Abdominal pain during pregnancy
Mitchell S.Cappell,MD,PhD,FACG a,b,*,
David Friedel,MD c
a Division of Gastroenterology,Department of Medicine,Woodhull Medical Center,
760Broadway Avenue,Brooklyn,NY 11206,USA
b State University of New York Downstate Medical School,450Clarkson Avenue,
Brooklyn,NY 11203,USA
c Division of Gastroenterology,Department of Medicine,
Temple University School of Medicine,3401North Broad Street,Philadelphia,
PA 19149,USA
Abdominal pain is a common complaint of female inpatients and outpatients of all ages [1],including women during their childbearing years,and thus often occurs during pregnancy.Abdominal pain during pregnancy presents unique clinical challenges.First,the differential diagnosis during pregnancy is extensive,in that the abdominal pain may be caused by obstetric or gynecologic disorders related to pregnancy,as well as by intraabdominal diseases incidental to pregnancy.
Second,the clinical presentation and natural history of many abdominal disorders are altered during pregnancy.Third,the diagnostic evaluation is altered and constrained by pregnancy.For example,radiologic tests and invasive examinations raise issues of fetal safety during pregnancy.Fourth,the interests of both the mother and the fetus must be considered in therapy during https://www.doczj.com/doc/e77514991.html,ually,these interests do not con?ict,because what is good for the mother is generally good for the fetus.Sometimes,however,maternal therapy must be modi?ed to substitute alternative but safer therapy because of concerns about drug teratogenicity (eg,substituting a histamine 2receptor antagonist for misoprostol,an abortifacient that is contraindicated during pregnancy)[2,3].Rarely,the maternal and fetal interests are diametri-cally opposed,as in the use of chemotherapy for maternal cancer,a therapy that is potentially life-saving to the mother but life-threatening to the fetus [4].These con?icts raise signi?cant medical,legal,and ethical issues.
Gastroenterologists,as well as obstetricians,gynecologists,internists,and surgeons,should be familiar with the medical and surgical conditions Gastroenterol Clin N Am
32(2003)
1–58
*Corresponding author.Department
of Medicine,Woodhull Medical Center,760
Broadway Avenue,Brooklyn,NY 11206.0889-8553/03/$–see front matter ó2003,Elsevier Science (USA).All rights reserved.PII:S 0889-8553(02)00064-X
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that can present in pregnancy and how these conditions a?ect and are a?ected by pregnancy.This article reviews obstetric,gynecologic,medical, and surgical causes of abdominal pain during pregnancy,with a focus on aspects of abdominal diseases unique to pregnancy.
Abdominal pain during pregnancy:general considerations Neurophysiology of abdominal pain
Nociception involves a?ective or autonomic re?exes from abdominal viscera to the cerebral cortex involving three levels of neurons.The?rst-order neurons are either C or A-delta?bers.C?bers are narrow,slowly conducting,and unmyelinated and produce a dull and nonlocalized sensation of pain.A-delta?bers are wider,partly myelinated,and faster conducting and produce a sharp and localized sensation of pain.The?rst-level a?erent neurons travel from abdominal structures to synapse in the dorsal horn of the spinal cord.The second-order neurons cross the mid-line to the contralateral side of the spinal cord to ascend through the spinothalamic and spinoreticular tracts to the thalamic and reticular areas of the pons and medulla[5].Third-order neurons travel to the limbic system and sensory cortex where pain is perceived[6–8].
Abdominal pain can be visceral,arising from gastrointestinal organs; parietal,arising from peritoneal irritation;somatic,arising from the abdominal wall;neurologic,arising from diseases a?ecting abdominal nerves;extraintestinal,from referred pain;or cerebral,from neuropyschi-atric disorders or factitious disease.Visceral pain tends to be dull,poorly localized,and perceived in the midabdomen because a?erent nerve?bers from abdominal viscera typically are C?bers and receive multisegmental and bilateral a?erent innervation from the spinal cord.Visceral pain may be accompanied by autonomic concomitants of nausea,diaphoresis,and pallor.Abdominal viscera are most sensitive to mural stretch.Parietal pain tends to be more acute,intense,and focal because it is conveyed by a mixture of A-delta and C?bers and tends to have more discrete innerva-tion from the spinal cord[9].Parietal pain is exacerbated by coughing, movement,and deep inspiration.Somatic tissue in skin,subcutaneous tissue,and muscle is innervated predominantly by A-delta nerve?bers so that somatic pain is focal and sharp.
Referred pain is felt remotely from the a?ected area because of the convergence of visceral and somatic a?erent neurons to the same level of the spinal cord and the use of the same second-order neurons.For example, pain from gastrointestinal disorders,such as acute cholecystitis,or pain from obstetric disorders,such as ectopic pregnancy,may be referred to the shoulder or back[10].Conversely,pain from an extraabdominal condition, such as a migraine headache,may be referred to the abdomen.
Pain can be modi?ed centrally or peripherally by the emotional state or psychologic stress [11,12].Descending pathways from the cortex,thalamus,and brainstem inhibit nociceptive neural impulses at the level of the spinal cord,providing cerebral control and inhibition of painful sensations [13].Hormones or in?ammatory mediators,such as cytokines,also alter the threshold to noxious stimuli [14,15].These mechanisms may explain abdominal pain secondary to stress,in support of the hypothesis of hyperalgesia in the irritable bowel syndrome and other functional gastro-intestinal disorders [16,17].Persistent visceral pain is often referred to more super?cial structures and often becomes hyperalgesic [18],because of factors such as centrally mediated long-term potentiation,possibly mediated by N -methyl-d-aspartate [19–21].
Differential diagnosis of abdominal pain during pregnancy
The di?erential diagnosis of abdominal pain is extensive.The di?erential diagnosis of pain varies according to location.Di?use abdominal pain may arise from
Uremia
Porphyria
Peritonitis
Leaking abdominal aneurysm
Hepatic abscess
Gastroenteritis
In?ammatory bowel disease
Early appendicitis
Pancreatitis
Small bowel obstruction
Malaria
Intestinal pseudoobstruction
Partial intestinal obstruction
Pain in the left upper quadrant can be caused by
Peptic ulcer disease
Perforated peptic ulcer
Splenic infarct or rupture
Splenic abscess
Dissecting aortic aneurysm
Nephrolithiasis
Pyelonephritis
Gastric volvulus
Incarcerated paraesophageal hernia
Esophageal rupture
Esophageal stricture
Mallory-Weiss tear
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Pneumonia
Rib fracture
Radiculopathy
Pulmonary embolus or infarct
Pain in the right upper quadrant can result from
Peptic ulcer disease
Perforated duodenal ulcer
Hepatitis
Hepatic vascular engorgement
Hepatic hematoma
Hepatic malignancy
Biliary colic
Choledocholithiasis
Cholangitis
Cholecystitis
Preeclampsia or eclampsia
Hemolysis,elevated liver enzymes,and low platelet count
(HELLP)syndrome
Pyelonephritis
Nephrolithiasis
Rib fracture
Shingles
Pneumonia
Pulmonary embolus or infarct
Pleural effusion
Radiculopathy
Inferior wall myocardial infarction
Colon cancer
Causes of pain in the right lower quadrant include
Appendicitis
Ruptured Meckel’s diverticulum
Crohn’s disease
Ovarian cyst rupture
Ovarian torsion
Ovarian tumor
Ruptured ectopic pregnancy
Intussusception
Nephrolithiasis
Cystitis
Pyelonephritis
Trochanteric bursitis
Endometriosis
Uterine leiomyomas
Cecal perforation
Colon cancer
Pain in the left lower quadrant can result from gastrointestinal causes,gyne-cologic and obstetric causes,and other causes.Gastrointestinal causes include
Diverticulitis
Sigmoid volvulus
Colon cancer
Colonic perforation
Urinary tract infection
Small bowel obstruction
In?ammatory bowel disease
Irritable bowel disease
Mesenteric ischemia
Gynecologic and obstetric causes of left lower quadrant abdominal pain include
Ruptured ectopic pregnancy
Ovarian cyst rupture
Pelvic in?ammatory disease
Tubo-ovarian abscess
Uterine leiomyomas (including rupture or necrosis)
Abortion (threatened,incomplete,or complete)
Ovarian/adnexal mass
Acute salpingitis
Endometriosis
Ruptured corpus luteum
Cancer of cervix or ovary
Other causes of left lower quadrant abdominal pain are
Nephrolithiasis
Pyelonephritis
Leaking abdominal aneurysm
The abdominal pain is somewhat delimited by the pain location (Table 1).Conditions range from minor to life-threatening.In addition,physiologic changes during pregnancy may cause abdominal symptoms.Nausea,emesis,early satiety,bloating,and pyrosis are common during pregnancy.Serious disorders that produce these symptoms may,therefore,be dif?cult to distinguish from physiologic changes during pregnancy.Serious symptoms should not be dismissed as normal during pregnancy without a careful history and appropriate evaluation.
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In the medical history,the pain intensity,nature,temporal pattern,radiation pattern,exacerbating factors,and alleviating factors help narrow the di?erential diagnosis.The abdominal pain is progressively increasing in appendicitis but is nonprogressive in viral gastroenteritis.The pain from small intestinal obstruction may be intermittent but is severe [22].Renal and biliary colic also produce a waxing and waning intensity of pain.Acute cholecystitis is associated with right upper quadrant pain,as well as with pain referred to the right shoulder.The pain of acute pancreatitis is often boring in quality,located in the abdominal midline and radiating to the back.Careful physical examination of the abdomen including inspection,palpation,and auscultation can further pinpoint the cause of the https://www.doczj.com/doc/e77514991.html,boratory evaluation of signi?cant abdominal pain routinely includes a hemogram,serum electrolytes,and liver function tests,and often includes a leukocyte differential,coagulation pro?le,and serum amylase determina-tion.In evaluating the laboratory results,gestational changes in normative values,as described later,must be considered.Radiologic tests may be extremely helpful diagnostically,but the choice of radiologic imaging is constrained by the pregnancy,as discussed later.
The character,severity,localization,or instigating factors of abdominal pain often vary with time.For example,acute appendicitis typically changes from a dull,poorly localized,moderate pain to an intense and focal pain as the in?ammation extends from the appendiceal wall to the surrounding peritoneum.When the diagnosis and therapy is uncertain,close and vigilant monitoring by a surgical team,with frequent abdominal examination and regular laboratory tests,can often clarify the diagnosis.
Occasionally,the pregnancy is not known by the patient or is not revealed to the physician,particularly in early pregnancy,when physical
Table 1
Common causes of acute,severe abdominal pain in the pregnant woman
Condition
Location Character Radiation Ruptured ectopic
pregnancy
Lower abdominal or pelvic Localized,severe None Pelvic in?ammatory
disease
Lower abdominal or pelvic Gradual in onset,localized Flanks and thighs Appendicitis First periumbilical,
later RLQ (RUQ
in late pregnancy)
Gradual in onset,focal in RLQ Back /?ank Acute cholecystitis RUQ
Focal Right scapula,shoulder,or back Pancreatitis Epigastric
Localized,boring Middle of back Perforated peptic ulcer Epigastric or
RUQ
Burning,boring Right back Urolithiasis Abdomen or
?anks Varies from intermittent and aching to severe
and unremitting Groin
Abbreviations :RUQ,right upper quadrant;RLQ,right lower quadrant.
