外科学肠梗阻PBL培训课件

1、外科学肠梗阻PBL外科学肠梗阻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?外科学肠梗阻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外科学肠梗阻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?外科学肠梗阻PBL4Case one(scene1)Q2：To make a d外科学肠梗阻PBL5外科学肠梗阻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、学肠梗阻PBL6Main point of the physical exaLocal pathophysiology of intestinal obstruction肠蠕动增加1.各类刺激长时间强蠕动肠麻痹2.肠腔膨胀、积气积液吞咽下的气体，以氮气为主，不易向血液内弥散长时间梗阻，肠腔内液体不再回流入血，而仍有液体自血液流入肠腔3.肠壁水肿、通透性增加梗阻近段肠腔压力升高，静脉回流受阻。细胞缺氧，能量代谢障碍，肠壁通透性增加。外科学肠梗阻PBL7Local pathophysiology of intesQ3: What is your diagnosis? Case one(scene1

7、)外科学肠梗阻PBL8Case one(scene1)外科学肠梗阻PBL8Definition & ClassificationDefinition:Intestinal contents can not pass successfully,which cause many pathophysiology and clinical symptoms. Classification:按照梗阻发生基本原因可分为三类：1. Mechanical Obstruction 2. Dynamic Obstruction3. Vascular Obstrucion外科学肠梗阻PBL9Definition &

8、 ClassificationDefMechanical obstruction include：Intraluminal obstructionExtraluminal obstruction Obstruction intrinsic to the bowel wall 外科学肠梗阻PBL10外科学肠梗阻PBL10Reasons of the intraluminal obstruction:Foreign bodiesGallstonesAscarid and etc. 蛔虫引起小肠梗阻 胆囊十二指肠内瘘引起胆石性肠梗阻外科学肠梗阻PBL11Reasons of the intralum

9、inal obCT scan show the stone in the intestine外科学肠梗阻PBL12CT scan show the stone in the Reason of the extraluminal obstruction :AdhesionsIncarceration herniaVolvulus and etc. 图中圆圈处显示束带压迫小肠引起梗阻 腹股沟斜疝嵌顿引起肠梗阻外科学肠梗阻PBL13Reason of the extraluminal obReason of the obstruction intrinsic to the bowel wall:盲肠

10、菜花样肿瘤导致肠梗阻 炎症性肠病导致肠壁炎性狭窄TumorInflammatory bowel disease and etc.外科学肠梗阻PBL14Reason of the obstruction intrParalytic ileus Drug indusedMetabolicNeurogenic InfectionsSpastic ileusDynamic obstruction include:外科学肠梗阻PBL15Paralytic ileus Dynamic obstru Plain Abdominal radiographs reveal ： Distended small b

11、owel as well as large bowel loops外科学肠梗阻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.外科学肠梗阻PBL17 Vascular Obstrucion外科学肠梗阻PBL按照有无血运障碍分为：1: Simple Obstruction 2: Strangulating Obstruction 其他分类：Proximal obstruction- Distal obstructionComplete obstruction- Incomplete obstructionClosed-loop Obstruction : Volvulus Colonic obstruction Internal hernia外科学肠梗阻

13、PBL18外科学肠梗阻PBL18Case one(scene2)Discussion： Please list your therapeutic-schedule.外科学肠梗阻PBL19Case one(scene2)Discussion： 外科Case one(scene3)见附页2外科学肠梗阻PBL20Case one(scene3)外科学肠梗阻PBL20General pathophysiology of intestinal obstruction消化液的回吸收停止、液体仍向肠腔渗出大量呕吐、禁食1.大量体液丧失和酸碱失调肠内容物淤积，毒素产生肠壁通透性增加，细菌毒素移位2.感染与中毒

14、3.休克肠腔压力升高，横膈抬高4.呼吸困难，心肺功能障碍外科学肠梗阻PBL21General pathophysiology of int 复查平片如下图外科学肠梗阻PBL22 复查平片如下图外科学肠梗阻PBL22Case one(scene3) （Strangulated intestinal obstruction, internalhernia） 患者即刻完善术前准备后行剖腹探查，术中见Treitz ligment 远端2m处小肠与腹部原切口下方粘连成角梗阻，并有远端小肠钻入其中形成内疝。Q4: What should we pay attention to during the ope

