上海交大外科學上血演示文稿

上海交大外科學上血演示文稿目前一頁\總數(shù)七十九頁\編于二十點（優(yōu)選）上海交大外科學上血目前二頁\總數(shù)七十九頁\編于二十點BasicConcepts目前三頁\總數(shù)七十九頁\編于二十點WhatIsMassiveBleeding>20%(>800ml)bloodlossHemodynamicinstability血流動力學不穩(wěn)Clinicalsignsofpoorperfusion組織灌注差目前四頁\總數(shù)七十九頁\編于二十點WhatIsUGIEsophagus食道Stomach胃Duodenum十二指腸Jejunum空腸Ileum回腸AscendingColon升結(jié)腸TransverseColon橫結(jié)腸DescendingColon降結(jié)腸SigmoidColon乙結(jié)腸Rectum直腸Anus肛門目前五頁\總數(shù)七十九頁\編于二十點目前六頁\總數(shù)七十九頁\編于二十點目前七頁\總數(shù)七十九頁\編于二十點PleaseRememberUGIBisnotuncommonintheemergencyroomMortalityrateisabout10%UGIBisaseriesofdiseasesmainlytreatedbyinternalmedicine.3-15%requireasurgicalprocedure目前八頁\總數(shù)七十九頁\編于二十點Let’shaveaproblem!目前九頁\總數(shù)七十九頁\編于二十點PatientCome45-yrfemalefirstepisodeofhematemesis嘔血transferredfromasmallhospital2unitsofpackederythrocyte紅細胞tranfusednasogastrictube胃管introducedwithactivebleedingpulse120bpm,BP80/40mmHg目前十頁\總數(shù)七十九頁\編于二十點WhatIsYourDecisionWhatisyourintuition直覺?目前十一頁\總數(shù)七十九頁\編于二十點ForReferenceDoesthepatienthavelife-threateningsituation?hypovolemicshock低血容量性休克lowbodytemperature體溫降低anemia/hypoxemia貧血/低氧血癥comorbidities并存病Isitamassiveorminorbleeding?Whereisthemostprobablebleedingsite?目前十二頁\總數(shù)七十九頁\編于二十點Worrisomeclinicalsignsandsymptomstachycardia心動過速morethan100beatsperminute(bpm)systolicbloodpressure(SBP)收縮壓≤90mmHgposturalhypotension體位性低血壓SBPdecrease≥15mmHgorpulserateincrease≥10bpmcoolextremities四肢厥冷syncope暈厥ongoingbriskhematemesis進行性/活躍地嘔血maroonstool棗紅便目前十三頁\總數(shù)七十九頁\編于二十點MassiveorMinorClassIClassIIClassIIIClassIVBloodLossml≤750750-15001500-2000＞2000BloodLoss%≤1515-3030-40＞40PulseRatebpm≤100＞100＞120＞140BloodPressurenormalnormaldecreasedecreaseCNS神經(jīng)系統(tǒng)癥狀Slightlyanxious輕度焦慮Mildlyanxious中度焦慮Anxious,confused焦慮/意識模糊Confused,lethargic意識模糊/嗜睡目前十四頁\總數(shù)七十九頁\編于二十點UGIBorLGIBManifestation癥狀UGIBLGIBHematemesis嘔血AlmostcertainRareMelena黑便ProbablePossibleHematochezia便血PossibleProbableBlood-streakstool便中帶血絲RareAlmostcertainOccultbloodstool大便隱血PossiblePossible目前十五頁\總數(shù)七十九頁\編于二十點EstimationofBloodLossoccultbloodstool –5-10ml/24hmelena –50-100ml/24hhematemesis –250-300mlinstomachCNSchange –>500mlhypovolemia –>1000ml/shortperiod目前十六頁\總數(shù)七十九頁\編于二十點Child-PughClassificationNo.ofPoints123Bilirubin(μmol/L)總膽紅素<3434-51>51Albumin(g/L)白蛋白>3528-35<28ProthrombinTime凝血酶原時間(s)≤1415-17≥18Ascites腹水NoneSlight>ModerateEncephalopathy腦病NoneSlight>ModerateGradeA=5-8points,GradeB=9-11points,GradeC=12-15points目前十七頁\總數(shù)七十九頁\編于二十點WhatIsYourDecisionWhatarethemanagementpriorities優(yōu)先順序tothispatient?