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急性化脓性腹膜炎课件_2

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单击此处编辑母版标题样式 单击此处编辑母版副标题样式 *1 急性化脓性腹膜炎 Acute Peretonitis With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 一.概述 ¨(一).定义 是由于细菌感染.损伤或消化液.尿液. 血液.等刺激引起的腹膜急性炎症.是外 科常见危重疾病,多需手术治疗才能挽 救病人生命. With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (二).分类 ¨1. 按病因分类 ¨(1).继发性腹膜炎:最常见,是由于腹腔内脏 器的器质性病变引起.如炎症或外伤引起 腹脏内脏器破裂穿孔.占整个腹膜炎的 98%.致病菌以G-大肠杆菌厌氧菌为主引起 的混合感染 ¨(2).原发性腹膜炎:少见,腹腔内无原发病.病 原菌通过血行或淋巴管到达腹腔引起.多 见于10岁以下的儿童和婴儿.常因抵抗低 下,在上感,丹毒,肾病等疾病的过程中发生. 发病率占2%.致病菌以溶血性链球菌(约占 70%),肺炎双球菌(约占30%)为主. With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society ¨2. 按病变范围 ¨(1) 局限性—局限于腹部一个象限(即1/4). ¨(2).弥漫性—病变超过一个象限. With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society ¨3.按有无细菌感染 ¨ (1).非细菌性—肝破裂大血管破裂出血 早期无细菌但6一8小时后均要继发细 菌感染 ¨. (2). 细菌性—几乎所有的腹膜炎都是细 菌性的 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (三).腹膜的解剖生理 ¨1.解剖 ¨腹膜是一层很薄的浆膜.分脏层和壁层. ¨脏层—覆盖于内赃表面,受内脏神经(植物N)支 配.对疼痛不敏感定位差,对牵拉膨胀敏感. ¨壁层腹膜—覆盖于腹壁盆腔内面横膈脏面.受躯 体神经(周围N)支配,对疼痛敏感定位准确. ¨腹腔: 大腹腔---壁层和脏层腹膜之间腔隙. ¨ With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society ¨小腹腔—胃和小网膜后方胰腺前方之 间腔隙.经小网膜孔与大腹腔相通. ¨网膜:大网膜—连接胃与横结肠悬垂于 小肠前,又称胃结肠韧带. ¨ 小网膜 –连接肝胃十二指肠的腹膜. ¨血管:动脉—肋间动脉和腹主动脉分支 .静脉回流入门静脉和下腔静脉. With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 2.生理功能: ¨(1).分泌功能—每日约分泌75-100 ml液体 润滑内脏.当受刺激时分泌增多. ¨(2).吸收功能—有强大的吸收作用可吸收 积液,血液,空气.上腹 大于下腹. ¨(3).防御功能—渗出液中含大量吞噬细胞 吞噬侵入的细菌异物.下腹大于上腹. ¨(4).修复功能—当腹膜受损时,纤维蛋白渗 出沉积形成粘连,防止感染扩散并修复受 损组织.但广泛粘连易引起肠梗阻. With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 二.病因 ¨(一).急性感染所致的腹腔内脏器破裂穿孔,炎性 渗出 ¨ 急性坏疽性胆囊炎,急性坏疽性阑尾炎,肝脓肿 等破裂穿孔和炎性渗出.急性胰腺炎,盆腔炎引 起炎性渗出. ¨(二).非炎症性破裂穿孔:如溃疡病穿孔,绞窄性 肠梗阻坏死穿孔子宫外孕破裂.→ ¨(三).外伤和手术 ¨ 外伤:肝脾破裂,胃肠穿孔等.手术:如术中误伤 和术后吻合口瘘等. With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 三、病理生理: 急性腹膜炎 腹膜水肿 呕吐 渗液 肠麻痹 纤维蛋白 肠内积液 毒素吸收 细胞外液 肺交换量 容量减少 抗利尿激素 尿量 心排出量 组织缺氧 周围血管收缩 休克 代谢性酸中毒 死亡 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 腹膜炎的结局 取决于两方面: 1)病人的防御能力 2)污染细菌的性质,数量和时间 ü早期:细菌及毒素刺激机体,激活炎性介质(肿 瘤坏死因子,白介素,弹性蛋白酶等) ü后期:没被清除的介质最终生成一氧化氮导致细 胞缺氧,窒息,造成多器官功能衰竭而死亡。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 结局: 年轻体壮,抗病能力强,细菌毒力差,炎症局限: 局限性腹膜炎 局限性脓肿 渗出物吸收,炎症消散,痊愈 年老体弱,细菌毒力强,炎症扩散: 弥漫性腹膜炎 脱水,电解质紊乱,代谢性酸中 毒 感染中毒性 休克 死亡 腹膜炎治愈后易造成腹腔粘连,严重者可造成机械性肠梗 阻。