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
History/Background
a) Age b) GI history required c) Food intolerance d) Timing with meals e) Consistency
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。
发生机制
迷走兴奋表现
恶心
干呕 呕吐
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）
Mechanisms of emesis
f) Content
g) Odor h) Frequency i) Fever j) Weight loss k) Precipitating factors l) Myalgias（肌痛）, visual disturbances, headache, pain outside abdomen
CAUSES OF NAUSEA/VOMITING
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…）
咽部刺激
Pharyngal Mechanisms
Gastrointestinal Mechanisms
Emetic Center
1、分泌唾液中枢 2、血管收缩中枢
Emetic Center
3、呼吸中枢
4、中枢神经
Spinal nerve Abdominal muscles
1.Salivary center 2. Vasomotor center 3. Respiratory center 4. Cranial nerves phrenic nerve Diaphragm vagus nerve Stomach Esophagus
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）
CTZ & Emetic Center (Vomiting center)
健康快乐每一天！
临床诊断学
上海第二医科大学仁济临床医学院
Nausea and Vomiting As the symptoms
症状学：恶心与呕吐
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.
内脏传入
呕吐中枢（Vomiting center)
ICP=Inductively Coupled Plasma 感应耦合等离子体
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)
1. Time 2. Taking food 3. Characteristics 4. Characters of contents
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 夜间或隔夜呕吐 贲门失弛缓症 幽门梗阻
呕吐与进食的关系 （ Timing with meals）

Vital signs Skin HEENT （head,eyes,ear,nose,throat) Abdomen Neurological
LABORATORY


Rule out obstruction and peritonitis HCG Urinalysis Electrolytes, BUN, creatinine, glucose Transaminases, amylase EKG, head CT, upper GI &/or endoscopies
孤束核
Emetic Center
化学感受器触发带 中脑ICP受体 Midbrain Chemoreceptor ICP Receptor Trigger Zone
Visceral afferents
边缘系统 Limbic System
Vestibular system
前庭系统
Emetic Center
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
Break
泸沽湖黄昏
泸沽湖黄昏
泸沽湖•摩梭女
玉龙雪山•雪月
47
Constipation
Shanghai Second Medical university Renji clinical medical college
Background
C
Constipation Is a Constellation of Symptoms
Definition of Nausea and Vomiting



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
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
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

Chronic constipation
脊神经
膈神经
迷走神经
nausea and vomiting
1. Reflective vomiting 2.Central vomiting 3. Neurological vomiting
反射性呕吐 中枢性呕吐 神经性呕吐
Reflective vomiting （反射性呕吐）
Pharyngeal Mechanisms Gastrointestinal Mechanisms Disease of biliary tract Peritoneal and mesentery
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 and Vomiting
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。