嘔血與便血6課件

Diagnosisof

GastrointestinalBleedingProf.ChengweiTang(唐承薇教授)Dept.ofGastroenterology,WestChinaHospitalSichuanUniversityDiagnosisof

GastrointestinalHematemesisandHematochezia

嘔血與便血HematemesisandHematochezia

2

Theapproachtogastro-intestinal(GI)bleedingistailoredtothemannerofappearance. Theapproachtogastro-intest3Isbleedingacuteorchronic?IntensivecareWhereisthesourceofbleeding?EmpirictherapyDiagnosisTreatment(經(jīng)驗治療)Whatisthecausesofbleeding?Recognitionofhemorrhage

Isbleedingacuteorchronic?I4IntensivecareWhereisthesourceofbleeding?EmpirictherapyDiagnosisTreatment(經(jīng)驗治療)Whatisthecausesofbleeding?Isbleedingacuteorchronic?RecognitionofhemorrhageIntensivecareWhereisthesou5ClinicalManifestations1Mannerofbleedingpresentation2Hypovolemia(低血容量)orshock3Anemia(貧血)

RecognitionofhemorrhageClinicalManifestations1Mann6Patientsmanifestbloodloss1)

Hematemesis

嘔血

Bloodyvomitus,eitherfreshandbrightredorolderand“coffee-ground”(hematin酸化正鐵血紅素)incharacterHemoptysis? Nosebleeding?MannerofbleedingpresentationfromtheGItract

infiveways:Patientsmanifestbloodloss1)72)Melena

黑便Shiny,black,sticky,foul-smellingstooldegradationofbloodexogenousstooldarkenersironbismuth(鉍劑)

Mannerofbleedingpresentation2)Melena黑便Mannerofble8Mannerofbleedingpresentation3)

Hematochezia

便血brightredormaroonbloodfromtherectum

purebloodbloodintermixedwithformedstoolbloodydiarrheaMannerofbleedingpresentatio9Mannerofbleedingpresentation4)

Occult

隱血detectedonlybytestingthestoolwithamonoclonalantibodyforhumanhemoglobin

Mannerofbleedingpresentatio10EstimateamountofbleedingfromupperGItract5~10ml/dOB+50~70ml/dMelena

250~300mlinshorttimeHematemesis

Estimateamountofbleedingfr11Mannerofbleedingpresentationwithoutanyobjectivesignofbleedingwithsymptomsofbloodloss

dizziness,dyspnea,anginacordis(心絞痛),orevenshock

digitalexamination(指檢)oftherectumMannerofbleedingpresentatio12HypovolemiaorshockSpeedandvolumeofbloodlossWeakness,giddiness(眩暈),oliguria,(少尿)coldextremity,sweatingVitalsigns:tachycardia,(心動過速)hypotention(低血壓)HypovolemiaorshockSpeedand13AnemiapaledizzinesspalpitationeasyfatigabilitydyspneaanginacordisAnemiapaleeasy14Isbleedingacuteorchronic?1)Bleedingspeed

Hematemesisoffreshbloodgenerallyindicatesamoreseverebleedingepisodethanmelena,whichoccurswhenbleedingisslowenoughtoallowtimefordegradationofblood

Isbleedingacuteorchronic?115嘔血與便血6課件16Isbleedingacuteorchronic?2)Hematocrit

bleedingslowly

hypochromic(血紅蛋白過少)microcytic(小細胞)redbloodcells

meancorpuscularvolume(MCV，

平均血球壓積)ofthecellsmaybelow

Isbleedingacuteorchronic?217Isbleedingacuteorchronic?

