1、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 Nausea and VomitingAs the symptoms症状学：恶心与呕吐症状学：恶心与呕吐文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。GoalsBriefly defineOutline the prominent disease states associated with nausea and vomiting.Characterize Nausea and Vomiting caused by the prominent disorders Discrimi
2、nate the accompanying symptoms.Suggest diagnostic strategies of the symptoms.文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Definition 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 stom
3、ach.nVomiting：the forceful oral expulsion of gastric contents 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！文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Nausea and Vomiting1、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
4、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（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
5、 and abdominal musculature that frequently precedes or accompanies vomiting.3.Vomiting-the forceful oral expulsion of gastric contents via retroperistalsis.(Abdominal effects).文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。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文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。呕吐区别于反食呕吐区别于反食
6、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）文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Mechanisms of emesis文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。CTZ&Emetic Center(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
7、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）的冲动文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。CTZ&Emetic Center(Vomiting center)孤束核文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Emetic Center Midbrain Chemoreceptor Limbic Vestibular ICP Receptor Trigger Zone System system Visceral afferents Emetic Center 内脏传入 中脑ICP受体化学感受器触发
8、带边缘系统前庭系统呕吐中枢（Vomiting center)ICP=Inductively Coupled Plasma 感应耦合等离子体文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Neurotransmitters in CTZ&Emetic CenterNeurotransmitters involved in stimulating the emetic center,chemo-receptor trigger zone and GI tract include;5-HT,acetylcholine,histamine,dopamine(opiates
9、 and receptors for benzodiazepines are also found here)文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Emetic Center Emetic Center 1.Salivary center 2.Vasomotor center 3.Respiratory center 4.Cranial nerves Spinal nerve phrenic nerv
10、e 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文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。nausea 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文档仅供参考，不能作为
11、科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Reflective 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 mesenterythe five sense organsCardiovascular diseases kidneyPelvic文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。咽
12、部刺激Pharyngal Mechanisms文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Gastrointestinal Mechanisms文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。肝、胆、胰腺文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。其他文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Intra-cranial infectionCerebrovascular disordersCraniocerebral injuryEpilepsyMetabolic
13、 disorders DrugsCentral vomiting（中枢性呕吐）中枢性呕吐）颅内感染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）文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。颅内感染（脑炎、脑膜炎）文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。脑血管疾病、颅脑损伤文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。癫痫文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。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文档
14、仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Drug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文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Neurologic&Psychogenic causesNeurologic and Psychogenic causes胃肠道神经官能症（Gastrointestinal tract neurosis）神经厌食症（apositia）文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或
15、本人删除。Characteristics of Nausea and Vomiting1.Time2.Taking food3.Characteristics4.Characters of contents文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。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文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。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
16、空障碍餐后较久、多餐后或隔夜：提示幽门梗阻文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。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文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。The 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
17、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：应想到药物反应文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。问诊要点n起病情况：诱因、急缓、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文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。History/Backgrounda)Ageb)GI history requiredc)Food intoleranced)Timing wi
18、th mealse)Consistencyf)Contentg)Odorh)Frequencyi)Feverj)Weight lossk)Precipitating factorsl)Myalgias（肌痛）,visual disturbances,headache,pain outside abdomen文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。CAUSES OF NAUSEA/VOMITINGnEarly pregnancynPsychogenesis vomitingnBulimia(易饿病易饿病)nPyloric channel ulcernAcut
19、e 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 toxicitynCancer therapynDrug withdrawal文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。PHYSICAL EXAMnVital signsnSkinnHEENT（head
20、,eyes,ear,nose,throat)nAbdomennNeurological文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。LABORATORYnRule out obstruction and peritonitisnHCGnUrinalysisnElectrolytes,BUN,creatinine,glucosenTransaminases,amylasenEKG,head CT,upper GI&/or endoscopies文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。文档仅供参考，不能作为科学依据，请勿模仿；如
21、有不当之处，请联系网站或本人删除。泸沽湖黄昏泸沽湖黄昏文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。泸沽湖黄昏泸沽湖黄昏文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。泸沽湖泸沽湖摩梭摩梭女女文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。玉龙雪山玉龙雪山雪雪月月46ConstipationnShanghai Second Medical universitynRenji clinical medical collegeBackground文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网
22、站或本人删除。Constipation Is a Constellation of SymptomsnMost commonly reported symptomsnHard,lumpy stoolsnIncreased strainingnInfrequent bowel movementsnSensation of incomplete evacuationnBloating/fullnessnChronic constipationnMore persistent than intermittent or episodicnSeveral months durationC文档仅供参考，不
23、能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。52524444343432322020191911110 0101020203030404050506060StrainingStraining Hard Hard stoolsstools Want to Want to but cantbut cantInfrequentInfrequentstoolsstoolsAbdominalAbdominaldiscomfortdiscomfortHaventHaventfinishedfinishedExcessExcesstoilet timetoilet timePatients
24、,%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文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Reduced Stool Frequency Is Not the Most Commonly Reported Symptom in Constipation1313262632323636656583830
