醫(yī)學(xué)《小兒消化外科》課件

小兒消化外科

Peadiatricdigistivesurgery消化外科？

Digestivesurgery

腸壞死患兒腸切除腸造瘺術(shù)后Thechildwithintestinalnecrosisafteroperationofintestinalresectionandintestinalfistula病情復(fù)雜，病種繁多

Theconditioniscomplex,manykindsofdiseases

先天性巨結(jié)腸CongenitalmegacolonNEC腸穿孔Intestinalperforationduetonecrotizingenterocolitis膽總管囊腫Choledochalcyst食管閉鎖Esophagealatresia小腸閉鎖Intestinalatresia新生兒胃穿孔Neonatalgastricperforation高胰高性低血糖癥Highglucagonhypoglycemia小兒消化系統(tǒng)解剖生理特點

Anatomicalandphysiologicalcharacteristicsofpediatricdigestivesystem

解剖生理特點及臨床意義Anatomyandclinicalsignificanceofphysiologicalcharacteristics口腔、食管、胃、腸、胰腺、肝臟、腸道細(xì)菌、小兒糞便

Oralcavity,esophagus,stomach,intestine,pancreas,liver,intestinalbacteria,pediatricstool

1．口腔Oralcavity

小兒口腔粘膜柔嫩,血管豐富,易受損而發(fā)生感染。局部軟組織感染。Pediatricoralmucosalisvulnerabletoinfections.Localsofttissueinfection.2.食管Esophagus食管閉鎖Esophagealatresia3．胃Stomach新生兒胃壁肌肉發(fā)育不良時，可發(fā)生胃穿孔。Whentheneonatalgastricmuscledevelops

notwell,gastricperforationmayoccur.4.腸

固定差，易發(fā)生腸套疊及腸扭轉(zhuǎn)。5．肝、膽Liverandgallbladder肝母細(xì)胞瘤肝母細(xì)胞瘤Hepatoblastoma膽道閉鎖與Biliaryatresiaand

膽總管囊腫Choledochalcyst6.腸道細(xì)菌

Intestinalbacteria胎兒消化道內(nèi)無細(xì)菌，出生后細(xì)菌很快從口、鼻、肛門侵入腸道，大多集中在大腸及直腸內(nèi)。Nobacteriaexistsinthedigestivetractofthefetus.Afterbirthbacteriaquicklyinvadestheintestinalsystemfrommouth,nose,analandconcentrateinthecolonandrectum.7．健康小兒糞便

Faecesofhealthchildren新生兒最初排出的大便為深墨綠色、粘稠、無臭味，稱胎糞。Neonatefirstdefecatesmeconiumwiththecolourofdeepdarkgreenandnosmell.多數(shù)新生兒生后10小時內(nèi)開始排便，2～3天漸過渡為黃糊狀糞便。Mostnewbornsstartdefecationwithin10hoursafterbirthandstoolgraduallytransitestoyellowpastyin2~3days.24小時內(nèi)無胎糞排出，應(yīng)注意檢查有無肛門閉鎖等消化道畸形。Ifnostoolin24hoursweshouldcheckwhethertheanalatresiaorotherdigestivetractmalformationexist.常見疾病Commondiseases食管閉鎖Esophagealatresia十二指腸梗阻Duodenalobstruction

先天性肥厚性幽門梗阻Congenitalhypertrophicpyloricstenosis小腸閉鎖Intestinalatresia腸重復(fù)畸形Intestinalduplication腸旋轉(zhuǎn)不良Intestinalmalrotation先天性巨結(jié)腸Congenitalmegacolon先天性肛門直腸畸形Congenitalanorectalmalformation先天性膽道閉鎖Congenitalbiliaryatresia先天性膽總管囊腫Congenitalcholedochalcyst重點講述Keypoints食管閉鎖Esophagealatresia十二指腸梗阻Duodenalobstruction先天性肥厚性幽門梗阻Congenitalhypertrophicpyloricstenosis腸套疊Intussusception先天性巨結(jié)腸

Congenitalmegacolon肛門閉鎖Analatresia食管閉鎖分型

Typesofesophagealatresia最常見Ⅲ型：近端閉鎖遠(yuǎn)端氣管食瘺占85%~90%ThemostcommontypeIII:theproximalatresia,thedistaltracheafistula,whichaccountsfor85%~90%特殊類型食管閉鎖—隔膜型?食管璞?

Specialtypesofesophagealatresia-diaphragmtype?

