咯血呕血便血.ppt

咯血、呕血、黑便Hemoptysis、Hematemesis、Hematochezia,湖北医药学院附属太和医院消化内科郜元军博士副教授,Intensivecare,Whereisthesourceofbleeding?,Empirictherapy,Diagnosis,Treatment,(经验治疗),Whatisthecausesofbleeding?,Isbleedingacuteorchronic?,Recognitionofhemorrhage,咯血Hemoptysis,BleedingbelowthelevelofthelarynxthatbeingcoughedoutDegrees:fromblood-tingedsputumtomassivegrossblood,evenleadingtoairwayocclusion(apnea)13-443):438,国内917例患者的病因分布：支气管、肺部炎症：44.1%肺癌：34.6%肺结核：8.2%支扩：4.4%,国内另一组5488例患者病因分布恶性肿瘤：44.6%支气管、肺部炎症：35.3%肺结核：5.8%支扩：4.3%,在大咯血病人中：1.支扩：302.肺癌：203.肺结核：1520,Manifestation临床表现,1、年龄2、咯血量3、颜色和性状,1.年龄,青壮年常见于肺结核、支气管扩张症、二尖瓣狭窄等40岁以上有长期吸烟史支气管肺癌儿童慢性咳嗽伴少量咯血与低色素贫血，须注意特发性含铁血黄素沉着症的可能,痰中带血肺癌、肺结核、慢支、肺炎、支气管结核、结石少量咯血肺结核、肺脓肿中等量咯血肺结核、支扩、二尖瓣狭窄大咯血支扩、肺结核空洞、晚期肿瘤,2.咯血量,临床表现,鲜红色肺结核、支气管扩张、出血性疾病铁锈色血痰肺炎链球菌肺炎砖红色胶冻样痰典型的肺炎克雷伯杆菌肺炎暗红色二尖瓣狭窄粉红色泡沫痰左心衰所致肺水肿粘稠暗红色血痰肺梗死,3.颜色和性状,咯血的伴随症状,发热：肺结核、肺炎、肺脓肿、流行性出血热胸痛：肺炎、肺梗塞、肺癌、肺结核呛咳：肺癌、支原体肺炎脓痰：支扩、肺脓肿、肺结核空洞皮肤粘膜出血：血液病、风湿病及肺出血型钩端螺旋体病和流行性出血热杵状指：支气管扩张症、肺脓肿、支气管肺癌黄疸：钩端螺旋体病、肺炎球菌肺炎、肺梗死,【问诊要点】,确定是否咯血发病年龄及咯血性状伴随症状个人史,呕血与便血hematemesisandhematochezia,Patientsmanifestbloodloss,1)Hematemesis呕血Bloodyvomitus,eitherfreshandbrightredorolderand“coffee-ground”(hematin酸化正铁血红素)incharacterHemoptysis?Nosebleeding?,Mannerofbleedingpresentation,fromtheGItractinfiveways:,2)Melena黑便Shiny,black,sticky,foul-smellingstooldegradationofbloodexogenousstooldarkenersironbismuth(铋剂),Mannerofbleedingpresentation,Mannerofbleedingpresentation,3)Hematochezia便血brightredormaroonbloodfromtherectumpurebloodbloodintermixedwithformedstoolbloodydiarrhea,Mannerofbleedingpresentation,4)Occult隐血detectedonlybytestingthestoolwithamonoclonalantibodyforhumanhemoglobin,EstimateamountofbleedingfromupperGItract,510ml/dOB+5070ml/dMelena250300mlinshorttimeHematemesis,Mannerofbleedingpresentation,withoutanyobjectivesignofbleedingwithsymptomsofbloodlossdizziness,dyspnea,anginacordis(心绞痛),orevenshockdigitalexamination(指检