呕血与便血课件

1、1 呕血与便血呕血与便血 Hematemesis and Hematochezia 2 Definition Hematemesis :Bloody vomitus from the upper gastro-intestinal(GI) tract （before the ligament of Treitz) Hematochezia: bright red , maroon or black blood from the rectum 3 Treitz: The ligament of Treitz is an anatomic landmark for the duodenal-jej

2、unal junction 4 Clinical Manifestation 1 Manner of bleeding presentation 2 Hypovolemia (低血容量) or shock 3 Anemia (贫血) 5 Patients manifest blood loss (A) Hematemesis 呕呕 血血 Character Bloody vomitus, either fresh and bright red or older and “coffee - ground” (hematin 酸化正铁血红素酸化正铁血红素) Manner of bleeding p

3、resentation from the GI tract in five ways: 6 cause of disease 90% upper GI bleeding is due to four lesions: 1) peptic ulcer (消化性溃疡消化性溃疡) 2) esophageal or gastric varices (食管胃底静脉曲张破裂食管胃底静脉曲张破裂) 3) hemorrhagic gastritis (急性糜烂性出血性胃炎急性糜烂性出血性胃炎) 4) gastric cancer 7 peptic ulcer 8 hemorrhagic gastritis 9

4、 esophageal varices 10 gastric cancer 11 Other causes of upper GI bleeding Mallory-Weiss tear 食道食道 - 贲门撕裂伤贲门撕裂伤 Foreign body in esophagus 食管异物食管异物 Ancylostomiasis 钩虫病钩虫病 Post-sphincterotomy 括约肌切开术后括约肌切开术后 12 Differentiation Nosebleeding? Hemoptysis? 13 Differntiating hemoptysis and hematemesis Hemop

5、tysisHematemesis Cause of disease TB, bronchiectasis, pneumonia, lung cancer,heart disease PU, liver cirrhosis, acute erosive and hemorrhagic gastritis Syptom before bleeding itch of laryngeal, dyspnea, cough epigastric discomfort, nausea and vomit Manner of bleeding hawkvomit , spurting Blood colou

6、r fresh redmaroon, coffee-ground Mixture in blood sputum foam food debris gastric juice Power of hydrogen alkalityacidity Melena nohave Sputum with bloody sputumno sputum 14 Manner of bleeding presentation (B) Hematochezia 便便 血血 Character u bright red or maroon blood from the rectum u pure blood u b

7、lood intermixed with formed stool 1. bloody diarrhea 15 (C) Melena 黑黑 便便 Character Shiny, black, sticky, foul-smelling stool Tarry stool(柏油样便柏油样便)(degradation of blood) Differentiation exogenous stool darkeners : animal blood, iron , bismuth (铋剂铋剂) Manner of bleeding presentation 16 Manner of bleedi

8、ng presentation (D) Stool with occult blood 隐血便隐血便 Detected only by testing the stool with a monoclonal antibody for human hemoglobin 17 Estimate amount of bleeding from upper GI tract 510 ml/d OB + 5070 ml/d Melena 250300 ml in short time Hematemesis 18 Causes of bleeding Colorectal cancer Colitis

9、Large hemorrhoid 大痔大痔 Rectum tear 肛裂肛裂 Vascular anomalies Hematologic diseases 19 Manner of bleeding presentation (E) without any objective sign of bleeding , with symptoms of blood loss 20 1. Hypovolemia or shock Depending on speed and volume of blood loss 1000mL: Weakness, giddiness (眩晕眩晕), tachyc

10、ardia(心动过速心动过速) , cold extremity, sweating Shock: hypotention (低血压低血压), oliguria, (少少 尿尿) 21 2. Anemia and hemogram changing If blood loss is acute, the hematocrit (红细红细 胞比容胞比容)dose not change during the first few hours after hemorrhage About 24 to 72 hours later, plasma volume is larger than normal

11、 and the hematocrit is at its lowest point 22 bleeding slowly hypochromic (血红蛋白过少血红蛋白过少) microcytic (小细胞小细胞) red blood cells mean corpuscular volume (MCV， 平均血球压积平均血球压积) of the cells may be low 23 7 6 5 4 3 2 1 Volume (Liters) 45 % 45 % 27 % ABC Hematocrit changes A Before bleeding B Immediately afte

12、r bleeding C 2472 hours after bleeding 24 3.Fever low grade fever in 24 hours after bleeding 25 4. Azotemia(氮质血症氮质血症) Degradation of protein in intestinal tract BUN in several hours after bleeding up to the peak in about 24-48 hours normal after 3-4days 26 5. Bowel sound Active bowel sound usually b

13、e presented in acute bleeding from GI tract 27 Where is the source of bleeding? Localization Upper GI bleeding: bleeding from a source proximal to the ligament of Treitz Lower GI bleeding: bleeding from a site distal to the ligament of Treitz 28 Localization Differentiating features of upper GI and

14、lower GI bleeding Upper GILower GI ManifestationHematemesisHematochezia melena Nasogastric aspirateBloodyClear BUNElevatedNormal Bowel soundHyperactiveNormal 29 Upper GI tract bleeding ? Clinical manifestation (hematemesismelena) Bowel sound Nasogastric tube 30 Hematemesis Melena Hematochezia More p

15、roximal lesions produce hematemesis or melena, whereas more distal lesions are more likely to produce hematochezia 31 Diagnostic approach 1. History and physical examination 2. Laboratory examination 3. Auxiliary examination 32 History and physical examination A history of previously documented GI t

16、ract disease determined by radiography, endoscopy, or surgical procedures is very useful Diagnostic approach to GI bleeding 33 Diagnostic approach to GI bleeding A history of epigastric (上腹部上腹部) burning pain promptly relieved by food or antacids (抗酸剂抗酸剂) or nocturnal (夜间夜间) pain suggests peptic ulce

17、r disease, particularly duodenal (十二指肠十二指肠) ulcer 34 Diagnostic approach to GI bleeding Patients with stigmata (特征特征) of hepatitis B or other chronic active liver disease e.g spider angioma (蜘蛛痣蜘蛛痣), ascites (腹水腹水), gynecomastia (男性乳男性乳 房发育房发育) may present with painless hematemesis from esophageal v

18、arices 35 Diagnostic approach to GI bleeding Patients with forceful, retching (干呕干呕)or multiple episodes of vomiting of food prior to the onset of hematemesis may be bleeding from Mallory Weisstears of the gastro-esophageal junction 36 Diagnostic approach to GI bleeding A history of gradual weight l

19、oss intermittent blood in the stools altered bowel habits often suggests colorectal malignancy 37 Diagnostic approach to GI bleeding Hemorrhoidal bleeding is often suggested by the presence of bright red blood surrounding well-formed, normal-appearing stools 38 Diagnostic approach to GI bleeding A r

20、ectal examination is essential to document stool color as well as to palpate for gross anorectal (肛直肠肛直肠) mass lesions such as polyps(息肉息肉), cancers, or large hemorrhoids. 39 Diagnostic approach to GI bleeding Auxiliary examination Endoscopy (内镜内镜) Endoscopy is the diagnostic procedure of choice because of its high accuracy and immediate therapeutic potential. Endoscopy , however , must be performed only following adequate resuscitation (复苏复苏) 40 Diagnosti