便血病理全面版课件

1、1便血病理第1页/共52页1便血病理第1页/共52页Five Ways of GI BleedingHematemesis：vomitting of blood of altered blood（coffee grounds） indicates bleeding proximal to ligament of TreitzMelena：Tarry stool. Altered （black） blood per rectum （60ml）Hematochezia： Bright red or maroon rectal bleeding implies bleeding beyond Lig

2、.T.*FOB+ and Iron deficiency anemia第2页/共52页Five Ways of GI BleedingHemateFactors affect the way to manifestSite of bleeding Speed of bleedingAmount of blood lossFlora of enterocolon. 第3页/共52页Factors affect the way to maniDifferentiating Upper from Low GI BleedingHematochezia usually represents a low

3、er GI source bleedingUpper GI lesion may bleed so briskly that blood doesnt remain in bowl long enough to become melena Bleeding lesion distal to T Lig.may be either M.or hematochezia, but never manifests hematemesis 第4页/共52页Differentiating Upper from LowCommon cause of up GI bleeding Peptic ulcer ；

4、Gastropathy （alcohol， aspirin， NSAIDs， stress）；GE varices； Gastric cancer第5页/共52页Common cause of up GI bleedingLess common cause of up GI bleedingEsophageal or intestinal neoplamEsophagitis； Malloy-weiss tear，Hemoptysis: Swallowed bloodAnticoagulant fibrinoloytic therapy:Telangiectases； aneurysm ；va

5、sculitis；Dieulafoy ulcer； AV malformationConnective tissue disease；Hemabilia（biliary origin；Crohns disease；amyloidosis , hematological diseases第6页/共52页Less common cause of up GI bleBENIGN GASTRIC ULCERThe classical presentation of gastric ulcer :with weight loss and indigestion made worse by eating,

6、 patients more often describe symptoms that would fit equally well for duodenal ulcer - investigation with barium meal or (preferably) endoscopy is, of course, appropriate for either. Benign ulcers may occur at any site in the stomach, but are commonest on the lesser curve away from acid-secreting e

7、pithelium. 第7页/共52页BENIGN GASTRIC ULCERThe class Location of benign gastric ulcers in relationship to the distance from the pylorus. The majority of benign ulcers will be found on the lesser curvature within 3 cm of the angulus.第8页/共52页 Location of benign gastric ulDuodenum UlcerThe lesion most comm

8、only affecting the duodenum is ulceration, and it is now known that both antral infection with Helicobacter pylori and the presence of gastric acid are virtual prerequisites for it. 第9页/共52页Duodenum UlcerThe lesion most Bleeding From EVA number of cutaneous features (stigmata) may develop in a patie

9、nt with cirrhosis, and these are important as they aid clinical recognition of chronic liver disease. 第10页/共52页Bleeding From EVA number of cu第11页/共52页第11页/共52页第12页/共52页第12页/共52页第13页/共52页第13页/共52页Bleeding Survey: Endoscopic Findings in 214 Patients With Clear Nasogastric AspiratesFINDING NUMBER OF PA

10、TIENTS INCIDENCE (%)Telangiectasia 0第14页/共52页Bleeding Survey: Endoscopic FiClinical manifestation of GI BleedingAbdominal disconfortNausea, Hemadynamic change: reduction in blood volume (syncope,light-headedness, sweating,therst) or shockLaboratory changes: HCT, BUN第15页/共52页Clinical manifestation of

11、 GI BHematemesis with other symptomsHematemesis with upper abdominal painHematemesis with hepatomegly and spleenomeglyHematemesis with jaundiceHematemesis with Skin & mucosa hemorrhageHematemesis with upper abdominal massOthers: NSAIDs, Stress, Burning, Brain operation, Trauma, Vomiting 第16页/共52页Hem

12、atemesis with other symptoLab.Examination in Localization & Diagnosis of GI BleedingEndoscopyBarium RadiographsAngiographyRadionuclide imaging第17页/共52页Lab.Examination in LocalizatioLaboratory changes: HCT, BUNGastric cancerSevere acute ulcerative colitis.Hematemesis：vomitting of blood of altered blo

13、od（coffee grounds） indicates bleeding proximal to ligament of TreitzHematochezia with other symptomspatients more often describe symptoms that would fit equally well for duodenal ulcer - investigation with barium meal or (preferably) endoscopy is, of course, appropriate for either.Upper GI lesion ma

14、y bleed so briskly that blood doesnt remain in bowl long enough to become melenaCauses of Low GI BleedingAltered （black） blood per rectum （60ml）Diffuse erythema, spontaneous bleeding, and loss of the vascular pattern with formation of telangiectasis are present.Approach to the patient with acute upp

15、er gastrintesttinal hemorrhage Acute upper Gastrointestinal Hemorrhage Rapid assessment Monitor hemodynamic status Fluid resuscitation Gastric lavage(?) self-limited (80%) bleeding (10-20%) Empiric medical therapy Urgent endoscopy recurrent hemorrhage endoscopy Site not localized Localized further a

