呕血与便血4课件

呕血与便血

HematemesisandHematochezia呕血与便血

HematemesisandHematoch1DefinitionHematemesis

:Bloodyvomitusfromtheuppergastro-intestinal(GI)tract（beforetheligamentofTreitz)Hematochezia:brightred,maroonorblackbloodfromtherectumDefinitionHematemesis:Bloody2Treitz:

TheligamentofTreitzisananatomiclandmarkfortheduodenal-jejunaljunctionTreitz: 3ClinicalManifestation1Mannerofbleedingpresentation2Hypovolemia(低血容量)orshock3Anemia(贫血)ClinicalManifestation1Manne4Patientsmanifestbloodloss(A)

Hematemesis

呕血

Character

Bloodyvomitus,eitherfreshandbrightredorolderand“coffee-ground”(hematin酸化正铁血红素)MannerofbleedingpresentationfromtheGItract

infiveways:Patientsmanifestbloodloss(A5causeofdisease90%upperGIbleedingisduetofourlesions:1)pepticulcer(消化性溃疡)2)esophagealorgastricvarices(食管胃底静脉曲张破裂)3)hemorrhagicgastritis(急性糜烂性出血性胃炎)4) gastriccancercauseofdisease90%upperGIb6pepticulcerpepticulcer7hemorrhagicgastritishemorrhagicgastritis8esophagealvaricesesophagealvarices9gastriccancergastriccancer10OthercausesofupperGIbleedingMallory-Weisstear食道-贲门撕裂伤Foreignbodyinesophagus食管异物Ancylostomiasis 钩虫病Post-sphincterotomy

括约肌切开术后OthercausesofupperGIbleed11

DifferentiationNosebleeding?Hemoptysis?

Differentiation12DifferntiatinghemoptysisandhematemesisHemoptysisHematemesisCauseofdiseaseTB,bronchiectasis,pneumonia,lungcancer,heartdiseasePU,livercirrhosis,acuteerosiveandhemorrhagicgastritisSyptombeforebleedingitchoflaryngeal,dyspnea,coughepigastricdiscomfort,nauseaandvomitMannerofbleedinghawkvomit,spurtingBloodcolourfreshredmaroon,coffee-groundMixtureinbloodsputumfoamfooddebrisgastricjuicePowerofhydrogenalkalityacidityMelenanohaveSputumwithbloodysputumnosputumDifferntiatinghemoptysisand13Mannerofbleedingpresentation(B)

Hematochezia

便血

Character

brightredormaroonbloodfromtherectum

purebloodbloodintermixedwithformedstoolbloodydiarrheaMannerofbleedingpresentatio14(C)

Melena黑便

Character

Shiny,black,sticky,foul-smellingstool

Tarrystool(柏油样便)(degradationofblood)Differentiation

exogenousstooldarkeners:animalblood,iron,bismuth(铋剂)

Mannerofbleedingpresentation(C)Melena黑便Mannerofbl15Mannerofbleedingpresentation(D)Stoolwithoccult

blood

隐血便

Detectedonlybytestingthestoolwithamonoclonalantibodyforhumanhemoglobin

Mannerofbleedingpresentatio16EstimateamountofbleedingfromupperGItract5~10ml/dOB+50~70ml/dMelena

250~300mlinshorttimeHematemesis

Estimateamountofbleedingfr17CausesofbleedingColorectalcancerColitisLargehemorrhoid 大痔Rectumtear 肛裂VascularanomaliesHematologicdiseasesCausesofbleedingColorectal18Mannerofbleedingpresentation(E)withoutanyobjectivesignofbleeding,withsymptomsofbloodloss

Mannerofbleedingpresentatio191.HypovolemiaorshockDependingonspeedandvolumeofbloodloss＜1000mL:Weakness,giddiness(眩晕),tachycardia(心动过速),coldextremity,sweatingShock:hypotention(低血压),oliguria,(少尿)1.HypovolemiaorshockDependi202.Anemiaandhemogramchanging

Ifbloodlossisacute,thehematocrit(红细胞比容)dosenotchangeduringthefirstfewhoursafterhemorrhageAbout24to72hourslater,plasmavolumeislargerthannormalandthehematocritisatitslowestpoint

