上消化道出血課件(同名1)

Hematemesis

嘔血UPPERGASTROINTESTINALBLEEDINGDepartmentofGastroenterologyXuanwuhospitalHematemesi1Overview

Definition

Etiology

Clinicalmanifestation

Differentialdiagnosis

Diagnosticapproach

TreatmentOverview2Definition

Indicatesanuppergastro-intestinalsiteofbleedingDefinition

Indicatesanupper3ClassficationofEtiologyEsophagealdiseasesGastroduodenaldieasesBiliaryandPancreaticdiseasesSystemicdiseasesClassficationofEtiologyEsop4ClassficationofEtiologyClassficationofEtiology5ClassficationofEtiologyClassficationofEtiology6Etiology1EsophagealdiseasesVaricesruptureRefluxesophagitisMallory-WeisstearEsophagealcancerEtiology1EsophagealdiseasesVa7EsophagealVaricesEsophagealVarices8Mallory-Weisstear

Mallory-Weisstear

9Etiology2GastroduodenaldieasesGastriculcerDuodenalulcerDieulafoylesionStressulcerCancerEtiology2Gastroduodenaldiease10PepticulcerPepticulcer11Etiology(3)

Biliarydiseases

Gallstones\cholecystitisCarcinomaofgallbladderCarcinomaofbileduct

PancreaticcancerPancreatitisPancreaticdiseases

Etiology(3)Biliarydisease12Etiology(4)SystemicdiseasesAnaphylactoidpurpuraEpidemichemorrhagicfever(EHF)Disseminatedintravascular-Coagulation(DIC)

Etiology(4)Systemicdiseases13

Clinicalmanifestation上消化道出血課件(同名1)14Casereport1Athirty-year-oldmanpresentswiththreeepisodesofvomitingredbloodinthetwodays,theamountisestimatedthreebottles,meanwhilehepassedblackstoolsixtimes.Hehadaregularepigastricpaininthepasttwoweeks.Healsofeelsdizziness\fatigabilityandthirstphysicalExaminationrevealsBP90/60mmHgHR102/min,paleskinCasereport1Athirty-year-old15Casereport2A42-year-oldmanpresentwithvomitingalargemountoffreshbloodandclotsfortwohours,Hecomplainsoffaint、sweating、palpitation.withahistoryofchronicliverdisease.ExaminationrevealsBP70/50mmHgHR124/min,lethargy、moistcoldskin、jaundice、spiderangioma、splenomegaliaCasereport2A42-year-oldman16Keypoint&AimAssessofseverityofHypovolemiaDeterminethecauseKeypoint&AimAssessofDetermi17HistoryDuration:fromonsettopresentPriorsymptomsPriorbleedingPrior

gastrointestinaldiseaseHistoryDuration:fromonsetto18Color&Character--Freshred--Darkred--Coffee-ground--Clots

Color&Character--Freshre19AmountofbleedingHowtoassess:1.--cup\--bottle?--basin\--pile?what’sthevolumeofthesevessels2.howmanytimes?3.totalAmount?AmountofbleedingHowtoas20AmountversusSigns

Minimal

amountofbleedingwithsymptoms250~300mlHematemesis50~70ml/dMelena

2-5ml/dOB+AmountversusSignsMinimal21Melena

--Melena

isdefinedaspassageofblack,tarry(柏油)stool--Melenaalwaysfollows

hematemesisMelena--Melenaisdefinedas22MildHypovolemia

1.Bloodloss>500ml2.Lightheaded、weakness

palpitation、thirst3.RapidpulseMildHypovolemia

1.Bloodlos23

1.Bloodloss>1000ml2.Syncope(暈厥)anxiety

sweating

3.Posturalhypotension(recumbenttoupright)drop>15-20mmHgTachycardiaModerateHypovolemia1.Bloodloss>1000mlModerate24Shock

1.bloodloss>1500ml2.lethargy,palecoldmoistskin,oliguria,(少尿)dyspnea

3.hypotension\TachycardiaShock1.bloodloss>1500ml25RateofbloodlossAcaseanalysis:a45-yearoldmanwhofaintedinabathroomat6amwhilevomitingredblood,thenhassystolicpressureof70mmHgat9amisestimatedtohavelost1500mlofbloodin3hoursTherateis500ml/hourRateofbloodlossA26HemodynamicsandBloodLossHemodynamicsBloodLoss(%)SeverityofBleedVitalSignsFractionofIntravascularVolumeShock20-30massivePostural-hypotension

tachycardia10-20Moderatenormal<10minorHemodynamicsandBloodLossHem27Itreflectsamassivearterialbleedspraying(greaterthan1000ml).

