上海交大外科学上血PBL

上消化道大出血Massive Upper Gastrointestinal Bleeding,上海交通大学医学院瑞金临床医学院2009,Introduce Ourselves,Dr. Yang&Dr. Li,Basic Concepts,What Is Massive Bleeding,20% (800ml) blood lossHemodynamic instability血流动力学不稳Clinical signs of poor perfusion组织灌注差,What Is UGI,Esophagus食道Stomach胃Duodenum十二指肠,Jejunum空肠Ileum回肠Ascending Colon升结肠Transverse Colon横结肠Descending Colon降结肠Sigmoid Colon乙结肠Rectum直肠Anus肛门,Please Remember,UGIB is not uncommon in the emergency roomMortality rate is about 10% UGIB is a series of diseases mainly treated by internal medicine.3-15% require a surgical procedure,Lets have a problem!,Patient Come,45-yr femalefirst episode of hematemesis呕血transferred from a small hospital2 units of packed erythrocyte红细胞 tranfusednasogastric tube胃管 introduced with active bleedingpulse 120 bpm, BP 80/40 mmHg,What Is Your Decision,What is your intuition直觉?,For Reference,Does the patient have life-threatening situation?hypovolemic shock低血容量性休克low body temperature体温降低anemia/hypoxemia贫血/低氧血症comorbidities并存病Is it a massive or minor bleeding?Where is the most probable bleeding site?,Worrisome clinical signs and symptoms,tachycardia心动过速 more than 100 beats per minute (bpm)systolic blood pressure (SBP)收缩压 90mmHgpostural hypotension体位性低血压 SBP decrease 15mmHg or pulse rate increase 10 bpmcool extremities四肢厥冷syncope晕厥ongoing brisk hematemesis进行性/活跃地呕血maroon stool枣红便,Massive or Minor,UGIB or LGIB,Estimation of Blood Loss,occult blood stool 5-10ml/24hmelena 50-100ml/24hhematemesis 250-300ml in stomachCNS change 500mlhypovolemia 1000ml/short period,Child-Pugh Classification,Grade A=5-8 points, Grade B=9-11 points, Grade C= 12-15 points,What Is Your Decision,What are the management priorities优先顺序 to this patient?,For Reference,Resuscitation复苏Hemostasis止血Differential diagnosis鉴别诊断Basic disease treatment治疗原发病Comorbidity management处理并存病,Initial Resuscitation,ABCairway保持气道通畅breathing维持呼吸和供氧circulation维持循环bilateral intravenous access (at least)双路静脉通路short, large pore短而粗fast fluid replacement快速液体输入3-for-1 rule: 1ml blood loss, 3ml crystalloid fluidblood transfusion: 2-6 units of packed erythrocyteclose monitoring密切监护,Medical Therapy,vasopressin血管加压素somatostatin or analogs生长抑素或同类物antacid agents制酸剂H2-receptor antagonist H2受体拮抗剂proton pump inhibitor 质子泵抑制剂hemostatic agents & blood coagulation factors止血剂和凝血因子,Nasogastric Tube Introduction,aspiration & lavage吸引和冲洗site of bleedingbile without blood UGIB not likelygastric fluid & blood UGIBclear gastric fluid duodenal bleeding still possiblefalse negative假阴性 approximately 10%hemostasis & monitoring止血和监控icy saline lavage with epinephrine肾上腺素aspiration color & amountreduce vomiting减少呕吐, protect the airway,Balloon Tamponade气囊压迫,temporary measure during resuscitation (24-48hr)20% complication rateairway obstruction气道阻塞aspiration误吸esophagus necrosis食管粘膜坏死arrhythmia心律失常recurrent bleeding after release of balloonfirst inflate gastric balloon to 60mmHg(200ml)then inflate esophagus balloon to 40mmHg(150ml)pulling weight 0.25kg using a pulley滑车release for 15min every 4hrs,What Is Your Decision,What question would you ask the patient?,For