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肠 梗 阻

肠 梗 阻. INTESTINAL OBSTRUCTION RuiJin hospital Zhang Haobo. Introduction. 肠内容物不能正常运行 , 顺利通过肠道. 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. 病因学. 肠梗阻是否伴血运障碍

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肠 梗 阻

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  1. 肠 梗 阻 INTESTINAL OBSTRUCTION RuiJin hospital Zhang Haobo

  2. Introduction 肠内容物不能正常运行, 顺利通过肠道

  3. 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 病因学

  4. 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

  5. 病理生理

  6. 病理生理

  7. Clinical Appearance • 腹痛 • 呕吐 • 便秘 • 停止排气

  8. 视 诊 腹胀 Abdomen distention 蠕动波 Peristalic wave 手术疤痕 Surgical scars 嵌顿疝 Incarcerated hernias Physical Examination

  9. 触 诊 • 腹胀 • 腹块 • 腹肌紧张 • 腹膜炎

  10. 腹部听诊 肠鸣音亢进 直肠指检 Physical Examination

  11. Laboratory Tests • 血浆电解质和PH值 • Blood WBC  Hematocrit  • Serum amylase BUN

  12. X射线检查Radiologic Examination • 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 • 扩张小肠襻 • 气液平 • 倒U字型 • 直肠和结肠内无气体

  13. 小肠梗阻 Small intestinal OB 小肠黏膜呈鱼刺样 valvulae conniventes 肠段位于腹中部 central portions 小量/无结肠气体 minimal /no colonic gas 结肠梗阻 Colon Obstruction 结肠袋影 colonic haustral marking 扩张肠段位于腹部外周/盆腔 periphery of abdomen/in the pelvic Radiologic Examination

  14. 诊 断Diagnosis 1.有否肠梗阻？ Does the patient have bowel obstruction? 2.梗阻在那一段肠段 If so , where is it? 3.病因是什么？ What is the anatomic and pathologic nature ? 4.是否存在绞榨性肠梗阻 Has strangulation occurred? 5.患者全身情况如何？ What is the general condition of the patients?

  15. 临床表现Clinical Appearance • 腹痛 Abdominal pain • 呕吐 Vomiting • 便秘 Obstipation • 腹胀 Abdominal distention • 停止排气 Failure to pass flatus

  16. 鉴别部分梗阻和完全性梗阻 • Differentiation of partial from complete SBO • Partial SBO: pass flatus or liquid stools • Complete SBO: obstipation Differentiation of partial from complete SBO Partial SBO: pass flatus or liquid stools Complete SBO: obstipation Differentiation of Proximal / distal SBO: pain: epigastric/periumbilical area vomiting: prominent /later onset distention: no /predominate • 鉴别近端和远端梗阻 • Differentiation of Proximal / distal SBO: • pain: epigastric / periumbilical area • vomiting: prominent / later onset • distention: no / predominate

  17. 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 单纯性和绞榨性肠梗阻的鉴别

  18. 治 疗Treatment of SBO • 保守治疗和手术治疗 Medical and surgical management • 三个连续的阶段：观察、治疗、手术 The overlapping sequence :investigation resuscitation operation • 手术时机的把握： • The timing of operation depends on three factors: 病程 duration 重要器官的功能opportunity of vital organ function 绞榨的可能 risk of strangulation The timing of operation depends on three factors: 病程 duration 器官功能 opportunity of vital organ function 绞榨的可能 risk of strangulation

  19. Medical managment • 胃肠减压 Nasointestinal /nasogastric intubation • 纠正水电解质的紊乱 Intravenous fluids /blood plasma administration • 广谱抗菌素的应用 Broad-spectrum antibiotics administration

  20. Surgical principle • 病因 The nature of problem determines approach to management of SBO. • 肠管活性的判断：色泽、活力、动脉搏动 The criteria of determining bowel viability: color motility arterial pulsation • 处理 If questionable , released and placed ,re-examined.

  21. 结肠梗阻Large Bowel Obstruction • 病因学 Etiology carcinoma 55% volvulus 11% diverticulitis 9% extrinsic carcinoma 8% adhesions 4% fecal impaction 3%

  22. Daignosis • 慢性梗阻 Chronic complaints • 腹痛位于下腹部和脐周 Pain related to lower abdomen or periumbilical area. • 腹胀明显 Abdominal distension prominent • 隐血试验 Guaiac-positive stools • 直肠指检 Rectal examination

  23. Management • 直肠乙状结肠镜 Proctosigmoidoscopy visualized/biopsied/decompressed • 结肠梗阻大多数需要手术治疗 Most large bowel obstruction need surgery expcet for fecal impaction • 闭襻性梗阻需急症手术 Closed loop obstruction need emergency • 分期手术 one/two/three -stage surgical procedures

  24. 肠粘连 Adhesive obstruction • 形成： 粘连锐角 纤维束带压迫 surgical trauma infections bleeding intestinal ischemia chemical trauma foreign bodies （powder） • 肠坏死 Risk of strangulation: 9% • 再次手术 肠排列手术 ( M-A管)

  25. 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

  26. 肠套叠Intussusception • Intussusceptum telescopes into an intussuscipiens(sheath) • enteroenteral ,ileocecal,ileocolic ,colocolic • children rate is high • 1/3 cases of adults is malignancies • resection is necessary • ( 香肠状, 空虚感, 粘液血便)

  27. 肠扭转Volvulus • Most patient are elderly men • sigmoid 60%~70% • psychiatric disorders and chromic laxative abuse • gangrenous colon must resect • sigmoid volvulus proctossigmoidoscopy

  28. 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%

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