Massivebleeding

Itreflectsamassivearterial28Hematocrit（紅細(xì)胞壓積）Ifbloodlossisacute,thehematocritdosenotchangeduringthefirstfewhoursafterhemorrhage（出血）About24to72hourslater,plasmavolumeislargerthannormalandthehematocritisatitslowestpoint

Hematocrit（紅細(xì)胞壓積）Ifblo29Hematocrit（紅細(xì)胞壓積）HematocritchangesABeforebleedingBImmediatelyafterbleedingC24~72hoursafterbleeding7654321Volume(Liters)45%45%27%ABCHematocrit（紅細(xì)胞壓積）Hematocritch30clinicalmanifestationBowelsound

ActivebowelsoundusuallybepresentedinactivebleedingclinicalmanifestationBowelso31clinicalmanifestation

Fever:biginwithin24hours,moderate<38.5。C,thecauseisunknow.

BUN:usefulmeasurementofbleedingoftenelevatedbyabsorptionofammoniafromingestedblood

clinicalmanifestationFever:32Differentialdiagnosis UpperGI LowerGI Manifestation Hematemesis Hematochezia melena Nasogastricaspirate Bloody Clear BUN Elevated Normal Bowelsound Hyperactive NormalDifferentialdiagnosis33Differentialdiagnosishematemesishemoptysis（咯血）

Symptomvomitingcough& nauseastethocatharsis

PHvalue<4.0 >6.0

Mixture

foodfoam

&sputum

Differentialdiagnosis34DifferentialdiagnosisBloodinthenoseortricklingdownthepharynxsuggeststhenasopharynx（鼻咽）asthesourceTraditionalChinesedrug（中藥）bismuth(鉍)、

iron(鐵)Animal’sblood(liver)DifferentialdiagnosisBloodin35Diagnostictest上消化道出血課件(同名1)36

Retainingofnasogastrictube1.Determinethesiteofbleeding2.Dynamicmonitoring3.therpyNasogastrictube

Nasogastrictube37Endoscopy(內(nèi)鏡)

Endoscopyisthediagnosticprocedureofchoiceofaccuracyimmediatetherapeuticpotential.

Endoscopy,however,mustbePerformedonlyfollowingadequateresuscita-tion(復(fù)蘇).Endoscopy(內(nèi)鏡)

Endoscopy38

Bariumradiography(鋇餐)

Bariumradiographyisnoninvasivebuthassignificantdisadvantages,particularlyinpatientswhoarebleedingbriskly(actively).

Bariumradiography(鋇餐)

Bari39Angiography(血管造影)

AngiographymaylocalizethesiteofbleedingUsinginaobscurebleedingAngiography(血管造影)40Angiography

Bleedingmustbeactivebecauseangiographydetectsonlyextravasation(外滲)ofcontrast(造影劑)intotheGItract.Angiography

41radionuclideimaging1.Usefulfortheobscurebleedingifendoscopyexaminationisnegative2.Activebleedingisneedtobeexistingwitharate>0.5ml/minradionuclideimaging1.Usefulf42

Prognosis&Treament上消化道出血課件(同名1)43Prognosticfactors:endoscopic80%60%40%20%0%CleanbaseFlatspotAdherentclot%ofpatientsrebleedingIncidenceofrebleedingbyappearanceofulceratendoscopyNonbleedingvisiblevesselActivebleeding510224355Prognosticfactors:endoscopic44UlcersofbleedingUlcersofbleeding45OutcomeofAcuteGIBleedingOutcomeofAcuteGIBleeding46InfluenceofDiagnosisonOutcomeInfluenceofDiagnosisonOutc47VascularAnatomyVascularAnatomy48VascularAnatomy-RelationshiptoTherapyVascularAnatomy-49RoleofEndoscopyRoleofEndoscopy50StigmataofRecentHaemorrhage-PrevalenceStigmataofRecentHaemorrhage51NatureofthevisiblevesselNatureofthevisiblevessel52Overviewofmanagement

