上消化道大出血

1、上消化道大出血上消化道大出血Introduce OurselvesDr. Yang&Dr. LiIntroduce OurselvesDr. Yang&Basic ConceptsBasic ConceptsWhat Is Massive Bleeding20% (800ml) blood lossHemodynamic instability血流动力学不稳Clinical signs of poor perfusion组织灌注差What Is Massive Bleeding20% (What Is UGIEsophagus食道Stomach胃Duodenum十二指肠Jejunum空肠Ile

2、um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What Is UGIEsophagus食道Jejunum空上消化道大出血上消化道大出血Please RememberUGIB 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

3、surgical procedurePlease RememberUGIB is not uncLets have a problem!Lets have a problem!Patient Come45-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 mmHgPatie

4、nt Come45-yr femaleWhat Is Your DecisionWhat is your intuition直觉?What Is Your DecisionWhat is yFor ReferenceDoes 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 prob

5、able bleeding site?For ReferenceDoes the patient Worrisome clinical signs and symptomstachycardia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 hema

6、temesis进行性/活跃地呕血maroon stool枣红便Worrisome clinical signs and sMassive or MinorClass IClass IIClass IIIClass IVBlood Loss ml750750-15001500-20002000Blood Loss %1515-3030-4040Pulse Rate bpm100100120140Blood PressurenormalnormaldecreasedecreaseCNS 神经系统症状Slightly anxious轻度焦虑Mildly anxious中度焦虑Anxious, con

7、fused焦虑/意识模糊Confused, lethargic意识模糊/嗜睡Massive or MinorClass IClass IUGIB or LGIBManifestation症状UGIBLGIBHematemesis呕血Almost certainRareMelena黑便 ProbablePossibleHematochezia 便血PossibleProbableBlood-streak stool便中带血丝RareAlmost certainOccult blood stool大便隐血PossiblePossibleUGIB or LGIBManifestation症状UGIE

8、stimation of Blood Lossoccult blood stool 5-10ml/24hmelena 50-100ml/24hhematemesis 250-300ml in stomachCNS change 500mlhypovolemia 1000ml/short periodEstimation of Blood LossoccultChild-Pugh ClassificationNo. of Points123Bilirubin(mol/L)总胆红素51Albumin(g/L) 白蛋白3528-35ModerateEncephalopathy 脑病NoneSligh

9、t ModerateGrade A=5-8 points, Grade B=9-11 points, Grade C= 12-15 pointsChild-Pugh ClassificationNo. oWhat Is Your DecisionWhat are the management priorities优先顺序 to this patient?What Is Your DecisionWhat are For ReferenceResuscitation复苏Hemostasis止血Differential diagnosis鉴别诊断Basic disease treatment治疗原

10、发病Comorbidity management处理并存病For ReferenceResuscitation复苏Initial ResuscitationABCairway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

11、packed erythrocyteclose monitoring密切监护Initial ResuscitationABCMedical Therapyvasopressin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Medical Therapyvasopressin血管加压Nasogastric Tube I

12、ntroductionaspiration & 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 vomi

13、ting减少呕吐, protect the airwayNasogastric Tube IntroductionaBalloon 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 60mm

14、Hg(200ml)then inflate esophagus balloon to 40mmHg(150ml)pulling weight 0.25kg using a pulley滑车release for 15min every 4hrsBalloon Tamponade气囊压迫temporary上消化道大出血What Is Your DecisionWhat question would you ask the patient?What Is Your DecisionWhat quesFor ReferenceHistory of illness病史Precipitating fac

15、tors诱因Comorbidities并存病For ReferenceHistory of illnesHistoryhistory 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othersHistoryhistory of bleeding出血情况Precipitating factorsalcohol abuse酒瘾NSAIDs

16、 (nonsteroid anti-inflammatory drugs) ingestion非甾体类抗炎药物应用stress应激: burn injuries Curling head injuries CushingPrecipitating factorsalcohol aFrequent SymptomsHematemesis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

17、% 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%Frequent SymptomsHematemesis呕血What Is Your DecisionWhat is the differential Diagnosis鉴别诊断?What Is Your DecisionWhat is tFor ReferencePeptic ul

18、cer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For ReferencePeptic ulcer消化性溃疡Peptic Ulcerhistory 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 cort

19、ical hormone肾上腺皮质激素usually melena, sometimes hematemesisPeptic Ulcerhistory of chronicStress Gastritishistory 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 respo

