医学《小儿消化外科》课件

小儿消化外科

Peadiatricdigistivesurgery消化外科？

Digestivesurgery

肠坏死患儿肠切除肠造瘘术后Thechildwithintestinalnecrosisafteroperationofintestinalresectionandintestinalfistula病情复杂，病种繁多

Theconditioniscomplex,manykindsofdiseases

先天性巨结肠CongenitalmegacolonNEC肠穿孔Intestinalperforationduetonecrotizingenterocolitis胆总管囊肿Choledochalcyst食管闭锁Esophagealatresia小肠闭锁Intestinalatresia新生儿胃穿孔Neonatalgastricperforation高胰高性低血糖症Highglucagonhypoglycemia小儿消化系统解剖生理特点

Anatomicalandphysiologicalcharacteristicsofpediatricdigestivesystem

解剖生理特点及临床意义Anatomyandclinicalsignificanceofphysiologicalcharacteristics口腔、食管、胃、肠、胰腺、肝脏、肠道细菌、小儿粪便

Oralcavity,esophagus,stomach,intestine,pancreas,liver,intestinalbacteria,pediatricstool

1．口腔Oralcavity

小儿口腔粘膜柔嫩,血管丰富,易受损而发生感染。局部软组织感染。Pediatricoralmucosalisvulnerabletoinfections.Localsofttissueinfection.2.食管Esophagus食管闭锁Esophagealatresia3．胃Stomach新生儿胃壁肌肉发育不良时，可发生胃穿孔。Whentheneonatalgastricmuscledevelops

notwell,gastricperforationmayoccur.4.肠

固定差，易发生肠套叠及肠扭转。5．肝、胆Liverandgallbladder肝母细胞瘤肝母细胞瘤Hepatoblastoma胆道闭锁与Biliaryatresiaand

胆总管囊肿Choledochalcyst6.肠道细菌

Intestinalbacteria胎儿消化道内无细菌，出生后细菌很快从口、鼻、肛门侵入肠道，大多集中在大肠及直肠内。Nobacteriaexistsinthedigestivetractofthefetus.Afterbirthbacteriaquicklyinvadestheintestinalsystemfrommouth,nose,analandconcentrateinthecolonandrectum.7．健康小儿粪便

Faecesofhealthchildren新生儿最初排出的大便为深墨绿色、粘稠、无臭味，称胎粪。Neonatefirstdefecatesmeconiumwiththecolourofdeepdarkgreenandnosmell.多数新生儿生后10小时内开始排便，2～3天渐过渡为黄糊状粪便。Mostnewbornsstartdefecationwithin10hoursafterbirthandstoolgraduallytransitestoyellowpastyin2~3days.24小时内无胎粪排出，应注意检查有无肛门闭锁等消化道畸形。Ifnostoolin24hoursweshouldcheckwhethertheanalatresiaorotherdigestivetractmalformationexist.常见疾病Commondiseases食管闭锁Esophagealatresia十二指肠梗阻Duodenalobstruction

先天性肥厚性幽门梗阻Congenitalhypertrophicpyloricstenosis小肠闭锁Intestinalatresia肠重复畸形Intestinalduplication肠旋转不良Intestinalmalrotation先天性巨结肠Congenitalmegacolon先天性肛门直肠畸形Congenitalanorectalmalformation先天性胆道闭锁Congenitalbiliaryatresia先天性胆总管囊肿Congenitalcholedochalcyst重点讲述Keypoints食管闭锁Esophagealatresia十二指肠梗阻Duodenalobstruction先天性肥厚性幽门梗阻Congenitalhypertrophicpyloricstenosis肠套叠Intussusception先天性巨结肠

Congenitalmegacolon肛门闭锁Analatresia食管闭锁分型

Typesofesophagealatresia最常见Ⅲ型：近端闭锁远端气管食瘘占85%~90%ThemostcommontypeIII:theproximalatresia,thedistaltracheafistula,whichaccountsfor85%~90%特殊类型食管闭锁—隔膜型?食管璞?

Specialtypesofesophagealatresia-diaphragmtype?

