上消化道出血(修改)PPT课件

.,1,上消化道出血,乐亭县医院,洪素妹,.,2,简介,上消化道出血:Treitz韧带以上的消化道引起的出血:食管,胃,十二指肠,胰,胆,胃空肠吻合术后的空肠病变下消化道出血:Treitz韧带以下的消化道引起的出血上消化道出血引起的大量出血较下消化道更为常见大量出血:短期内失血超过1000ml或循环血量20%,.,3,常见病因,消化性溃疡(十二指肠和胃)33-51%食管和胃静脉曲张23-33%Mallory-Weiss综合征3-10%胃或十二指肠糜烂1-19%血管瘤0-7%肿瘤1-5%,.,4,Withtheinvertedgastroscopeaspurtinghemorrhagefromafundalvariceisdiscerbnable.HemostasisisachievedwithseverallowvolumeinjectionsofHistoacryl-glue.Therightpictureshowsthetherapeuticsuccess.,.,5,Therearebloodcoverederrosionsthroughoutthewholestomach.ThishasledtoaupperGIhemorrhagecompromisingthepatienthemodynamically.Thesolereasonwasasingleingestionof400mgofibuprofen,.,6,Thismassivevesselwithactivebleedingwasdiagnosedina58year-oldpatient,whopresentedwithtarystools.Thefirstpictureshowsthelesionafterinjectionoffibringlue.Therightpictureshowsadditionallyappliedhemoclips.Bleedingstoppedattheendoftheprocedure,butreccurredtwicebeforethepatienthadtobetreatedsurgically.Indieu-la-foyulcersanarterialvesselofabnormalsizereachesthemucosacausingatinyulzerationbypermanentcompressionofthemucosallayer.,.,7,EsophagealvaricesgradeII(right)undgradeIII(left).Cherryredspotsaresignsofimminenthemorrhage(right).Theycorrespondtoareasofespeciallythinandalteredvaricealwall.,.,8,Thisduodenalulcerattheleftedgeofthefigure,showsanoozing,activebleeding.AccordingtotheForrestclassificationofgastrointestinalhemorrhageoftheupperGI-tract,thisbleedingisgradedasForrestIb.Thevisiblevesselistreatedbyprimaryapplicationofahemoclip.Atthe3weekfollow-up(fig)theClipisstillintheoriginalposition.Theulcershowsaprogressivehealing.,.,9,Inoperablecholedochalcancer.Awallstenthadbeeninserted3monthsearlier.Thepatientwasadmittedforseverehemorrhage,whichwasendoscopicallyprovedtooriginatefromthebiliaryduct.Thehemorrhagewasnotamenabletoendoscopyandsurgery.Hugebloodclotsprolapsefromthebiliaryduct.,.,10,临床表现,呕血与黑粪,失血性周围循环衰竭,血象变化,发热,氮质血症,失血量和休克的估计,.,11,诊断思路,是上消化道出血吗?,出了多少血?,出血停止了吗?,什么原因引起的出血?,.,12,上消化道出血的确立,呕血和黑粪,失血性周围循环衰竭,血和粪便的检查,早期识别:直肠指诊,排除消化道以外的病因:咯血、口鼻咽出血、事物或药物,.,13,出血量的估计,粪便隐血试验阳性每日消化道出血510ml黑粪50100ml呕血250300ml出现全身症状400500ml周围循环衰竭1000ml,最有价值的标准:周围循环衰竭的临床表现动态观察血压和心率,.,14,出血是否停止,继续出血或再出血的表现:反复呕血或黑粪周围循环衰竭经治疗后无改善或波动HbRBC继续下降,Ret持续升高补液与尿量足够的情况下,血尿素氮持续或再次升高,出血后48小时以上未再继续出血,再出血可能性小;既往有大出血史、本次出血量大、24小时内反复大量出血、食管胃底静脉曲张出血、有明显的高血压或动脉硬化者,再出血可能性大,.,15,出血的病因,病史实验室检查胃镜:首选;推畅急诊胃镜检查(2448hr)X线钡餐其他:选择性动脉造影,.,16,治疗,原则:抗休克,积极补充血容量,一般的急救措施:禁食,卧床休息,保持呼吸道通畅严密监测生命体征,.,17,积极补充血容量:立即配血,输足量全血紧急输血指征:改变体位出现晕厥,血压下降1520mmHg,心率上升10次/分收缩压90mmHg(或较基础下降25%)Hb7g/L或Hct25%,治疗,.,18,止血措施,食管胃底静脉曲张破裂大出血-出血量大,再出血率高,死亡率高,治疗,药物止血血管加压素(vasopressin)机制:收缩内脏血管,减少门静脉血流,降低门静脉及侧枝循环压力用量:0.2U/分持续静脉滴注不良反应:腹痛,血压升高,心律失常,心绞痛,心肌梗死建议:与硝酸甘油同时用禁忌:有冠心病者,.,19,药物止血生长抑素(somatostatin)机制:减少内脏血流,减少奇静脉血流优点:疗效确实,无全身血流动力学改变缺点:价格昂贵用量:14肽天然生长抑素:首剂250ug静脉缓注,继以250ug/h静脉滴注注意:该药半衰期短,中断超过5分钟须再次首剂8肽生长抑素:首剂100ug静脉缓注,继以2550ug/h持续静脉滴注,治疗,.,20,气囊压迫止血,治疗,三腔二囊管,食管囊(3545mmHg),胃囊(5070mmHg),优点:止血确实,缺点:痛苦并发症多(吸入性肺炎,窒息,食管粘膜坏死,心律失常等)早期再出血率高,不推荐作为首选治疗措施,.,21,内镜治疗硬化剂注射皮圈套扎硬化剂注射+皮圈套扎,治疗,优点:止血确实可有效防止早期再出血是治疗食管胃底静脉曲张的重要手段,并发症:局部溃疡,出血,穿孔,瘢痕狭窄等,时机:大出血基本控制,患者基本情况稳定,.,22,外科治疗,外科手术适应症:内科治疗无效