上消化道出血内镜表现和治疗

上 消 化 道 出 血 With the inverted gastroscope a spurting hemorrhage from a fundal varice is discerbnable. Hemostasis is achieved with several low volume injections of Histoacryl - glue. The right picture shows the therapeutic success. This massive vessel with active bleeding was diagnosed in a 58 year- old patient, who presented with tary stools. The first picture shows the lesion after injection of fibrin glue. The right picture shows additionally applied hemoclips. Bleeding stopped at the end of the procedure, but reccurred twice before the patient had to be treated surgically. In dieu-la-foy ulcers an arterial vessel of abnormal size reaches the mucosa causing a tiny ulzeration by permanent compression of the mucosal layer. Esophageal varices grade II (right) und grade III (left). Cherry red spots are signs of imminent hemorrhage (right). They correspond to areas of especially thin and altered variceal wall. This duodenal ulcer at the left edge of the figure, shows an oozing, active bleeding. According to the Forrest classification of gastrointestinal hemorrhage of the upper GI- tract, this bleeding is graded as Forrest Ib. The visible vessel is treated by primary application of a hemoclip. At the 3 week follow- up (fig )the Clip is still in the original position. The ulcer shows a progressive healing. Inoperable choledochal cancer. A wall stent had been inserted 3 months earlier. The patient was admitted for severe hemorrhage, which was endoscopically proved to originate from the biliary duct. The hemorrhage was not amenable to endoscopy and surgery. Huge blood clots prolapse from the biliary duct. 临床表现 v呕血与黑粪 v失血性周围循环衰竭 v血象变化 v发热 v氮质血症 诊 断 思 路 是上消化道出血吗? 出了多少血? 出血停止了吗? 什么原因引起的出血? 上消化道出血的确立 呕血和黑粪,失血性周围循环衰竭,血和粪便 的检查 早期识别:直肠指诊 排除消化道以外的病因:咯血、口鼻咽出血、 事物或药物 出血量的估计 粪便隐血试验阳性 每日消化道出血510ml 黑粪 50100ml 呕血 250300ml 出现全身症状 400500ml 周围循环衰竭 1000ml v最有价值的标准:周围循环衰竭的临床表现 v动态观察血压和心率 出血是否停止 继续出血或再出血的表现: 反复呕血或黑粪 周围循环衰竭经治疗后无改善或波动 HbRBC继续下降,Ret持续升高 补液与尿量足够的情况下,血尿素氮持续或 再次升高 出血后48小时以上未再继续出血,再出血可能性小; 既往有大出血史、本次出血量大、24小时内反复大量 出血、食管胃底静脉曲张出血、有明显的高血压或动 脉硬化者,再出血可能性大 出血的病因 v病史 v实验室检查 v胃镜:首选;推畅急诊胃镜检查(2448hr) vX线钡餐 v其他:选择性动脉造影 治 疗 原则: 抗休克,积极补充血容量 v一般的急救措施: 禁食,卧床休息,保持呼吸道通畅 严密监测生命体征 v积极补充血容量:立即配血,输足量全血 q紧急输血指征: 改变体位出现晕厥,血压下降1520mmHg, 心率上升10次/分 收缩压90mmHg(或较基础下降25%) Hb7g/L或Hct25% 治 疗 v止血措施 q食管胃底静脉曲张破裂大出血 -出血量大,再出血率高,死亡率高 治 疗 药物止血 血管加压素(vasopressin) 机制:收缩内脏血管,减少门静脉血流,降低门静 脉 及侧枝循环压力 用量:0.2U/分持续静脉滴注 不良反应:腹痛,血压升高,心律失常,心绞痛,心 肌梗死 建议:与硝酸甘油同时用 禁忌:有冠心病者 药物止血 生长抑素(somatostatin) 机制:减少内脏血流,减少奇静脉血流 优点:疗效确实,无全身血流动力学改变 缺点:价格昂贵 用量: 14肽天然生长抑素:首剂250ug静脉缓注, 继以250ug/h静脉滴注 o 注意:该药半衰期短,中断超过5分钟须再次首剂 8肽生长抑素:首剂100ug静脉缓注, 继以2550ug/h持续静脉滴注 治疗 气囊压迫止血 治 疗 三腔二囊管 食管囊 (3545mmHg) 胃囊 (5070mmHg) 优点:止血确实 缺点: 痛苦 并发症多(吸入性肺炎,窒息, 食管