1、临床诊断学,Nausea and VomitingAs the symptoms,症状学：恶心与呕吐,Goals,Briefly defineOutline the prominent disease states associated with nausea and vomiting.Characterize Nausea and Vomiting caused by the prominent disorders Discriminate the accompanying symptoms. Suggest diagnostic strategies of the symptoms.,De
2、finition of Nausea and Vomiting,Nausea ：the inclination or feeling of imminent desire to vomit, usually felt in the throat or epi-gastrum. Associated with decreased activity of the stomach.Vomiting： the forceful oral expulsion of gastric contents via retro-peristalsis.Nausea-Vomiting: simultaneity o
3、r separateness,恶心：紧迫欲吐，通常伴有上腹不适和迷走兴奋的临床征候群。呕吐：胃和/或小肠内容物经食管和口腔排除体外恶心和呕吐常伴随存在，也可单独出现！,Nausea and Vomiting,1、恶心：咽部及上腹部不适，胃张力和蠕动减弱，幽门和贲门开放。2、干呕：胃窦部和腹壁肌肉收缩，腹压增加，食管及咽部开放。3、呕吐：胃和/或小肠内容物经食管和口腔排除体外。,Definition of emesis. (Three phases)呕吐反射过程（三个阶段）,1. Nausea - the inclination or feeling of imminent desire to
4、vomit, usually felt in the throat or epigastrum. Associated with decreased activity of the stomach.2. Retching - the labored rhythmic contraction of respiratory and abdominal musculature that frequently precedes or accompanies vomiting.3. Vomiting - the forceful oral expulsion of gastric contents vi
5、a retroperistalsis. (Abdominal effects).,迷走兴奋表现,恶心,干呕,呕吐,发生机制,呕吐区别于反食,呕吐：多数情况有恶心的感觉和呕吐反射的协调动作。,反食：无恶心的感觉和呕吐反射的协调动作。（儿童、饱餐）,Mechanisms of emesis,CTZ & Emetic Center (Vomiting center),CTZ化学感受器触发带（第四脑室底面）：外源性或内源性化学物质（阿片吗啡、洋地黄、代谢产物）,Emetic Center（延髓外侧网状结构背测）接受大脑皮质、消化器官、心血管以及化学感受器触发带（CTZ）的冲动,CTZ & Emetic
6、 Center (Vomiting center),孤束核,Emetic Center,内脏传入,中脑ICP受体,化学感受器触发带,边缘系统,前庭系统,呕吐中枢（Vomiting center),ICP=Inductively Coupled Plasma 感应耦合等离子体,Neurotransmitters in CTZ & Emetic Center,Neurotransmitters involved in stimulating the emetic center, chemo-receptor trigger zone and GI tract include; 5-HT, acet
7、ylcholine, histamine, dopamine (opiates and receptors for benzodiazepines are also found here),Emetic Center,1、分泌唾液中枢2、血管收缩中枢3、呼吸中枢4、中枢神经,脊神经,膈神经,迷走神经,nausea and vomiting,1. Reflective vomiting 反射性呕吐2.Central vomiting 中枢性呕吐3. Neurological vomiting 神经性呕吐,Reflective vomiting （反射性呕吐）,咽部刺激胃十二指肠疾病胆道疾病肠道疾
8、病肝胆疾病腹膜肠系膜全身性疾病（五官、心血管、泌尿、盆腔）,Pharyngeal MechanismsGastrointestinal MechanismsDisease of biliary tractPeritoneal and mesenterythe five sense organsCardiovascular diseases kidneyPelvic,咽部刺激,Pharyngal Mechanisms,Gastrointestinal Mechanisms,肝、胆、胰腺,其他,Intra-cranial infectionCerebrovascular disordersCran
9、iocerebral injuryEpilepsyMetabolic disorders Drugs,Central vomiting （中枢性呕吐）,颅内感染脑血管疾病颅脑损伤癫痫全身疾病（尿毒症、肝昏迷、糖尿病代谢紊乱）,颅内感染（脑炎、脑膜炎）,脑血管疾病、颅脑损伤,癫痫,全身疾病,尿毒症,肝昏迷,酮症酸中毒,各种原因引起的脑水肿和颅内压升高,代谢紊乱,早孕,Drug,抗生素抗癌药洋地黄吗啡,兴奋呕吐中枢或影响胃肠平滑肌运动,AntibioticsAnti-carcinomaDigitalismorphia,Neurologic & Psychogenic causes,Neurolog
