外科學(xué)腸梗阻PBL培訓(xùn)課件

1、外科學(xué)腸梗阻PBL外科學(xué)腸梗阻PBLCase one(scene1) Male , age: 65, “Paraxymal abdominal pain 48h with nausea and vomiting one day”, you are the doctor on duty.Q1. According to the chief complaint, which kind of information you should collect during ask the history?外科學(xué)腸梗阻PBL2Case one(scene1) Male , aMain point of th

2、e history1:Abdominal painThe position、level、kind of pain, with or without radiation ,the relationship between bowel sound and pain, paroxymal or continuing.2:Nausea and vomitingThe kind、volumn、color and smell of vomitus, the relationship between vomiting and pain.3:Abdominal distentionTime,level and

3、 position 4:Failure to pass flatus and fecesThe kind、quantity of feces and the relationship between it and pain,if the pain relieve after pass flatus and feces.5:Past history外科學(xué)腸梗阻PBL3Main point of the history1:AbdCase one(scene1)Q2：To make a definite diagnosis，which kind of information we should pa

4、y attention to in the next Physical Examination and Auxiliary Examination?外科學(xué)腸梗阻PBL4Case one(scene1)Q2：To make a d外科學(xué)腸梗阻PBL5外科學(xué)腸梗阻PBL5Main point of the physical examinationGeneral Examination： T:37.2 HR:96bpm R:22bpm BP:130/70mmhg No dehydration, no anemia, no jaundice Abdominal Examination： Inspect

5、ion：Distended abdomen, no peristaltic waves can be observed,previous scar in the upper abdomen. Palpation: Mild abdominal tenderness, no rebound,no guarding,no mass, no incarcerated hernia in the groin. Percussion：Tympany. Auscultation：Hyperactive bowel sounds , 6-8bpm.Rectal Examination：Negative 外科

6、學(xué)腸梗阻PBL6Main point of the physical exaLocal pathophysiology of intestinal obstruction腸蠕動(dòng)增加1.各類刺激長(zhǎng)時(shí)間強(qiáng)蠕動(dòng)腸麻痹2.腸腔膨脹、積氣積液吞咽下的氣體，以氮?dú)鉃橹?，不易向血液?nèi)彌散長(zhǎng)時(shí)間梗阻，腸腔內(nèi)液體不再回流入血，而仍有液體自血液流入腸腔3.腸壁水腫、通透性增加梗阻近段腸腔壓力升高，靜脈回流受阻。細(xì)胞缺氧，能量代謝障礙，腸壁通透性增加。外科學(xué)腸梗阻PBL7Local pathophysiology of intesQ3: What is your diagnosis? Case one(scene1

7、)外科學(xué)腸梗阻PBL8Case one(scene1)外科學(xué)腸梗阻PBL8Definition & ClassificationDefinition:Intestinal contents can not pass successfully,which cause many pathophysiology and clinical symptoms. Classification:按照梗阻發(fā)生基本原因可分為三類：1. Mechanical Obstruction 2. Dynamic Obstruction3. Vascular Obstrucion外科學(xué)腸梗阻PBL9Definition &

8、 ClassificationDefMechanical obstruction include：Intraluminal obstructionExtraluminal obstruction Obstruction intrinsic to the bowel wall 外科學(xué)腸梗阻PBL10外科學(xué)腸梗阻PBL10Reasons of the intraluminal obstruction:Foreign bodiesGallstonesAscarid and etc. 蛔蟲引起小腸梗阻 膽囊十二指腸內(nèi)瘺引起膽石性腸梗阻外科學(xué)腸梗阻PBL11Reasons of the intralum

9、inal obCT scan show the stone in the intestine外科學(xué)腸梗阻PBL12CT scan show the stone in the Reason of the extraluminal obstruction :AdhesionsIncarceration herniaVolvulus and etc. 圖中圓圈處顯示束帶壓迫小腸引起梗阻 腹股溝斜疝嵌頓引起腸梗阻外科學(xué)腸梗阻PBL13Reason of the extraluminal obReason of the obstruction intrinsic to the bowel wall:盲腸

10、菜花樣腫瘤導(dǎo)致腸梗阻 炎癥性腸病導(dǎo)致腸壁炎性狹窄TumorInflammatory bowel disease and etc.外科學(xué)腸梗阻PBL14Reason of the obstruction intrParalytic ileus Drug indusedMetabolicNeurogenic InfectionsSpastic ileusDynamic obstruction include:外科學(xué)腸梗阻PBL15Paralytic ileus Dynamic obstru Plain Abdominal radiographs reveal ： Distended small b

