Nausea and Vomiting As the symptoms

1. Nausea and Vomiting As the symptoms 症状学：恶心与呕吐

2. Goals • Briefly define • Outline the prominent disease states associated with nausea and vomiting. • Characterize Nausea and Vomiting caused by the prominent disorders • Discriminate the accompanying symptoms. • Suggest diagnostic strategies of the symptoms.

3. Definition of Nausea and Vomiting 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！ • 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-peristalsis. • Nausea-Vomiting: simultaneity or separateness

4. Nausea and Vomiting

5. 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. Associated 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). 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。

6. 发生机制 迷走兴奋表现 恶心 干呕 呕吐

7. 呕吐区别于反食 呕吐：多数情况有恶心的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）

8. Mechanisms of emesis

9. CTZ & Emetic Center (Vomiting center) 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 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）

10. CTZ & Emetic Center (Vomiting center) 孤束核

11. Emetic Center 化学感受器触发带 边缘系统 中脑ICP受体 前庭系统 内脏传入 呕吐中枢（Vomiting center) ICP=Inductively Coupled Plasma 感应耦合等离子体

12. Neurotransmitters in CTZ & Emetic Center Neurotransmitters involved in stimulating the emetic center, chemo-receptor trigger zone and GI tract include; 5-HT, acetylcholine, histamine, dopamine (opiates and receptors for benzodiazepines are also found here)

15. Emetic Center 1、分泌唾液中枢 2、血管收缩中枢 3、呼吸中枢 4、中枢神经 迷走神经 脊神经 膈神经

17. nausea and vomiting 1. Reflective vomiting反射性呕吐 2.Central vomiting 中枢性呕吐 3. Neurological vomiting 神经性呕吐

18. Reflective vomiting （反射性呕吐） Pharyngeal Mechanisms Gastrointestinal Mechanisms Disease of biliary tract Peritoneal and mesentery the five sense organs Cardiovascular diseases kidney Pelvic 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…）

19. 咽部刺激 Pharyngal Mechanisms

20. Gastrointestinal Mechanisms

21. 肝、胆、胰腺

22. 其他

23. Central vomiting （中枢性呕吐） Intra-cranial infection Cerebrovascular disorders Craniocerebral injury Epilepsy Metabolic disorders Drugs 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）

24. 颅内感染（脑炎、脑膜炎）

25. 脑血管疾病、颅脑损伤

26. 癫痫

27. 全身疾病 代谢紊乱 尿毒症 酮症酸中毒 早孕 各种原因引起的脑水肿和颅内压升高 肝昏迷

28. Drug Antibiotics Anti-carcinoma Digitalis morphia 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

29. Neurologic and Psychogenic causes Neurologic & Psychogenic causes 胃肠道神经官能症（Gastrointestinal tract neurosis） 神经厌食症（apositia）

30. Characteristics of Nausea and Vomiting • Time • Taking food • Characteristics • Characters of contents

31. 早孕反应 功能性消化不良 晨起呕吐 酒精中毒 鼻咽部疾患 胃食管反流病 幽门梗阻 夜间或隔夜呕吐 贲门失弛缓症

32. 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

33. 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 无酸腐味：贲门失迟缓症或胃酸缺乏 发酵、腐臭味：提示胃潴留 粪臭味：提示较低位置的肠梗阻 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

34. 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

35. 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

36. a) Age b) GI history required c) Food intolerance d) Timing with meals e) Consistency f) Content g) Odor h) Frequency i) Fever j) Weight loss k) Precipitating factors l) Myalgias（肌痛）, visual disturbances, headache, pain outside abdomen History/Background

37. Early pregnancy Psychogenesis vomiting Bulimia(易饿病) Pyloric channel ulcer Acute gastritis Gastric retention(潴留） Viral gastroenteritis（中毒性胃肠炎） Acute gastroenteritis Myocardial infarction Peritonitis（腹膜炎） Acute obstruction Neurological emergency Drug toxicity Cancer therapy Drug withdrawal CAUSES OF NAUSEA/VOMITING

38. PHYSICAL EXAM • Vital signs • Skin • HEENT （head,eyes,ear,nose,throat) • Abdomen • Neurological

39. LABORATORY • Rule out obstruction and peritonitis • HCG • Urinalysis • Electrolytes, BUN, creatinine, glucose • Transaminases, amylase • EKG, head CT, upper GI &/or endoscopies

40. Break

41. 泸沽湖黄昏

42. 泸沽湖黄昏

43. 泸沽湖•摩梭女

44. 玉龙雪山•雪月

46. Constipation Shanghai Second Medical university Renji clinical medical college

47. Background

48. C Constipation Is a Constellation of Symptoms • Most commonly reported symptoms • Hard, lumpy stools • Increased straining • Infrequent bowel movements • Sensation of incomplete evacuation • Bloating/fullness • Chronic constipation • More persistent than intermittent or episodic • Several months duration

49. 53 Constipation Is More Than Just Infrequent Passage of Stool Constipation symptoms reported most often n = 1128 Sandler RS, et al. Dig Dis Sci. 1987;32:841-845.

50. C Reduced Stool Frequency Is Not the Most Commonly Reported Symptom in Constipation Constipation symptoms reported most often Stewart (EPOC) 19991 Paré 20012 n = 1476 n = 1149 EPOC = Epidemiology of constipation; BM = Bowel movement. 1. Stewart WF, et al. Am J Gastroenterol. 1999;94:3530-3540. 2. Paré P, et al. Am J Gastroenterol. 2001;96:3130-3137.