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1 新生儿呕吐性疾病的诊断思路中山一院儿科余慕雪

2 呕吐定义胃内容物在消化道内逆行自口腔排出的反射性动作

3 新生儿胃容量

4 呕吐相关的几个定义 Vomiting Nausea Regurgitation GER Forceful oral expulsion of gastric contents associated with contraction of the abdominal and chest wall musculature The unpleasant sensation of the imminent need to vomit, usually referred to the throat or epigastrium The act by which food is brought back into the mouth without the abdominal and diaphragmatic muscular activity that characterizes vomiting Passage of gastric content into esophagus Quigley EM, et al.. AGA technical review on nausea and vomiting. Gastroenterology. 2001,120(1):263-86

5 病因消化道疾病食道胃肠道消化道以外的疾病感染中枢系统疾病遗传代谢病

8 诊断发生时间呕吐物的性状呕吐的性质伴随症状体格检查实验室检查及选择

9 发生时间 1~2 天咽下综合征食管闭锁高位肠梗阻缺氧缺血颅内出血颅高压 3~7 天幽门痉挛低位肠梗阻肠旋转不良胎粪排出延迟喂养不当感染 1 周后感染喂养不当肥厚性幽门狭窄肠旋转不良胃扭转

10 呕吐物的性状胆汁壶腹部远端的梗阻肠旋转不良肠闭锁胎粪性肠梗阻先天性巨结肠症肛门直肠畸形麦克尔憩室环状胰腺感染 NEC 败血症代谢性疾病其他墨绿色区别黄色的初乳和胎粪

11 胆汁性呕吐 63 (35 boys, 28 girls) 例胆汁性呕吐中位 GA 40 W ( 31 to 42) 平均 BW 3.5 kg (1.67 to 4.64). 平均年龄 26 hours (9 hr to 28 days). 外科情况胆汁性呕吐 24 (38%): Hirschsprung s disease (9), small bowel atresia (5), intestinal malrotation (4), meconium ileus (3), meconium plug (1), colonic atresia (1), milk inspissation (1). 19 例有腹部体征和异常影像学 Walker G M,et al. Colour of bile vomiting in intestinal obstruction in the newborn: questionnaire study. BMJ,2006,332(7554):1363.

12 胆汁性呕吐非外科情况的胆汁性呕吐 39 (62%) 35 例体检和腹部平片正常 4 例轻度肠扩张 15 例胃食管十二指肠胃返流功能性肠梗阻代谢性疾病感染 Walker G M,et al. Colour of bile vomiting in intestinal obstruction in the newborn: questionnaire study. BMJ,2006,332(7554):1363.

13 胆汁性呕吐 bilious vomiting in the [neonate] should be considered as due to mechanical intestinal obstruction until proved otherwise. Walker G M,et al. Colour of bile vomiting in intestinal obstruction in the newborn: questionnaire study. BMJ,2006,332(7554):1363.

14 胆汁性呕吐 Walker G M,et al. Colour of bile vomiting in intestinal obstruction in the newborn: questionnaire study. BMJ,2006,332(7554):1363.

15 胆汁性呕吐绿色 Walker G M,et al. Colour of bile vomiting in intestinal obstruction in the newborn: questionnaire study. BMJ,2006,332(7554):1363.

17 呕吐物的性状非胆汁性血性鲜红色咖啡色出生时咽下综合征母乳喂养乳头损伤出血性疾病维生素 K 缺乏溃疡

18 呕吐物的性状非胆汁性粘液未消化乳汁食管乳凝块胃幽门十二指肠上段

19 新生儿非胆汁性呕吐 Hutson J, Beasley S. Non-Bile-Stained Vomiting in Infancy. 2013:83-89.

