm， No peritonitis nshifting dullness IN RLQnn
6、oisy and is heard as rushes. nDuring attacks of colic ,the sounds become loud ,high-pitched and metallic .nLow rectal carcinoma and intussuscepted segment dont be palpatednrectal exam reveals no stool in the rectum.Knee-elbow PositionnA hemoglobin of 16, hematocrit 48, white blood cell count 12,200
7、with 74 polys.n Serum electrolytes show the level of serum sodium and potassium is 130mol/l and 3.0mol/l. Arterial blood gas analysis reveals that the result of PH is 7.30.nAn abdominal X-RAY reveals multiple dilated loops of small bowel with numerous air-fluid levels. There is no gas or stool visib
8、le in the colonAdmitting laboratory data2008-12-42008-12-5 X-rays UprightSupineX-rays2008-12-52008-12-4CT scanB-UltraSoundn2008-12-4 distended small intestine; no liquid in the abdomenn2008-12-5 dilated loops of small intestine; liquid in RLQ (7CM Deep)Symptoms of the patientsnPainnVomitingnObstipat
9、ionnAbdominal distentionSigns of the patientsnVital Signs: temperature of 38nHis abdomen is distended.nMild tenderness periumbilically but no guarding or rebound. nHigh-pitched bowel sounds nRectal exam reveals no stool in the rectumLaboratory StudynA hemoglobin of 16, hematocrit 48, which shows hem
10、oconcentrationnWhite blood cell count 12,200 , which shows inflammation.n Serum electrolytes are abnormal , which shows body liquid imbalance with hyponatremia and hypokalemia.nArterial blood gas analysis reveals acidosisRadiography examnAn abdominal X-RAY reveals multiple dilated loops of small bow
11、el with numerous air fluid levels. There is no gas or stool visible in the colonnTo confirm the diagnosis :intestinal obstrutionDiagnosismust make clear the following questions:n1.Whether intestinal obstruction exists: Through symptoms and signs, the diagnosis can be made without difficulty. 2.Wheth
12、er the obstruction is mechanical or dynamic:mechanical obstruction: typical symptoms and signs. paralytic obstruction: episodic and cramping abdominal pain is absent;distention is prominent 3.Whether the obstruction is simple or strangulation obstruction: Indications for strangulation:1).Abrupt onse
13、t with continuous acute abdominal pain,2).Shock3).Manifestation of peritonitis: leukocytosis, sepsis,rebound and guarding 4).Asymmetrical distention, local bulge, or mass with tenderness.5).Hematic vomitus, 6).Conservative treatment in vain and no improvement in symptoms and signs.7).Isolated, bulge
14、d, and distended intestinal loop on abdominal plain film.4.Whether the obstruction is high or low: Vomiting in proximal intestinal obstruction. Distention in low obstruction, feculent vomitus 5.Whether the obstruction is complete or incomplete: frequency of vomiting, extent of distention, Contispati
15、on and obstipation6.Which causes leads to obstruction: According to the age, history, symptoms and signs. Postoperative adhesions; postinflammatory HeniasCongenital malformationsIntestinal intussusceptionObstruction of parasite originCarcinomas and dry feces.1. Obstruction arising from extraluminal
16、causes 2. Obstruction intrinsic to the bowel wall 3. Intraluminal obturator obstruction肠壁外因素肠壁外因素肠壁因素肠壁因素肠腔内因素肠腔内因素outsideoninsideOutside: AdhesionsOn :Tumor Intussusception Inside : fecal impaction 1 Mechanical obstruction 机械性肠梗阻机械性肠梗阻2 Paralytic ileus 3 Strangulating obstruction 4 原因不明的假性肠梗阻原因不明的假
17、性肠梗阻 othersothers：根据有无血运障碍：根据有无血运障碍：单纯性单纯性 Simple obstruction, 绞窄性绞窄性 strangulation obstruction 梗阻部位：梗阻部位：高位高位 Proximal intestinal 低位低位 distal intestinal 大肠大肠 large bowel 小肠小肠 small bowel 梗阻程度梗阻程度: : 不完全性不完全性 Incomplete obstruction 完全性完全性 complete obstruction 发展过程发展过程: : 急性急性 Acute obstruction 慢性慢性
18、chronic obstruction1.老年女性，急性病程老年女性，急性病程2.典型临床表现：痛、呕、闭、胀典型临床表现：痛、呕、闭、胀3.腹部体征腹部体征4.X-Rays 和腹部和腹部CT表现表现5.既往腹部手术病史既往腹部手术病史急性粘连性小肠低位完全梗阻急性粘连性小肠低位完全梗阻Mechanical obstructionParalytic ileusStrangulating obstructionThe principle: ncorrection of systemic disturbance nreduction of obstruction. 1).Gastrointesti
19、nal decompression: Nasogastric suction2).Correction of water-electrolytic disturbance, acid-base imbalance3).Prevention and treatment of infection and toxemia: Antibioticsn1)Lysis of adhesion, reduction of intussusception,n 2)Enterectomy and anastomosis.n3)Bypass procedure for nonresectable lesions.
