1、 Department of general surgery Bi Jing-Tao frankbjt Clinical CaseClinical Case DiscussionDiscussion 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 t
2、hat her abdomen has become distended over the last 12 hours. Her last bowel movement was three days prior to presentation. CASE 1 n女性，60岁，“腹痛、呕吐、腹胀和 肛门停止排便排气2天,加重12小时” 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? Doctor need to a
3、nswer: nDiagnosis nEtiology nTreatment nWhat should be done next? nHer past medical history is remarkable in that she underwent an appendectomy 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.
4、 Clinical Manifestations Abdominal pain Nausea and vomiting Obstipation Distention Abdominal pain Colicky abdominal pain in early period lasting abdominal pain later Nausea and vomiting 1).The nature of the vomitus. undigested food particles. becomes bilious. feculent. 2).The onset and character of
5、vomiting. Recurrent vomiting of bile -stained fluid Prolonged nausea precedes vomiting, feculent. Contispation and obstipation nThe onset of obstipation, a late development Still pass flatus: the distal, unobstructed intestine empties. partial or incomplete obstruction Distention Develop later in th
6、e course of the obstruction little by little Physical Examination Inspection Palpation Percussion Auscultation Inspection right upper quadrant right lower quadrant left upper quadrant Left lower quadrant Palpation mild tenderness in RLQ but no guarding or rebound Mass 5cmX4cm， No peritonitis Percuss
7、ion nshifting dullness IN RLQ Auscultation nnoisy and is heard as rushes. nDuring attacks of colic ,the sounds become loud ,high- pitched and metallic . Rectal examination: nLow rectal carcinoma and intussuscepted segment dont be palpated nrectal exam reveals no stool in the rectum. Knee-elbow Posit
8、ion nA hemoglobin of 16, hematocrit 48, white blood cell count 12,200 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 sm
9、all bowel with numerous air-fluid levels. There is no gas or stool visible in the colon Admitting laboratory data Radiological Examinations 2008-12-4 2008-12-5 X-rays Upright Supine X-rays 2008-12-52008-12-4 CT scan B-UltraSound n2008-12-4 distended small intestine; no liquid in the abdomen n2008-12
10、-5 dilated loops of small intestine; liquid in RLQ (7CM Deep) Summury Symptoms of the patients nPain nVomiting nObstipation nAbdominal distention Signs of the patients nVital Signs: temperature of 38 nHis abdomen is distended. nMild tenderness periumbilically but no guarding or rebound. nHigh-pitche
11、d bowel sounds nRectal exam reveals no stool in the rectum Laboratory Study nA hemoglobin of 16, hematocrit 48, which shows hemoconcentration nWhite blood cell count 12,200 , which shows inflammation. n Serum electrolytes are abnormal , which shows body liquid imbalance with hyponatremia and hypokal
12、emia. nArterial blood gas analysis reveals acidosis Radiography exam nAn abdominal X-RAY reveals multiple dilated loops of small bowel with numerous air fluid levels. There is no gas or stool visible in the colon nTo confirm the diagnosis :intestinal obstrution Diagnosis must make clear the followin
13、g questions: n1.Whether intestinal obstruction exists: Through symptoms and signs, the diagnosis can be made without difficulty. 2.Whether the obstruction is mechanical or dynamic: mechanical obstruction: typical symptoms and signs. paralytic obstruction: episodic and cramping abdominal pain is abse
14、nt; distention is prominent 3.Whether the obstruction is simple or strangulation obstruction: Indications for strangulation: 1).Abrupt onset with continuous acute abdominal pain, 2).Shock 3).Manifestation of peritonitis: leukocytosis, sepsis,rebound and guarding 4).Asymmetrical distention, local bul
15、ge, or mass with tenderness. 5).Hematic vomitus, 6).Conservative treatment in vain and no improvement in symptoms and signs. 7).Isolated, bulged, and distended intestinal loop on abdominal plain film. 4.Whether the obstruction is high or low: Vomiting in proximal intestinal obstruction. Distention i