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?ndings are absent.The physician should be vigilant for possible pregnancy in a fertile woman with abdominal pain,particularly in the setting of missed menses,because pregnancy a?ects the di?erential diagnosis,clinical evaluation,and mode of therapy.Pregnancy tests should be performed early in the evaluation of abdominal pain in a fertile woman.Pregnancy is assayed by radioimmunoassay (RIA)or enzyme-linked immunoassay (ELISA)determination of the B -unit of human chorionic gonadotropin (hCG)in urine or serum [23].
Physiologic effects of pregnancy on abdominal disorders
Abdominal assessment during pregnancy is modi?ed by displacement of abdominal viscera by the expanding gravid uterus [24].For example,the location of maximal abdominal pain and tenderness from acute appendicitis migrates superiorly and laterally as the appendix is displaced by the growing gravid uterus [25].A rigid abdomen with rebound tenderness remains a valid indicator of peritonitis during pregnancy,but abdominal wall laxity in late pregnancy might mask the classic signs of peritonitis [26,27].An abdominal mass may be missed on physical examination because of the presence of the enlarged gravid uterus [4].
Physiologic alterations of laboratory values during pregnancy must be appreciated,including mild leukocytosis,physiologic anemia of pregnancy,mild dilutional hypoalbuminemia,mildly increased alkaline phosphatase level,and electrolyte changes,particularly mild hyponatremia [28–30].The erythrocyte sedimentation rate is physiologically elevated and thus is a less reliable monitor of in?ammatory activity during pregnancy [31].Gestational hormones,particularly estrogen,contribute to a mild hypercoagulopathy during pregnancy by increasing the synthesis of clotting factors [32].Thromboembolic phenomena are also promoted by intraabdominal vas-cular stasis resulting from compression by the enlarged gravid uterus.Urinary stasis and ureteral dilatation are promoted during pregnancy by urinary tract muscle relaxation induced by progesterone and by mechanical compression of the ureters by the fetal skull [33].The changes in glucose serum levels during pregnancy are complex.Normal pregnancy is char-acterized by fasting hypoglycemia,postprandial hyperglycemia,and hyper-insulinemia [34].Strict control of the serum glucose level is important in diabetic patients for proper fetal development [35].
Mucosal immunity may be diminished during pregnancy as part of physiologic immunologic tolerance of the foreign fetal antigens in the uterus
[36].This reduced mucosal immunity contributes to an increased rate of pyelonephritis during pregnancy.Pregnancy promotes cholelithiasis because of increased cholesterol synthesis and gallbladder hypomotility related to gestational hormones.
The fetus poorly tolerates maternal hypotension,hypovolemia,anemia,and hypoxia.This intolerance a?ects the type and timing of therapy for 7
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abdominal disorders during pregnancy.The gravid uterus can compress the inferior vena cava in the supine position and thereby compromise venous return,aggravating systemic hypoperfusion from hypovolemia or gastro-intestinal bleeding.Simply turning the patient to the left side to displace the uterus may relieve this compression,improve venous return,and normalize the blood pressure[29].During pregnancy the blood pressure normally declines modestly.A rise in blood pressure during pregnancy may,therefore, portend preeclampsia or eclampsia.
Diagnostic imaging during pregnancy
Fetal safety during diagnostic imaging is a concern for pregnant patients and pregnant medical personnel.Ultrasonography is considered safe during pregnancy and is the preferred imaging modality for abdominal pain during pregnancy[37,38].Unfortunately,the test sensitivity depends on operator technique,patient cooperation,and patient anatomy,in that sensitivity is decreased by abdominal fat and intestinal gas[38].Magnetic resonance imaging(MRI)is preferable to computerized tomography(CT)scanning during pregnancy to avoid ionizing radiation,but gadolinium administra-tion should be avoided during the?rst trimester[39–43].Rapid-sequence MR imaging is preferable to conventional MR imaging because of the briefer exposure[41].The patient should undergo counseling before diagnostic roentgenography.
Data concerning fetal malformations,growth retardation,and mortality from ionizing radiation are derived from past experience,especially from Japanese atomic bomb survivors.Radiation can cause chromosomal mutations and neurologic abnormalities including mental retardation and moderately increases the risk of childhood leukemia[43,44].Radiation dosage is the most important risk factor,but fetal age at exposure and proximity to the radiation source are also important[43,44].Fetal mortality is greatest from radiation exposure during the?rst week after conception, before oocyte implantation[40,43,44].Exposure to more than15rads during the second and third trimesters or more than5rads during the?rst trimester,when the risk of neurologic malformations is greatest,should prompt consideration of elective termination of pregnancy[40,43–45]. Diagnostic studies with the most radiation exposure,such as intravenous pyelography or barium enema,typically expose the fetus to less than1rad [40,42,45].Thus,one diagnostic?uoroscopic procedure is relatively safe in pregnancy.A medical physicist can estimate the fetal exposure from the study[40,42].Fetal radiation exposure should be minimized by shielding, collimation,and rapid-sequence studies.
Endoscopy during pregnancy
Endoscopy is often performed in the evaluation of abdominal pain in nonpregnant patients.Flexible sigmoidoscopy is performed to evaluate
minor lower gastrointestinal complaints including rectal symptoms,and esophagogastroduodenoscopy (EGD)is performed to evaluate epigastric pain,dyspepsia,or pyrosis.Although endoscopy is extremely safe in the general population,endoscopy during pregnancy raises the unique issue of fetal safety.Endoscopy could potentially cause fetal complications from medication teratogenicity,placental abruption or fetal trauma during endoscopic intubation,cardiac arrhythmias,systemic hypotension or hypertension,and transient hypoxia.Medication teratogenicity is of partic-ular concern during the ?rst trimester during organogenesis.
Sigmoidoscopy seems to be relatively safe during pregnancy.No woman su?ered endoscopic complications in a study of 46patients undergoing sigmoidoscopy during pregnancy [46].Excluding 1unknown pregnancy outcome and 4voluntary abortions,38of 41pregnant women delivered healthy infants,including 27at full term.Their mean Apgar scores were not signi?cantly different from the mean national Apgar scores.Moreover,study patients did not have a worse outcome than pregnant controls matched for sigmoidoscopy indications who did not undergo sigmoidoscopy,because of maternal and physician choice,in terms of mean infant Apgar scores at birth,and in terms of the rates of fetal or neonatal demise,premature delivery,low birth weight,and delivery by cesarean section.Additionally,no endoscopic complications were reported in 13?exible sigmoidoscopies during pregnancy analyzed by a mailed survey of 3300gastroenterologists [47].All pregnancies resulted in delivery of healthy infants at term.
These studies,in addition to scattered case reports,strongly suggest that sigmoidoscopy during pregnancy does not induce labor or cause congenital malformations,is not contraindicated,and should be strongly considered in medically stable patients with important indications.Sigmoidoscopy is not recommended during pregnancy for weak indications,such as routine cancer screening or surveillance,which can be deferred until at least 6weeks postpartum.Sigmoidoscopy should be performed with maternal monitoring by electrocardiography,sphygmomanometry,and pulse oximetry,after obstetric consultation and medical stabilization.Analgesic medication is minimized during sigmoidoscopy,especially during the ?rst trimester.The safety of EGD during pregnancy is peripheral to this article but is considered in detail in a companion article on the safety of endoscopy during pregnancy.Team approach and informed consent
A team approach with consultation and referral helps optimize the management of complex diseases during pregnancy that a?ect both the mother and the fetus and that require disparate areas of expertise.The gastroenterologist contemplating endoscopy may consult with the obstetri-cian about the optimal procedure timing and with the anesthesiologist about analgesia during endoscopy.The internist may discuss with the radiologist the bene?ts versus risks of radiologic tests,and the radiologist may in turn consult 9
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with a physicist about methods to monitor and reduce fetal radiation exposure.The surgeon may consult with the obstetrician about the timing of abdominal surgery in relation to the pregnancy and about the possibility of performing simultaneous cesarean section and abdominal https://www.doczj.com/doc/e77514991.html,plex gastrointestinal or surgical problems during pregnancy may be best handled at a tertiary hospital with the requisite experience and expertise.
The patient should be informed about the consequences to both herself and her fetus of diagnostic tests and therapy and should be actively involved in medical decisions.The patient makes the decision,under the vigilant guidance of the experts,and with advice by the father,family,and friends. When an intervention,such as roentgenographic tests,entails signi?cant potential fetal risk,a signed,witnessed,and informed consent is recom-mended,even though this intervention would be routine and not require consent in the nonpregnant patient.
Obstetric disorders
Ectopic pregnancy
In ectopic pregnancy(EP),the blastocyst implants at a site other than the uterine endometrium.Ninety-?ve percent of EPs implant in the oviduct, including the ampulla,isthmus,or?mbria[23].The remainder implant in the uterine interstitium,cervix,ovaries,or elsewhere in the abdomen[23,48].
Risk factors for EP include prior EP[49,50],advanced maternal age[51], prior pelvic in?ammatory disease(PID)[52],tubal surgery[53],laboratory-assisted reproduction[54],previous abortion[55],endometriosis[56], preexisting fallopian,adnexal,or uterine pathology[57],and prior compli-cated abdominal surgery,such as ruptured appendicitis(Box1)[58].Other reported associations include cigarette smoking[59],low socioeconomic status,and black race[60].Some cases are idiopathic.Ectopic embryos do not have more chromosomal mutations than intrauterine embryos[61].
The incidence of EP has increased in the United States from0.5%of pregnancies,or18,000women in1970,to2.0%of pregnancies,or110,000 women in1992[62,63],as a result of more fallopian tube surgery,more laboratory-assisted pregnancies,better PID therapy,more accurate detec-tion of early pregnancy,and use of intrauterine devices or low-dose pro-gestational agents which prevent intrauterine,but not ectopic,pregnancy [64–66].The age of presentation depends on the cause:sexually active young women tend to have EP from PID,whereas older women tend to have EP from laboratory-assisted reproduction and prior tubal surgery[67].
About70%of patients present with the classic history of abdominopelvic pain and vaginal bleeding after a period of amenorrhea[48].The pain may initially be diffuse and vague but later becomes focal and severe[68,69]. The pain may initially be contralateral to the EP because of a leaking corpus luteum[70].The implantation site affects the clinical presentation.
Symptoms can occur within 2weeks of a missed menses when the conceptus implants in the narrow proximal isthmus but usually occur more than 6weeks after a missed menses when the conceptus implants in the wider distal ampulla [71].Physical signs vary greatly but may include mild uteromegaly,cervical tenderness,and an adnexal mass [72].