16、ssessment enteroscopy, radioisotope s scan, angiography, exploratory surgery Definitive therapy Definitive therapy 第18页/共52页Laboratory changes: HCT, BUNA第19页/共52页第19页/共52页Endoscopic view of a Mallory-Weiss tear with active bleeding (gastric lumen is at top left). B, Endoscopic view of an organized c

17、lot adherent to a Mallory-Weiss tear (gastric lumen is at bottom left ).第20页/共52页Endoscopic view of a Mallory-WEndoscopic view of a Dieulafoy lesion on the lesser curvature of the stomach第21页/共52页Endoscopic view of a DieulafoyEndoscopic view of a vascular ectasia (angiodysplasia) in the duodenum. 第2

18、2页/共52页Endoscopic view of a vascular Endoscopic view of the gastric antrum with watermelon stomach. The pylorus is at top center. Note the linear distribution pattern of the vascular lesions arranged radially around the pylorus.第23页/共52页Endoscopic view of the gastricEndoscopic views of ulcers with s

19、tigmata of recent hemorrhage. A, Duodenal ulcer with a visible vessel. B, Gastric ulcer with a red spot in the center of the crater. C, Duodenal ulcer with a red spot in the center of the crater. D, Purplish clot adherent to a gastric ulcer. 第24页/共52页Endoscopic views of ulcers wit第25页/共52页第25页/共52页T

20、ypical picture of a trivial nonsteroidal anti-inflammatory drug (NSAID)-induced injury to the gastric mucosa. There are multiple small erosions with brown-black staining of the center as a result of local bleeding and petechiae.第26页/共52页Typical picture of a trivial nSite of bleedingEndoscopic views

21、of ulcers with stigmata of recent hemorrhage.Five Ways of GI Bleedingfurther assessmentRadionuclide scanningLinear ulceration runs circumferentially along the interhaustral septum with tiny satellite ulcerations.Advantage colon carcinomaRadionuclide imagingCauses of Low GI BleedingHematemesis with o

22、ther symptomsB, Gastric ulcer with a red spot in the center of the crater.self-limited (80%) bleeding (10-20%)Diffuse erythema, spontaneous bleeding, and loss of the vascular pattern with formation of telangiectasis are present.B, Mucosa surrounding the ulcers is nodular (cobblestoning).amyloidosis

23、, hematological diseasesBENIGN GASTRIC ULCERrecurrent hemorrhageTypical round gastric ulcer at the angulus (incisura) of the stomach.第27页/共52页Site of bleedingTypical round Causes of Low GI Bleeding 第28页/共52页Causes of Low GI Bleeding 第28Differentiating Upper from Low GI BleedingHematochezia usually r

24、epresents a lower GI source bleedingUpper GI lesion may bleed so briskly that blood doesnt remain in bowl long enough to become melena Bleeding lesion distal to T. Lig. may be either M.or hematochezia, but never manifests hematemesis 第29页/共52页Differentiating Upper from LowHematochezia with other sym

25、ptomsAbdominal painFeverTenesmusSystemic Hemorrhage Dermal signAbdominal mass第30页/共52页Hematochezia with other symptLab. Examination For detecting Low GI BleeedingAnoscopy & sigmoidoscopyBarium Edema (BE)AngiographyRadionuclide scanning第31页/共52页Lab. Examination For detecting第32页/共52页第32页/共52页第33页/共52

26、页第33页/共52页A, Linear ulcers of Crohns colitis. B, Mucosa surrounding the ulcers is nodular (cobblestoning).第34页/共52页A, Linear ulcers of Crohns coShigella colitis. Patchy areas of erythema, spontaneous bleeding, and loss of the normal vascular pattern are evident第35页/共52页Shigella colitis. Patchy areas

27、Salmonella colitis. Diffuse erythema, spontaneous bleeding, and loss of the vascular pattern with formation of telangiectasis are present.第36页/共52页Salmonella colitis. Diffuse erTuberculosis. Linear ulceration runs circumferentially along the interhaustral septum with tiny satellite ulcerations. This

28、 must be distinguished from the longitudinal linear ulcerations seen in inflammatory bowel disease. 第37页/共52页Tuberculosis. Linear ulceratioPseudomembranous (antibiotic-associated) colitis. Numerous elevated yellowish plaques are present on the mucosal surface.第38页/共52页Pseudomembranous (antibiotic-aA

29、mebiasis. Discrete punched-out ulcers are present in the right colon. 第39页/共52页Amebiasis. Discrete punched-ouSevere acute ulcerative colitis. No vascular pattern is discernible. A severe degree of spontaneous bleeding is present第40页/共52页Severe acute ulcerative colitiLarge colonic ulcer in a patient

30、with ischemic colitis. 第41页/共52页Large colonic ulcer in a patieAdvantage colon carcinoma第42页/共52页Advantage colon carcinoma第42页/Barium enema appearance of an ischemic stricture with features of carcinoma: asymmetry, mucosal destruction, and shouldering.第43页/共52页Barium enema appearance of an Summary of Acute GI BleedingUpper GI source bleeding-HemetemesisMajor upper GI bleding- Hemetemesis & hemetocheziaThe more distant from the rectum, the more likely that melaena occursThe colon l