急诊上消化道出血共识解读王仲

2011-03,急性上消化道出血急诊诊治专家共识,中国医师协会急诊医师分会,急诊科特点-多界面的学科,人多开放轻重不一各种病人多项技术时间依赖性强,EMD,消化科,呼吸科,外科,ICU,手术室,院前急救,保命是我们的第一任务,先开枪，后瞄准,急诊判断处理诊断治疗,门诊诊断治疗,固定靶射击与双向飞碟,上消化道出血概述,急诊常见病之一潜在危险大定义：指屈氏韧带以上的消化道(食管,胃,十二指肠, 胰腺,胆道)的急性出血,是临床常见急症分类：非静脉曲张性出血、静脉曲张性出血常见病因：十二指肠溃疡、胃溃疡和食管静脉曲张1,概述,大多数急性上消化道出血病人首诊于急诊科，病人常以头晕、乏力、晕厥等不典型症状就诊急诊医师的职责：正确、迅速、合理地判断和诊治,哪些病人应当考虑急性上消化道出血,急性上消化道出血（或疑似）,以典型症状就诊的患者，容易诊断（呕血、黑便或血便，伴有周围循环功能衰竭） 以不典型症状（头晕、乏力、晕厥等）就诊的患者，急诊医师应保持高度警惕，积极明确或排除上消化道出血的诊断2-4,急诊就诊病人大出血比例高于门诊病人门脉高压病人出血更凶猛（6%）部分没有肝病史的EVB病人上消化道出血病人以消化性溃疡居多即使有肝病的病人，70%为溃疡病出血,轻与重我们知道吗？,大出血病人的紧急处理应当综合考虑,他们多长时间死亡,即刻数分钟数分钟至小时小时至数天数天至数月数月至数十月,心源性猝死窒息大出血（内、外）重症感染肿瘤免疫病,紧急评估（即刻完成）,患者意识丧失、呼吸停止及大动脉搏动不能触及立即开始心肺复苏5,紧急评估,对未出现呼吸心跳停止的病人，首先进行意识状态判断Glassgow评分 8分，表示病人昏迷，应对呼吸道采取保护措施,意识判断,意识状态评分表（Glassgow 评分）,急性血色素下降的结果,昏迷：自我保护能力的丧失，包括对气道的保护,紧急评估,A. 气道,B. 呼吸,C. 循环,急性上消化道出血急诊诊治流程,急性上消化道出血（或疑似）,紧急处置（2分钟内完成）,心电、血压、血氧饱和度持续监测对严重出血的病人，开放静脉通路，配血，液体复苏意识障碍、排尿困难及所有休克患者留置尿管，记录尿量患者绝对卧床，意识障碍患者将头偏向一侧，避免误吸意识清楚，能够配合的病人可留置胃管并冲洗肝硬化，食道胃底静脉曲张出血及配合度差的病人留置胃管时慎重，避免加重出血7,常规处理,急性失血的循环影响,处理原则保证灌注,大出血的紧急处置,常用复苏液体：生理盐水、平衡液、人工胶体和血液制品,液体复苏,大出血的紧急处置,药物治疗是急性上消化道出血的首选治疗手段,病情危重患者，特别是初次发病，既往病史不详患者,静脉应用生长抑素质子泵抑制剂（PPI）7，17,病因明确之前，可经验性联合用药9，12，16,上消化道大出血及高度怀疑静脉曲张性出血时,血管加压素抗生素14，18，19,以上基础上联用,明确病因后，再根据具体情况调整治疗方案,初始药物治疗,大出血的紧急处置,常用药物,生长抑素及其类似物,抑酸药物,血管加压素及其类似物,抗菌药物,止血药物,初始药物治疗,减少血流促进凝血,控制损害促进凝血,减少血流,促进凝血,大出血的紧急处置,生长抑素14肽,减少内脏血流、降低门静脉阻力抑制胃酸和胃蛋白酶分泌抑制胃肠道及胰腺肽类激素分泌,作用机制,肝硬化急性食道胃底静脉曲张出血的首选药物之一20，21急性非静脉曲张出血的治疗9,临床应用,大出血的紧急处置,A. 可迅速有效控制急性上消化道出血21B. 预防早期再出血的发生22，23C. 有效预防内镜治疗后的肝静脉压力梯度（HVPG）升高， 从而提高内镜治疗的成功率24D. 可显著降低消化性溃疡出血患者的手术率E. 对于高危患者，选用高剂量生长抑素在改善患者内脏血流 动力学、出血控制率和存活率方面均优于常规剂量20，23,特点,生长抑素,大出血的紧急处置,生长抑素用法,用法,大出血的紧急处置,生长抑素类似物,血管加压素及其类似物,包括垂体后叶素血管加压素特利加压素,抑酸药物,PPI针剂埃索美拉唑：80mg bolus 80mg/h奥美拉唑: 80mg bolus 80mg/h泮妥拉唑兰索拉唑雷贝拉唑H2RA雷尼替丁法莫替丁等,提高胃肠道内pH值促进血凝块的形成，防止血凝块溶解促进病变部位愈合,紧急处理中的其他药物,抗菌药物喹诺酮类抗菌素对喹诺酮类耐药者也可使用头孢类 抗菌素止血药物：止血药物的疗效尚未证实，不推荐作为一线药物使用,急性上消化道大出血急诊诊治流程,急性上消化道出血（或疑似）,二次评估病因评估,在解除危及生命的情况、液体复苏和初始经验治疗开始后；或初次评估判断病情较轻，生命体征稳定的病人，开始进行二次评估全面评估,病史 详细询问病史有助于对出血病因的初步判断全面查体 重点注意血流动力学状态、腹部、慢性肝脏疾病或 门脉高压体征、直肠指诊实验室和辅助检查 血细胞分析、肝功能、肾脏功能和电解质、 凝血功能、血型、心电图、胸片、腹部超声,二次评估,病情严重程度的评估 病情严重度与失血量呈正相关。如根据血容量减少导致周围循环的改变来判断失血量，休克指数（心率/收缩压）是判断失血量的重要指标之一6，15,上消化道出血病情严重程度分级,注：休克指数=心率/收缩压,二次评估,是否存在活动性出血的评估 临床上出现下列情况考虑有活动性出血,呕血或黑便次数增多，呕吐物呈鲜红色或排出暗红血便，或伴有肠鸣音活跃,经快速输液输血，周围循环衰竭的表现未见明显改善，或虽暂时好转而又再恶化，中心静脉压仍有波动，稍稳定又再下降,红细胞计数、血红蛋白测定与Hct 继续下降，网织红细胞计数持续增高,补液与尿量足够的情况下，血尿素氮持续或再次增高,胃管抽出物有较多新鲜血,1,2,3,4,5,二次评估,出血预后的评估,急性上消化道出血急诊诊治流程,急性上消化道出血（或疑似）,药物治疗,内镜,内镜检查为上消化道出血病因诊断的关键检查47，应尽量在出血后2448h内进行；药物与内镜联合治疗是目前首选的治疗方式24，26，47，48，内镜治疗方法的选择请参加消化专业有关指南8，13，14，19,急性上消化道出血急诊诊治流程,急性上消化道出血（或疑似）,紧急处置,二次评估,药物治疗+内镜联合治疗,治疗后再次评估,经上述治疗后再次评估患者出血是否得到有效控制。