The diagnosis is initially missed in nearly one half of cases because of the insensitivity of the patient history and physical examination [72,73].The mean serum progesterone level is higher in a viable intrauterine pregnancy Box 1.Clinical presentation and diagnosis of ectopic pregnancy Epidemiology
0.5%of all pregnancies
10%in women with prior ectopic pregnancy
Risk factors
Fallopian tube pathology (congenital abnormalities,including diethylstilbesterol [DES]exposure,salpingitis)
Prior fallopian tube surgery (tubal ligation,prior EP)
Previous abortion (especially induced abortion)
Endometriosis
Intrauterine device (IUD)use
Hormonally altered tubal transport (estrogen or progesterone administration)
Ovulation induction
In vitro fertilization (including intrafallopian transfer)
Clinical presentation
Abdominopelvic pain
Amenorrhea followed by vaginal bleeding (variable)
Abdominal mass
Hypotension,syncope (from massive ?uid loss)
Diagnosis
Beta-human chorionic gonadotropin (b -hCG)level
Serum progesterone level
Ultrasound evaluation (transabdominal or transvaginal
ultrasound)
Culdocentesis
Suction curettage–chorionic villi sampling
Laparascopy
Laparotomy
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than in EP,but this test is not clinically useful because the individual values sometimes overlap[74,75].A viable intrauterine pregnancy is often differentiated from EP by serial b-hCG determinations,in that the b-hCG level increases faster with a viable intrauterine pregnancy than with EP [37,69].Ectopic pregnancy is,however,best differentiated from intrauterine pregnancy by pelvic ultrasonography with simultaneous b-hCG determi-nation[38,76].Ultrasound?ndings in an intrauterine pregnancy include uteromegaly and a double-decidual sac sign,produced by separation between the decidua vera and capsularis[45].This sac sign is usually detected by conventional abdominal ultrasonography at about4weeks of gestation,when the b-hCG level is greater than6500IU/L(the discriminatory zone)[73],and by transvaginal ultrasonography(TVUS)at about2weeks of gestation when the b-hCG level is greater than1500IU/L because of greater test sensitivity[75].Absence of this sign on abdominal ultrasound study when the b-hCG level is greater than6500IU/L,or on TVUS when the b-hCG level is greater than1500IU/L suggests EP[75]. Both the sensitivity and speci?city of TVUS in conjunction with serum b-hCG level determination are nearly90%[37,77].Absence of chorionic villi in a uterine curettage can con?rm the diagnosis of EP[70].
Ectopic pregnancy is increasingly managed medically[76,78,79].Patients with early,small,and nonruptured EPs with low and declining serum b-hCG levels are occasionally monitored without therapy,because these character-istics are predictors of spontaneous resorption[80].Methotrexate is injected intramuscularly to promote EP absorption in hemodynamically stable women with a nonruptured tubal EP when the mass is less than3.5cm in diameter, gestation is less than6weeks,fetal heart sounds are not detectable,the b-hCG level is low,and bleeding is not evident[81].The serum b-hCG level and sonogram should be repeated to verify therapeutic success[80].
Laparoscopy with salpingostomy or,occasionally,salpingotomy is recommended for EPs smaller than2cm in diameter in the distal third of the oviduct without rupture.In other cases,segmental resection and anas-tomosis are required[48].
The EP ruptures and hemorrhages in about5%of cases.Rupture can cause di?use abdominal pain,rebound tenderness,hypotension,confusion, syncope,anemia,and leukocytosis[68,69].Signs and symptoms are variable [82],however.Shoulder pain suggests free intraperitoneal?uid from intraperitoneal hemorrhage[83].
Culdocentesis can detect hemoperitoneum but is now rarely performed to diagnose rupture because ultrasound is so sensitive and noninvasive. Moreover,a nonbloody aspirate during culdocentesis does not exclude hemoperitoneum in patients with adhesions from prior salpingitis or peritonitis[69].Ectopic pregnancy rupture requires expedient laparotomy, with salpingectomy or hysterectomy,after?uid resuscitation,even if the patient is hemodynamically stable[56].Preoperative abdominal ultrasound helps guide the surgeon.
Ectopic pregnancy causes about 10%of all maternal mortality [84].Mortality from EP has decreased sharply during the last 30years to a current level of 0.4%but remains higher in minority women [37,62].Advances in ultrasonography have contributed to earlier diagnosis,a decreased rate of rupture,and the declining mortality [38,76].
Abdominal pregnancy
Abdominal pregnancy,in which the fetus grows in the peritoneal cavity,occurs in about 1.0of 10,000pregnancies.It usually arises from intra-peritoneal rupture of a tubal pregnancy.Rarely,the blastocyst implants on the liver or https://www.doczj.com/doc/e77514991.html,mon symptoms and signs of abdominal pregnancy include abdominal pain,abdominal tenderness,a closed none?aced cervix,and a palpable mass distinct from the uterus [85].Sonography and other radiologic modalities,as well as serial b -hCG determinations are used to detect and localize an abdominal pregnancy.Surgery is usually necessary because of the risk of rupture and hemorrhage [48].Without surgery,abdominal pregnancy may also result in a lithopedion,an abscess,or rarely a viable infant [63].Small,uncomplicated abdominal pregnancies can be terminated by methotrexate administration.Resolution is monitored by abdominal sonography and serial b -hCG determinations.The placenta is often left in the abdomen after methotrexate administration to avoid intraoperative hemorrhage [63].
Heterotopic pregnancy
In heterotopic pregnancy,intrauterine and ectopic pregnancies coexist.The incidence is about 1in 5000pregnancies [70].The incidence has increased exponentially during the last 2decades because of intrauterine device (IUD)usage;PID [54,70];and increasing infertility treatment with pharmacologic ovulation induction,tubal surgery,and assisted reproduction procedures [70].Abdominal pain is the most common symptom.Serum b -hCG levels are less helpful than in EP because of the concurrent intrauterine pregnancy [86].Abdominal ultrasound is sometimes diagnostic,but laparotomy may be required for the diagnosis [54].The management is complicated by the need to maintain the viable intrauterine https://www.doczj.com/doc/e77514991.html,paroscopy with intraabdomi-nal aspiration may be performed for a small heterotopic pregnancy,but an advanced heterotopic pregnancy requires laparotomy [63].
Spontaneous abortion
Spontaneous abortion,whether threatened,incomplete,or complete,typically presents with vaginal bleeding followed by di?use,crampy lower abdominal or pelvic pain [55].Some patients have no pain or only a backache [55].The pain from spontaneous abortion tends to be milder and 13
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more diffuse than that of EP[72].Medically induced abortion also causes crampy abdominal pain because of prostaglandin administration[87].
Fetal viability is assessed by serum b-hCG levels,serum progesterone levels,and abdominal ultrasonography.Threatened abortion is generally treated by bed rest and analgesia and is sometimes treated by progesterone administration to help preserve the pregnancy[88].
Placental abruption
In placental abruption the placenta prematurely separates from the uterine wall.Placental abruption occurs in about1of80deliveries[89].Risk factors include blunt abdominal trauma,advanced maternal age,multiparity,prior abruption,cocaine abuse,chronic hypertension,preeclampsia or eclampsia, premature rupture of membranes,hypercoagulopathies,and uterine leio-myomas[89,90].Eighty percent of women with placental abruption have vaginal bleeding.Abdominal pain is common and occasionally is severe[72]. Most patients exhibit uterine tenderness and frequent uterine contractions. Severe abruption is associated with maternal disseminated intravascular coagulation(DIC),renal failure,and shock and with fetal distress[89]. Sonography is only moderately sensitive because the echogenicity of fresh blood resembles that of normal placenta[38].Treatment includes intravenous ?uid administration for hypovolemia,packed erythrocyte transfusions for hemorrhage,and prompt delivery of a mature fetus by cesarean section to control the maternal hemorrhage and potentially salvage the fetus. Placenta previa
In placenta previa the placenta is near or over the cervical os so that the os is partially or completely obstructed.Risk factors include advanced maternal age,multiparity,cigarette smoking,and prior cesarean section[91].The incidence is about1in300pregnancies[92].Placenta previa presents in late pregnancy with vaginal hemorrhage,occasionally associated with abdominal pain or painful uterine contractions.The differential diagnosis includes threatened abortion,EP,pregnancy-related liver disease,appendicitis,acute cholecystitis,ovarian torsion,and premature labor.Placenta previa usually presents in the second half of pregnancy,whereas EP presents in the?rst half.
Sonography is usually diagnostic[38].Digital or instrumental probing of the cervix should be avoided,because these maneuvers can precipitate massive vaginal hemorrhage[89].Placenta previa usually requires cesarean section when the fetus is suf?ciently mature.
Placenta previa may be associated with an abnormally adherent placenta. In placenta accreta the placental villi are attached to the myometrium;in placenta increta the villi invade the myometrium;and in placenta percreta the villi penetrate up to the uterine serosa[93].The overall incidence is1in 2000pregnancies[94].Risk factors include multiparity,prior cesarean sections,prior placenta previa,uterine infection,and prior uterine curettage
[93].These disorders are usually diagnosed intrapartum when they mani-fest as hemorrhage during placental delivery [95].Placenta percreta occa-sionally causes antepartum abdominal pain,vaginal bleeding,or hematuria.Intrapartum hemorrhage is treated by ?uid resuscitation,correction of coagulopathy,blood transfusions,and by surgical ligation of the bleeding vessel,selective angiographic embolization of the bleeding vessel,or hysterectomy [95].
Trophoblastic proliferations
Gestational trophoblastic proliferations include hydatiform mole,in-vasive mole,and choriocarcinoma.Hydatiform mole arises from andro-genesis,in which an ovum is fertilized by a paternal haploid sperm that replicates without any maternal chromosomal contribution [96].Hydati-form mole usually produces painless vaginal bleeding.Abdominal sonogram is usually diagnostic.Treatment consists of mole evacuation.About 10%of moles progress to gestational trophoblastic tumors [97].
The most common clinical ?ndings with choriocarcinoma are an abdominal mass and vaginal bleeding,but abdominal pain may occur
[98].Clinical symptoms usually occur after term pregnancy,abortion,or incomplete evacuation of a hydatiform mole.The diagnosis is suggested by persistently elevated b -hCG levels in the absence of a pregnancy.Che-motherapy is indicated for metastatic disease.There is a high cure rate.Premature labor
Premature (preterm)labor is the premature onset of uterine contractions that may result in premature birth [99].Cervical os incompetence,uterine infection,and premature rupture of membranes (PROM)are etiologic factors [99].Symptoms include vaginal discharge or spotting,lower abdominal pain,back pain,urinary urgency,and vaginal pressure.Both the diagnosis and therapy are evolving.Cervical examination is followed by external and internal fetal monitoring and high-resolution sonography.Tocolytic therapy is usually recommended [99].
Gynecologic disorders
Adnexal masses
Ultrasonography has increased the rate of detection of adnexal masses during pregnancy to 2%[100].The pathology ranges from asymptomatic nonneoplastic ovarian cysts to the surgical emergencies of ovarian torsion,ruptured ovarian cyst,and tubo-ovarian abscess.About half of adnexal masses are less than 5cm in diameter,about one quarter are between 5and 10cm in diameter,and about one quarter are more than 10cm in diameter 15
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16M.S.Cappell,D.Friedel/Gastroenterol Clin N Am32(2003)1–58 [101].Ninety-?ve percent are unilateral[102].Most adnexal masses are nonneoplastic cysts,including the corpus luteum cyst and the follicle cyst [102].Both of these cysts usually involute by midterm[38].Cystic teratomas and cystadenomas are the most common benign ovarian neoplasms during pregnancy[103,104].Malignancies,including germ cell tumors,low-grade ovarian cancers,and invasive epithelial ovarian cancers,comprise3%of ovarian masses during pregnancy,for an incidence of1in5000pregnancies [103,105].Most women with ovarian cancer present with stage I disease during pregnancy[105].Cancers from the gastrointestinal tract or elsewhere rarely metastasize to the ovaries[106].
