上消化道大出血課件

上消化道大出血

MassiveUpperGastrointestinalBleeding上海交通大學醫(yī)學院瑞金臨床醫(yī)學院2009上消化道大出血

MassiveUpperGastroin1IntroduceOurselvesDr.Yang

&Dr.LiIntroduceOurselvesDr.Yang

&2BasicConceptsBasicConcepts3WhatIsMassiveBleeding>20%(>800ml)bloodlossHemodynamicinstability血流動力學不穩(wěn)Clinicalsignsofpoorperfusion組織灌注差WhatIsMassiveBleeding>20%(4WhatIsUGIEsophagus食道Stomach胃Duodenum十二指腸Jejunum空腸Ileum回腸AscendingColon升結腸TransverseColon橫結腸DescendingColon降結腸SigmoidColon乙結腸Rectum直腸Anus肛門WhatIsUGIEsophagus食道Jejunum空5上消化道大出血課件6上消化道大出血課件7PleaseRememberUGIBisnotuncommonintheemergencyroomMortalityrateisabout10%UGIBisaseriesofdiseasesmainlytreatedbyinternalmedicine.3-15%requireasurgicalprocedurePleaseRememberUGIBisnotunc8Let’shaveaproblem!Let’shaveaproblem!9PatientCome45-yrfemalefirstepisodeofhematemesis嘔血transferredfromasmallhospital2unitsofpackederythrocyte紅細胞tranfusednasogastrictube胃管introducedwithactivebleedingpulse120bpm,BP80/40mmHgPatientCome45-yrfemale10WhatIsYourDecisionWhatisyourintuition直覺?WhatIsYourDecisionWhatisy11ForReferenceDoesthepatienthavelife-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?ForReferenceDoesthepatient12Worrisomeclinicalsignsandsymptomstachycardia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Worrisomeclinicalsignsands13MassiveorMinorClassIClassIIClassIIIClassIVBloodLossml≤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MassiveorMinorClassIClassI14UGIBorLGIBManifestation癥狀UGIBLGIBHematemesis嘔血AlmostcertainRareMelena黑便ProbablePossibleHematochezia便血PossibleProbableBlood-streakstool便中帶血絲RareAlmostcertainOccultbloodstool大便隱血PossiblePossibleUGIBorLGIBManifestation癥狀UGI15EstimationofBloodLossoccultbloodstool –5-10ml/24hmelena –50-100ml/24hhematemesis –250-300mlinstomachCNSchange –>500mlhypovolemia –>1000ml/shortperiodEstimationofBloodLossoccult16Child-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=12-15pointsChild-PughClassificationNo.o17WhatIsYourDecisionWhatarethemanagementpriorities優(yōu)先順序tothispatient?WhatIsYourDecisionWhatare18ForReferenceResuscitation復蘇Hemostasis止血Differentialdiagnosis鑒別診斷Basicdiseasetreatment治療原發(fā)病Comorbiditymanagement處理并存病ForReferenceResuscitation復蘇19InitialResuscitationABCairway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InitialResuscitationABC20MedicalTherapyvasopressin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質子泵抑制劑hemostaticagents&bloodcoagulationfactors止血劑和凝血因子MedicalTherapyvasopressin血管加壓21NasogastricTubeIntroductionaspiration&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,protecttheairwayNasogastricTubeIntroductiona22BalloonTamponade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releasefor15minevery4hrsBalloonTamponade氣囊壓迫temporary23上消化道大出血課件24WhatIsYourDecisionWhatquestionwouldyouaskthepatient?WhatIsYourDecisionWhatques25ForReferenceHistoryofillness病史Precipitatingfactors誘因Comorbidities并存病ForReferenceHistoryofillnes26Historyhistoryofbleeding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othersHistoryhistoryofbleeding出血情況27Precipitatingfactorsalcoholabuse酒癮NSAIDs(nonsteroidanti-inflammatorydrugs)ingestion非甾體類抗炎藥物應用stress應激:burninjuries–Curling

