Upload
buikhanh
View
223
Download
1
Embed Size (px)
Citation preview
WelcheLeitsymptome?
Unklar?
? ?
? ?Schmerz
Schmerz
Hämatemesis
Erbrechen
Ikterus
Ileus
Obstipation
Schwäche
GasproblemDurchfall
??
?
Diagnose / Modell
Klinischer Alltag
ModellFunktion-
Problem
Klinisches Fach
Struktur-Patho
Physiologie / Anatomie
Lehre
Strukturell ?Funktionell?
Therapie
Restitition
Prognose
Exitus
Erkenntnisgang
Experten-wissen
=Muster-
erkennen
Demonstration of the neuroanatomic basis of referred pain
• . Visceral afferent fibers innervating the diaphragm are stimulated by local irritation (e.g., subdiaphragmaticabscess). These visceral afferent fibers (A) synapse with second-order neurons in the spinal cord (B) at the samelevel as somatic afferent fibers (C) arising from the shoulder area (cervical roots 3 to 5). The brain interprets thepain to be somatic in origin and localizes it to the shoulder.
Pathways of visceralsensory innervation.
Pathways of visceral sensoryinnervation. The visceral afferentfibers mediating pain travel withautonomic nerves to communicatewith the central nervous system. Inthe abdomen, these include bothvagal and pelvic parasympatheticnerves and thoracolumbarsympathetic nerves. Sympatheticfibers (red lines); parasympathetics(blue lines).
Localization of visceral pain
Pain arising from organareas depicted in 1, 2, and 3is felt in the epigastrium,midabdomen, andhypogastrium, respectively,as shown in A.
Pa:ernsofacuteabdominalpain
A, Many causes of abdominal pain subside spontaneously with time (e.g., gastroenteritis).B, Some pain is colicky (i.e., the pain progresses and remits over time); examples include intestinal, renal, and biliary
pain ("colic"). The time course may vary widely from minutes in intestinal and renal pain to days, weeks, oreven months in biliary pain.
C, Commonly, abdominal pain is progressive, as in appendicitis or diverticulitis.D, Certain conditions have a catastrophic onset, such as ruptured aortic aneurysm.
PrakAschesVorgehenAnamnese
• Schmerzbeginn,Schmerzcharakter• VorausgehendeEreignisse• IniAale/jetzigeSchmerzlokalisaAon(beimÜbergang
vomviszeralenzumSomaAschenSchmerzhatdieErkrankungdieOrgangrenzenüberschri:en
• Regelanamnese(anEUGdenken!)
• Cave:StadiumderIllusion(abklingendeSchmerzsymptomaAknachdeminiAalstarkenPerforaAonsschmerzundvordemBeginnderPeritoniAssymptomaAk)
SchemaAscheDarstellungderhäufigstenUrsacheneinesakutenAbdomen
RechterOberbauch1 akuter Zystikusverschluss2 akute Cholezystitis Gallenblasenempyem,
emphysematöse Cholezystitis3 Cholelithiasis4 Duodenalulkus5 Magenulkus6 Akute Pankreatitis7 Nieren-Ureterkonkrement8 akute Appendizitis bei retrozökal
hochgeschlagener Appendix9 rechtsbasale Pleuritis/Pneumonie10 Leberabszess, akute Leberstauung
AbdomenLeerRöntgenvs.CT
1 akute Appendizitis2 Lymphadenitis mesenterialis3 Meckel-Divertikulitis4 Enteritis regionalis (Mb Crohn)5 Divertikulits bei Sigma elongatum6 ZäkumKarzinom7 Nieren-/Ureterkonkrement re8 re-seitiger akuter Adnexprozess, Extrauteringravidität9 akutes Harnverhalten akute Zystitis
SchemaAscheDarstellungderhäufigstenUrsacheneinesakutenAbdomen
RechterUnterbauch
Dieses EKG befundet …..?