Most adnexal masses are asymptomatic and are incidentally detected by sonography[38,101,102].Even ovarian cancer is often asymptomatic [82,103].Symptoms can include vague abdominal pain,abdominal dis-tension,and urinary frequency[103].Torsion,hemorrhage,or rupture produces severe abdominal pain.Ten percent to15%of adnexal masses undergo torsion[103].Germ cell tumors may cause endocrine dysfunction, especially virilization[105].
The management of an ovarian mass during pregnancy is controversial [100].Abdominal sonography is highly sensitive at mass detection but is insuf?ciently accurate at distinguishing malignant from benign lesions[38]. Surgery is indicated for likely or certain carcinoma or for an acute abdomen caused by complications such as torsion or hemorrhage.Asymptomatic ovarian masses with benign sonographic features are usually followed closely by serial sonography into the second trimester,the optimal time for abdominal surgery in terms of maternal and fetal safety[102,103,105].First-trimester surgery is associated with fetal wastage,and third-trimester surgery is associated with premature https://www.doczj.com/doc/e77514991.html,paroscopy often suf?ces to extirpate the mass while preserving the pregnancy[107].Patients with malignancy detected during late pregnancy are candidates for prompt cesarean section[100,103].Prognosis depends on the histologic grade and pathologic stage of the cancer[103,105,107].
Adnexal torsion
Adnexal torsion occurs in about1of1800pregnancies,an incidence similar to that of acute appendicitis[108].About one quarter of adnexal torsions occur during pregnancy[109],because of the greater laxity of the tissue supporting the ovaries and oviducts during pregnancy[110].Torsion usually occurs between the sixth and fourteenth weeks of gestation.Both ovarian cysts and tumors,particularly the benign cystic teratoma,may undergo torsion,but many torsions are idiopathic or occur about extra-ovarian structures[111].Right-sided torsion is more common than left-sided torsion[109,111].
The clinical presentation is variable[111,112].The lower abdominal pain is often sharp and sudden in onset and may last from several hours to days.
Intermittent pain may indicate detorsion or devitalization of sensory nerves
[108].Patients often have nausea and emesis.Signs include unilateral lower quadrant tenderness,a palpable adnexal mass,cervical tenderness,or rebound tenderness from peritonitis [111].Leukocytosis is common.
The diagnosis is often missed.Right-sided adnexal torsion may be di?cult to di?erentiate from appendicitis.Other diagnostic considerations include a ruptured ovarian cyst or EP [72].Ultrasonography,including duplex scanning,is valuable in the detection of adnexal masses,particularly cysts,but additional diagnostic imaging tests may be necessary.Adnexal torsion,diagnosed before tissue necrosis,is managed with adnexa-sparing laparoscopic detorsion,followed by progesterone therapy if the corpus luteum is removed [113].Laparotomy with salpingo-oophorectomy is necessary if necrosis or peritonitis has occurred.
Pelvic inflammatory disease
The term pelvic in?ammatory disease (PID)refers to infection of the upper genital tract including the oviducts.It is characterized by the triad of lower abdominal pain,pyrexia,and vaginal discharge.Management of PID during gestation is complicated in terms of antibiotic selection and whether to continue the pregnancy [114].Complications include salpingitis and tubo-ovarian abscess.Patients may become infertile or have a high risk for EP
[67,115,116].
Tubo-ovarian abscess
Tubo-ovarian abscess is an emergency associated with maternal mortal-ity and fetal wastage [115].It can result from pelvic surgery,assisted reproduction,bowel perforation,appendicitis,infected EP,pelvic malig-nancy,and PID,especially with chlamydial infection [116,117].Abdominal pain,pyrexia,a palpable mass,and leukocytosis commonly occur.Magnetic resonance imaging,CT scanning,or sonography are helpful in the diagnosis,but laparoscopy is often required for con?rmation.Treatment includes ?uid resuscitation,parenteral antibiotics,and expedient surgery unless the abscess is small,well contained,and amenable to radiologic drainage [118].Endometriosis
Endometriosis is a common cause of abdominal pain in younger women.Endometriosis usually does not cause infertility;women with endometriosis usually have an uncomplicated pregnancy and delivery [119].Ovarian endometriosis is associated with genetic abnormalities and with clear cell and endometrioid carcinoma [120].Endometrioid cysts account for about 4%of adnexal masses during pregnancy.Peritonitis from endometrial cyst rupture may be dif?cult to differentiate from appendicitis or EP [121].17
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Uterine leiomyoma
Uterine leiomyomas(?broids)are well-circumscribed,benign,smooth muscle tumors.Careful pathologic examination reveals up to80%of women of reproductive age have uterine leiomyomas[122],but only about 4%of pregnant women have sonographically evident uterine leiomyomas, about12%of which are multiple[123].Symptoms include uterine bleeding, pelvic pressure,urinary urgency,and abdominal https://www.doczj.com/doc/e77514991.html,rge and strategically located leiomyomas can cause infertility[124].Small leiomyo-mas are usually asymptomatic.
Leiomyomas tend to become smaller during pregnancy,and leiomyomas initially less than5cm in diameter usually involute completely during pregnancy[125].Complications occur in about1in500pregnancies[126]. Large leiomyomas can undergo hemorrhagic infarction resulting in the painful myoma syndrome[127].Symptoms may be minimal or may include severe abdominal pain,nausea,emesis,and pyrexia[128].Ultrasonography and MR imaging are usually diagnostic[129].Treatment consists of bed rest and nonsteroidal anti-in?ammatory drugs(NSAIDs),but these drugs should be avoided after the thirty-fourth week of gestation because they affect labor[126,127].Other complications of leiomyomas are premature rupture of membranes,placental abnormalities,uterine rupture(especially after prior myomectomy),dystocia,more frequent cesarean delivery, postpartum hemorrhage,and puerperal sepsis[130].
Uterine rupture
Uterine rupture is rare during pregnancy.Risk factors include prior ce-sarean section,especially with lower uterine incision,pharmacologic induc-tion of labor with oxytocin or prostaglandins,multiparity,placental percreta, fetal malpresentation,and blunt trauma[131,132].Patients often present in shock with diffuse abdominal pain.Treatment includes?uid resuscitation, emergency surgery,and fetal delivery.Hysterectomy is often required. Fetal demise is likely with intraabdominal expulsion of the fetus[131,132]. Gastrointestinal disorders
Acute appendicitis
Acute appendicitis is the most common nonobstetric surgical emergency during pregnancy,with an incidence of about 1.0in1000pregnancies [27,133,134].Appendicitis may occur at any time during pregnancy but is slightly more likely during the second trimester[27,135].Pregnancy does not predispose to appendicitis[133].Appendiceal obstruction,usually from an appendicolith,is the primary pathophysiologic event,although stasis and other factors are also implicated[135].As the appendiceal lumen distends,
the patient initially experiences poorly localized pain [24].Severe luminal distension,mural in?ammation and edema,and bacterial translocation produce somatic pain that becomes severe and well localized in the right lower quadrant [22].
Although abdominal pain is often localized to the right lower quadrant at McBurney’s point,displacement of the appendix by the gravid uterus during late pregnancy may cause the point of maximal abdominal pain and tenderness to migrate superiorly and laterally from McBurney’s point [25].Other clinical ?ndings include anorexia,nausea,emesis,pyrexia,tachycardia,and abdominal tenderness [136].Periappendiceal in?ammation or peritonitis causes involuntary guarding and rebound tenderness.Involuntary guarding and rebound tenderness are less reliable signs of peritonitis in late pregnancy because of abdominal wall laxity [26,27].Rectal or pelvic tenderness may occur in early pregnancy but is unusual in late pregnancy as the appendix migrates from its pelvic location [10,26].Patients may have signi?cant leukocytosis,a predominance of neutrophils in the leukocyte differential,an abnormal urinalysis,and nonspeci?c electrolyte abnormalities [137,138].
The diagnosis is made clinically without overreliance on radiologic imaging.Sonography may demonstrate appendiceal mural thickening and periappendiceal ?uid,but the ?ndings are usually nonspeci?c and mostly help to exclude other pathology,such as an adnexal mass [38,45].Computed tomography is more accurate but exposes the fetus to radiation [139].
The diagnosis is more frequently missed in pregnant than in nonpregnant patients [138]because:
Leukocytosis,a classic sign of acute appendicitis,occurs physiologically during pregnancy.
Nausea and emesis,common symptoms of acute appendicitis,are also common during pregnancy.
The abdominal pain is sometimes atypically located because the growing gravid uterus displaces the appendix laterally and superiorly.
Other diseases are often confused with appendicitis.The di?erential diagnosis for appendicitis in pregnancy is shown in Box 2.
Up to one quarter of pregnant women with appendicitis develop ap-pendiceal perforation [140].Appendiceal displacement predisposes to rapid development of generalized peritonitis after perforation because the omentum is not nearby to contain the infection [26].
Appendicitis during pregnancy requires surgery [141].Preoperative management during pregnancy is challenging (Table 2).Patients require intravenous hydration and correction of electrolyte abnormalities [142].Antibiotics are usually administered for uncomplicated appendicitis and are absolutely required for appendicitis complicated by perforation,abscess,or peritonitis [143].Penicillins (including ampicillin/sulbactam),cephalospor-ins,clindamycin,and gentamicin are considered safe during pregnancy [83].Quinolones are not recommended because safer alternatives are available 19
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Box2.Differential diagnosis of appendicitis during pregnancy Gynecologic conditions
Ruptured ovarian cyst
Adnexal torsion
Pelvic in?ammatory disease or salpingitis
Endometriosis
Obstetric causes
Abruptio placenta
Chorioamnionitis
Endometritis
Fibroid degeneration
Labor(preterm or term)
Viscus perforation after abortion
Other causes
Exacerbation of Crohn’s disease
Diverticulitis(right side)
Cholecystitis
Pancreatitis
Mesenteric lymphadenitis
Gastroenteritis
Colon cancer
Intestinal obstruction
Pyelonephritis
Urolithiasis
Hernia(incarcerated inguinal or internal)
[144].Clindamycin is preferred to metronidazole for anerobic coverage,even though both are category B drugs in pregnancy[145].Clindamycin and gentamicin is a relatively inexpensive,effective,and safe antibiotic https://www.doczj.com/doc/e77514991.html,paroscopy may be considered during the?rst2trimesters for nonperforated appendicitis or when the diagnosis is uncertain[146]. Appendectomy is recommended even if appendicitis is not evident at surgery [136,138,140].Maternal mortality from appendicitis has diminished sig-ni?cantly and is currently about0.1%without perforation but exceeds 4%with perforation[133,134].Fetal mortality is less than2%without perforation but exceeds30%with perforation[133].Mortality is usually related to delayed diagnosis[27,136,140].Preterm labor is common,but preterm delivery is unusual[138].