食管闭锁的典型表现

Thetypicalmanifestationsofesophagealatresia

唾液多，喂奶时呛咳，反复肺炎Saliva,nursingcough,repeatedpneumonia影像学在食道闭锁中的作用

Imagingintheroleofesophagealatresia

三维CT重建

ThreedimensionalCTreconstruction

造影与支气管镜检查确诊

ConfirmedbyangiographyandbronchoscopyH型基础手术方法Operationmethod食管闭锁的解剖Anatomyofesophagealatresia

上腔V近端食管迷走N已结扎的奇V气管并发症Complications1、吻合口瘘Anastomoticfistula2、吻合口狭窄Anastomoticstricture预后Prognosis

预后良好，不影响儿童的生长发育Theprognosisisgoodanditdoesnotaffectthegrowthanddevelopmentofchildren新生儿胃穿孔(neonatalgastricperforation)一般于生后2～7天发病，病死率很高。Itoccursin2~7daysafterbirthanditsfatalityrateishigh.好发于胃大弯处。Itusuallyoccursinthegreatercurvatureofstomach.原因：Reasons1.胃壁肌层缺损Gastricmuscularwalldefects2.胃收缩拉力不对称Asymmetryofgastriccontractiontension3.贲门部大弯部过分扩张Excessiveexpansionofgreatercurvature

小儿肠梗阻Childrenintestinalobstruction

病因Etiology

梗阻原因

Causesofobstruction机械性Mechanical动力性Dynamic血运性Vascular

血运障碍

Bloodcirculationdisorder

单纯性与绞窄性Simpleandstrangulatedintestinalobstruction痛吐胀闭Abdominalpain,vomiting,abdominaldistentionandstoppingexhausting.胃肠型Gastrointestinaltype腹部压痛Abdominaltenderness肠鸣音亢进Hyperactivebowelsounds临床表现Clinicalmanifestations肠旋转不良

Intestinalmalrotation

肠旋转不良

Intestinalmalrotation环状胰腺Annularpancreas

十二指肠闭锁Duodenalatresia小肠闭锁Intestinalatresia肠重复畸形Intestinalduplication先天性肛门闭锁Congenitalanalatresia嵌顿疝Strangulatedhernia梅克尔憩室

Meckel'sdiverticulum

先天性肥厚性幽门狭窄

Congenitalhypertrophicpyloricstenosis

定义Definition该病是由于幽门环肌肥厚增生使幽门管狭窄而引起的机械性梗阻。Thediseaseismechanicalobstructioncausedbypyloricstenosisduetopyloricmusclehypertrophy.概述Overview

发病率为1/1000~3000（国内）

Theincidencerateis1/1000~3000(domestic)男：女=5：1Theproportionofboysandgirlsis5:1白人>黄人>黑人Themorbidityfromlargetosmallinturnisthewhite,yellowandblack占消化道畸形的第三位Thediseaseranksthirdindigestivetractmalformation遗传因素Geneticfactors内分泌因素Endocrinefactors神经发育异常Abnormalnervousdevelopment病因

Etiology病理

Pathology

HPS肌肉增厚以环肌为主，肌厚可达4-7mmCircularmusclethickenswithmusclethicknessupto4-7mm镜下

Undermicroscope环肌增厚为主，纵肌轻度增生Circularmusclethickensandlongitudinalmusclehasmildhyperplasia粘膜水肿、溃疡、充血Mucosahasedema,hyperemia,ulcer神经节细胞减少、缺如或发育不良Ganglioncellsdecreaseorwiththecellsabsenceorhypoplasia临床表现Clinicalmanifestations足月头胎男孩多见Thediseasepreferstooccurinthefirstfull-termmalebaby呕吐Vomiting：出生后2－4周发生，呕吐进行性加重，吐后求食欲望强烈。Vomitingoccurs

in2-4weeksafterbirthandaggravateswithstrongdesireforfoodaftervomiting.消瘦或体重不增Weightlossorweightdoesnotincrease二便减少Thestoolandurinedecrease脱水与电解质紊乱：Dehydrationandelectrolytedisorder：多伴低氯低钾性碱中毒Mostaccompaniedwithlowchlorinehypokalemicalkalosis腹部体征Abdominalsigns视诊Inspection：上腹膨隆，可见胃型，逆行蠕动波Upperabdominaldistention,visiblegastrictype,retrogradeperistalticwave触诊Palpation：可触特征性包块Wecantouchcharacteristicmass触诊Palpation超声诊断Ultrasonicdiagnosis幽门长>17mm宽＞13mm肌肉厚＞4mm

Pyloriclengthismorethan17mm,thewidthismorethan13mmandmusclethicknessismorethan4mm.诊断Diagnosis典型病史Typicalhistory右上腹包块Rightupperabdominalmass辅助检查Accessoryexamination鉴别诊断Differentialdiagnosis先天性消化道畸形Congenitaldigestivetractmalformation喂养不当Improperfeeding幽门痉挛Pylorospasm胃食管反流