1、 Department of general Department of general surgerysurgery Bi Jing-TaoBi Jing-Tao 肠梗阻病例讨论 A A 60-year-old female is admitted 60-year-old female is admitted to the emergency room withto the emergency room with a 48-hour a 48-hour history of lower abdominal pain,history of lower abdominal pain,nausea
2、,vomiting and constipation.The nausea,vomiting and constipation.The patient describes the pain as crampy patient describes the pain as crampy in early and notes that her abdomen in early and notes that her abdomen has become distended over the last 12 has become distended over the last 12 hours.Her
3、last bowel movement was hours.Her last bowel movement was three days prior to presentation.three days prior to presentation.CASE 1CASE 1肠梗阻病例讨论女性，女性，6060岁，岁，“腹痛、呕吐、腹胀和腹痛、呕吐、腹胀和肛门停止排便排气肛门停止排便排气2 2天天,加重加重1212小时小时”急诊入院急诊入院肠梗阻病例讨论Question 1.whats wrong with the old woman?1.whats wrong with the old woman
4、?2.what causes it?2.what causes it?3.How can3.How can she she get well?get well?Operation is need or notOperation is need or not?肠梗阻病例讨论Doctor need to answer:DiagnosisDiagnosisEtiologyEtiologyTreatmentTreatment肠梗阻病例讨论What should be done next?肠梗阻病例讨论Her Her past medical historypast medical history is
5、 remarkable in that she is remarkable in that she underwent an appendectomy for acute appenditis ten years underwent an appendectomy for acute appenditis ten years ago.She is otherwise healthy and takes no medications.ago.She is otherwise healthy and takes no medications.nPhysical examPhysical exam
6、reveals a temperature of reveals a temperature of 38.Her abdomen is distended.38.Her abdomen is distended.肠梗阻病例讨论Clinical ManifestationsAbdominal painAbdominal painNausea and vomitingNausea and vomitingObstipationObstipationDistentionDistention肠梗阻病例讨论Abdominal pain Colicky abdominal pain in early pe
7、riod lasting abdominal pain later 肠梗阻病例讨论Nausea and vomiting 1).The nature of the vomitus.1).The nature of the vomitus.undigested food undigested food particles.particles.becomes bilious.becomes bilious.feculent.feculent.2).The onset and character of 2).The onset and character of vomitingvomiting.Re
8、current vomiting of Recurrent vomiting of bile-stained fluidbile-stained fluid Prolonged nausea Prolonged nausea precedes vomiting,feculent.precedes vomiting,feculent.肠梗阻病例讨论Contispation and obstipation The onset of obstipation,a late developmentStill pass flatus:Still pass flatus:the distal,unobstr
9、ucted intestine empties.partial or incomplete obstruction肠梗阻病例讨论Distention Develop later in the course of the obstructionlittle by little肠梗阻病例讨论Physical ExaminationInspectionInspectionPalpationPalpationPercussionPercussionAuscultationAuscultation肠梗阻病例讨论Inspection right upper quadrantright lower quad
10、rantleft upper quadrantLeft lower quadrant肠梗阻病例讨论Palpation mild tenderness in RLQ but mild tenderness in RLQ but no guarding or reboundno guarding or rebound Mass 5cmX4cm Mass 5cmX4cm，No peritonitis No peritonitis肠梗阻病例讨论Percussion shifting dullnessshifting dullness IN RLQ IN RLQ肠梗阻病例讨论Auscultationno
11、isy and is heard as rushes.noisy and is heard as rushes.During attacks of colic,the sounds become loud,high-During attacks of colic,the sounds become loud,high-pitched and metallicpitched and metallic.肠梗阻病例讨论Rectal examination:Low rectal carcinoma and intussuscepted segment Low rectal carcinoma and
12、intussuscepted segment dont be palpateddont be palpatedrectal exam reveals no stool in the rectum.rectal exam reveals no stool in the rectum.Knee-elbow PositionKnee-elbow Position肠梗阻病例讨论A hemoglobin of 16,hematocrit 48,white blood cell count 12,200 with 74 polys.Serum electrolytes show the level of
13、serum sodium and potassium is 130mol/l and 3.0mol/l.Arterial blood gas analysis reveals that the result of PH is 7.30.An abdominal X-RAY reveals multiple dilated loops of small bowel with numerous air-fluid levels.There is no gas or stool visible in the colonAdmitting laboratory data肠梗阻病例讨论Radiologi
