1、臨床診斷學(xué),Nausea and Vomiting As the symptoms,癥狀學(xué)：惡心與嘔吐,Goals,Briefly define Outline the prominent disease states associated with nausea and vomiting. Characterize Nausea and Vomiting caused by the prominent disorders Discriminate the accompanying symptoms. Suggest diagnostic strategies of the symptoms.

2、,Definition of Nausea and Vomiting,Nausea ：the inclination or feeling of imminent desire to vomit, usually felt in the throat or epi-gastrum. Associated with decreased activity of the stomach. Vomiting： the forceful oral expulsion of gastric contents via retro-peristalsis. Nausea-Vomiting: simultane

3、ity or separateness,惡心：緊迫欲吐，通常伴有上腹不適和迷走興奮的臨床征候群。 嘔吐：胃和/或小腸內(nèi)容物經(jīng)食管和口腔排除體外 惡心和嘔吐常伴隨存在，也可單獨(dú)出現(xiàn)！,Nausea and Vomiting,1、惡心：咽部及上腹部不適，胃張力和蠕動減弱，幽門和賁門開放。 2、干嘔：胃竇部和腹壁肌肉收縮，腹壓增加，食管及咽部開放。 3、嘔吐：胃和/或小腸內(nèi)容物經(jīng)食管和口腔排除體外。,Definition of emesis. (Three phases) 嘔吐反射過程（三個(gè)階段）,1. Nausea - the inclination or feeling of imminent

4、desire to vomit, usually felt in the throat or epigastrum. Associated with decreased activity of the stomach. 2. Retching - the labored rhythmic contraction of respiratory and abdominal musculature that frequently precedes or accompanies vomiting. 3. Vomiting - the forceful oral expulsion of gastric

5、 contents via retroperistalsis. (Abdominal effects).,迷走興奮表現(xiàn),惡心,干嘔,嘔吐,發(fā)生機(jī)制,嘔吐區(qū)別于反食,嘔吐：多數(shù)情況有惡心的感覺和嘔吐反射的協(xié)調(diào)動作。,反食：無惡心的感覺和嘔吐反射的協(xié)調(diào)動作。（兒童、飽餐）,Mechanisms of emesis,CTZ 5-HT, acetylcholine, histamine, dopamine (opiates and receptors for benzodiazepines are also found here),Emetic Center,1、分泌唾液中樞 2、血管收縮中樞 3、呼

6、吸中樞 4、中樞神經(jīng),脊神經(jīng),膈神經(jīng),迷走神經(jīng),nausea and vomiting,1. Reflective vomiting 反射性嘔吐 2.Central vomiting 中樞性嘔吐 3. Neurological vomiting 神經(jīng)性嘔吐,Reflective vomiting （反射性嘔吐）,咽部刺激 胃十二指腸疾病 膽道疾病 腸道疾病 肝膽疾病 腹膜腸系膜 全身性疾病（五官、心血管、泌尿、盆腔）,Pharyngeal Mechanisms Gastrointestinal Mechanisms Disease of biliary tract Peritoneal and

7、 mesentery the five sense organs Cardiovascular diseases kidney Pelvic,咽部刺激,Pharyngal Mechanisms,Gastrointestinal Mechanisms,肝、膽、胰腺,其他,Intra-cranial infection Cerebrovascular disorders Craniocerebral injury Epilepsy Metabolic disorders Drugs,Central vomiting （中樞性嘔吐）,顱內(nèi)感染 腦血管疾病 顱腦損傷 癲癇 全身疾?。蚨景Y、肝昏迷、糖

8、尿病代謝紊亂）,顱內(nèi)感染（腦炎、腦膜炎）,腦血管疾病、顱腦損傷,癲癇,全身疾病,尿毒癥,肝昏迷,酮癥酸中毒,各種原因引起的腦水腫和顱內(nèi)壓升高,代謝紊亂,早孕,Drug,抗生素 抗癌藥 洋地黃 嗎啡,興奮嘔吐中樞或影響胃腸平滑肌運(yùn)動,Antibiotics Anti-carcinoma Digitalis morphia,Neurologic 32:841-845.,n = 1128,Constipation Is More Than Just Infrequent Passage of Stool,53,Constipation symptoms reported most often,Red

9、uced Stool Frequency Is Not the Most Commonly Reported Symptom in Constipation,EPOC = Epidemiology of constipation; BM = Bowel movement. 1. Stewart WF, et al. Am J Gastroenterol. 1999;94:3530-3540. 2. Par P, et al. Am J Gastroenterol. 2001;96:3130-3137.,Stewart (EPOC) 19991,Par 20012,n = 1476,n = 11

10、49,Constipation symptoms reported most often,C,Prevalence in the General Population,1. Stewart WF, et al. Am J Gastroenterol. 1999;94:3530-3540. 2. Drossman DA, et al. Dig Dis Sci. 1993;38:1569-1580. 3. Harris Interactive Study, Wave 2. Data on file. 4. Par P, et al. Am J Gastroenterol. 2001;96:3130

11、-3137.,53,Epidemiology,Chronic constipation is common Slightly more common in women F/M ratio = range 1.3 to 2.5 (China=4:1) Affects all age groups,Stewart WF, et al. Am J Gastroenterol. 1999;94:3530-3540. Par P, et al. Am J Gastroenterol. 2001;96:3130-3137. Sandler RS, et al. Dig Dis Sci. 1987;32:8