21 Hutson J, Beasley S. Non-Bile-Stained Vomiting in Infancy. 2013:83-89.

22 Common Causes Type of Vomiting Comment/Associated Features 1.Intestinal atresia/webs 1.Bilious, depending on level of lesion 1. May occur at level of esophagus, Duodenum or jejunum 2.Meconium ileus 2. Bilious 2. Strongly associated with CF 3. Hirschsprung disease 3. Bilious or nonbilious 3. History of non-passage of stools in nursery suggestive; suction rectal biopsy may demonstrate lack of ganglion cells 4. Necrotizing Enterocolitis 4. Bilious or nonbilious 4. Plain films of abdomen may reveal intestinal pneumatoses 5. Inborn irrors of metabolism 5. Bilious or nonbilious 5. May have acidosis or Hypoglycemia

23 Common Causes 1.Pyloric stenosis Type of vomiting 1.Nonbilious Comment/Associated features 1.Hypochloremic metabolic Alkalosis 2. Malrotation with midgut volvulus 3. Inborn errors of Metabolism 2.Bilious 3.Bilious or nonbilious 2. Abdominal distention may be present, plain X rays may show air fluid levels & paucity of distal bowel gas. 3. Newborn metabolic screen may be abnormal; acidosis or hypoglycemia may be present 4. Milk/soy protein allergy 4.Bilious or nonbilious 4. may have gross or occult blood, extreme fussiness,fecal occult blood testing of stools may be positive 5.Gastroesophagal Reflux 6. infections/sepsis 5.Nonbilious 6.Bilious or nonbilious 5. Emesis usually within 30 minutes of feeding; symptoms worse in supine flat position 6. H&P may suggest infections( GBS, Herpes) bandemia, CSF.

24 呕吐的性质喷射性呕吐部分或完全消化道梗阻肥厚性幽门狭窄 GERD( 喂养不当 ) 反复呕吐伴青紫呼吸暂停恶心肺炎胃扭转合并 GERD 持续性呕吐消化道梗阻间歇性呕吐幽门痉挛肥厚性幽门狭窄 GERD 牛奶蛋白过敏喂养不当胃肠炎肠旋转不良

25 体格检查观察进食情况喷射呕吐返流体格生长牛奶蛋白过敏 GERD 皮肤黄疸瘀斑湿疹肛周

26 牛奶蛋白过敏陈洁. 重视食物过敏在儿童胃肠道疾病中的作用. 中华儿科杂志,2010,48(4):

27 牛奶蛋白过敏 Benhamou A H, et al. An overview of cow's milk allergy in children. Swiss Med Wkly,2009,139(21-22):300

28 体格检查腹部视诊触诊听诊腹胀蠕动波包块紧张肠鸣音神经系统颅高压

29 实验室检查血常规生化钠钾血糖 HCO2 尿素氮血氨乳酸大便潜血

30 实验室检查影像学检查胆汁性呕吐间歇性非胆汁性呕吐喷射性非胆汁性呕吐

31 实验室检查胆汁性呕吐腹部 X 线照片胃肠扩张梗阻正常不能排除胃肠道畸形上消化道造影胃幽门十二指肠 Treitz 发现机械性肠梗阻肠旋转不良灌肠检查下消化道畸形假阴性

32 十二指肠闭锁近端十二指肠胃

33 十二指肠闭锁

34 回肠闭锁

35 肠旋转不良

36 胎粪性肠梗阻

37 Bulas D, et al. National G C N. ACR Appropriateness Criteria vomiting in infants up to 3 months of age p.

38 Bulas D, et al. National G C N. ACR Appropriateness Criteria vomiting in infants up to 3 months of age p.

39 实验室检查间歇性非胆汁性呕吐上消化道造影了解解剖结构 GERD 特异性低于 ph 监测了解粘膜的完整性了解胃排空幽门肌肉胃扭转其他

40 胃食管返流并食管裂孔疝

41 肥厚性幽门狭窄

42 Bulas D, et al. National G C N. ACR Appropriateness Criteria vomiting in infants up to 3 months of age p.

43 实验室检查喷射性非胆汁性呕吐腹部超声腹部包块肥厚性幽门狭窄上消化道造影肥厚性幽门狭窄鉴别 GERD 胃扭转等

44 肥厚性幽门狭窄

45 Bulas D, et al. National G C N. ACR Appropriateness Criteria vomiting in infants up to 3 months of age p.

Microsoft PowerPoint - 17-10-2008《都市病─胃酸倒流及腸胃病》.ppt

Microsoft PowerPoint - 17-10-2008《都市病─胃酸倒流及腸胃病》.ppt 胃酸倒流 ( 胃食道反流性疾病 GERD) 馮騰達醫生腸胃及肝臟專科醫生甚麼是胃酸倒流? 胃部的食物及胃酸倒流入食道一個在飯後特別容易出現的生理現象甚麼時候胃酸倒流是一種病? 當胃酸倒流導致 : 併發症影響生活質素的症狀下食