headinjuries–CushingPrecipitatingfactorsalcohola28FrequentSymptomsHematemesis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%FrequentSymptomsHematemesis嘔血29WhatIsYourDecisionWhatisthedifferentialDiagnosis鑒別診斷?WhatIsYourDecisionWhatist30ForReferencePepticulcer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ForReferencePepticulcer消化性潰瘍31PepticUlcerhistoryofchroniculcerepigastricpain(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腎上腺皮質激素usuallymelena,sometimeshematemesisPepticUlcerhistoryofchronic32StressGastritishistoryofstress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StressGastritishistoryofstr33StomachNeoplasmsmiddleage中年weightloss體重減輕anorexia厭食irregularepigastricpain不規(guī)則腹痛abdominalmass腹部包塊StomachNeoplasmsmiddleage中年34PortalHypertensionpredisposinghistoryofcirrhosis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PortalHypertensionpredisposin35FormationofPortalSystem3inflowveincollectbloodfromspleen,pancreas,stomach,intestine,colon,andrectumsplenicveinsuperiormesentericveininferiormesentericvein2branchesintoleft&righthepaticlobethroughhepaticsinustohepaticveintoIVC75%bloodsupply,50%oxygensupplyofliverFormationofPortalSystem3in36上消化道大出血課件37CollateralVascularSystem側支循環(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CollateralVascularSystem側支循環(huán)38上消化道大出血課件39DefinitionofPortalHypertensionnormalportalpressure:13-24cmH2Onormalhepaticveinpressuregradient(HVPG):5-9cmH2Oportalhypertension:30-50cmH2OHVPG>12mmHgleadstoUGIBDefinitionofPortalHypertens40上消化道大出血課件41CauseofHypertensioncirrhosishepaticsinusnarrownessportalbloodinflowblockedhighpressurehepaticarteryflowtolowpressureportalveinCauseofHypertensioncirrhosis42上消化道大出血課件43PathophysiologyofPortalHypertensionsplenemegaly&hypersplenism脾腫大/脾功能亢進peripheraltotalbloodcountdecreasecollateralvascularvarix側支靜脈曲張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PathophysiologyofPortalHype44CaputMedusaeCaputMedusae45Hemobiliahemobiliatriad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膽道結石Hemobiliahemobiliatriad膽道出血三聯(lián)46MiscellaneousMallory-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MiscellaneousMallory-Weisssyn47WhatIsYourDecisionWhatphysicalexamination體格檢查findingswouldyousearchfor?WhatIsYourDecisionWhatphys48ForReferenceSignsofshockandbloodlossSignsofchronicliverdiseaseSignsoftumorForReferenceSignsofshockan49Shock&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結膜甲床蒼白signsofpoorperfusion:coldextremities四肢厥冷,coldsweating冷汗,oliguria少尿,chestpain胸痛Shock&BloodLosspulseandbl50ChronicLiverDiseasesspiderangiomata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ChronicLiverDiseasesspidera51Tumorupperabdominalmass上腹包塊leftsupraclavicularlymphnode(Virchow’snode)左鎖骨上淋巴結腫大umbilicalnodular(SisterMaryJoseph’snode)臍周結節(jié)Douglaspouchnodular(Bloomer’sshelf)直腸子宮（膀胱）陷凹結節(jié)Tumorupperabdominalmass上腹包塊52WhatIsYourDecisionWhatdiagnosticstudieswouldyouorder?WhatIsYourDecisionWhatdiag53ForReferenceCompletebloodcount(