恶心呕吐宣讲培训课件

1、恶心呕吐宣讲恶心呕吐宣讲临床诊断学上海第二医科大学仁济临床医学院 恶心呕吐宣讲2临床诊断学上海第二医科大学仁济临床医学院 恶心呕吐宣讲2Nausea and VomitingAs the symptoms症状学：恶心与呕吐恶心呕吐宣讲3Nausea and Vomiting症状学：恶心与呕吐恶心GoalsBriefly defineOutline the prominent disease states associated with nausea and vomiting.Characterize Nausea and Vomiting caused by the prominent dis

2、orders Discriminate the accompanying symptoms. Suggest diagnostic strategies of the symptoms.恶心呕吐宣讲4GoalsBriefly define恶心呕吐宣讲4Definition of Nausea and VomitingNausea ：the inclination or feeling of imminent desire to vomit, usually felt in the throat or epi-gastrum. Associated with decreased activity

3、 of the stomach.Vomiting： the forceful oral expulsion of gastric contents via retro-peristalsis.Nausea-Vomiting: simultaneity or 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！恶心呕吐宣讲5Definition of Nausea and VomitNausea and Vomiting恶心呕吐宣讲6Nausea and Vomiting恶心呕吐宣讲61、

4、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 vomit, usually felt in the throat or epigastrum. Associated with decreased activity of the stomach.2. Retchi

5、ng - the labored rhythmic contraction of respiratory and abdominal musculature that frequently precedes or accompanies vomiting.3. Vomiting - the forceful oral expulsion of gastric contents via retroperistalsis. (Abdominal effects).恶心呕吐宣讲71、恶心：咽部及上腹部不适，胃张力和蠕动减弱，幽门和贲门开放迷走兴奋表现恶心干呕呕吐发生机制恶心呕吐宣讲8迷走兴奋表现恶心

6、干呕呕吐发生机制恶心呕吐宣讲8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）恶心呕吐宣讲9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Mechanisms of emesis恶心呕吐宣讲10Mechanisms of emesis恶心呕吐宣讲10CTZ & 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（

7、CTZ）的冲动恶心呕吐宣讲11CTZ & Emetic Center (Vomiting CTZ & Emetic Center (Vomiting center)孤束核恶心呕吐宣讲12CTZ & Emetic Center (Vomiting 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 感应耦合等离子体恶心呕吐宣讲13Emetic Center 内脏传入 中脑ICP受体化学感受Neurotransmitters in CTZ & Emetic Cen

8、terNeurotransmitters involved in stimulating the emetic center, chemo-receptor trigger zone and GI tract include; 5-HT, acetylcholine, histamine, dopamine (opiates and receptors for benzodiazepines are also found here)恶心呕吐宣讲14Neurotransmitters in CTZ & Eme恶心呕吐宣讲15恶心呕吐宣讲15恶心呕吐宣讲16恶心呕吐宣讲16Emetic Cente

9、r 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恶心呕吐宣讲17Emetic Center 1、分泌唾液中枢脊神经膈神经迷走恶心呕吐宣讲18恶心呕吐宣讲18nausea and vomiting1. Reflective vomiting 反射性呕吐2.Central vomiting 中枢性呕吐3. Neurological vomiting 神经性呕吐恶心呕吐宣讲19nausea and vomiting1. ReflectiReflective vomiting （反射性呕吐）咽部刺激胃十二指肠疾病胆道疾病肠道疾病肝胆疾病腹膜肠系膜全身性疾病（五官、心血管

10、、泌尿、盆腔）Pharyngeal MechanismsGastrointestinal MechanismsDisease of biliary tractPeritoneal and mesenterythe five sense organsCardiovascular diseases kidneyPelvic恶心呕吐宣讲20Reflective vomiting （反射性呕吐）咽部刺咽部刺激Pharyngal Mechanisms恶心呕吐宣讲21咽部刺激Pharyngal Mechanisms恶心呕吐宣讲Gastrointestinal Mechanisms恶心呕吐宣讲22Gastr

11、ointestinal Mechanisms恶心呕肝、胆、胰腺恶心呕吐宣讲23肝、胆、胰腺恶心呕吐宣讲23其他恶心呕吐宣讲24其他恶心呕吐宣讲24Intra-cranial infectionCerebrovascular disordersCraniocerebral injuryEpilepsyMetabolic disorders DrugsCentral 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）恶心呕吐宣讲25Intra-cranial infectionCentral颅内感染（脑炎、脑膜炎）恶心呕吐宣讲26颅内感染（脑炎

12、、脑膜炎）恶心呕吐宣讲26脑血管疾病、颅脑损伤恶心呕吐宣讲27脑血管疾病、颅脑损伤恶心呕吐宣讲27癫痫恶心呕吐宣讲28癫痫恶心呕吐宣讲28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恶心呕吐宣讲29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恶心呕吐宣讲30Drug抗生素兴奋呕吐中枢或影响胃肠平滑肌运动AntibioNeurologic & Psychogenic causesNeurologic and

