肠梗阻教案-上海第二医科大学附属瑞金医院课件

肠梗阻INTESTINALOBSTRUCTIONRuiJinhospitalZhangHaoboIntroduction

肠内容物不能正常运行,顺利通过肠道

病因学机械性梗阻

肠腔阻塞:结石、粪块、异物肠管受压:粘连带、肠扭转、疝肠壁病变：肿瘤、炎性、先天性动力性肠梗阻麻痹性：神经、毒素、炎性痉挛性：肠动力紊乱、铅中毒血运性肠梗阻肠系膜血管栓塞或血栓形成肠梗阻是否伴血运障碍单纯性/绞窄性肠梗阻部位高位：空肠上段低位：回肠末段结肠梗阻肠梗阻程度：不完全性/完全性发展进程：急性/慢性病理生理病理生理ClinicalAppearance腹痛呕吐便秘停止排气

PhysicalExamination

视诊腹胀Abdomendistention蠕动波Peristalicwave手术疤痕Surgicalscars嵌顿疝Incarceratedhernias

触诊腹胀腹块腹肌紧张腹膜炎PhysicalExamination腹部听诊

肠鸣音亢进

直肠指检LaboratoryTests血浆电解质和PH值BloodWBCHematocrit

Serumamylase

BUN

X射线检查

RadiologicExamination诊断正确率80~85%

平卧位

立位

侧卧位

急性完全性机械性梗阻

扩张小肠襻

气液平倒U字型

直肠和结肠内无气体

RadiologicExamination小肠梗阻SmallintestinalOB

小肠黏膜呈鱼刺样

valvulae

conniventes

肠段位于腹中部

centralportions

小量/无结肠气体

minimal/nocolonicgas结肠梗阻

ColonObstruction

结肠袋影

colonichaustralmarking

扩张肠段位于腹部外周/盆腔

peripheryofabdomen/inthepelvic1.有否肠梗阻？

Doesthepatienthavebowelobstruction?2.梗阻在那一段肠段

Ifso,whereisit?3.病因是什么？

Whatistheanatomicandpathologicnature?4.是否存在绞榨性肠梗阻

Hasstrangulationoccurred?5.患者全身情况如何？

Whatisthegeneralconditionofthepatients?诊断

Diagnosis临床表现

ClinicalAppearance腹痛Abdominalpain呕吐Vomiting便秘Obstipation腹胀Abdominaldistention停止排气

Failuretopassflatus

DifferentiationofpartialfromcompleteSBOPartialSBO:passflatusorliquidstoolsCompleteSBO:obstipation

DifferentiationofProximal/distalSBO:pain:epigastric/periumbilicalareavomiting:prominent/lateronsetdistention:no/predominate

鉴别近端和远端梗阻DifferentiationofProximal/distalSBO:

pain:epigastric/periumbilicalareavomiting:prominent/lateronsetdistention:no/predominate鉴别部分梗阻和完全性梗阻DifferentiationofpartialfromcompleteSBO

PartialSBO:passflatusorliquidstoolsCompleteSBO:obstipation单纯性和绞榨性肠梗阻的鉴别

单纯性肠梗阻腹痛阵发性轻度-中度呕吐较少休克无，少见发热不常见腹痛和肌卫少见对补液治疗有效绞榨性肠梗阻腹痛持续性重度呕吐严重休克早、常见发热明显腹痛和肌卫早、明显对补液治疗效果差治疗

TreatmentofSBO保守治疗和手术治疗

Medicalandsurgicalmanagement三个连续的阶段：观察、治疗、手术

Theoverlappingsequence:investigationresuscitationoperation手术时机的把握：Thetimingofoperationdependsonthreefactors:

病程duration重要器官的功能opportunityofvitalorganfunction绞榨的可能riskofstrangulationThetimingofoperationdependsonthreefactors:

病程duration

器官功能opportunityofvitalorganfunction

绞榨的可能riskofstrangulationMedicalmanagment胃肠减压Nasointestinal/nasogastricintubation纠正水电解质的紊乱Intravenousfluids/bloodplasmaadministration广谱抗菌素的应用Broad-spectrumantibioticsadministrationSurgicalprinciple病因

ThenatureofproblemdeterminesapproachtomanagementofSBO.肠管活性的判断：色泽、活力、动脉搏动

Thecriteriaofdeterminingbowelviability:colormotilityarterialpulsation处理

Ifquestionable,releasedandplaced,re-examined.结肠梗阻

LargeBowelObstruction病因学Etiologycarcinoma55%volvulus11%diverticulitis9%extrinsiccarcinoma8%adhesions4%fecalimpaction3%Daignosis慢性梗阻Chroniccomplaints腹痛位于下腹部和脐周

Painrelatedtolowerabdomenorperiumbilicalarea.腹胀明显Abdominaldistensionprominent隐血试验Guaiac-positivestools直肠指检RectalexaminationManagement直肠乙状结肠镜Proctosigmoidoscopy

visualized/biopsied/decompressed结肠梗阻大多数需要手术治疗

Mostlargebowelobstructionneedsurgeryexpcetforfecalimpaction闭襻性梗阻需急症手术

Closedloopobstructionneedemergency分期手术

one/two/three-stagesurgicalprocedures肠粘连

Adhesiveobstruction形成：粘连锐角纤维束带压迫

surgicaltraumainfectionsbleedingintestinalischemiachemicaltraumaforeignbodies（powder）肠坏死Riskofstrangulation:9%再次手术肠排列手术(M-A管)疝源性肠梗阻外疝:

下腹痛,腹外疝好发部位肿块,无法回纳手术松解疝环,疝修补,坏死肠段切除。内疝:

疝环为先天或手术形成腹内间隙.

多为闭襻性,X线平片仅为一致密影.

症状剧烈,病情急骤,诊断困难,需急诊手术

肠套叠

IntussusceptionIntussusceptumtelescopesintoanintussuscipiens(sheath)enteroenteral,ileocecal,ileocolic,colocolicchildrenrateishigh1/3casesofadultsismalignanciesresectionisnecessary(香肠状,空虚感,粘液血便)肠扭转