腹部急症.ppt

急性腹痛 ER 最常見的主訴 醫師最大的挑戰 腹痛：神經支配 Parietal innervation (腹膜的壁層) T7~T12 肋間神經 及 L1 腰椎神經 Somatic pain: 尖銳、持續、 定位明確 源於腹部的腹痛 中空臟器的阻塞 腸道、膽道、輸尿管之阻塞 固體臟器表面之撐脹或腸系膜之拉扯移位 血管障礙 腸系動脈之血栓、栓塞、扭轉或血管破裂 腹膜發炎 化學性（潰瘍穿破或胰臟炎）或細菌性（闌尾破裂、骨盆腔炎） 源於腹部之外的腹痛 牽延痛 (Refer pain) 由胸腔、泌尿系、脊惟、脊髓、骨盆腔 代謝疾病 (Toxic-metabolic) 尿毒症、糖尿病酸血症、副甲狀腺機能亢進症、紫質病、血脂肪過高、細菌毒素、蛇毒、藥物 神經疾患 (Neurogenic) 帶狀痀疹、灼性神經痛、脊髓癆 心理疾患 (Psychogenic) 腹痛：病史 Onset / frequency / duration Location / radiation Intensity Character / Pattern Associated symptoms Relieving / aggravating factors Onset /frequency / duration Sudden onset Vascular: SMA occlusion (腸系動脈之栓塞); AAA rupture (腹部主動脈瘤破裂); Aortic dissection (主動脈剝離) Rupture: PPU ? 化學性腹膜炎; Ectopic pregnancy; tumor / cyst rupture Colic: Urinary colic, biliary colic, intestinal colic Location RUQ Epigastric LUQ R’t lumbar area Periumbilical L’t lumbar area RLQ Hypogastric / suprapubic LLQ Intensity Severe Moderate Mild Character / Pattern 絞痛 (Colic): 周期性增減的疼痛 ? 臟器平滑肌的攣縮，多為結石、腸阻塞、急性腸炎 持續性的腹痛 (Persistent) : ? 臟器的炎症 脹痛：多為機能性腸胃障礙 刺痛、火燒心：多為消化性潰瘍 悶痛、咬痛 饑餓過度會引起疼 ? 消化性潰瘍或前兆 油膩食物引起 RUQ 疼痛 ? 膽囊/膽道結石/發炎 Character / Pattern Migration of pain App: Central ? RLQ Aortic dissection: Retrosternal ? jaw ? upper back ? epigastric ? flanks / lower back Associated symptoms Anorexia / nausea / vomiting Constipation / diarrhea Fever / chills Jaundice Anemia / smooth tongue, spoon nails Hematemesis / tarry / melena / hematochezia Conjunctivitis / arthritis / dermatitis LMP / sexual activity / vaginal discharge Relieving / aggravating factors Relieving Hot milk / antacids Sitting up Aggravating Walking Coughing Lying down 腹痛：理學檢查 Vital signs Inspection Palpation Percussion Auscultation 理學檢查：別忘了！ 肛門指檢 痔瘡 直腸腫瘤 糞便嵌塞 陰道內診 骨盆腔內炎症 骨盆腔內腫瘤 骨盆腔內爛尾炎 Blood Tests CBC, D/C, Plt Glucose, BUN, Cr, GOT, Na, K PT, APTT Amylase / Lipase Bil (T/D), Alp NH3 ABG, ketone UGI / LGI series Single contrast Double contrast 外科腹部急症 急性腹膜炎 爛尾炎 胃/十二指腸穿孔 膽囊、膽道結石及膽囊炎 壞死性胰臟炎 肝膿瘍破裂 急性腹膜炎：機轉 內臟器官破裂 潰瘍性穿孔，爛尾炎、憩室炎、膽囊炎破裂，肝膿瘍破裂，創傷性腹膜內出血，腸壞死破裂 內臟器官炎症 爛尾炎，憩室炎，膽囊