呕血黑便(1)PPT课件.ppt

1,HEMATEMESIS,caiqiaoyinDepartmentofGastroenterology,AffiliatedMindaHospitalMedicalCollege,HubeiUniversityforNationalities,.,2,TheGastrointestinalSystem,anatomyWhatconstitutesthedigestivesystem?GItractconsistsofahollowmusculartubestartingfromtheoralcavity,goingthroughtherectumandisendedattheanus,wherefoodisexpelled.,3,TheGastrointestinalSystem,digestivetractStartsatmouthpharynxesophagusstomachsmallintestinelargeintestinerectumendsatanusdigestiveglandsalivaryglands,liver,pancreasgallbladder,4,TheGastrointestinalSystem,PhysiologicalfunctionThemainfunctionoftheGItractisdigestionandabsorptionofnutrientsThemovementofthesmoothmusclesintheGIiscalledperistasisandpropelsfoodintheforwarddirection-grindandexpelfoodAccessoryorgansthatassistthetractbysecretingenzymestohelpbreakdownfoodintoitscomponentnutrients(salivaryglands,liver,pancreasandgallbladder),5,TheGastrointestinalSystem,DigestiveandabsorptiveprocesstakeplaceintheGItract,Themotherriverofthehumanbody,6,TheGastrointestinalSystem,pathology,Sciencediet,doyouhavehealthydiet?,inflammation,bleeding,erosion,necrosis,ulcer,cancerous.,7,GastrointestinalProblems,uppergastrointestinaltractdisorderDysphagiaNauseaVomitinghematemesishematocheziamelena.lowerGItracthematochezia.,jejunum,duodenum,suspensoryligamentofduodenum,duodenojejunalflexure,uppergastrointestinaltract,lowergastrointestinaltract,8,definitionofhematemesisandmelaena,hematemesis-isvomitingofblood.whichcanbefreshandred,ordegradedbygastricpepsin,whenitisdarkbrownincolourandresemblescoffeegrounds.melaena-isthepassageoftarry,shinyblackstoolswithacharacteristicodourandresultsfromuppergastrointestinalbleeding.,9,colourofhematemesis,colourofhematemesisdependsontheamountandcharacterofthegastriccontentsatthetimebloodisvomitedandonthelengthoftimethebloodhasbeeninthestomach.brightredblood-thesourceofbleedingisabovethegastroesophagealsphincter,e.g.fromesophagealvarices,activelyvomited.Brightredbloodinthevomitindicatesafreshhemorrhageandlittlecontactofthebloodwithgastricjuicesbrownish/darkbrown(coffee-ground)Gastricacidschangebrightredbloodtoabrownishcolorandthevomitisoftendescribedas“coffee-ground”incolor.,10,colourofmelaena,colourofmelaenaistarry,shinyblackstoolsdistinguishmelaenafromthemattblackstoolsassociatedwithoralironorbismuththerapy.OB(-)hemoglobin(Fe2+)-Hydrochloricacid(HCl)-Acidificationofmethemoglobin(Fe3+)(Reddishbrown)-Bacterialaction-Ironsulfide-Fe(2)S(3)-FeS(black)Fe2+(Bivalentironion)-Fe3+(Ferricironion),血红蛋白的化学式为(C34H32O4N4Fe)-二价铁Fe2+(Bivalentironion)多种氧化物均可将血红蛋白氧化成高铁(Fe3+Ferricironion)血红蛋白，而失去带氧能力。高铁血红蛋白呈红褐色三硫化二铁Fe2S3为黄绿色固体;相对密度4.3;强热则分解;不溶于水，在热水中分解成硫化亚铁和硫;遇酸分解，放出硫化氢气体,硫化亚铁FeS为棕黑色块状物,11,amountofhematemesisandmelena,Evaluationofbleedingamount5-10mlOB(+)50-100mlMelena250-300mlHematemesis/Hematochezia400-500mlSymptomsofhypovolemicshock(lowcirculatingbloodvolume)dizziness,palecomplexion,coldsweats,acromegalydamp,drymouthdysphoria,lessurine1000mlhemorrhagicshock,SBP90mmHg,P120bpm(20%-30%Systemiccirculationbloodvolume),12,Causesofhematemesis,1.uppergastrointestinaltractdiseasepepticulceresophagitis,gastritis,duodenitisMallory-Weissesphagealtearesophagealvaricesesophagealorgastricmalignancy(cancer)vascularmalfomation.2.others:nosebleedinghematologicalsystemdiseasesuremiaDiseasesofthebodysystemthrombolyticsandanticoagulants.,VarisesVarisesesofagusVarisesfundusDieulafoyhaemangiomas,Nonvarisesesofagitis,gastritisduodenitispepticulcerStressulcerMallory-WeisstearTumor/Carcinoma,13,Causesofhematemesis,Themostcommoncausesofhematemesisare:pepticulcer,gastritis,esophagealvaricesorlesions,andcancerofthestomach.Benigntumors,traumaticpostoperativebleeding,andswallowedbloodfrompointsinthenose,mouth,andthroatcanalsoproducehematemesis.,14,esophagealvarices,15,Mallory-Weisssyndrome,Mallory-Weisssyndrome:bleedingtearsintheesophagalmucosa,usuallycausedbyprolongedandvigorousretching.,16,esophagalcancer,Tumorsofesophagus.,17,gastriculcer(GU),Dieulafoydisease,alcoholdrug:NSAID/steroidsHelicobacterpylori,helicobacterpylori,18,ganstriccancer,19,acuteerosiveandhemorrhagicgastritis,alcoholdrugNSAIDsteroidsthrombolyticsandanticoagulants,20,NSAID-inducedhemorrhagicgastritis,21,duodenalulcer(DU),Vascularmalfunctionsofthegastrointestinaltract,suchasbleedinggastricvaricesorduodenumvarices,22,predictionoftheriskofmortalityinpatientswithupperGIbleeding-RockallScore,criterionscoreage:60/60-79/80012shock:none/pulse100bpmSBp100mmHg/SBp100mmHg012comorbidity:none/heartfailure/ischaemicheartdiseaseorothermajordisease/renalfailureordisseminatedmalignancy023endoscopicfindings:Mallory-Weisstearandnovisiblebleeding/allotherdiagnoses/uppergastrointestinalmalignancy012majorstigmataofrecenthaemorrhage:none/visiblebleedingvesseloradherentclot02totalscorepre-endoscopyscore4=25%mortality(maximumscore=7)pre-endoscopypostendoscopyscore8+=40%mortality(maximumscore=11)postendoscopy,23,predictionoftheriskofmortalityinpatientswithupperGIbleeding-RockallScore,24,differentialdiagnosis,hemoptysis-isspittingorcoughingofblood,thebleedinglesionsmaybeanywherefromnosetolung.hemoptysishematemesispathogenesisrespiratorytractdiseaseupperGItractdisease(causes)bronchitis/pneumonia)PU/livercirrhosis/cancertuberculosis/carcinomagastritis/esophagealvaricesheartfailurebleedingdisordercomplaintslarynx(throat)itchabdominaldiscomfortable(beforebleeding)chestpain/distress,coughnasea,vomitstyleofbleedingspitting/coughingoutvomitingoutPHalkline7acidity7melena-+sputumafterbleeding+-+,25,clinicaloccurance,symptoms-historytakingdependontheamountandspeedofbleedingchiefcomplaints:hematemesis/melena/Hematocheziaaccompanycomplaints:abodominalpain/dizzy/sweat/conscious/shortofbreath/pasthistory:IsthereaprevioushistoryofPUorliverdisease?Isthereahistoryofalcohol,NSAIDorcorticosteroidingestion?Didthevomituscomprisefreshbloodorcoffeeground-stainedfluid?Wasthehnatemesisprecededbyintenseretching?Wasbloodstainningofthevomitusapparentinthefirstvomit?,26,clinicaloccurance,physicalexamination(signs)Vitals:T,P,R,Bp(Tachycardia,hypotension)Skinexaminationjaundice/spidernaevi/caputmedusae/palmarerythema/mucotutaneoushemorrhagepallor/hydration/edma,palmarerythema,distendedveins,27,clinicaloccurance,physicalexamination(signs)Abdominalexaminationinspection:scars/swellings/distendedveins/varicesofabdominalwallpalpation:tnderness/hepatomegaly/splenomegalypercussion:ascitesausculation:bowelsounds/bruits,28,clinicaloccurance,Laboratoryexaminationbloodroutineexamination(RBC/hemoglobin/Hct/WBC/PLTcount)coagulationfunction:PT/APTTliverfunction:TBil(totalbilirubin):directbilirubin(DBIL),indirectbilirubin(IBIL)albuminenzymology(AST/ALT/GGT/ALP)renalfunction:BUNandcreatinine,29,clinicaloccurance,endoscopyexamination,30,clinicaloccurance,diagnosishistorytaking-complaintsphysicalexaimation-signsLaboratoryexaminationendoscopyexamination,31,ClinicalScenario,67yoMwithhistoryofHTNandosteoarthritiswhopresentstotheEDwith3episodesofcoffeegroundemesistoday.Noabdominalpain,melenaorhematochezia.Nohistoryofliverdiseaseorcoagulopathy,+occasionalETOHuse.MedicationsincludeHCTZ,Lisinopril,andIbuprofenPRNforjointpainVSonarrival:T37,HR102,BP108/72,similarBPstanding,Pox99%RAExamina