Nausea and VomitingAs 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.

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

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

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。

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).

迷走兴奋表现

恶心干呕

呕吐

发生机制

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

CTZ & Emetic Center (Vomiting center)

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）

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 & Emetic Center (Vomiting center)

孤束核孤束核

Emetic Center

Midbrain Chemoreceptor Limbic Vestibular ICP Receptor Trigger Zone System system Visceral afferents Emetic Center

内脏传入

中脑 ICP 受体 化学感受器触发带 边缘系统

前庭系统

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)

Emetic Center

Emetic Center 1.Salivary center 2. Vasomotor center 3. Respiratory center 4. Cranial nerves Spinal nerve phrenic nerve vagus nerve Abdominal Diaphragm Stomach Esophagus muscles

1 、分泌唾液中枢

2 、血管收缩中枢

3 、呼吸中枢

4 、中枢神经

脊神经 膈神经 迷走神经

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

Reflective vomiting （反射性呕吐）

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…）

Pharyngeal MechanismsGastrointestinal

MechanismsDisease of biliary tract

Peritoneal and mesentery

the five sense organsCardiovascular diseases kidneyPelvic

咽部刺激

Pharyngal Mechanisms

Gastrointestinal Mechanisms

肝、胆、胰腺

其他

Intra-cranial infection

Cerebrovascular disorders

Craniocerebral injury

Epilepsy

Metabolic disorders

Drugs

Central vomiting （中枢性呕吐）

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）

颅内感染（脑炎、脑膜炎）

脑血管疾病、颅脑损伤

癫痫

全身疾病

尿毒症

肝昏迷

酮症酸中毒

各种原因引起的脑水肿和颅内压升高

代谢紊乱

早孕

Drug

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

Antibiotics

Anti-carcinoma

Digitalis

morphia

Neurologic & Psychogenic causes

Neurologic and Psychogenic causes

胃肠道神经官能症（ Gastrointestinal tract

neurosis ）

神经厌食症（ apositia ）

Characteristics of Nausea and Vomiting

1. Time

2. Taking food

3. Characteristics

4. Characters of contents

晨起呕吐

早孕反应

功能性消化不良

酒精中毒

胃食管反流病鼻咽部疾患

夜间或隔夜呕吐

幽门梗阻

贲门失弛缓症

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

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

发酵、腐臭味：提示胃潴留粪臭味：提示较低位置的肠梗阻

无酸腐味：贲门失迟缓症或胃酸缺乏

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

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

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/Backgrounda) Ageb) GI history requiredc) Food intoleranced) Timing with mealse) Consistency

f) Content

g) Odorh) Frequencyi) Feverj) Weight lossk) Precipitating factorsl) Myalgias （肌痛） ,

visual disturbances, headache, pain outside abdomen

CAUSES OF NAUSEA/VOMITING

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

PHYSICAL EXAM

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

BreakBreak

泸沽湖黄昏

泸沽湖黄昏

泸沽湖•摩梭女

玉龙雪山•雪月

45

Constipation

Shanghai Second Medical university

Renji clinical medical college

Background

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

C

52

44

34 32

20 19

11

0

10

20

30

40

50

60

Strai ni ng Hard stool s

Want to but can' t

Infrequentstool s

Abdomi naldi scomfort

Haven' tfi ni shed

Excesstoi l et ti me

Pa

tie

nts

, %

Sandler RS, et al. Dig Dis Sci. 1987;32:841-845.

n = 1128

Constipation Is More Than Just Infrequent Passage of Stool

53

Constipation symptoms reported most often

Reduced Stool Frequency Is Not the Most Commonly Reported Symptom in Constipation

13

26

32

36

65

83

0 50 100

< 3 BM/ wk

Abdomi nalbl oati ng ≥

Press onabdomen

Abdomi naldi scomfort

UnsuccessfulBM

Incompl eteBM

Patients, %

28

36

37

39

54

72

81

0 50 100

Press onanus

< 3 BM/ wk

Abdomi nalbl oati ng

Stoolcannot pass

Incompl eteevacuati on

Hard stool

Strai ni ng

Patients, %

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.