目前十八頁\總數(shù)七十九頁\編于二十點ForReferenceResuscitation復蘇Hemostasis止血Differentialdiagnosis鑒別診斷Basicdiseasetreatment治療原發(fā)病Comorbiditymanagement處理并存病目前十九頁\總數(shù)七十九頁\編于二十點InitialResuscitationABCairway保持氣道通暢breathing維持呼吸和供氧circulation維持循環(huán)bilateralintravenousaccess(atleast)雙路靜脈通路short,largepore短而粗fastfluidreplacement快速液體輸入3-for-1rule:1mlbloodloss,3mlcrystalloidfluidbloodtransfusion:2-6unitsofpackederythrocyteclosemonitoring密切監(jiān)護目前二十頁\總數(shù)七十九頁\編于二十點MedicalTherapyvasopressin血管加壓素somatostatinoranalogs生長抑素或同類物antacidagents制酸劑H2-receptorantagonistH2受體拮抗劑protonpumpinhibitor質(zhì)子泵抑制劑hemostaticagents&bloodcoagulationfactors止血劑和凝血因子目前二十一頁\總數(shù)七十九頁\編于二十點NasogastricTubeIntroductionaspiration&lavage吸引和沖洗siteofbleedingbilewithoutblood–UGIBnotlikelygastricfluid&blood–UGIBcleargastricfluid–duodenalbleedingstillpossiblefalsenegative假陰性approximately10%hemostasis&monitoring止血和監(jiān)控icysalinelavagewithepinephrine腎上腺素aspirationcolor&amountreducevomiting減少嘔吐,protecttheairway目前二十二頁\總數(shù)七十九頁\編于二十點BalloonTamponade氣囊壓迫temporarymeasureduringresuscitation(24-48hr)20%complicationrateairwayobstruction氣道阻塞aspiration誤吸esophagusnecrosis食管粘膜壞死arrhythmia心律失常recurrentbleedingafterreleaseofballoonfirstinflategastricballoonto60mmHg(200ml)theninflateesophagusballoonto40mmHg(150ml)pullingweight0.25kgusingapulley滑車releasefor15minevery4hrs目前二十三頁\總數(shù)七十九頁\編于二十點目前二十四頁\總數(shù)七十九頁\編于二十點WhatIsYourDecisionWhatquestionwouldyouaskthepatient?目前二十五頁\總數(shù)七十九頁\編于二十點ForReferenceHistoryofillness病史Precipitatingfactors誘因Comorbidities并存病目前二十六頁\總數(shù)七十九頁\編于二十點Historyhistoryofbleeding出血情況time持續(xù)時間symptoms表現(xiàn)癥狀amount出血量historyofrelateddiseasespepticulcer消化性潰瘍liverdiseases肝臟疾病cholangio-pancreaticdiseases膽胰疾病coagulopathy凝血障礙others目前二十七頁\總數(shù)七十九頁\編于二十點Precipitatingfactorsalcoholabuse酒癮NSAIDs(nonsteroidanti-inflammatorydrugs)ingestion非甾體類抗炎藥物應用stress應激:burninjuries–Curling

headinjuries–Cushing目前二十八頁\總數(shù)七十九頁\編于二十點FrequentSymptomsHematemesis嘔血-40-50%Melena黑便-70-80%Hematochezia便血-15-20%Eitherhematocheziaormelena-90-98%Syncope暈厥-14.4%Presyncope暈厥前期-43.2%Dyspepsia消化不良-18%Epigastricpain上腹痛-41%Heartburn胃灼熱-21%Diffuseabdominalpain彌漫性腹痛-10%Dysphagia吞咽困難-5%Weightloss體重減輕-12%Jaundice黃疸-5.2%目前二十九頁\總數(shù)七十九頁\編于二十點WhatIsYourDecisionWhatisthedifferentialDiagnosis鑒別診斷?目前三十頁\總數(shù)七十九頁\編于二十點ForReferencePepticulcer消化性潰瘍Stressgastritis應激性胃炎Stomachneoplasms胃腫瘤Portalhypertension門脈高壓Hemobilia膽道出血Miscellaneous其他少見原因目前三十一頁\總數(shù)七十九頁\編于二十點PepticUlcerhistoryofchroniculcerepigastricpain(nocturnalsymptoms)上腹痛（夜間痛）dyspepsia消化不良satiety飽脹historyofmucosadamagedietsmokingNSAIDs非甾體類抗炎藥物Adrenalcorticalhormone腎上腺皮質(zhì)激素usuallymelena,sometimeshematemesis目前三十二頁\總數(shù)七十九頁\編于二十點StressGastritishistoryofstress應激病史burninjuriesheadinjuriespredisposingclinicalconditions可導致應激的臨床情況shock休克multipletrauma多發(fā)傷ARDS(acuterespiratorydistresssyndrome)急性呼吸窘迫綜合征SIRS(systemicinflammatoryresponsesyndrome)全身炎癥反應綜合征MODS(multipleorgandysfunctionsyndrome)多臟器功能障礙綜合征sepsis膿毒癥目前三十三頁\總數(shù)七十九頁\編于二十點StomachNeoplasmsmiddleage中年weightloss體重減輕anorexia厭食irregularepigastricpain不規(guī)則腹痛abdominalmass腹部包塊目前三十四頁\總數(shù)七十九頁\編于二十點PortalHypertensionpredisposinghistoryofcirrhosis肝硬化基礎疾病hepatitis肝炎Schistosomiasis血吸蟲病alcoholabuse酒癮specialfeatures特殊體征jaundice黃疸ascites腹水dilatedveinintheanteriorabdominalwall腹壁靜脈怒張rectalhemorrhoids痔目前三十五頁\總數(shù)七十九頁\編于二十點FormationofPortalSystem3inflowveincollectbloodfromspleen,pancreas,stomach,intestine,colon,andrectumsplenicveinsuperiormesentericveininferiormesentericvein2branchesintoleft&righthepaticlobethroughhepaticsinustohepaticveintoIVC75%bloodsupply,50%oxygensupplyofliver目前三十六頁\總數(shù)七十九頁\編于二十點目前三十七頁\總數(shù)七十九頁\編于二十點CollateralVascularSystem側(cè)支循環(huán)esophageal-fundussubmucosalvenousplexus食管下段-胃底交通支rectalhemorrhoidalsystem直腸下段肛管交通支retroperitonealsystem后腹膜交通支anteriorabdominalwallsystem前腹壁交通支目前三十八頁\總數(shù)七十九頁\編于二十點目前三十九頁\總數(shù)七十九頁\編于二十點DefinitionofPortalHypertensionnormalportalpressure:13-24cmH2Onormalhepaticveinpressuregradient(HVPG):5-9cmH2Oportalhypertension:30-50cmH2OHVPG>12mmHgleadstoUGIB目前四十頁\總數(shù)七十九頁\編于二十點目前四十一頁\總數(shù)七十九頁\編于二十點CauseofHypertensioncirrhosishepaticsinusnarrownessportalbloodinflowblockedhighpressurehepaticarteryflowtolowpressureportalvein目前四十二頁\總數(shù)七十九頁\編于二十點目前四十三頁\總數(shù)七十九頁\編于二十點PathophysiologyofPortalHypertensionsplenemegaly&hypersplenism脾腫大/脾功能亢進peripheraltotalbloodcountdecreasecollateralvascularvarix側(cè)支靜脈曲張esophageal-fundussubmucosalvenousplexushasgreatestgradient,causemassiveUGIBhemorrhoidCaputMedusae海蛇頭ascitescapillaryfiltrationpressureincrease毛細血管滲透壓增加hypoalbuminemia低白蛋白血癥excessivelymphaticfluidgeneration淋巴液生成過多hyperaldosteronemia高醛固酮血癥portalgastropathy/encephalopathy門脈性胃病/腦病stomachmucousedema胃粘膜水腫portalsystemicshunt門體分流目前四十四頁\總數(shù)七十九頁\編于二十點CaputMedusae目前四十五頁\總數(shù)七十九頁\編于二十點Hemobiliahemobiliatriad膽道出血三聯(lián)癥biliarycolic膽絞痛obstructivejaundice梗阻性黃疸gastrointestinalbleeding消化道出血livertrauma肝外傷hepatichemangioma肝血管瘤hepaticneoplasm肝腫瘤hepaticabscess肝膿腫biliarytractstone膽道結(jié)石目前四十六頁\總數(shù)七十九頁\編于二十點MiscellaneousMallory-Weisssyndrome:linearmucosallacerationnearcardia賁門asaresultofforcefulvomiting,retching干嘔orcoughingDieulafoylesion:vascularmalformationinstomachAngiodysplasia血管發(fā)育不良:abnormaldilated,thin-walledmucosalorsubmucosalvessels粘膜/粘膜下血管目前四十七頁\總數(shù)七十九頁\編于二十點WhatIsYourDecisionWhatphysicalexamination體格檢查findingswouldyousearchfor?