Ifbloodlossisacute,thehematocritdosenotchangeduringthefirstfewhoursafterhemorrhageAbout24to72hourslater,plasmavolumeislargerthannormalandthehematocritisatitslowestpoint

Isbleedingacuteorchronic?187654321Volume(Liters)45%45%27%ABCIsbleedingacuteorchronic?HematocritchangesABeforebleedingBImmediatelyafterbleedingC24~72hoursafterbleeding7654321Vo19Isbleedingacuteorchronic?3)Bloodpressureandheartratedependon

amountofbloodlosssuddennessofbloodlossextentofcardiacandvascularcompensation

Isbleedingacuteorchronic?320posturalhypotension

----earlyphysicalfindingtachycardia

----greaterloss,compensaterecumbent(臥位)hypotension

----finalresults

Isbleedingacuteorchronic?posturalhypotensionIsbleedi21Isbleedingacuteorchronic?Posturalhypotension

Aposturaldropinbloodpressureof10to15mmHgIsbleedingacuteorchronic?P22Isbleedingacuteorchronic?4)

Bowelsound

ActivebowelsoundusuallybepresentedinacutebleedingfromGItractIsbleedingacuteorchronic?423Emergentandintensivecare

InitiallyvitalsignssupineanduprightbloodpressurepulseEmergentandintensivecareIn24Ifbloodlossissignificant,intravenousfluidsmustbestartedSalineorotherbalancedelectrolytesolutionsaremostrapidlyavailable

Ifbloodlossissignificant,25

Bpletebloodcountclottingstudiesroutinechemistrystudies.

Bloodfortypingandcross-matchingissenttothebloodbank.Bloodissenttothelab.26Whereisthesourceofbleeding?

Localization

UpperGIbleeding:bleedingfromasourceproximaltotheligamentofTreitz.

LowerGIbleeding:bleedingfromasitedistaltotheligamentofTreitz.Whereisthesourceofbleedin27

Localization

Treitz: TheligamentofTreitzisananatomiclandmarkfortheduodenal-jejunaljunction.Localization Treitz: 28

Localization

DifferentiatingfeaturesofupperGIandlowerGIbleeding UpperGI LowerGI Manifestation Hematemesis Hematochezia melena Nasogastricaspirate Bloody Clear BUN Elevated Normal Bowelsound Hyperactive NormalLocalization Differentiating29UpperGItractbleeding?ClinicalmanifestationBowelsoundNasogastrictubeUpperGItractbleeding?Clini30HematemesisMelenaHematocheziaHematemesisMelenaHematochezia31Moreproximallesionsproducehematemesisormelena,whereasmoredistallesionsaremorelikelytoproducehematochezia.Moreproximallesionspr32

IfhematocheziaisfromanupperGIsource,itusuallyreflectsamassivebleed(i.e.,greaterthan1000ml).

Ifhematocheziaisfroman33Whatisthecausesofbleeding?90%upperGIbleedingisduetofourlesions:1)pepticulcer(消化性潰瘍)2)hemorrhagicgastritis(胃炎)3)esophagealorgastricvarices (靜脈曲張)4) gastriccancerWhatisthecausesofbleeding34pepticulcerpepticulcer35hemorrhagicgastritishemorrhagicgastritis36esophagealvaricesesophagealvarices37gastriccancergastriccancer38Causesofgastrointestinalbleeding

Mallory-Weisstear

食道-賁門撕裂傷Causesofgastrointestinalble39CausesofgastrointestinalbleedingPortal-hypertensivegastropathy

門脈高壓胃病Ancylostomiasis

鉤蟲病Post-sphincterotomy

括約肌切開術(shù)后Causesofgastrointestinalble40CausesofgastrointestinalbleedingColorectalcancerColitisLargehemorrhoid 大痔Rectumtear 肛裂VascularanomaliesHematologicdiseasesCausesofgastrointestinalble41Diagnosticapproachtogastrointestinalbleeding

1

Historyandphysicalexamination2Endoscopy3Bariumradiography4Angiography5NuclearscintigraphyDiagnosticapproachtogastroi42History

andphysicalexaminationAhistoryofpreviouslydocu-mentedGItractdiseasedeterminedbyradiography,endoscopy,orsurgicalproceduresisveryuseful.DiagnosticapproachtoGIbleedingHistoryandphysicalexaminati43DiagnosticapproachtoGIbleeding

PatientswithhepatitisBorchronicactiveliverdiseasemaypresentwithpainlesshematemesisfromesophagealvarices.