14、cal Examinations 2008-12-42008-12-42008-12-52008-12-5 X-rays X-rays UprightUpright肠梗阻病例讨论SupineSupineX-raysX-rays2008-12-52008-12-52008-12-42008-12-4肠梗阻病例讨论CT scanCT scan肠梗阻病例讨论B-UltraSound2008-12-42008-12-4 distended small intestine;distended small intestine;no liquid in the abdomenno liquid in the
15、 abdomen2008-12-52008-12-5 dilated loops of small intestine;dilated loops of small intestine;liquid in RLQ (7CM liquid in RLQ (7CM Deep)Deep)肠梗阻病例讨论Summury肠梗阻病例讨论Symptoms of the patientsPainVomitingObstipationAbdominal distention肠梗阻病例讨论Signs of the patientsVital Signs:temperature of 38His abdomen is
16、 distended.Mild tenderness periumbilically but no guarding or rebound.High-pitched bowel sounds Rectal exam reveals no stool in the rectum肠梗阻病例讨论Laboratory StudyA hemoglobin of 16,hematocrit 48,which shows hemoconcentrationWhite blood cell count 12,200 ,which shows inflammation.Serum electrolytes ar
17、e abnormal,which shows body liquid imbalance with hyponatremia and hypokalemia.Arterial blood gas analysis reveals acidosis肠梗阻病例讨论Radiography examAn abdominal X-RAY reveals multiple dilated loops of small bowel with numerous air fluid levels.There is no gas or stool visible in the colonTo confirm th
18、e diagnosis:intestinal obstrutionintestinal obstrution肠梗阻病例讨论Diagnosismust make clear the following questions:肠梗阻病例讨论1.Whether intestinal obstruction exists:1.Whether intestinal obstruction exists:Through symptoms and signs,the diagnosis can be made without difficulty.肠梗阻病例讨论2.Whether the obstructio
19、n is mechanical or dynamic:mechanical obstruction:typical symptoms and signs.paralytic obstruction:episodic and cramping abdominal pain is absent;distention is prominent 肠梗阻病例讨论3.Whether the obstruction is simple or strangulation obstruction:Indications for strangulation:1).Abrupt onset with continu
20、ous acute abdominal pain,2).Shock3).Manifestation of peritonitis:leukocytosis,sepsis,rebound and guarding肠梗阻病例讨论 4).4).Asymmetrical distention,local bulge,or mass with tenderness.5).5).Hematic vomitus,6).6).Conservative treatment in vain and no improvement in symptoms and signs.7).7).Isolated,bulged
21、,and distended intestinal loop on abdominal plain film.肠梗阻病例讨论4.Whether the obstruction is high or low:Vomiting in proximal intestinal obstruction.Distention in low obstruction,feculent vomitus 肠梗阻病例讨论5.Whether the obstruction is complete or incomplete:5.Whether the obstruction is complete or incomp
22、lete:frequency of vomiting,extent of distention,Contispation and obstipation肠梗阻病例讨论6.Which causes leads to obstruction:According to the age,history,symptoms and signs.Postoperative adhesions;postinflammatory HeniasCongenital malformationsIntestinal intussusceptionObstruction of parasite originCarcin
23、omas and dry feces.肠梗阻病例讨论Etiology肠梗阻病例讨论Etiology for mechanical Intestinalobstruction1.1.Obstruction arising Obstruction arising from extraluminal from extraluminal causes causes 2.2.Obstruction Obstruction intrinsic to the intrinsic to the bowel wall bowel wall 3.3.Intraluminal Intraluminal obtura
24、tor obstructionobturator 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outsideoninside肠梗阻病例讨论Outside:Adhesions Volvulus Hernias Tumor肠梗阻病例讨论On:Tumor Intussusception 肠梗阻病例讨论Inside:fecal impaction 肠梗阻病例讨论Intestinal obstruction肠梗阻病例讨论Classification 1 1 Mechanical obstruction Mechanical obstruction 机械性肠梗阻机械性肠梗
25、阻 2 2 Paralytic ileus Paralytic ileus 动力性肠梗阻动力性肠梗阻 3 Strangulating3 Strangulating obstruction obstruction 血运性肠梗阻血运性肠梗阻 4 4 原因不明的假性肠梗阻原因不明的假性肠梗阻 肠梗阻病例讨论others：根据有无血运障碍：根据有无血运障碍：单纯性单纯性 Simple obstructionSimple obstruction,绞窄性绞窄性 strangulation obstructionstrangulation obstruction 梗阻部位：梗阻部位：高位高位 Proxima
26、l intestinalProximal intestinal 低位低位 distal intestinaldistal intestinal 大肠大肠 large bowellarge bowel 小肠小肠 small bowelsmall bowel 梗阻程度梗阻程度:不完全性不完全性 Incomplete obstructionIncomplete obstruction 完全性完全性 complete obstructioncomplete obstruction 发展过程发展过程:急性急性 Acute obstructionAcute obstruction 慢性慢性 chronic
