上消化道出血 课件

G I Bleeding Presentedby AhmedT Al SuwaidiMohamedS Al Hoqani G I BleedingCase 50yrs Pakistani maleC O Bleeding rectum Abd painPainlessbleeding 1yr excessbleeding 1monthBlack 4 5times day littlequant Abd painVomiting 1week G I BleedingCase M H nopepticulcerdisease nomedications NSAIDs nourinarysymptoms notknownDM HPTN IHD weightloss G I BleedingCase O E Afebrile nopallor notdyspneaic nolymphoadenopathies noS C L N G I BleedingCase VitalSigns Pulse 78bts min BP 130 80 RR 18br minHeart NADLung NAD G I BleedingCase Abd notdistended noepigast tenderness tender firm partlymobilemassatRtlumbarregion spleennotpalpable Ltlobeliverpalpable mildlytender bowelsoundspresent G I BleedingCase PR noenlargedpiles noactivebleeding nopalpablemass nobloodonfingerECG CBC SrAmylase Bleedingprofile AbdX ray fecalloadingascendingcolon G I BleedingCase LabResults Hb 14 1g dl Plt 252 103 Hypochromic microcytic PT 17 3sec aPTT 35 4sec SrAmy 129U l 106U l Na 140mmol l K 4 1mmol l BUN 17mg dl G I Bleeding AcuteVsChronicAcuteUpperG I Bleeding AcuteLowerG I Bleeding AcuteUpperG I Bleeding HaematemesisMelaenaSite Time AcuteU G I Bleeding Aetiology 1 Drugs Aspirin NSAIDs 2 Alcohol3 Chronicpepticulceration 50 ofGIhemorrhage 4 Others refluxesophagitis varices gastriccarcinoma acutegastriculcers erosions AcuteU G I Bleeding Clinicalapproach 1 recent 24hrs thenhospitalized 2 ifsmallamount noimmediateTx becauseCVScancompensate3 85 stopbleedingduring48hrs4 historyhelpsindiagnosingthecauseofthehemorrhage eg longhistoryofindigestion orprevioushem fromulcers AcuteU G I Bleeding Clinicalapproach 5 factorsinclude age 60 amountofbldlost continuingvisiblebldloss signsofchronicliverdisease classicalclinicalfeaturesofshock AcuteU G I Bleeding Clinicalapproach 6 liverdisease severe recurrentbleeding iffromvarices 7 splenomegaly portalhypertension AcuteU G I Bleeding Immediatemanagement Emergencymanagement History exam Monitor pulse BP 30min Bldsample haemoglobin urea electrolytes grouping cross matching I v access AcuteU G I Bleeding Emergencymanagement cntd Bldtransfusionincaseof1 shock2 haemoglobin 10g dl Urgentendoscopy Surgerywhenrecommended AcuteU G I Bleeding Shockmanagement ABC Airway endotrachealtube oropharyngealairway Giveoxygen AcuteU G I Bleeding Shockmanagement cntd Breathing supportrespiratoryfunction Monitor resp rate bldgases chestradiograph Circulation expandcirculatingvolume blood colloids crystalloidssupportCVSfunction vasodilators Monitor skincolor peripheraltemp urineflow BP ECG AcuteU G I Bleeding GeneralInvestigations 1 Hb PCV2 CBC WBC etc 3 Bldglucose4 Platelets coagulation5 Urea creatinine electrolytes6 Liverbiochem 7 Acid basestate8 Imaging chest abd radiography US CT AcuteU G I Bleeding Generalmanagement Bloodvolume1 restorevolumetonormal2 transfusion Endoscopy1 shock suspectedliverdiseaseorcontinuedbleeding2 controlvaricesorulcerstoreducere bleeding AcuteU G I Bleeding Generalmanagement Drugtherapy1 H2 receptorantagonists2 protonpumpinhibitors Factorsinreassessment1 age 60 greatermortality2 recurrenthemorrhage mortality3 re bleeding mostlywithinthe1st48hrs4 surgicalproceduresincaseofseverebleeding Lowergastrointestinalhaemorrhage Causes Diverticulardisease Angiodysplasia Inflammatoryboweldisease Ischaemiccolitis Infectivecolitis Colorectalcarcinoma Investigation Mayshowangiodysplasticlesionsevenoncebleedinghasceased Mostpatientsarestableandcanbeinvestigatedoncebleedinghasstopped Intheactivelybleedingpatientconsider Colonoscopy canbedifficult Selectivemesentericangiography Requirescontinuedbleedingof 1ml minute RadionuclidescanningUsestechnetium 99mlabeledredbloodcells Management Ifsourceofcolonicbleedingunclearperformasubtotalcolectomyandend ileostomy Acutebleedingtendstobeselflimiting Considerselectivemesentericembolisationiflifethreateninghaemorrhage Ifbleedingpersistsperf