【英语词汇】 pain、ache、sore、distress、 anguish、misery、agony、torment pain ache sore 这三个名词均含有身体“疼痛”之意。 pain 指一般的痛，也可指剧痛，疼痛范围可以是局部或全身，时间可长可短。 1）He could feel the pain again as the medicine wore away. 药性消退后，他又感到疼痛了。 2）He was working in the garden, when he felt a sharp pain in the abdomen. 他正在花园里干活，突然他感觉腹部剧烈疼痛。 3）This medicine will help to relieve you from your pain. 这种药将帮助你解除疼痛。 ●pain也可指精神上的痛苦。 1）It gave us much pain to learn of the news. 我们听到这个消息十分悲痛。 2）Do you really think enjoyment should be based on others' pain? 你以为一个人应该把自己的快乐建筑在别人的痛苦上面吗 ?
ache多指人体某一器官持续的隐隐的疼痛，常放在身体部位名词后构成病痛名 称，如: toothache 牙痛、head ache 头痛、stomach ache 胃痛。有时可与pain 换用。 1）She felt an ache / pian in her back. 她感到后背隐隐作痛。 2）The dull ache in his head turned out to be suffering from brain tumor. 他的头隐隐作痛，结果竟是罹患脑瘤。 3）Poor posture can cause neck ache, headaches and breathing problems. 姿势不当会导致颈部疼痛、头痛和呼吸困难。 4）Sedentary will lead to muscle ache, stiff neck and headache and dizziness. 久坐不动会引发全身肌肉酸痛、脖子僵硬和头痛头晕。 ●ache也可指精神上的痛苦。 1）There was a little ache in her fancy of all he described. 她想象着他所描绘的一切，心里不禁有些刺痛。 2）The ache in the her body is no worse than the ache in her heart. 她身体的疼痛比不上她心头的疼痛。 ●ache可用作动词。 1）Mother says she is aching all over with fatigue.
腹痛的辨证论治 一、辨证要点 1、辨寒热虚实腹痛拘急冷痛，疼痛暴作，痛无间断，腹部胀满，肠鸣切痛，遇冷痛剧，得热则痛减者，为寒痛；腹痛灼热，时轻时重，腹胀便秘，得凉痛减者，为热痛；痛势绵绵，喜揉喜按，时缓时急，痛而无形，饥则痛增，得食痛减者，为虚痛；痛势急剧，痛时拒按，痛而有形，疼痛持续不减，得食则甚者，为实痛。 2、辨在气在，血腹痛胀满，时轻时重，痛处不定，攻撑作痛，得暖气矢气则胀痛减轻者，为气滞痛；腹部刺痛，痛无休止，痛处不移，痛处拒按，入夜尤甚者，为血瘀痛。 3、辨急缓突然发病，腹痛较剧，伴随症状明显，因外邪入侵，饮食所伤而致者，属急性腹痛；发病缓慢，病程迁延，腹痛绵绵，痛势不甚，多由内伤情志，脏腑虚弱，气血不足所致者，属慢性腹痛。 4、辨部位诊断腹痛，辨其发生在哪一位置往往不难，辨证时主要应明确与脏腑的关系。大腹疼痛，多为脾胃、大小肠受病；胁腹、少腹疼痛，多为厥阴肝经及大肠受病；小腹疼痛，多为肾、膀胱病变；绕脐疼痛，多属虫病。 二、治疗原则 腹痛的治疗以“通”为大法，进行辨证论治：实则泻之，虚则补之，热者寒之，寒者热之，滞者通之，瘀者散之。腹痛以“通”为治疗大法，系据腹痛痛则不通，通则不痛的病理生理而制定的。肠腑以通为顺，以降为和，肠腑病变而用通利，因势利导，使邪有出路，腑气得通，腹痛自止。但通常所说的治疗腹痛的通法，属广义的“通”，并非单指攻下通利，而是在辨明寒热虚实而辨证用药的基础上适当辅以理气、活血、通阳等疏导之法，标本兼治。如《景岳全书·心腹痛》曰：“凡治心腹痛证，古云痛随利减，又曰通则不痛，此以闭结坚实者为言。若腹无坚满，痛无结聚，则此说不可用也。其有因虚而作痛者，则此说更如冰炭。”《医学真传·腹痛》谓：“夫通则不痛，理也。但通之之法，各有不同，凋气以和血，调血以和气通也；下逆者使之上行，中结者使之旁达，亦通也；虚者助之使通，寒者温之使通，无非通之之法也。若必以下泄为通，则妄矣。” 三、分证论治 寒邪内阻 症状：腹痛急起，剧烈拘急，得温痛减，遇寒尤甚，恶寒身蜷，手足不温，口淡不渴，小便清长，大便自可，苔薄白，脉沉紧。 治法：温里散寒，理气止痛。 方药：良附丸合正气天香散。 方中高良姜、干姜、紫苏温中散寒，乌药、香附、陈皮理气止痛。若腹中雷鸣切痛，胸胁逆满，呕吐，为寒气上逆者，用附于粳米汤温中降逆；若腹中冷痛，周身疼痛，内外皆寒者，用乌头桂枝汤温里散寒；若少腹拘急冷痛，寒滞肝脉者，用暖肝煎暖肝散寒；若腹痛拘急，大便不通，寒实积聚者，用大黄附子汤以泻寒积；若脐中痛不可忍，喜温喜按者，为肾阳不足，寒邪内侵，用通脉四逆汤温通肾阳。 湿热积滞 症状：腹部胀痛，痞满拒按，得热痛增，遇冷则减，胸闷不舒，烦渴喜冷饮，大便秘结，或溏滞不爽，身热自汗，小便短赤，苔黄燥或黄腻，脉滑数。
常见疾病自我治疗 【眼、耳、鼻、喉科疾病】 【黑眼圈】 1.冰敷可收缩血管帮助消肿，也减少引起黑眼圈的内出血 2.避免阿司匹林，因其为抗凝血剂，使血液不易凝结，会使造成黑眼圈的出血不易停止 3.勿擤鼻涕，以免因压迫与眼眶相邻的鼻窦，而使空气注入眼皮下，不但造成肿大，也会增加感染机会 【眼睛疲劳】 1.注意光线，太暗的灯光使眼睛容易疲劳，使用能提供明暗对比的柔和灯光较佳 2.每二至三个小时连续使用计算机，应将眼睛移开计算机十至十五分钟，让眼睛休息 3.减弱屏幕的光线，让屏幕的亮度降低，可避免疲劳 4.将计算机套上全黑的厚纸板，使屏幕光线可以降到很低 5.闭眼休息，是消除眼睛疲劳的好方法 6.将毛巾浸入茶里，用来敷眼十至十五分钟，可消除眼睛疲劳 7.将双手摩擦生热，再盖住眼睛，勿压迫双眼，深缓地呼吸，有助于消除眼睛疲劳 8.眨眼三百下，有助于清洁眼睛同时达到按摩效果 【眼布血丝】 1.睡眠充足有助于滋润眼睛，减少眼睛的血丝 2.清洁眼睑，以免因残屑、油脂、细菌、化妆品等尘屑导致眼睛发炎，布满血丝 3.使用人工泪液，减少干涩 4.以冷毛巾敷眼部，可收缩血管，滋润眼睛 【夜盲症】 1.如果坐在黑暗中五分钟还看不到的话，可能就是患了夜盲症 2.维他命Ａ影响人的夜间视觉能力，若有夜盲的症状，服用大量维他命Ａ可在数小时获得改善，但服用大量维他命Ａ须经医师同意 3.增加夜间开车的可见度，保持前灯干净，在光线不足时，避免戴太阳眼镜，有助于增加可见度 4.夜盲者应避免夜间开车 5.事先计划路线，选择交通流量较小的道路，可减少夜间开车的麻烦，若天况不佳，最好不要开车 【结膜炎】 1.以温毛巾敷眼 2.保持干净，以棉球沾清水擦拭分泌物，可加速复原 3.可以将婴儿洗发精与温水以一比十制成溶液，用棉球沾湿擦拭眉毛，可软化清洁眼睑与睫毛 4.勿与任何人共享毛巾、手帕，以免互相传染 5.游泳时请戴泳镜 6.如果你的眼睛痒得像是被蚊子咬，眼内也有成丝的脓，那可能是过敏性结膜炎，最好以抗组织胺的成药，并加以冷敷
常见名词辨析 ● ability, capacity, capability, competence, faculty, aptitude 【辨析】这些名词均可表示人的“能力，才能”之意。 ability 普通用词，指人先天的或学来的各种能力。 capacity 侧重指人的潜在能力，通常不指体力，多指才智，尤指接受与领悟能力。capability 多用于人，指胜任某项具体工作的能力，也指本身具有、尚未发挥的潜在能力。常与of或for连用。 competence 正式用词，侧重指令人满意的业务能力与水平，达到胜任某项工作等的要求。faculty 指特殊的才能或智力。 aptitude 多指先天或后天习得的运用自如的能力，常暗指接受能力强，能迅速掌握一种学术思想或艺术技巧。 He has the ability to do the work. 他有做这项工作的能力。 Some people have a greater capacity for happiness than others. 有的人享得起福，有的人享不起福。 You have the capability to do/ of doing this job well. 你有能力把这个工作做好。 No one doubts her competence as a teacher. 谁也不怀疑她能胜任教师工作。 Man is the only animal that has the faculty of speech. 人类是唯一有说话能力的动物。 Does she show any aptitude for games？能看得出她有体育方面的天赋吗？ ● accident, incident, event, occurrence, happenin g 【辨析】这些名词均有“事故、事件”之意。 accident 常指不幸的、预料不到的、突发性的意外事件，如车祸、灾难等，常与by连用。incident 既可指小事件或附带事件，又可指政治上具有影响的事件或事变、战争等。 event 可指任何大小事件，但尤指历史上的重大事件。 occurrence 和happening 这两个词多指日常生活中发生的一般事件，有时也指偶然发生的事。He had met with an accident on the way. This is why he was late for the meeting. 他在路上遇到了交通事故，所以他开会迟到了。 The other day I came across an interesting accident. 我前几天碰到一件有趣的事。 My father told me of an incident that took place on his first day at school. 父亲告诉我他开学头一天发生的一件事。 Don’t be troubled with the incident. 别因那件小事而烦恼。 The May 4th Movement was an important event in the Chinese history. 五四运动是中国历史上一件重大的事件。 ● account, report 【辨析】这两个名词都有“报道，叙述”之意。 account 普通用词，不如report正式，侧重对亲身经历或目睹之事所作的书面或口头的报道或叙述。 report正式用词，多指报刊上的报道，强调对情况经过调查或审核后作出的详尽叙述，具有一定权威性。 The policeman gave an account of the traffic accident. 警察叙述了交通事故的经过。 Tom wrote a report about his discoveries. 汤姆就他的发现，写了一篇报道。 ● ache, pain, sore 【辨析】这些名词均含有“疼、疼痛”之意。 ache 指人体某一器官较持久的疼痛，常常是隐痛。 pain 可与ache换用，但pain既可指一般疼痛，也可指剧痛，疼痛范围可以是局部或全身，