Reference,History of illness病史Precipitating factors诱因Comorbidities并存病,History,history of bleeding出血情况time持续时间symptoms表现症状amount出血量history of related diseasespeptic ulcer消化性溃疡liver diseases肝脏疾病cholangio-pancreatic diseases胆胰疾病coagulopathy凝血障碍others,Precipitating factors,alcohol abuse酒瘾NSAIDs (nonsteroid anti-inflammatory drugs) ingestion非甾体类抗炎药物应用stress应激: burn injuries Curling head injuries Cushing,Frequent Symptoms,Hematemesis呕血 - 40-50% Melena黑便 - 70-80% Hematochezia便血 - 15-20% Either hematochezia or melena - 90-98% Syncope晕厥 - 14.4% Presyncope晕厥前期 - 43.2% Dyspepsia消化不良 - 18% Epigastric pain上腹痛 - 41% Heartburn胃灼热 - 21% Diffuse abdominal pain弥漫性腹痛 - 10% Dysphagia吞咽困难 - 5% Weight loss体重减轻 - 12% Jaundice黄疸 - 5.2%,What Is Your Decision,What is the differential Diagnosis鉴别诊断?,For Reference,Peptic ulcer消化性溃疡Stress gastritis应激性胃炎Stomach neoplasms胃肿瘤Portal hypertension门脉高压Hemobilia胆道出血Miscellaneous其他少见原因,Peptic Ulcer,history of chronic ulcerepigastric pain (nocturnal symptoms) 上腹痛（夜间痛）dyspepsia消化不良satiety饱胀history of mucosa damage dietsmokingNSAIDs 非甾体类抗炎药物Adrenal cortical hormone肾上腺皮质激素usually melena, sometimes hematemesis,Stress Gastritis,history of stress应激病史burn injurieshead injuriespredisposing clinical conditions可导致应激的临床情况shock休克multiple trauma多发伤ARDS (acute respiratory distress syndrome)急性呼吸窘迫综合征SIRS (systemic inflammatory response syndrome)全身炎症反应综合征MODS (multiple organ dysfunction syndrome)多脏器功能障碍综合征sepsis脓毒症,Stomach Neoplasms,middle age中年weight loss体重减轻anorexia厌食irregular epigastric pain不规则腹痛abdominal mass腹部包块,Portal Hypertension,predisposing history of cirrhosis肝硬化基础疾病hepatitis肝炎Schistosomiasis血吸虫病alcohol abuse酒瘾special features特殊体征jaundice黄疸ascites腹水dilated vein in the anterior abdominal wall腹壁静脉怒张rectal hemorrhoids痔,Formation of Portal System,3 inflow vein collect blood from spleen, pancreas, stomach, intestine, colon, and rectumsplenic veinsuperior mesenteric veininferior mesenteric vein2 branches into left & right hepatic lobethrough hepatic sinus to hepatic vein to IVC75% blood supply, 50% oxygen supply of liver,Collateral Vascular System侧支循环,esophageal-fundus submucosal venous plexus食管下段-胃底交通支rectal hemorrhoidal system直肠下段肛管交通支retroperitoneal system后腹膜交通支anterior abdominal wall system前腹壁交通支,Definition of Portal Hypertension,normal portal pressure: 13-24cmH2Onormal hepatic vein pressure gradient (HVPG) : 5-9cmH2Oportal hypertension: 30-50cmH2OHVPG 12mmHg leads to UGIB,Cause of Hypertension,Pathophysiology of Portal Hypertension,splenemegaly & hypersplenism脾肿大/脾功能亢进peripheral total blood count decreasecollateral vascular varix侧支静脉曲张esophageal-fundus submucosal venous plexus has greatest gradient, cause massive UGIBhemorrhoidCaput Medusae海蛇头ascitescapillary filtration pressure increase毛细血管渗透压增加hypoalbuminemia低白蛋白血症excessive lymphatic fluid generation淋巴液生成过多hyperaldosteronemia高醛固酮血症 portal gastropathy/encephalopathy门脉性胃病/脑病stomach mucous edema胃粘膜水肿portal systemic shunt门体分流,Caput Medusae,Hemobilia,hemobilia triad胆道出血三联症biliary colic胆绞痛obstructive jaundice梗阻性黄疸gastrointestinal bleeding消化道出血liver trauma肝外伤hepatic hemangioma肝血管瘤hepatic