)oftherectum,呕血hematemesis,一、定义（Definition）,Bleedingthatbeingvomited,withuppergastrointestinalorsystemicdiseasesOftenwithmelena(黑便)Acutecirculatoryfailure(急性周围循环衰竭),假性呕血药物及食物呕血与咯血的鉴别,Differentiating（鉴别）,二、病因（causees）,WhatisthecausesofupperGIbleeding?,90%upperGIbleedingisduetofourlesionsinChina:1)pepticulcer(消化性溃疡)2)acutegastricmucosallesion(急性胃粘膜病变)3)esophagealorgastricvarices(静脉曲张)4)gastriccancer,（一）食管疾病食管静脉曲张破裂(esophagealorgastricvarices)食道贲门粘膜撕裂(Malloy-Weisstear)食管裂孔疝反流性食管炎食管癌,（二）胃及十二指肠疾病,（三）胆道出血,（四）胰腺疾病,1、慢性胰腺炎2、急性胰腺炎3、胃泌素瘤（Zollinger-EllisonS）4、胰腺癌,（五）全身性疾病（六）急性传染病血液系统疾病流行性出血热尿毒症钩体病重症肝炎,三、临床表现(Manifestation),(一)消化道局部症状AbdominaldiscomfortNausea,hematemesis,malena,1.上消化道出血是否呕血取决于出血量：300ml部位：幽门以上部位出血量小或速度较慢可不呕血幽门以下病变如十二指肠病变出血量大、速度快，血液可反流入胃而呕出,2、上消化道出血呕血的颜色取决于量和时间量小、时间长为咖啡色量大、时间短为鲜红色Hb+HCl正铁血红蛋白咖啡色3、呕血后4小时即可出现黑便结肠段Hb+硫化物硫化亚铁柏油样,(二)全身症状,1、失血性贫血Anemia,paledizzinesspalpitation,easyfatigabilitydyspneaanginacordis,2、循环衰竭失血性休克Hypovolemiaorshock,SpeedandvolumeofbloodlossWeakness,giddiness(眩晕),oliguria,(少尿)coldextremity（四肢阙冷）,sweatingVitalsigns:tachycardia(心动过速),hypotention(低血压),（三）血象变化及氮质血症,早期可无明显变化3-4h后，Hb和Hct下降BUN和Cr渐升高,四、伴随症状(accompanyingsymptom),1.上腹痛中青年人慢性反复发作周期性，节律性消化性溃疡（Pepticulcer）?中老年人慢性上腹痛无规律，厌食，消瘦胃癌(gastriccancer)?,2、肝脾肿大蜘蛛痣，肝掌腹壁静脉曲张脾大，腹水肝硬化(cirrhosis)？肝大，肝区痛肝区结节，质硬肝癌(hepaticcarcinoma)？,3.黄疸黄疸、寒战，发热伴右上腹绞痛胆道疾病？黄疸、发热，全身皮肤出血倾向感染性疾病？4、皮肤黏膜出血血液病,5、其他：非甾类药大面积烧伤颅脑手术严重外伤伴呕血急性胃粘膜病变AGML剧烈呕吐后呕血贲门粘膜撕裂MalorryWeissSyndrome,6、头晕、黑朦、口渴、冷汗血容量不足肠鸣、黑便或便血活动性出血,五问诊要点,确定是否呕血呕血的诱因呕血的颜色伴随症状既往病史,便血Hematochezia,便血指消化道出血，血液由肛门排出，颜色可呈鲜红、暗红、或柏油样隐血：消化道出血量小，肉眼看不到粪便颜色的改变，须隐血试验确定,上消化道疾病小肠疾病肠结核、肠伤寒、急性出血坏死性肠炎、小肠肿瘤、肠套叠结肠疾病急性菌痢、阿米巴痢疾、溃疡性结肠炎、结肠癌直肠肛管疾病直肠息肉、直肠癌、痔疮、肛裂全身性疾病肝病、血液病、传染病,一、病因,痔疮,溃疡性结肠炎,大肠癌,憩室炎,肠道息肉,血管畸形,二、临床表现,便血颜色出血部位出血量血液在肠腔停留时间长短性状柏油便潜血试验OB抗人Hb单克隆抗体,几种特殊性状的血便,黏液脓血便急性菌痢暗红色果酱样脓血便阿米巴痢疾洗肉水样血便,并有特殊腥臭味急性出血坏死性肠炎血色鲜红不与粪便混合痔疮、肛裂、直肠肿瘤,（三）伴随症状,1.