2.Anemiaandhemogramchangin21

bleedingslowly

hypochromic(血红蛋白过少)microcytic(小细胞)redbloodcells

meancorpuscularvolume(MCV，

平均血球压积)ofthecellsmaybelow

bleedingslowly227654321Volume(Liters)45%45%27%ABCHematocritchangesABeforebleedingBImmediatelyafterbleedingC24~72hoursafterbleeding7654321Vo233.Feverlowgradefeverin24hoursafterbleeding3.Feverlowgradefeverin24h244.Azotemia(氮质血症)

DegradationofproteininintestinaltractBUN

↗

inseveralhoursafterbleeding

uptothepeakinabout24-48hours

↘normal

after3-4days4.Azotemia(氮质血症)Degradati255.Bowelsound

ActivebowelsoundusuallybepresentedinacutebleedingfromGItract5.Bowelsound 26Whereisthesourceofbleeding?

Localization

UpperGIbleeding:bleedingfromasourceproximaltotheligamentofTreitzLowerGIbleeding:bleedingfromasitedistaltotheligamentofTreitzWhereisthesourceofbl27

Localization

DifferentiatingfeaturesofupperGIandlowerGIbleeding

UpperGI LowerGI Manifestation Hematemesis Hematochezia melena Nasogastric

aspirate

Bloody Clear BUN

Elevated Normal Bowelsound Hyperactive NormalLocalization Differentiating28UpperGItractbleeding?Clinicalmanifestation(hematemesis melena) BowelsoundNasogastrictubeUpperGItractbleeding?Clini29HematemesisMelenaHematocheziaMoreproximallesionsproducehematemesisormelena,whereasmoredistallesionsaremorelikelytoproducehematocheziaHematemesisMelenaHematocheziaM30Diagnosticapproach

1.Historyandphysicalexamination2.Laboratoryexamination3.AuxiliaryexaminationDiagnosticapproach

1.Histor31HistoryandphysicalexaminationAhistoryofpreviouslydocumentedGItractdiseasedeterminedbyradiography,endoscopy,orsurgicalproceduresisveryusefulDiagnosticapproachtoGIbleedingHistoryandphysicalexaminati32DiagnosticapproachtoGIbleeding

Ahistoryofepigastric(上腹部)burningpainpromptlyrelievedbyfoodorantacids(抗酸剂)

ornocturnal(夜间)painsuggestspepticulcerdisease,particularlyduodenal(十二指肠)

ulcerІDiagnosticapproachtoGIblee33DiagnosticapproachtoGIbleeding

Patientswithstigmata

(特征)

ofhepatitisBorotherchronicactiveliverdisease[e.gspiderangioma

(蜘蛛痣),ascites(腹水),gynecomastia(男性乳房发育)]maypresentwithpainlesshematemesisfromesophagealvaricesⅡDiagnosticapproachtoGIblee34DiagnosticapproachtoGIbleeding

Patientswithforceful,retching

(干呕)ormultipleepisodesofvomitingoffoodpriortotheonsetofhematemesismaybebleedingfrom

Mallory－Weisstears

ofthegastro-esophagealjunctionⅢDiagnosticapproachtoGIblee35DiagnosticapproachtoGIbleeding

Ahistoryof

gradualweightlossintermittentbloodinthestoolsalteredbowelhabitsoftensuggests

colorectalmalignancy

ⅣDiagnosticapproachtoGIblee36DiagnosticapproachtoGIbleeding

Hemorrhoidalbleedingisoftensuggestedbythepresenceofbrightredbloodsurroundingwell-formed,normal-appearingstoolsⅤDiagnosticapproachtoGIblee37DiagnosticapproachtoGIbleeding

A

rectalexamination

isessentialtodocumentstoolcoloraswellastopalpateforgrossanorectal

(肛直肠)

masslesionssuchaspolyps(息肉),cancers,orlargehemorrhoids.DiagnosticapproachtoGIblee38DiagnosticapproachtoGIbleeding

AuxiliaryexaminationEndoscopy(内镜)Endoscopyisthediagnosticprocedureofchoicebecauseofitshighaccuracyandimmediatetherapeuticpotential.

