【医学生物】Present 课件.ppt

Morning meeting,Present：王又德醫師Supervisor：楊浚銘醫師,1,Morning meetingPresent：王又德醫師1,Introduction,Bowel obstruction, gastroenteritis Severe pain, especially visceral painSevere systemic illness (myocardial infarction, sepsis, or shock)Pregnancy (hormones)Increased intracranial pressure (central mechanism)Chemotherapy (chemoreceptor trigger zone).,2,IntroductionBowel obstruction,3,3,History,ContentTimeAssociated symptoms (fever, headache, abdominal pain.) Social history (drug or alcohol abuse)Past medical history (any GI disease, surgery)Medication list,4,HistoryContent4,5,5,6,6,Complication,Hypovolemia Metabolic alkalosis Hypokalemia Mallory-Weiss tears typically follow a forceful bout of retching and vomiting. The lesion itself is a 1- to 4-cm tear through the mucosa and submucosa; Boerhaaves syndrome - perforation of all layers of the esophagus - free passage of esophageal contents into the mediastinum and thorax - 80% of cases involve the posterolateral aspect of the distal esophagus - surgical emergency. - Mortality is 50% if surgery is not performed within 24 hoursAspiration of gastric contents,7,ComplicationHypovolemia 7,8,8,Hiatal hernia,9,Hiatal hernia9,Introduction,Frequent finding by radiologists and gastroenterologists.,10,Introduction Frequent finding,Type I: Sliding hernia,95 % of cases.Widening of the muscular hiatal tunnel and circumferential laxity of the phrenoesophageal membrane gastric cardia to herniate upward. The phrenoesophageal membrane remains intact Posterior mediastinum,11,Type I: Sliding hernia 95 % o,12,12,13,13,Type I: Sliding hernia,Most small hiatal hernias are asymptomatic and, even with larger type I herniasClinical implication is the propensity to develop gastroesophageal reflux disease (GERD). The likelihood of symptomatic gastroesophageal reflux increases with the size of the hiatal hernia.,14,Type I: Sliding herniaMost sma,Other types of hiatal hernia,Less common types of hiatal hernia, types II, III, and IV, are varieties of paraesophageal hernias up to 5 % of all hiatal hernias Surgical dissection of the hiatus as occurs during antireflux procedures, esophagomyotomy, or partial gastrectomy.,15,Other types of hiatal herniaLe,Type II hernia,Defect in the phrenoesophageal membraneGastroesophageal junction remains fixed to the preaortic fascia and the median arcuate ligament. Gastric fundus serves as the leading point of herniation,16,Type II hernia Defect in the p,17,17,Type III hernias,Both types I and II.,18,Type III herniasBoth types I a,Type IV hiatus hernia,Large defect in the phrenoesophageal membraneAllowing other organs, such as the colon, spleen, pancreas, and small intestine, to enter the hernia sac.,19,Type IV hiatus herniaLarge def,Symptoms,Epigastric or substernal painPostprandial fullness, substernal fullness, Nausea, and retching.,20,SymptomsEpigastric or substern,Complication,Gastric volvulus dysphagiaPostcibal pain gastric torsion. Within the incarcerated hernia pouch gastric ulceration, gastritis, or erosions BleedingRespiratory complications result from mechanical compression of the lung by a large hernia or other organs herniating through the hiatus.,21,ComplicationGastric volvulus ,Treatment,Head of bed elevation Dietary modificationRefraining from assuming a supine position after meals and avoidance of meals before bedtimeAvoidance of tight fitting garments Obesity is a risk factor Restriction of alcohol use,22,TreatmentHead of bed elevation,Medical treatment,AntacidsH2 blockerPPIProkinetic drugs,23,Medical treatmentAntacids23,Surgical treatment,Reduction of the herniated stomach into the abdomen Herniotomy (excision of the hernia sac) Herniorraphy (closure of the hiatal defect) An antireflux procedure Gastropexy (attachment of the stomach subdiaphragmatically to prevent reherniation),24,Surgical treatmentReduction of,Thanks a lot,References from Uptodate,25,Thanks a lotReferences from Up,