惡心嘔吐講訴

惡心嘔吐講訴臨床診斷學(xué)上海第二醫(yī)科大學(xué)仁濟(jì)臨床醫(yī)學(xué)院

NauseaandVomitingAsthesymptoms癥狀學(xué)：惡心與嘔吐GoalsBrieflydefineOutlinetheprominentdiseasestatesassociatedwithnauseaandvomiting.CharacterizeNauseaandVomitingcausedbytheprominentdisordersDiscriminatetheaccompanyingsymptoms.Suggestdiagnosticstrategiesofthesymptoms.DefinitionofNauseaandVomitingNausea：theinclinationorfeelingofimminentdesiretovomit,usuallyfeltinthethroatorepi-gastrum.Associatedwithdecreasedactivityofthestomach.Vomiting：theforcefuloralexpulsionofgastriccontentsviaretro-peristalsis.Nausea-Vomiting:simultaneityorseparateness惡心：緊迫欲吐，通常伴有上腹不適和迷走興奮的臨床征候群。嘔吐：胃和/或小腸內(nèi)容物經(jīng)食管和口腔排除體外惡心和嘔吐常伴隨存在，也可單獨(dú)出現(xiàn)！NauseaandVomiting1、惡心：咽部及上腹部不適，胃張力和蠕動(dòng)減弱，幽門和賁門開放。2、干嘔：胃竇部和腹壁肌肉收縮，腹壓增加，食管及咽部開放。3、嘔吐：胃和/或小腸內(nèi)容物經(jīng)食管和口腔排除體外。Definitionofemesis.(Threephases)嘔吐反射過程（三個(gè)階段）1.Nausea-theinclinationorfeelingofimminentdesiretovomit,usuallyfeltinthethroatorepigastrum.Associatedwithdecreasedactivityofthestomach.2.Retching-thelaboredrhythmiccontractionofrespiratoryandabdominalmusculaturethatfrequentlyprecedesoraccompaniesvomiting.3.Vomiting-theforcefuloralexpulsionofgastriccontentsviaretroperistalsis.(Abdominaleffects).迷走興奮表現(xiàn)惡心干嘔嘔吐發(fā)生機(jī)制嘔吐區(qū)別于反食嘔吐：多數(shù)情況有惡心的感覺和嘔吐反射的協(xié)調(diào)動(dòng)作。反食：無惡心的感覺和嘔吐反射的協(xié)調(diào)動(dòng)作。（兒童、飽餐）MechanismsofemesisCTZ&EmeticCenter(Vomitingcenter)CTZ化學(xué)感受器觸發(fā)帶（第四腦室底面）：外源性或內(nèi)源性化學(xué)物質(zhì)（阿片嗎啡、洋地黃、代謝產(chǎn)物）EmeticCenter（延髓外側(cè)網(wǎng)狀結(jié)構(gòu)背測）接受大腦皮質(zhì)、消化器官、心血管以及化學(xué)感受器觸發(fā)帶（CTZ）的沖動(dòng)CTZ&EmeticCenter(Vomitingcenter)孤束核EmeticCenter

內(nèi)臟傳入中腦ICP受體化學(xué)感受器觸發(fā)帶邊緣系統(tǒng)前庭系統(tǒng)嘔吐中樞（Vomitingcenter)ICP=InductivelyCoupledPlasma感應(yīng)耦合等離子體NeurotransmittersinCTZ&EmeticCenterNeurotransmittersinvolvedinstimulatingtheemeticcenter,chemo-receptortriggerzoneandGItractinclude;5-HT,acetylcholine,histamine,dopamine(opiatesandreceptorsforbenzodiazepinesarealsofoundhere)EmeticCenter

1、分泌唾液中樞2、血管收縮中樞3、呼吸中樞4、中樞神經(jīng)脊神經(jīng)膈神經(jīng)迷走神經(jīng)nauseaandvomiting1.Reflectivevomiting