12、41-845.,C,Constipation Affects All Age Groups,53,Canadian population. Par P, et al. Am J Gastroenterol. 2001;96:3130-3137.,N = 1149,n = 378,n = 367,n = 217,n = 187,Profile of a Typical Chronic Constipation Patient in My Practice,Generally female Symptomatic for 10 yr Majority have tried lifestyle ch

13、anges, fiber, and OTC laxatives prior to seeking care Manages condition with multiple therapies Most often referred by a primary care physician Copes with condition, but is not completely satisfied,C,Constipation Can Have a Negative Impact on Quality of Life,People with CC reported significant impai

14、rment in QoL on SF-36 scale (n = 126)1 In Canada, people with self-reported or Rome II constipation had significantly worse SF-36 scores than the normal population (n = 472)2 In Australia, people with constipation had significantly worse SF-12 scores on both mental and physical scales (n = 227)3,1.

15、OKeefe EA, et al. J Gerontol A Biol Sci Med Sci. 1995;50:M184-M189.2. Irvine EJ, et al. Am J Gastroenterol. 2002;97:1986-1993. 3. Koloski NA, et al. Am J Gastroenterol. 2000;95:67-71.,C,Constipation Significantly Impacts Healthcare Utilization,5.7 million constipation-related outpatient visits annua

16、lly1,2 4.1 million physician office-based visits 991,000 emergency room visits 587,000 hospital outpatient visits $2752/patient for tertiary care evaluation3,1. National Ambulatory Medical Care Survey, 2001. 2. National Hospital Ambulatory Care Survey, 2001. 3. Rantis PC Jr,

17、et al. Dis Colon Rectum. 1997;40:280-286.,C,Complications related with constipation,Colonic and rectal carcinoma Other colon-rectal-anus disorders hepatic coma acute myocardial infarction mammary gland disorders presenile dementia(早老性癡呆） psycho-problems appearance,Definition: Causes of Chronic Const

18、ipation,Secondary Drug induced Metabolic factors Comorbid conditions Primary Impaired colonic transit/motility Altered neuroenteric function and reflexes Failure of muscular apparatus Ineffective defecation (functional outlet obstruction) Pelvic dyssynergia and anismus Normal transit constipation,Pr

19、esentation Objectives,Define constipation The pathophysiological mechanisms Etiologies of constipation Characterize manifestation Discriminate the accompanying symptoms. Suggest diagnostic strategies of the symptoms.,C,What is Constipation?,Passage of hard, dry, lumpy stools; Infrequent bowel moveme

20、nts, usually fewer than three times a week Symptoms: painful bowel movements straining Uncomfortable（Sensation of incomplete evacuation） bloated sluggish,Rome II Defines Functional Constipation Based on Multiple Symptoms,Rome II diagnostic criteria for functional constipation At least 12 wk, which n

21、eed not be consecutive, over the past 12 months of 2 or more of Straining* Lumpy or hard stools* Sensation of incomplete evacuation* Sensation of anorectal obstruction/blockage* Manual maneuvers to facilitate defecation* 3 defecations/wk Loose stools not present Insufficient criteria for IBS,* 1/4 o

22、f defecations. Drossman DA, et al. In: Rome II: The Functional Gastrointestinal Disorders. 2000:382-391.,C,Normal metabolism,As food moves through your intestines, it absorbs water while forming waste products Muscles contract in the colon, pushing the stool toward the rectum,Defecation Process,Yiel

23、d awareness of defecation Anal intra- and extra-sphincter Relaxation Abdominal effects,Mechanical stimulation,1. Yield awareness of defecation,2. Anal intra- and extra-sphincter Relaxation,intra- sphincter,extra-sphincter,Levator ani muscle,2. Abdominal effects,gastric contents via anus,What Causes

24、Constipation?,Eating too little fiber Not drinking enough liquids Lack of exercise/physical activity,What Causes Constipation?,Change in routine travel Older age Slower metabolism Frequent use of laxatives Certain diseases or conditions,What Causes Constipation?,Certain diseases or conditions Rectal

25、 and Anal disorders Colonic disorders Systemic diseases or conditions,What Causes Constipation?,pain (narcotics麻藥) antacids containing aluminum antidepressants iron supplements diuretics (“water” pills),Medications,Classification of etiologies,Eating too little fiber Not drinking enough liquids Lack

26、 of exercise/physical activity Change in routine Travel psycho-related Older age Slower metabolism,Frequent use of laxatives tediously long Colon Medications Travel pain (narcotics麻藥) antacids containing aluminum antidepressants iron supplements diuretics (“water” pills),Functional etiologies,psycho

27、-related,Tediously long Colon,結(jié)腸冗長,Organic constipation (certain diseases or conditions cause constipation),Classification of etiologies,Rectal and Anal disorders Benign or malignancy tumor Tumor or mass outside Systemic diseases or conditions (e.g. disorders make dyscinesia: spasm and paralysis）,Rectal and Anal disorders,Cancer Nevus anal fissure anal fistula Proctoptosis (直腸脫垂）,intestinal obstruction,Benign or malignancy tumor,P