呕血与便血6课件

Diagnosisof

GastrointestinalBleedingProf.ChengweiTang(唐承薇教授)Dept.ofGastroenterology,WestChinaHospitalSichuanUniversityDiagnosisof

GastrointestinalHematemesisandHematochezia

呕血与便血HematemesisandHematochezia

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Theapproachtogastro-intestinal(GI)bleedingistailoredtothemannerofappearance. Theapproachtogastro-intest3Isbleedingacuteorchronic?IntensivecareWhereisthesourceofbleeding?EmpirictherapyDiagnosisTreatment(经验治疗)Whatisthecausesofbleeding?Recognitionofhemorrhage

Isbleedingacuteorchronic?I4IntensivecareWhereisthesourceofbleeding?EmpirictherapyDiagnosisTreatment(经验治疗)Whatisthecausesofbleeding?Isbleedingacuteorchronic?RecognitionofhemorrhageIntensivecareWhereisthesou5ClinicalManifestations1Mannerofbleedingpresentation2Hypovolemia(低血容量)orshock3Anemia(贫血)

RecognitionofhemorrhageClinicalManifestations1Mann6Patientsmanifestbloodloss1)

Hematemesis

呕血

Bloodyvomitus,eitherfreshandbrightredorolderand“coffee-ground”(hematin酸化正铁血红素)incharacterHemoptysis? Nosebleeding?MannerofbleedingpresentationfromtheGItract

infiveways:Patientsmanifestbloodloss1)72)Melena

黑便Shiny,black,sticky,foul-smellingstooldegradationofbloodexogenousstooldarkenersironbismuth(铋剂)

Mannerofbleedingpresentation2)Melena黑便Mannerofble8Mannerofbleedingpresentation3)

Hematochezia

便血brightredormaroonbloodfromtherectum

purebloodbloodintermixedwithformedstoolbloodydiarrheaMannerofbleedingpresentatio9Mannerofbleedingpresentation4)

Occult

隐血detectedonlybytestingthestoolwithamonoclonalantibodyforhumanhemoglobin

Mannerofbleedingpresentatio10EstimateamountofbleedingfromupperGItract5~10ml/dOB+50~70ml/dMelena

250~300mlinshorttimeHematemesis

Estimateamountofbleedingfr11Mannerofbleedingpresentationwithoutanyobjectivesignofbleedingwithsymptomsofbloodloss

dizziness,dyspnea,anginacordis(心绞痛),orevenshock

digitalexamination(指检)oftherectumMannerofbleedingpresentatio12HypovolemiaorshockSpeedandvolumeofbloodlossWeakness,giddiness(眩晕),oliguria,(少尿)coldextremity,sweatingVitalsigns:tachycardia,(心动过速)hypotention(低血压)HypovolemiaorshockSpeedand13AnemiapaledizzinesspalpitationeasyfatigabilitydyspneaanginacordisAnemiapaleeasy14Isbleedingacuteorchronic?1)Bleedingspeed

Hematemesisoffreshbloodgenerallyindicatesamoreseverebleedingepisodethanmelena,whichoccurswhenbleedingisslowenoughtoallowtimefordegradationofblood

Isbleedingacuteorchronic?115呕血与便血6课件16Isbleedingacuteorchronic?2)Hematocrit

bleedingslowly

hypochromic(血红蛋白过少)microcytic(小细胞)redbloodcells

meancorpuscularvolume(MCV，

平均血球压积)ofthecellsmaybelow

Isbleedingacuteorchronic?217Isbleedingacuteorchronic?

Ifbloodlossisacute,thehematocritdosenotchangeduringthefirstfewhoursafterhemorrhageAbout24to72hourslater,plasmavolumeislargerthannormalandthehematocritisatitslowestpoint

Isbleedingacuteorchronic?187654321Volume(Liters)45%45%27%ABCIsbleedingacuteorchronic?HematocritchangesABeforebleedingBImmediatelyafterbleedingC24~72hoursafterbleeding7654321Vo19Isbleedingacuteorchronic?3)Bloodpressureandheartratedependon

amountofbloodlosssuddennessofbloodlossextentofcardiacandvascularcompensation

Isbleedingacuteorchronic?320posturalhypotension

----earlyphysicalfindingtachycardia

----greaterloss,compensaterecumbent(卧位)hypotension

----finalresults

Isbleedingacuteorchronic?posturalhypotensionIsbleedi21Isbleedingacuteorchronic?Posturalhypotension

Aposturaldropinbloodpressureof10to15mmHgIsbleedingacuteorchronic?P22Isbleedingacuteorchronic?4)

Bowelsound

ActivebowelsoundusuallybepresentedinacutebleedingfromGItractIsbleedingacuteorchronic?423Emergentandintensivecare

InitiallyvitalsignssupineanduprightbloodpressurepulseEmergentandintensivecareIn24Ifbloodlossissignificant,intravenousfluidsmustbestartedSalineorotherbalancedelectrolytesolutionsaremostrapidlyavailable

Ifbloodlossissignificant,25

Bloodissenttothelab.completebloodcountclottingstudiesroutinechemistrystudies.

Bloodfortypingandcross-matchingissenttothebloodbank.Bloodissenttothelab.26Whereisthesourceofbleeding?

Localization

UpperGIbleeding:bleedingfromasourceproximaltotheligamentofTreitz.