反射性嘔吐2.Centralvomiting中樞性嘔吐3.Neurologicalvomiting神經(jīng)性嘔吐Reflectivevomiting（反射性嘔吐）咽部刺激胃十二指腸疾病膽道疾病腸道疾病肝膽疾病腹膜腸系膜全身性疾病（五官、心血管、泌尿、盆腔…）PharyngealMechanismsGastrointestinalMechanismsDiseaseofbiliarytractPeritonealandmesenterythefivesenseorgansCardiovasculardiseaseskidneyPelvic咽部刺激PharyngalMechanismsGastrointestinalMechanisms肝、膽、胰腺其他Intra-cranialinfectionCerebrovasculardisordersCraniocerebralinjuryEpilepsyMetabolicdisordersDrugsCentralvomiting（中樞性嘔吐）顱內(nèi)感染腦血管疾病顱腦損傷癲癇全身疾病（尿毒癥、肝昏迷、糖尿病代謝紊亂）顱內(nèi)感染（腦炎、腦膜炎）腦血管疾病、顱腦損傷癲癇全身疾病尿毒癥肝昏迷酮癥酸中毒各種原因引起的腦水腫和顱內(nèi)壓升高代謝紊亂早孕Drug抗生素抗癌藥洋地黃嗎啡興奮嘔吐中樞或影響胃腸平滑肌運(yùn)動(dòng)AntibioticsAnti-carcinomaDigitalismorphiaNeurologic&PsychogeniccausesNeurologicandPsychogeniccauses胃腸道神經(jīng)官能癥（Gastrointestinaltractneurosis）神經(jīng)厭食癥（apositia）CharacteristicsofNauseaandVomitingTimeTakingfoodCharacteristicsCharactersofcontents晨起嘔吐早孕反應(yīng)功能性消化不良酒精中毒胃食管反流病鼻咽部疾患夜間或隔夜嘔吐幽門梗阻賁門失弛緩癥嘔吐與進(jìn)食的關(guān)系（Timingwithmeals）餐后即刻：神經(jīng)精神性；集體發(fā)病系食物中毒餐后1小時(shí)以上：為延遲性嘔吐：可考慮為胃張力低下排空障礙餐后較久、多餐后或隔夜：提示幽門梗阻嘔吐特點(diǎn)神經(jīng)性或顱內(nèi)高壓：惡心輕、嘔吐頻；“噴射性嘔吐”嘔吐物性質(zhì)發(fā)酵、腐臭味：提示胃潴留糞臭味：提示較低位置的腸梗阻無酸腐味：賁門失遲緩癥或胃酸缺乏不含膽汁：幽門梗阻病史較長或量多：提示體液和電解質(zhì)丟失Theaccompanyingsymptoms腹痛、腹瀉：食物中毒、腸道傳染病、胃腸炎；節(jié)律性腹痛：消化性潰瘍右上腹痛，伴發(fā)熱、黃疸：膽囊炎、膽道結(jié)石、感染。頭痛、頭暈、視力異常、噴射性嘔吐：顱內(nèi)高壓性疾病、屈光不正、青光眼。伴眩暈、眼球震顫：前庭障礙育齡婦女（停經(jīng)）：應(yīng)排除妊娠與服藥有時(shí)間關(guān)聯(lián)：應(yīng)想到藥物反應(yīng)問診要點(diǎn)起病情況：誘因、急緩、與進(jìn)食關(guān)系、腹部手術(shù)史、育齡婦女月經(jīng)史發(fā)作時(shí)間：晨、夜、與進(jìn)食、活動(dòng)、體位的關(guān)系嘔吐物性狀、味道伴隨癥狀診療和癥狀演變情況History/Backgrounda)Ageb)GIhistoryrequiredc)Foodintoleranced)Timingwithmealse)Consistencyf)Contentg)Odorh)Frequencyi)Feverj)Weightlossk)Precipitatingfactorsl)Myalgias（肌痛）,visualdisturbances,headache,painoutsideabdomenCAUSESOFNAUSEA/VOMITINGEarlypregnancyPsychogenesisvomitingBulimia(易餓病)PyloricchannelulcerAcutegastritisGastricretention(潴留）Viralgastroenteritis（中毒性胃腸炎）AcutegastroenteritisMyocardialinfarctionPeritonitis（腹膜炎）AcuteobstructionNeurologicalemergencyDrugtoxicityCancertherapyDrugwithdrawalPHYSICALEXAMVitalsignsSkinHEENT（head,eyes,ear,nose,throat)AbdomenNeurologicalLABORATORYRuleoutobstructionandperitonitisHCGUrinalysisElectrolytes,BUN,creatinine,glucoseTransaminases,amylaseEKG,headCT,upperGI&/orendoscopiesBreak瀘沽湖黃昏瀘沽湖黃昏瀘沽湖?摩梭女玉龍雪山?雪月47ConstipationShanghaiSecondMedicaluniversityRenjiclinicalmedicalcollegeBackgroundConstipationIsaConstellationofSymptomsMostcommonlyreportedsymptomsHard,lumpystoolsIncreasedstrainingInfrequentbowelmovementsSensationofincompleteevacuationBloating/fullnessChronicconstipationMorepersistentthanintermittentorepisodicSeveralmonthsdurationCSandlerRS,etal.DigDisSci.1987;32:841-845.n=1128ConstipationIsMoreThanJustInfrequentPassageofStool53ConstipationsymptomsreportedmostoftenReducedStoolFrequencyIsNotthe

