学上血PBLPPT课件.ppt

上消化道大出血MassiveUpperGastrointestinalBleeding,IntroduceOurselves,Dr.Yang&Dr.Li,BasicConcepts,WhatIsMassiveBleeding,20%(800ml)bloodlossHemodynamicinstability血流动力学不稳Clinicalsignsofpoorperfusion组织灌注差,WhatIsUGI,Esophagus食道Stomach胃Duodenum十二指肠,Jejunum空肠Ileum回肠AscendingColon升结肠TransverseColon横结肠DescendingColon降结肠SigmoidColon乙结肠Rectum直肠Anus肛门,PleaseRemember,UGIBisnotuncommonintheemergencyroomMortalityrateisabout10%UGIBisaseriesofdiseasesmainlytreatedbyinternalmedicine.3-15%requireasurgicalprocedure,Letshaveaproblem!,PatientCome,45-yrfemalefirstepisodeofhematemesis呕血transferredfromasmallhospital2unitsofpackederythrocyte红细胞tranfusednasogastrictube胃管introducedwithactivebleedingpulse120bpm,BP80/40mmHg,WhatIsYourDecision,Whatisyourintuition直觉?,ForReference,Doesthepatienthavelife-threateningsituation?hypovolemicshock低血容量性休克lowbodytemperature体温降低anemia/hypoxemia贫血/低氧血症comorbidities并存病Isitamassiveorminorbleeding?Whereisthemostprobablebleedingsite?,Worrisomeclinicalsignsandsymptoms,tachycardia心动过速morethan100beatsperminute(bpm)systolicbloodpressure(SBP)收缩压90mmHgposturalhypotension体位性低血压SBPdecrease15mmHgorpulserateincrease10bpmcoolextremities四肢厥冷syncope晕厥ongoingbriskhematemesis进行性/活跃地呕血maroonstool枣红便,MassiveorMinor,UGIBorLGIB,EstimationofBloodLoss,occultbloodstool5-10ml/24hmelena50-100ml/24hhematemesis250-300mlinstomachCNSchange500mlhypovolemia1000ml/shortperiod,Child-PughClassification,GradeA=5-8points,GradeB=9-11points,GradeC=12-15points,WhatIsYourDecision,Whatarethemanagementpriorities优先顺序tothispatient?,ForReference,Resuscitation复苏Hemostasis止血Differentialdiagnosis鉴别诊断Basicdiseasetreatment治疗原发病Comorbiditymanagement处理并存病,InitialResuscitation,ABCairway保持气道通畅breathing维持呼吸和供氧circulation维持循环bilateralintravenousaccess(atleast)双路静脉通路short,largepore短而粗fastfluidreplacement快速液体输入3-for-1rule:1mlbloodloss,3mlcrystalloidfluidbloodtransfusion:2-6unitsofpackederythrocyteclosemonitoring密切监护,MedicalTherapy,vasopressin血管加压素somatostatinoranalogs生长抑素或同类物antacidagents制酸剂H2-receptorantagonistH2受体拮抗剂protonpumpinhibitor质子泵抑制剂hemostaticagents&bloodcoagulationfactors止血剂和凝血因子,NasogastricTubeIntroduction,aspiration&lavage吸引和冲洗siteofbleedingbilewithoutbloodUGIBnotlikelygastricfluid&bloodUGIBcleargastricfluidduodenalbleedingstillpossiblefalsenegative假阴性approximately10%hemostasis&monitoring止血和监控icysalinelavagewithepinephrine肾上腺素aspirationcolor&amountreducevomiting减少呕吐,protecttheairway,BalloonTamponade气囊压迫,temporarymeasureduringresuscitation(24-48hr)20%complicationrateairwayobstruction气道阻塞aspiration误吸esophagusnecrosis食管粘膜坏死arrhythmia心律失常recurrentbleedingafterreleaseofballoonfirstinflategastricballoonto60mmHg(200ml)theninflateesophagusballoonto40mmHg(150ml)pullingweight0.25kgusingapulley滑车releasefor15minevery4hrs,WhatIsYourDecision,Whatquestionwouldyouaskthepatient?,ForReference,Historyofillness病史Precipitatingfactors诱因Comorbidities并存病,History,historyofbleeding出血情况time持续时间symptoms表现症状amount出血量historyofrelateddiseasespepticulcer消化性溃疡liverdiseases肝脏疾病cholangio-pancreaticdiseases胆胰疾病coagulopathy凝血障碍others,Precipitatingfactors,alcoholabuse酒瘾NSAIDs(nonsteroidanti-inflammatorydrugs)ingestion非甾体类抗炎药物应用stress应激:burninjuriesCurlingheadinjuriesCushing,FrequentSymptoms,Hematemesis呕血-40-50%Melena黑便-70-80%Hematochezia便血-15-20%Eitherhematocheziaormelena-90-98%Syncope晕厥-14.4%Presyncope晕厥前期-43.2%Dyspepsia消化不良-18%Epigastricpain上腹痛-41%Heartburn胃灼热-21%Diffuseabdominalpain弥漫性腹痛-10%Dysphagia吞咽困难-5%Weightloss体重减轻-12%Jaundice黄疸-5.2%,WhatIsYourDecision,WhatisthedifferentialDiagnosis鉴别诊断?,ForReference,Pepticulcer消化性溃疡Stressgastritis应激性胃炎Stomachneoplasms胃肿瘤Portalhypertension门脉高压Hemobilia胆道出血Miscellaneous其他少见原因,PepticUlcer,historyofchroniculcerepigastricpain(nocturnalsymptoms)上腹痛（夜间痛）dyspepsia消化不良satiety饱胀historyofmucosadamagedietsmokingNSAIDs非甾体类抗炎药物Adrenalcorticalhormone肾上腺皮质激素usuallymelena,sometimeshematemesis,StressGastritis,historyofstress应激病史burninjuriesheadinjuriespredisposingclinicalconditions可导致应激的临床情况shock休克multipletrauma多发伤ARDS(acuterespiratorydistresssyndrome)急性呼吸窘迫综合征SIRS(systemicinflammatoryresponsesyndrome)全身炎症反应综合征MODS(multipleorgandysfunctionsyndrome)多脏器功能障碍综合征sepsis脓毒症,StomachNeoplasms,middleage中年weightloss体重减轻anorexia厌食irregularepigastricpain不规则腹痛abdominalmass腹部包块,PortalHypertension,predisposinghistoryofcirrhosis肝硬化基础疾病hepatitis肝炎Schistosomiasis血吸虫病alcoholabuse酒瘾specialfeatures特殊体征jaundice黄疸ascites腹水dilatedveinintheanteriorabdominalwall腹壁静脉怒张rectalhemorrhoids痔,FormationofPortalSystem,3inflowveincollectbloodfromspleen,pancreas,stomach,intestine,colon,andrectumsplenicveinsuperiormesentericveininferiormesentericvein2branchesintoleft&righthepaticlobethroughhepaticsinustohepaticveintoIVC75%bloodsupply,50%oxygensupplyofliver,CollateralVascularSystem侧支循环,esophageal-fundussubmucosalvenousplexus食管下段-胃底交通支rectalhemorrhoidalsystem直肠下段肛管交通支retroperitonealsystem后腹膜交通支anteriorabdominalwallsystem前腹壁交通支,DefinitionofPortalHypertension,normalportalpressure:13-24cmH2Onormalhepaticveinpressuregradient(HVPG):5-9cmH2Oportalhypertension:30-50cmH2OHVPG12mmHgleadstoUGIB,CauseofHypertension,PathophysiologyofPortalHypertension,splenemegaly&hypersplenism脾肿大/脾功能亢进peripheraltotalbloodcountdecreasecollateralvascularvarix侧支静脉曲张esophageal-fundussubmucosalvenousplexushasgreatestgradient,causemassiveUGIBhemorrhoidCaputMedusae海蛇头ascitescapillaryfiltrationpressureincrease毛细血管渗透压增加hypoalbuminemia低白蛋白血症excessivelymphaticfluidgeneration淋巴液生成过多hyperaldosteronemia高醛固酮血症portalgastropathy/encephalopathy门脉性胃病/脑病stomachmucousedema胃粘膜水肿portalsystemicshunt门体分流,CaputMedusae,Hemobilia,hemobiliatriad胆道出血三联症biliarycolic胆绞痛obstructivejaundice梗阻性黄疸gastrointestinalbleeding消化道出血livertrauma肝外伤hepatichemangioma肝血管瘤hepaticneoplasm肝肿