Upper GI Bleeding上消化道出血英文版课件

UpperGIBleedingTadKim,M.D.UFSurgerytad.ki(c)682-3793;(p)413-3222UpperGIBleeding上消化道出血英文版OverviewDefinitionsInitialPatientAssessmentABC&ResuscitationDifferentialDiagnosisIdentifytheSource&StoptheBleedingHistory&PhysicalEndoscopy&PotentialComplicationsOtherdiagnosticstestsRoleofSurgeryPreventionUpperGIBleeding上消化道出血英文版DefinitionsUpperGIBleeding=proximaltoligamentofTreitzHematemesis=vomitingbloodThisisdiagnosticofupperGIbleedingMelena=passageoftarryormaroonstoolCanbeupperorlower(morecommonlyupper)Hematochezia=BrightredbloodperrectumUsuallycharacteristicofcolonichemorrhageUpperGIBleeding上消化道出血英文版InitialPatientAssessmentGettopatient’sbedside,assessABCCanthepatientprotecthisairway?Doesheneedtobeintubated?Isthepatienthemodynamicallyunstable?Isheinhemorrhagicshock?2largeboreIV,Bolus2Lfluids,Type&Crossblood,sendCBC&CoagsPlacepatientonO2&continuousmonitorPlaceanNGTandlavagewithNSToconfirmifthebleedingsourceisupperGIUpperGIBleeding上消化道出血英文版DifferentialDiagnosisPepticUlcerDisease(PUD)>50%casesGastritis/Duodenitis(15-30%)SubsetduetoNSAIDuseVaricesfromportalhypertension(10-20%)Mallory-WeisstearsatGEjunction(5%)Esophagitis(3-5%)Malignancy(3%)Dieulafoy’slesion(1-3%)Nasopharyngealbleed–swallowedbloodOther-Aortoentericfistula,angiodysplasia,Crohn’s,hemobilia,hemosuccuspancreaticusUpperGIBleeding上消化道出血英文版History&PhysicalHistoryofpriorulcers,NSAIDuse,stressHistoryofHelicobacterpylori&treatmentAlcoholabuseRetching->MalloryWeisstearAlcoholiccirrhosis->portalhypertensionandvaricesOnPhysicalExam,assesshydrationLookforstigmataofcirrhosis&portalHTNUpperGIBleeding上消化道出血英文版Management–AcuteUGIBleedOnceagain,makesureptisresuscitatedIfanemicandsymptomatic,givebloodPlaceNGT/lavage(helpsforendoscopy)PerformUpperendoscopy(EGD)Forulcers:ifvisibleclot,visiblevessel,oractivebleeding,shouldcauterize/coagulateandinjectsclerosingagentForacutevaricealbleeding:sclerotherapy+somatostatinorendoscopicbandligation.Iffail/rebleed:TIPSvssurgicalshunt.BalloontamponadeisanemergencytemporizingmeasureStartprotonpumpinhibitor(PPI)infusionUpperGIBleeding上消化道出血英文版PotentialComplicationsPerforationofesophagusAspirationDesaturationorrespiratorydistressAdversereactiontoconscioussedation↑riskofcomplicationswith:InadequateresuscitationorhypotensionComorbiditiesConsiderelectiveintubationpriortoEGDifactivebleeding,alteredrespiratoryormentalstatusUpperGIBleeding上消化道出血英文版OtherDiagnosticTestsIfbleedingisunresolvedwithendoscopyorendoscopyiscontraindicated1.Angiography(Diagnostic&Therapeutic)Intra-arterialvasopressinEmbolization2.Taggedredbloodcell(TRBC)scanOnlydiagnostic&usuallyforoccultbleedingMoresensitivethanangiographyCandetectbleedingrateof0.1-0.5mL/minUpperGIBleeding上消化道出血英文版RoleofSurgeryIfmedicalandendoscopictherapyfailIntheeventthatbleedingsourceisunidentified->exploratorylaparotomyRecurrentbleedingpepticulcersAnti-ulcersurgery(i.e.vagotomy/antrectomy,orvagotomy/pyloroplasty,orselectivevagot)UpperGIBleeding上消化道出血英文版PreventionAftertheacutesituationisresolved,educatepatientonpreventivemeasuresTop2reasonsforulcers:Hpylori&NSAID1.TestingforH.pylori(i.e.antralbiopsyduringendoscopy)2.TreatH.pylori(amoxicill,clarithromycinx1wkplusPPIx4wk)3.ReduceintakeofNSAIDUpperGIBleeding上消化道出血英文版TakeHomePointsAlways,alwaysperformABC’sfirst&resuscitatewithtwo#16gaIV’s&isotoniccrystalloids(bloodifptdoesn’trespond)NGT/lavagetoconfirmactivebleedingFocusedH&Plookingforcommoncauses:ulcers,varices,“-itis”,Mallory-Weiss,AVMEndoscopyis