临床诊断学恶心呕吐

健康快乐每一天！临床诊断学上海第二医科大学仁济临床医学院NauseaandVomitingAsthesymptoms症状学：恶心与呕吐GoalsBrieflydefineOutlinetheprominentdiseasestatesassociatedwithnauseaandvomiting.CharacterizeNauseaandVomitingcausedbytheprominentdisordersDiscriminatetheaccompanyingsymptoms.Suggestdiagnosticstrategiesofthesymptoms.DefinitionofNauseaandVomitingNausea：theinclinationorfeelingofimminentdesiretovomit,usuallyfeltinthethroatorepi-gastrum.Associatedwithdecreasedactivityofthestomach.Vomiting：theforcefuloralexpulsionofgastriccontentsviaretro-peristalsis.Nausea-Vomiting:simultaneityorseparateness恶心：紧迫欲吐，通常伴有上腹不适和迷走兴奋的临床征候群。呕吐：胃和/或小肠内容物经食管和口腔排除体外恶心和呕吐常伴随存在，也可单独出现！NauseaandVomiting1、恶心：咽部及上腹部不适，胃张力和蠕动减弱，幽门和贲门开放。2、干呕：胃窦部和腹壁肌肉收缩，腹压增加，食管及咽部开放。3、呕吐：胃和/或小肠内容物经食管和口腔排除体外。Definitionofemesis.(Threephases)呕吐反射过程（三个阶段）1.Nausea-theinclinationorfeelingofimminentdesiretovomit,usuallyfeltinthethroatorepigastrum.Associatedwithdecreasedactivityofthestomach.2.Retching-thelaboredrhythmiccontractionofrespiratoryandabdominalmusculaturethatfrequentlyprecedesoraccompaniesvomiting.3.Vomiting-theforcefuloralexpulsionofgastriccontentsviaretroperistalsis.(Abdominaleffects).迷走兴奋表现恶心干呕呕吐发生机制呕吐区别于反食呕吐：多数情况有恶心的感觉和呕吐反射的协调动作。反食：无恶心的感觉和呕吐反射的协调动作。（儿童、饱餐）MechanismsofemesisCTZ&EmeticCenter(Vomitingcenter)CTZ化学感受器触发带（第四脑室底面）：外源性或内源性化学物质（阿片吗啡、洋地黄、代谢产物）EmeticCenter（延髓外侧网状结构背测）接受大脑皮质、消化器官、心血管以及化学感受器触发带（CTZ）的冲动CTZ&EmeticCenter(Vomitingcenter)孤束核EmeticCenterMidbrainChemoreceptorLimbicVestibularICPReceptorTriggerZoneSystemsystemVisceralafferentsEmeticCenter内脏传入中脑ICP受体化学感受器触发带边缘系统前庭系统呕吐中枢（Vomitingcenter)ICP=InductivelyCoupledPlasma感应耦合等离子体NeurotransmittersinCTZ&EmeticCenterNeurotransmittersinvolvedinstimulatingtheemeticcenter,chemo-receptortriggerzoneandGItractinclude;5-HT,acetylcholine,histamine,dopamine(opiatesandreceptorsforbenzodiazepinesarealsofoundhere)EmeticCenterEmeticCenter1.Salivarycenter2.Vasomotorcenter3.Respiratorycenter4.CranialnervesSpinalnervephrenicnervevagusnerveAbdominalDiaphragmStomachEsophagusmuscles1、分泌唾液中枢2、血管收缩中枢3、呼吸中枢4、中枢神经脊神经膈神经迷走神经nauseaandvomiting1.Reflectivevomiting反射性呕吐2.Centralvomiting中枢性呕吐3.Neurologicalvomiting神经性呕吐Reflectivevomiting（反射性呕吐）咽部刺激胃十二指肠疾病胆道疾病肠道疾病肝胆疾病腹膜肠系膜全身性疾病（五官、心血管、泌尿、盆腔…）PharyngealMechanismsGastrointestinalMechanismsDiseaseofbiliarytractPeritonealandmesenterythefivesenseorgansCardiovasculardiseaseskidneyPelvic咽部刺激PharyngalMechanismsGastrointestinalMechanisms肝、胆、胰腺其他Intra-cranialinfectionCerebrovasculardisordersCraniocerebralinjuryEpilepsyMetabolicdisordersDrugsCentralvomiting（中枢性呕吐）颅内感染脑血管疾病颅脑损伤癫痫全身疾病（尿毒症、肝昏迷、糖尿病代谢紊乱）颅内感染（脑炎、脑膜炎）脑血管疾病、颅脑损伤癫痫全身疾病尿毒症肝昏迷酮症酸中毒各种原因引起的脑水肿和颅内压升高代谢紊乱早孕Drug抗生素抗癌药洋地黄吗啡兴奋呕吐中枢或影响胃肠平滑肌运动AntibioticsAnti-carcinomaDigitalismorphiaNeurologic&PsychogeniccausesNeurologicandPsychogeniccauses胃肠道神经官能症（Gastrointestinaltractneurosis）神经厌食症（apositia）CharacteristicsofNauseaandVomiting1.Time2.Takingfood3.Characteristics4.Charactersofcontents晨起呕吐早孕反应功能性消化不良酒精中毒胃食管反流病鼻咽部疾患夜间或隔夜呕吐幽门梗阻贲门失弛缓症呕吐与进食的关系（Timingwithmeals）餐后即刻：神经精神性；集体发病系食物中毒餐后1小时以上：为延迟性呕吐：可考虑为胃张力低下排空障碍餐后较久、多餐后或隔夜：提示幽门梗阻呕吐特点神经性或颅内高压：恶心轻、呕吐频；“喷射性呕吐”呕吐物性质发酵、腐臭味：提示胃潴留粪臭味：提示较低位置的肠梗阻无酸腐味：贲门失迟缓症或胃酸缺乏不含胆汁：幽门梗阻病史较长或量多：提示体液和电解质丢失Theaccompanyingsymptoms腹痛、腹泻：食物中毒、肠道传染病、胃肠炎；节律性腹痛：消化性溃疡右上腹痛，伴发热、黄疸：胆囊炎、胆道结石、感染。头痛、头晕、视力异常、喷射性呕吐：颅内高压性疾病、屈光不正、青光眼。伴眩晕、眼球震颤：前庭障碍育龄妇女（停经）：应排除妊娠与服药有时间关联：应想到药物反应问诊要点起病情况：诱因、急缓、与进食关系、腹部手术史、育龄妇女月经史发作时间：晨、夜、与进食、活动、体位的关系呕吐物性状、味道伴随症状诊疗和症状演变情况History/Backgrounda)Ageb)GIhistoryrequiredc)Foodintoleranced)Timingwithmealse)Consistencyf)Contentg)Odorh)Frequencyi)Feverj)Weightlossk)Precipitatingfactorsl)Myalgias（肌痛）,visualdisturbances,headache,painoutsideabdomenCAUSESOFNAUSEA/VOMITINGEarlypregnancyPsychogenesisvomitingBulimia(易饿病)PyloricchannelulcerAcutegastritisGastricretention(潴留）Viralgastroenteritis（中毒性胃肠炎）AcutegastroenteritisMyocardialinfarctionPeritonitis（腹膜炎）AcuteobstructionNeurologicalemergencyDrugtoxicityCancertherapyDrugwithdrawalPHYSICALEXAMVitalsignsSkinHEENT（head,eyes,ear,nose,throat)AbdomenNeurologicalLABORATORYRuleoutobstructionandperitonitisHCGUrinalysisElectrolytes,BUN,creatinine,glucoseTransaminases,amylaseEKG,headCT,upperGI&/orendoscopiesBreak泸沽湖黄昏泸沽湖黄昏泸沽湖•摩梭女玉龙雪山•雪月47ConstipationShanghaiSecondMedicaluniversityRenjiclinicalmedicalcollegeBackgroundConstipationIsaConstellationofSymptomsMostcommonlyreportedsymptomsHard,lumpystoolsIncreasedstrainingInfrequentbowelmovementsSensationofincompleteevacuationBloating/fullnessChronicconstipationMorepersistentthanintermittentorepisodicSeveralmonthsdurationC524434322019110102030405060StrainingHardstoolsWanttobutcan'tInfrequentstoolsAbdominaldiscomfortHaven'tfinishedExcesstoilettimePatients,%SandlerRS,etal.DigDisSci.1987;32:841-845.n=1128ConstipationIsMoreThanJustInfrequentPassageofStool53ConstipationsymptomsreportedmostoftenReducedStoolFrequencyIsNottheMostCommonlyReportedSymptominConstipation1326323665830501003BM/wkAbdominalbloating≥PressonabdomenAbdominaldiscomfortUnsuccessfulBMIncompleteBMPatients,%28363739547281050100Pressonanus3BM/wkAbdominalbloatingStoolcannotpassIncompleteevac