放射性直腸炎護理及相關護理措施

1、放射性直腸炎護理及相關措施,張瑜,概述,放射性直腸炎是婦科惡性腫瘤男性前列腺惡性腫瘤放射治療的主要并發(fā)癥。文獻報道宮頸癌體外照射結合腔內高劑量率放射治療時，中、重度放射性直腸炎的發(fā)生率約為5.3～15.6%。放射性直腸炎也是盆腔放射治療的常見并發(fā)癥。它是一種自愈性疾病。如治療和護理及時、得當，可縮短其病程，減輕患者的痛苦和經(jīng)濟負擔，提高其生存質量。,癥狀,,,一般照射總劑量在3000cGy以下者很少發(fā)病。腹腔內放療總量超過4000cG

2、y時發(fā)生癥狀，若達7000cGy以上則發(fā)病率高達36%。癥狀可出現(xiàn)在治療早期，療程結束后不久或治療后數(shù)月至數(shù)年。,癥狀,直腸流血，為鮮紅或暗紅色，多在排便時流出，一般是少量出血，偶爾大量出血。破潰后有壞死組織脫落排出，有臭味，肛門直腸部酸痛或灼痛，以后因括約肌受刺激而出現(xiàn)里急后重。,癥狀,,,,,晚期癥狀,早期癥狀,,,由于神經(jīng)系統(tǒng)對放射線的反應，早期出現(xiàn)胃腸道的癥狀。多出現(xiàn)在放療開始后1～2周內。惡心、嘔吐、腹瀉、排出粘液或血樣便。累

3、及直腸者伴有里急后重。持久便血可引起缺鐵性貧血。便秘少見。偶有低熱。腹痛型腸易激綜合癥則提示小腸受累，乙狀結腸鏡檢查可見粘膜水腫、充血，嚴重者可有糜爛或潰瘍。,急性期的癥狀遷延不愈或直至放療結束6個月至數(shù)年后始有顯著癥狀者，均提示病變延續(xù)，終將發(fā)展引起纖維化或狹窄。此期內的癥狀，早的可在放療后半年，晚的可在10年后甚至30年后才發(fā)生，多與腸壁血管炎以及扣續(xù)病變有關。,癥狀,（1）結腸、直腸炎 常出現(xiàn)于照射后6～18個月。癥狀有

4、腹瀉、便血、黏液便和里急后重、大便變細和進行性便秘或出現(xiàn)腹痛者提示腸道發(fā)生狹窄。嚴重的病損與鄰近臟器形成瘺管，如直腸陰道瘺，糞便從陰道排出；直腸小腸瘺可出現(xiàn)食糜混于糞便中排出，也可因腸穿孔引起腹膜炎，腹腔或盆腔膿腫。由于腸道的狹窄和腸袢纏繞可發(fā)生腸梗阻。（2）小腸炎 小腸受到放射線嚴重損傷時出現(xiàn)劇烈腹痛、惡心嘔吐、腹脹、血樣腹瀉。但晚期表現(xiàn)以消化吸收不良為主，伴有間歇性腹痛、脂肪瀉、消瘦、乏力、貧血等。,并發(fā)癥,誘發(fā)結、直腸

5、癌等,胃腸道潰瘍和穿孔,腸狹窄和腸梗阻,直腸陰道瘺,直腸膀胱瘺或回乙結腸瘺,病因,,婦女宮頸癌、外陰與陰道癌及肛管直腸癌,,常組織也有損害，損害直腸粘膜時，可造成放射性直腸炎,放射性直腸炎,應用放射性鐳、鈷、銫等進行照射治療， 這些放射性原素,,診斷,大便帶膿血、 粘液和脫落的壞死組織,病理檢查可見：細胞急速分裂，纖維組織肥大，血管、淋巴管擴張，管壁變性，應與惡性腫瘤鑒別。,有鐳照射治療史,

6、直腸鏡下可見：腸壁充血、腫脹呈赤褐色，或已浸潤、變硬、壞死、潰瘍、穿孔，最后形成狹窄。,,腸粘膜充血、水腫、顆粒樣改變和脆性增加,腸道鋇劑檢查有助于病損范圍與性質的確定,一、直腸指診,二、內窺鏡檢查,三、X線檢查,檢查,包括糞便脂肪測定、維生素B12及D—木糖吸收試驗,可觸及潰瘍、狹窄或瘺道，3%嚴重者直腸陰道瘺,小腸吸收功能的測定：,治療原則,,1、藥物保留灌腸。,2、直腸狹窄，甚至梗阻，出血嚴重以及瘺管形成，均需手術治療。,,,凡已

7、經(jīng)確診為慢性放射性直腸炎的患者，除治療必需之外，嚴禁再作直腸鏡檢查。長期便血，出現(xiàn)貧血現(xiàn)象，根據(jù)臨床癥狀，對癥處理，抗炎止血，潤腸通便等。飲食以富含營養(yǎng)易消化，少纖維素的食物為主。必要時臥床休息減少疲勞。,3、全身治療可參照急性放射性直腸炎的處理。,治療,1.一般治療急性期應臥床休息。飲食以無刺激、易消化、營養(yǎng)豐富、多次少餐為原則。限制纖維素攝入。腹瀉嚴重者可采用靜脈高營養(yǎng)療法。2.手術治療腸狹窄、梗阻、瘺道等后期病變多需外科手術