InitialmanagementEndoscopictherapySurgicaltherapyPharmacologicaltherapyOverviewofmanagementInitial53InitialManagement

AssesshaemodynamicinstabilityResuscitationHaemogramandcoagulationstudiesNasogastrictube(in/out)MonitoringofvitalsignsandurineoutputInitialManagementAssesshaem54EndoscopictherapyPerformearly(ideallywithin24h)Indicationsforhaemostatictherapy11.+/-Adherentclot2.Nonbleedingvisiblevessel3.Activebleeding(oozing,spurting)Heaterprobe,bipolarelectrocoagulationorinjectiontherapyDecreasesinrebleeding,surgeryandmortality2,31.Laine&Peterson;19942.Cooketal;19923.Sacksetal;1990EndoscopictherapyPerformearl55上消化道出血課件(同名1)56EffectofTherapyonre-bleedingrates(VisibleVessel)EffectofTherapyonre-bleedi57EffectofTherapyonre-bleedingrates(ActiveBleeding)EffectofTherapyonre-bleedi58RoleofacidinhaemostasisImpairsclotformation

ImpairsplateletaggregationandcausesdisaggregationAcceleratesclotlysis

Predominantlyacid-stimulatedpepsinMayimpairintegrityofmucus/bicarbonatebarrierRoleofacidinhaemostasisImp59pH=7.4Aggregation(%)EffectofplasmapHonplateletaggregationGreenetal;1978Time(minutes)020406080100012345pH=5.9pH=6.8AADPpH=7.4Aggregation(%)Effect60EffectofPPIongastricpHIncreaseintragastricpH

pH>6.0for84-99%ofdayNoreportedtoleranceContinuousinfusion(CI)superiortointermittentbolusadministrationClinicalimprovementsinrebleedingand/orsurgerywith:Bolus80mg+CI8mg/hEffectofPPIongastricpHInc61OmeprazoleintheUpperGIBleedingPatientswithStigmataofrecenthaemorrhageOmeprazoleintheUpperGIBle62OmeprazoletherapyinthetreatmentofupperGIbleedingfromspecificlesionsOmeprazoletherapyinthetre63PreventionofRecurrentUpperGIBleedingPreventionofRecurrentUpper64StressBleedingprophylaxis-IndicationsStressBleedingprophylaxis-65StressProphylaxis-TreatmentStressProphylaxis-Treatment66

Oesophagealvaricescause+10%ofcasesofacuteupperGIbleedingadmittedtohospitalsVaricealHaemorrhage

Mortalityrate30-50%Oesophagealvaricescause+167Gastro-oesophagealvaricesarepresentin+50%ofcirrhoticpatients.TheirpresencecorrelateswithseverityofliverdiseaseVaricealHaemorrhageBleedingfromoesophagealvaricesceasesspontaneouslyinupto40%ofpatientsGastro-oesophagealvaricesare68

ControlofhemorrhageTreatmentofAcuteVaricealHemorrhage

PreventionofearlyrecurrenceControlofhemorrhageTreatme69

Highrateofmajorcomplications

PharmacotherapyVasoactivetherapy-Vasopressin

ConflictingresultswithTerlipressinand Nitroglycerin Highrateofmajorcomplicat70

NativeSomatostatin

Reducessplanchnicbloodflowand azygosbloodflow

Useisrestrictedduetoitsshorthalflife(1-2min)PharmacotherapyNativeSomatostatinPharmacot71

Isaseffectiveasendoscopicsclerotherapy andisasafetreatmentforacutevariceal bleedingPharmacotherapySyntheticsomatostatinanalogue-OctreotideHalflife1-2hoursMoreeffectivethanplacebo,vasopressinandballoontamponade Isaseffectiveasendosc72

Nonselective?-adrenergicblockers-propranolol,nadololortimolol

Pharmacotherapy Theydecreaseportalvenousinflowbytwo mechanisms -decreasingcardiacoutput(?1

blockade)-splanchnicvasoconstriction(?2

blockadeandunopposedalphaadrenergicactivity)Nonselective?-adrenergicb73

Antibioticprophilaxisismandatory

Pharmacotherapy-Reducesrateofbacterialinfections-Increasessurvival

Avoidintravascularoverexpansion

BloodreplacementtotargetHemato