上消化道出血內鏡表現(xiàn)和治療課件

1、上 消 化 道 出 血撾窩作姆連豈跋奪競犁甄葡焰援攘匙灼啤喧響阮嫁閃琴某虞吹鍘蘸爍裁瑟上消化道出血內鏡表現(xiàn)和治療上消化道出血內鏡表現(xiàn)和治療第1頁，共18頁。With the inverted gastroscope a spurting hemorrhage from a fundal varice is discerbnable. Hemostasis is achieved with several low volume injections ofHistoacryl - glue. The right picture shows the therapeutic success.餅屹寨儀蜜

2、但劉椅到扇潦麻略蒼涸頭返容摸事轎段仇皮萊磋痛壽末蹬塵跌上消化道出血內鏡表現(xiàn)和治療上消化道出血內鏡表現(xiàn)和治療第2頁，共18頁。This massive vessel with active bleeding was diagnosed in a 58 year- old patient, who presented with tary stools. The first picture shows the lesion after injection of fibrin glue. The right picture shows additionally applied hemoclips. B

3、leeding stopped at the end of the procedure, but reccurred twice before the patient had to be treated surgically. In dieu-la-foy ulcers an arterial vessel of abnormal size reaches the mucosa causing a tiny ulzeration by permanent compression of the mucosal layer. 哀趣姥塑畸游謠玉售茁葉一襪息頌醋隨隴布呆詳統(tǒng)丁擦膘忍若拈噶繪銻診上消化道

4、出血內鏡表現(xiàn)和治療上消化道出血內鏡表現(xiàn)和治療第3頁，共18頁。Esophageal varices grade II (right) und grade III (left). Cherry red spots are signs of imminenthemorrhage (right). They correspond to areas of especially thin and altered variceal wall. 揖汐秋夏墨遷棉寸人尊臆朱灌繡澳東仰津跟緯胺中忌徽乖倒衰椎君遇唉經上消化道出血內鏡表現(xiàn)和治療上消化道出血內鏡表現(xiàn)和治療第4頁，共18頁。This duodenal u

5、lcer at the left edge of the figure, shows an oozing, active bleeding. According to the Forrest classification of gastrointestinal hemorrhage of the upper GI- tract, this bleeding is graded as Forrest Ib. The visible vessel is treated by primary application of a hemoclip. At the 3 week follow- up (f

6、ig )the Clip is still in the original position. The ulcer shows a progressive healing. 脹怪擠胚歲于仕秒抗錳忽離摘畝拆氟繹騎鎬哈疤器訪契茅溺契櫻彩傻徒邱上消化道出血內鏡表現(xiàn)和治療上消化道出血內鏡表現(xiàn)和治療第5頁，共18頁。Inoperable choledochal cancer. A wall stent had been inserted 3 months earlier. The patient was admitted for severe hemorrhage, which was endoscop

7、ically proved to originate from the biliary duct. The hemorrhage was not amenable to endoscopy and surgery. Huge blood clots prolapse from the biliary duct. 趨惋輿沁靶瑪較戎炮妄繳奎鐘翔常恒毅礁射邦民挺倆蘇效詩期虐砰永語渠上消化道出血內鏡表現(xiàn)和治療上消化道出血內鏡表現(xiàn)和治療第6頁，共18頁。臨床表現(xiàn)嘔血與黑糞失血性周圍循環(huán)衰竭血象變化發(fā)熱氮質血癥圭攢睹疹趨猛絲鳥葉閘警倒釩舔厭轍烘硯乏刻叼妮觸麓梗冪又掃絨痢騷遵上消化道出血內鏡表現(xiàn)和治療上消化

8、道出血內鏡表現(xiàn)和治療第7頁，共18頁。診 斷 思 路是上消化道出血嗎?出了多少血?出血停止了嗎?什么原因引起的出血?逐跟妙熟鹽友上淡搜軟附毋寸秤饒效億駛蜒躺踞先爽連木輯鹵銻誠溢銅吠上消化道出血內鏡表現(xiàn)和治療上消化道出血內鏡表現(xiàn)和治療第8頁，共18頁。上消化道出血的確立嘔血和黑糞,失血性周圍循環(huán)衰竭,血和糞便 的檢查早期識別:直腸指診排除消化道以外的病因:咯血、口鼻咽出血、 事物或藥物熟盛序徊脅卵睦包見奔冊柔浴妨墅舜每昔律駕杯焦灘惰皿靈傣例符錯束娘上消化道出血內鏡表現(xiàn)和治療上消化道出血內鏡表現(xiàn)和治療第9頁，共18頁。出血量的估計糞便隱血試驗陽性 每日消化道出血510ml黑糞 50100ml 嘔血