neoplasm肝肿瘤hepatic abscess肝脓肿biliary tract stone胆道结石,Miscellaneous,Mallory-Weiss syndrome: linear mucosal laceration near cardia贲门 as a result of forceful vomiting, retching干呕 or coughing Dieulafoy lesion: vascular malformation in stomachAngiodysplasia血管发育不良: abnormal dilated, thin-walled mucosal or submucosal vessels粘膜/粘膜下血管,What Is Your Decision,What physical examination体格检查 findings would you search for?,For Reference,Signs of shock and blood lossSigns of chronic liver diseaseSigns of tumor,Shock & Blood Loss,pulse and blood pressure脉率血压postural hypotension体位性低血压mental disorder: anxious焦虑, confusion意识模糊, delirium谵妄, lethargy嗜睡, presyncope晕厥前期, syncope晕厥signs of anemia: pale conjunctiva and nail bed结膜甲床苍白 signs of poor perfusion: cold extremities四肢厥冷, cold sweating冷汗, oliguria少尿, chest pain胸痛,Chronic Liver Diseases,spider angiomata蜘蛛痣palma erythema肝掌gynecomastia男性乳房发育splenomegaly脾肿大ascites腹水pedal edema足部水肿asterixis扑翼样震颤Caput Medusae海蛇头,Tumor,upper abdominal mass上腹包块left supraclavicular lymph node (Virchows node)左锁骨上淋巴结肿大umbilical nodular (Sister Mary Josephs node)脐周结节Douglas pouch nodular (Bloomers shelf)直肠子宫（膀胱）陷凹结节,What Is Your Decision,What diagnostic studies would you order?,For Reference,Complete blood count (CBC)全血细胞计数Blood cross match交叉配血Coagulation profile凝血功能Liver & Renal function肝肾功能Calcium level血钙Gastrin level血胃泌素CT scan计算机断层扫描 or Ultrasonography超声检查Digital Subtraction Angiography (DSA)数字减影血管造影Endoscope内镜,Endoscopic Explore,diagnosis & treatment诊断/治疗双重作用most reliable & effective method最可靠最有效within 24-48hrs after bleeding应在出血后24-48小时内进行contraindication反指征hemodynamic instablility血流动力学不稳定severe cardiac decompensation严重心功能失代偿acute myocardial infarction急性心肌梗塞perforated viscus脏器穿孔,Ulcer with Black Spot10% Rebleeding,Ulcer with Blood Clot22% Rebleeding,Ulcer with Visible Vessel43% Rebleeding,Ulcer with Active Bleeding55% Rebleeding,Esophagus Varices,Hypertensive Portal Gastropathy,Injection of Sclerosant硬化剂,Band Ligation皮圈套扎,Hemoclip止血夹,Laser Application激光止血,Heater Probe加热探针,What Is Your Decision,What are the therapeutic options for each common etiology病因 of massive UGIB after initial resuscitation?,For Reference,MedicineEndoscopeSurgery,Non-Variceal Bleeding,therapeutic endoscope with/without medicineif effective then continue drug therapyeradication of H. pylorimucous protection2 attempts of endoscopic failure pursue surgeryother surgical indicationssevere life-threatening bleeding not responsive to resuscitationcoexisting reason of perforation,obstruction or malignanciessecond hospitalization of peptic ulcer,Variceal Bleeding,drug therapy with/without balloon temponadeendoscopic binding or sclerotherapytransjugular intrahepatic portosystemic shunt (TIPS) 经颈静脉肝内门体分流术effective rate 90%rebleeding rate in one year 16-30%shunt disfunction rate in 6 months 50-60%inducing encephalopathy rate 25-35%30 day mortality rate 14-16%can be used as a temporary method before transplantationChild A & B surgeryChild C transplantation,TIPS,8-12mm,What Is Your Decision,How to perform the operation?,For Reference,Exploration探查Hemostasis止血Radical Operation