目前四十八頁\總數(shù)七十九頁\編于二十點ForReferenceSignsofshockandbloodlossSignsofchronicliverdiseaseSignsoftumor目前四十九頁\總數(shù)七十九頁\編于二十點Shock&BloodLosspulseandbloodpressure脈率血壓posturalhypotension體位性低血壓mentaldisorder:anxious焦慮,confusion意識模糊,delirium譫妄,lethargy嗜睡,presyncope暈厥前期,syncope暈厥signsofanemia:paleconjunctivaandnailbed結(jié)膜甲床蒼白signsofpoorperfusion:coldextremities四肢厥冷,coldsweating冷汗,oliguria少尿,chestpain胸痛目前五十頁\總數(shù)七十九頁\編于二十點ChronicLiverDiseasesspiderangiomata蜘蛛痣palmaerythema肝掌gynecomastia男性乳房發(fā)育splenomegaly脾腫大ascites腹水pedaledema足部水腫asterixis撲翼樣震顫CaputMedusae海蛇頭目前五十一頁\總數(shù)七十九頁\編于二十點Tumorupperabdominalmass上腹包塊leftsupraclavicularlymphnode(Virchow’snode)左鎖骨上淋巴結(jié)腫大umbilicalnodular(SisterMaryJoseph’snode)臍周結(jié)節(jié)Douglaspouchnodular(Bloomer’sshelf)直腸子宮（膀胱）陷凹結(jié)節(jié)目前五十二頁\總數(shù)七十九頁\編于二十點WhatIsYourDecisionWhatdiagnosticstudieswouldyouorder?目前五十三頁\總數(shù)七十九頁\編于二十點ForReferenceCompletebloodcount(CBC)全血細胞計數(shù)Bloodcrossmatch交叉配血Coagulationprofile凝血功能Liver&Renalfunction肝腎功能Calciumlevel血鈣Gastrinlevel血胃泌素CTscan計算機斷層掃描orUltrasonography超聲檢查DigitalSubtractionAngiography(DSA)數(shù)字減影血管造影Endoscope內(nèi)鏡目前五十四頁\總數(shù)七十九頁\編于二十點EndoscopicExplorediagnosis&treatment診斷/治療雙重作用mostreliable&effectivemethod最可靠最有效within24-48hrsafterbleeding應在出血后24-48小時內(nèi)進行contraindication反指征hemodynamicinstablility血流動力學不穩(wěn)定severecardiacdecompensation嚴重心功能失代償acutemyocardialinfarction急性心肌梗塞perforatedviscus臟器穿孔目前五十五頁\總數(shù)七十九頁\編于二十點目前五十六頁\總數(shù)七十九頁\編于二十點UlcerwithBlackSpot10%Rebleeding目前五十七頁\總數(shù)七十九頁\編于二十點UlcerwithBloodClot22%Rebleeding目前五十八頁\總數(shù)七十九頁\編于二十點UlcerwithVisibleVessel43%Rebleeding目前五十九頁\總數(shù)七十九頁\編于二十點UlcerwithActiveBleeding55%Rebleeding目前六十頁\總數(shù)七十九頁\編于二十點EsophagusVarices目前六十一頁\總數(shù)七十九頁\編于二十點目前六十二頁\總數(shù)七十九頁\編于二十點HypertensivePortalGastropathy目前六十三頁\總數(shù)七十九頁\編于二十點InjectionofSclerosant硬化劑目前六十四頁\總數(shù)七十九頁\編于二十點BandLigation皮圈套扎目前六十五頁\總數(shù)七十九頁\編于二十點Hemoclip止血夾目前六十六頁\總數(shù)七十九頁\編于二十點LaserApplication激光止血目前六十七頁\總數(shù)七十九頁\編于二十點HeaterProbe加熱探針目前六十八頁\總數(shù)七十九頁\編于二十點WhatIsYourDecisionWhatarethetherapeuticoptionsforeachcommonetiology病因ofmassiveUGIBafterinitialresuscitation?目前六十九頁\總數(shù)七十九頁\編于二十點ForReferenceMedicineEndoscopeSurgery目前七十頁\總數(shù)七十九頁\編于二十點Non-VaricealBleedingtherapeuticendoscopewith/withoutmedicineifeffectivethencontinuedrugtherapyeradicationofH.pylorimucousprotection2attemptsofendoscopicfailurepursuesurgeryothersurgicalindicationsseverelife-threateningbleedingnotresponsivetoresuscitationcoexistingreasonofperforation,obstructionormalignanciessecondhospitalizationofpepticulcer目前七十一頁\總數(shù)七十九頁\編于二十點VaricealBleedingdrugtherapywith/withoutballoontemponadeendoscopicbindingorsclerotherapytransjugularintrahepaticportosystemicshunt(TIPS)經(jīng)頸靜脈肝內(nèi)門體分流術effectiverate90%rebleedingrateinoneyear16-30%shuntdisfunctionratein6months50-60%inducingencephalopathyrate