1、乳腺增生—正常的生理现象 一个体检下来，10个女生8个有“乳腺增生”问题。这时很多女性往往会跑去医院问医生“乳腺增生会不会癌变成乳腺癌？”、“吃点什么药才能‘消灭’增生”。其实，大部分乳腺增生的患者根本不用治疗。 在医学上，有些乳腺增生属于正常的生理现象。最典型的莫过于经期引起的乳腺增生，女性月经前乳房会特别不舒服，感觉胀胀的，还有点痛，但生理期过了胀痛就渐渐消失。另外，一些女性为了凸显“好身材”，内衣经常会穿得过紧；亦或时最近发生了不开心的事情心情比较郁闷，精神压力比较大，同样也会引起短期的乳腺增生。 郑州大学第三附属医院乳腺科主任医师贾国丛介绍，乳腺增生其实是一种良性病变，正常的生理现象，无特别的治疗方法，极少数会发展为乳腺癌，注意定期复查即可。另外，只要每天保持良好心态，少吃含激素较高的食品，坚持适量运动就能有效缓解乳腺增生。 2、宫颈糜烂—只是名字吓人
“糜烂”一词威力巨大，第一次听到“宫颈糜烂”这个词，脑中已经脑补出“宫颈开始慢慢溃烂、发臭，进而波及整个子宫”的可怕画面。其实，这只是医学名词史上一个大失误。 在国际上，“宫颈糜烂”这个名称已经被取消，我国妇科教材也取消了这个称谓。它的真身是“宫颈柱状上皮异位”，属于正常的生理现象。 北京协和医院妇产科主任医师谭先杰介绍，宫颈糜烂是女性一种正常生理改变现象，并不能称之为病，大部分宫颈糜烂的女性只是受激素水平的影响出现上皮异位，待激素水平稳定后所谓“糜烂”情况就会得到改善。 许多女性被街边小广告忽悠，通过所谓“物理治疗”处理宫颈糜烂、宫颈炎，弄得不好还会引起无谓的感染，钱包受伤的同时还伤身，简直是大整蛊！ 3、子宫肌瘤—多数都相安无事 “子宫肌瘤”这个词实在太容易让人联想到癌症了！其实，此“瘤”非彼“瘤”，子宫肌瘤的瘤多数是良性的。子宫肌瘤也是妇科体检的“常客”，几乎三分之一的妈妈级人物都会遇到。有些小肌瘤不但没有任何症状，甚至连妇科检查也难以觉察，偶尔做B超才发现。
中医内科学教案 讲授课程：中医内科学 授课专业：中西医结合临床本科 授课年级：授课教师：
病历一： 一患者三年来有胃痛史，经常服用某老中医中药而缓解。某晨患者感腹痛，自服“十香肚痛散”一支，痛稍缓解，旋即疼痛，下午二时疼痛加剧，请老医生出诊，诊后认为是“胃肠积火、腑气不通（患者二天未大便）”，用调胃承气汤加味，一剂药后疼痛加剧。其家人请老医生复诊，答曰：需二、三剂才能见效，不用焦急。当夜十一时，病人汗出淋漓，腹痛翻滚，急往某医院外科急诊，诊为“弥漫性腹膜炎、中毒性休克”。经剖腹见：胃内容物、药液漏入腹腔，穿孔处在十二指肠球部。经抢救转危为安，40天后痊愈出院。 2、腹痛与胃痛及其它内科病症中出现的腹痛症状相鉴别。 （1）腹痛与胃痛：部位、兼症、联系 （2）腹痛与痢疾：里急后重，下痢赤白脓血。 （3）腹痛与霍乱：吐泻交作。 （4）腹痛与积聚：腹中包块。 （5）腹痛与鼓胀：外形胀大，脉络显露。 四、腹痛的辨证及治疗要点。 1、辨证要点： （1）辨腹痛性质： ①辨虚实 ②辨寒热 ③辨气滞 ④辨血瘀 ⑤辨伤食痛 （2）辨腹痛部位（大腹、脐腹、胁腹、少腹、小腹） 2、治疗要点 （1）“通”则不痛：腑以通为顺，以降为和。 如何理解“通”法： 《医学真传》说：“夫通则不痛，理也。但通之之法，各有不同，调气以和血，调血以和气，通也；下逆者使之上行，中结者使之旁达，亦通也，虚者助之使通，寒者温之使通，无非通之之法也。若必以下泄为通，则妄矣。” （2）审证求因，辨证用药：明辨寒热虚实。 （3）标本兼治：通非通下，不可单纯泻下，辅以理气通导之品；不可过用香燥，中病即止；虚痛宜温中补虚，益气养血。 （4）久痛入络：加辛温活血剂。 五、分证论治 讲授方法：结合临床讲解。 讲授内容： （1）寒邪内阻 主症：腹痛急迫、剧烈、拘急,得温痛减，遇寒更甚。 兼次症：恶寒身蜷，手足不温，口淡不渴，小便清长。 舌苔白腻。脉沉紧。 治法：温里散寒，理气止痛。 方药：良附丸合正气天香散。 高良姜、干姜：温中散寒； 乌药、香附、陈皮、紫苏：理气止痛。 临床应用： 寒气上逆，腹中雷鸣切痛，呕吐者，以附子粳米汤温中降逆； 内外皆寒，腹中冷痛，身体疼痛者，以乌头桂枝汤温里散寒； 寒滞肝脉，少腹拘急冷痛者，以暖肝煎暖肝散寒；10min 25min
专四词语辨析大全 近义词辨析 abandon, desert, forsake, leave, give up 这些动词或词组均含“抛弃、放弃”之意 abandon: 强调永远或完全放弃或抛弃人或事物等，这可能是被迫的，也可能是自愿的。desert: 着重指违背法律责任和义务，或自己的信仰与誓言的行为，多含非难的意味。forsake: 侧重断绝感情上的依恋，自愿抛弃所喜欢的人或物。也指抛弃信仰或改掉恶习。leave: 普通用词，指舍弃某事或某一职业，或终止同一某人的关系，但不涉及动机与果。give up: 普通用语，侧重指没有希忚或因外界压力而放弃。 ability, capacity, capability, genius, talent, competence, faculty, gift, aptitude 这些名词均可表示人的“能力，才能”之意。 ability: 普通用词，指人先天的或学来的各种能力。 capacity: 侧重指人的潜在能力，通常不指体力，多指才智，尤指接受与领悟能力。capability: 多用于人，指胜任某项具体工作的能力，也指本身具有、尚未发挥的潜在能力。常与of或for连用。 genius: 语气最强，指天赋的高度才能与智力。 talent: 着重指人某方面具有可发展和倍养的突出天赋才能，但语意比genius弱。competence: 正式用词，侧重指令人满意的业务能力与水平，达到胜任某项工作等的要求。faculty: 指特殊的才能或智力。 gift: 着重个人的天赋的才能或在某方面的显著本领，常暗含不能用一般规律作解释的意味。 aptitude: 多指先天或后天习得的运用自如的能力，常暗示接受能力强，能迅速掌握一种学术训练或艺术技巧。 able, capable, competent 这些形容词均含有“有能力的，能干的”之意 able: 最常用词，多用于褒义，着重指多方面的，经常性的，或潜在性的能力。有时也指高超、非凡的能力。 capable: 语气弱于able，指有能力、有潜力或有条件做某事，常与of连用。competent: 强调具有能胜任某项工作的足够技能或其它所需的条件。 abolish, cancel, repeal 这些动词均含“取消、废除”之意 abolish: 正式用词，指彻底废除某种制度、规章或习俗。 cancel: 用法广泛，多指取消债务、合同、证书、比赛、旅行、计划或约会等。 repeal书面用词，指撤销立法机关通过的协议、法案或法律等。 about, around, round 这些词均有“在周围、在附近”之意。 about: 既可表静态，也可表动态。 around: 主要用于美国，静态或动态均可。
羊快疫 羊快疫是由腐败梭菌引起的一种急性，致死性传染病，不同品种的羊均可感染，以 一岁以内，膘情好的多发。发病季节多在初春和秋末。其特征是死快，真胃和十二支 肠出血水肿和坏死。呈散发或地方性流行。 （一）、临床症状 突然发生，往往不出现临床症状，急性死亡。病程稍长的病羊离群独处，卧地，不 愿走动，强迫行走时，运动失调。腹部膨胀，有疼痛感，排出黑色稀粪，磨牙。体温 一般正常，饮食欲废绝。发病后通常数分钟至数小时痉挛而死，很少延长一天以上的 病例。 （二）、病理变化 尸体迅速腐败，膨胀，剖开有恶臭，天然孔流出血样液体，可视粘膜充血呈兰紫色。胸腹腔及心包积液，心内外膜有出血点。肝肿大，呈土黄色。真胃和指肠出血水肿和 坏死。 （三）、诊断要点 羊快疫由于病程短，缺乏特征病状，要结合流行病学和病理解剖变化综合判定。 （四）、预防与治疗 1、由于病程短，来不及治疗，所以应注射羊快疫—猝疽—肠毒血症三联苗进行预防。对病死羊应深埋，对用具，圈舍用20%漂白粉或3%烧碱液消毒。 2、0.5%高锰酸钾溶液250毫升，灌服，每天一次。
3、非常粉针和注射用硫酸链霉素，每公斤0.2—0.5万单位，败血康10—20毫升，分别肌肉注射，每天2次。 3、来一针注射液，每头每次2—20毫升，肌肉注射，每天2次。 羔羊痢疾 羔羊痢疾主要是B型产气荚膜杆菌引起初生羔羊的急性肠道传染病。本病发生于7 天以内，以2-3天发病最多。病羔是主要传染源，病源随粪便排除，污染羊圈，用具 母羊体表和乳头，健康羔羊经消化道，脐带或伤口传染。其特征是剧烈腹泻和神精症状，死亡率很高，给羊业带来严重的危害。 （一）临床症状 潜伏期1-2天。病初羔羊精神萎顿，垂头弓背，不吮乳。腹胀腹痛，腹泻，粪便呈 粥样或水样，颜色呈灰白色，黄色或黄绿色，恶臭。病羔虚弱脱水，眼球下陷，皮毛 粗乱，卧地不起而发生死亡。 （二）病理变化 真胃内有未消化的凝乳块，小肠充血，发红，溃疡，肠子膜淋巴结肿大，充血。心 包积液，心内膜有出血点，肺充血或瘀血。 （三）诊断要点 7日龄以内羔羊下痢，很快死亡，即可诊断为羔羊痢疾。 （四）预防与治疗
脾胃病科腹痛病(功能性腹痛)中医诊疗方案(试行版) 腹痛病（功能性腹痛）中医诊疗方案 一、诊断 （一）疾病诊断 1.中医诊断标准 参照《中医内科常见病诊疗指南》“中医病证部分”（中华中医药学会编，中国中医药出版社，2008年）。 指胃脘以下，耻骨毛际以上的部位发生疼痛为主要表现的病证，属于中医“腹痛病”的范畴。 2.西医诊断 参照“功能性胃肠病罗马III诊断标准”。 功能性腹痛的诊断必须符合以下所有条件： （1）持续或近乎持续的腹痛； （2）疼痛与生理事件（如进食、排便或月经）无关或仅偶尔有关； （3）日常活动能力部分丧失； （4）疼痛并非伪装（如诈病）； （5）症状不满足其他能解释疼痛的功能性胃肠病的诊断标准。诊断前症状出现至少6个月，近3个月症状符合以上标准。 （二）证候诊断 1.肝郁气滞证：腹痛时轻时重，痛引两胁，胀满窜痛，后重窘迫，