腹痛慢性、周期性、节律性，出血后疼痛减轻消化性溃疡上腹绞痛、黄疸伴便血胆道出血腹痛时排血便或脓血便，便后腹痛减轻痢疾、溃结其他急性出血性坏死性肠炎、肠套叠、肠系膜血栓形成或栓塞等,伴随症状,2.里急后重肛门、直肠疾病痢疾、直肠炎、直肠癌3.发热传染性疾病：败血症、流行性出血热、钩体病肿瘤：肠道淋巴瘤、白血病,伴随症状,4.全身出血倾向急性传染病及血液病5.皮肤改变蜘蛛痣、肝掌、毛细血管扩张6.腹块肿瘤、肠结核、肠套叠、Crohn,四、问诊要点,1.便血的病因和诱因2.便血量3.患者一般情况4.过去有否腹泻、腹痛、痔疮、肛裂、抗凝药物、胃肠手术,DifferentiatingfeaturesofupperGIandlowerGIbleedingUpperGILowerGIManifestationHematemesisHematocheziamelenaNasogastricaspirateBloodyClearBUNElevatedNormalBowelsoundHyperactiveNormal,医源性出血（iatrogenicbleeding）,Diagnostic（诊断）Therapeutic（治疗）,便秘Constipation,Definition-simple,FrequencyStoolslessfrequentthan3perweekProcessStraining（费力）StoolsignatureHardorlumpy（多块状）stools,Definition-complicated,Strainingin25%ofmovementsFeelingofincompleteevacuation（不尽感）after25%Senseofanorectalobstruction/blockadein25%Manualmanoeuvres（人工）tohelpin25%Hardorlumpystoolsin25%Stoolslessfrequentthan3perweek(2+foratleast3monthsduringthelastyear),Epidemiology（流行病学）,ChronicconstipationiscommonSlightlymorecommoninwomenF/Mratio=range1.3to2.5Affectsallagegroups,Causes（病因）,Functional（功能性）Organic（器质性）,Functional,Decreasedexercise（锻炼）Noteatingenoughfibre（纤维）Notdrinkingenoughfluid（液体）Depression/grief/anxiety（抑郁、悲伤、焦虑）Motility（动力）disorder:IBS（肠易激综合征）,Organic,Analsphincterspasm:proctitis（直肠炎）,analfissure（肛裂）Powerlessevacuation:ascites（腹水）,systemicsclerosis（硬皮病）Obstruction:Benignstricture（良性狭窄）,malignancy（恶性疾病）SystemicdiseasesDrugs,Systemicdiseases,PeripheralneurogenicHirschsprungs（先天性巨结肠）,autonomicneuropathy（自主神经疾病）,Diabetes（糖尿病）,pseudo-obstruction（假性肠梗阻）CentralneurogenicParkinsons（帕金森病）,multiplesclerosis（多发性硬化）,spinalcordinjury（脊髓损伤）Non-neurogenicHypothyroidism（甲减）,hypercalcaemia（高钙血症）,panhypopituitarism（垂体功能减退）,pregnancy（怀孕）,anorexianervosa（神经性厌食）,systemicsclerosis（硬皮病）,Drugs,ANALGESICS（镇痛药）Opiates!(thisincludestramadol)ANTICHOLINERGICS（抗胆碱药）Antispasmodics,antidepressants,antipsychoticsCATION-CONTAINING（阳离子结合剂）Ironsupplements,antacids,NEUR