《肠梗阻病例讨论》

Departmentofgeneralsurgery

BiJing-Taofrankbjt@126.com

ClinicalCase

Discussion精选ppt

A

60-year-oldfemaleisadmittedtotheemergencyroomwith

a48-hourhistoryoflowerabdominalpain,nausea,vomitingandconstipation.Thepatientdescribesthepainascrampyinearlyandnotesthatherabdomenhasbecomedistendedoverthelast12hours.Herlastbowelmovementwasthreedayspriortopresentation.CASE1精选ppt女性，60岁，“腹痛、呕吐、腹胀和肛门停止排便排气2天,加重12小时”急诊入院精选pptQuestion

1.what’swrongwiththeoldwoman?

2.whatcausesit?

3.Howcanshegetwell?Operationisneedornot?精选pptDoctorneedtoanswer:DiagnosisEtiologyTreatment精选pptWhat

shouldbedonenext?精选pptHerpastmedicalhistoryisremarkableinthatsheunderwentanappendectomyforacuteappenditistenyearsago.Sheisotherwisehealthyandtakesnomedications.Physicalexamrevealsatemperatureof38℃.Herabdomenisdistended.精选ppt

ClinicalManifestationsAbdominalpainNauseaandvomitingObstipationDistention精选pptAbdominalpain

Colickyabdominalpain

inearlyperiod

lasting

abdominalpain

later

精选pptNauseaandvomiting

1).Thenatureofthevomitus.

undigestedfoodparticles.

becomesbilious.

feculent.

2).Theonsetandcharacterofvomiting.

Recurrentvomitingofbile-stainedfluid

Prolongednauseaprecedesvomiting,feculent.

精选ppt

Contispationandobstipation

Theonsetofobstipation,alatedevelopmentStillpassflatus:

thedistal,unobstructedintestineempties.

partialorincompleteobstruction精选pptDistention

Developlaterinthecourseoftheobstruction

littlebylittle精选pptPhysicalExaminationInspectionPalpationPercussionAuscultation精选pptInspection

rightupperquadrantrightlowerquadrantleftupperquadrantLeftlowerquadrant精选pptPalpation

mildtendernessinRLQbutnoguardingorrebound

Mass5cmX4cm，

Noperitonitis精选pptPercussion

shiftingdullnessINRLQ精选pptAuscultationnoisyandisheardasrushes.Duringattacksofcolic,thesoundsbecomeloud,high-pitchedandmetallic.精选pptRectalexamination:Lowrectalcarcinomaandintussusceptedsegmentdon’tbepalpatedrectalexamrevealsnostoolintherectum.Knee-elbowPosition精选pptAhemoglobinof16,hematocrit48,whitebloodcellcount12,200with74polys.Serumelectrolytesshowthelevelofserumsodiumandpotassiumis130mol/land3.0mol/l.ArterialbloodgasanalysisrevealsthattheresultofPHis7.30.AnabdominalX-RAYrevealsmultipledilatedloopsofsmallbowelwithnumerousair-fluidlevels.ThereisnogasorstoolvisibleinthecolonAdmittinglaboratorydata精选pptRadiologicalExaminations

2008-12-42008-12-5X-rays

Upright精选pptSupineX-rays2008-12-52008-12-4精选ppt精选pptCTscan精选pptB-UltraSound2008-12-4

distendedsmallintestine;

noliquidintheabdomen2008-12-5

dilatedloopsofsmallintestine;liquidinRLQ(7CMDeep)精选pptSummury

精选pptSymptomsofthepatientsPainVomitingObstipationAbdominaldistention精选pptSignsofthepatientsVitalSigns:temperatureof38℃Hisabdomenisdistended.Mildtendernessperiumbilicallybutnoguardingorrebound.High-pitchedbowelsoundsRectalexamrevealsnostoolintherectum精选pptLaboratoryStudyAhemoglobinof16,hematocrit48,whichshowshemoconcentrationWhitebloodcellcount12,200,whichshowsinflammation.Serumelectrolytesareabnormal,whichshowsbodyliquidimbalancewithhyponatremiaandhypokalemia.Arterialbloodgasanalysisrevealsacidosis精选pptRadiographyexamAnabdominalX-RAYrevealsmultipledilatedloopsofsmallbowelwithnumerousairfluidlevels.ThereisnogasorstoolvisibleinthecolonToconfirmthediagnosis:intestinalobstrution精选pptDiagnosis

mustmakeclearthefollowingquestions:

