內(nèi)科學消化系統(tǒng)總論

DigestiveSystem

IntroductionProf.JiyaoWang第1頁AssimilationofnutrientsEliminationofwasteStructureandfunctions第2頁StructureandfunctionsThetwoactivitiesundervoluntarycontrolareswallowinganddefecation.第3頁CharacteristicsofDigestiveSystemManynormalGIreflexesinvolveextrinsicvagusorsplanchnicnervepathways.

Anactivebrain-gutaxisfurtheraltersfunctioninregions第4頁Immuneorgan Gastrointestinal-associatedlymphoidtissue,(GALT)

CharacteristicsofDigestiveSystem第5頁Notonlyadigestiveorganbutalsoendocrineorgan pancreas gastrin(胃泌素) glucagon(胰高糖素) somatostatin(生長抑素) VIP(血管活性腸肽) insulin(胰島素)CharacteristicsofDigestiveSystem第6頁Structure/functionanddiseasesThebiggestorganHomeostasis

Synthesis

Excretion

FilterDefense

symptomssignsDeath第7頁

inflammation(炎癥)

Ulcer(潰瘍)

bleeding(出血)

perforation(穿孔)

neoplasm(腫瘤)

functionaldisturbances(功能失調(diào))CommonLesionsofDigestiveSystem第8頁ClassificationofGIDiseases

ImpairedDigestionandAbsorption

(Biliaryobstruction,Chronicpancreatitis)AlteredSecretion(Zollinger-Ellisonsyndrome,atrophicgastritis,smallintestinalbacterialovergrowth)AlteredGutTransit

(obstructionbygastriccancerorcoloncancer,Achalasia,constipation,diarrhea)第9頁ImmuneDysregulation(ulcerativecolitis,Crohn’sdisease)ImpairedGutBloodFlow

(intestinalandcolonicischemia)NeoplasticDegeneration

(Esophageal,gastric,colon,pancreatic,biliarycancer)DisorderswithoutObviousOrganicAbnormalities

(IBS)GeneticInfluences第10頁ClassificationofLiverDiseasesViralHepatitsNonalcoholicfattyliverAlcoholicliverdiseaseImmune&autoimmuneliverdiseasesDrug-inducedliverdiseaseGeneticliverdiseasesMasslesionsVascularinjuryLiverinvolvementinsystemicdiseases第11頁LaboratorytestsHistory+Symptoms+SignImagingstudies

EVALUATIONOFPATIENTWITHGIDISEASE

第12頁Thediagnosisdrivespredominantlyfromthepatient’shistoryThephysicianmustidentifythetiming,type,locationandseverityofthesymptoms,whenandwheretheyoccur,aggravatingandalleviatingfactors,andanyassociatedsymptoms.History&symptoms第13頁CardinalSymptomsofGIdiseasesAbdominalpain(GIandextraGI)(pepticulcer,appendicitis,IBD)Heartburn(gastroesophagealrefluxdisease,GERD)Nausea&VomitingAlteredbowelhabits(constipation,diarrhea,steatorrhea)GIbleeding(melena/hematemesis/hematochezia)Jaundice(Choledocholithiasis,cholangitis,pancreas,pancreaticcancer)第14頁CardinalsymptomsofliverdiseasesFatigue:mostcommon,intermittent&variableNausea&vomiting:mostsevereliverdis.Rightupperquadrantdiscomfort/liverpainItching:acutehepatitis,primarybiliarycirrhosis(PBC),sclerosingcholangitisJaundice:hemolytic,hepatocellulardamage,cholestasis第15頁History&symptomsDetailedhistory:

alcoholusemedicationspersonalhabitssexualactivityexposuretojaundicedpersontravelinjectiondruguse,recentsurgerybloodtransfusions,occupationaccidentalexposurefamilialhistorytobloodorneedlestick,ofliverdisease

第16頁Thehistoryandphysicalexaminationremainthebasesofevaluation.

DiagnosisofDigestiveSystemdiseases

Adirectedphysicalexaminationcanrefinethedifferentialdiagnosis

第17頁LaboratoryTestBloodroutinetests:HB,RBC,WBC+DC,PlateletStoolsample:routine,occultblood.parasitesliverfunctiontest(TB.CB.ALT.AST.A.G.ALP.PT)ANA,AMA,IgG,IgM,serumceruloplasminVirusmarkers(hepatitis.ABCDE.etc)Tumormarkers(AFP,CEA,CA19-9,CA125…)AnalysisofascitesfluidEsophagealpHtesting

第18頁DiagnosticImagingRadiology:

plainfilm bariummealexamination bariumenema small-bowelcontractradiology Angiogram,DSA第19頁DiagnosticImagingUS(ultrasound)CT(computedtomograpy)VirtualCTendoscopyMRI(magneticresonanceimaging)MRCP(MRcholangiopancreatography)ERCP(endoscopicretrogradeCP)PET(positronemissiontomography)Isotopeexamination:biliaryexcretiongastricemptying,13c.14c-UBT第20頁Endoscopies

(diagnosis&treatment)

upperendoscopy:dyspepsia,upperGIbleedingColonoscopy:lowerGIbleeding,diarrhea,cancerscreeningERCP(therapeutic):jaundice,gallstonepancreatitis,pancreas/biliary/ampulladisordersendoscopicultrasound:stagingofmalignancy,submucosalmassDoublebloomintestinalendoscopy:lowerGIbleeding,Crohn’sileitis第21頁第22頁ABiopsyofaPancreaticMassGuidedbyEndoscopicUltrasonography

thePlacementofaStentintoaMalignantBile-DuctStricturewithEndoscopicRetrogradeCholangiopancreatography第23頁EvaluationpatientswithliverdiseasesEstablishingthediagnosisGrading:estimatingdiseaseseverity(mild,moderate,severe)oractivity(activeorinactive)Staging:establishingdiseasestage

(acute/chronic;early/late;pre-cirrhotic/end-stage)IdentifyingtheunderlyingcauseLiverbiopsyChild-Pughclassification/MELD第24頁

Child-PughclassificationScorea

Factor

123

1.EncephalopathyNoneMinimalAdvanced2.AscitesNoneEasilycontrolledpoorlycontrolled3.Bilirubin(umol/L)<3434-51>514.Albumin(g/L)>3530-35<305.PTprolonged(s)or0-44-6>6ProthrombinTime(INR)<1.71.7～2.3

>2.3

aScoresiscalculatedbyaddingthescoresof5factorstodetermineChild-Pughclass:classA=5-6classB=7-9classC=10-15第25頁ModelofEnd-StageLiverDisease,(MELD)MELDscore=9.6loge(serumcreatininemg/dL)+3.8loge(serumbilirubinmg/dL)+11.2loge(INR)+6.4Scorerangefrom6－40.MELDiscurrentlyusedtoestablishprioritylistingforlivertransplantatio