1、恶心呕吐宣讲恶心呕吐宣讲临床诊断学临床诊断学n上海第二医科大学仁济临床医学院上海第二医科大学仁济临床医学院 2Nausea and VomitingAs the symptoms症状学：恶心与呕吐症状学：恶心与呕吐3GoalsBriefly defineOutline the prominent disease states associated with nausea and vomiting.Characterize Nausea and Vomiting caused by the prominent disorders Discriminate the accompanying sym
2、ptoms.Suggest diagnostic strategies of the symptoms.恶心呕吐宣讲4Definition of Nausea and VomitingnNausea：the inclination or feeling of imminent desire to vomit,usually felt in the throat or epi-gastrum.Associated with decreased activity of the stomach.nVomiting：the forceful oral expulsion of gastric cont
3、ents via retro-peristalsis.nNausea-Vomiting:simultaneity or separateness恶心：紧迫欲吐，通常伴有上腹不适和迷走兴奋的临床征候群。呕吐：胃和/或小肠内容物经食管和口腔排除体外恶心和呕吐常伴随存在，也可单独出现！恶心呕吐宣讲5Nausea and Vomiting恶心呕吐宣讲61、恶心：咽部及上腹部不适，胃张力和蠕动减弱，幽门和贲门开放。2、干呕：胃窦部和腹壁肌肉收缩，腹压增加，食管及咽部开放。3、呕吐：胃和/或小肠内容物经食管和口腔排除体外。Definition of emesis.(Three phases)呕吐反射过程（
4、三个阶段）1.Nausea-the inclination or feeling of imminent desire to vomit,usually felt in the throat or epigastrum.Associated with decreased activity of the stomach.2.Retching-the labored rhythmic contraction of respiratory and abdominal musculature that frequently precedes or accompanies vomiting.3.Vomi
5、ting-the forceful oral expulsion of gastric contents via retroperistalsis.(Abdominal effects).7迷走兴奋表现迷走兴奋表现恶心恶心干呕干呕呕吐呕吐发生机制发生机制恶心呕吐宣讲8呕吐区别于反食呕吐区别于反食呕吐：多数情呕吐：多数情况有恶心的感况有恶心的感觉和呕吐反射觉和呕吐反射的协调动作。的协调动作。反食：无恶心反食：无恶心的感觉和呕吐的感觉和呕吐反射的协调动反射的协调动作。（儿童、作。（儿童、饱餐）饱餐）恶心呕吐宣讲9Mechanisms of emesis恶心呕吐宣讲10CTZ&Emetic Cent
6、er(Vomiting center)CTZ化学感受器触发带（第四脑室底面）：外源性或内源性化学物质（阿片吗啡、洋地黄、代谢产物）Emetic Center（延髓外侧网状结构背测）接受大脑皮质、消化器官、心血管以及化学感受器触发带（CTZ）的冲动恶心呕吐宣讲11CTZ&Emetic Center(Vomiting center)孤束核恶心呕吐宣讲12Emetic Center Midbrain Chemoreceptor Limbic Vestibular ICP Receptor Trigger Zone System system Visceral afferents Emetic Cen
7、ter 内脏传入 中脑ICP受体化学感受器触发带边缘系统前庭系统呕吐中枢（Vomiting center)ICP=Inductively Coupled Plasma 感应耦合等离子体恶心呕吐宣讲13Neurotransmitters in CTZ&Emetic CenterNeurotransmitters involved in stimulating the emetic center,chemo-receptor trigger zone and GI tract include;5-HT,acetylcholine,histamine,dopamine(opiates and rec
8、eptors for benzodiazepines are also found here)恶心呕吐宣讲14恶心呕吐宣讲15恶心呕吐宣讲16Emetic Center Emetic Center 1.Salivary center 2.Vasomotor center 3.Respiratory center 4.Cranial nerves Spinal nerve phrenic nerve vagus nerve Abdominal DiaphragmStomach Esophagus muscles 1、分泌唾液中枢2、血管收缩中枢3、呼吸中枢4、中枢神经脊神经膈神经迷走神经恶心呕吐
9、宣讲17恶心呕吐宣讲18nausea and vomiting1.Reflective vomiting 反射性呕吐反射性呕吐2.Central vomiting 中枢性呕吐中枢性呕吐3.Neurological vomiting 神经性呕吐神经性呕吐恶心呕吐宣讲19Reflective vomiting（反射性呕吐）反射性呕吐）咽部刺激胃十二指肠疾病胆道疾病肠道疾病肝胆疾病腹膜肠系膜全身性疾病（五官、心血管、泌尿、盆腔）Pharyngeal MechanismsGastrointestinal MechanismsDisease of biliary tractPeritoneal and
10、mesenterythe five sense organsCardiovascular diseases kidneyPelvic恶心呕吐宣讲20咽部刺激Pharyngal Mechanisms恶心呕吐宣讲21Gastrointestinal Mechanisms恶心呕吐宣讲22肝、胆、胰腺恶心呕吐宣讲23其他恶心呕吐宣讲24Intra-cranial infectionCerebrovascular disordersCraniocerebral injuryEpilepsyMetabolic disorders DrugsCentral vomiting（中枢性呕吐）中枢性呕吐）颅内感染