SchemaAscheDarstellungderhäufigstenUrsacheneinesakutenAbdomen
LinkerOberbauch1 Magenperforation2 akute Pankreatitis3 links-subphrenischer Abszess4 Milzinfarkt/-ruptur5 Herzinfarkt6 links-basale Pleuritis/Pneumonie7 Hiatushernie8 linksseitige Nierenerkrankungen Harnleiterkonkrement
SchemaAscheDarstellungderhäufigstenUrsacheneinesakutenAbdomen
LinkerUnterbauch1 Sigmadivertikulitis, Divertikelperforation,
Perforation nach endoskopischerPolypabtragung
2 Sigmakarzinom3 linksseitiger akuter Adnexprozess,
Extrauteringravidität4 Nieren-/Ureterkonkrement links5 akutes Harnverhalten, akute Zystitis
Pathophysiologie bei Darmobstruktion
CausesofChronicAbdominalPainThatMayManifestasanAcuteExacerba:on
ChronicIntermi<entPain
ChronicConstantPain
MechanicalIntermi:entintesAnalobstrucAon(hernia,intussuscepAon,adhesions,volvulus)GallstonesSphincterofOddidysfuncAonInflammatoryInflammatoryboweldiseaseEndometriosisandendometriAsAcuterelapsingpancreaAAsFamilialMediterraneanfeverNeurologicandMetabolicPorphyriaAbdominalepilepsyDiabeAcradiculopathyNerverootcompressionorentrapmentUremiaMiscellaneousIrritablebowelsyndromeFuncAonaldyspepsiaChronicmesentericischemiaMi:elschmerz(painwithovulaAon)
Malignancy(primaryormetastaAc)AbscessChronicpancreaAAsPsychiatric(depression,somatoformdisorder)Inexplicable(chronicintractableabdominalpain)
Extra‐AbdominalCausesofAcuteAbdominalPain
MetabolicUremiaDiabetes mellitusPorphyriaAcute adrenal insufficiency (Addison's disease)HyperlipidemiaHyperparathyroidism
HematologicSickle cell anemiaHemolytic anemiaHenoch-Schönlein purpuraAcute leukemia
ThoracicPneumonitisPleurodynia (Bornholm's disease)Pulmonary embolism and infarctionPneumothoraxEmpyemaEsophagitisEsophageal spasmEsophageal rupture (Boerhaave's syndrome)
CardiacMyocardial ischemia and infarctionMyocarditisEndocarditisCongestive heart failure
InfectionsHerpes zosterOsteomyelitisTyphoid fever
ToxinsHypersensitivity reactions, insect bites, reptile venomsLead poisoning
MiscellaneousMuscular contusion, hematoma, tumorNarcotic withdrawalFamilial Mediterranean feverPsychiatric disordersHeat stroke
NeurologicRadiculitis: spinal cord or peripheral nerve tumors,
degenerative arthritis of spineAbdominal epilepsyTabes dorsalis
Differential Diagnosis of Chronic or Recurrent AbdominalPainStructural (or Organic) Disorders
Peptic ulcer diseaseGallstones
Chronic pancreatitis Abdominal neoplasms
Inflammatory bowel diseasesMesenteric ischemia
Pelvic inflammatory diseasesEndometriosis
Abdominal adhesionsIntestinal obstruction
Functional Gastrointestinal Disorders
Irritable bowel syndromeFunctional (nonulcer) dyspepsia
Functional abdominal pain syndromeLevator ani syndrome
Biliary pain (gallbladder or sphincter of Oddi dysfunction)
AbiopsychosocialmodeloffuncAonalabdominalpainsyndrome(FAPS)
RomeIICriteriaforFunc:onalAbdominalPainSyndrome
Atleast6monthsofthefollowing:
ConAnuousornearlyconAnuousabdominalpainNooronlyoccasionalrelaAonshipofpainwithphysiologicevents
(e.g.,eaAng,defecaAon,menses)SomelossofdailyfuncAoningThepainisnotfeigned(e.g.,malingering)InsufficientcriteriaforotherfuncAonalgastrointesAnaldisordersthatwouldexplaintheabdominalpain
Zusammenfassung
AkuteundchronischeabdominelleSchmerzzuständehabenvielfälAgsteUrsachenundPathogenesen.
DerjungeArztistangehalten,PaAentensystemaAschzuuntersuchenundbreitedifferenAaldiagnosAscheÜberlegungenanzustellen.
ErsollsichdabeiabernichtselbstüberschätzenundzeitgerechtHilfebeimälterenKollegenholen.