13、Psychogenic causes胃肠道神经官能症（Gastrointestinal tract neurosis）神经厌食症（apositia）恶心呕吐宣讲31Neurologic & Psychogenic causeCharacteristics of Nausea and VomitingTimeTaking foodCharacteristicsCharacters of contents恶心呕吐宣讲32Characteristics of Nausea and 晨起呕吐早孕反应功能性消化不良酒精中毒胃食管反流病鼻咽部疾患夜间或隔夜呕吐幽门梗阻贲门失弛缓症恶心呕吐宣讲33晨起呕吐早

14、孕反应功能性消化不良酒精中毒胃食管反流病鼻咽部疾患呕吐与进食的关系（ 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：提示幽门梗阻恶心呕吐宣讲34呕吐与进食的关系餐后即刻：神经精神性；集体发病系食物中毒餐后呕吐特点神经性或颅内高压：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恶心呕吐宣讲35呕吐特点神经性或颅内高压：恶心轻、呕吐频；“喷射性呕吐”呕吐The

15、 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：应想到药物反应恶心呕吐宣讲36The accompanying symptoms腹痛、腹泻问诊要点起病情况：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恶心呕吐宣讲37问诊要点起病情况：诱因、急缓、与进食关系、腹部

16、手术史、育龄妇History/Backgrounda) Ageb) GI history requiredc) Food intoleranced) Timing with mealse) Consistencyf) Contentg) Odorh) Frequencyi) Feverj) Weight lossk) Precipitating factorsl) Myalgias（肌痛）, visual disturbances, headache, pain outside abdomen恶心呕吐宣讲38History/Backgrounda) Ageg) OdoCAUSES OF NAU

17、SEA/VOMITINGEarly pregnancyPsychogenesis vomitingBulimia(易饿病)Pyloric channel ulcerAcute gastritisGastric retention(潴留）Viral gastroenteritis（中毒性胃肠炎）Acute gastroenteritisMyocardial infarctionPeritonitis（腹膜炎）Acute obstructionNeurological emergencyDrug toxicityCancer therapyDrug withdrawal恶心呕吐宣讲39CAUSES

18、 OF NAUSEA/VOMITINGEarlyPHYSICAL EXAMVital signsSkinHEENT （head,eyes,ear,nose,throat)AbdomenNeurological恶心呕吐宣讲40PHYSICAL EXAMVital signs恶心呕吐宣讲LABORATORYRule out obstruction and peritonitisHCGUrinalysisElectrolytes, BUN, creatinine, glucoseTransaminases, amylaseEKG, head CT, upper GI &/or endoscopies

19、恶心呕吐宣讲41LABORATORYRule out obstructionBreak恶心呕吐宣讲42Break恶心呕吐宣讲42泸沽湖黄昏恶心呕吐宣讲43泸沽湖黄昏恶心呕吐宣讲43泸沽湖黄昏恶心呕吐宣讲44泸沽湖黄昏恶心呕吐宣讲44泸沽湖摩梭女恶心呕吐宣讲45泸沽湖摩梭女恶心呕吐宣讲45玉龙雪山雪月恶心呕吐宣讲46玉龙雪山雪月恶心呕吐宣讲46恶心呕吐宣讲47恶心呕吐宣讲47ConstipationShanghai Second Medical universityRenji clinical medical college恶心呕吐宣讲48ConstipationShanghai Second

20、MeBackground恶心呕吐宣讲49Background恶心呕吐宣讲49Constipation Is a Constellation of SymptomsMost commonly reported symptomsHard, lumpy stoolsIncreased strainingInfrequent bowel movementsSensation of incomplete evacuationBloating/fullnessChronic constipationMore persistent than intermittent or episodicSeveral m

21、onths durationC恶心呕吐宣讲50Constipation Is a ConstellatioSandler RS, et al. Dig Dis Sci. 1987;32:841-845.n = 1128Constipation Is More Than Just Infrequent Passage of Stool53Constipation symptoms reported most often恶心呕吐宣讲51Sandler RS, et al. Dig Dis SciReduced Stool Frequency Is Not the Most Commonly Rep

22、orted Symptom in ConstipationEPOC = Epidemiology 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) 19991Par 20012n = 1476n = 1149Constipation symptoms reported most oftenC恶心呕吐宣讲52Redu

23、ced Stool Frequency Is NotPrevalence in the General Population1. Stewart WF, 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;96:3130-3137.53PopulationnCrite

24、riaPrevalence, n (%)US110,018Rome I 461 (4.6)US25430Rome I 195 (3.6)US315,183Rome II2429 (16)Canada41149Rome II 171 (14.9)China (18-70ys)?RomeII?(6.07)China(60ys)?RomeII?(15-20)恶心呕吐宣讲53Prevalence in the General PopuEpidemiologyChronic constipation is commonSlightly more common in women F/M ratio = r

25、ange 1.3 to 2.5 (China=4:1)Affects all age groupsStewart 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恶心呕吐宣讲54EpidemiologyChronic constipatiConstipation Affects All Age Groups53Canadian populati

