Upper gastrointestinal bleeding

Upper gastrointestinal bleeding上消化道出血,Upper gastrointestinal bleeding,A massive upper GI hemorrhage is generally defined as a loss of more than 1000ml of blood or a loss of 20% of intravascular blood volume. The severity of bleeding depends on whether the origin is venous, capillary or arterial.This type of bleeding may have come from the slow of a venous or capillary origin.,Common causes of upper gastrointestinal bleeding,Esophagus origin(most severe)Esophageal varices食管静脉曲张Esophogitis 食管炎Mallory-Weiss syndrom 食管贲门黏膜撕裂综合征 Stomach and duodenum(most common)Peptic ulcer diseaseStress ulcer 应激性溃疡Hemorrhagic gastriticCarcinoma 癌症Palyps 息肉,Systemic diseasesBlood dyscrasias 恶血质Leukemia Uremia 尿毒症Drug induced Salicylates 水杨酸 CorticosteroidsPhenylbutazone 保泰松 Indomethacin 吲哚美辛,Mallory-Weiss syndrome（食管贲门黏膜撕裂综合征）,Clinical manifestation,Hematemesis 呕血 and melena 黑便：are the most characteristic clincal maniestation.Hematemesis: the bright red color indicates that the blood has not been in contact with the stomachs acid secretions.the “coffee ground” vomitus reveals that the blood and other contents have been contact with gastric secrections.Melena: The longer the passage of blood through the intestines, the darker the color of the stool as a result of the degradations 降解 of hemoglobin 血红蛋白 and the release of iron.,Clinical manifestation,Hemorrhagic peripheral circulatory failure 失血性周围循环衰竭: dizziness, fatigue, palpitation 心悸, sweating, thirst, syncope晕厥, and shock. Fever: may be related to dysfunction of central thermoregulation体温调节中枢 induced by peripheral circulatory failure , normally T does not exceed 38.5 c with sustainable 3-5 day. Azotemia 氮质血症(Enterogenic 肠源性): after upper gastrointestinal hemorrhage, protein digestive product of the blood 血液蛋白质消化产物 in intestine is absorbed, causing increased urea nitrogen concentration 尿素氮浓度in the blood. (Nephrogenic 肾源性): peripheral circulatory failure reduced renal blood flow, resulting in mass of nitrogen retention氮质潴留. Acute hemorrhagic anemia 急性出血性贫血,Diagnostic studies,Endoscopy: preferred checking for upper gastrointestinal bleeding CBCBlood urea nitrogen (BUN)尿素氮Serum electrolytesBlood glucoseProthrombin timeLiver enzymesArterial blood gasesType and cross-match for possible blood transfusionsVomitus and stool occult blood testsUrinalysis,Emergency assessment and management,The immediate physical examination must be include a systemic evaluation of the patients condition with emphasis on BP, rate and character of pulse, peripheral perfusion with capillary refill.Vital sign should be monitored every 15 minutes. Signs and symptoms of shock must be evaluated and treatment should be started as soon as possible.The patient should be approached in a clam and assured manner to decrease the level of anxiety. when patient become irritated, intramuscular tranquillizers 安定10m could be applied.,Emergency assessment and management,When bleeding, patients should be in supine position with elevation of lower extremity; vomiting patient access semi-Fowlers 半卧位 or lateral position 侧卧位.Open IV line with large-gauge needle for fluid and blood replacement. It is generally best to begin with an isotonic crystalloid solution等渗晶体液 (lactated Ringers solution乳酸林格氏液).Whole blood, packed red blood cells 便携红细胞and fresh frozen plasma 新鲜冰冻血浆may be used for replacement of lost volume in massive hemorrhage.When upper GI bleeding is less profuse, infusion of isotonic saline solution等渗盐水 followed by packed red blood cells便携红细胞 permits restoration of the hematocrit红细胞压积more quickly.,Emergency assessment and management,NG tube should be in place for suction and lavage 灌洗.For most patients who are bleeding profusely, an indwelling urinary catheter will be inserted so that urine volume can be assessed hourly. Urine output should be measured hourly. A rate of at least 0.5 ml/kg per hour indicates adequate renal perfusion, lesser amount may indicates renal ischemia secondary to loss