10、ic and Psychogenic causes,胃肠道神经官能症（Gastrointestinal tract neurosis）神经厌食症（apositia）,Characteristics of Nausea and Vomiting,TimeTaking foodCharacteristicsCharacters of contents,夜间或隔夜呕吐,幽门梗阻,贲门失弛缓症,呕吐与进食的关系（ Timing with meals）,餐后即刻：神经精神性；集体发病系食物中毒,餐后1小时以上：为延迟性呕吐：可考虑为胃张力低下排空障碍,餐后较久、多餐后或隔夜：提示幽门梗阻,呕吐特点,神经
11、性或颅内高压：恶心轻、呕吐频；“喷射性呕吐”,呕吐物性质,发酵、腐臭味：提示胃潴留,粪臭味：提示较低位置的肠梗阻,无酸腐味：贲门失迟缓症或胃酸缺乏,不含胆汁：幽门梗阻,病史较长或量多：提示体液和电解质丢失,The accompanying symptoms,腹痛、腹泻：食物中毒、肠道传染病、胃肠炎；节律性腹痛：消化性溃疡,右上腹痛，伴发热、黄疸：胆囊炎、胆道结石、感染。,头痛、头晕、视力异常、喷射性呕吐：颅内高压性疾病、屈光不正、青光眼。,伴眩晕、眼球震颤：前庭障碍,育龄妇女（停经）：应排除妊娠,与服药有时间关联：应想到药物反应,问诊要点,起病情况：诱因、急缓、与进食关系、腹部手术史、育龄妇女
12、月经史发作时间：晨、夜、与进食、活动、体位的关系呕吐物性状、味道伴随症状诊疗和症状演变情况,History/Background,a) Ageb) GI history requiredc) Food intoleranced) Timing with mealse) Consistencyf) Content,g) Odorh) Frequencyi) Feverj) Weight lossk) Precipitating factorsl) Myalgias（肌痛）, visual disturbances, headache, pain outside abdomen,CAUSES OF
13、 NAUSEA/VOMITING,Early pregnancyPsychogenesis vomitingBulimia(易饿病)Pyloric channel ulcerAcute gastritisGastric retention(潴留）Viral gastroenteritis（中毒性胃肠炎）Acute gastroenteritis,Myocardial infarctionPeritonitis（腹膜炎）Acute obstructionNeurological emergencyDrug toxicityCancer therapyDrug withdrawal,PHYSICA
14、L EXAM,Vital signsSkinHEENT （head,eyes,ear,nose,throat)AbdomenNeurological,LABORATORY,Rule out obstruction and peritonitisHCGUrinalysisElectrolytes, BUN, creatinine, glucoseTransaminases, amylaseEKG, head CT, upper GI &/or endoscopies,Break,泸沽湖黄昏,泸沽湖黄昏,泸沽湖摩梭女,玉龙雪山雪月,46,Constipation,Shanghai Second M
15、edical universityRenji clinical medical college,Background,Constipation Is a Constellation of Symptoms,Most commonly reported symptomsHard, lumpy stoolsIncreased strainingInfrequent bowel movementsSensation of incomplete evacuationBloating/fullnessChronic constipationMore persistent than intermitten
16、t or episodicSeveral months duration,C,Sandler RS, et al. Dig Dis Sci. 1987;32:841-845.,n = 1128,Constipation Is More Than Just Infrequent Passage of Stool,53,Constipation symptoms reported most often,Reduced Stool Frequency Is Not the Most Commonly Reported Symptom in Constipation,EPOC = Epidemiolo
17、gy of constipation; BM = Bowel movement.1. Stewart WF, et al. Am J Gastroenterol. 1999;94:3530-3540.2. Par P, et al. Am J Gastroenterol. 2001;96:3130-3137.,Stewart (EPOC) 19991,Par 20012,n = 1476,n = 1149,Constipation symptoms reported most often,C,Prevalence in the General Population,1. Stewart WF,
18、 et al. Am J Gastroenterol. 1999;94:3530-3540.2. Drossman DA, et al. Dig Dis Sci. 1993;38:1569-1580.3. Harris Interactive Study, Wave 2. Data on file. 4. Par P, et al. Am J Gastroenterol. 2001;96:3130-3137.,53,Epidemiology,Chronic constipation is commonSlightly more common in women F/M ratio = range
19、 1.3 to 2.5 (China=4:1)Affects all age groups,Stewart WF, et al. Am J Gastroenterol. 1999;94:3530-3540.Par P, et al. Am J Gastroenterol. 2001;96:3130-3137.Sandler RS, et al. Dig Dis Sci. 1987;32:841-845.,C,Constipation Affects All Age Groups,53,Canadian population.Par P, et al. Am J Gastroenterol. 2