20、nse 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Stress Gastritishistory of strStomach Neoplasmsmiddle 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Stomach Neoplasmsmiddle age中年Portal Hypertensionpredisposing history of cirrhosis肝硬化基

21、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Portal HypertensionpredisposinFormation of Portal System3 inflow vein collect blood from spleen, pancreas, stomach, intestine, colon, and rectums

22、plenic veinsuperior mesenteric veininferior mesenteric vein2 branches into left & right hepatic lobethrough hepatic sinus to hepatic vein to IVC75% blood supply, 50% oxygen supply of liverFormation of Portal System3 in上消化道大出血Collateral Vascular System侧支循环esophageal-fundus submucosal venous plexus食管下

23、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Collateral Vascular System侧支循环上消化道大出血Definition of Portal Hypertensionnormal portal pressure: 13-24cmH2Onormal hepatic vein pressure gradient (HVPG) : 5-9cmH2Oportal hypertension: 30-50cmH2OHVPG

24、 12mmHg leads to UGIBDefinition of Portal Hypertens上消化道大出血Cause of Hypertensioncirrhosishepatic sinus narrownessportal blood inflow blockedhigh pressure hepatic artery flow to low pressure portal vein Cause of Hypertensioncirrhosis上消化道大出血Pathophysiology of Portal Hypertensionsplenemegaly & hypersple

25、nism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 generati

26、on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Pathophysiology of Portal HypeCaput MedusaeCaput MedusaeHemobiliahemobilia 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h

27、epatic hemangioma肝血管瘤hepatic neoplasm肝肿瘤hepatic abscess肝脓肿biliary tract stone胆道结石Hemobiliahemobilia triad胆道出血三联MiscellaneousMallory-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 stomachAngio

28、dysplasia血管发育不良: abnormal dilated, thin-walled mucosal or submucosal vessels粘膜/粘膜下血管MiscellaneousMallory-Weiss synWhat Is Your DecisionWhat physical examination体格检查 findings would you search for?What Is Your DecisionWhat physFor ReferenceSigns of shock and blood lossSigns of chronic liver diseaseSig

29、ns of tumorFor ReferenceSigns of shock anShock & Blood Losspulse 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

30、肢厥冷, cold sweating冷汗, oliguria少尿, chest pain胸痛Shock & Blood Losspulse and blChronic Liver Diseasesspider 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Chronic Liver Diseasesspider aTumorupper abdominal mass上腹包块left supraclavicular

31、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Tumorupper abdominal mass上腹包块What Is Your DecisionWhat diagnostic studies would you order?What Is Your DecisionWhat diagFor ReferenceComplete blood count (CBC)全血细胞计数Bl

32、ood 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For ReferenceComplete blood coEndoscopic Explorediagnosis & treatment诊断/治疗双重作用most reliable & effective met

33、hod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Endoscopic Explorediagnosis & 上消化道大出血Ulcer with Black Spot10% RebleedingUlcer with Black SpotUlcer with

34、Blood Clot22% RebleedingUlcer with Blood ClotUlcer with Visible Vessel43% RebleedingUlcer with Visible VesselUlcer with Active Bleeding55% RebleedingUlcer with Active BleedingEsophagus VaricesEsophagus Varices上消化道大出血Hypertensive Portal GastropathyHypertensive Portal GastropathInjection of Sclerosant

35、硬化剂Injection of Sclerosant硬化剂Band Ligation皮圈套扎Band Ligation皮圈套扎Hemoclip止血夹Hemoclip止血夹Laser Application激光止血Laser Application激光止血Heater Probe加热探针Heater Probe加热探针What Is Your DecisionWhat are the therapeutic options for each common etiology病因 of massive UGIB after initial resuscitation?What Is Your Dec

36、isionWhat are For ReferenceMedicineEndoscopeSurgeryFor ReferenceMedicineNon-Variceal Bleedingtherapeutic endoscope with/without medicineif effective then continue drug therapyeradication of H. pylorimucous protection2 attempts of endoscopic failure pursue surgeryother surgical indicationssevere life

37、-threatening bleeding not responsive to resuscitationcoexisting reason of perforation,obstruction or malignanciessecond hospitalization of peptic ulcerNon-Variceal BleedingtherapeutVariceal Bleedingdrug therapy with/without balloon temponadeendoscopic binding or sclerotherapytransjugular intrahepati

38、c 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 transplantationVariceal Bleedingdrug therapy TIPS8-12mmTIPS8-12mmWhat Is Your DecisionHow to perform the operation?What Is Your DecisionHow to peFor ReferenceExploration探查Hemostasis