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 四.临床表现 ¨(一).症状 ¨1. 腹痛—持续性剧痛 其程度与病变性质轻重 和病人对疼痛的敏感度有关. ¨2. 呕吐一早期为反射性呕吐,后期为麻痹性肠 梗阻所致. ¨3. 发热—体温随病情加重而逐浙增高 ¨4. 休克—胃十二指肠穿孔,实质腔器破裂大出 血,可早期出现休克.其它原因引起时出现休克 稍迟. ¨5. 全身反应—表情痛苦,烦燥不安,卷曲卧位,发 热;口干,眼眶凹陷,皮肤弹性差,呼吸脉搏增快,血 压下降等脱水,酸中毒,休克表现. With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (二).体征 ¨1. 腹膜刺激征—即压痛 反跳痛 腹肌紧张 肌紧张重者可有板状腹. ¨2. 气腹征—胃肠穿孔才有,即肝浊音界缩 小或消失 ¨3. 腹式呼吸减弱或消失 ,腹叩有移动性浊 音,肠鸣音减弱或消失. With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (三).辅助检查 1.白细胞记数及中性粒细胞比例增高 ,涂片可见中毒颗粒。 2. 腹部立位平片:小肠普遍胀气并有多个 小液 平,是肠麻痹征象,胃肠道穿孔 时,多可见膈下游离气体。肠间隙增宽 ,以及腹膜外脂肪线模糊或消失。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 3.B超检查:显示腹腔内有不等量的液体,可在 B超下引导腹腔穿刺抽液或腹腔灌洗帮助诊断 。腹穿: 部位—右下腹或左下腹麦氏点. ¨注意:穿刺处应叩诊有移浊才能穿刺. ¨穿刺液鉴别表 4.CT:对腹腔内实质性脏器病变诊断帮助较大 。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 腹腔穿刺液鉴别诊断 疾病肉眼外观观及臭味显显微镜检查镜检查 原发发性腹膜炎脓脓性、色白黄或 草绿绿,均无臭味 有大量中性粒 细细 胞,G+球菌 胃、十二指肠溃疡肠溃疡 穿孔 色黄,含胆汁, 混浊浊,无臭,淀 粉酶含量增高 有大量中性粒细细 胞,革兰兰氏染色 细细菌很少 小肠肠穿孔 或破裂色黄,稀粪样粪样 混浊浊稍臭 有大量中性粒细细 胞,较较多G-杆 菌 肠绞肠绞 窄坏死血性液有腥臭味 大量中性粒细细胞 , G-杆菌 阑阑尾穿孔脓脓性,色白或微 黄,混浊浊,稀, 无臭味或稍臭 大量中性粒细细胞 , G-杆菌 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 胆囊穿孔色黄,含胆汁浑浊浑浊 无 臭味 大量中性粒细细胞,G- 杆菌 出血坏死性胰腺炎血性,无臭味(淀粉 酶含量很高) 大量中性粒细细胞,无 细细菌 急性结结核性腹膜炎草黄色渗出液,可凝 固,无臭味 粒细细胞不多,多为为L 细细胞单单核细细胞,浓浓 缩图缩图 片可见见抗酸杆菌 肝脾破裂鲜鲜血放置数分钟钟不凝大量红细红细 胞 穿刺误误入血管鲜鲜血放置数分钟钟可凝大量完整红细红细 胞 穿刺误误入肠肠管黄色粪样粪样 混浊浊有臭味 , 无白细细胞 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 五.诊断 ¨1. 有无腹膜炎有在 ¨(1) .症状:腹痛,呕吐,发热 ¨(2).体征:腹膜刺激征,腹部压痛,反跳痛 ,肌张力增高,有移浊,肠鸣减弱或消 失,腹穿:抽出脓性液体(性质如上述) ¨(3).血象: 白细胞总数和中性粒细胞增高. With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society ¨2.性质 ¨(1).继发性:病变局限于腹部—腹痛先局限后弥 漫,逐渐加重.先腹痛后发热.腹穿液细菌涂片可 查出G-大肠杆菌为主的细菌. ¨ ¨(2).原发性: 先有上感或其他感染病史, 先发热 后腹痛,腹穿细菌涂片可查见以溶血性链球菌为 主的细菌. ¨3.原发病变部位:根据病史,查体,辅助检查可确 诊. With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 鉴别诊断 ¨(一)内科疾病 有不少内科疾病具有与腹膜炎相似 的临床表现,必须严加区别,以免错误治疗。肺炎、 胸膜炎、心包炎、冠心病等都可引起反射性腹痛,疼 痛也可因呼吸活动而加重。因此呼吸短促、脉搏变快 ,有时出现上腹部腹肌紧张而被误认为腹膜炎。但详 细追问疼痛的情况,细致检查胸部,加以腹部缺乏明 显和 肯定的压痛及反跳痛,即可作出判断。急性胃肠 炎、 痢疾等也有急性腹痛、恶心、呕吐、高热、腹部 压痛等,易误认为腹膜炎。但饮食不当的病史、腹部 压痛不重、无腹肌紧张、听诊肠鸣音增强等,均有助 于排除腹膜炎的存在。