20、001;96:3130-3137.,N = 1149,n = 378,n = 367,n = 217,n = 187,Profile of a Typical Chronic Constipation Patient in My Practice,Generally femaleSymptomatic for 10 yrMajority have tried lifestyle changes, fiber, and OTC laxatives prior to seeking careManages condition with multiple therapiesMost often re
21、ferred by a primary care physician Copes with condition, but is not completely satisfied,C,Constipation Can Have a Negative Impact on Quality of Life,People with CC reported significant impairment in QoL on SF-36 scale (n = 126)1In Canada, people with self-reported or Rome II constipation had signif
22、icantly worse SF-36 scores than the normal population (n = 472)2In Australia, people with constipation had significantly worse SF-12 scores on both mental and physical scales (n = 227)3,1. OKeefe EA, et al. J Gerontol A Biol Sci Med Sci. 1995;50:M184-M189.2. Irvine EJ, et al. Am J Gastroenterol. 200
23、2;97:1986-1993. 3. Koloski NA, et al. Am J Gastroenterol. 2000;95:67-71.,C,Constipation Significantly Impacts Healthcare Utilization,5.7 million constipation-related outpatient visits annually1,24.1 million physician office-based visits 991,000 emergency room visits587,000 hospital outpatient visits
24、$2752/patient for tertiary care evaluation3,1. National Ambulatory Medical Care Survey, 2001. www.cdc.gov2. National Hospital Ambulatory Care Survey, 2001. www.cdc.gov3. Rantis PC Jr, et al. Dis Colon Rectum. 1997;40:280-286.,C,Complications related with constipation,Colonic and rectal carcinomaOthe
25、r colon-rectal-anus disordershepatic coma acute myocardial infarctionmammary gland disorderspresenile dementia(早老性痴呆）psycho-problemsappearance,Definition: Causes of Chronic Constipation,SecondaryDrug induced Metabolic factorsComorbid conditionsPrimaryImpaired colonic transit/motility Altered neuroen
26、teric function and reflexesFailure of muscular apparatusIneffective defecation (functional outlet obstruction)Pelvic dyssynergia and anismusNormal transit constipation,Presentation Objectives,Define constipationThe pathophysiological mechanisms Etiologies of constipation Characterize manifestationDi
27、scriminate the accompanying symptoms. Suggest diagnostic strategies of the symptoms.,C,What is Constipation?,Passage of hard, dry, lumpy stools; Infrequent bowel movements, usually fewer than three times a weekSymptoms:painful bowel movements strainingUncomfortable（Sensation of incomplete evacuation
28、）bloatedsluggish,Rome II Defines Functional Constipation Based on Multiple Symptoms,Rome II diagnostic criteria for functional constipationAt least 12 wk, which need not be consecutive, over the past 12 months of 2 or more of Straining*Lumpy or hard stools*Sensation of incomplete evacuation*Sensatio