16、n low obstruction, feculent vomitus 5.Whether the obstruction is complete or incomplete: frequency of vomiting, extent of distention, Contispation and obstipation 6.Which causes leads to obstruction: According to the age, history, symptoms and signs. Postoperative adhesions; postinflammatory Henias
17、Congenital malformations Intestinal intussusception Obstruction of parasite origin Carcinomas and dry feces. Etiology Etiology for mechanical Intestinal obstruction 1. Obstruction arising from extraluminal causes 2. Obstruction intrinsic to the bowel wall 3. Intraluminal obturator obstruction 肠壁外因素肠
18、壁因素肠腔内因素 outside on inside Outside: Adhesions Volvulus Hernias Tumor On :Tumor Intussusception Inside : fecal impaction Intestinal obstruction Classification 1 Mechanical obstruction 机械性肠梗阻 2 Paralytic ileus 动力性肠梗阻 3 Strangulating obstruction 血运性肠梗阻 4 原因不明的假性肠梗阻 others： 根据有无血运障碍：单纯性 Simple obstructi
19、on, 绞窄性 strangulation obstruction 梗阻部位：高位 Proximal intestinal 低位 distal intestinal 大肠 large bowel 小肠 small bowel 梗阻程度: 不完全性 Incomplete obstruction 完全性 complete obstruction 发展过程: 急性 Acute obstruction 慢性 chronic obstruction Diagnosis 1.老年女性，急性病程 2.典型临床表现：痛、呕、闭、胀 3.腹部体征 4.X-Rays 和腹部CT表现 5.既往腹部手术病史 急性粘连
20、性小肠低位完全梗阻 Does Strangulating obstruction exist？ Mechanical obstruction Paralytic ileus Strangulating obstruction Differential Diagnosis nupper gastrointestinal perforation nacute pancreatitis nacute cholecystisis nacute cholangitis Treatment The principle: ncorrection of systemic disturbance nreduct
21、ion of obstruction. Conservative treatment 1).Gastrointestinal decompression: Nasogastric suction 2).Correction of water-electrolytic disturbance, acid-base imbalance 3).Prevention and treatment of infection and toxemia: Antibiotics Surgical intervention n1)Lysis of adhesion, reduction of intussusce
22、ption, n 2)Enterectomy and anastomosis. n3)Bypass procedure for nonresectable lesions. n4)Enterostomy and exteriorization of intestine. 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 n体温从36.5度升高至38度 n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 n化验：WBC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 laparetomy In operation postoperation Ca
23、se 2 Marry 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 medica
24、l 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. Marrys tentative diagnosis is
25、 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). 1.Based on the nurses report, what signs of bowel obstruction did M
26、arry manifest? QUESTION 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 obstruction, your docto
27、r may 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 sympt
28、oms that 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
29、 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 related to strangulation
30、Peritoneal signs Abdominal distention Hyperactive bowel sounds occur early as GI contents attempt to overcome the obstruction; hypoactive bowel sounds occur late Gross or occult blood - late strangulation or malignancy Masses - obturator hernia 3.Marry and her grandson arrive on your unit. You admit
31、 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? Build up a relationship of trust; attempt to obtain patients cooperation 4.The grandso
32、n, an attorney, tells 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 confidentiality Give the patient an understand
33、ing of her problem Be non-judgmental 5.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/diet
34、 Health/medical history Any other allergies? Dates and type of immunizations received 6.How would the description of pain differ if she has a small versus large bowel obstruction? SBO pain is colicky, cramp-like, and intermittent LBO pain is low-grade, cramping abdominal pain Summary Etiology Manifestations Diagnosis Treatment Reference n吴阶平，裘法祖主编 黄家驷外科学（第 六版）人民卫生出版社 n黄志强，黎鳌，张肇祥主编 外科手术学 （第二版）人民卫生出版社 nSabiston Textbook of Surgery, 18th ed