其他,如急性肾盂肾炎、糖尿 病酮中毒、尿毒症等也均可有不同程度的急性腹痛、 恶心、呕吐等症状,而无腹膜炎的典型体征,只要加 以分析,应能鉴别。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society ¨(二)急性肠梗阻 多数急性肠梗阻具 有明显的阵发性腹部绞痛、肠鸣音亢进 ,腹胀,而无肯定压痛及腹肌紧张,易 与腹膜炎鉴别。但如梗阻不解除,肠壁 水肿郁血,肠蠕动由亢进转为麻痹,临 床可出现鸣音减弱或消失,易与腹膜炎 引起肠麻痹混淆。除细致分析症状及体 征,并通过腹部X线摄片和密切观察等予 以区分外,必要时需作剖腹探查,才能 明确。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society ¨(三)急性胰腺炎 水肿性或出血坏死 性胰腺炎均有轻重不等的腹膜刺激症状 与体征,但并非腹膜感染;在鉴别时, 血清或尿淀粉酶升高有重要意义,从腹 腔穿刺液中测定淀粉酶值有时能肯定诊 断。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society ¨(四)腹腔内或腹膜后积血 各种病因 引起腹内或腹膜后积血,可以出现腹痛 、腹胀、肠鸣音减弱等临床现象,但缺 乏压痛、反跳痛、腹肌紧张等体征。腹 部X线摄片、腹腔穿刺和观察往往可以明 确诊断。 ¨(五)其他 泌尿系结石症、腹膜后炎 症等均由于各有其特征,只要细加分析 ,诊断并不困难。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 六.治疗 ¨(一).手术治疗 ¨1. 适应证 ¨(1).凡继发性腹膜炎诊断成立立即手术. ¨(2).诊断不明确的腹膜炎或经非手术治疗观察8一12 小时无效者. ¨2. 方法 ¨(1).术前准备:禁食,胃肠减压,补液,纠正水电酸碱平衡 失调, 防治休克,抗感染,止痛,备皮,备血等. ¨(2).处理原发灶:如胃穿孔作胃大部切除或穿孔修补术 . ¨(3).清理腹腔:清除干净腹腔内的脓液及异物. ¨(4).腹腔引流:术毕腹腔内放置引流管. With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (二).非手术治疗 ¨1. 适应证: ¨(1).原发性或盆腔炎引起的或诊断尚未明确的腹膜 炎. ¨(2).急性腹膜炎超过48—72小时已局限. ¨2. 方法 ¨(1).体位:半卧位 ¨(2).禁食 胃肠减压 ¨(3).补液 纠正水电酸碱平衡失调, 防治休克. ¨(4).抗感染:选择针对性强的二联以上抗生素. ¨(5).止痛:对诊断明确治疗方案已定的可用止痛药. ¨(6).中药:对炎症已好转可进饮食的病人可服中药. With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society ¨【诊断治疗思路】 ¨一、持续性腹痛,恶心呕吐及高热、大汗 、脉快为急性腹膜炎的主要临床特征。 ¨二、急性腹膜炎的诊断首先是明确是不是 腹膜炎。急性腹膜炎的发生往往有一定病 史,结合临床症状和体征,必要时进行X线 或腹腔穿刺检查,诊断一般不难。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society ¨三、对急性腹膜炎的诊断重要的是找出腹 膜炎的原因,尽可能找出原发病灶。早期 病例,原发病灶比较容易发现。晚期病例 必须从病史、症状、体征、实验室和X线检 查等作全面分析,才能找到病灶。如仍不 能明确原发病灶,由于急性腹膜炎本身就 是施行手术的适应症,可考虑进行剖腹探 查术。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society ¨ 四、严格掌握非手术与手术治疗的适 应症。在非手术治疗过程中,应密切观察 病人的病情变化,如腹痛范围、体温、白 细胞、腹肌紧张、腹胀的程度等,作为判 断腹膜炎症进退的参考,也可作为是否中 转手术的重要依据。 ¨ 五、临床过程中,一定要根据腹膜炎 的症状、体征和检验结果等,以及病情发 展情况来选择手术的适宜时间。如属下列 病症均应施行急诊手术: With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society ¨ (一)腹腔内病变严重者,如腹内脏 器损伤破裂,胃肠道或胆囊坏死、穿孔, 手术后胃肠吻合口漏等所致的腹膜炎。 ¨ (二)腹膜炎重,无局限趋势而病因 不明者。 ¨ (三)病人一般情况差,腹腔渗液多 ,肠麻痹或中毒症状明显,尤其是有休克 表现者。 ¨ (四)经短期非手术治疗(一般不超 过12小时),如腹膜炎症状与体征不见缓 解或反而加重者。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society ¨ 六、在手术去除病因后,应尽可能吸净 腹腔脓液,清除食物残渣、粪便、异物等 。为了防止膈下及盆腔脓肿的形成,该两 处可结合原发病灶部位及腹膜炎的范围予 以引流,放置引流物部位应适当。 ¨ 七、术后病人中毒症状明显好转后,可 取半坐卧位,使脓液向下顺流入盆腔。由 于盆腔腹膜吸收能力较上腹部为差,中毒 症状较轻,该处的脓液引流也较容易。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society ¨ 八、急性腹膜炎经治疗,炎症被控制后 ,常可引起相应的纤维粘连。多数粘连不 会产生任何后果,但有部分粘连可能引起 肠梗阻,因此应控制感染,预防肠粘连的 形成。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 腹 腔 脓 肿 abdominal abscess With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 膈下脓肿 subphrenic abscess With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 膈下间隙 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 左肝上间隙 肝上间隙 右肝上间隙 膈下间隙 左肝下前 间隙 左肝下间隙 肝下间隙 左肝下后 间隙 右肝下间隙 腹膜外间隙 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 病 理 1.感染途径 (1)流注 (2)细菌经门静脉和淋巴系统到达 2.发生率 70%急性腹膜炎的病人经手术或药物治疗 后腹腔内的脓液被完全吸收;30%发生局限性脓 肿。 3.脓肿的位置 十二指肠溃疡穿孔、胆管化脓性疾病、阑尾 炎穿孔,脓肿常发生在右膈下;胃穿孔、脾切除 术后感染,脓肿常发生在左膈下。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 4.转归 (1)小脓肿经非手术治疗可被吸收。 (2)大脓肿,长期感染衰竭,死亡。 膈下感染可引起反应性胸腔积液,或经淋 巴蔓延到胸腔引起胸膜炎;亦可穿入胸腔引起 脓胸。 个别的可穿透结肠形成内屡而“自家”引流 。 腐蚀消化道管壁引起消化道反复出血和肠 瘘、胃瘘。 如病人的身体抵抗力低下可发生脓毒血症 。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 脓肿好发部位 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 临床表现 ①全身症状: 发热,初为弛张热,脓肿形成以后 持续高热,也可为中等程度的持续发热 。脉率增快,舌苔厚腻。逐渐出现乏力 、衰弱、盗汗、厌食、消瘦、白细胞计 数升高、中性粒细胞比例增加。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society ②局部症状: 脓肿部可有持续钝痛,咳嗽、深呼吸 时加重。疼痛常位于近中线的肋缘下或剑 突下。 脓肿位于肝下靠后方可有肾区痛,有 时可牵涉到肩、颈部。 脓肿刺激膈肌可引起呃逆。 膈下感染可通过淋巴引起胸膜、肺反 应,出现胸水,咳嗽、胸痛。脓肿穿破到 胸腔发生脓胸。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 近年由于大量应用抗生素,局部症 状多不典型。 严重时出现局部皮肤凹陷性水肿, 皮肤温度升高。 患侧胸部下方呼吸音减弱或消失, 有时可听到湿罗音。 右膈下脓肿可使肝浊音界扩大。 约有10%~25%的脓腔内含有气体。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 诊断和鉴别诊断 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 1.病史: 急性腹膜炎或腹腔内脏器的炎症性 病变经治疗好转后,或腹部手术数日后 ,出现发热腹痛。 2.X线透视: 患侧膈肌升高,随呼吸活动度受限或 消失,肋膈角模糊,积液。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 3.X线摄片 发现胸膜反应,胸腔积液,肺下叶部分不 张等; 膈下可见占位阴影。 左膈下脓肿,胃底可受压下降移位; 脓肿含气者可有液气平面。 4.B超检查: 可发现液性平段及脓肿的部位和大小。 5.CT检查 定位可靠,可以看出脓肿与周围脏器的关 系。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 6.在B超或X线指引下行诊断性穿刺 定位、定性。 小的脓肿可在吸脓后注入抗生素治 疗。但穿刺阴性者不能排除有脓肿的可 能。 脓胸、肝脓肿与此病部位接近,三 者早期不易区别, With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the n
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