26、on.Par P, et al. Am J Gastroenterol. 2001;96:3130-3137.N = 1149n = 378n = 367n = 217n = 187恶心呕吐宣讲55Constipation Affects All Age GProfile of a Typical Chronic Constipation Patient in My PracticeGenerally femaleSymptomatic for 10 yrMajority have tried lifestyle changes, fiber, and OTC laxatives prior

27、to seeking careManages condition with multiple therapiesMost often referred by a primary care physician Copes with condition, but is not completely satisfiedC恶心呕吐宣讲56Profile of a Typical Chronic CConstipation Can Have a Negative Impact on Quality of LifePeople with CC reported significant impairment

28、 in QoL on SF-36 scale (n = 126)1In Canada, people with self-reported or Rome II constipation had significantly 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)31. OKeefe E

29、A, et al. J Gerontol A Biol Sci Med Sci. 1995;50:M184-M189.2. Irvine EJ, et al. Am J Gastroenterol. 2002;97:1986-1993. 3. Koloski NA, et al. Am J Gastroenterol. 2000;95:67-71. C恶心呕吐宣讲57Constipation Can Have a NegatiConstipation Significantly Impacts Healthcare Utilization5.7 million constipation-rel

30、ated outpatient visits annually1,24.1 million physician office-based visits 991,000 emergency room visits587,000 hospital outpatient visits$2752/patient for tertiary care evaluation31. National Ambulatory Medical Care Survey, 2001. 2. National Hospital Ambulatory Care Survey, 2001. 3. Rantis PC Jr,

31、et al. Dis Colon Rectum. 1997;40:280-286.C恶心呕吐宣讲58Constipation Significantly ImpComplications related with constipationColonic and rectal carcinomaOther colon-rectal-anus disordershepatic coma acute myocardial infarctionmammary gland disorderspresenile dementia(早老性痴呆）psycho-problemsappearance恶心呕吐宣讲5

32、9Complications related with conDefinition: Causes of Chronic ConstipationSecondaryDrug induced Metabolic factorsComorbid conditionsPrimaryImpaired colonic transit/motility Altered neuroenteric function and reflexesFailure of muscular apparatusIneffective defecation (functional outlet obstruction)Pel

33、vic dyssynergia and anismusNormal transit constipation恶心呕吐宣讲60Definition: Causes of Chronic Presentation ObjectivesDefine constipationThe pathophysiological mechanisms Etiologies of constipation Characterize manifestationDiscriminate the accompanying symptoms. Suggest diagnostic strategies of the sy

34、mptoms.C恶心呕吐宣讲61Presentation ObjectivesDefine 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）bloatedsluggish恶心呕吐宣讲62What is Constipati

35、on?Passage oRome II Defines Functional Constipation Based on Multiple SymptomsRome 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*Sensation of a

36、norectal 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恶心呕吐宣讲63Rome II Defines Functional ConNormal metabolismAs food moves through your intestines, it absorbs water while f

37、orming waste products Muscles contract in the colon, pushing the stool toward the rectum恶心呕吐宣讲64Normal metabolismAs food movesDefecation ProcessYield awareness of defecation Anal intra- and extra-sphincter RelaxationAbdominal effects恶心呕吐宣讲65Defecation ProcessYield awarenMechanical stimulation1. Yiel

38、d awareness of defecation恶心呕吐宣讲66Mechanical stimulation1. Yield2. Anal intra- and extra-sphincter Relaxationintra- sphincterextra-sphincterLevator ani muscle恶心呕吐宣讲672. Anal intra- and extra-sphin2. Abdominal effectsgastric contents via anus恶心呕吐宣讲682. Abdominal effectsgastric coWhat Causes Constipati

39、on?Eating too little fiber Not drinking enough liquidsLack of exercise/physical activity恶心呕吐宣讲69What Causes Constipation?EatinWhat Causes Constipation?Change in routinetravelOlder ageSlower metabolismFrequent use of laxativesCertain diseases or conditions恶心呕吐宣讲70What Causes Constipation?ChangWhat Ca

40、uses Constipation?Certain diseases or conditionsRectal and Anal disordersColonic disordersSystemic diseases or conditions恶心呕吐宣讲71What Causes Constipation?Certa恶心呕吐宣讲培训课件Classification of etiologiesEating too little fiber Not drinking enough liquidsLack of exercise/physical activityChange in routineT

41、ravelpsycho-relatedOlder ageSlower metabolismFrequent use of laxativestediously long ColonMedicationsTravelpain (narcotics麻药)antacids containing aluminumantidepressantsiron supplementsdiuretics (“water” pills)Functional etiologies恶心呕吐宣讲73Classification of etiologiesEapsycho-related恶心呕吐宣讲74psycho-rel

42、ated恶心呕吐宣讲74Tediously long Colon结肠冗长恶心呕吐宣讲75Tediously long Colon结肠冗长恶心呕吐宣讲 Organic constipation (certain diseases or conditions cause constipation)Classification of etiologiesRectal and Anal disordersBenign or malignancy tumorTumor or mass outsideSystemic diseases or conditions (e.g. disorders make dyscinesia: spasm and paralysis）恶心呕吐宣讲76 Organic constipation ClassifiRectal and Anal disordersCancerNevusanal fissur