8、治療。3.中醫(yī)治療中醫(yī)學認為，早期的胃腸反應是放射線照射后致津液耗損，胃腸蘊熱。癥見惡心、嘔吐、食納減少。治宜養(yǎng)陰和胃。藥用旋覆花、代赭石降逆止嘔；沙參、玉竹、蘆根養(yǎng)陰清熱；橘皮、竹茹、薏苡仁化痰和胃。另外還可配合針刺內關、足三里等穴位。放射性小腸炎的預后較放射性結腸、直腸炎為差。2/3輕癥患者可在4～18個月內好轉或痊愈。有人認為廣泛的盆腔手術如再放療則病變組織血供更中不良，其預后常較差。,治療,4.內科治療（1）收斂解痙:&

9、#160;可用巔茄合劑、復方樟腦酊、石榴皮煎劑（石榴皮30g加水200～300ml煎制50ml，每日1次口服）。阿司匹林可有效地控制放射性腸炎的早期腹瀉，可能與抑制前列腺素的合成有關。（2）局部鎮(zhèn)痛劑和糞便軟化劑:有顯著里急后和疼痛者，可用2%苯唑卡因棉籽油保留灌腸。用溫石蠟油保留灌腸或溫水坐浴。（3）激素灌腸: 琥珀酰氫化可的松50mg加200ml溫鹽水保留灌腸，特別是里急后重者有效。 （4）骶前封閉療法: 0.5%的普魯

10、卡因40ml、維生素B6100mg、維生素B1200mg、α—糜蛋白酶2～5mg、鏈霉素0.5g，可使疼痛減輕。（5）止血:低位腸出血可在內鏡直視下壓迫止血或使用止血劑或出血點做“8”字縫合止血。但不能做燒灼止血。部位較高的出血點可用去甲腎上腺素或新福林稀釋于200ml溫鹽水中保留灌腸，或用凝血酶加入200ml溫鹽水中保留灌腸，一般在1～3分鐘內即可止血。大量難以控制的高位出血需做外科處理。（6）抗感染:有繼發(fā)性感染時，需用抗生

11、素。（7）α2巨球蛋白:國內已試用α2巨球蛋白治療放射性腸炎，效果良好。用藥后黏膜出血和疼痛明顯好轉。潰瘍趨向愈合。它是通過制血漿激肽釋放酶，使之減少，從而減輕毛細血管滲出和疼痛。,,飲食指導,1.高熱能、高蛋白質以補償長期腹瀉而導致的營養(yǎng)消耗，可根據(jù)病人消化吸收耐受情況循序漸進地提高供給量。一般熱能按每日每公斤體重40千卡供給。蛋白質每日每公斤體重1.5克，其中優(yōu)質蛋白占50%為好。 熱量的單位：大卡

12、1大卡 = 1000卡　 　2.維生素無機鹽要充足以補償腹瀉引起的營養(yǎng)丟失。,飲食指導,3.限制脂肪和膳食纖維：腹瀉常伴有脂肪吸收不良，嚴重者伴有脂肪瀉。因此膳食脂肪量要限制，應采用少油的食物和少油的烹調方法。對伴有脂肪瀉者，可采用中鏈脂肪酸油脂。避免食用含刺激性和纖維高的食物，如辛辣食物、白薯、蘿卜、芹菜、生蔬菜、水果以及帶刺激性的蔥、姜、蒜和粗雜糧、干豆類等。4.少食多餐：為減輕腸道負擔，以少食多餐方式補充營養(yǎng)攝入量。,飲

13、食指導,5.膳食安排:1）急性發(fā)作或手術前后采用流食或少渣半流食，食物內容:米湯、蒸蛋、藉粉、牛奶一般不主張采用。必須禁用蔬菜水果。可將之制成菜水、菜泥、果汁、果泥、果凍等食用。少渣半流可選用含優(yōu)質蛋白的魚肉、瘦肉、蛋類制成軟而少油的食物，如氽魚丸、芙蓉粥、雞絲龍須面及面包類;2）對病情嚴重不能口服者可用管飼要素膳或靜脈營養(yǎng)支持，待營養(yǎng)狀況改善后逐漸增加口服自然食物。,相關護理措施,1、避免進食纖維素多或對腸壁有刺激的食物，宜食用少

14、渣、低脂及產氣少的食物。如胡蘿卜、菠菜等，既潤腸又補充維生素。2、保持肛門及會陰部清潔，穿寬松內褲。癥狀明顯者，可在肛門、會陰部熱敷以減輕癥狀，口服或經(jīng)肛門應用消炎藥物。3、有出血者可用消炎藥。腹瀉明顯者，可用止瀉藥。4、疼痛明顯者，可用消炎痛栓。癥狀嚴重者，可暫停放療，并大劑量應用維生素、輸液補充各種靜脈營養(yǎng)及應用腎上腺皮質激素、抗生素，以減輕局部炎癥反應，促進恢復。,相關護理措施,（1）病人出現(xiàn)腹痛、腹瀉、里急后重等腸道刺激癥

15、狀，甚至直腸充血、潰瘍而導致血便。應配合醫(yī)生擬定個體放療計劃，通過適當調整，使子宮位置前移。進行腔內治療時要保持直腸空虛，有利于陰道填塞，減少直腸的輻射受量?！　。?）對急性直腸炎應立即停止放療，用消化道黏膜保護劑：思密達，口服，3次/d，或每晚保留灌腸；腹瀉次數(shù)多，口服易蒙停，抑制腸蠕動，延長腸內容物的滯留時間?！　。?）嚴密觀察大便的性狀、腹痛的性質，防止水電解質紊亂；了解貧血程度，貧血嚴重者應少量多次輸血，并加強全身支持治療。

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