1、,VOMITING & DIARRHEA,Concept Clinical characters & Etiology Mechanism Diagnostic & therapeutic approach,Retrograde fashion，from stomach through mouth Rapid evacuation of gastric contents,Vomiting,Nausea Regurgitation Rumination,Serious Complications of Vomiting,不同病因的呕吐表现-1,Food poisoning / GI Infect
2、ions,Inflammation of peritoneum or viscera,Cardiovascular disease,不同病因的呕吐表现-2,Metabolic - uremia, acidosis, hypoxia, pregnancy,Motion sickness, labyrinthitis,Sinusitis, glaucoma,Increased intracranial pressure Psychogenic,Medication,呕吐的反射通路,呕吐反射区 - CTZ 呕吐中枢 传入神经 - 迷走神经 内脏神经 化学信息 传出神经 - 迷走神经 交感神经 体神经
3、 脑神经,Neural Pathways -1,Chemo-receptor Trigger Zone (CTZ) Upper center (CNS) & peripheral nerves Response to medication or metabolic diseases Vestibular area,Neural Pathways -2,Vomiting Center (reticular formation) GI & extra-GI Vestibular area CTZ Upper center of the brain (CNS),Timing in relation
4、to meals Relief of pain by vomiting Ejective vomiting Contents of vomitus Odor of vomitus,如何诊断呕吐？ - Features of Vomiting,FeverDiarrhea Abdominal painAppetite and weight lossHeadache,- Associated Symptoms,Epidemiology or exposureChronic renal diseasesDM & other endocrine diseasesMenstruation: pregnan
5、cyDrugs Previous abdominal surgery,- Related History or Diseases,Succussion splash & visible peristalsisBowel sounds Abdominal mass HerniaJaundiceDehydrationOthers,- Physical Examination,初步评估是否严重,是,严重： - 脱水 循环不良 - 剧烈 - 外科指征,否,进一步评估,消化科病因所致,非消化科病因所致,紧急处理： - 纠正水电平衡 - 对症支持 - 药物,呕吐,- 纠正水电平衡 - 对症支持 - 病因治
6、疗 - 止吐治疗,MIMS 2011,呕吐的诊治流程,VOMITING & DIARRHEA,Definition of diarrhea Stool liquidity Daily stool weight 300g/d Frequency 3/d,Fecal incontinence Paradoxical diarrhea,Bristol Stool Form Scale,Normal Physiology of Intestines,Level of Flow K+ Na+ Cl HCO3 mOsmIntestine ml/d mEq/L mEq/L mEq/L mEq/L /kg,D
7、uodenum 9000 60 15 60 15 VariableJejunum 3000 140 6 100 30 IsotonicIleum 1000 140 8 60 70 IsotonicRectum 100 40 90 15 30 Isotonic,Secretory diarrhea (分泌性腹泻) Osmotic diarrhea (渗透性腹泻) Exudative diarrhea (渗出性腹泻) Deranged motility induced diarrhea (动力紊乱引起的腹泻),Classification of Diarrhea, secretion of act
8、ive ion & water absorption of ion & water,I. Secretory Diarrhea,Mechanisms,Vast watery diarrhea Dehydration and acid-alkali disturbance Stool 1 L/d (20 ml/kg/d)Stool 500 ml/d after a 2-day fasting Stool isotonic, anion gap 10 mEq/L ( 50 mEq/L) Stool basic or neutral No blood, pus, fat,Secretory Diar
9、rhea - Clinical Features-1,No abdominal pain or mild painNo tenesmus (里急后重),Secretory Diarrhea - Clinical Features-2, Enterotoxins: cholera, E. coli Circulating secretagogues，VIP Gastrin hypersecretion，ZES Bile salts, fatty acids, laxatives Villous adenoma of colon,Secretory Diarrhea - Etiology,Accu
10、mulation of poorly absorbed solutes in the lumenWater drawn into the lumen to make the contents isotonic,II. Osmotic Diarrhea,Mechanisms,Large, greasy, foul stoolNo blood or pus, Stool 40 mEq/L,II. Osmotic Diarrhea - Clinical Features-1,No pain or mild painNo tenesmusMay be associated with mal-diges
11、tion and malnutrition,II. Osmotic Diarrhea - Clinical Features-2,Carbohydrate malabsorption due to enzyme deficiencyCeliac spruePancreatic insufficiency,II. Osmotic Diarrhea - Etiology,Bloody or pussy stool Abdominal pain May have tenesmus，fever & toxemia,III. Exudative Diarrhea:- Clinical Features,
12、Infectious enteritis of a variety of cytotoxic pathogensInflammatory bowel disease (IBD)Damage of intestinal mucosa with inflammation: tumors, etc.,III. Exudative Diarrhea: - Etiology,Increased small bowel motilityRapid colonic transit Diminished motility leading to bacterial overgrowth,IV. Diarrhea
13、 due to Deranged Motility: Mechanisms,ThyrotoxicosisDiabetes mellitusIrritable bowel syndrome (D-IBS)Pseudo-obstructionDrugs,Etiology of Deranged Motility,Inquiring about the following Onset and duration Frequency Amount of stool: once and total Characters of stool,什么病因引起腹泻？ - 病史,- Acute or chronic
14、- Infectious or non-infectious - Progressive or self-limited - Right-sided or left-sided,病史帮助判断是哪一类腹泻,Right-sided Left-sided Diarrhea Diarrhea“Large” stool “Small” stool Less frequent frequent No tenesmus tenesmus Less likely- visible blood & pus,病史帮助确定不同部位的腹泻,- Fever - Abdominal pain - Nausea and v
15、omiting - Tenesmus or constipation - General health：Appetite, weight, strength, nutrition,病史：相关的症状, Epidemiology and travelling Drugs: antibiotics, laxatives Sex contact,病史：有关的信息,Related systemic diseasesInfectious diseasesEndocrine diseasesConnective tissue diseasesTumorsCeliac disease, malabsorpti
16、onSex-transmissible diseasesAllergies,病史：有关的疾病史,General conditionLymph nodesAbdomenSigns of related diseases,如何识别不同病因引起的腹泻？ - Physical Examination,Stool - routine，OB - bacteria, parasitesBlood electrolytes, BUN, CrLab tests for related diseases Colonoscopy & biopsyImaging X-ray BUS CT,检验和特殊检查,急性腹泻评估
17、流程,急性腹泻评估流程-继,Modified, from Sellin, 2002,Exclude Structural disease,慢性腹泻的诊治流程,Chronic osmotic diarrhea - stool analysis - carbohydrate malabsorption - inadvertent ingestion - laxative abuse,Dietary reviewBreath H2 test (lactose)Lactase assay,慢性腹泻的诊治流程,腹泻便次3/d持续4周以上,初步评估,诊断：器质性腹泻,诊断：功能性腹泻,怀疑吸收不良腹泻,怀疑末端回肠病变,暂不能判断病因的腹泻,小肠/胰腺疾病检查,进一步评估,住院评估,处理和治疗原则：针对病因，纠正水电平衡，合理饮食和用药 对症支持 针对病因 经验治疗,MIMS 2011,慢性腹泻的诊治流程,VOMITING & DIARRHEA,Concept Clinical characters & Etiology Mechanism Diagnostic & therapeutic approach,