LowerGIbleeding:bleedingfromasitedistaltotheligamentofTreitz.Whereisthesourceofbleedin27

Localization

Treitz: TheligamentofTreitzisananatomiclandmarkfortheduodenal-jejunaljunction.Localization Treitz: 28

Localization

DifferentiatingfeaturesofupperGIandlowerGIbleeding UpperGI LowerGI Manifestation Hematemesis Hematochezia melena Nasogastricaspirate Bloody Clear BUN Elevated Normal Bowelsound Hyperactive NormalLocalization Differentiating29UpperGItractbleeding?ClinicalmanifestationBowelsoundNasogastrictubeUpperGItractbleeding?Clini30HematemesisMelenaHematocheziaHematemesisMelenaHematochezia31Moreproximallesionsproducehematemesisormelena,whereasmoredistallesionsaremorelikelytoproducehematochezia.Moreproximallesionspr32

IfhematocheziaisfromanupperGIsource,itusuallyreflectsamassivebleed(i.e.,greaterthan1000ml).

Ifhematocheziaisfroman33Whatisthecausesofbleeding?90%upperGIbleedingisduetofourlesions:1)pepticulcer(消化性溃疡)2)hemorrhagicgastritis(胃炎)3)esophagealorgastricvarices (静脉曲张)4) gastriccancerWhatisthecausesofbleeding34pepticulcerpepticulcer35hemorrhagicgastritishemorrhagicgastritis36esophagealvaricesesophagealvarices37gastriccancergastriccancer38Causesofgastrointestinalbleeding

Mallory-Weisstear

食道-贲门撕裂伤Causesofgastrointestinalble39CausesofgastrointestinalbleedingPortal-hypertensivegastropathy

门脉高压胃病Ancylostomiasis

钩虫病Post-sphincterotomy

括约肌切开术后Causesofgastrointestinalble40CausesofgastrointestinalbleedingColorectalcancerColitisLargehemorrhoid 大痔Rectumtear 肛裂VascularanomaliesHematologicdiseasesCausesofgastrointestinalble41Diagnosticapproachtogastrointestinalbleeding

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Historyandphysicalexamination2Endoscopy3Bariumradiography4Angiography5NuclearscintigraphyDiagnosticapproachtogastroi42History

andphysicalexaminationAhistoryofpreviouslydocu-mentedGItractdiseasedeterminedbyradiography,endoscopy,orsurgicalproceduresisveryuseful.DiagnosticapproachtoGIbleedingHistoryandphysicalexaminati43DiagnosticapproachtoGIbleeding

PatientswithhepatitisBorchronicactiveliverdiseasemaypresentwithpainlesshematemesisfromesophagealvarices.

DiagnosticapproachtoGIblee44DiagnosticapproachtoGIbleeding

Patientswithforceful,retching(干呕)ormultipleepisodesofvomitingoffoodpriortotheonsetofhematemesismaybebleedingfromMallory－Weisstearsofthegastroesophagealjunction.DiagnosticapproachtoGIblee45DiagnosticapproachtoGIbleeding

Ahistoryofepigastric(上腹部)

burningpainpromptlyrelievedbyfoodorantacids(抗酸剂)

ornocturnal(夜间)painsuggestspepticulcerdisease,particularlyduodenal(十二指肠)ulcer.

DiagnosticapproachtoGIblee46DiagnosticapproachtoGIbleeding

Colorectalmalignancy

isoftensuggestebyahistoryofgradualweightlossintermittentbloodinthestoolsalteredbowelhabitsDiagnosticapproachtoGIblee47DiagnosticapproachtoGIbleeding

Hemorrhoidalbleedingisoftensuggestedbythepresenceofbrightredbloodsurroundingwell-formed,normal-appearingstools.DiagnosticapproachtoGIblee48DiagnosticapproachtoGIbleeding

Patientswithstigmata(特征)ofchronicliverdisease[e.g.,spiderangioma(蜘蛛痣),ascites(腹水),gynecomastia(男性乳房发育)]andupperGIbleedingoftenbleedfromesophagealvaricesorerosion(糜烂).DiagnosticapproachtoGIblee49DiagnosticapproachtoGIbleeding

Localizedepigastrictenderness(触痛)

topalpationmayindicatepepticulcerdiseaseorgastritis.DiagnosticapproachtoGIblee50DiagnosticapproachtoGIbleeding

OccasionallypatientswithlowerGItractbleedingfromamalignancyhaveapalpablelowerabdominalmass,hepatomegaly(肝肿大)，signsofobviousweightloss.

DiagnosticapproachtoGIblee51DiagnosticapproachtoGIbleeding

Arectalexaminationisessen-tialtodocumentstoolcoloraswellastopalpateforgrossano-rectal(肛直肠)masslesionssuchaspolyps,cancers,orlargehemorrhoids.DiagnosticapproachtoGIblee52DiagnosticapproachtoGIbleeding

Endoscopy(内镜)

Endoscopyisthediagnosticprocedureofchoicebecauseofitshighaccuracyandimmediatetherapeuticpotential.

Endoscopy,however,mustbePerformedonlyfollowingadequateresuscita-tion(复苏).DiagnosticapproachtoGIblee53DiagnosticapproachtoGIbleeding

Endoscopy

Contraindications：

acutemyocardialinfarctio