若仍可能存在活动性出血，可根据患者病情选择重复内镜治疗或外科手术治疗。对严重出血患者或因脏器低灌注而引起相应并发症者应尽快收入监护病房进行加强监护治疗,急性上消化道出血急诊诊治流程小结,参考文献,1.Henrion, J., et al., Upper gastrointestinal bleeding: what has changed during the last 20 years? Gastroenterol Clin Biol, 2008. 32(10): p. 839-47.2.Alkhatib, A.A. and F.A. Elkhatib, Acute Upper Gastrointestinal Bleeding Among Early and Late Elderly Patients. Dig Dis Sci, 2010.3.Alkhatib, A.A., et al., Acute upper gastrointestinal bleeding in elderly people: presentations, endoscopic findings, and outcomes. J Am Geriatr Soc, 2010. 58(1): p. 182-5.4.Eisen, G.M., et al., An annotated algorithmic approach to upper gastrointestinal bleeding. Gastrointest Endosc, 2001. 53(7): p. 853-8.5.2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 2005. 112(24 Suppl): p. IV1-203.6.Cappell, M.S. and D. Friedel, Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy. Med Clin North Am, 2008. 92(3): p. 491-509, xi.7.Chiu, P.W. and J.J. Sung, Acute nonvariceal upper gastrointestinal bleeding. Curr Opin Gastroenterol, 2010. 26(5): p. 425-8.8.中华内科杂志编委会, 中华消化杂志编委会,中华消化内镜杂志编委会., 急性非静脉曲张性上消化道出血诊治指南(2009,杭州). 中华内科杂志, 2009. 48(10): p. 891-894.9.Barkun, A.N., et al., International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med, 2010. 152(2): p. 101-13.10.Non-variceal upper gastrointestinal haemorrhage: guidelines. Gut, 2002. 51 Suppl 4: p. iv1-6.11.Hearnshaw, S.A., et al., Outcomes following early red blood cell transfusion in acute upper gastrointestinal bleeding. Aliment Pharmacol Ther, 2010. 32(2): p. 215-24.12.Garcia-Tsao, G., et al., Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology, 2007. 46(3): p. 922-38.13.中华内科杂志编辑部, 食管胃静脉曲张出血的诊治建议(草案). 中华内科杂志, 2006. 45(6): p. 524-526.14.中华医学会消化病学分会, 中华医学会肝病学分会, 中华医学会内镜学分会, 肝硬化门静脉高压食管胃静脉曲张出血的防治共识. 中华肝脏病杂志, 2008. 16(8): p. 564-570.15.中华医学会重症医学分会, 低血容量休克复苏指南(2007). 中国实用外科杂志, 2007. 27(8): p. 581-587.16.Seo, Y.S., et al., Clinical features and treatment outcomes of upper gastrointestinal bleeding in patients with cirrhosis. J Korean Med Sci, 2008. 23(4): p. 635-43.17.Leontiadis, G.I. and C.W. Howden, The role of proton pump inhibitors in the management of upper gastrointestinal bleeding. Gastroenterol Clin North Am, 2009. 