Endoscopy,however,mustbeperformedonlyfollowingadequateresuscitation(复苏)DiagnosticapproachtoGIblee39DiagnosticapproachtoGIbleeding

Bariumradiography(钡餐)Bariumradiographyisnoninvasivebuthassignificantdisadvantages,particularlyinpatientswhoarebleedingactivelyDiagnosticapproachtoGIblee40DiagnosticapproachtoGIbleeding

Angiography(血管造影)

AngiographymaylocalizethesiteofbleedingBleedingmustbeactivebecauseangiographydetectsonlyextravasation(外渗)ofcontrast(造影剂)intotheGItractDiagnosticapproachtoGIblee41Isbleedingacuteorchronic?IntensivecareWhereisthesourceofbleeding?EmpirictherapyDiagnosisTreatment(经验治疗)Whatisthecausesofbleeding?Recognitionofhemorrhage

DiagnosticapproachIsbleedingacuteorchronic?I42Questions1.名词解释:呕血便血隐血便2.呕血最常见原因有哪些?(至少4种)Questions1.名词解释:呕血43呕血与便血

HematemesisandHematochezia呕血与便血

HematemesisandHematoch44DefinitionHematemesis

:Bloodyvomitusfromtheuppergastro-intestinal(GI)tract（beforetheligamentofTreitz)Hematochezia:brightred,maroonorblackbloodfromtherectumDefinitionHematemesis:Bloody45Treitz:

TheligamentofTreitzisananatomiclandmarkfortheduodenal-jejunaljunctionTreitz: 46ClinicalManifestation1Mannerofbleedingpresentation2Hypovolemia(低血容量)orshock3Anemia(贫血)ClinicalManifestation1Manne47Patientsmanifestbloodloss(A)

Hematemesis

呕血

Character

Bloodyvomitus,eitherfreshandbrightredorolderand“coffee-ground”(hematin酸化正铁血红素)MannerofbleedingpresentationfromtheGItract

infiveways:Patientsmanifestbloodloss(A48causeofdisease90%upperGIbleedingisduetofourlesions:1)pepticulcer(消化性溃疡)2)esophagealorgastricvarices(食管胃底静脉曲张破裂)3)hemorrhagicgastritis(急性糜烂性出血性胃炎)4) gastriccancercauseofdisease90%upperGIb49pepticulcerpepticulcer50hemorrhagicgastritishemorrhagicgastritis51esophagealvaricesesophagealvarices52gastriccancergastriccancer53OthercausesofupperGIbleedingMallory-Weisstear食道-贲门撕裂伤Foreignbodyinesophagus食管异物Ancylostomiasis 钩虫病Post-sphincterotomy

括约肌切开术后OthercausesofupperGIbleed54

DifferentiationNosebleeding?Hemoptysis?

Differentiation55DifferntiatinghemoptysisandhematemesisHemoptysisHematemesisCauseofdiseaseTB,bronchiectasis,pneumonia,lungcancer,heartdiseasePU,livercirrhosis,acuteerosiveandhemorrhagicgastritisSyptombeforebleedingitchoflaryngeal,dyspnea,coughepigastricdiscomfort,nauseaandvomitMannerofbleedinghawkvomit,spurtingBloodcolourfreshredmaroon,coffee-groundMixtureinbloodsputumfoamfooddebrisgastricjuicePowerofhydrogenalkalityacidityMelenanohaveSputumwithbloodysputumnosputumDifferntiatinghemoptysisand56Mannerofbleedingpresentation(B)

Hematochezia

便血

Character

brightredormaroonbloodfromtherectum

purebloodbloodintermixedwithformedstoolbloodydiarrheaMannerofbleedingpresentatio57(C)

Melena黑便

Character

Shiny,black,sticky,foul-smellingstool

Tarrystool(柏油样便)(degradationofblood)Differentiation

exogenousstooldarkeners:animalblood,iron,bismuth(铋剂)

Mannerofbleedingpresentation(C)Melena黑便Mannerofbl58Mannerofbleedingpresentation(D)Stoolwithoccult

blood

隐血便

Detectedonlybytestingthestoolwithamonoclonalantibodyforhumanhemoglobin

Mannerofbleedingpresentatio59EstimateamountofbleedingfromupperGItract5~10ml/dOB+50~70ml/dMelena