DiagnosticapproachtoGIblee44DiagnosticapproachtoGIbleeding

Patientswithforceful,retching(干嘔)ormultipleepisodesofvomitingoffoodpriortotheonsetofhematemesismaybebleedingfromMallory－Weisstearsofthegastroesophagealjunction.DiagnosticapproachtoGIblee45DiagnosticapproachtoGIbleeding

Ahistoryofepigastric(上腹部)

burningpainpromptlyrelievedbyfoodorantacids(抗酸劑)

ornocturnal(夜間)painsuggestspepticulcerdisease,particularlyduodenal(十二指腸)ulcer.

DiagnosticapproachtoGIblee46DiagnosticapproachtoGIbleeding

Colorectalmalignancy

isoftensuggestebyahistoryofgradualweightlossintermittentbloodinthestoolsalteredbowelhabitsDiagnosticapproachtoGIblee47DiagnosticapproachtoGIbleeding

Hemorrhoidalbleedingisoftensuggestedbythepresenceofbrightredbloodsurroundingwell-formed,normal-appearingstools.DiagnosticapproachtoGIblee48DiagnosticapproachtoGIbleeding

Patientswithstigmata(特征)ofchronicliverdisease[e.g.,spiderangioma(蜘蛛痣),ascites(腹水),gynecomastia(男性乳房發(fā)育)]andupperGIbleedingoftenbleedfromesophagealvaricesorerosion(糜爛).DiagnosticapproachtoGIblee49DiagnosticapproachtoGIbleeding

Localizedepigastrictenderness(觸痛)

topalpationmayindicatepepticulcerdiseaseorgastritis.DiagnosticapproachtoGIblee50DiagnosticapproachtoGIbleeding

OccasionallypatientswithlowerGItractbleedingfromamalignancyhaveapalpablelowerabdominalmass,hepatomegaly(肝腫大)，signsofobviousweightloss.

DiagnosticapproachtoGIblee51DiagnosticapproachtoGIbleeding

Arectalexaminationisessen-tialtodocumentstoolcoloraswellastopalpateforgrossano-rectal(肛直腸)masslesionssuchaspolyps,cancers,orlargehemorrhoids.DiagnosticapproachtoGIblee52DiagnosticapproachtoGIbleeding

Endoscopy(內(nèi)鏡)

Endoscopyisthediagnosticprocedureofchoicebecauseofitshighaccuracyandimmediatetherapeuticpotential.

Endoscopy,however,mustbePerformedonlyfollowingadequateresuscita-tion(復(fù)蘇).DiagnosticapproachtoGIblee53DiagnosticapproachtoGIbleeding

Endoscopy

Contraindications：

acutemyocardialinfarction severechroniclungdisease hemodynamicinstability patientagitation(焦慮不安) terminalmalignancyDiagnosticapproachtoGIblee54DiagnosticapproachtoGIbleeding

Bariumradiography(鋇餐)Bariumradiographyisnoninvasivebuthassignificantdisadvantages,particularlyinpatientswhoarebleedingbriskly(actively).DiagnosticapproachtoGIblee55DiagnosticapproachtoGIbleeding

Angiography(血管造影)

Angiographymaylocalizethesiteofbleeding.DiagnosticapproachtoGIblee56DiagnosticapproachtoGIbleeding

AngiographyBleedingmustbeactivebecauseangiographydetectsonlyextravasation(外滲)ofcontrast(造影劑)intotheGItract.DiagnosticapproachtoGIblee57思考題：胃腸道出血有哪些表現(xiàn)形式？胃腸道出血的病因有哪些？對胃腸道出血的診斷通常采用哪些方式？思考題：胃腸道出血有哪些表現(xiàn)形式？58References：Textbookofphysicaldiagnosis.4thedition.MHSwartz.Elsevierscience.2002.

