肠哽阻

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/慢性病理生理梗阻部位扩张肠管空陷肠管梗阻以上积气积液肠蠕动增强肠壁充血水肿通透性增高渗液血运受阻血栓形成肠管病变病理生理体液丢失脱水电解质紊乱代谢性酸中毒感染和中毒肠腔内细菌大量繁殖肠壁通透性增高入血休克呼吸循环障碍全身性变化ClinicalAppearance•腹痛•呕吐•便秘•停止排气PhysicalExamination视诊•腹张•Abdomendistention•蠕动波•Peristalicwave•手术疤痕•Surgicalscars•嵌顿疝•Incarceratedhernias触诊•腹张•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•BloodWBCHematocrit•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RadiologicExamination小肠梗阻SmallintestinalOB小肠黏膜呈鱼刺样valvulaeconniventes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•腹张Abdominaldistention•停止排气Failuretopassflatus•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DifferentiationofpartialfromcompleteSBOPartialSBO: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Proctosigmoidoscopyvisualized/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Intussusception•Intussusceptumtelescopesintoanintussuscipiens(sheath)•enteroenteral,ileocecal,ileocolic,colocolic•childrenrateishigh•1/3casesofadultsismalignancies•resectionisnecessary•(香肠状,空虚感,粘液血便)肠扭转Volvulus•Mostpatientareelderlymen•sigmoid60%~70%•psychiatricdisordersandchromiclaxativeabuse•gangrenouscolonmustresect•sigmoidvolvulusproctossigmoidoscopy肠系膜血管缺血性疾病•急性、慢性肠系膜缺血和非闭塞性缺血•病因：栓子来源心梗、房颤等心源疾病•临床：症状和体征不相符（早期特点）•诊断：早期诊断困难CT(+)、DSA•治疗困难，预后差死亡率50%