症状与情绪明显相关，得嗳气矢气则舒。舌质淡红，脉弦。 2.脾胃湿热证：腹部胀满疼痛，胸闷不舒，口苦，烦渴不欲饮，大便秘结或泻而不爽，或色黄而臭，小便短赤。舌红，苔黄腻，脉濡数或滑数。 3.肝郁脾虚证：腹部或胁肋胀痛，腹痛即泻，泻后痛减，情绪抑郁或急躁易怒，善太息，食少纳呆，或便溏不爽，肠鸣失气。舌淡红，苔白或腻，脉弦或细。 4.中虚脏寒证：腹痛绵绵，时作时止，饥饿劳累后加重，喜热恶冷，痛时喜按，形寒肢冷，神疲乏力，纳食不佳，大便溏薄。舌质淡，苔薄白，脉沉细。 二、治疗方法 （一）辨证选择口服中药汤剂、中成药 1.肝郁气滞证 治法：疏肝解郁，理气止痛。 推荐方药：柴胡疏肝散加减。柴胡、香附、川芎、陈皮、枳壳、白芍、炙甘草、郁金、元胡等。 中成药：金佛止痛丸、四磨汤口服液、沉香舒气丸、木香顺气丸等。 2.脾胃湿热证 治法：清热化湿，理气止痛。 推荐方药：连朴饮加减。厚朴、川连、石菖蒲、法半夏、香豉（炒）、焦山栀、芦根、郁金、元胡等。
近义词辨析 ①abandon, desert, forsake, leave, give up 这些动词或词组均含“抛弃、放弃”之意 abandon: 强调永远或完全放弃或抛弃人或事物等，这可能是被迫的，也可能是自愿的。 desert: 着重指违背法律责任和义务，或自己的信仰与誓言的行为，多含非难的意味。 forsake: 侧重断绝感情上的依恋，自愿抛弃所喜欢的人或物。也指抛弃信仰或改掉恶习。 leave: 普通用词，指舍弃某事或某一职业，或终止同一某人的关系，但不涉及动机与果。 give up: 普通用语，侧重指没有希望或因外界压力而放弃。 ②ability, capacity, capability, genius, talent, competence, faculty, gift, aptitude 这些名词均可表示人的“能力，才能”之意。 ability: 普通用词，指人先天的或学来的各种能力。 capacity: 侧重指人的潜在能力，通常不指体力，多指才智，尤指接受与领悟能力。 capability: 多用于人，指胜任某项具体工作的能力，也指本身具有、尚未发挥的潜在能力。常与of或for连用。genius: 语气最强，指天赋的高度才能与智力。 talent: 着重指人某方面具有可发展和倍养的突出天赋才能，但语意比genius弱。 competence: 正式用词，侧重指令人满意的业务能力与水平，达到胜任某项工作等的要求。 faculty: 指特殊的才能或智力。 gift: 着重个人的天赋的才能或在某方面的显著本领，常暗含不能用一般规律作解释的意味。 aptitude: 多指先天或后天习得的运用自如的能力，常暗示接受能力强，能迅速掌握一种学术训练或艺术技巧。able, capable, competent 这些形容词均含有“有能力的，能干的”之意 able: 最常用词，多用于褒义，着重指多方面的，经常性的，或潜在性的能力。有时也指高超、非凡的能力。capable: 语气弱于able，指有能力、有潜力或有条件做某事，常与of连用。 competent: 强调具有能胜任某项工作的足够技能或其它所需的条件。 abolish, cancel, repeal 这些动词均含“取消、废除”之意 abolish: 正式用词，指彻底废除某种制度、规章或习俗。 cancel: 用法广泛，多指取消债务、合同、证书、比赛、旅行、计划或约会等。 repeal书面用词，指撤销立法机关通过的协议、法案或法律等。 about, around, round 这些词均有“在周围、在附近”之意。 about: 既可表静态，也可表动态。 around: 主要用于美国，静态或动态均可。 round: 主要用于英国，多半指动态。 above, on, over 这些前置词均含“在……上”之意。 above: 一般指位置高于某物，但不一定在正上方，也不接触另一物，其反义词是below。 on: 指与另一物表面相接触。 over: 指一物在另一物的垂直上方，多暗示悬空，但也含“覆盖于……之上”之意。其反义词是under。absorb, suck, digest, incorporate 这些动词均有“吸收”之意。 absorb: 普通用词，词义广泛，既可指吸收光、热、液体等具体东西，又可指吸收知识等抽象概念的东西。suck: 作“吸收”解时，可与absorb换用，但还可有“吮吸”之意。 digest: 侧重在消化道内改变食物的化学结构后被人体吸收。 incorporate: 指一物或多物与它物相融合，形成一整体。 absurd, ridiculous 这两个形容词均含有“荒谬的”之意 absurd: 普通用词，强调指违背常理的荒谬。 ridiculous: 强调荒谬到令人发笑的地步。 abundant, plentiful, ample 这些形容词均有“充分的、丰富的”之意。 abundant: 着重某物极为丰富有或大量的供应。 plentiful: 普通用词，指某物的数量多得称心如意，不过剩，但较少用于描写抽象之物。 ample: 指某物不仅满足了需要而且有余。 accept, receive, admit, take 这些动词均有“接受、接纳”之意。 accept: 强调主动地或自愿地接受，或者说，经过考虑后同意接受。 receive: 着重仅仅接到或收到这一支轮船或事实，而不含采取主动或积极行动的意思。
常见疾病宣传资料 要有效地预防传染病的发生与流行，关键在于切断传染病流行的三个环节形成的传播链。为此，要切实做到： 1、养成良好的卫生习惯，提高自我防病能力。 2、加强体育锻炼，增强对传染病的抵抗力。 3、按规定进行预防接种，提高免疫力。 4、搞好环境卫生，消灭传播疾病的蚊、蝇、鼠、蟑螂等害虫。 5、传染病人要早发现、早报告、早诊断、早隔离、早治疗、防止交叉感染。 6、传染病人接触过的用品及居室均严格消毒。 一、呼吸传染病的预防宣传资料 冬春季是呼吸道传染病的好发季节。学校这种人员比较密集、相对比较集中的地方，一旦出现更是比较容易传播，会对广大师生的工作学习带来较大的影响，因此我们有必要对春季常见的传染病及其预防措施有所了解。常见的传染性疾病包括：普通感冒、流行性感冒、麻疹、风疹、水痘、单纯疱疹、流行性腮腺炎、流脑、猩红热，传染性非典型肺炎（SARS）和人感染高致病性禽流感两类新病种。这些传染病大多都是呼吸道传染病，可通过空气、短距离飞沫或接触呼吸道分泌物等途径传播 冬春季寒冷，学生在外边活动减少，多集中在教室内，这更增加了传染机会。为了御寒，习惯把门窗关得很严，室内外的空气很难交换，空气相对静止的室内，带有病菌、病毒的飞沫在空
气中飘浮，学生在教室时间长，空气不新鲜，自然容易感染呼吸道传染病。另外，寒冷的空气会使鼻黏膜的血管收缩，降低呼吸道的抵抗力，这也是容易得病的一个原因。 二、流脑的预防 流脑是由脑膜炎双球菌感染引起的经呼吸道传播的一种化脓性脑膜炎，多在春季流行。 该病的一般表现症状是：突然高热，剧烈头痛，频繁呕吐，精神不振，颈项强直，重者可出现昏迷、抽搐。流脑根据病情轻重分为普通型和暴发型。暴发型起病急骤，常在24小时内出现严重休克和呼吸衰竭，危及生命。因此，在流脑高发期，若出现类似上呼吸道感染的症状，或者突发高热、身上有出血点、头痛、喷射状呕吐、嗜睡、烦躁不安等症状，要立即到正规医院抢救治疗，以免延误病情。 流脑有以下并发症：脑及其周围组织因炎症或粘连可引起第Ⅱ、Ⅲ、Ⅶ及Ⅷ对颅神经损害、肢体运动障碍，失语、大脑功能不全、癫痫等。脑室间孔或蛛网膜下腔粘连可发生脑积水，后者又导致智能障碍、癫痫等。经脑膜间的桥静脉发生栓塞性静脉炎后可形成硬膜下积水，多见于1-2岁的幼儿。当及时和适当的治疗效果不满意，恢复期出现抽搐，喷射性呕吐，特别伴有定位体征，颅内压持续升高，以及发热等即应想到硬膜下积水的可能。化脓性迁延性病变有结合膜炎、全眼炎、中耳炎、关节炎、肺炎、脓胸、心内膜炎、心包炎、睾丸炎等. 流脑虽来势凶猛，发病急剧，但只要掌握发病规律，采取综
16种常见急性腹痛，怎样鉴别呢？ 一、急性胃肠炎 发病前常有不洁饮食史，或共餐者也有类似症状病史。腹痛以上腹部和脐周围为主，常呈持续性痛伴阵发性加剧。常伴恶心、呕吐、腹泻，亦可有发热。可有上腹部或脐周围压痛，多无肌紧张，更无反跳痛，肠鸣音稍亢进。实验室检查：大便常规检查可有异常发现。 二、急性阑尾炎 大多数病人起病时先有中上腹持续性隐痛，数小时后腹痛转移至右下腹，呈持续性隐痛，伴阵发性加剧。少数病人起病时即感右下腹痛。中上腹隐痛经数小时后转移至右下腹痛是急性阑尾炎腹痛的特点，约占70%至80%。可伴恶心、呕吐或腹泻。重者可有发热、乏力、精神差。右下腹固定压痛点是诊断急性阑尾炎的最重要体征，典型的是麦氏点(Mc Bunery点)压痛或伴有肌紧张、反跳痛；结肠充气试验、腰大肌试验或闭孔内肌试验阳性不仅有助于诊断，还有助于术前阑尾定位。直肠指检及妇女盆腔检查对鉴别很有必要。实验室检查：血白细胞计数升高，中性粒细胞升高。B超检查：可发现阑尾肿胀或阑尾周围液性暗区。稀钡灌肠造影：对反复发作右下腹部疼痛，疑为慢性阑尾炎者有助于诊断。若在右下腹扪及边缘模糊的肿块，则提示已形成阑尾包块，如伴有畏寒、发热，B超提示右下腹有液性暗区，则应考虑阑尾脓肿形成。此外，在老年病人如诊断为阑尾包块经抗生素治疗后长期不消退者，应考虑并存结肠癌可能，应进一步做结肠镜检查。阑尾炎早期在右下腹压痛出现前易误诊为急性胃肠炎，而在阑尾炎穿孔后又易误诊为急性腹膜炎。此外，高位阑尾炎应与胆囊炎鉴别，腹膜后阑尾炎应与腹膜后脓肿鉴别，还需与胃十二指肠溃疡穿孔、右侧尿路结石、妇科炎症及卵巢囊肿扭转、右侧胸膜炎或右下肺炎等众多疾病鉴别。如术中发现阑尾炎症较轻微，与
