肠阻塞（Ileus）.pptVIP

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 Tympanic percussion 可能診斷 Impression 腸阻塞 (Ileus) 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 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 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 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 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 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 Malrotation Volvulus SMA occlusion 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 * Volvulus Intussusception Fecal Impaction Hernia Carcinoma Adhesion 大腸 小腸 Corkscrew appearance hurricane or swirl appearance Inverted U-shaped or Coffee-bean sign *