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ForReferenceCompletebloodco54EndoscopicExplorediagnosis&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EndoscopicExplorediagnosis&55上消化道大出血課件56UlcerwithBlackSpot10%RebleedingUlcerwithBlackSpot57UlcerwithBloodClot22%RebleedingUlcerwithBloodClot58UlcerwithVisibleVessel43%RebleedingUlcerwithVisibleVessel59UlcerwithActiveBleeding55%RebleedingUlcerwithActiveBleeding60EsophagusVaricesEsophagusVarices61上消化道大出血課件62HypertensivePortalGastropathyHypertensivePortalGastropath63InjectionofSclerosant硬化劑InjectionofSclerosant硬化劑64BandLigation皮圈套扎BandLigation皮圈套扎65Hemoclip止血夾Hemoclip止血夾66LaserApplication激光止血LaserApplication激光止血67HeaterProbe加熱探針HeaterProbe加熱探針68WhatIsYourDecisionWhatarethetherapeuticoptionsforeachcommonetiology病因ofmassiveUGIBafterinitialresuscitation?WhatIsYourDecisionWhatare69ForReferenceMedicineEndoscopeSurgeryForReferenceMedicine70Non-VaricealBleedingtherapeuticendoscopewith/withoutmedicineifeffectivethencontinuedrugtherapyeradicationofH.pylorimucousprotection2attemptsofendoscopicfailurepursuesurgeryothersurgicalindicationsseverelife-threateningbleedingnotresponsivetoresuscitationcoexistingreasonofperforation,obstructionormalignanciessecondhospitalizationofpepticulcerNon-VaricealBleedingtherapeut71VaricealBleedingdrugtherapywith/withoutballoontemponadeendoscopicbindingorsclerotherapytransjugularintrahepaticportosystemicshunt(TIPS)經(jīng)頸靜脈肝內(nèi)門體分流術effectiverate90%rebleedingrateinoneyear16-30%shuntdisfunctionratein6months50-60%inducingencephalopathyrate25-35%30daymortalityrate14-16%canbeusedasatemporarymethodbeforetransplantationChildA&B–surgeryChildC–transplantationVaricealBleedingdrugtherapy72TIPS8-12mmTIPS8-12mm73WhatIsYourDecisionHowtoperformtheoperation?WhatIsYourDecisionHowtope74ForReferenceExploration探查Hemostasis止血RadicalOperation根治ForReferenceExploration探查75ExplorationSequencemostpopularsite:stomach&duodenum胃十二指腸cirrhosisornot:liverandspleen肝脾gallbladderandcommonbileduct膽道系統(tǒng)upperportionofjejunum上段空腸ExplorationSequencemostpopul76Non-VaricealBleedingpepticulcerorstressgastritis消化性潰瘍和應激性胃炎vagotomy迷走神經(jīng)切除術gastrectomy胃切除sewingofbleedingulcer潰瘍縫扎stomachneoplasm胃腫瘤gastrectomy胃切除hemobilia膽道出血self-limited,seldomneedsoperation自限性，很少需要手術Non-VaricealBleedingpepticul77VaricealBleedingemergency:devascularizationprocedure斷流術splenectomy脾切除gastroesophagealdevascularization胃底食管血管離斷esophagealtransection食管下段橫斷ChildA/B:decompressiveshunt分流術totalportalsystemicshunt非選擇性分流excellentcontrolofbleeding止血效果好40-50%encephalopathy肝性腦病發(fā)生率高selectiveportalsystemicshunt選擇性分流maintainportalflowtoliver保持門脈入肝血流10-15%encephalopathy肝性腦病發(fā)生率低produceascites可產(chǎn)生腹水ChildC:transplantation肝移植VaricealBleedingemergency:de78EsophagealTransectionEsophagealTransection79Porto-CavaShuntPorto-CavaShunt80DistalSplenorenalShuntDistalSplenorenalShunt81ConclusionSavelifefirstBleedingsitenotsoimportantPrimarychoiceendoscopeOperationusuallynotnecessaryConclusionSavelifefirst82Wehavethegun,