食管閉鎖的典型表現(xiàn)

Thetypicalmanifestationsofesophagealatresia

唾液多，喂奶時嗆咳，反復(fù)肺炎Saliva,nursingcough,repeatedpneumonia影像學(xué)在食道閉鎖中的作用

Imagingintheroleofesophagealatresia

三維CT重建

ThreedimensionalCTreconstruction

造影與支氣管鏡檢查確診

ConfirmedbyangiographyandbronchoscopyH型基礎(chǔ)手術(shù)方法Operationmethod食管閉鎖的解剖Anatomyofesophagealatresia

上腔V近端食管迷走N已結(jié)扎的奇V氣管并發(fā)癥Complications1、吻合口瘺Anastomoticfistula2、吻合口狹窄Anastomoticstricture預(yù)后Prognosis

預(yù)后良好，不影響兒童的生長發(fā)育Theprognosisisgoodanditdoesnotaffectthegrowthanddevelopmentofchildren新生兒胃穿孔(neonatalgastricperforation)一般于生后2～7天發(fā)病，病死率很高。Itoccursin2~7daysafterbirthanditsfatalityrateishigh.好發(fā)于胃大彎處。Itusuallyoccursinthegreatercurvatureofstomach.原因：Reasons1.胃壁肌層缺損Gastricmuscularwalldefects2.胃收縮拉力不對稱Asymmetryofgastriccontractiontension3.賁門部大彎部過分?jǐn)U張Excessiveexpansionofgreatercurvature

小兒腸梗阻Childrenintestinalobstruction

病因Etiology

梗阻原因

Causesofobstruction機械性Mechanical動力性Dynamic血運性Vascular

血運障礙

Bloodcirculationdisorder

單純性與絞窄性Simpleandstrangulatedintestinalobstruction痛吐脹閉Abdominalpain,vomiting,abdominaldistentionandstoppingexhausting.胃腸型Gastrointestinaltype腹部壓痛Abdominaltenderness腸鳴音亢進(jìn)Hyperactivebowelsounds臨床表現(xiàn)Clinicalmanifestations腸旋轉(zhuǎn)不良

Intestinalmalrotation

腸旋轉(zhuǎn)不良

Intestinalmalrotation環(huán)狀胰腺Annularpancreas

十二指腸閉鎖Duodenalatresia小腸閉鎖Intestinalatresia腸重復(fù)畸形Intestinalduplication先天性肛門閉鎖Congenitalanalatresia嵌頓疝Strangulatedhernia梅克爾憩室

Meckel'sdiverticulum

先天性肥厚性幽門狹窄

Congenitalhypertrophicpyloricstenosis

定義Definition該病是由于幽門環(huán)肌肥厚增生使幽門管狹窄而引起的機械性梗阻。Thediseaseismechanicalobstructioncausedbypyloricstenosisduetopyloricmusclehypertrophy.概述Overview

發(fā)病率為1/1000~3000（國內(nèi)）

Theincidencerateis1/1000~3000(domestic)男：女=5：1Theproportionofboysandgirlsis5:1白人>黃人>黑人Themorbidityfromlargetosmallinturnisthewhite,yellowandblack占消化道畸形的第三位Thediseaseranksthirdindigestivetractmalformation遺傳因素Geneticfactors內(nèi)分泌因素Endocrinefactors神經(jīng)發(fā)育異常Abnormalnervousdevelopment病因

Etiology病理

Pathology

HPS肌肉增厚以環(huán)肌為主，肌厚可達(dá)4-7mmCircularmusclethickenswithmusclethicknessupto4-7mm鏡下

Undermicroscope環(huán)肌增厚為主，縱肌輕度增生Circularmusclethickensandlongitudinalmusclehasmildhyperplasia粘膜水腫、潰瘍、充血Mucosahasedema,hyperemia,ulcer神經(jīng)節(jié)細(xì)胞減少、缺如或發(fā)育不良Ganglioncellsdecreaseorwiththecellsabsenceorhypoplasia臨床表現(xiàn)Clinicalmanifestations足月頭胎男孩多見Thediseasepreferstooccurinthefirstfull-termmalebaby嘔吐Vomiting：出生后2－4周發(fā)生，嘔吐進(jìn)行性加重，吐后求食欲望強烈。Vomitingoccurs

in2-4weeksafterbirthandaggravateswithstrongdesireforfoodaftervomiting.消瘦或體重不增Weightlossorweightdoesnotincrease二便減少Thestoolandurinedecrease脫水與電解質(zhì)紊亂：Dehydrationandelectrolytedisorder：多伴低氯低鉀性堿中毒Mostaccompaniedwithlowchlorinehypokalemicalkalosis腹部體征Abdominalsigns視診Inspection：上腹膨隆，可見胃型，逆行蠕動波Upperabdominaldistention,visiblegastrictype,retrogradeperistalticwave觸診Palpation：可觸特征性包塊Wecantouchcharacteristicmass觸診Palpation超聲診斷Ultrasonicdiagnosis幽門長>17mm寬＞13mm肌肉厚＞4mm

Pyloriclengthismorethan17mm,thewidthismorethan13mmandmusclethicknessismorethan4mm.診斷Diagnosis典型病史Typicalhistory右上腹包塊Rightupperabdominalmass輔助檢查Accessoryexamination鑒別診斷Differentialdiagnosis先天性消化道畸形Congenitaldigestivetractmalformation喂養(yǎng)不當(dāng)Improperfeeding幽門痙攣Pylorospasm胃食管反流