急腹癥醫(yī)學的學習課件

急腹癥醫(yī)學的學習課件第1頁/共41頁急腹癥

AcuteAbdominalPain

第2頁/共41頁概念外科急腹癥是一組以急性腹痛為主要表現(xiàn)，絕大多數(shù)需要緊急外科手術(shù)處理的急性炎癥、出血、梗阻、穿孔及血運障礙性疾病的總稱。第3頁/共41頁前言Abdominalpainisacomplaintseencommonlyintheoutpatientsetting.Thedifferentialdiagnosisofapatientpresentingwithacuteabdominalpains.pathophysiologyofthepaintheclinicalpresentationCourseinitialmanagement第4頁/共41頁Afocusedhistoryphysicalexaminationadjunctivetestingstrategy第5頁/共41頁pathophysiologyofthepainTheabdominalvisceraareinnervatedwithnocioceptiveafferentswithinthemesentery,onperitonealsurfaces,andwithinthemucosaandmuscularisofholloworgans.第6頁/共41頁ThepaingenesisMechanicalstretchChemicalsubstancePserotoninprostaglandinshydrogenions第7頁/共41頁Stimuli

Dullcrampypoorlylocalizedpainsensations第8頁/共41頁ThreebroadpatternsvisceralParietalreferred第9頁/共41頁Visceraltypicallyinvolvesstretchanddistensionoftheabdominalorgans.althoughtorsion,andcontractionalsocontribute.

Thepainstimulusiscarriedonslow-conductingC-fibers.第10頁/共41頁dullache.Painlocationcorrespondstothosedermatomesthatmatchtheinnervationoftheinjuredorgan.第11頁/共41頁ParietalSharpwelllocalized

A-〥fibers,witharapidconductionvelocity第12頁/共41頁Referredpainoccurswhenvisceralafferentscarryingstimulifromadiseasedorganenterthespinalcordatthesamelevelassomaticafferentsfromaremoteanatomiclocation.第13頁/共41頁Furthermore,

diseaseprocessesfromorgansoutsideoftheabdominalcavitycanpresentwithabdominalpain.第14頁/共41頁Historyassessmentoftheconditionmedicalproblemsmedicationsfamilyhistory,substanceabusehistory,recenttravelhistoryoccupationalhistory.第15頁/共41頁NatureofthepainitsqualityLocationrapidityofonsetChronicityradiation,IntensityexacerbatingfactorsalleviatingfactorsAssociatedsymptoms第16頁/共41頁Physicalexaminationgeneralobservation(reviewofthevitalsigns)abdominalinspectionauscultationpalpation第17頁/共41頁第18頁/共41頁Diagnosisofabdominalpain

basedonlocationanddistributionRightupperquadrant

PepticulcerdiseaseBiliarydiseaseBiliarycolicCholedocholithiasisCholecystitisCholangitisLiverdiseaseHepatitisNeoplasmAbscessCongestivehepatopathyLungdiseasePneumoniaSubphrenicabscessPulmonaryembolismPneumothoraxAbdominalwallHerpeszosterMuscularStainKidneydiseasePyelonephritisPerinephricabscessNephrolithiasisColoniccausesColitisRightsideddiverticulitis第19頁/共41頁MiddleupperabdomenPepticulcerdiseasePancreatiticdiseasePancreatitisPancreaticneoplasmBiliarydiseaseBiliarycolicCholedocholithiasisCholecystitisCholangitisEsophagealdiseaseRefluxesophagitisInfectiousesophagitisPillesophagitisCardiacdiseaseMyocardialischemiainfarctionPericarditisAAArupture/aorticdissectionMesentericischemia第20頁/共41頁LeftupperquadrantPepticulcerdiseaseSplenicdiseaseSplenicruptureSplenicinfarctPancreaticdiseasePancreatitisPancreaticneoplasmLungdiseasePneumoniaSubphrenicabscessPulmonaryembolismPneumothoraxKidneydiseasePyelonephritisPerinephricabscessNephrolithiasis第21頁/共41頁PeriumbilicalAppendicitis(early)SmallbowelobstructionGastroenteritisMesentericischemiaAAAruptureAorticdissection第22頁/共41頁RightlowerquadrantAppendicitisInflammatoryboweldiseaseOB-GYNcausesOvariantumorOvariantorsionEctopicpregnancyPelvicinflammatorydisease(PID)KidneydiseasePyelonephritisPerinephricabscessNephrolithiasisIntestinaldiseaseRightsideddiverticulitisIleocolitisGastroenteritisHernia第23頁/共41頁SuprapubicInflammatoryboweldiseaseOB-GYNcausesOvariantumorOvariantorsionEctopicpregnancyPIDDysmenorrheaColonicdiseaseProctocolitisDiverticulitisUrinarytractdiseaseCystitisNephrolithiasisProstatitis第24頁/共41頁LeftlowerquadrantInflammatoryboweldiseaseOB-GYNcausesOvariantumorOvariantorsionEctopicpregnancyPIDKidneydiseasePyelonephritisPerinephricabscessNephrolithiasisIntestinaldiseaseSigmoiddiverticulitisIleocolitisGastroenteritisHernia第25頁/共41頁DiffuseGastroenteritisBowelobstructionPeritonitisMesentericischemiaInflammatoryboweldiseaseDiabeticketoacidosisPorphyriaUremiaHypercalcemiaSicklecellcrisisVasculitisHeavymetalintoxicationOpiatewihdrawalFamilialmediterraneanfeverHereditaryangioedema第26頁/共41頁basedonhistoryandphysicalalone,Physicianswereabletocorrectlydifferentiatebetweenorganicandnonorganiccausesofabdominalpainnearly80%第27頁/共41頁significantabnormalityofthevitalsigns,mentalstatuschanges,involuntaryguarding,reboundabdominaltenderness,completeabsenceofbowelsounds,andpainoutofproportiontoabdominaltenderness第28頁/共41頁withoutsignsorsymptomsofanacuteabdominalcatastrophe,anacuteexpeditedoutpatientevaluationshouldbeperformed.第29頁/共41頁laboratoryandimagingstudiesplainabdominalradiographshavebeentheinitialimagingtestofchoice.rapidlyatarelativelylowcost第30頁/共41頁upto60%ofcasesofsuspectedsmallbowelobstruction.withaperforatedviscus,sensitivityofplainfilmsisreportedtobeashighas100%.assmallas1to2ccofairhasbeenreportedusingthismethod第31頁/共41頁CTissensitiveforthediagnosisrapidhelicalscanningmethods,advancesinintravenousandoralcontrastagents,three-dimensionalreformatting第32頁/共41頁Computedtomographyhasproventobemoresensitiveandspecificfornearlyalletiologiesofacuteabdominalpain第33頁/共41頁

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