上消化道出血課件

上消化道出血2G.I.BleedingPresentedby: AhmedT.Al-Suwaidi MohamedS.Al-Hoqani上消化道出血2G.I.BleedingCase50yrs,Pakistani,maleC/O:Bleeding/rectum&Abd.painPainlessbleeding,1yr–excessbleeding,1monthBlack,4-5times/day,littlequant.Abd.painVomiting,1week上消化道出血2G.I.BleedingCaseM.H: *nopepticulcerdisease *nomedications(NSAIDs) *nourinarysymptoms *notknownDM,HPTN,IHD **weightloss上消化道出血2G.I.BleedingCaseO/E: *Afebrile *nopallor *notdyspneaic *nolymphoadenopathies *noS.C.L.N上消化道出血2G.I.BleedingCaseVitalSigns: *Pulse:78bts/min *BP:130/80 *RR:18br/minHeart:NADLung:NAD上消化道出血2G.I.BleedingCaseAbd.: *notdistended *noepigast.tenderness *tender,firm,partlymobilemassatRt lumbarregion. *spleennotpalpable *Ltlobeliverpalpable,mildlytender *bowelsoundspresent上消化道出血2G.I.BleedingCasePR: *noenlargedpiles *noactivebleeding *nopalpablemass *nobloodonfingerECG,CBC,SrAmylase,Bleedingprofile,AbdX-ray,fecalloadingascendingcolon上消化道出血2G.I.BleedingCaseLabResults: *Hb:14.1g/dl *Plt:252*103 *Hypochromic,microcytic *PT:17.3sec *aPTT:35.4sec *SrAmy:129U/l106U/l *Na+:140mmol/l *K+:4.1mmol/l *BUN:17mg/dl上消化道出血2G.I.BleedingAcuteVsChronicAcuteUpperG.I.Bleeding:AcuteLowerG.I.Bleeding:上消化道出血2AcuteUpperG.I.BleedingHaematemesisMelaenaSite&Time上消化道出血2AcuteU.G.I.Bleeding·

Aetiology:

1.Drugs(Aspirin&NSAIDs)2.Alcohol3.Chronicpepticulceration(50%ofGIhemorrhage)4.Others:refluxesophagitis,varices,gastriccarcinoma,acutegastriculcers&erosions.上消化道出血2AcuteU.G.I.Bleeding·

Clinicalapproach:1.recent(24hrs),thenhospitalized.2.ifsmallamount,noimmediateTx,becauseCVScancompensate3.85%stopbleedingduring48hrs4.historyhelpsindiagnosingthecauseofthehemorrhage,eg:longhistoryofindigestion,orprevioushem.fromulcers.上消化道出血2AcuteU.G.I.Bleeding

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Clinicalapproach:5.factorsinclude: ·

age(60+)·

amountofbldlost·

continuingvisiblebldloss.·

signsofchronicliverdisease·

classicalclinicalfeaturesofshock上消化道出血2AcuteU.G.I.Bleeding

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Clinicalapproach:

6.liverdisease

severe,recurrentbleeding (iffromvarices) 7.splenomegaly

portalhypertension上消化道出血2AcuteU.G.I.Bleeding·

Immediatemanagement: **Emergencymanagement:·

History+exam.·

Monitor:pulse&BP/30min·

Bldsample:haemoglobin,urea,electrolytes,grouping&cross-matching·

I.v.access上消化道出血2AcuteU.G.I.Bleeding**Emergencymanagement(cntd):· Bldtransfusionincaseof1)shock 2)haemoglobin<10g/dl·

Urgentendoscopy·

Surgerywhenrecommended上消化道出血2AcuteU.G.I.Bleeding

**Shockmanagement:·

ABC·Airway:endotrachealtube,oropharyngealairway. *Giveoxygen上消化道出血2AcuteU.G.I.Bleeding

**Shockmanagement(cntd):·

Breathing:supportrespiratoryfunction *Monitor:resp.rate,bldgases,chest radiograph·Circulation:expandcirculatingvolume:blood,colloids,crystalloidssupportCVSfunction:vasodilators *Monitor:skincolor,peripheraltemp.,urine flow,BP,ECG上消化道出血2AcuteU.G.I.Bleeding·

GeneralInvestigations: 1.

Hb,PCV 2.

CBC(WBC…etc) 3.

Bldglucose 4.

Platelets,coagulation 5.

Urea,creatinine,electrolytes 6.

Liverbiochem. 7.

Acid-basestate

8.Imaging:chest&abd.radiography,US,CT上消化道出血2AcuteU.G.I.Bleeding **Generalmanagement:·

Bloodvolume 1.restorevolumetonormal 2.transfusion·

Endoscopy 1.shock,suspectedliverdiseaseor continuedbleeding 2.controlvaricesorulcerstoreduce re-bleeding上消化道出血2AcuteU.G.I.Bleeding **Generalmanagement:·

Drugtherapy 1.H2–receptorantagonists 2.protonpumpinhibitors·

Factorsinreassessment 1.age:60+

greatermortality 2.recurrenthemorrhage:+++mortality 3.re-bleeding:mostlywithinthe1st48hrs 4.surgicalproceduresincaseofsevere bleeding.上消化道出血2LowergastrointestinalhaemorrhageCausesDiverticulardiseaseAngiodysplasiaInflammatoryboweldiseaseIschaemiccolitisInfectivecolitisColorectalcarcinoma上消化道出血2InvestigationMayshowangiodysplasticlesionsevenoncebleedinghasceasedMost

patientsarestableandcanbeinvestigatedoncebleedinghasstoppedIntheactivelybleedingpatientconsiderColonoscopy-canbedifficultSelectivemesentericangiographyRequirescontinuedbleedingof>1ml/minute上消化道出血2RadionuclidescanningUsestechnetium-99mlabeledredbloodcells上消化道出血2ManagementIfsourceofcolonicbleedingunclearperformasubtotalcolectomyandend-ileostomyAcutebleedingtendstobeselflimitingConsiderselectivemesentericembolisationiflifethreateninghaemorrhageIfbleed