診斷學(xué) 嘔血和便血(英文)

DepartmentofGastroenterology

Gastrointestinal(GI)Bleeding（HematemesisandHematochezia）Hematemesis(嘔血)DefinitionHema-:bloodemesis:vomitingHematemesisisvomitingblood,itcouldbefresh(brightred)ordarkwith/withoutclotsinseverebleeding,alsocouldbe‘coffeegrounds’inminimalbleeding.clotsHemoglobin+gastricacid=HaematinHemoglobin:brightredHaematin:darkbrownBloodsourceUpperGI(abovetheligamentofTreitz)Liver,Pancreas,Gallbladder,BiliaryductsMisleadingfactorsHemoptysis(咯血):coughingupblood,happeninginpulmonarydiseasesMisleadingfactorsBleedingoutsideofupperGItract:Oral,nasal,pharyngeal(咽部)bleedingFoodanddrugs:animalblood,charcoal,ironpreparations.Confusedwith‘coffeegrounds’EtiologyEsophagus:varices,carcinoma,esophagitis,Mallory-Weisstear,diverticulitis,hiatushernia,etcStomachandduodenum:pepticulcer,varices,carcinoma,erosivegastritis,dieulafoy’slesion,etcLiver,gallbladderandbileducts:carcinoma,infection,stones,parasite,etcPancreas:acutepancreatitiswithpseudocystorabscess,carcinoma,etcEtiologySystemicdiseasesHematologicaldiseases:leukemia,hemophilia,lymphoma,coagulationdisorders,hereditarytelangiectasia,thrombocytopenicpurpura(TTP),anaphylactoidpurpura,etcOthers:uremia,epidemichemorrhagicfever,leptospir-osis,etcThecommoncausesPepticulcerAcuteerosivegastritisVaricesUpperGICarcinomasPepticulcerGastriculcer(GU)Duodenalulcer(DU)SubmucosaerosionArteriesorveinsruptureBleedingisspontaneouslystoppedin80%patients,

but

easilyrecurredwithouttreatmentAcuteerosivegastritisAcutemucosallesionsCapillariesruptureMinimalbleedingInducementsInducedbynon-steroidalanti-inflammatorydrugs(NSAIDs),alcoholorstressNSAIDs:helpingustocontrolpain,likeasprin,ibuprofen,indomethacinVaricesEsophagealvaricesGastricvaricesVeinsextremelydilatedinesophagusandgastricfundusPortalhypertensionLivercirrhosisDangerousUpperGIcarcinomasCommoninelderTumorveinserodedOthersEsophagitisMallory-WeisstearInflammationofesophagusMucosalerosionMinimalbleedingOthersGeorgesDieulafoy(1839–1911)

Dieulafoy'slesion:anabnormallylarge(1–3mm),tortuous,submucosalarteryisrupturedDangerous,massive,rapidormortalbleedingFirstlydescribedbyGeorgesDieulafoyin1898ClinicalmanifestationsBleedingfeaturesHypovolemiaorshockAnemiaandbloodabnormalityFeverAzotemia(氮質(zhì)血癥)Bleedingfeaturesuptothesite,amountandspeedofbleedingMostofthetimeChronic,moderatebleeding---vomiting‘coffeegrounds’,leadingtoanemia,likepepticulcerAcute,severe,massivebleeding---vomitingfreshblood,leadingtohypovolemia,shock,andevendeath,likevaricesSometimesAcute,minimal,esophagealbleeding---Vomitingfreshblood,stable,likeMalloryWeisstearHypovolemiaandshock

Losingofblooddecreasesbloodvolume(hypovolemia),thefurtherbloodlosswillcauseshock,so,thesymptomsandsignsofhematemesisdependonhowmuchbloodthepatientslosingSymptomsWeaknessGiddiness(眼花)Oliguria(少尿)Cold(feet,hands)SweatingSigns:Bloodpressure↓Pulse↑Hypo-:underorbelow-volemia:bloodvolumeHypovolemiaandshockPosturalhypotension(tension:bloodpressure)----earlyphysicalfindingBloodpressureisdroppedby10to15mmHg

when

patients

stand

upTachycardia(tachy:quick,cardia:heart)----greaterloss,compensationofheartforbloodlossShock(bloodlosing＞800ml)----SBP＜90mmHg,

Pulse＞120bpmDangerous,maycausedeathAnemiaandbloodabnormalitySymptomsPaleDizziness(頭昏)Palpitation(心悸)Fatigability(乏力)BloodabnormalityRBCcount,Hb(hemoglobin),Hct(hematocrit)Earlystageofbleeding:mayappearnormalHemoglobin:red,carryoxygenAnemia:hemoglobin↓,redbloodcells(RBC)↓,hematocrit↓FeverAcutemassiveGIbleedingFoundwithin24hrs<38.5℃Lastfor3-5daysAzotemia

Bloodureanitrogen(BUN)↑Asaresultofbreakdownofbloodproteinsbybacteriatourea,reuptakefromthegutBleedingassessmentGrade

