腸梗阻教案-上海第二醫(yī)科大學(xué)附屬瑞金醫(yī)院課件

腸梗阻INTESTINALOBSTRUCTIONRuiJinhospitalZhangHaoboIntroduction

腸內(nèi)容物不能正常運行,順利通過腸道

病因?qū)W機(jī)械性梗阻

腸腔阻塞:結(jié)石、糞塊、異物腸管受壓:粘連帶、腸扭轉(zhuǎn)、疝腸壁病變：腫瘤、炎性、先天性動力性腸梗阻麻痹性：神經(jīng)、毒素、炎性痙攣性：腸動力紊亂、鉛中毒血運性腸梗阻腸系膜血管栓塞或血栓形成腸梗阻是否伴血運障礙單純性/絞窄性腸梗阻部位高位：空腸上段低位：回腸末段結(jié)腸梗阻腸梗阻程度：不完全性/完全性發(fā)展進(jìn)程：急性/慢性病理生理病理生理ClinicalAppearance腹痛嘔吐便秘停止排氣

PhysicalExamination

視診腹脹Abdomendistention蠕動波Peristalicwave手術(shù)疤痕Surgicalscars嵌頓疝Incarceratedhernias

觸診腹脹腹塊腹肌緊張腹膜炎PhysicalExamination腹部聽診

腸鳴音亢進(jìn)

直腸指檢LaboratoryTests血漿電解質(zhì)和PH值BloodWBCHematocrit

Serumamylase

BUN

X射線檢查

RadiologicExamination診斷正確率80~85%

平臥位

立位

側(cè)臥位

急性完全性機(jī)械性梗阻

擴(kuò)張小腸襻

氣液平倒U字型

直腸和結(jié)腸內(nèi)無氣體

RadiologicExamination小腸梗阻SmallintestinalOB

小腸黏膜呈魚刺樣

valvulae

conniventes

腸段位于腹中部

centralportions

小量/無結(jié)腸氣體

minimal/nocolonicgas結(jié)腸梗阻

ColonObstruction

結(jié)腸袋影

colonichaustralmarking

擴(kuò)張腸段位于腹部外周/盆腔

peripheryofabdomen/inthepelvic1.有否腸梗阻？

Doesthepatienthavebowelobstruction?2.梗阻在那一段腸段

Ifso,whereisit?3.病因是什么？

Whatistheanatomicandpathologicnature?4.是否存在絞榨性腸梗阻

Hasstrangulationoccurred?5.患者全身情況如何？

Whatisthegeneralconditionofthepatients?診斷

Diagnosis臨床表現(xiàn)

ClinicalAppearance腹痛Abdominalpain嘔吐Vomiting便秘Obstipation腹脹Abdominaldistention停止排氣

Failuretopassflatus

DifferentiationofpartialfromcompleteSBOPartialSBO:passflatusorliquidstoolsCompleteSBO:obstipation

DifferentiationofProximal/distalSBO:pain:epigastric/periumbilicalareavomiting:prominent/lateronsetdistention:no/predominate

鑒別近端和遠(yuǎn)端梗阻DifferentiationofProximal/distalSBO:

pain:epigastric/periumbilicalareavomiting:prominent/lateronsetdistention:no/predominate鑒別部分梗阻和完全性梗阻DifferentiationofpartialfromcompleteSBO

PartialSBO:passflatusorliquidstoolsCompleteSBO:obstipation單純性和絞榨性腸梗阻的鑒別

單純性腸梗阻腹痛陣發(fā)性輕度-中度嘔吐較少休克無，少見發(fā)熱不常見腹痛和肌衛(wèi)少見對補液治療有效絞榨性腸梗阻腹痛持續(xù)性重度嘔吐嚴(yán)重休克早、常見發(fā)熱明顯腹痛和肌衛(wèi)早、明顯對補液治療效果差治療

TreatmentofSBO保守治療和手術(shù)治療

Medicalandsurgicalmanagement三個連續(xù)的階段：觀察、治療、手術(shù)

Theoverlappingsequence:investigationresuscitationoperation手術(shù)時機(jī)的把握：Thetimingofoperationdependsonthreefactors:

病程duration重要器官的功能opportunityofvitalorganfunction絞榨的可能riskofstrangulationThetimingofoperationdependsonthreefactors:

病程duration

器官功能opportunityofvitalorganfunction

絞榨的可能riskofstrangulationMedicalmanagment胃腸減壓Nasointestinal/nasogastricintubation糾正水電解質(zhì)的紊亂Intravenousfluids/bloodplasmaadministration廣譜抗菌素的應(yīng)用Broad-spectrumantibioticsadministrationSurgicalprinciple病因

ThenatureofproblemdeterminesapproachtomanagementofSBO.腸管活性的判斷：色澤、活力、動脈搏動

Thecriteriaofdeterminingbowelviability:colormotilityarterialpulsation處理

Ifquestionable,releasedandplaced,re-examined.結(jié)腸梗阻

LargeBowelObstruction病因?qū)WEtiologycarcinoma55%volvulus11%diverticulitis9%extrinsiccarcinoma8%adhesions4%fecalimpaction3%Daignosis慢性梗阻Chroniccomplaints腹痛位于下腹部和臍周

Painrelatedtolowerabdomenorperiumbilicalarea.腹脹明顯Abdominaldistensionprominent隱血試驗Guaiac-positivestools直腸指檢RectalexaminationManagement直腸乙狀結(jié)腸鏡Proctosigmoidoscopy

visualized/biopsied/decompressed結(jié)腸梗阻大多數(shù)需要手術(shù)治療

Mostlargebowelobstructionneedsurgeryexpcetforfecalimpaction閉襻性梗阻需急癥手術(shù)

Closedloopobstructionneedemergency分期手術(shù)

one/two/three-stagesurgicalprocedures腸粘連

Adhesiveobstruction形成：粘連銳角纖維束帶壓迫

surgicaltraumainfectionsbleedingintestinalischemiachemicaltraumaforeignbodies（powder）腸壞死Riskofstrangulation:9%再次手術(shù)腸排列手術(shù)(M-A管)疝源性腸梗阻外疝:

下腹痛,腹外疝好發(fā)部位腫塊,無法回納手術(shù)松解疝環(huán),疝修補,壞死腸段切除。內(nèi)疝:

疝環(huán)為先天或手術(shù)形成腹內(nèi)間隙.

多為閉襻性,X線平片僅為一致密影.

癥狀劇烈,病情急驟,診斷困難,需急診手術(shù)

腸套疊

IntussusceptionIntussusceptumtelescopesintoanintussuscipiens(sheath)enteroenteral,ileocecal,ileocolic,colocolicchildrenrateishigh1/3casesofadultsismalignanciesresectionisnecessary(香腸狀,空虛感,粘液血便)腸扭轉(zhuǎn)