呕血便血诊断学9版,2学时.ppt

1、石国庆 主任医师,诊断学,消化系统疾病诊断学第9版,呕血与便血Hematemesis and hematochezia,第十二节 呕血（P31） Haematemesis,呕血：是上消化道疾病或全身性疾病所致的上消化道出血，血液经口腔呕出。 Hematemesis is upper gastrointestinal bleeding caused by upper gastrointestinal diseases (digestive organs above the flexors ligament, including esophageal, gastric, duodenal, hep

2、atic, biliary, pancreatic diseases) or systemic diseases. Blood is vomited through the mouth.,定 义 Definition,指Treitz韧带以上的消化器官, 包归食管、胃、十二指肠、肝、 胆、胰疾病。,病 因 pathogeny,一、上消化道疾病Upper digestive tract diseases 1、食管疾病：食管炎、食管癌、Mallory-Weiss综合征等。 Esophageal diseases: esophagitis, esophageal cancer, Mallory-Wei

3、ss syndrome and so on. 2、胃、十二指肠疾病：消化性溃疡、急性糜烂出血性胃炎、胃癌等。 Gastroduodenal diseases: peptic ulcer, acute erosive hemorrhagic gastritis, gastric cancer and so on.,3、门脉高压:食管胃底静脉曲张破裂或门脉高压性胃病。 Portal hypertension: bleeding from esophagogastric varices or portal hypertensive gastropathy. 二、上消化道邻近器官疾病：肝胆、胰腺疾病。

4、 Upper digestive tract adjacent organ diseases: hepatobiliary and pancreatic diseases.,病 因 pathogeny,三、全身性疾病Systemic disease （1）血液病：过敏性紫癜、白血病、凝血机制障碍性疾病等。 Hematological diseases: allergic purpura, leukemia, coagulation disorders, and so on. （2）感染性疾病：流行性出血热、钩体病、败血症、爆发性肝炎等。 Infectious diseases: epidemi

5、c hemorrhagic fever, leptospirosis, septicemia, fulminant hepatitis and so on.,病 因 pathogeny,（3）结缔组织病等：系统性红斑狼疮（SLE）、皮肌炎、结节性多动脉炎累及上消化道。 Connective tissue disease, such as systemic lupus erythematosus (SLE), dermatomyositis, nodular polyarteritis involving the upper gastrointestinal tract. （4）其他：尿毒症、肺

6、心病等。 Others: uremia, pulmonary heart disease and so on.,病 因 pathogeny,常见病因common etiology,消化性溃疡 Peptic ulcer 食管胃底静脉曲张破裂 Esophageal and gastric varices bleeding 急性糜烂出血性胃炎 Acute erosive hemorrhagic gastritis 胃癌 gastric cancer,消化性溃疡,EGVB,急性糜烂出血性胃炎,胃 癌,常见病因common etiology,食管贲门粘膜撕裂Mallory-Weiss syndrome,

7、食管溃疡Esophageal ulcers,其他病因Other causes,恒径动脉破裂Dieulafoy disease,胃肠间质瘤Gastrointestinal stromal tumor（GIST）,其他病因Other causes,毕II式术后出血Billroth II postoperative bleeding,门脉高压性胃病Portal hypertensive gastropathy,其他病因Other causes,胆道出血Biliary tract hemorrhage,EST术后出血Bleeding after EST,其他病因Other causes,临床表现Cli

8、nical manifestation,1.呕血与黑便Hematemesis and melena:特征性表现。 呕血：可为鲜红色、暗红色或咖啡色（棕褐色） Hematemesis: bright red, dark red or brown. 黑便：血液经肠道排出体外形成黑便（Hb与硫化物结合形成硫化亚铁）。 Melena: blood passes through the intestines to form black stools (Hb combines with sulfide to form ferrous sulfide).,血液在胃内停留时间长，血红蛋白与胃酸作用形成酸化正铁

9、血红蛋白。,颜色取决于：出血量、 出血部位、出血速度。,临床表现Clinical manifestation,2.周围循环血容量不足表现：出血量占循环血量10%以 下，无明显表现；10-20%时可有头昏乏力等；20-30% 时可有冷汗、四肢厥冷、心慌、脉搏增快等；30%以上 时可有周围循环衰竭表现（失血性休克）。 Peripheral circulation insufficiency manifestations: the amount of bleeding accounted for less than 10% of the circulating blood volume, no ob

10、vious performance; 10-20% may have dizziness and fatigue; 20-30% may have cold sweat, cold limbs, panic, rapid pulse and so on; more than 30% may have peripheral circulation failure (hemorrhagic shock).,临床表现Clinical manifestation,3.血液学变化：Hb降低，早期可无明显血液学改变。 Hematological changes: Hb decreased, but the