Amount

Bloodpressure

Hb

Symptoms

%bloodvolume

Pulse

Mild

<500mlnormal

decreasemildly

Dizziness

10-15%Moderate500-1000mldecreasemildly

70-100g/Lthirsty,oliguria,

20%≈100bmp

syncopeSevere>1000mlSBP＜80mmHg

<70g/Lpalpitation,

>30%>120bmpclammyandsweatywithcoldperipheries,oliguria,

anuria,disturbanceofconsciousnessAccompanyingsymptomsWithupperabdominalpainPepticulcerprobably:young,chronic,periodic,rhythmicCarcinomaprobably:old,chronic,lossofappetite,lossofweightAccompanyingsymptomsWithhepatosplenomegalySplenomegaly,ascites,caputmedusa,spidernevusliverpalms(Cirrhosis)Hepatomegaly,weightloss(hepaticcarcinoma)Megaly:large,hugeAccompanyingsymptomsWithjaundice:biliaryorliverdiseasesprobablyWithmucocutaneoushemorrhage:HematologicaldiseasesprobablyDiagnosticpointsTruehematemesis?InducementsMedicalhistoryClinicalmanifestationsTestsAccompanyingsymptomsDiagnosticstrategyHematochezia(便血)Hematochezia

bloodpassperrectumHematochezia:

freshblood,dark,clottedbloodMelena:black,tarry,foul-smellingstoolsOccultblood:onlydetectedbytestFakehematochezia:

colorofstoolisaffectedbydrugsorfood,likeanimalblood,beeturia,pitaya,bismuth,charcoal,licoriceandironpreparationsDefinitionEtiologyUpperGIbleeding:descriptpreviouslySmallbowelbleeding:diverticulosis,angiodysplasia,polyp,tumor,corhn’sdisease,enterophthisis,ileotyphus,acutehemorrhagenecrotizingenteritis,hookwormdisease,ulcer,indigitation,etcColonicbleeding:haemorrhoids,tumor,ulcerativecolitis,ischemiccolitis,diverticulosis,angiodysplasia,analfissure,analfistula,bacillarydysentery,amebicdysentery,etc.Etiology-lowerGIbleeding*

post-polypectomybleedsAngiodysplasia(血管畸形)SmallvascularmalformationCausingmelenaandoccultbloodCommoninunexplainedGIbleedingElderDiverticulosis(憩室病)MucosalherniationMucosalvesselsrupturedMelenaandoccultbloodElderNeoplasmspolypsCarcinomaBenign(良性)Malignant(惡性)UlcerativecolitisInflammatoryboweldiseaseCrohn’sdiseaseDiarrheaandbleedingMucosalerosiveMucopurulentbloodystoolAbdominalpain,bleedingisnotoftenMucosalhyperplasiaIschemicColitisColonicbloodsupplydecreasingBleeding+abdominalpainWithvascularandcardiacdiseaseElderHemorrhoidsandanalfissureexternalhemorrhoidinternalhemorrhoidanalfissureCommonVascularcushionsIntermittentfreshbleedingBloodontheoutsideofstoolsoronthetoiletpaperRarelySkintearofanalcanalMeckel’sDiverticulumCongenitalmalformationTheendofileumSimilartodiverticulosisAcutehemorrhagenecrotizingenteritisOthersbacillarydysenteryhookwormdiseasesmallbowelulcerationduetoNSAIDSClinicalmanifestationClinicalmanifestationUptotheamountandthetimeofbleeding,whichissimilartohematemesisAccompanyingsymptomsWithabdominalpainAbdominalpain,jaundice:biliaryandliverdiseaseAbdominalpain,fever:hemorrhagenecrotizingenteritisChronicupperabdominalpain:

pepticulcerAbdominalpainrelievedafterdefecation:

colon

ornot:smallbowelAccompanyingsymptomsFreshblooddon’tmixwithstools:analdisease(hemorrhoid)Mucopurulentbloodystool:UC,bacillarydysenteryJamstool:

amebicdysenteryTenesmus:

rectum,anusFever:infection,tumorAbdominalmass:crohn’sdisease,tumor,TB,intussusceptionmucocutaneoushemorrhage:Hematologicaldiseases

DiagnosticpointsBloodsource?Bloodmixedwithstool?InducementsClinicalmanifestationsAccompanyingsymptomsMedicalhistoryTestsCase1XXX,Male,52y.Hematemesisfor12h,withanimmediatesyncopeHevomitedfreshbloodfor3timesin12hours,200-400mleachtime,totalamountisapproximate1500ml,withanimmediatesyncope,lastfor5seconds.Hefeelsthirsty,fatigues,dizziness,sweaterandanuria.HeinfectedwithhepatitisvirusBfor10yearswithouttreatment.Hedoesnothavedrinkingandsmokinghistory.PhysicalexaminationspresentBP80/48mmHg,P120