butdon’twanttoshootWehavethegun,

butdon’twan83ThankYouThankYou84上消化道大出血

MassiveUpperGastrointestinalBleeding上海交通大學醫(yī)學院瑞金臨床醫(yī)學院2009上消化道大出血

MassiveUpperGastroin85IntroduceOurselvesDr.Yang

&Dr.LiIntroduceOurselvesDr.Yang

&86BasicConceptsBasicConcepts87WhatIsMassiveBleeding>20%(>800ml)bloodlossHemodynamicinstability血流動力學不穩(wěn)Clinicalsignsofpoorperfusion組織灌注差WhatIsMassiveBleeding>20%(88WhatIsUGIEsophagus食道Stomach胃Duodenum十二指腸Jejunum空腸Ileum回腸AscendingColon升結腸TransverseColon橫結腸DescendingColon降結腸SigmoidColon乙結腸Rectum直腸Anus肛門WhatIsUGIEsophagus食道Jejunum空89上消化道大出血課件90上消化道大出血課件91PleaseRememberUGIBisnotuncommonintheemergencyroomMortalityrateisabout10%UGIBisaseriesofdiseasesmainlytreatedbyinternalmedicine.3-15%requireasurgicalprocedurePleaseRememberUGIBisnotunc92Let’shaveaproblem!Let’shaveaproblem!93PatientCome45-yrfemalefirstepisodeofhematemesis嘔血transferredfromasmallhospital2unitsofpackederythrocyte紅細胞tranfusednasogastrictube胃管introducedwithactivebleedingpulse120bpm,BP80/40mmHgPatientCome45-yrfemale94WhatIsYourDecisionWhatisyourintuition直覺?WhatIsYourDecisionWhatisy95ForReferenceDoesthepatienthavelife-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?ForReferenceDoesthepatient96Worrisomeclinicalsignsandsymptomstachycardia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Worrisomeclinicalsignsands97MassiveorMinorClassIClassIIClassIIIClassIVBloodLossml≤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MassiveorMinorClassIClassI98UGIBorLGIBManifestation癥狀UGIBLGIBHematemesis嘔血AlmostcertainRareMelena黑便ProbablePossibleHematochezia便血PossibleProbableBlood-streakstool便中帶血絲RareAlmostcertainOccultbloodstool大便隱血PossiblePossibleUGIBorLGIBManifestation癥狀UGI99EstimationofBloodLossoccultbloodstool –5-10ml/24hmelena –50-100ml/24hhematemesis –250-300mlinstomachCNSchange –>500mlhypovolemia –>1000ml/shortperiodEstimationofBloodLossoccult100Child-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=12-15pointsChild-PughClassificationNo.o101WhatIsYourDecisionWhatarethemanagementpriorities優(yōu)先順序tothispatient?WhatIsYourDecisionWhatare102ForReferenceResuscitation復蘇Hemostasis止血Differentialdiagnosis鑒別診斷Basicdiseasetreatment治療原發(fā)病Comorbiditymanagement處理并存病ForReferenceResuscitation復蘇103InitialResuscitationABCairway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InitialResuscitationABC104MedicalTherapyvasopressin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質子泵抑制劑hemostaticagents&bloodcoagulationfactors止血劑和凝血因子MedicalTherapyvasopressin血管加壓105NasogastricTubeIntroductionaspiration&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,protecttheairwayNasogastricTubeIntroductiona106BalloonTamponade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releasefor15minevery4hrsBalloonTamponade氣囊壓迫temporary107上消化道大出血課件108WhatIsYourDecisionWhatquestionwouldyouaskthepatient?WhatIsYourDecisionWhatques109ForReferenceHistoryofillness病史Precipitatingfactors誘因Comorbidities并存病ForReferenceHistoryofillnes110Historyhistoryofbleeding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othersHistoryhistoryofbleeding出血情況111Precipitatingfactorsalcoholabuse酒癮NSAIDs(nonsteroidanti-inflammatorydrugs)ingestion非甾體類抗炎藥物應用stress應激:burninjuries–Curling

