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1、急 腹 症Acute Abdominal Pain,昆明医学院第一附属医院急诊科郑宏宇,概念,外科急腹症是一组以急性腹痛为主要表现，绝大多数需要紧急外科手术处理的急性炎症、出血、梗阻、穿孔及血运障碍性疾病的总称。,前言,Abdominal pain is a complaint seen commonly in the outpatient setting.The differential diagnosis of a patient presenting with acute abdominal pains.,pathophysiology of the pain,the clinical
2、presentation,Course,initial management,A focused historyphysical examination adjunctive testing strategy,pathophysiology of the pain,The abdominal viscera are innervated with nocioceptive afferents within the mesentery,on peritoneal surfaces,and within the mucosa and muscularis of hollow organs.,The
3、 pain genesis,Mechanicalstretch,Chemical substance P serotonin prostaglandins hydrogen ions,Stimuli,Dullcrampypoorly localized pain sensations,Three broad patterns,visceralParietalreferred,Visceral,typically involves stretch and distension of the abdominal organs.although torsion,and contraction als
4、o contribute.The pain stimulus is carried on slow-conducting C-fibers.,dull ache.Pain location corresponds to those dermatomes that match the innervation of the injured organ.,Parietal,Sharpwell localized A-fibers,with a rapid conduction velocity,Referred,pain occurs when visceral afferents carrying
5、 stimuli from a diseased organ enter the spinal cord at the same level as somatic afferents from a remote anatomic location.,Furthermore,disease processes from organs outside of the abdominal cavity can present with abdominal pain.,History,assessment of the conditionmedical problemsmedicationsfamily
6、 history,substance abuse history,recent travel historyoccupational history.,Nature of the pain,its qualityLocationrapidity of onsetChronicityradiation,Intensityexacerbating factorsalleviating factorsAssociated symptoms,Physical examination,general observation(review of the vital signs)abdominal insp
7、ectionauscultationpalpation,Diagnosis of abdominal pain based on location and distribution,Right upper quadrant Peptic ulcer diseaseBiliary diseaseBiliarycolicCholedocholithiasisCholecystitisCholangitisLiver diseaseHepatitisNeoplasmAbscessCongestive hepatopathy,Lung diseasePneumoniaSubphrenic absces
8、sPulmonary embolismPneumothoraxAbdominal wallHerpes zosterMuscular StainKidney diseasePyelonephritisPerinephric abscessNephrolithiasisColonic causesColitisRight sided diverticulitis,Middle upper abdomen,Peptic ulcer diseasePancreatitic diseasePancreatitisPancreatic neoplasmBiliary diseaseBiliary col
9、icCholedocholithiasisCholecystitisCholangitis,Esophageal diseaseReflux esophagitisInfectious esophagitisPill esophagitisCardiac diseaseMyocardial ischemiainfarctionPericarditisAAA rupture/aorticdissectionMesenteric ischemia,Left upper quadrant,Peptic ulcer diseaseSplenic diseaseSplenic ruptureSpleni
10、c infarctPancreatic diseasePancreatitisPancreatic neoplasm,Lung diseasePneumoniaSubphrenic abscessPulmonary embolismPneumothoraxKidney diseasePyelonephritisPerinephric abscessNephrolithiasis,Periumbilical,Appendicitis(early)Small bowel obstructionGastroenteritisMesenteric ischemiaAAA ruptureAortic d
11、issection,Right lower quadrant,AppendicitisInflammatory bowel diseaseOB-GYN causesOvarian tumorOvarian torsionEctopic pregnancyPelvic inflammatory disease(PID),Kidney diseasePyelonephritisPerinephric abscessNephrolithiasisIntestinal diseaseRight sided diverticulitisIleocolitisGastroenteritisHernia,S
12、uprapubic,Inflammatory bowel diseaseOB-GYN causesOvarian tumorOvarian torsionEctopic pregnancyPIDDysmenorrhea,Colonic diseaseProctocolitisDiverticulitisUrinary tract diseaseCystitisNephrolithiasisProstatitis,Left lower quadrant,Inflammatory bowel diseaseOB-GYN causesOvarian tumorOvarian torsionEctop
13、ic pregnancyPIDKidney diseasePyelonephritisPerinephric abscessNephrolithiasis,Intestinal diseaseSigmoid diverticulitisIleocolitisGastroenteritisHernia,Diffuse,GastroenteritisBowel obstructionPeritonitisMesenteric ischemiaInflammatory bowel diseaseDiabetic ketoacidosisPorphyriaUremia,HypercalcemiaSic
14、kle cell crisisVasculitisHeavy metal intoxicationOpiate wihdrawalFamilial mediterranean feverHereditary angioedema,based on history and physical alone,Physicians were able to correctly differentiate between organic and nonorganic causes of abdominal pain nearly 80%,significant abnormality of the vit
15、al signs,mental status changes,involuntary guarding,rebound abdominal tenderness,complete absence of bowel sounds,and pain out of proportion to abdominal tenderness,without signs or symptoms of an acute abdominal catastrophe,an acute expedited outpatient evaluation should be performed.,laboratory an
16、d imaging studies,plain abdominal radiographs have been the initial imaging test of choice.rapidly at a relatively low cost,up to 60%of cases of suspected small bowel obstruction.with a perforated viscus,sensitivity of plain films is reported to be as high as 100%.as small as 1 to 2 cc of air has be
17、en reported using this method,CT is sensitive for the diagnosis,rapid helical scanning methods,advances in intravenous and oral contrast agents,three-dimensional reformatting,Computed tomography has proven to be more sensitive and specific for nearly all etiologies of acute abdominal pain,there is a
18、 spectrum of systemic medical disorders,such as adrenal insufficiency,diabetic ketoacidosis,porphyria that can present with abdominal pain.,外科急腹症的治疗原则,非手术治疗 适应证就诊时腹膜炎已局限且病人全身情况良好；就诊时不明确且又无紧急手术指证；出血性疾病经输血治疗，血压回升，病情稳定无再出血表现；诊断明确，非手术治疗疗效明显；病情危重，全身情况极差或合并重要器官功能不全，不能耐受手术者。,外科急腹症的治疗原则,非手术治疗的一般方法禁止饮食通畅有效的胃肠减压密切观察生命体征的变化应用必要的抗生素，预防和治疗感染反复观察腹部体征的变化及时有效的输血、输液扩充有效血容量，防止休克止痛药物的应用,外科急腹症的治疗原则,手术治疗 适应证急性剧烈的腹痛，非手术治疗无效或加重腹内活动性出血性疾病有明显腹膜炎刺激症状空腹脏器穿孔，腹膜炎较广泛腹腔化脓性感染，需要及时减压引流腹部闭合性损伤，确有内脏损伤或可疑者,外科急腹症的治疗原则,手术治疗 原则简单有效,Thank you!,