Sleisenger&Fordtran'sGastrointestinalandliverdisease.6thedition.MFeldman,BFScharschmidt,MHSleisenger.W.B.Saunders,2001.physicalDiagnosis，F(xiàn)ourthEdition,Jo-AnnReteguiz,M.D.,McGraw-Hill

References：59嘔血與便血6課件60Diagnosisof

GastrointestinalBleedingProf.ChengweiTang(唐承薇教授)Dept.ofGastroenterology,WestChinaHospitalSichuanUniversityDiagnosisof

GastrointestinalHematemesisandHematochezia

嘔血與便血HematemesisandHematochezia

62

Theapproachtogastro-intestinal(GI)bleedingistailoredtothemannerofappearance. Theapproachtogastro-intest63Isbleedingacuteorchronic?IntensivecareWhereisthesourceofbleeding?EmpirictherapyDiagnosisTreatment(經(jīng)驗治療)Whatisthecausesofbleeding?Recognitionofhemorrhage

Isbleedingacuteorchronic?I64IntensivecareWhereisthesourceofbleeding?EmpirictherapyDiagnosisTreatment(經(jīng)驗治療)Whatisthecausesofbleeding?Isbleedingacuteorchronic?RecognitionofhemorrhageIntensivecareWhereisthesou65ClinicalManifestations1Mannerofbleedingpresentation2Hypovolemia(低血容量)orshock3Anemia(貧血)

RecognitionofhemorrhageClinicalManifestations1Mann66Patientsmanifestbloodloss1)

Hematemesis

嘔血

Bloodyvomitus,eitherfreshandbrightredorolderand“coffee-ground”(hematin酸化正鐵血紅素)incharacterHemoptysis? Nosebleeding?MannerofbleedingpresentationfromtheGItract

infiveways:Patientsmanifestbloodloss1)672)Melena

黑便Shiny,black,sticky,foul-smellingstooldegradationofbloodexogenousstooldarkenersironbismuth(鉍劑)

Mannerofbleedingpresentation2)Melena黑便Mannerofble68Mannerofbleedingpresentation3)

Hematochezia

便血brightredormaroonbloodfromtherectum

purebloodbloodintermixedwithformedstoolbloodydiarrheaMannerofbleedingpresentatio69Mannerofbleedingpresentation4)

Occult

隱血detectedonlybytestingthestoolwithamonoclonalantibodyforhumanhemoglobin

Mannerofbleedingpresentatio70EstimateamountofbleedingfromupperGItract5~10ml/dOB+50~70ml/dMelena

250~300mlinshorttimeHematemesis

Estimateamountofbleedingfr71Mannerofbleedingpresentationwithoutanyobjectivesignofbleedingwithsymptomsofbloodloss

dizziness,dyspnea,anginacordis(心絞痛),orevenshock

digitalexamination(指檢)oftherectumMannerofbleedingpresentatio72HypovolemiaorshockSpeedandvolumeofbloodlossWeakness,giddiness(眩暈),oliguria,(少尿)coldextremity,sweatingVitalsigns:tachycardia,(心動過速)hypotention(低血壓)HypovolemiaorshockSpeedand73AnemiapaledizzinesspalpitationeasyfatigabilitydyspneaanginacordisAnemiapaleeasy74Isbleedingacuteorchronic?1)Bleedingspeed

Hematemesisoffreshbloodgenerallyindicatesamoreseverebleedingepisodethanmelena,whichoccurswhenbleedingisslowenoughtoallowtimefordegradationofblood

Isbleedingacuteorchronic?175嘔血與便血6課件76Isbleedingacuteorchronic?2)Hematocrit

bleedingslowly

hypochromic(血紅蛋白過少)microcytic(小細胞)redbloodcells

meancorpuscularvolume(MCV，

平均血球壓積)ofthecellsmaybelow

Isbleedingacuteorchronic?277Isbleedingacuteorchronic?

Ifbloodlossisacute,thehematocritdosenotchangeduringthefirstfewhoursafterhemorrhageAbout24to72hourslater,plasmavolumeislargerthannormalandthehematocritisatitslowestpoint

Isbleedingacuteorchronic?787654321Volume(Liters)45%45%27%ABCIsbleedingacuteorchronic?HematocritchangesABeforebleedingBImmediatelyafterbleedingC24~72hoursafterbleeding7654321Vo79Isbleedingacuteorchronic?3)Bloodpressureandheartratedependon

amountofbloodlosssuddennessofbloodlossextentofcardiacandvascularcompensation

Isbleedingacuteorchronic?380posturalhypotension

----earlyphysicalfindingtachycardia

----greaterloss,compensaterecumbent(臥位)hypotension

----finalresults

Isbleedingacuteorchronic?posturalhypotensionIsbleedi81Isbleedingacuteorchronic?Posturalhypotension