11、owel as well as large bowel loops外科學(xué)腸梗阻PBL16 Plain Abdominal rad Vascular Obstrucion Caution： In the early stage of vascular obstruction, patients often have obvious chief complaint but without abdominal sign. But in the late stage, besides the obvious chief complaint, patients will have peritoneal

12、irritation sign and bloody stool.外科學(xué)腸梗阻PBL17 Vascular Obstrucion外科學(xué)腸梗阻PBL按照有無(wú)血運(yùn)障礙分為：1: Simple Obstruction 2: Strangulating Obstruction 其他分類：Proximal obstruction- Distal obstructionComplete obstruction- Incomplete obstructionClosed-loop Obstruction : Volvulus Colonic obstruction Internal hernia外科學(xué)腸梗阻

13、PBL18外科學(xué)腸梗阻PBL18Case one(scene2)Discussion： Please list your therapeutic-schedule.外科學(xué)腸梗阻PBL19Case one(scene2)Discussion： 外科Case one(scene3)見附頁(yè)2外科學(xué)腸梗阻PBL20Case one(scene3)外科學(xué)腸梗阻PBL20General pathophysiology of intestinal obstruction消化液的回吸收停止、液體仍向腸腔滲出大量嘔吐、禁食1.大量體液?jiǎn)适Ш退釅A失調(diào)腸內(nèi)容物淤積，毒素產(chǎn)生腸壁通透性增加，細(xì)菌毒素移位2.感染與中毒

14、3.休克腸腔壓力升高，橫膈抬高4.呼吸困難，心肺功能障礙外科學(xué)腸梗阻PBL21General pathophysiology of int 復(fù)查平片如下圖外科學(xué)腸梗阻PBL22 復(fù)查平片如下圖外科學(xué)腸梗阻PBL22Case one(scene3) （Strangulated intestinal obstruction, internalhernia） 患者即刻完善術(shù)前準(zhǔn)備后行剖腹探查，術(shù)中見Treitz ligment 遠(yuǎn)端2m處小腸與腹部原切口下方粘連成角梗阻，并有遠(yuǎn)端小腸鉆入其中形成內(nèi)疝。Q4: What should we pay attention to during the ope

15、ration?Q5: Whats your suggestion when the patient discharge?外科學(xué)腸梗阻PBL23Case one(scene3) 患者即刻完善術(shù)腹部立臥位平片外科學(xué)腸梗阻PBL24腹部立臥位平片外科學(xué)腸梗阻PBL24造影劑檢查對(duì)于腸梗阻也是重要診斷方法外科學(xué)腸梗阻PBL25造影劑檢查對(duì)于腸梗阻也是重要診斷方法外科學(xué)腸梗阻PBL25CT不是首選外科學(xué)腸梗阻PBL26CT不是首選外科學(xué)腸梗阻PBL26 但有時(shí)會(huì)有意外發(fā)現(xiàn)外科學(xué)腸梗阻PBL27 但有時(shí)會(huì)有意外發(fā)現(xiàn)外科學(xué)腸梗阻PBL2Case two(scene1) 見附頁(yè)3外科學(xué)腸梗阻PBL28Case

16、 two(scene1) 外科學(xué)腸梗阻PBL28Case two(scene1)Q1: What is your primary diagnosis? To prove your diagnosis,which kind of examination do you need?外科學(xué)腸梗阻PBL29Case two(scene1)Q1: What is yoCase two(scene1) Supine & upright radiographs of the patient外科學(xué)腸梗阻PBL30Case two(scene1) Supine & upriCase two(scene1)外科學(xué)腸

17、梗阻PBL31Case two(scene1)外科學(xué)腸梗阻PBL31外科學(xué)腸梗阻PBL培訓(xùn)課件Case two(scene1)Admitting diagnosis: Colonic obstruction.Q2: What is the treatment? Operation or Conservation ？外科學(xué)腸梗阻PBL33Case two(scene1)外科學(xué)腸梗阻PBL33Case two(scene2)見附頁(yè)4外科學(xué)腸梗阻PBL34外科學(xué)腸梗阻PBL34Case two(scene2)Q3：What is the special preparation before the