15、ration?Q5: Whats your suggestion when the patient discharge?外科学肠梗阻PBL23Case one(scene3) 患者即刻完善术腹部立卧位平片外科学肠梗阻PBL24腹部立卧位平片外科学肠梗阻PBL24造影剂检查对于肠梗阻也是重要诊断方法外科学肠梗阻PBL25造影剂检查对于肠梗阻也是重要诊断方法外科学肠梗阻PBL25CT不是首选外科学肠梗阻PBL26CT不是首选外科学肠梗阻PBL26 但有时会有意外发现外科学肠梗阻PBL27 但有时会有意外发现外科学肠梗阻PBL2Case two(scene1) 见附页3外科学肠梗阻PBL28Case

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

17、梗阻PBL31Case two(scene1)外科学肠梗阻PBL31外科学肠梗阻PBL培训课件Case two(scene1)Admitting diagnosis: Colonic obstruction.Q2: What is the treatment? Operation or Conservation ？外科学肠梗阻PBL33Case two(scene1)外科学肠梗阻PBL33Case two(scene2)见附页4外科学肠梗阻PBL34外科学肠梗阻PBL34Case two(scene2)Q3：What is the special preparation before the

18、operation？外科学肠梗阻PBL35Case two(scene2)Q3：What is theCase two(scene2) 患者完善肠道准备后，于入院第9天行剖腹探查术，术中见腹腔内无明显肿瘤，乙结肠部分冗长扩张，内有肛管支撑，乙结肠系膜较短，降结肠无明显充血水肿，内无明显肠内容物，行冗长部分乙结肠切除术，并行一期吻合。患者恢复顺利，术后第10天出院。外科学肠梗阻PBL36Case two(scene2) 患者完善肠道准备后，Discussion：Please compare case 1 with case 2.1：History2：Clinical manifestation3

19、：Auxiliary examination4：Treatment外科学肠梗阻PBL37Discussion：外科学肠梗阻PBL37请从以上两个病例讨论肠梗阻的诊断流程外科学肠梗阻PBL38外科学肠梗阻PBL38腹痛腹胀伴恶心呕吐入院详细询问病史和体格检查 有痛吐胀闭共同特点，考虑肠梗阻有正常排气排便，暂时排出肠梗阻根据病史特点及体检选择相关检查（血常规，B超，腹部平片及CT等）排除消化道穿孔，胰腺炎，阑尾炎，胆道疾病等外科常见急腹症必要时请相关科室会诊，排除尿路梗阻，卵巢扭转，胃肠炎等疾病 首选腹部立卧位平片检查针对病史，体检及辅检对各类型肠梗阻进行诊断（腹部CT，造影剂口服/灌肠摄片均是临

20、床常用检查） 选择治疗方案（保守/手术）机械性/动力性、完全性/非完全性，单纯性/绞窄性、小肠/结肠梗阻。肠梗阻诊断流程外科学肠梗阻PBL39腹痛腹胀伴恶心呕吐入院详细询问病史和体格检查 有痛吐胀闭共同请归纳肠梗阻的治疗方案外科学肠梗阻PBL40外科学肠梗阻PBL40肠梗阻的治疗方案基础治疗（任何肠梗阻无论手术或非手术均需要基础治疗）胃肠减压，纠正水电解质酸碱失衡，适当解痉，抗感染治疗非手术治疗（需要观察哪些事项?）（禁食，石蜡油胃管注入，腹部按摩，皮硝外敷，大承气汤攻下等）单纯性机械性不全小肠梗阻麻痹性肠梗阻正常排气排便，腹痛腹胀缓解。非手术治疗成功正规保守治疗 24-48小时后症状无缓解或加重绞窄性肠梗阻 完全性小肠梗阻结肠梗阻手术治疗最简单的方法解除梗阻和恢复肠道功能手术的方式根据梗阻的性质、部位、患者的全身情况决定。外科学肠梗阻PBL41肠梗阻的治疗方案基础治疗（任何肠梗阻无论手术或非手术均需要基肠梗阻诊疗过程中几个注意点1: 肠梗阻病因不一，临床表现多样，诊疗有一定困难，有 较高死亡率。2: 体格检查中切勿遗漏腹股沟部位和直肠指检。3: 病史中即使有少量排气排便也不可完全排除肠梗阻。4: 肠梗阻患者症状与体征不符合时，应考虑到血运性肠梗阻可 能。5: 单纯性不全性肠梗阻治疗过程中可能随时变成绞窄性肠梗