11、脑血管疾病颅脑损伤癫痫全身疾病（尿毒症、肝昏迷、糖尿病代谢紊乱）恶心呕吐宣讲25颅内感染（脑炎、脑膜炎）恶心呕吐宣讲26脑血管疾病、颅脑损伤恶心呕吐宣讲27癫痫恶心呕吐宣讲28全身疾病尿毒症肝昏迷酮症酸中毒各种原因引起的脑水肿和颅内压升高代谢紊乱早孕恶心呕吐宣讲29Drug抗生素抗癌药洋地黄吗啡兴奋呕吐中枢或影响胃肠平滑肌运动AntibioticsAnti-carcinomaDigitalismorphia恶心呕吐宣讲30Neurologic&Psychogenic causesNeurologic and Psychogenic causes胃肠道神经官能症（Gastrointestinal
12、 tract neurosis）神经厌食症（apositia）恶心呕吐宣讲31Characteristics of Nausea and Vomiting1.Time2.Taking food3.Characteristics4.Characters of contents恶心呕吐宣讲32晨起呕吐早孕反应功能性消化不良酒精中毒胃食管反流病鼻咽部疾患夜间或隔夜呕吐幽门梗阻贲门失弛缓症恶心呕吐宣讲33呕吐与进食的关系（Timing with meals）餐后即刻：神经精神性；集体发病系食物中毒餐后1小时以上：为延迟性呕吐：可考虑为胃张力低下排空障碍餐后较久、多餐后或隔夜：提示幽门梗阻恶心呕吐宣讲3
13、4呕吐特点呕吐特点神经性或颅内高压：恶心轻、呕吐频；“喷射性呕吐”呕吐物性质呕吐物性质发酵、腐臭味：提示胃潴留粪臭味：提示较低位置的肠梗阻无酸腐味：贲门失迟缓症或胃酸缺乏不含胆汁：幽门梗阻病史较长或量多：提示体液和电解质丢失恶心呕吐宣讲35The accompanying symptoms腹痛、腹泻：食物中毒、肠道传染病、胃肠炎；节律性腹痛：消化性溃疡右上腹痛，伴发热、黄疸：胆囊炎、胆道结石、感染。头痛、头晕、视力异常、喷射性呕吐：颅内高压性疾病、屈光不正、青光眼。伴眩晕、眼球震颤：前庭障碍育龄妇女（停经）：应排除妊娠与服药有时间关联：应想到药物反应恶心呕吐宣讲36问诊要点n起病情况：诱因、急
14、缓、与进食关系、腹部手术史、育龄妇女月经史n发作时间：晨、夜、与进食、活动、体位的关系n呕吐物性状、味道n伴随症状n诊疗和症状演变情况恶心呕吐宣讲37History/Backgrounda)Ageb)GI history requiredc)Food intoleranced)Timing with mealse)Consistencyf)Contentg)Odorh)Frequencyi)Feverj)Weight lossk)Precipitating factorsl)Myalgias（肌痛）,visual disturbances,headache,pain outside abdom
15、en恶心呕吐宣讲38CAUSES OF NAUSEA/VOMITINGnEarly pregnancynPsychogenesis vomitingnBulimia(易饿病易饿病)nPyloric channel ulcernAcute gastritisnGastric retention(潴潴留）留）nViral gastroenteritis（中毒性胃肠炎）中毒性胃肠炎）nAcute gastroenteritisnMyocardial infarctionnPeritonitis（腹膜炎）nAcute obstructionnNeurological emergencynDrug to
16、xicitynCancer therapynDrug withdrawal恶心呕吐宣讲39PHYSICAL EXAMnVital signsnSkinnHEENT（head,eyes,ear,nose,throat)nAbdomennNeurological恶心呕吐宣讲40LABORATORYnRule out obstruction and peritonitisnHCGnUrinalysisnElectrolytes,BUN,creatinine,glucosenTransaminases,amylasenEKG,head CT,upper GI&/or endoscopies恶心呕吐宣讲
17、41恶心呕吐宣讲42泸沽湖黄昏泸沽湖黄昏恶心呕吐宣讲43泸沽湖黄昏泸沽湖黄昏恶心呕吐宣讲44泸沽湖泸沽湖摩梭摩梭女女恶心呕吐宣讲45玉龙雪山玉龙雪山雪雪月月恶心呕吐宣讲4647ConstipationnShanghai Second Medical universitynRenji clinical medical college48Background49Constipation Is a Constellation of SymptomsnMost commonly reported symptomsnHard,lumpy stoolsnIncreased strainingnInfreq
18、uent bowel movementsnSensation of incomplete evacuationnBloating/fullnessnChronic constipationnMore persistent than intermittent or episodicnSeveral months durationC恶心呕吐宣讲5052524444343432322020191911110 0101020203030404050506060StrainingStraining Hard Hard stoolsstools Want to Want to but cantbut ca
19、ntInfrequentInfrequentstoolsstoolsAbdominalAbdominaldiscomfortdiscomfortHaventHaventfinishedfinishedExcessExcesstoilet timetoilet timePatients,%Sandler RS,et al.Dig Dis Sci.1987;32:841-845.n=1128Constipation Is More Than Just Infrequent Passage of Stool53Constipation symptoms reported most often恶心呕吐
20、宣讲51Reduced Stool Frequency Is Not the Most Commonly Reported Symptom in Constipation1313262632323636656583830 05050100100 3 BM/wk 3 BM/wkAbdominalAbdominalbloating bloating Press onPress onabdomenabdomenAbdominalAbdominaldiscomfort discomfort UnsuccessfulUnsuccessfulBMBMIncompleteIncompleteBMBMPati
21、ents,%28283636373739395454727281810 05050100100Press onPress onanusanus 3 BM/wk60ys)?RomeII?(15-20)恶心呕吐宣讲53EpidemiologynChronic constipation is commonnSlightly more common in women nF/M ratio=range 1.3 to 2.5(China=4:1)nAffects all age groupsStewart WF,et al.Am J Gastroenterol.1999;94:3530-3540.Par