18、operation？外科學(xué)腸梗阻PBL35Case two(scene2)Q3：What is theCase two(scene2) 患者完善腸道準(zhǔn)備后，于入院第9天行剖腹探查術(shù)，術(shù)中見腹腔內(nèi)無(wú)明顯腫瘤，乙結(jié)腸部分冗長(zhǎng)擴(kuò)張，內(nèi)有肛管支撐，乙結(jié)腸系膜較短，降結(jié)腸無(wú)明顯充血水腫，內(nèi)無(wú)明顯腸內(nèi)容物，行冗長(zhǎng)部分乙結(jié)腸切除術(shù)，并行一期吻合?；颊呋謴?fù)順利，術(shù)后第10天出院。外科學(xué)腸梗阻PBL36Case two(scene2) 患者完善腸道準(zhǔn)備后，Discussion：Please compare case 1 with case 2.1：History2：Clinical manifestation3

19、：Auxiliary examination4：Treatment外科學(xué)腸梗阻PBL37Discussion：外科學(xué)腸梗阻PBL37請(qǐng)從以上兩個(gè)病例討論腸梗阻的診斷流程外科學(xué)腸梗阻PBL38外科學(xué)腸梗阻PBL38腹痛腹脹伴惡心嘔吐入院詳細(xì)詢問病史和體格檢查 有痛吐脹閉共同特點(diǎn)，考慮腸梗阻有正常排氣排便，暫時(shí)排出腸梗阻根據(jù)病史特點(diǎn)及體檢選擇相關(guān)檢查（血常規(guī)，B超，腹部平片及CT等）排除消化道穿孔，胰腺炎，闌尾炎，膽道疾病等外科常見急腹癥必要時(shí)請(qǐng)相關(guān)科室會(huì)診，排除尿路梗阻，卵巢扭轉(zhuǎn)，胃腸炎等疾病 首選腹部立臥位平片檢查針對(duì)病史，體檢及輔檢對(duì)各類型腸梗阻進(jìn)行診斷（腹部CT，造影劑口服/灌腸攝片均是臨

20、床常用檢查） 選擇治療方案（保守/手術(shù)）機(jī)械性/動(dòng)力性、完全性/非完全性，單純性/絞窄性、小腸/結(jié)腸梗阻。腸梗阻診斷流程外科學(xué)腸梗阻PBL39腹痛腹脹伴惡心嘔吐入院詳細(xì)詢問病史和體格檢查 有痛吐脹閉共同請(qǐng)歸納腸梗阻的治療方案外科學(xué)腸梗阻PBL40外科學(xué)腸梗阻PBL40腸梗阻的治療方案基礎(chǔ)治療（任何腸梗阻無(wú)論手術(shù)或非手術(shù)均需要基礎(chǔ)治療）胃腸減壓，糾正水電解質(zhì)酸堿失衡，適當(dāng)解痙，抗感染治療非手術(shù)治療（需要觀察哪些事項(xiàng)?）（禁食，石蠟油胃管注入，腹部按摩，皮硝外敷，大承氣湯攻下等）單純性機(jī)械性不全小腸梗阻麻痹性腸梗阻正常排氣排便，腹痛腹脹緩解。非手術(shù)治療成功正規(guī)保守治療 24-48小時(shí)后癥狀無(wú)緩解或加重絞窄性腸梗阻 完全性小腸梗阻結(jié)腸梗阻手術(shù)治療最簡(jiǎn)單的方法解除梗阻和恢復(fù)腸道功能手術(shù)的方式根據(jù)梗阻的性質(zhì)、部位、患者的全身情況決定。外科學(xué)腸梗阻PBL41腸梗阻的治療方案基礎(chǔ)治療（任何腸梗阻無(wú)論手術(shù)或非手術(shù)均需要基腸梗阻診療過程中幾個(gè)注意點(diǎn)1: 腸梗阻病因不一，臨床表現(xiàn)多樣，診療有一定困難，有 較高死亡率。2: 體格檢查中切勿遺漏腹股溝部位和直腸指檢。3: 病史中即使有少量排氣排便也不可完全排除腸梗阻。4: 腸梗阻患者癥狀與體征不符合時(shí)，應(yīng)考慮到血運(yùn)性腸梗阻可 能。5: 單純性不全性腸梗阻治療過程中可能隨時(shí)變成絞窄性腸梗