1、腹 瀉Diarrhea教學大綱掌握腹瀉發(fā)生機制；臨床表現(xiàn)、伴隨癥狀和體征、問診要點。便秘概念和問診要點。熟悉 腹瀉概念和病因。便秘發(fā)病機制、臨床表現(xiàn)、伴隨癥狀。 腹瀉（Diarrhea）Diarrhea denotes increased frequency of bowel movement or with loose, watery, mucus, pus-bloody or undigested food. It is classified into two types, acute and chronic diarrhea.Diarrhea over one month is rega

2、rded as chronic diarrhea. 腹瀉（Diarrhea）指排便次數(shù)增多， 3次/日便稀薄，或帶有粘液、膿血或未消化的食物。急 性 腹 瀉慢性腹瀉:1月 【Etiology】腸道疾病intestinal diseases急性中毒acute poisoning全身性感染systematic infection其 他 others1、急性腹瀉(Acute diarrhea) （1） intestinal diseases病毒、細菌、霉菌原蟲、蠕蟲等感染所引起的腸炎 enteritis of various causes急性出血性壞死性腸炎 acute hemorrhagic ne

3、crotic enteritis克羅恩氏病 Crohns disease潰瘍性結腸炎急性發(fā)作 ulcerative colitis急性腸道缺血 ischemic enteritis醫(yī)院內(nèi)感染可致腹瀉 hospital acquired diarrhea抗生素相關性腸炎 antibiotics-related enteritis （2）acute poisoning毒蕈 mushroom河豚 puffer fish化學藥物如砷 arsenic磷 phosphorus鉛 lead汞 mercury（3）systematic infection敗血癥 septicemia傷寒或副傷寒 typhoid

4、 fever or para-typhoid鉤端螺旋體病 leptospirosis（4）others變態(tài)反應性腸炎 allergic enteritis過敏性紫癜 allergic purpura消化系統(tǒng)疾病全身性疾病藥物副作用神經(jīng)功能紊亂2、慢性腹瀉 【Etiology】 Digestive system disease(1) gastric diseases慢性萎縮性胃炎 chronic atrophic gastritis大部切除后胃酸缺乏 acid deficiency of post-gastroectomy(2)intestinal infection腸結核 intestinal

5、 TB慢性細菌性痢疾 chronic bacillary dysentery慢性阿米巴性痢疾 amebic dysentery血吸蟲病 schistosomiasis 梨形鞭毛蟲病 giardiasis鉤蟲病 hookworm disease絳蟲病 taeniasis (3)non-infection disease 克羅恩病 Crohns disease潰瘍性結腸炎 ulcerative colitis結腸多發(fā)性息肉 multiple polyps of colon吸收不良綜合征 mal-absorption syndrome(4)intestinal tumors結腸絨毛狀腺瘤 villo

6、us adenoma小腸惡性腫瘤 malignant tumors of intestines 結腸惡性腫瘤 malignant tumor of colon 惡性淋巴瘤 malignant lymphoma(5)pancreatic diseases慢性胰腺炎 chronic pancreatitis胰腺癌 pancreatic cancer囊性纖維化 cystic fibrosis胰腺廣泛切除 pancreatoctomy (6)hepatobiliary diseases肝硬化 liver cirrhosis膽汁淤積性黃疸 biliary stasis慢性膽囊炎 chronic chol

7、ecystitis膽石癥 biliary stone Systematic disorders (1) endocrine and metabolic diorders：甲狀腺功能亢進 hyperthyroidism腎上腺皮質(zhì)功能減退 hypo-adrenocorticism胃泌素瘤 gastrioma血管活性腸肽瘤 VIPoma類癌綜合征 carcinoid syndrome及糖尿病性腸病 diabetic enteropathy（2）others：系統(tǒng)性紅斑狼瘡 systemic lupus erythromatosus SLE 硬皮病 dermatosclerosis 尿毒癥 uremi

8、a放射性腸炎 radioactive enteritisside effects of drugs Some drugs e.g. lifanpin, thyroidinand digitalis anti-cancer drugs, antibiotic etc. may cause diarrhea due to their side effects. Intestinal neurosis 腸易激綜合征 irritable bowl syndrome IBS神經(jīng)功能性腹瀉 functional diarrhea分泌性腹瀉 Secretory diarrhea 霍亂cholera滲透性腹瀉

9、 Osmotic diarrhea 滲出性腹瀉 Exudative diarrhea動力性腹瀉 Motility diarrhea 吸收不良性腹瀉 Malabsorption diarrhea【Mechanism】 1. Secretory diarrhea Excessive secretion of fluid from the gastrointestinal mucosaMassive watery diarrhea caused by exo-toxin of vibrio cholera typically belongs to this type. Toxin producing

10、 E coli infection, secretary GI tumors, such as gastrioma胃泌素瘤, VIPoma may cause secretory diarrhea. 2. 滲透性腹瀉 Osmotic diarrhea Increased osmotic pressure in the intestine prevents the absorption of water and electrolytes. Due to lactase deficiency乳糖酶缺乏, lactose can not be hydrolyzed forming high osmo