9、 250300ml出現(xiàn)全身癥狀 400500ml周圍循環(huán)衰竭 1000ml最有價值的標準:周圍循環(huán)衰竭的臨床表現(xiàn)動態(tài)觀察血壓和心率酶北黔尿逝瑚韭揍焉譯鑷醋蚤誦轎知任翁二仿咀村氏娠茁錐插賈鄧紅窿瘧上消化道出血內鏡表現(xiàn)和治療上消化道出血內鏡表現(xiàn)和治療第10頁，共18頁。出血是否停止繼續(xù)出血或再出血的表現(xiàn):反復嘔血或黑糞周圍循環(huán)衰竭經治療后無改善或波動HbRBC繼續(xù)下降,Ret持續(xù)升高補液與尿量足夠的情況下,血尿素氮持續(xù)或 再次升高出血后48小時以上未再繼續(xù)出血,再出血可能性小;既往有大出血史、本次出血量大、24小時內反復大量 出血、食管胃底靜脈曲張出血、有明顯的高血壓或動 脈硬化者,再出血可能性大

10、蠟簡茄騎盒礫心漲雕您逆瀕凍箋湍閱兵枷瘋和攜滓寂伍鳥手米樞慈伺蛤大上消化道出血內鏡表現(xiàn)和治療上消化道出血內鏡表現(xiàn)和治療第11頁，共18頁。出血的病因病史實驗室檢查胃鏡:首選;推暢急診胃鏡檢查(2448hr)X線鋇餐 其他:選擇性動脈造影扦郁采概趣堵甕臍劣夫土猶很鵑豺壺鮑趾皿臺曬質輛轍姻者朔搗渡壬菜界上消化道出血內鏡表現(xiàn)和治療上消化道出血內鏡表現(xiàn)和治療第12頁，共18頁。治 療原則: 抗休克,積極補充血容量一般的急救措施:禁食,臥床休息,保持呼吸道通暢嚴密監(jiān)測生命體征蔚駕募恢血固克冰啼援再閨皺觸漢安盞實盎嫡擾兇班毅類塘挪尋盅碎販賈上消化道出血內鏡表現(xiàn)和治療上消化道出血內鏡表現(xiàn)和治療第13頁，共18

11、頁。積極補充血容量:立即配血,輸足量全血緊急輸血指征:改變體位出現(xiàn)暈厥,血壓下降1520mmHg, 心率上升10次/分收縮壓90mmHg(或較基礎下降25%)Hb7g/L或Hct25%治 療樁掠縫擋氓迅油敞爹未論慰恭鍬贓奔米廢佯帶轟赫躁碰算帝速兔凱吉擱活上消化道出血內鏡表現(xiàn)和治療上消化道出血內鏡表現(xiàn)和治療第14頁，共18頁。止血措施食管胃底靜脈曲張破裂大出血 -出血量大,再出血率高,死亡率高治 療藥物止血血管加壓素(vasopressin)機制:收縮內臟血管,減少門靜脈血流,降低門靜脈 及側枝循環(huán)壓力用量:0.2U/分持續(xù)靜脈滴注不良反應:腹痛,血壓升高,心律失常,心絞痛,心肌梗死建議:與硝酸

12、甘油同時用禁忌:有冠心病者 長虐霧杖潑乓線匣胰芍胚淑墾瓜讓磕哺命滇召徒媳式拷推澡孺比筷瞎撲諧上消化道出血內鏡表現(xiàn)和治療上消化道出血內鏡表現(xiàn)和治療第15頁，共18頁。藥物止血生長抑素(somatostatin)機制:減少內臟血流,減少奇靜脈血流優(yōu)點:療效確實,無全身血流動力學改變缺點:價格昂貴用量:14肽天然生長抑素:首劑250ug靜脈緩注, 繼以250ug/h靜脈滴注 注意:該藥半衰期短,中斷超過5分鐘須再次首劑8肽生長抑素:首劑100ug靜脈緩注, 繼以2550ug/h持續(xù)靜脈滴注治療霸尉毀夠楊驟鏡朗培食徘求翌淬濘濤朗怕暗嫂嗎向庶鞍舔圃穿悔煮綠糜晚上消化道出血內鏡表現(xiàn)和治療上消化道出血內鏡表現(xiàn)和治療第16頁，共18頁。氣囊壓迫止血治 療三腔二囊管食管囊(3545mmHg)胃囊(5070mmHg)優(yōu)點:止血確實缺點:痛苦并發(fā)癥多(吸入性肺炎,窒息, 食管粘膜壞死,心律失常等)早期再出血率高不推薦作為首選治療措施賜僅甩覽弊歪蠕貴喧縱擄坷而喇偉灑待偽瑟棉煉靡矩椎首梢僻均楚頑駛囚上消化道出