38(2): p. 199-213.18.Adler, D.G., et al., ASGE guideline: The role of endoscopy in acute non-variceal upper-GI hemorrhage. Gastrointest Endosc, 2004. 60(4): p. 497-504.19.中华外科学会门静脉高压症学组, 肝硬化门静脉高压症消化道出血治疗共识. 外科理论与实践, 2009. 14(1): p. 79-81.20.Moitinho, E., et al., Multicenter randomized controlled trial comparing different schedules of somatostatin in the treatment of acute variceal bleeding. J Hepatol, 2001. 35(6): p. 712-8.21.Yang, J.F., et al., Effect of somatostatin versus octreotide on portal haemodynamics in patients with cirrhosis and portal hypertension. Eur J Gastroenterol Hepatol, 2005. 17(1): p. 53-7.22.Gotzsche, P.C. and A. Hrobjartsson, Somatostatin analogues for acute bleeding oesophageal varices. Cochrane Database Syst Rev, 2008(3): p. CD000193.23.Villanueva, C., et al., Somatostatin treatment and risk stratification by continuous portal pressure monitoring during acute variceal bleeding. Gastroenterology, 2001. 121(1): p. 110-7.24.Cappell, M.S., Therapeutic endoscopy for acute upper gastrointestinal bleeding. Nat Rev Gastroenterol Hepatol, 2010. 7(4): p. 214-29.25.Fortune, B.E., et al., Vapreotide: a somatostatin analog for the treatment of acute variceal bleeding. Expert Opin Pharmacother, 2009. 10(14): p. 2337-42.26.Sreedharan, A., et al., Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database Syst Rev, 2010. 7: p. CD005415.27.Yachimski, P.S., et al., Proton pump inhibitors for prophylaxis of nosocomial upper gastrointestinal tract bleeding: effect of standardized guidelines on prescribing practice. Arch Intern Med, 2010. 170(9): p. 779-83.,参考文献,28.Andriulli, A., et al., Proton-pump inhibitors and outcome of endoscopic hemostasis in bleeding peptic ulcers: a series of meta-analyses. Am J Gastroenterol, 2005. 100(1): p. 207-19.29.Barkun, A.N., et al., Cost effectiveness of high-dose intravenous esomeprazole for peptic ulcer bleeding. Pharmacoeconomics, 2010. 28(3): p. 217-30.30.Baker, D.E., Peptic ulcer bleeding following therapeutic endoscopy: a new indication for intravenous esomeprazole. Rev Gastroenterol Disord, 2009. 9(4): p. E111-8.31.Sung, J.J., et al., Intravenous esomeprazole for prevention of recurrent peptic ulcer bleeding: a randomized trial. Ann Intern Med, 2009. 150(7): p. 455-64.32.Thomson, A.B., Intravenous esomeprazole for prevention of recurrent peptic ulcer bleeding. Curr Gastroenterol Rep, 2009. 