内科学消化系统总论

内科学消化系统总论内科学消化系统总论第1页AssimilationofnutrientsEliminationofwasteStructureandfunctions内科学消化系统总论第2页StructureandfunctionsThetwoactivitiesundervoluntarycontrolareswallowinganddefecation.内科学消化系统总论第3页CharacteristicsofDigestiveSystemManynormalGIreflexesinvolveextrinsicvagusorsplanchnicnervepathways.

Anactivebrain-gutaxisfurtheraltersfunctioninregions内科学消化系统总论第4页Immuneorgan Gastrointestinal-associatedlymphoidtissue,(GALT)

CharacteristicsofDigestiveSystem内科学消化系统总论第5页Notonlyadigestiveorganbutalsoendocrineorgan pancreas gastrin(胃泌素) glucagon(胰高糖素) somatostatin(生长抑素) VIP(血管活性肠肽) insulin(胰岛素)CharacteristicsofDigestiveSystem内科学消化系统总论第6页Structure/functionanddiseasesThebiggestorganHomeostasis

Synthesis

Excretion

FilterDefense

symptomssignsDeath内科学消化系统总论第7页

inflammation(炎症)

Ulcer(溃疡)

bleeding(出血)

perforation(穿孔)

neoplasm(肿瘤)

functionaldisturbances(功效失调)CommonLesionsofDigestiveSystem内科学消化系统总论第8页ClassificationofGIDiseases

ImpairedDigestionandAbsorption

(Biliaryobstruction,Chronicpancreatitis)AlteredSecretion(Zollinger-Ellisonsyndrome,atrophicgastritis,smallintestinalbacterialovergrowth)AlteredGutTransit

(obstructionbygastriccancerorcoloncancer,Achalasia,constipation,diarrhea)内科学消化系统总论第9页ImmuneDysregulation(ulcerativecolitis,Crohn’sdisease)ImpairedGutBloodFlow

(intestinalandcolonicischemia)NeoplasticDegeneration

(Esophageal,gastric,colon,pancreatic,biliarycancer)DisorderswithoutObviousOrganicAbnormalities

(IBS)GeneticInfluences内科学消化系统总论第10页ClassificationofLiverDiseasesViralHepatitsNonalcoholicfattyliverAlcoholicliverdiseaseImmune&autoimmuneliverdiseasesDrug-inducedliverdiseaseGeneticliverdiseasesMasslesionsVascularinjuryLiverinvolvementinsystemicdiseases内科学消化系统总论第11页LaboratorytestsHistory+Symptoms+SignImagingstudies

EVALUATIONOFPATIENTWITHGIDISEASE

内科学消化系统总论第12页Thediagnosisdrivespredominantlyfromthepatient’shistoryThephysicianmustidentifythetiming,type,locationandseverityofthesymptoms,whenandwheretheyoccur,aggravatingandalleviatingfactors,andanyassociatedsymptoms.History&symptoms内科学消化系统总论第13页CardinalSymptomsofGIdiseasesAbdominalpain(GIandextraGI)(pepticulcer,appendicitis,IBD)Heartburn(gastroesophagealrefluxdisease,GERD)Nausea&VomitingAlteredbowelhabits(constipation,diarrhea,steatorrhea)GIbleeding(melena/hematemesis/hematochezia)Jaundice(Choledocholithiasis,cholangitis,pancreas,pancreaticcancer)内科学消化系统总论第14页CardinalsymptomsofliverdiseasesFatigue:mostcommon,intermittent&variableNausea&vomiting:mostsevereliverdis.Rightupperquadrantdiscomfort/liverpainItching:acutehepatitis,primarybiliarycirrhosis(PBC),sclerosingcholangitisJaundice:hemolytic,hepatocellulardamage,cholestasis内科学消化系统总论第15页History&symptomsDetailedhistory:

alcoholusemedicationspersonalhabitssexualactivityexposuretojaundicedpersontravelinjectiondruguse,recentsurgerybloodtransfusions,occupationaccidentalexposurefamilialhistorytobloodorneedlestick,ofliverdisease

内科学消化系统总论第16页Thehistoryandphysicalexaminationremainthebasesofevaluation.

DiagnosisofDigestiveSystemdiseases

Adirectedphysicalexaminationcanrefinethedifferentialdiagnosis

内科学消化系统总论第17页LaboratoryTestBloodroutinetests:HB,RBC,WBC+DC,PlateletStoolsample:routine,occultblood.parasitesliverfunctiontest(TB.CB.ALT.AST.A.G.ALP.PT)ANA,AMA,IgG,IgM,serumceruloplasminVirusmarkers(hepatitis.ABCDE.etc)Tumormarkers(AFP,CEA,CA19-9,CA125…)AnalysisofascitesfluidEsophagealpHtesting

内科学消化系统总论第18页DiagnosticImagingRadiology:

plainfilm bariummealexamination bariumenema small-bowelcontractradiology Angiogram,DSA内科学消化系统总论第19页DiagnosticImagingUS(ultrasound)CT(computedtomograpy)VirtualCTendoscopyMRI(magneticresonanceimaging)MRCP(MRcholangiopancreatography)ERCP(endoscopicretrogradeCP)PET(positronemissiontomography)Isotopeexamination:biliaryexcretiongastricemptying,13c.14c-UBT内科学消化系统总论第20页Endoscopies

(diagnosis&treatment)

upperendoscopy:dyspepsia,upperGIbleedingColonoscopy:lowerGIbleeding,diarrhea,cancerscreeningERCP(therapeutic):jaundice,gallstonepancreatitis,pancreas/biliary/ampulladisordersendoscopicultrasound:stagingofmalignancy,submucosalmassDoublebloomintestinalendoscopy:lowerGIbleeding,Crohn’sileitis内科学消化系统总论第21页内科学消化系统总论第22页ABiopsyofaPancreaticMassGuidedbyEndoscopicUltrasonography

thePlacementofaStentintoaMalignantBile-DuctStricturewithEndoscopicRetrogradeCholangiopancreatography内科学消化系统总论第23页EvaluationpatientswithliverdiseasesEstablishingthediagnosisGrading:estimatingdiseaseseverity(mild,moderate,severe)oractivity(activeorinactive)Staging:establishingdiseasestage

(acute/chronic;early/late;pre-cirrhotic/end-stage)IdentifyingtheunderlyingcauseLiverbiopsyChild-Pughclassification/MELD内科学消化系统总论第24页

Child-PughclassificationScorea

Factor

123

1.EncephalopathyNoneMinimalAdvanced2.AscitesNoneEasilycontrolledpoorlycontrolled3.Bilirubin(umol/L)<3434-51>514.Albumin(g/L)>3530-35<305.PTprolonged(s)or0-44-6>6ProthrombinTime(INR)<1.71.7～2.3

>2.3

aScoresiscalculatedbyaddingthescoresof5factorstodetermineChild-Pughclass:classA=5-6classB=7-9classC=10-15内科学消化系统总论第25页ModelofEnd-StageLiverDisease,(MELD)MELDscore=9.6loge(serumcreatininemg/dL)+3.8loge(serumbilirubinmg/dL)+11.2loge(INR)+6.4Scorerangefrom6－40.MELDiscurrentlyusedtoestablishprioritylistingforlivertransplantatio