بسم الله الرحمن الرحیم
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فهرست
سندروم روده تحریک پذیر
پاتوفیزیولوژی
تظاهرات بالینی
ارزیابی ویافته های تشخیصی
مدیریت پزشکی
التهاب اپاندیس
پاتوفیزیولوژی
تظاهرات بالینی
ارزیابی ویافته های تشخیصی
عوارض
مدیریت پزشکی
پریتونیت
تظاهربالینی
ارزیابی ویافته تشخیصی
مدیریت پزشکی
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IRRITABLE BOWEL SYNDROME
IBS is one of the most common GI problems.
Approximately one in six otherwise healthy persons report classic symptoms of IBS
It occurs more commonly in women than in men, and the cause is still unknown.
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IRRITABLE BOWEL SYNDROME
Although no anatomic or biochemical abnormalities have been found that explain the common symptoms, various factors are associated with the syndrome:
heredity,
psychological stress or conditions such as depression and anxiety,
a diet high in fat and stimulating or irritating foods,
alcohol consumption
smoking.
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IRRITABLE BOWEL SYNDROME
The small intestine has become a focus of investigation as an additional site of dysmotility in IBS, and cluster contractions in the jejunum and ileum are being studied
The diagnosis is made only after tests have been completed that prove the absence of structural or other disorders.
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Pathophysiology
IBS results from a functional disorder of intestinal motility.
The change in motility may be related to the neurologic regulatory system, infection or irritation, or a vascular or metabolic disturbance.
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Pathophysiology
The peristaltic waves are affected at specific segments of the intestine
There is no evidence of inflammation or tissue changes in the intestinal mucosa.
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Clinical Manifestations
There is a wide variability in symptom presentation.
Symptoms range in intensity and duration from mild and infrequent to severe and continuous.
The primary symptom is an alteration in bowel patterns—constipation, diarrhea, or a combination of both.
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Clinical Manifestations
Pain, bloating, and abdominal distention often accompany this change in bowel pattern.
The abdominal pain is sometimes precipitated by eating and is frequently relieved by defecation
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Assessment and Diagnostic Findings
A definite diagnosis of IBS requires tests that prove the absence of structural or other disorders.
Stool studies, contrast x-ray studies, may be performed to rule out other colon diseases.
Barium enema and colonoscopy may reveal spasm, distention, or mucus accumulation in the intestine
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Medical Management
The goals of treatment are aimed at relieving abdominal pain, controlling the diarrhea or constipation, and reducing stress.
Restriction and then gradual reintroduction of foods that are possibly irritating may help determine what types of food are acting as irritants (eg, beans, caffeinated products, fried foods, alcohol, spicy foods).
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Medical Management
A healthy, high-fiber diet is prescribed to help control the diarrhea and constipation.
Exercise can assist in reducing anxiety
and increasing intestinal motility.
Patients often find it helpful to participate in a stress reduction or behavior-modification program
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Medical Management
antidiarrheal agents (eg, loperamide) may be given to control the diarrhea
Antidepressants can assist in treating underlying anxiety and depression.
Anticholinergics and calcium channel blockers decrease smooth muscle spasm, decreasing cramping and constipation.
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APPENDICITIS
The appendix is a small, finger-like appendage about 10 cm (4 in) long that is attached to the cecum just below the ileocecal valve.
The appendix fills with food and empties regularly into the cecum.
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APPENDICITIS
Because it empties inefficiently and its lumen is small, the appendix is prone to obstruction and is particularly vulnerable to infection (ie, appendicitis).
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Pathophysiology
The appendix becomes inflamed and edematous as a result of either becoming kinked or occluded by a fecalith (ie, hardened mass of stool), tumor, or foreign body.
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Pathophysiology
The inflammatory process increases intraluminal pressure, initiating a progressively severe, generalized or upper abdominal pain that becomes localized in the right lower quadrant of the abdomen within a few hours.
Eventually, the inflamed appendix fills with pus.
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Clinical Manifestations
Vague epigastric or periumbilical pain progresses to right lower quadrant pain and is usually accompanied by a low-grade fever and nausea and sometimes by vomiting.
Loss of appetite is common.
Local tenderness is elicited at McBurney’s point when pressure is applied
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Clinical Manifestations
Rebound tenderness (ie, production or intensification of pain when pressure is released) may be present.
If the appendix curls around behind the cecum, pain and tenderness may be felt in the lumbar region.