27、 chronic obstructionobstruction肠梗阻病例讨论Diagnosis1.1.老年女性，急性病程老年女性，急性病程2.2.典型临床表现：痛、呕、闭、胀典型临床表现：痛、呕、闭、胀3.3.腹部体征腹部体征4.X-Rays 4.X-Rays 和腹部和腹部CTCT表现表现5.5.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肠梗阻病例讨论Does Strangulating obstruction exist？Mechanical Mechanical obstructionobstructionParalytic Paralytic i
28、leusileusStrangulating Strangulating obstructionobstruction肠梗阻病例讨论Differential Diagnosisupper gastrointestinal perforationacute pancreatitisacute cholecystisisacute cholangitis肠梗阻病例讨论TreatmentThe principle:The principle:correction of systemic disturbance correction of systemic disturbance reduction
29、of obstruction.reduction of obstruction.肠梗阻病例讨论Conservative treatment 1).Gastrointestinal decompression:Nasogastric suction2).Correction of water-electrolytic disturbance,acid-base imbalance3).Prevention and treatment of infection and toxemia:Antibiotics肠梗阻病例讨论Surgical intervention 1)1)Lysis of adhe
30、sion,reduction of Lysis of adhesion,reduction of intussusception,intussusception,2)2)Enterectomy and anastomosis.Enterectomy and anastomosis.3)3)Bypass procedure for nonresectable Bypass procedure for nonresectable lesions.lesions.4)4)Enterostomy and exteriorization of Enterostomy and exteriorizatio
31、n of intestine.intestine.肠梗阻病例讨论本病例治疗方案：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，保守无效体温从体温从36.536.5度升高至度升高至3838度度查体：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，肠鸣音变弱腹穿：有血性液腹穿：有血性液化验：化验：WBCWBC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X-rays:X-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laparetomylaparetomy肠梗阻病例讨论In operation postoperationp
32、ostoperation肠梗阻病例讨论Case 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 grands
33、on.肠梗阻病例讨论Past medical history(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.肠梗阻病例讨论Marrys tent
34、ative diagnosis is small 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).肠梗阻病例讨论1.Based on the nurses report,what signs of bowel o
35、bstruction did Marry manifest?QUESTION肠梗阻病例讨论Intermittent 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 obstruc
36、tion,your doctor may hear high-pitched sounds when listening with a stethoscope.The sounds decrease as movement of the bowel slows.肠梗阻病例讨论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.肠梗阻病例讨论2.Are the
37、re other signs and symptoms that you should observe for while Marryis in your care?肠梗阻病例讨论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.肠梗阻病例讨论Constipation(late finding)and inabi
38、lity to pass gas are common signs of a bowel 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 r
39、elated to strangulation肠梗阻病例讨论Peritoneal 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 hernia肠梗阻病例讨论3.Marry and her grandson ar
40、rive on your unit.You admit Marry to her room 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?肠梗阻病例讨论Build up a relationship of trust;attempt to obtain patien
41、ts cooperation肠梗阻病例讨论4.The grandson,an attorney,tells you elderly Italian women are extremely modest and may not answer questions completely.How might you gather info in this case?肠梗阻病例讨论Explaining to the patient that the info she gives will be treated as confidential,and maintaining this confidenti
42、alityGive the patient an understanding of her problemBe non-judgmental肠梗阻病例讨论5.What key questions must you ask this patient while you have the use of an interpreter?肠梗阻病例讨论 Ask about the location,duration,intensity,and frequency of abdominal pain Onset,frequency,color,odor,and amount of vomitus Bowe
43、l and renal functioning Nutritional/dietHealth/medical historyAny other allergies?Dates and type of immunizations received肠梗阻病例讨论6.How would the description of pain differ if she has a small versus large bowel obstruction?肠梗阻病例讨论SBO pain is colicky,cramp-like,and intermittentLBO pain is low-grade,cr
44、amping abdominal pain肠梗阻病例讨论SummaryEtiologyEtiologyManifestationsManifestationsDiagnosisDiagnosisTreatmentTreatment肠梗阻病例讨论ReferenceReference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（第六（第六版）人民卫生出版社版）人民卫生出版社黄志强，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Sabiston Textbook of Surgery,18th edSabiston Textbook of Surgery,18th ed 肠梗阻病例讨论肠梗阻病例讨论