临床药物治疗学——常见自身免疫性疾病的药物治疗考点 常见自身免疫病的药物治疗 ◆类风湿关节炎 ◆系统性红斑狼疮 考点考纲要求 类风湿关节炎 ◆抗风湿药物的分类掌握 ◆常用NSAIDs类药物的用法及不良反应熟练掌握 ◆常用的药物治疗方案了解 ◆治疗药物的相互作用掌握 一、类风湿关节炎 类风湿关节炎（RA）累及多个关节的慢性炎症性自身免疫病。 其主要症状为对称性的小关节晨僵，肿痛，功能障碍，部分患者伴有低热、乏力、血管炎等。 本病应在早期就进行合理治疗，否则必致骨破坏、关节畸形和功能丧失。 （一）抗类风湿药物的分类 治疗类风湿关节炎药物有四大类： 1.改善病情的抗风湿药（DMARDs） 这类药物可以延缓RA病情的发展，但无根治作用。它们减轻RA的症状，有的有停止骨破坏的作用。 2.非甾体抗炎药（NSAID）用于减轻关节炎患者的关节痛、肿的症状，起效较快，改善其生活质量。但不能控制病情进展，故需与免疫抑制剂同时应用。 3.糖皮质激素抗炎力强，可迅速控制关节肿痛症状。在某些关节炎患者可能起DMARD样作用。应用不当时有较大不良反应。 4.TNF拮抗剂是抑制TNF（致炎性细胞因子）的靶向生物制剂。它对炎性关节症状、炎症指标的控制有较好作用。它亦有一定阻止骨破坏进展、甚或修复作用。然而它不根治RA。目前它被列为生物性DMARD 类。 下列不属于抗类风湿药物分类的是 A.改善病情药 B.非甾体抗炎药 C.糖皮质激素药 D.抗生素类药 E.TNF拮抗剂
『正确答案』D （二）常用NSAIDs类药物的用法及不良反应 非甾体抗炎药： ◆一大类化学结构式各异，但有共同的药理作用的药物。 ◆它们具有抗炎、对急性和慢性疼痛有良好的镇痛以及解热作用； ◆临床应用广泛，特别是炎性关节病、软组织风湿的常用药。 【NSAIDs分类】 非选择性NSAIDs选择性COX（环氧化酶）－2抑制剂 布洛芬洛索洛芬 萘普生依托度酸 萘丁美酮尼美舒利 吲哚美辛塞来昔布 双氯芬酸 布洛芬 【适应证】 缓解各种慢性关节炎的关节肿痛症状； 治疗各种软组织风湿性疼痛； 急性疼痛如手术后、创伤后、劳损后、原发性痛经、牙痛、头痛等，有解热作用。 【注意事项】 （1）对阿司匹林或其他非甾体抗炎药过敏者对本品可有交叉过敏反应。 （2）本品可能增加胃肠道出血的风险并导致水钠潴留。 （3）轻度肾功能不全者可使用最小有效剂量并密切监测肾功能和水钠潴留情况。 （4）孕妇及哺乳期妇女尽量避免使用。 （5）避免本品与小剂量阿司匹林同用以防后者减效。 （6）有消化道溃疡病史、支气管哮喘、心功能不全、高血压、血友病或其他出血性疾病、有骨髓功能减退病史的患者慎用。 （7）长期用药时应定期检查血象及肝、肾功能。 【禁忌证】 （1）活动性消化性溃疡。 （2）对阿司匹林或其他非甾体抗炎药过敏者。 （3）服用此类药物诱发哮喘、鼻炎或荨麻疹患者。 （4）严重肝病患者及中重度肾功能不全者。 【不良反应】消化道症状，罕见的为肾功能不全。 洛索洛芬 萘普生 双氯芬酸----有眩晕史或其他中枢神经疾病史的患者服用本品期间应禁止驾车或操纵机器。 吲哚美辛 美洛昔康 【适应证】 用于慢性关节病，包括缓解急慢性脊柱关节病、类风湿关节炎、骨性关节炎等的疼痛、肿胀及软组织炎性、创伤性疼痛、手术后疼痛。 【注意事项】 本品出现胃肠道溃疡和出血风险略低于其他传统NSAID。服用时宜从最小有效剂量开始。有消化性溃疡史者慎用。服药者定期检查其肝肾功能，尤其是65岁以上老年患者。
急性腹痛 急性腹痛（acute abdominalgia）是指起病急骤，以胃脘部以下，耻骨以上的围发生的疼痛而言。 本篇所讨论的腹痛主要是科围的急性腹痛，同时也将外科、妇科急腹症列出以利于鉴别。 常见病因 “腹中乃脏腑之郛郭”。由于脾胃、肝、胆、肾、膀胱、大小肠等脏腑均居其中，手足三阴、足阳明、足少阳经及冲、任、带三脉亦循行腹部，因此腹痛的成因很复杂，既可因腹脏器的病变引起，又可为腹外疾患所致。 （一）消化系统疾病：如急性胃炎、消化性溃疡穿孔、急性胃扩、急性胃扭转、急性胃潴留、胃痉挛、急性肠梗阻，急性胆囊炎，胆石症、胆道蛔虫症，急性胰腺炎等。 （二）泌尿生殖系统疾病：急性肾盂肾炎、肾石病、肾下垂、急性盆腔炎、异位妊娠、卵巢囊肿扭转、卵巢破裂、痛经等。 （三）分泌及代障碍疾病：糖尿病酮症酸中毒、尿毒症、甲状腺功能亢进症、腹型嗜铬细胞瘤、急性肾上腺皮质功能不全、低血糖症、血卟啉病、高脂血症。 （四）神经系统疾病：腹型癫痫、腹壁神经痛，神经官能性腹痛。 （五）中毒性疾病：如铅中毒、砷中毒、汞中毒、食物中毒等。 （六）传染病：流行性出血热、登革热、登革出血热、伤寒、急性细菌性痢疾、急性阿米巴痢疾等。 （七）腹外脏器疾病：胸部疾病，如细菌性肺炎、急性充血性心力衰竭、急性心肌梗塞、急性心包炎。
中医学认为，急性腹痛常因气、血、寒、热、湿、食、虫等因素引起脏腑气机升降失和，经络血脉阻滞，即所谓“不通则痛”。 临床思维 由于引起急性腹痛的疾病种类繁多，病因复杂。因此，在短时间，准确地寻找病因，迅速地确诊甚为必要。科的急性腹痛多以消化系统疾病所致，但必须注意与外科、妇科的急腹症相鉴别。为了确诊必须详尽地了解病史、起病诱因、发病方式，然后再根据腹痛的部位、性质、程度、规律及伴随症状，作出综合分析。先考虑常见病，后考虑少见病，对某些难以确诊的疾病，尚须借助必要的辅助检查，如心电图、X线、B型超声波以及CT等。 （一）辨腹痛的部位：一般最先出现疼痛或疼痛最明显的位置多为病变部位。如剑突下疼痛多为急性胃肠炎、胃或十二指肠溃疡、急性胃穿孔、急性胃扩；中上腹疼痛应考虑急性胰腺炎；右上腹痛常见胆石绞痛、急性胆囊炎；腰部疼痛常见肾及输尿管结石、急性肾盂肾炎，下腹疼痛常见急性盆腔炎、异位妊娠、痛经；左下腹疼痛常见于急性菌痢；右下腹疼痛多为急性阑尾炎；如果腹痛部位呈弥漫性或部位不定则应考虑急性机械性肠梗阻、急性穿孔、胃肠神经官能症、急性坏死性肠炎等。 （二）辨腹痛的性质：如持续性绞痛常提示空腔脏器发生痉挛或出现阻塞性、扭转性病变、反复间歇发作亦是其特征之一，如肾绞痛，胆绞痛，胃肠痉挛；持续性疼痛伴阵发性加剧，常见于炎症与梗阻同时并有，如胆石症并发胆囊炎；刀割样剧痛常见于消化性溃疡急性穿孔；阵发性钻顶样疼痛多为胆道蛔虫症；持续性钝痛多表示炎症性、出血性或郁血性病变，如大叶性肺炎导致的腹痛、急性肝脓肿等。 （三）辨腹痛的程度：腹痛的程度在一般情况下可反映出疾病的种类和病
1 a bit/ a little 这两个词都意为“一点儿”有时可以互换，但有时不能。 Ⅰ．二者作程度副词修饰形容词、副词、动词或比较级时，意义相同，为“一点儿”“有些”。如： ①I am a bit / a little hungry. 我有点饿。 ②He walked a bit / a little slowly. 他走路有点慢。 Ⅱ．二者都可以作名词词组，充当主语或宾语。如： ①A little / bit is enough for me. 我有一点儿就够了。 ② I know only a little / a bit about her. 我对她的情况只了解一点。 Ⅲ。a little可直接修饰名词；a bit后须加of才可以。如： ①.There is a little water in the bottle. = There is a bit of water in the bottle. [注意] a little of后的名词通常特指，表“……中的一些”，如： ①May I have a little of your tea? Ⅳ. 否定形式 not a little 作状语，相当于very/ quite, “很”，“非常”；作定语和宾语时，相当于much, 意为“许多”。而not a bit 作状语时，相当于not at all, 意为“一点也不”，作宾语时则相当于not much. Eg: ①He is not a little (=very) hungry. 他饿极了。 ②He is not a bit (=not at all) hungry.他一点也不饿。 ③She ate not a little (=much). 她吃得很多。 Ⅴ. Not a bit中的not 可以分开使用；not a littl e中的not 则不能分开。Eg: ①He felt not a bit tired. = He didn’t feel a bit tired. 他觉得一点也不累。 ②He felt not a little tired. 他觉得非常累。但不能说：He didn’t fell a little tired. §2 a few/ few/ a little/ little Ⅰ. a few和few修饰可数名词，a little和little修饰不可数名词；a few和a little表示肯定意义，few和little表示否定意义，可受only修饰。如： ①Few people will agree to the plan because it’s too dangerous. ②This text is easy to understand though there are a few new words in it. ③There is little water left in glass. Will you please give me some ④Don’t worry, we have a little time left. ⑤ §3 about/ on Ⅰ.about “关于”表示的内容较为普通或指人时用它。侧重于叙事，多用于叙述个人经历和事迹，故事内容涉及一些较浅的问题。是非正式用语。 Ⅱ.on “关于”侧重于论述政治理论，国际形势，学术报告等。也就是说，当表示这本书，这篇文章或演说是严肃的或学术性的可供专门研究这一问题的人阅读时用。eg: This is a text book on African history. 这是一本关于非州历史的教科书。[注]：它们有时可通用。 §4 above/over/on/upon Ⅰ. 方位介词，“在……之上” Ⅱ. above 着重指：在……上方，不一定含有垂直在上的意思。反义词为：below. ①The sun rose above the horizon. 太阳升到了地平线上。 ②The aero plane flew above the clouds.飞机在云层上飞行。 Ⅲ.over 表盖在……上面，或铺在……上面。此时不能用above.代替。含有垂直在上的意思。反义词为under. ①Spread the tablecloth over the table.把桌布铺在桌子上。 Ⅳ. on 含有与表面相接触的意思。 ①The book is on the desk. ②There is an oil painting on the wall. 墙上有一幅油画。 Ⅴ.upon 也含有和表面相接触的意思。与on没有多大的区别，但较正式，口语中较少用。 ①He laid his hand upon the boy’s head. 他把手放在孩子的头上。 [注] up 与以上几个不同，它表示向上方或高处，含有由下而上，由低而高的意思。常和表示运动的动词连用。作副词时，表示在上方或高处。