1、20211健康快乐每一天！20212临床诊断学临床诊断学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 20213Nausea and VomitingAs the symptoms症状学：恶心与呕吐症状学：恶心与呕吐20214GoalsBriefly defineOutline the prominent disease states associated with nausea and vomiting.Characterize Nausea and Vomiting caused by the prominent disorders Discriminate the acc
2、ompanying symptoms.Suggest diagnostic strategies of the symptoms.20215Definition 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 g
3、astric 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！20216Nausea and Vomiting202171、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)
4、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 and abdominal musculature that frequently precedes or accompanies vomiting
5、.3.Vomiting-the forceful oral expulsion of gastric contents via retroperistalsis.(Abdominal effects).20218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20219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）202110Mechanisms of emesis202111CTZ&Emeti
6、c 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202112CTZ&Emetic Center(Vomiting center)孤束核202113Emetic Center Midbrain Chemoreceptor Limbic Vestibular ICP Receptor Trigger Zone System system Visceral afferents Emetic C
7、enter 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202114Neurotransmitters 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)202115202116202117Emetic 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2021182021
9、19nausea 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202120Reflective 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
10、 five sense organsCardiovascular diseases kidneyPelvic202121咽部刺激Pharyngal Mechanisms202122Gastrointestinal Mechanisms202123肝、胆、胰腺202124其他202125Intra-cranial infectionCerebrovascular disordersCraniocerebral injuryEpilepsyMetabolic 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
11、迷、糖尿病代谢紊乱）202126颅内感染（脑炎、脑膜炎）202127脑血管疾病、颅脑损伤202128癫痫202129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202130Drug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-carcinomaDigitalismorphia202131Neurologic&Psychogenic causesNeurologic and Psychogenic causes胃肠道神经官能症（Gastrointestinal tract neurosis）神经厌食症（apositia）202
12、132Characteristics of Nausea and VomitingTimeTaking foodCharacteristicsCharacters of contents202133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202134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202135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：
13、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202136The 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202137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
14、随症状n诊疗和症状演变情况202138History/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 abdomen202139CAUSES OF NAUSEA/VOMITINGnEarly pregnancynPsycho
15、genesis 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 toxicitynCancer therapynDrug withdrawal202140PHYSICAL EXAMnV
16、ital signsnSkinnHEENT（head,eyes,ear,nose,throat)nAbdomennNeurological202141LABORATORYnRule out obstruction and peritonitisnHCGnUrinalysisnElectrolytes,BUN,creatinine,glucosenTransaminases,amylasenEKG,head CT,upper GI&/or endoscopies202142202143泸沽湖黄昏泸沽湖黄昏202144泸沽湖黄昏泸沽湖黄昏202145泸沽湖泸沽湖摩梭摩梭女女202146玉龙雪山玉龙
17、雪山雪雪月月202147202148ConstipationShanghai Second Medical universityRenji clinical medical college202149Background202150Constipation Is a Constellation of SymptomsnMost commonly reported symptomsnHard,lumpy stoolsnIncreased strainingnInfrequent bowel movementsnSensation of incomplete evacuationnBloating
18、/fullnessnChronic constipationnMore persistent than intermittent or episodicnSeveral months durationC20215152524444343432322020191911110 0101020203030404050506060StrainingStraining Hard Hard stoolsstools Want to Want to but cantbut cantInfrequentInfrequentstoolsstoolsAbdominalAbdominaldiscomfortdisc
19、omfortHaventHaventfinishedfinishedExcessExcesstoilet 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 often202152Reduced Stool Frequency Is Not the Most Commonly Reported Sympto
20、m in Constipation1313262632323636656583830 05050100100 3 BM/wk 3 BM/wkAbdominalAbdominalbloating bloating Press onPress onabdomenabdomenAbdominalAbdominaldiscomfort discomfort UnsuccessfulUnsuccessfulBMBMIncompleteIncompleteBMBMPatients,%28283636373739395454727281810 05050100100Press onPress onanusa
21、nus 3 BM/wk60ys)?RomeII?(15-20)202154EpidemiologynChronic 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
22、Sci.1987;32:841-845.C202155Constipation 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=187202156Profile of a Typical C
23、hronic 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 care physician nCopes with condition,but is not completely
24、satisfiedC202157Constipation 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 significantly worse SF-36 scores than the normal population(n=472)2nIn Australia,peo
25、ple 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.Koloski NA,et al.Am J Gastroenterol.2000;95:67-71.C202158Constipation Signif
26、icantly 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/patient for tertiary care evaluation31.National Ambulatory Medical Care Survey,2001.
