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1、恶心与呕吐,Nausea and Vomiting,Nausea and Vomiting,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
2、-peristalsis.Nausea-Vomiting:simultaneity or separateness,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！,病因,1.Reflective vomiting 反射性呕吐2.Central vomiting 中枢性呕吐3.Neurological vomiting 神经性呕吐,Reflective vomiting（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）,Pharyngeal Mec
3、hanismsGastrointestinal MechanismsDisease of biliary tractPeritoneal and mesenterythe five sense organsCardiovascular diseases kidneyPelvic,咽部刺激,Pharyngal Mechanisms,Gastrointestinal Mechanisms,肝、胆、胰腺,其他,Intra-cranial infectionCerebrovascular disordersCraniocerebral injuryEpilepsyMetabolic disorders
4、 Drugs,Central vomiting（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-carcinomaDigitalismorphia,Neurologic&Psychogenic causes,Neurologic and Psychogenic causes,胃肠道神经官能症（Gastrointest
5、inal tract neurosis）神经厌食症（apositia）,迷走兴奋表现,恶心,干呕,呕吐,发生机制,1、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。,Definition of emesis.(Three phases)呕吐反射过程（三个阶段）,1.Nausea-the inclination or feeling of imminent desire to vomit,usually felt in the throat or epigastrum.Asso
6、ciated 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 contents via retroperistalsis.(Abdominal effects).,呕吐区别于反食,呕吐：多数情况有恶心的
7、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）,CTZ&Emetic Center(Vomiting center),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）,Emetic Center（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,Emetic Center,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（Vomiting center),ICP=Inductively Coupled Plasma 感应耦合等离子体,临床表现Chara
8、cteristics of Nausea and Vomiting,TimeTaking foodCharacteristicsCharacters of contents,夜间或隔夜呕吐,幽门梗阻,贲门失弛缓症,呕吐的时间,呕吐与进食的关系（Timing with meals）,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,伴随症状The accompanying symptoms,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,谢谢！,