11(5): p. 339-41.33.Simon-Rudler, M., et al., Continuous infusion of high-dose omeprazole is more effective than standard-dose omeprazole in patients with high-risk peptic ulcer bleeding: a retrospective study. Aliment Pharmacol Ther, 2007. 25(8): p. 949-54.34.Netzer, P. and W. Inauen, Continuous infusion or repeated intravenous bolus injection of high-dose omeprazole in patients at high risk of rebleeding from peptic ulcers? Am J Gastroenterol, 2006. 101(12): p. 2888-9; author reply 2889.35.Wu, L.C., et al., High-dose vs low-dose proton pump inhibitors for upper gastrointestinal bleeding: a meta-analysis. World J Gastroenterol, 2010. 16(20): p. 2558-65.36.Soderlund, C., Vasopressin and glypressin in upper gastrointestinal bleeding. Scand J Gastroenterol Suppl, 1987. 137: p. 50-5.37.Elzouki, A.N., et al., Terlipressin-induced severe left and right ventricular dysfunction in patient presented with upper gastrointestinal bleeding: case report and literature review. Am J Emerg Med, 2010. 28(4): p. 540 e1-6.38.Bernard, B., et al., Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta-analysis. Hepatology, 1999. 29(6): p. 1655-61.39.Rockall, T.A., et al., Risk assessment after acute upper gastrointestinal haemorrhage. Gut, 1996. 38(3): p. 316-21.40.Chen, I.C., et al., Risk scoring systems to predict need for clinical intervention for patients with nonvariceal upper gastrointestinal tract bleeding. Am J Emerg Med, 2007. 25(7): p. 774-9.41.Stanley, A.J., et al., Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation. Lancet, 2009. 373(9657): p. 42-7.42.Soga, K., et al., MELD score, child-pugh score, and decreased albumin as risk factors for gastric variceal bleeding. Hepatogastroenterology, 2009. 56(94-95): p. 1552-6.43.Benedeto-Stojanov, D., et al., The model for the end-stage liver disease and Child-Pugh score in predicting prognosis in patients with liver cirrhosis and esophageal variceal bleeding. Vojnosanit Pregl, 2009. 66(9): p. 724-8.44.Pasquale, M.D. and F.B. Cerra, Sengstaken-Blakemore tube placement. Use of balloon tamponade to control bleeding varices. Crit Care Clin, 1992. 8(4): p. 743-53.45.Minocha, A. and R.J. Richards, Sengstaken-Blakemore tube for control of massive bleeding from gastric varices in hiatal hernia. J Clin Gastroenterol, 1992. 14(1): p. 36-8.46.Feneyrou, B., et al., Initial control of bleeding from esophageal varices with the Sengstaken-Blakemore tube. Experience in 82 patients. Am J Surg