MostCommonlyReportedSymptominConstipationEPOC=Epidemiologyofconstipation;BM=Bowelmovement.1.StewartWF,etal.AmJGastroenterol.1999;94:3530-3540.2.ParéP,etal.AmJGastroenterol.2001;96:3130-3137.Stewart(EPOC)19991Paré20012n=1476n=1149ConstipationsymptomsreportedmostoftenCPrevalenceintheGeneralPopulation1.StewartWF,etal.AmJGastroenterol.1999;94:3530-3540.2.DrossmanDA,etal.DigDisSci.1993;38:1569-1580.3.HarrisInteractiveStudy,Wave2.Dataonfile.

4.ParéP,etal.AmJGastroenterol.2001;96:3130-3137.53PopulationnCriteriaPrevalence,n(%)US110,018RomeI461(4.6)US25430RomeI195(3.6)US315,183RomeII2429(16)Canada41149RomeII171(14.9)China(18-70ys)?RomeII?(6.07)China(>60ys)?RomeII?(15-20)EpidemiologyChronicconstipationiscommonSlightlymorecommoninwomenF/Mratio=range1.3to2.5(China=4:1)AffectsallagegroupsStewartWF,etal.AmJGastroenterol.1999;94:3530-3540.ParéP,etal.AmJGastroenterol.2001;96:3130-3137.SandlerRS,etal.DigDisSci.1987;32:841-845.CConstipationAffectsAllAgeGroups53Canadianpopulation.ParéP,etal.AmJGastroenterol.2001;96:3130-3137.N=1149n=378n=367n=217n=187ProfileofaTypicalChronicConstipationPatientinMyPracticeGenerallyfemaleSymptomaticfor>10yrMajorityhavetriedlifestylechanges,fiber,andOTClaxativespriortoseekingcareManagesconditionwithmultipletherapiesMostoftenreferredbyaprimarycarephysicianCopeswithcondition,butisnotcompletelysatisfiedCConstipationCanHaveaNegativeImpactonQualityofLifePeoplewithCCreportedsignificantimpairmentinQoLonSF-36scale(n=126)1InCanada,peoplewithself-reportedorRomeIIconstipationhadsignificantlyworseSF-36scoresthanthenormalpopulation(n=472)2InAustralia,peoplewithconstipationhadsignificantlyworseSF-12scoresonbothmentalandphysicalscales(n=227)31.O’KeefeEA,etal.JGerontolABiolSciMedSci.1995;50:M184-M189.

2.IrvineEJ,etal.AmJGastroenterol.2002;97:1986-1993.