22、P,et al.Am J Gastroenterol.2001;96:3130-3137.Sandler RS,et al.Dig Dis Sci.1987;32:841-845.C恶心呕吐宣讲54Constipation Affects All Age Groups53Canadian population.Par P,et al.Am J Gastroenterol.2001;96:3130-3137.0 05 5101015152020252518-3418-3435-4935-4950-6450-64 64 64Age group,yrConstipated,%Rome I Rome
23、I Rome II Rome II N=1149n=378n=367n=217n=187恶心呕吐宣讲55Profile of a Typical Chronic Constipation Patient in My PracticenGenerally femalenSymptomatic for 10 yrnMajority have tried lifestyle changes,fiber,and OTC laxatives prior to seeking carenManages condition with multiple therapiesnMost often referre
24、d by a primary care physician nCopes with condition,but is not completely satisfiedC恶心呕吐宣讲56Constipation Can Have a Negative Impact on Quality of LifenPeople with CC reported significant impairment in QoL on SF-36 scale(n=126)1nIn Canada,people with self-reported or Rome II constipation had signific
25、antly worse SF-36 scores than the normal population(n=472)2nIn Australia,people with constipation had significantly worse SF-12 scores on both mental and physical scales(n=227)31.OKeefe EA,et al.J Gerontol A Biol Sci Med Sci.1995;50:M184-M189.2.Irvine EJ,et al.Am J Gastroenterol.2002;97:1986-1993.3.
26、Koloski NA,et al.Am J Gastroenterol.2000;95:67-71.C恶心呕吐宣讲57Constipation Significantly Impacts Healthcare Utilizationn5.7 million constipation-related outpatient visits annually1,2n4.1 million physician office-based visits n991,000 emergency room visitsn587,000 hospital outpatient visitsn$2752/patien
27、t for tertiary care evaluation31.National Ambulatory Medical Care Survey,2001.www.cdc.gov2.National Hospital Ambulatory Care Survey,2001.www.cdc.gov3.Rantis PC Jr,et al.Dis Colon Rectum.1997;40:280-286.C恶心呕吐宣讲58Complications related with constipationvColonic and rectal carcinomavOther colon-rectal-a
28、nus disordersvhepatic coma vacute myocardial infarctionvmammary gland disordersvpresenile dementia(早老性痴呆）vpsycho-problemsvappearance恶心呕吐宣讲59Definition:Causes of Chronic ConstipationnSecondarynDrug induced nMetabolic factorsnComorbid conditionsnPrimarynImpaired colonic transit/motility nAltered neuro
29、enteric function and reflexesnFailure of muscular apparatusnIneffective defecation(functional outlet obstruction)nPelvic dyssynergia and anismusnNormal transit constipation恶心呕吐宣讲60Presentation ObjectivesnDefine constipationnThe pathophysiological mechanisms nEtiologies of constipation nCharacterize
30、manifestationnDiscriminate the accompanying symptoms.nSuggest diagnostic strategies of the symptoms.C恶心呕吐宣讲61What is Constipation?nPassage of hard,dry,lumpy stools;Infrequent bowel movements,usually fewer than three times a weeknSymptoms:npainful bowel movements nstrainingnUncomfortable（Sensation of
31、 incomplete evacuation）nbloatednsluggish恶心呕吐宣讲62Rome II Defines Functional Constipation Based on Multiple SymptomsRome II diagnostic criteria for functional constipationnAt least 12 wk,which need not be consecutive,over the past 12 months of 2 or more of nStraining*nLumpy or hard stools*nSensation o