Stewart (EPOC) 19991 Paré 20012

n = 1476 n = 1149

Constipation symptoms reported most often

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Prevalence in the General Population

1. Stewart WF, et al. Am J Gastroenterol. 1999;94:3530-3540.2. Drossman DA, et al. Dig Dis Sci. 1993;38:1569-1580.3. Harris Interactive Study, Wave 2. Data on file. 4. Paré P, et al. Am J Gastroenterol. 2001;96:3130-3137.

53

Population n CriteriaPrevalence, n

(%)US1 10,018 Rome I 461 (4.6)US2 5430 Rome I 195 (3.6)US3 15,183 Rome II 2429 (16)Canada4 1149 Rome II 171 (14.9)China (18-70ys)

? RomeII ?(6.07)

China(>60ys) ? RomeII ?(15-20)

Epidemiology Chronic constipation is common

Slightly more common in women

F/M ratio = range 1.3 to 2.5 (China=4:1)

Affects all age groupsStewart WF, et al. Am J Gastroenterol. 1999;94:3530-3540.Paré P, et al. Am J Gastroenterol. 2001;96:3130-3137.Sandler RS, et al. Dig Dis Sci. 1987;32:841-845.

C

Constipation Affects All Age Groups

53

Canadian population.Paré P, et al. Am J Gastroenterol. 2001;96:3130-3137.

0

5

10

15

20

25

18 - 34 35 - 49 50 - 64 > 64

Age group, yr

Co

nst

ipat

ed,

%

Rome I Rome I I

N = 1149

n = 378 n = 367 n = 217 n = 187

Profile of a Typical Chronic Constipation Patient in My Practice

Generally female

Symptomatic for > 10 yr

Majority have tried lifestyle changes, fiber, and OTC laxatives prior to seeking care

Manages condition with multiple therapies

Most often referred by a primary care physician

Copes with condition, but is not completely satisfied

C

Constipation Can Have a Negative Impact on Quality of Life

People with CC reported significant impairment in QoL on SF-36 scale (n = 126)1

In Canada, people with self-reported or Rome II constipation had significantly worse SF-36 scores than the normal population (n = 472)2

In Australia, people with constipation had significantly worse SF-12 scores on both mental and physical scales (n = 227)3

1. O’Keefe EA, et al. J Gerontol A Biol Sci Med Sci. 1995;50:M184-M189.2. Irvine EJ, et al. Am J Gastroenterol. 2002;97:1986-1993. 3. Koloski NA, et al. Am J Gastroenterol. 2000;95:67-71.

C

Constipation Significantly Impacts Healthcare Utilization 5.7 million constipation-related outpatient

visits annually1,2

4.1 million physician office-based visits

991,000 emergency room visits

587,000 hospital outpatient visits

$2752/patient for tertiary care evaluation3

1. National Ambulatory Medical Care Survey, 2001. www.cdc.gov2. National Hospital Ambulatory Care Survey, 2001. www.cdc.gov3. Rantis PC Jr, et al. Dis Colon Rectum. 1997;40:280-286.

C

Complications related with constipation

Colonic and rectal carcinoma

Other colon-rectal-anus disorders

hepatic coma

acute myocardial infarction

mammary gland disorders

presenile dementia( 早老性痴呆）psycho-problems

appearance

Definition: Causes of Chronic Constipation Secondary

Drug induced Metabolic factors Comorbid conditions

Primary Impaired colonic transit/motility

Altered neuroenteric function and reflexes Failure of muscular apparatus

Ineffective defecation (functional outlet obstruction)

Pelvic dyssynergia and anismus Normal transit constipation

Presentation Objectives Define constipation

The pathophysiological mechanisms

Etiologies of constipation

Characterize manifestation

Discriminate the accompanying symptoms.

Suggest diagnostic strategies of the symptoms.

