便秘和腸梗阻的姑息性處理課件

便秘和腸梗阻的姑息性處理目的討論姑息關(guān)懷領(lǐng)域便秘的病因和處理通過(guò)使用一個(gè)病例來(lái)闡明繼發(fā)于晚期癌癥的腸梗阻的內(nèi)科處理ManagementofconstipationandbowelobstructioninpalliativecareDr.CharlieBond.SirmichaelSobellHouse.oxfordAimsToconsiderthecausesandmanagementofconstipationinpalliativecareTodemonstrate,throughtheuseofacaseexample,themedicalmanagementofbowelobstructionsecondarytoadvancedcancer便秘和腸梗阻的姑息性處理便秘和腸梗阻的姑息性處理目的討論姑息關(guān)懷領(lǐng)域便秘的病因和處理通過(guò)使用一個(gè)病例來(lái)闡明繼發(fā)于晚期癌癥的腸梗阻的內(nèi)科處理ManagementofconstipationandbowelobstructioninpalliativecareDr.CharlieBond.SirmichaelSobellHouse.oxfordAimsToconsiderthecausesandmanagementofconstipationinpalliativecareTodemonstrate,throughtheuseofacaseexample,themedicalmanagementofbowelobstructionsecondarytoadvancedcancer便秘一病因藥物阿片類(lèi)藥物(引起過(guò)多分節(jié))抗毒蕈堿類(lèi)藥物虛弱制動(dòng)脫水癌癥高鈣血癥瘤旁?xún)?nèi)臟神經(jīng)病Constipation-causesDrugsOpioids(causehypersegmentation)AntimuscarinicsDebilityInactivityDehydrationancerHypercalcaemiaParaneoplasticvisceralneuropath緩瀉劑刺激劑-增加蠕動(dòng)例如:番瀉葉,便塞停滲透性藥物-增加水的含量&軟化氫氧化鎂,乳果糖表面潤(rùn)濕劑-例如:多庫(kù)酯鈉潤(rùn)滑劑一液體石蠟(礦物油)LaxativesStimulant-increaseperistalsisSenna,BisacodylOsmotic-increasewatercontentsoftenMagnesiumhydroxideLactuloseSurfacewettingagentse.gdocusatesodiumLubricantsLiquidParaffin(mineraloil便秘一病因藥物阿片類(lèi)藥物(引起過(guò)多分節(jié))抗毒蕈堿類(lèi)藥物虛弱制動(dòng)脫水癌癥高鈣血癥瘤旁?xún)?nèi)臟神經(jīng)病Constipation-causesDrugsOpioids(causehypersegmentation)AntimuscarinicsDebilityInactivityDehydrationancerHypercalcaemiaParaneoplasticvisceralneuropath緩瀉劑刺激劑-增加蠕動(dòng)例如:番瀉葉,便塞停滲透性藥物-增加水的含量&軟化氫氧化鎂,乳果糖表面潤(rùn)濕劑-例如:多庫(kù)酯鈉潤(rùn)滑劑一液體石蠟(礦物油)LaxativesStimulant-increaseperistalsisSenna,BisacodylOsmotic-increasewatercontentsoftenMagnesiumhydroxideLactuloseSurfacewettingagentse.gdocusatesodiumLubricantsLiquidParaffin(mineraloilOrallaxativeclassification口服緩瀉劑的分類(lèi)PredominantlyLiquidParaffin(mineraloil)Softening液體石蠟(礦物油)以軟化為主Bulk-forminglaxativese.gMethylcellulose,ispaghula容積性緩瀉劑,例如甲基纖維素,Polyethyleneglycol聚乙二醇DocusateSodium多庫(kù)酯鈉Lactulose乳果糖PredominantlyMagnesiumHydroxide氫氧化鎂peristalsisSennaanddanthronStimulating番瀉葉和丹蒽醌以刺激蠕動(dòng)為主Bisacodyl,sodiumpicosulphate便塞停(吡沙可啶),匹可硫酸鈉便秘的處理糾正可逆轉(zhuǎn)的因素:脫水;高鈣血癥;藥物非藥物治療:液體;飲食-果汁,纖維素;腹部按摩;針灸藥物治療:刺激性緩瀉劑+/-軟化性緩瀉劑;栓劑/灌腸劑ManagementofConstipationCorrectthecorrectableDehydrationHypercalcaemiaNondrugtreatmentfluidsDiet-fruitAbdominalmassageAcupunctureDrugtreatmentStimulantlaxative+/softeninglaxatiSuppositories/enemas便秘的處理如果直腸內(nèi)大便硬結(jié)經(jīng)直腸處理以軟化大便例如:甘油栓劑或十二烷酸灌腸首先使用軟化性緩瀉劑如果直腸內(nèi)為軟便:刺激性緩瀉劑+/-栓劑如果直腸內(nèi)沒(méi)有或只有少量大便刺激性緩瀉劑+/-軟化性緩瀉劑,栓劑/灌腸ManagementofConstipationIfrectumimpactedwithhardfaecesRectalmeasurestosoftene.gglycerinesuppositoriesorarachisoilenemaUsesofteninglaxativesfirstIfrectumisloadedwithsoftfaecesStimulantlaxatives+/-suppositoriesIfthereislittleornostoolinrectum:Stimulantlaxatives+/-softeninglaxativeSuppositories/enemas阿片類(lèi)藥物誘發(fā)的便秘90%接受阿片類(lèi)藥物的患者需要一種緩瀉劑阿片類(lèi)藥物增強(qiáng)結(jié)腸環(huán)收縮,導(dǎo)致“分節(jié)過(guò)多”刺激性緩瀉劑松弛結(jié)腸環(huán)的收縮用于阿片類(lèi)藥物誘發(fā)的便秘的緩瀉劑:刺激劑+/-軟化劑Opioidinducedconstipation:90%ofpatientsonmorphineneedalaxative.OpioidsenhanceringcontractionsleadingtoHypersegmentationStimulantlaxativesrelaxringcontractionsLaxativesforopioidinducedconstipationStimulant+/softener晚期癌癥消化道梗阻的病因梗阻性腫瘤團(tuán)塊癌癥引起的炎癥/水腫內(nèi)臟神經(jīng)病便秘CausesofgastrointestinalobstructioninadvancedcancerObstructingtumourmassInflammation/oedemafromcancerVisceralneuropathyConstipation腸梗阻-5個(gè)問(wèn)題梗阻的平面(節(jié)段)?單個(gè)或多個(gè)部位?器質(zhì)性或功能性?部分的或完全的?過(guò)性或持續(xù)的Bowelobstruction-5questionsLevelofobstructionSingleormultiplesites?Organicorfunctional?Partialorcomplete?Transientorpersistent腸梗阻:治療的選擇“滴注和吸吮”-鼻胃管+靜脈內(nèi)輸液外科手術(shù):切除和吻合,支架,“分流手術(shù)”,穿孔