11、tic pressure, leading to diarrhea. Oral intake of purgative鹽類瀉劑or mannitol甘露醇can also cause diarrhea of this type. 3.滲出性腹瀉 Exudative diarrheaDue to mucosa inflammation, ulcers or infiltrative lesions.Exudation of plasma, mucus, pus-blood etc. and seen in various inflammatory diseases of the intestin

12、es. 4.動力性腹瀉 Motility diarrhea Diarrhea caused by hyper-motility of the intestines which leads to shortened stay of chyme in the intestine and insufficient absorption, e.g. enteritis, gastrointestinal dysfunction, and hyperthyroidism甲亢. 5.吸收不良性腹瀉 Malabsorption diarrheaDiarrhea caused by decreased abs

13、orption area腸粘膜的吸收面積減少or disturbance of absorption of the intestinal mucosa吸收障礙, e.g. removal of small intestines小腸大部分切除, mal-absorption syndrome.【Manifestations】起病及病程 Onset and course 腹瀉次數(shù)及糞便性質(zhì) Frequency and features of Stool腹瀉與腹痛關系 Relationship between diarrhea and abdominal pain1.起病及病程 Onset and

14、course Acute diarrhea: acute onset, short course, seen in acute enteritis, or food poisoning.Chronic diarrhea: slow onset, long course, seen in patients with chronic infection, non-specific infection, mal-absorption, tumor, or neurosis. 2.腹瀉次數(shù)及糞便性質(zhì) Frequency and features of StoolAcute infectious dia

15、rrhea: over 10 times a day.Bacterial infection: bloody or pus bloody stool; Amebic dysentery阿米巴痢疾: dark red or jam-like.Chronic diarrhea: a few times a day, loose stool or mucus or pus stool, seen in patients with chronic dysentery痢疾, inflammatory bowel disease, rectum cancer.Diarrhea without pathol

16、ogical components: IBS腸易激綜合征. 3.腹瀉與腹痛的關系 Relationship between diarrhea and abdominal painWith frequent pain, especially in infection. Small intestinal diseases: umbilicus area, not relieved after stool.Colon diseases: hypogastric area, relieved after stool.Secretory diarrhea: usually no pain. With f

17、ever ：Seen in bacterial dysentery急性細菌性痢疾, typhoid fever, paratyphoid fever傷寒或副傷寒, intestinal TB, Crohns disease, ulcerative colitis, etc.With tenesmus里急后重： seen in colon and rectum diseases, e.g. acute dysentery, rectum infection or tumor.With weight loss: small intestinal diseases, gut malignant tu

18、mors, intestinal TB, mal-absorption, etc. 【 panying symptoms】With skin rash or subcutaneous bleeding: Seen in septicemia敗血癥, typhoid or paratyphoid, measles麻疹, allergic purpura過敏性紫癜.With mass: seen in gut tumors, gut TB, Crohns disease, schistosome gtanuloma血吸蟲性肉芽腫.With dehydration: seen in secretor

19、y diarrhea, cholera, bacterial food poisoning, etc. With joint pain: seen in Crohns disease, ulcerative colitis, SLE, etc.OnsetCharacter and smell of StoolFrequency and quantity of Stool panying symptoms Morbidity of family and region provocative-palliative factorgeneral condition 【 Key points of in

20、quiry】 便 秘Constipation便秘(Constipation)便秘(Constipation)是指排便頻率減少，7天內(nèi)排便次數(shù)少于23次，排便困難，糞便干結。Constipation denotes decreased frequency of bowel movement, less than 2-3 times within 7 days, with difficult defecation and dry stool. 【Etiology】Constipation can be classified into functional and organic ones. 1.

21、Functional constipation：(1) Sufficient food intake or lack of cellulose, decreased纖維素 stimulation to the colon motility.(2)Defecation habit change due to various reasons, e.g. time, place, environment, spiritual factors.(3)Long term cathartic abuse濫用瀉藥leading to drug dependence.(4)Dys-motility of co

22、lon結腸運動功能障礙, e.g. in the elderly and intestinal spasm, e.g. in IBS. (5)Abdominal muscle and pelvis muscle deficiency腹肌及盆肌張力不足.(6) Long colon結腸冗長.(7) Usage of morphine, anti-cholinergic drugs, calcium channel blocking agents, nerve blockers, sedatives, anti-depression, antacid containing calcium and

23、aluminum. anic constipation （1）Rectum and anal lesionsAnal sphincter spasm, defecation pain, fear of defecation, e.g. hemorrhoid痔瘡, anal fissure肛裂, peri-anal abscess.（2）Colon diseasesColonic benign or malignant tumor, intestinal obstruction of various types, intestinal adhesion, Crohns disease, and congenital mega-colon先天性巨結腸癥.(3) Tumor press in the abdominal cavity or in the pelvis e.g. myoma of uterus子宮肌瘤. (4) Weakened intestinal muscles腸肌松馳due to systematic diseases. e.g. in uremia尿毒癥, hypothyroidism甲狀腺功能低下.Besides, hematoporphyria血卟啉病and lead poisoning鉛中毒