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Clinical Manifestations
Pain on defecation suggests that the tip of the appendix is resting against the rectum;
pain on urination suggests that the tip is near the bladder or impinges on the ureter.
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Clinical Manifestations
Rovsing’s sign may be elicited by palpating the left lower quadrant; this paradoxically causes pain to be felt in the right lower quadrant
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Clinical Manifestations
If the appendix has ruptured, the pain becomes more diffuse; abdominal distention develops as a result of paralytic ileus, and the patient’s condition worsens
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Clinical Manifestations
Constipation can also occur with an acute process such as appendicitis.
Laxatives administered in this instance may produce perforation of the inflamed appendix.
In general, a laxative or cathartic should never be given while the person has fever, nausea, or pain
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Assessment and Diagnostic Findings
Diagnosis is based on results of a complete physical examination and on laboratory and x-ray findings.
The complete blood cell count demonstrates an elevated white blood cell count.
The leukocytecount may exceed 10,000 cells/mm3, and the neutrophil count may exceed 75%.
Abdominal x-ray films, ultrasound studies, and CT scans may reveal a right lower quadrant density or localized distention of the bowel.
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Complications
The major complication of appendicitis is perforation of the appendix, which can lead to peritonitis or an abscess.
The incidence of perforation is 10% to 32%.
The incidence is higher in young children and the elderly.
Perforation generally occurs 24 hours after the onset of pain.
Symptoms include a fever of 37.7°C (100°F) or higher, a toxic appearance, and continued abdominal pain or tenderness.
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Medical Management
Surgery is indicated if appendicitis is diagnosed.
To correct or prevent fluid and electrolyte imbalance and dehydration, antibiotics and intravenous fluids are administered until surgery is performed.
Analgesics can be administered after the diagnosis is made.
Appendectomy (ie, surgical removal of the appendix) is performed as soon as possible to decrease the risk of perforation.
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PERITONITIS
Peritonitis is inflammation of the peritoneum, the serous membrane lining the abdominal cavity and covering the viscera.
Usually, it is a result of bacterial infection;
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PERITONITIS
the organisms come from diseases of the GI tract or, in women, from the internal reproductive organs.
Peritonitis can also result from external sources such as injury or trauma (eg, gunshot wound, stab wound) or an inflammation that extends from an organ outside the peritoneal area, such as the kidney.
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PERITONITIS
The most common bacteria implicated are Escherichia coli, Klebsiella, Proteus, and Pseudomonas.
Inflammation and paralytic ileus are the direct effects of the infection.
Other common causes of peritonitis are appendicitis, perforated ulcer and bowel perforation.
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Clinical Manifestations
Symptoms depend on the location and extent of the inflammation.
The early clinical manifestations of peritonitis frequently are the symptoms of the disorder causing the condition.
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Clinical Manifestations
At first, a diffuse type of pain is felt.
The pain tends to become constant, localized, and more intense near the site of the inflammation.
Movement usually aggravates it.
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Clinical Manifestations
The affected area of the abdomen becomes extremely tender and distended, and the muscles become rigid.
Rebound tenderness and paralytic ileus may be present.
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Clinical Manifestations
Usually, nausea and vomiting occur and peristalsis is diminished.
The temperature and pulse rate increase, and there is almost always an elevation of the leukocyte count.
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Assessment and Diagnostic Findings
The leukocyte count is elevated.
The hemoglobin and hematocrit levels may be low if blood loss has occurred.
Serum electrolyte studies may reveal altered levels of potassium, sodium, and chloride.
An abdominal x-ray is obtained, and findings may show air and fluid levels as well as distended bowel loops.
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Assessment and Diagnostic Findings
A CT scan of the abdomen may show abscess formation.
Peritoneal aspiration and culture and sensitivity studies of the aspirated fluid may reveal infection and identify the causative organisms.
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Complications
Frequently, the inflammation is not localized and the whole abdominal cavity becomes involved in a generalized sepsis.
Sepsis is the major cause of death from peritonitis.
Shock may result from septicemia or hypovolemia.
The inflammatory process may cause intestinal obstruction, primarily from the development of bowel adhesions
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Medical Management
Fluid, colloid, and electrolyte replacement is the major focus of medical management.
Hypovolemia occurs because massive
amounts of fluid and electrolytes move from the intestinal lumen into the peritoneal cavity and deplete the fluid in the vascular space.
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