27、www.cdc.gov2.National Hospital Ambulatory Care Survey,2001.www.cdc.gov3.Rantis PC Jr,et al.Dis Colon Rectum.1997;40:280-286.C202159Complications related with constipationvColonic and rectal carcinomavOther colon-rectal-anus disordersvhepatic coma vacute myocardial infarctionvmammary gland disordersv
28、presenile dementia(早老性痴呆）vpsycho-problemsvappearance202160Definition:Causes of Chronic ConstipationnSecondarynDrug induced nMetabolic factorsnComorbid conditionsnPrimarynImpaired colonic transit/motility nAltered neuroenteric function and reflexesnFailure of muscular apparatusnIneffective defecation
29、(functional outlet obstruction)nPelvic dyssynergia and anismusnNormal transit constipation202161Presentation ObjectivesnDefine constipationnThe pathophysiological mechanisms nEtiologies of constipation nCharacterize manifestationnDiscriminate the accompanying symptoms.nSuggest diagnostic strategies
30、of the symptoms.C202162What is Constipation?nPassage of hard,dry,lumpy stools;Infrequent bowel movements,usually fewer than three times a weeknSymptoms:npainful bowel movements nstrainingnUncomfortable（Sensation of incomplete evacuation）nbloatednsluggish202163Rome II Defines Functional Constipation
31、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 of incomplete evacuation*nSensation of anorectal obstruction/blockage*nManual maneuvers t
32、o facilitate defecation*n 1/4 of defecations.Drossman DA,et al.In:Rome II:The Functional Gastrointestinal Disorders.2000:382-391.C202164Normal metabolismnAs food moves through your intestines,it absorbs water while forming waste products nMuscles contract in the colon,pushing the stool toward the re
33、ctum202165Defecation ProcessnYield awareness of defecation nAnal intra-and extra-sphincter RelaxationnAbdominal effects202166Mechanical stimulation1.Yield awareness of defecation2021672.Anal intra-and extra-sphincter Relaxationintra-sphincterextra-sphincterLevator ani muscle2021682.Abdominal effects
34、gastric contents via anus202169What Causes Constipation?nEating too little fiber nNot drinking enough liquidsnLack of exercise/physical activity202170What Causes Constipation?nChange in routinentravelnOlder agenSlower metabolismnFrequent use of laxativesnCertain diseases or conditions202171What Caus
35、es Constipation?nCertain diseases or conditionsnRectal and Anal disordersnColonic disordersnSystemic diseases or conditions202172What Causes Constipation?npain(narcotics麻药)nantacids containing aluminumnantidepressantsniron supplementsndiuretics(“water”pills)Medications202173Classification of etiolog
36、iesnEating 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 aluminumnantidepressantsniron supp
37、lementsndiuretics(“water”pills)Functional etiologies202174psycho-related202175Tediously long Colon结肠冗长202176 Organic constipation(certain diseases or conditions cause constipation)Classification of etiologiesnRectal and Anal disordersnBenign or malignancy tumornTumor or mass outsidenSystemic disease
38、s or conditions(e.g.disorders make dyscinesia:spasm and paralysis）202177Rectal and Anal disordersCancerNevusanal fissureanal fistulaProctoptosis(直肠脱垂）202178intestinal obstruction202179Benign or malignancy tumorPolypCancer202180Outside tumor or mass202181Systemic diseases or conditionsGastro-paresisD
39、iabetes mellitus;DMUremiaMyasthenia 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202182Characteristics 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202183Accompanying symptoms1。呕吐、腹胀、肠绞痛，提示肠梗阻2。伴包块：提示肿瘤、肠结核
40、、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 constipationVomiting,abdominal distention,Intestinal colicMassWith diarrhea alternativelyChange in routine202184202185202186Important information for etiological diagnosisa)Ageb)GI history requ
41、iredc)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 gastroenterology202187今天告诉你的事情可要记牢吆！