11、re was no obvious hematological changes in the early stage. 4.氮质血症：血液蛋白的分解产物在肠道被吸收。 azotemia：The decomposition products of blood proteins are absorbed in the intestinal tract. 5.发热：吸收热、体温调节中枢调定点上移。 fever：Absorption heat and thermoregulation center shifted upward.,伴随症状Concomitant symptoms,上腹痛:多为消化性溃疡

12、，中老年人注意胃癌。 Epigastric pain: mostly peptic ulcer, the middle-aged and the elderly pay attention to gastric cancer. 肝脾肿大:肝硬化、肝癌。 Hepatosplenomegaly: cirrhosis and liver cancer. 皮肤黏膜出血:血液病、败血症、重症肝炎。 Mucocutaneous hemorrhage: hematopathy, septicemia, severe hepatitis. 黄疸、发热、右上腹痛:胆系疾病。 Jaundice, fever, r

13、ight upper abdominal pain: biliary diseases.,左锁骨上淋巴结肿大:胃癌、胰腺癌。 Left supraclavicular lymph node enlargement: gastric cancer or pancreatic cancer. 服用NSAID、饮酒、应急状态：急性糜烂出血性胃炎。 Taking NSAID, drinking and emergency: acute erosive hemorrhagic gastritis 剧烈呕吐后：Mallory-Weiss综合征。 Severe vomiting: Mallory-Weiss

14、 syndrome.,伴随症状Concomitant symptoms,咯血与呕血的鉴别Identification of hemoptysis and hematemesis,消化性溃疡 肝硬化 急性糜烂出血性胃炎 胃癌等,肺结核 支扩 肺癌 肺炎 肺脓肿 心脏病等,喉痒 胸闷 咳嗽等,上腹不适 恶心 呕吐等,咯出,鲜红,痰 泡沫,碱性,咽下后可有,常有血痰数日,呕出 可为喷射状,棕黑 暗红 有时鲜红,食物残渣 胃液,酸性,有柏油便可持续数日,无血痰,第十三节 便血（P31） hematochezia,概述 Summary,定义：指消化道出血，血液由肛门排出。 Definition: ble

15、eding from the digestive tract and blood drained from the anus. 便血颜色可呈鲜红、暗红、黑色。 The color of bloody stool can be bright red, dark red and black. 隐血：指少量出血不造成粪便颜色改变，须经隐血试验才能确定者。 Occult blood: a small amount of bleeding that does not cause changes in the color of the stool. It can only be determined by

16、 occult blood test.,病 因 pathogeny,一、下消化道疾病Lower digestive tract diseases 1、小肠疾病 Small intestinal disease 2、结肠疾病Colonic disease 3、直肠肛管疾病Anorectal diseases 4、血管病变Angiopathy 二、上消化道疾病Upper digestive tract diseases 三、全身性疾病Systemic disease,临床表现Clinical manifestation,便血颜色和形式可因出血部位不同、出血量多少以及血液在肠腔内停留时间的长短而异。

17、 The colour and form of blood in the stool can vary depending on the site of bleeding, the amount of bleeding, and the length of time the blood stays in the intestinal cavity. 隐血便：消化道出血每日在5ml以下者，无肉眼可见的粪便颜色改变。 Occult blood: gastrointestinal bleeding is less than 5ml per day, and no fecal color change

18、.,伴随症状Concomitant symptoms,1、腹痛abdominal pain： 消化性溃疡、胆道出血；细菌性痢疾、阿米巴痢疾、溃疡性结肠炎；急性出血坏死性肠炎、肠套叠、肠系膜血栓或栓塞。 Peptic ulcer、Biliary tract hemorrhage、Bacterial dysentery、amebic dysentery、Ulcerative colitis、Acute hemorrhagic necrotlzing enteritis、intussusception、Mesenteric thrombosis or embolism.,2、里急后重tenesmus

19、： 细菌性痢疾、直肠炎、直肠癌。 Bacterial dysentery、Proctitis、rectal cancer. 3、发热fever： 伤寒、流行性出血热、钩体病、淋巴瘤等。 Typhoid fever、epidemic hemorrhagic fever、Leptospirosis、Lymphoma, etc.,伴随症状Concomitant symptoms,4、全身出血倾向Systemic bleeding tendency： 过敏性紫癜、流行性出血热、重症肝炎、白血病等。 Allergic purpura、epidemic hemorrhagic fever、Severe hepatitis、Leukemia and so on. 5、皮肤改变Skin change： 肝硬化、毛细血管扩张。 Cirrhosis、Telangiectasia.,伴随症状Concomitant symptoms,6、腹部肿块Abdominal mass： 结肠癌、淋巴瘤、肠结核、克罗恩病等。 Colon cancer、Lym