3.KoloskiNA,etal.AmJGastroenterol.2000;95:67-71.CConstipationSignificantlyImpactsHealthcareUtilization5.7millionconstipation-relatedoutpatientvisitsannually1,24.1millionphysicianoffice-basedvisits991,000emergencyroomvisits587,000hospitaloutpatientvisits$2752/patientfortertiarycareevaluation31.3.RantisPCJr,etal.DisColonRectum.1997;40:280-286.CComplicationsrelated

withconstipationColonicandrectalcarcinomaOthercolon-rectal-anusdisordershepaticcomaacutemyocardialinfarctionmammaryglanddisorderspreseniledementia(早老性癡呆）psycho-problemsappearanceDefinition:CausesofChronicConstipationSecondaryDruginducedMetabolicfactorsComorbidconditionsPrimaryImpairedcolonictransit/motilityAlteredneuroentericfunctionandreflexesFailureofmuscularapparatusIneffectivedefecation(functionaloutletobstruction)PelvicdyssynergiaandanismusNormaltransitconstipationPresentationObjectivesDefineconstipationThepathophysiologicalmechanismsEtiologiesofconstipationCharacterizemanifestationDiscriminatetheaccompanyingsymptoms.Suggestdiagnosticstrategiesofthesymptoms.CWhatisConstipation?Passageofhard,dry,lumpystools;Infrequentbowelmovements,usuallyfewerthanthreetimesaweekSymptoms:painfulbowelmovementsstrainingUncomfortable（Sensationofincompleteevacuation）bloatedsluggishRomeIIDefinesFunctionalConstipationBasedonMultipleSymptomsRomeIIdiagnosticcriteriaforfunctionalconstipationAtleast12wk,whichneednotbeconsecutive,overthepast12monthsof2ormoreofStraining*Lumpyorhardstools*Sensationofincompleteevacuation*Sensationofanorectalobstruction/blockage*Manualmaneuverstofacilitatedefecation*<3defecations/wkLoosestoolsnotpresentInsufficientcriteriaforIBS*>1/4ofdefecations.DrossmanDA,etal.In:RomeII:TheFunctionalGastrointestinalDisorders.2000:382-391.CNormalmetabolismAsfoodmovesthroughyourintestines,itabsorbswaterwhileformingwasteproductsMusclescontractinthecolon,pushingthestooltowardtherectumDefecationProcessYieldawarenessofdefecationAnalintra-andextra-sphincterRelaxationAbdominaleffectsMechanicalstimulation1.Yieldawarenessofdefecation2.Analintra-andextra-sphincterRelaxationintra-sphincterextra-sphincterLevatoranimuscle2.AbdominaleffectsgastriccontentsviaanusWhatCausesConstipation?EatingtoolittlefiberNotdrinkingenoughliquidsLackofexercise/physicalactivityWhatCausesConstipation?ChangeinroutinetravelOlderageSlowermetabolismFrequentuseoflaxativesCertaindiseasesorconditionsWhatCausesConstipation?CertaindiseasesorconditionsRectalandAnaldisordersColonicdisordersSystemicdiseasesorconditionsWhatCausesConstipation?pain(narcotics麻藥)antacidscontainingaluminumantidepressantsironsupplementsdiuretics(“water”pills)

MedicationsClassificationofetiologiesEatingtoolittlefiberNotdrinkingenoughliquidsLackofexercise/physicalactivityChangeinroutineTravelpsycho-relatedOlderageSlowermetabolismFrequentuseoflaxativestediouslylongColonMedicationsTravelpain(narcotics麻藥)antacidscontainingaluminumantidepressantsironsupplementsdiuretics(“water”pills)Functionaletiologiespsycho-relatedTediouslylongColon結(jié)腸冗長Organicconstipation(certaindiseasesorconditionscauseconstipation)ClassificationofetiologiesRectalandAnaldisordersBenignormalignancytumorTumorormassoutsideSystemicdiseasesorcondition