32、f incomplete evacuation*nSensation of anorectal obstruction/blockage*nManual maneuvers to facilitate defecation*n 1/4 of defecations.Drossman DA,et al.In:Rome II:The Functional Gastrointestinal Disorders.2000:382-391.C恶心呕吐宣讲63Normal metabolismnAs food moves through your intestines,it absorbs water w
33、hile forming waste products nMuscles contract in the colon,pushing the stool toward the rectum恶心呕吐宣讲64Defecation ProcessnYield awareness of defecation nAnal intra-and extra-sphincter RelaxationnAbdominal effects恶心呕吐宣讲65Mechanical stimulation1.Yield awareness of defecation恶心呕吐宣讲662.Anal intra-and ext
34、ra-sphincter Relaxationintra-sphincterextra-sphincterLevator ani muscle恶心呕吐宣讲672.Abdominal effectsgastric contents via anus恶心呕吐宣讲68What Causes Constipation?nEating too little fiber nNot drinking enough liquidsnLack of exercise/physical activity恶心呕吐宣讲69What Causes Constipation?nChange in routinentrav
35、elnOlder agenSlower metabolismnFrequent use of laxativesnCertain diseases or conditions恶心呕吐宣讲70What Causes Constipation?nCertain diseases or conditionsnRectal and Anal disordersnColonic disordersnSystemic diseases or conditions恶心呕吐宣讲71Classification of etiologiesnEating too little fiber nNot drinkin
36、g enough liquidsnLack of exercise/physical activitynChange in routinenTravelnpsycho-relatednOlder agenSlower metabolismnFrequent use of laxativesntediously long ColonnMedicationsnTravelnpain(narcotics麻药麻药)nantacids containing aluminumnantidepressantsniron supplementsndiuretics(“water”pills)Functiona
37、l etiologies恶心呕吐宣讲73psycho-related恶心呕吐宣讲74Tediously long Colon结肠冗长恶心呕吐宣讲75 Organic constipation(certain diseases or conditions cause constipation)Classification of etiologiesnRectal and Anal disordersnBenign or malignancy tumornTumor or mass outsidenSystemic diseases or conditions(e.g.disorders make
38、 dyscinesia:spasm and paralysis）恶心呕吐宣讲76Rectal and Anal disordersCancerNevusanal fissureanal fistulaProctoptosis(直肠脱垂）恶心呕吐宣讲77intestinal obstruction恶心呕吐宣讲78Benign or malignancy tumorPolypCancer恶心呕吐宣讲79Outside tumor or mass恶心呕吐宣讲80Systemic diseases or conditionsGastro-paresisDiabetes mellitus;DMUremi
39、aMyasthenia gravisHypothyroidismHematoporphyriaLead poisoning胃轻瘫糖尿病尿毒症重症肌无力甲状腺机能低下血卟啉病铅中毒恶心呕吐宣讲81Characteristics of manifestation急性便秘常伴随原发病的表现：腹痛、腹胀、恶心呕吐、排气停止，见于各种原因的肠梗阻。慢性便秘可有消化不良症状：便秘型IBS：大便形状：1.散粒2.团粒3.柱粒4.条形5.堆6.片7.水恶心呕吐宣讲82Accompanying symptoms1。呕吐、腹胀、肠绞痛，提示肠梗阻2。伴包块：提示肿瘤、肠结核、Crohn病3。便秘腹泻交替：肠结核、
40、IBS、UC4。继发于生活、环境改变：功能性Intestinal obstructionTumor,TB,Crhons diseaseTB,IBS,UCFunctional constipation1.Vomiting,abdominal distention,Intestinal colic2.Mass3.With diarrhea alternatively4.Change in routine恶心呕吐宣讲83恶心呕吐宣讲84恶心呕吐宣讲85Important information for etiological diagnosisa)Ageb)GI history requiredc)
41、Food habitd)Condition related(living,working,communicating,psychology)e)Consistency f)course of diseasesg)Frequency h)form,texture,Odor,Content,i)Increased straining,Sensation of incomplete j)Weight lossk)Precipitating factorsl)Medicationsm)Disorders outside gastroenterology恶心呕吐宣讲86今天告诉你的事情可要记牢吆！恶心呕吐宣讲87