250~300mlinshorttimeHematemesis

Estimateamountofbleedingfr60CausesofbleedingColorectalcancerColitisLargehemorrhoid 大痔Rectumtear 肛裂VascularanomaliesHematologicdiseasesCausesofbleedingColorectal61Mannerofbleedingpresentation(E)withoutanyobjectivesignofbleeding,withsymptomsofbloodloss

Mannerofbleedingpresentatio621.HypovolemiaorshockDependingonspeedandvolumeofbloodloss＜1000mL:Weakness,giddiness(眩晕),tachycardia(心动过速),coldextremity,sweatingShock:hypotention(低血压),oliguria,(少尿)1.HypovolemiaorshockDependi632.Anemiaandhemogramchanging

Ifbloodlossisacute,thehematocrit(红细胞比容)dosenotchangeduringthefirstfewhoursafterhemorrhageAbout24to72hourslater,plasmavolumeislargerthannormalandthehematocritisatitslowestpoint

2.Anemiaandhemogramchangin64

bleedingslowly

hypochromic(血红蛋白过少)microcytic(小细胞)redbloodcells

meancorpuscularvolume(MCV，

平均血球压积)ofthecellsmaybelow

bleedingslowly657654321Volume(Liters)45%45%27%ABCHematocritchangesABeforebleedingBImmediatelyafterbleedingC24~72hoursafterbleeding7654321Vo663.Feverlowgradefeverin24hoursafterbleeding3.Feverlowgradefeverin24h674.Azotemia(氮质血症)

DegradationofproteininintestinaltractBUN

↗

inseveralhoursafterbleeding

uptothepeakinabout24-48hours

↘normal

after3-4days4.Azotemia(氮质血症)Degradati685.Bowelsound

ActivebowelsoundusuallybepresentedinacutebleedingfromGItract5.Bowelsound 69Whereisthesourceofbleeding?

Localization

UpperGIbleeding:bleedingfromasourceproximaltotheligamentofTreitzLowerGIbleeding:bleedingfromasitedistaltotheligamentofTreitzWhereisthesourceofbl70

Localization

DifferentiatingfeaturesofupperGIandlowerGIbleeding

UpperGI LowerGI Manifestation Hematemesis Hematochezia melena Nasogastric

aspirate

Bloody Clear BUN

Elevated Normal Bowelsound Hyperactive NormalLocalization Differentiating71UpperGItractbleeding?Clinicalmanifestation(hematemesis melena) BowelsoundNasogastrictubeUpperGItractbleeding?Clini72HematemesisMelenaHematocheziaMoreproximallesionsproducehematemesisormelena,whereasmoredistallesionsaremorelikelytoproducehematocheziaHematemesisMelenaHematocheziaM73Diagnosticapproach

1.Historyandphysicalexamination2.Laboratoryexamination3.AuxiliaryexaminationDiagnosticapproach

1.Histor74HistoryandphysicalexaminationAhistoryofpreviouslydocumentedGItractdiseasedeterminedbyradiography,endoscopy,orsurgicalproceduresisveryusefulDiagnosticapproachtoGIbleedingHistoryandphysicalexaminati75DiagnosticapproachtoGIbleeding

Ahistoryofepigastric(上腹部)burningpainpromptlyrelievedbyfoodorantacids(抗酸剂)

ornocturnal(夜间)painsuggestspepticulcerdisease,particularlyduodenal(十二指肠)

ulcerІDiagnosticapproachtoGIblee76DiagnosticapproachtoGIbleeding

Patientswithstigmata

(特征)

ofhepatitisBorotherchronicactiveliverdisease[e.gspiderangioma

(蜘蛛痣),ascites(腹水),gynecomastia(男性乳房发育)]maypresentwithpainlesshematemesisfromesophagealvaricesⅡDiagnosticapproachtoGIblee77DiagnosticapproachtoGIbleeding

Patientswithforceful,retching

(干呕)ormultipleepisodesofvomitingoffoodpriortotheonsetofhematemesismaybebleedingfrom

Mallory－Weisstears

ofthegastro-esophagealjunctionⅢDiagnosticapproachtoGIblee78DiagnosticapproachtoGIbleeding

Ahistoryof

gradualweightlo