25、05050100100 3 BM/wk 3 BM/wkAbdominalAbdominalbloating bloating Press onPress onabdomenabdomenAbdominalAbdominaldiscomfort discomfort UnsuccessfulUnsuccessfulBMBMIncompleteIncompleteBMBMPatients,%28283636373739395454727281810 05050100100Press onPress onanusanus 3 BM/wk60ys)?RomeII?(15-20)文档仅供参考，不能作为科
26、学依据，请勿模仿；如有不当之处，请联系网站或本人删除。EpidemiologynChronic 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 P,et al.Am J Gastroenterol.2001;96:3130-3137.Sandler RS,et al.Dig Dis Sci.1987;3
27、2:841-845.C文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Constipation 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 I Rome II Rome II N=1149n=378n=367n=217n=187文档仅供参
28、考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Profile 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 referred by a primary car
29、e physician nCopes with condition,but is not completely satisfiedC文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Constipation 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
30、 had significantly 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
31、:1986-1993.3.Koloski NA,et al.Am J Gastroenterol.2000;95:67-71.C文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Constipation Significantly Impacts Healthcare Utilizationn5.7 million constipation-related outpatient visits annually1,2n4.1 million physician office-based visits n991,000 emergency room visitsn587
32、,000 hospital outpatient visitsn$2752/patient 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文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Complications
33、related with constipationvColonic and rectal carcinomavOther colon-rectal-anus disordersvhepatic coma vacute myocardial infarctionvmammary gland disordersvpresenile dementia(早老性痴呆）vpsycho-problemsvappearance文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Definition:Causes of Chronic ConstipationnSecondarynDr
34、ug induced nMetabolic factorsnComorbid conditionsnPrimarynImpaired colonic transit/motility nAltered neuroenteric function and reflexesnFailure of muscular apparatusnIneffective defecation(functional outlet obstruction)nPelvic dyssynergia and anismusnNormal transit constipation文档仅供参考，不能作为科学依据，请勿模仿；如
35、有不当之处，请联系网站或本人删除。Presentation ObjectivesnDefine constipationnThe pathophysiological mechanisms nEtiologies of constipation nCharacterize manifestationnDiscriminate the accompanying symptoms.nSuggest diagnostic strategies of the symptoms.C文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。What is Constipation?nP
36、assage of hard,dry,lumpy stools;Infrequent bowel movements,usually fewer than three times a weeknSymptoms:npainful bowel movements nstrainingnUncomfortable（Sensation of incomplete evacuation）nbloatednsluggish文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Rome II Defines Functional Constipation Based on Mult
37、iple 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 of incomplete evacuation*nSensation of anorectal obstruction/blockage*nManual maneuvers to facilitate
38、defecation*n 1/4 of defecations.Drossman DA,et al.In:Rome II:The Functional Gastrointestinal Disorders.2000:382-391.C文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Normal metabolismnAs food moves through your intestines,it absorbs water while forming waste products nMuscles contract in the colon,pushing the
39、 stool toward the rectum文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Defecation ProcessnYield awareness of defecation nAnal intra-and extra-sphincter RelaxationnAbdominal effects文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Mechanical stimulation1.Yield awareness of defecation文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人
40、删除。2.Anal intra-and extra-sphincter Relaxationintra-sphincterextra-sphincterLevator ani muscle文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。2.Abdominal effectsgastric contents via anus文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。What Causes Constipation?nEating too little fiber nNot drinking enough liquidsnLack
41、of exercise/physical activity文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。What Causes Constipation?nChange in routinentravelnOlder agenSlower metabolismnFrequent use of laxativesnCertain diseases or conditions文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。What Causes Constipation?nCertain diseases or conditionsnR
42、ectal and Anal disordersnColonic disordersnSystemic diseases or conditions文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。What Causes Constipation?npain(narcotics麻药)nantacids containing aluminumnantidepressantsniron supplementsndiuretics(“water”pills)Medications文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Classifi
43、cation of etiologiesnEating too little fiber nNot drinking enough liquidsnLack of exercise/physical activitynChange in routinenTravelnpsycho-relatednOlder agenSlower metabolismnFrequent use of laxativesntediously long ColonnMedicationsnTravelnpain(narcotics麻药麻药)nantacids containing aluminumnantidepr
44、essantsniron supplementsndiuretics(“water”pills)Functional etiologies文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。psycho-related文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Tediously long Colon结肠冗长文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Organic constipation(certain diseases or conditions cause constipation)Class
45、ification of etiologiesnRectal and Anal disordersnBenign or malignancy tumornTumor or mass outsidenSystemic diseases or conditions(e.g.disorders make dyscinesia:spasm and paralysis）文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Rectal and Anal disordersCancerNevusanal fissureanal fistulaProctoptosis(直肠脱垂）文档
46、仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。intestinal obstruction文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Benign or malignancy tumorPolypCancer文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Outside tumor or mass文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Systemic diseases or conditionsGastro-paresisDiabetes mellitus;DMU
47、remiaMyasthenia 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文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Characteristics 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.水文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Accomp
48、anying 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、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文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站
49、或本人删除。文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。Important information for etiological diagnosisa)Ageb)GI history requiredc)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文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。今天告诉你的事情可要记牢吆！
