便血病理全面版課件

1、1便血病理第1頁/共52頁1便血病理第1頁/共52頁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頁/共52頁Five Ways of GI BleedingHemateFactors affect the way to manifestSite of bleeding Speed of bleedingAmount of blood lossFlora of enterocolon. 第3頁/共52頁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頁/共52頁Differentiating Upper from LowCommon cause of up GI bleeding Peptic ulcer ；

4、Gastropathy （alcohol， aspirin， NSAIDs， stress）；GE varices； Gastric cancer第5頁/共52頁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頁/共52頁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頁/共52頁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頁/共52頁 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頁/共52頁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頁/共52頁Bleeding From EVA number of cu第11頁/共52頁第11頁/共52頁第12頁/共52頁第12頁/共52頁第13頁/共52頁第13頁/共52頁Bleeding Survey: Endoscopic Findings in 214 Patients With Clear Nasogastric AspiratesFINDING NUMBER OF PA

10、TIENTS INCIDENCE (%)Telangiectasia 0第14頁/共52頁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頁/共52頁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頁/共52頁Hem

12、atemesis with other symptoLab.Examination in Localization & Diagnosis of GI BleedingEndoscopyBarium RadiographsAngiographyRadionuclide imaging第17頁/共52頁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頁/共52頁Laboratory changes: HCT, BUNA第19頁/共52頁第19頁/共52頁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頁/共52頁Endoscopic view of a Mallory-WEndoscopic view of a Dieulafoy lesion on the lesser curvature of the stomach第21頁/共52頁Endoscopic view of a DieulafoyEndoscopic view of a vascular ectasia (angiodysplasia) in the duodenum. 第2

18、2頁/共52頁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頁/共52頁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頁/共52頁Endoscopic views of ulcers wit第25頁/共52頁第25頁/共52頁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頁/共52頁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頁/共52頁Site of bleedingTypical round Causes of Low GI Bleeding 第28頁/共52頁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頁/共52頁Differentiating Upper from LowHematochezia with other sym

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

26、頁第33頁/共52頁A, Linear ulcers of Crohns colitis. B, Mucosa surrounding the ulcers is nodular (cobblestoning).第34頁/共52頁A, Linear ulcers of Crohns coShigella colitis. Patchy areas of erythema, spontaneous bleeding, and loss of the normal vascular pattern are evident第35頁/共52頁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頁/共52頁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頁/共52頁Tuberculosis. Linear ulceratioPseudomembranous (antibiotic-associated) colitis. Numerous elevated yellowish plaques are present on the mucosal surface.第38頁/共52頁P(yáng)seudomembranous (antibiotic-aA

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

30、with ischemic colitis. 第41頁/共52頁Large colonic ulcer in a patieAdvantage colon carcinoma第42頁/共52頁Advantage colon carcinoma第42頁/Barium enema appearance of an ischemic stricture with features of carcinoma: asymmetry, mucosal destruction, and shouldering.第43頁/共52頁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