of blood volume.Urine special gravity should be measured: consistent readings greater than 1.025 indicate the urine is very concentrated and there is probably a low blood volume.A central venous pressure line may be inserted so that the patient s fluid volume can be monitored easily.,Emergency assessment and management,7. The nurses should be well informed as to what constitutes blood in the stools:Black tarry stools 黑色柏油便 indicate the presence of bleeding of prolonged duration.Bright red blood in the stool is usually from a source in the lower bowel.When vomitus contains blood but the stool contains no gross or occult blood, the hemorrhage is considered to have been of short duration.,Emergency assessment and management,Positive fecal occult blood test 大便潜血试验阳性indicates the amount of bleeding in 5 10ml;Melena 黑便 indicates the amount of bleeding occurs in 50 70ml or more;Hematemesis 呕血 indicates the blood volume of the stomach in 250 300ml;There systemic symptoms such as dizziness, palpitations, fatigue, suggests that bleeding volume of 400 500ml;If bleeding occurs more than 1000ml, it will causes acute peripheral circulatory failure, resulting in severe hemorrhagic shock.,Therapeutic management,Pharmacologic interventionInhibition of gastric acid secretion 抑制胃酸分泌药: used for hemorrhage caused by peptic ulcer and gastric mucosal lesions. AntacidHistamine receptor antagonists (cimetidine西米替丁, ranitidine 雷尼替丁; or oral omeprazole 洛赛克) or H+,K+-ATPase inhibitors,Therapeutic management,Pharmacologic interventionHemostatic 止血药: used for esophagogastric variceal bleeding.Vasopressin 血管加压素: cuases vasoconstriction, reduces pressure in the portal circulation and arrests bleeding. Its side effects consist of reducing coronary blood flow, increase heart rate and blood pressure. Therefore, it is suggested for combination of drug therapy using vasopressin and nitroglycerin 硝酸甘油. Nitroglycerin reduce the adverse effects of vasopressin while enhancing their beneficial impact.Somatostatin生长抑素: significantly reduce blood flow of azygos vein 奇静脉.,Emergency assessment and management,It has been common practice to lavage 灌洗 the stomach with cool or ice water or saline solution through NG tube to induce local vasoconstriction of the bleeding vessels.,Emergency assessment and management,10. The use of the endoscopic examination to perform transendoscopic electrocoagulation经内镜电凝, microwave hemostasis微波止血, laser to stop bleeding激光止血.Endoscopic hemostasis 内镜直视下止血 can be achieved by spraying喷洒 local hemostatic agents局部止血剂, such as norepinephrine 肾上腺素 or thrombin凝血酶; For esophageal variceal bleeding, endoscopic injection sclerotherapy硬化剂 ( 1% Aethoxysklerol 乙氧硬化醇 or 5% sodium morrhuate 鱼肝油酸钠) into the varicose veins and venous side, causing clots to stop bleeding.,Emergency assessment and management,The use of Sengstaken-Blakemore tube三腔双囊管 Surgical intervention Surgical intervention is indicated when bleeding continuous regardless of the therapy provided and when the site of the bleeding has been identified.,Condition observation 病情观察,Peripheral circulatory failure When patients change from the supine position 平卧 to semi-Fowlers 半卧, heart rate increases more than 10 times/min, drops in BP 1530mmHg, dizziness, sweating or syncope晕厥, these condition indicates large amount of bleeding, and obviously inadequate blood volume.Patients present restlessness烦躁不安, pale面色苍白, clammy skin皮肤湿冷, cold extremities四肢冰凉, indicating microcirculation perfusion deficiency 微循环灌注不足; if patient present gradually warmed skin, stopping in sweating, indicates improved blood perfusion.,Condition observation 病情观察,Judgment for continue or secondary bleeding recurrent hematemesis 呕血, vomit changed from brown to bright red.Increased melena with thin fecal and dark red color, accompanied by hyperaction of accommodation reflex 肠鸣音亢进. Clinical manifestations of peripheral circulatory failure can not improved after fluid replacement 补液 and blood transfusion 输血; or present ameli