headinjuries–CushingPrecipitatingfactorsalcohola112FrequentSymptomsHematemesis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%FrequentSymptomsHematemesis嘔血113WhatIsYourDecisionWhatisthedifferentialDiagnosis鑒別診斷?WhatIsYourDecisionWhatist114ForReferencePepticulcer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ForReferencePepticulcer消化性潰瘍115PepticUlcerhistoryofchroniculcerepigastricpain(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腎上腺皮質激素usuallymelena,sometimeshematemesisPepticUlcerhistoryofchronic116StressGastritishistoryofstress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StressGastritishistoryofstr117StomachNeoplasmsmiddleage中年weightloss體重減輕anorexia厭食irregularepigastricpain不規(guī)則腹痛abdominalmass腹部包塊StomachNeoplasmsmiddleage中年118PortalHypertensionpredisposinghistoryofcirrhosis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PortalHypertensionpredisposin119FormationofPortalSystem3inflowveincollectbloodfromspleen,pancreas,stomach,intestine,colon,andrectumsplenicveinsuperiormesentericveininferiormesentericvein2branchesintoleft&righthepaticlobethroughhepaticsinustohepaticveintoIVC75%bloodsupply,50%oxygensupplyofliverFormationofPortalSystem3in120上消化道大出血課件121CollateralVascularSystem側支循環(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CollateralVascularSystem側支循環(huán)122上消化道大出血課件123DefinitionofPortalHypertensionnormalportalpressure:13-24cmH2Onormalhepaticveinpressuregradient(HVPG):5-9cmH2Oportalhypertension:30-50cmH2OHVPG>12mmHgleadstoUGIBDefinitionofPortalHypertens124上消化道大出血課件125CauseofHypertensioncirrhosishepaticsinusnarrownessportalbloodinflowblockedhighpressurehepaticarteryflowtolowpressureportalveinCauseofHypertensioncirrhosis126上消化道大出血課件127PathophysiologyofPortalHypertensionsplenemegaly&hypersplenism脾腫大/脾功能亢進peripheraltotalbloodcountdecreasecollateralvascularvarix側支靜脈曲張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PathophysiologyofPortalHype128CaputMedusaeCaputMedusae129Hemobiliahemobiliatriad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膽道結石Hemobiliahemobiliatriad膽道出血三聯(lián)130MiscellaneousMallory-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MiscellaneousMallory-Weisssyn131WhatIsYourDecisionWhatphysicalexamination體格檢查findingswouldyousearchfor?WhatIsYourDecisionWhatphys132ForReferenceSignsofshockandbloodlossSignsofchronicliverdiseaseSignsoftumorForReferenceSignsofshockan133Shock&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結膜甲床蒼白signsofpoorperfusion:coldextremities四肢厥冷,coldsweating冷汗,oliguria少尿,chestpain胸痛Shock&BloodLosspulseandbl134ChronicLiverDiseasesspiderangiomata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ChronicLiverDiseasesspidera135Tumorupperabdominalmass上腹包塊leftsupraclavicularlymphnode(Virchow’snode)左鎖骨上淋巴結腫大umbilicalnodular(SisterMaryJoseph’snode)臍周結節(jié)Douglaspouchnodular(Bloomer’sshelf)直腸子宮（膀胱）陷凹結節(jié)Tumorupperabdominalmass上腹包塊136WhatIsYourDecisionWhatdiagnosticstudieswouldyouorder?WhatIsYourDecisionWhatdiag137ForReferenceCompletebloodcount(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ForReferenceCompletebloodco138EndoscopicExplorediagnosis&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EndoscopicExplorediagnosis&139上消化道大出血課件140UlcerwithBlackSpot10%RebleedingUlcerwithBlackSpot141UlcerwithBloodClot22%RebleedingUlcerwithBloodClot142UlcerwithVisibleVessel43%RebleedingUlcerwithVisibleVessel143UlcerwithActiveBleeding55%RebleedingUlcerwithActiveBleeding144EsophagusVaricesEsophagusVarices145上消化道大出血課件146HypertensivePortalGastropathyHypertensivePortalGastropath147InjectionofSclerosant硬化劑Injection