精选ppt1.Whetherintestinalobstructionexists:

Throughsymptomsandsigns,thediagnosiscanbemadewithoutdifficulty.精选ppt2.Whethertheobstructionismechanicalordynamic:

mechanicalobstruction:typicalsymptomsandsigns.

paralyticobstruction:episodicandcrampingabdominalpainisabsent;

distentionisprominent

精选ppt3.Whethertheobstructionissimpleorstrangulationobstruction:

Indicationsforstrangulation:

1).Abruptonsetwithcontinuousacuteabdominalpain,

2).Shock

3).Manifestationofperitonitis:leukocytosis,sepsis,reboundandguarding

精选ppt

4).Asymmetricaldistention,localbulge,ormasswithtenderness.

5).Hematicvomitus,

6).Conservativetreatmentinvainandnoimprovementinsymptomsandsigns.

7).Isolated,bulged,anddistendedintestinallooponabdominalplainfilm.精选ppt4.Whethertheobstructionishighorlow:

Vomitinginproximalintestinalobstruction.

Distentioninlowobstruction,feculentvomitus

精选ppt5.Whethertheobstructioniscompleteorincomplete:

frequencyofvomiting,extentofdistention,

Contispationandobstipation精选ppt6.Whichcausesleadstoobstruction:

Accordingtotheage,history,symptomsandsigns.

Postoperativeadhesions;postinflammatory

Henias

Congenitalmalformations

Intestinalintussusception

Obstructionofparasiteorigin

Carcinomasanddryfeces.精选pptEtiology精选pptEtiologyfor

mechanicalIntestinal

obstruction1.

Obstructionarisingfromextraluminalcauses2.

Obstructionintrinsictothebowelwall3.

Intraluminalobturatorobstruction肠壁外因素肠壁因素肠腔内因素outsideoninside精选pptOutside:Adhesions

Volvulus

Hernias

Tumor

精选pptOn:Tumor

Intussusception

精选pptInside:

fecalimpaction

精选pptIntestinalobstruction

精选ppt

Classification

1

Mechanicalobstruction机械性肠梗阻

2

Paralyticileus动力性肠梗阻

3Strangulating

obstruction血运性肠梗阻

4原因不明的假性肠梗阻

精选pptothers：根据有无血运障碍：单纯性Simpleobstruction,

绞窄性strangulationobstruction

梗阻部位：高位Proximalintestinal

低位distalintestinal

大肠largebowel

小肠

smallbowel

梗阻程度:

不完全性Incompleteobstruction

完全性

completeobstruction

发展过程:

急性Acuteobstruction

慢性chronicobstruction精选pptDiagnosis

1.老年女性，急性病程2.典型临床表现：痛、呕、闭、胀3.腹部体征4.X-Rays和腹部CT表现5.既往腹部手术病史急性粘连性小肠低位完全梗阻精选pptDoesStrangulatingobstructionexist？MechanicalobstructionParalyticileusStrangulatingobstruction精选pptDifferentialDiagnosisuppergastrointestinalperforationacutepancreatitisacutecholecystisisacutecholangitis精选pptTreatmentTheprinciple:

correctionofsystemicdisturbance

reductionofobstruction.精选pptConservativetreatment

1).Gastrointestinaldecompression:

Nasogastricsuction

2).Correctionofwater-electrolytic

disturbance,acid-baseimbalance

3).Preventionandtreatmentofinfectionandtoxemia:Antibiotics精选pptSurgical

intervention1)Lysisofadhesion,reductionofintussusception,

2)Enterectomyandanastomosis.3)Bypassprocedurefornonresectablelesions.4)Enterostomyandexteriorizationofintestine.精选ppt本病例治疗方案：病人腹痛逐渐加重，且呕吐频繁，保守无效体温从36.5度升高至38度查体：腹胀加重，右下腹压痛明显，肠鸣音变弱腹穿：有血性液化验：WBC及中性粒细胞均升高超过正常X-rays:可见固定肠袢，肠管扩张明显，加重laparetomy精选pptInoperationpostoperation精选pptCase2Marryisan87-year-oldwomanwitha3-dayhistoryofintermittentabdominalpain,abdominalbloating,nauseaandvomiting.MarrymovedfromItalytojoinhergrandsonandhisfamilyonly2monthsago,andshespeakslittleEnglish.Allinformationwasobtainedthroughhergrandson.

精选pptPastmedicalhistory(PMH)includescolectomyforcoloncancer6yearsagoandfemoralherniarepair2yearsago.Shehasnohistoryofcoronaryarterydisease(CAD),diabetesmellitus(DM),orpulmonarydisease.Shetakesnodrugs.AllergiesincludePenicillindrugsandDolantin.精选pptMarry’stentativediagnosisissmallbowelobstruction(SBO)secondarytoadhesion.Marryisbeingadmittedtoyourfloorfordiagnosticwork-up.Hervitalsignsarestable,shehasanIVofwith20mmolKCIat100ml/hr,and3Loxygenbynasalcannula(O2/NC).精选ppt1.Basedonthenurse’sreport,whatsignsofbowelobstructiondidMarrymanifest?

QUESTION精选ppt·Intermittentabdominalpain–mostSBOcausewavesofcrampingabdominalpainaroundtheperiumbilicalarea.

·Abdominalbloating-Blockagesmaycausebloatinginthelowerabdomen.Youmayalsoheargurglingsoundscomingfromyourbelly.Withacompleteobstruction,yourdoctormayhearhigh-pitchedsoundswhenlisteningwithastethoscope.Thesoundsdecreaseasmovementofthebowelslows.

精选ppt·Nauseaandvomiting-Thevomitisusuallygreeniftheobstructionisintheuppersmallintestineandbrownifitisinthelowersmallintestine.精选ppt2.ArethereothersignsandsymptomsthatyoushouldobserveforwhileMarryisinyourcare?

精选ppt·Continuousseverepaininoneareacanmeanthattheblockagehascutoffthebowel'sbloodsupply.Thisiscalledabowelstrangulationandrequiresemergencytreatment.

精选ppt·Constipation(latefinding)andinabilitytopassgasarecommonsignsofabowelobstruction.However,whenthebowelispartiallyblocked,youmayhavediarrhea(earlyfinding)andpasssomegas.Ifyouhaveacompleteobstruction,youmayhaveabowelmovementifthereisstoolbelowtheobstruction.

·Feverandtachycardia–latesign;mayberelatedtostrangulation

精选ppt·Peritonealsigns

·Abdominaldistention

·HyperactivebowelsoundsoccurearlyasGIcontentsattempttoovercometheobstruction;hypoactivebowelsoundsoccurlate

·Grossoroccultblood-latestrangulationormalignancy

·Masses-obturatorhernia精选ppt3.Marryandhergrandsonarriveonyourunit.YouadmitMarrytoherroomandintroduceyourselfashernurse.Ashergrandsoninterpretsforher,shepatsyourhand.Youknowthatyouneedtocompleteaphysicalexaminationandtakeahistory.Whatwillyoudofirst?

精选ppt·Builduparelationshipoftrust;attempttoobtainpatient’scooperation

精选