29、n of anorectal obstruction/blockage*Manual maneuvers to facilitate defecation* 1/4 of defecations.Drossman DA, et al. In: Rome II: The Functional Gastrointestinal Disorders. 2000:382-391.,C,Normal metabolism,As food moves through your intestines, it absorbs water while forming waste products Muscles
30、 contract in the colon, pushing the stool toward the rectum,Defecation Process,Yield awareness of defecation Anal intra- and extra-sphincter RelaxationAbdominal effects,Mechanical stimulation,1. Yield awareness of defecation,2. Anal intra- and extra-sphincter Relaxation,intra- sphincter,extra-sphinc
31、ter,Levator ani muscle,2. Abdominal effects,gastric contents via anus,What Causes Constipation?,Eating too little fiber Not drinking enough liquidsLack of exercise/physical activity,What Causes Constipation?,Change in routinetravelOlder ageSlower metabolismFrequent use of laxativesCertain diseases o
32、r conditions,What Causes Constipation?,Certain diseases or conditionsRectal and Anal disordersColonic disordersSystemic diseases or conditions,What Causes Constipation?,pain (narcotics麻药)antacids containing aluminumantidepressantsiron supplementsdiuretics (“water” pills),Medications,Classification o
33、f etiologies,Eating too little fiber Not drinking enough liquidsLack of exercise/physical activityChange in routineTravelpsycho-relatedOlder ageSlower metabolism,Frequent use of laxativestediously long ColonMedicationsTravelpain (narcotics麻药)antacids containing aluminumantidepressantsiron supplement
34、sdiuretics (“water” pills),Functional etiologies,psycho-related,Tediously long Colon,结肠冗长,Organic constipation (certain diseases or conditions cause constipation),Classification of etiologies,Rectal and Anal disordersBenign or malignancy tumorTumor or mass outsideSystemic diseases or conditions (e.g
35、. disorders make dyscinesia: spasm and paralysis）,Rectal and Anal disorders,CancerNevusanal fissureanal fistulaProctoptosis (直肠脱垂）,intestinal obstruction,Benign or malignancy tumor,Polyp,Cancer,Outside tumor or mass,Systemic diseases or conditions,Gastro-paresisDiabetes mellitus; DMUremiaMyasthenia
36、gravisHypothyroidismHematoporphyriaLead poisoning,胃轻瘫糖尿病尿毒症重症肌无力甲状腺机能低下血卟啉病铅中毒,Characteristics of manifestation,急性便秘常伴随原发病的表现：腹痛、腹胀、恶心呕吐、排气停止，见于各种原因的肠梗阻。慢性便秘可有消化不良症状：便秘型IBS：大便形状：,1.散粒2.团粒3.柱粒4.条形5.堆6.片7.水,Accompanying symptoms,1。呕吐、腹胀、肠绞痛，提示肠梗阻2。伴包块：提示肿瘤、肠结核、Crohn病3。便秘腹泻交替：肠结核、IBS、UC4。继发于生活、环境改变：功能性
37、,Intestinal obstructionTumor,TB,Crhons diseaseTB,IBS,UCFunctional constipation,Important information for etiological diagnosis,a) Ageb) GI history requiredc) Food habitd) Condition related (living,working, communicating, psychology) e) Consistency f) course of diseases,g) Frequency h) form, texture, Odor, Content, i) Increased straining, Sensation of incomplete j) Weight lossk) Precipitating factorsl) Medicationsm) Disorders outside gastroenterology,今天告诉你的事情可要记牢吆！,
