大腸直腸肛門外科 大腸直腸肛門外科 歐美已有60年以上獨立專科 台灣已有30年以上獨立專科經驗 N0-N1護理進階課程 造口治療室 大腸鏡檢室 肛門生理機能檢查室 癌症登記檔案室 專科住院醫師訓練 玫瑰之友 唐修治 醫師 1 上課內容 誘發原因 1. 內外痔 Mixed Hemorrhoids with prolapse 器官性 靜脈回流 心臟衰竭 肝硬化 腹壓上升 懷孕 攝護腺肥大 腹部腫瘤 1) Prolapse 2) Stenosis with ulcer 2. 肛門廔管 Anal fistula 遺傳性 1) Abscess 2) Fournier s gangrene 便秘 腸急躁症 飲食習慣 其他原因 3. 大腸直腸癌 4. 護理問題 直腸腫瘤 肛交 3 位置分類 外痔 齒狀線以外 栓 塞 痔核 肉蒂 2 4 鑑別診斷 n內痔 齒狀線以內 n出血 脫肛 內外痔 混合痔 5 6 1
內痔脫肛的分類 痔瘡內科療法 飲食控制 排便習慣 溫水坐浴 痔瘡軟膏 栓劑 鐵劑 第一度 腫入肛門 第二度 便後自行退縮入肛門 第三度 需用手推入肛門 第四度 已無法推入肛門 7 避免便秘 8 糞便量 每次約100公克 纖維量決定 巴布亞新幾內亞 排便次數 每天一次 每次五分鐘 飯後30分鐘排便 糞便成份 種瓜得瓜 9 糞便軟硬度 種瓜得瓜 10 治療法 纖維 脂肪 水份 內科療法 外科非手術法 外科手術法 11 12 2
拿破崙 滑鐵盧戰役 Open Hemorrhoidetomy 術後併發症 疼痛約一週 出血 1/200 排尿困難 1/10 肛門狹窄 贅肉 失禁 13 14 15 16 什麼是肛門廔管 症狀 肛門膿瘍 透腸 粒仔 膿包 痔漏 痔廔 肛門周圍的硬塊 會痛很像痔瘡 輕微發燒 類似感冒 很少肛門出血 肛門廔管 肛門膿瘍切開後 肛門周圍條狀硬塊 反覆流出血濃液 17 18 3
10% 19 20 perianal intersphincteric ischiorectal supralevator retrorectal 21 22 15 30 23 24 4
92 () ( ) 36,285 315.11 ( ) 288.98 ( ) 1.36 236.77 212.02 25 65 26,257 60 1 62,542 92 (6,753) 19% (5,025) 14% (4,677) 13% (4,040)11% (2,308) 6% (2,237)6% (1,318)4% (1,258)3% (1,157)3% (960)3% (6,552) 18% 36,285 20% 14% 10% (2,651) 9% (2,390) 5% (1,226) 22% (783) (5,659) 26,257 26 8% 4% 3% 3% 3% (5,325) (3,561) (2,061) (975) (833) (793) 88 ( ) 14 92 ( ) 18 135.32 58.88 57.39 51.33 40.99 23.53 18.2 15.78 10.36 8.43 88 / 567.87 156.01 54.98 52.23 44.38 36.3 22.98 22.6 19.08 14.16 8.17 92 / 575.63 29 81 82 83 84 85 86 87 88 89 90 91 92 93 94 92 33.0710 8,238 18.1010 < 5% 30 5
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1. Abdominal Perineal Resection(APR) 2. Restorative Proctectomy wit coloanalanastomosis 3. Lower/ (High) Anterior Resection / EEADouble-staple or Pull-through 4. (Extended) Left hemicolectomy / mesenteric tunnel 5. (Extended) Right hemicolectomy 6. Subtotal colectomy / ileostomy or ileosigmoidostomy 7. Total colectomy / J-pouch ileoanal anastomosis 8. Posterior / Total Pelvic Exenteration 9. Hartmanns procedure 10. TransrectalExcision (TRE) 11. Diversion procedure 1. Sigmoid colostomy (Loop or End) 2. Distal/ Proximal Transverse colostomy (Loop or End) 37 APR LAR (RHC, LHC, Subtotal colectomy) Foley Sump Penrose Foley 1 2 NPO 3 I/O, Karlex Hemovac output Foley care Foley care 4 Foley care U/A U/A IV line, NG out Nelaton, Neomycin Hemovac Wound care Wound care 38 5 6 U/A 7 8 9 10 Intake Intake & Output Intravenous fluid TPN Blood components Fluid challenge Feeding fluid NG feeding Jejunostomy feed Oral intake Output Urine GI tract NG Enterostomy, Colostomy Diarrhea Paralytic ileus Wound Change dressing Drainage (Sump.) Ventilation, Sweating 39 Intake & Output Balance Intake Output = 0 40 I/O Balance Cardiac Output Intake Output = 0 Urine output 0.5~1ml/kg/hr Children 1~2ml/kg/hr Intake Fluid challenge GI tract output >500ml/8hr Dehydration Replace half with Ringers Lactate solution 41 C.O. = Stroke volume * Heart rate S.V. Contractility * Preload Afterload Preload with CVP / Urine sp.gr. monitor 5-2 rule for CVP (0-10mmHg) 7-3 rule for PAWP (10-20mmHg) 42 7
The 5-2 rule for CVP < 1.015 <1ml/kg/hr >1ml/kg/hr Malnutrition Overhydration >1.015 Dehydration Osmotic Polyuria 1 unit = 1ml/kg CVP reading <8 CVP/10 min <14 =14 > 5 cm rise 2-5 cm rise < 2 cm rise > 2 cm rise = 2cm rise 4 units/ 10 min 2 units/ 10 min 1 units/ 10 min 10 4 units 10 4 units 43 44 Replacement of GI tract Non-Glucose solution! Isotonic for intestinal juice Rich in Potassium 20mEq/L Ringers Lactate is appropriate High K, Low Na & Hypotonic Gastric juice, Saliva and Right colon NSwith K is appropriate High bicarbonate Pancreatic juice 45-1 6-8 46-2 -3 Neostigmine Sennapur Dulcolax Austin powder, ; Dioctyl sodium sulfosuccinate Mineral oil 47 48 8
Dopamin 2~5 ug/kg/min Dopaminergic effect Vasodilation of renal and mesenteric vessels (redirection) Mild vasoconstricture of peripheral bed 5~10 ug/kg/min Inotropic effect on the myocardium leads to increased cardiac output and blood pressure >10 ug/kg/min peripheral vasoconstriction, shifting of blood from extremities to organs, decreased kidney function, and hypertension. 49 50 9