C

What is Constipation? Passage of hard, dry, lumpy stools;

Infrequent bowel movements, usually fewer than three times a week

Symptoms: painful bowel movements straining Uncomfortable （ Sensation of incomplete

evacuation ） bloated sluggish

Rome II Defines Functional Constipation Based on Multiple Symptoms

Rome II diagnostic criteria for functional constipation

At least 12 wk, which need not be consecutive, over the past 12 months of 2 or more of

Straining* Lumpy or hard stools* Sensation of incomplete evacuation* Sensation of anorectal obstruction/blockage* Manual maneuvers to facilitate defecation* < 3 defecations/wk

Loose stools not present Insufficient criteria for IBS

* > 1/4 of defecations.Drossman DA, et al. In: Rome II: The Functional Gastrointestinal Disorders. 2000:382-391.

C

Normal metabolism As food moves

through your intestines, it absorbs water while forming waste products

Muscles contract in the colon, pushing the stool toward the rectum

Defecation Process

Yield awareness of defecation

Anal intra- and extra-sphincter Relaxation

Abdominal effects

Mechanical stimulation

1. Yield awareness of defecation

2. Anal intra- and extra-sphincter Relaxation

intra- sphincter

extra-sphincter

Levator ani muscle

2. Abdominal effects

gastric contents via anus

What Causes Constipation? Eating too little

fiber Not drinking

enough liquids Lack of

exercise/physical activity

What Causes Constipation?

Change in routine travel

Older age Slower

metabolism Frequent use of

laxatives Certain diseases or

conditions

What Causes Constipation?

Certain diseases or conditions Rectal and Anal

disorders Colonic disorders Systemic diseases

or conditions

What Causes Constipation?

pain (narcotics 麻药 ) antacids containing

aluminum antidepressants iron supplements diuretics (“water” pills)

• Medications

Classification of etiologies

Eating too little fiber Not drinking enough

liquids Lack of

exercise/physical activity

Change in routine Travel psycho-related

Older age Slower

metabolism

Frequent use of laxatives

tediously long Colon Medications

Travel pain (narcotics 麻

药 ) antacids containing

aluminum antidepressants iron supplements diuretics (“water”

pills)

Functional etiologies

psycho-related

Tediously long Colon

结肠冗长

Organic constipation

(certain diseases or conditions cause constipation)

Classification of etiologies

Rectal and Anal disorders Benign or malignancy tumor Tumor or mass outside Systemic diseases or conditions (e.g.

disorders make dyscinesia: spasm and paralysis ）

Rectal and Anal disorders

Cancer

Nevus

anal fissure

anal fistula

Proctoptosis (直肠脱垂）

intestinal obstruction

Benign or malignancy tumor

Polyp Cancer

Outside tumor or mass

Systemic diseases or conditions

Gastro-paresis

Diabetes mellitus; DM

Uremia

Myasthenia gravis

Hypothyroidism

Hematoporphyria

Lead poisoning

胃轻瘫

糖尿病

尿毒症

重症肌无力

甲状腺机能低下

血卟啉病

铅中毒

Characteristics of manifestation

急性便秘常伴随原发病的表现：腹痛、腹胀、恶心呕吐、排气停止，见于各种原因的肠梗阻。

慢性便秘可有消化不良症状：

便秘型 IBS ：

大便形状：1.散粒 2.团粒 3.柱粒 4.条形 5.堆 6. 片7. 水

Accompanying symptoms

1 。呕吐、腹胀、肠绞痛，提示肠梗阻

2 。伴包块：提示肿瘤、肠结核、 Crohn 病

3 。便秘腹泻交替：肠结核、 IBS 、 UC

4 。继发于生活、环境改变：功能性

Intestinal obstructionTumor,TB,Crhon’s diseaseTB,IBS,UCFunctional constipation

1. Vomiting, abdominal distention, Intestinal colic

2. Mass

3. With diarrhea alternatively

4. Change in routine

Important information for etiological diagnosis

a) Ageb) GI history requiredc) Food habitd) Condition related

(living,working, communicating, psychology…)

e) Consistency

f) course of diseases

g) Frequency h) form, texture, Odor,

Content, i) Increased straining,

Sensation of incomplete

j) Weight lossk) Precipitating factorsl) Medicationsm) Disorders outside

gastroenterology

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