瘤hepaticabscess肝脓肿biliarytractstone胆道结石,Miscellaneous,Mallory-Weisssyndrome:linearmucosallacerationnearcardia贲门asaresultofforcefulvomiting,retching干呕orcoughingDieulafoylesion:vascularmalformationinstomachAngiodysplasia血管发育不良:abnormaldilated,thin-walledmucosalorsubmucosalvessels粘膜/粘膜下血管,WhatIsYourDecision,Whatphysicalexamination体格检查findingswouldyousearchfor?,ForReference,SignsofshockandbloodlossSignsofchronicliverdiseaseSignsoftumor,Shock&BloodLoss,pulseandbloodpressure脉率血压posturalhypotension体位性低血压mentaldisorder:anxious焦虑,confusion意识模糊,delirium谵妄,lethargy嗜睡,presyncope晕厥前期,syncope晕厥signsofanemia:paleconjunctivaandnailbed结膜甲床苍白signsofpoorperfusion:coldextremities四肢厥冷,coldsweating冷汗,oliguria少尿,chestpain胸痛,ChronicLiverDiseases,spiderangiomata蜘蛛痣palmaerythema肝掌gynecomastia男性乳房发育splenomegaly脾肿大ascites腹水pedaledema足部水肿asterixis扑翼样震颤CaputMedusae海蛇头,Tumor,upperabdominalmass上腹包块leftsupraclavicularlymphnode(Virchowsnode)左锁骨上淋巴结肿大umbilicalnodular(SisterMaryJosephsnode)脐周结节Douglaspouchnodular(Bloomersshelf)直肠子宫（膀胱）陷凹结节,WhatIsYourDecision,Whatdiagnosticstudieswouldyouorder?,ForReference,Completebloodcount(CBC)全血细胞计数Bloodcrossmatch交叉配血Coagulationprofile凝血功能Liver&Renalfunction肝肾功能Calciumlevel血钙Gastrinlevel血胃泌素CTscan计算机断层扫描orUltrasonography超声检查DigitalSubtractionAngiography(DSA)数字减影血管造影Endoscope内镜,EndoscopicExplore,diagnosis&treatment诊断/治疗双重作用mostreliable&effectivemethod最可靠最有效within24-48hrsafterbleeding应在出血后24-48小时内进行contraindication反指征hemodynamicinstablility血流动力学不稳定severecardiacdecompensation严重心功能失代偿acutemyocardialinfarction急性心肌梗塞perforatedviscus脏器穿孔,UlcerwithBlackSpot10%Rebleeding,UlcerwithBloodClot22%Rebleeding,UlcerwithVisibleVessel43%Rebleeding,UlcerwithActiveBleeding55%Rebleeding,EsophagusVarices,HypertensivePortalGastropathy,InjectionofSclerosant硬化剂,BandLigation皮圈套扎,Hemoclip止血夹,LaserApplication激光止血,HeaterProbe加热探针,WhatIsYourDecision,Whatarethetherapeuticoptionsforeachcommonetiology病因ofmassiveUGIBafterinitialresuscitation?,ForReference,MedicineEndoscopeSurgery,Non-VaricealBleeding,therapeuticendoscopewith/withoutmedicineifeffectivethencontinuedrugtherapyeradicationofH.pylorimucousprotection2attemptsofendoscopicfailurepursuesurgeryothersurgicalindicationsseverelife-threateningbleedingnotresponsivetoresuscitationcoexistingreasonofperforation,obstructionormalignanciessecondhospitalizationofpepticulcer,VaricealBleeding,drugtherapywith/withoutballoontemponadeendoscopicbindingorsclerotherapytransjugularintrahepaticportosystemicshunt(TIPS)经颈静脉肝内门体分流术effectiverate90%rebleedingrateinoneyear16-30%shuntdisfunctionratein6months50-60%inducingencephalopathyrate25-35%30daymortalityrate14-16%canbeusedasatemporarymethodbeforetransplantationChildA&BsurgeryChildCtransplantation,TIPS,8-12mm,WhatIsYourDecision,Howtoperformtheoperation?,ForReference,Exploration探查Hemostasis止血RadicalOperation根治,Exploration