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腸阻塞 (Ileus)

腸阻塞 (Ileus). 陳國智 醫師 新光醫院 急診醫學科. 蔡先生， 81 歲男性. 由家人陪同，自行步入急診 意識清楚 : A; 檢傷 : 3 級 生命徵象 T/P/R: 36.9/84/14; BP: 121/54 主訴 : 腹脹，約 3 天. 蔡先生， 81 歲男性. 病史詢問 自 94/06/10 出院後就沒有解大便或是排氣 肚子愈來愈脹 理學檢查 Abdomen : Soft but distended Bowel sound: hypoactive No palpable mass No tenderness

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腸阻塞 (Ileus)

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  1. 腸阻塞 (Ileus) 陳國智 醫師 新光醫院 急診醫學科

  2. 蔡先生，81歲男性 • 由家人陪同，自行步入急診 • 意識清楚: A; 檢傷: 3級 • 生命徵象 • T/P/R: 36.9/84/14; BP: 121/54 • 主訴: 腹脹，約3天

  3. 蔡先生，81歲男性 • 病史詢問 • 自94/06/10出院後就沒有解大便或是排氣 • 肚子愈來愈脹 • 理學檢查 • Abdomen : • Soft but distended • Bowel sound: hypoactive • No palpable mass • No tenderness • Tympanic percussion

  4. 可能診斷 Impression 腸阻塞 (Ileus)

  5. 急診處置 • Fleet enema  NPO + IV Fluid  (Lab) + Primperan 1amp. st & q8h + NG decom. • Fleet enema + KUB • On Anal tube / Consult GS / Sign 拒op • Fever :  B/C *2 , Cefazolin + GM • CXR , EKG , U/A , Admit to GI ward

  6. Clinical course • 92-11-30 ER, ABD fullness for 3-4 days, Imp: paralytic ileus, CT : colon dilation, Scopy: external compression at splenic flexture • 92-12-01~17 Admission. • 94-02-10 ER , ABD fullness for 3 days • 94-02-10~19 Admission, suggest op. • 94-06-09 ER, CT , GI LGI series but no volvulus, then MBD on 06-10

  7. 腸阻塞 • 定義: 食物及腸道的內容物無法正常排出 • 分類: • Adynamic ileus (paralytic) • Mechanical ileus • 常見原因

  8. 臨床症狀 痛 intermittent / crampy or constant 吐 bilious or feculent PE 位置 / 時間 / 病因 看 / 聽 / 摸 / 敲 / 壓 / 插 / 脫 併發症 脫水 / 電解質不平衡 / SIRS / 腸穿孔 / 敗血症

  9. 檢查項目 • X – ray • KUB + Standing Abdomen or Lat. decubitus • 看free air / mass / 定位 SBO or LBO • Lab. • CBC/DC , Electrolytes , BUN/Cr  看有無感染症 / 電解質不平衡 / 脫水 • Others • CT scan (最常) / Sigmoidoscopy • Barium enema / GI Series

  10. 治療方式 • Mechanical Ileus • Surgical intervention • NG decompression • Bowel evacuation: Fleet enema / S-S enema • Rectal tube / Sigmoidoscopy • IV fluid / Antibiotics • Adynamic Ileus • Conservative treatment • IV fluid / NG decompression / enema / antibiotics • Prokinetic agent (Primperan) • Avoid buscopan

  11. Malrotation Corkscrew appearance "hurricane" or swirl appearance

  12. Volvulus

  13. SMA occlusion

  14. Inverted U-shaped or Coffee-bean sign

  15. Take Home Message • Mechanical ilues: 外科治療為主 • Adynamic ileus: 內科治療為主 • 內科治療包含: • IV hydration / bowel evacuation / antibiotics • 臨床症狀及合併症是治療時重要的考量 • 愈老及愈小的病患要特別提高警覺 • 警訊: • 脫水，膽汁/糞便嘔吐物，發燒，心跳加速，血壓下降，腸音消失，腹膜剌激

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