20、n4)Enterostomy and exteriorization of intestine.本病例治疗方案：本病例治疗方案：n病人腹痛逐渐加重，且呕吐频繁，保守无效病人腹痛逐渐加重，且呕吐频繁，保守无效n体温从体温从36.5度升高至度升高至38度度n查体：腹胀加重，右下腹压痛明显，肠鸣音变弱查体：腹胀加重，右下腹压痛明显，肠鸣音变弱n腹穿：有血性液腹穿：有血性液n化验：化验：WBC及中性粒细胞均升高超过正常及中性粒细胞均升高超过正常nX-rays:可见固定肠袢，肠管扩张明显，加重可见固定肠袢，肠管扩张明显，加重laparetomyIn operation postoperationCase
21、 2Marry is an 87-year-old woman with a 3-day history of intermittent abdominal pain, abdominal bloating, nausea and vomiting. Marry moved from Italy to join her grandson and his family only 2 months ago, and she speaks little English. All information was obtained through her grandson. Past medical h
22、istory (PMH) includes colectomy for colon cancer 6 years ago and femoral hernia repair 2 years ago. She has no history of coronary artery disease (CAD), diabetes mellitus (DM), or pulmonary disease. She takes no drugs. Allergies include Penicillin drugs and Dolantin. Marrys tentative diagnosis is sm
23、all bowel obstruction (SBO) secondary to adhesion. Marry is being admitted to your floor for diagnostic work-up. Her vital signs are stable, she has an IV of with 20 mmol KCI at 100 ml/hr, and 3 L oxygen by nasal cannula (O2/NC). 1.Based on the nurses report, what signs of bowel obstruction did Marr
24、y manifest?QUESTIONIntermittent abdominal pain most SBO cause waves of cramping abdominal pain around the periumbilical area. Abdominal bloating - Blockages may cause bloating in the lower abdomen. You may also hear gurgling sounds coming from your belly. With a complete obstruction, your doctor may
25、 hear high-pitched sounds when listening with a stethoscope. The sounds decrease as movement of the bowel slows.Nausea and vomiting - The vomit is usually green if the obstruction is in the upper small intestine and brown if it is in the lower small intestine.2.Are there other signs and symptoms tha
26、t you should observe for while Marryis in your care?Continuous severe pain in one area can mean that the blockage has cut off the bowels blood supply. This is called a bowel strangulation and requires emergency treatment.Constipation (late finding) and inability to pass gas are common signs of a bow
27、el obstruction. However, when the bowel is partially blocked, you may have diarrhea (early finding) and pass some gas. If you have a complete obstruction, you may have a bowel movement if there is stool below the obstruction.Fever and tachycardia late sign; may be related to strangulationPeritoneal
28、signsAbdominal distentionHyperactive bowel sounds occur early as GI contents attempt to overcome the obstruction; hypoactive bowel sounds occur lateGross or occult blood - late strangulation or malignancy Masses - obturator hernia3.Marry and her grandson arrive on your unit. You admit Marry to her r
29、oom and introduce yourself as her nurse. As her grandson interprets for her, she pats your hand. You know that you need to complete a physical examination and take a history. What will you do first?Build up a relationship of trust; attempt to obtain patients cooperation4.The grandson, an attorney, t
30、ells you elderly Italian women are extremely modest and may not answer questions completely. How might you gather info in this case?Explaining to the patient that the info she gives will be treated as confidential, and maintaining this confidentialityGive the patient an understanding of her problemB
31、e non-judgmental5.What key questions must you ask this patient while you have the use of an interpreter? Ask about the location, duration, intensity, and frequency of abdominal pain Onset, frequency, color, odor, and amount of vomitus Bowel and renal functioning Nutritional/dietHealth/medical histor
32、yAny other allergies?Dates and type of immunizations received6.How would the description of pain differ if she has a small versus large bowel obstruction?SBO pain is colicky, cramp-like, and intermittentLBO pain is low-grade, cramping abdominal painSummaryEtiologyManifestationsDiagnosisTreatmentReferencen吴阶平，裘法祖主编吴阶平，裘法祖主编 黄家驷外科学黄家驷外科学（第（第六版）人民卫生出版社六版）人民卫生出版社n黄志强，黎鳌，张肇祥主编黄志强，黎鳌，张肇祥主编 外科手术学外科手术学（第二版）人民卫生出版社（第二版）人民卫生出版社nSabiston Textbook of Surgery, 18th