Aposturaldropinbloodpressureof10to15mmHgIsbleedingacuteorchronic?P82Isbleedingacuteorchronic?4)

Bowelsound

ActivebowelsoundusuallybepresentedinacutebleedingfromGItractIsbleedingacuteorchronic?483Emergentandintensivecare

InitiallyvitalsignssupineanduprightbloodpressurepulseEmergentandintensivecareIn84Ifbloodlossissignificant,intravenousfluidsmustbestartedSalineorotherbalancedelectrolytesolutionsaremostrapidlyavailable

Ifbloodlossissignificant,85

Bpletebloodcountclottingstudiesroutinechemistrystudies.

Bloodfortypingandcross-matchingissenttothebloodbank.Bloodissenttothelab.86Whereisthesourceofbleeding?

Localization

UpperGIbleeding:bleedingfromasourceproximaltotheligamentofTreitz.

LowerGIbleeding:bleedingfromasitedistaltotheligamentofTreitz.Whereisthesourceofbleedin87

Localization

Treitz: TheligamentofTreitzisananatomiclandmarkfortheduodenal-jejunaljunction.Localization Treitz: 88

Localization

DifferentiatingfeaturesofupperGIandlowerGIbleeding UpperGI LowerGI Manifestation Hematemesis Hematochezia melena Nasogastricaspirate Bloody Clear BUN Elevated Normal Bowelsound Hyperactive NormalLocalization Differentiating89UpperGItractbleeding?ClinicalmanifestationBowelsoundNasogastrictubeUpperGItractbleeding?Clini90HematemesisMelenaHematocheziaHematemesisMelenaHematochezia91Moreproximallesionsproducehematemesisormelena,whereasmoredistallesionsaremorelikelytoproducehematochezia.Moreproximallesionspr92

IfhematocheziaisfromanupperGIsource,itusuallyreflectsamassivebleed(i.e.,greaterthan1000ml).

Ifhematocheziaisfroman93Whatisthecausesofbleeding?90%upperGIbleedingisduetofourlesions:1)pepticulcer(消化性潰瘍)2)hemorrhagicgastritis(胃炎)3)esophagealorgastricvarices (靜脈曲張)4) gastriccancerWhatisthecausesofbleeding94pepticulcerpepticulcer95hemorrhagicgastritishemorrhagicgastritis96esophagealvaricesesophagealvarices97gastriccancergastriccancer98Causesofgastrointestinalbleeding

Mallory-Weisstear

食道-賁門撕裂傷Causesofgastrointestinalble99CausesofgastrointestinalbleedingPortal-hypertensivegastropathy

門脈高壓胃病Ancylostomiasis

鉤蟲病Post-sphincterotomy

括約肌切開術(shù)后Causesofgastrointestinalble100CausesofgastrointestinalbleedingColorectalcancerColitisLargehemorrhoid 大痔Rectumtear 肛裂VascularanomaliesHematologicdiseasesCausesofgastrointestinalble101Diagnosticapproachtogastrointestinalbleeding

1

Historyandphysicalexamination2Endoscopy3Bariumradiography4Angiography5NuclearscintigraphyDiagnosticapproachtogastroi102History

andphysicalexaminationAhistoryofpreviouslydocu-mentedGItractdiseasedeterminedbyradiography,endoscopy,orsurgicalproceduresisveryuseful.DiagnosticapproachtoGIbleedingHistoryandphysicalexaminati103DiagnosticapproachtoGIbleeding

PatientswithhepatitisBorchronicactiveliverdiseasemaypresentwithpainlesshematemesisfromesophagealvarices.

DiagnosticapproachtoGIblee104DiagnosticapproachtoGIbleeding

Patientswithforceful,retching(干嘔)ormultipleepisodesofvomitingoffoodpriortotheonsetofhematemesismaybebleedingfromMallory－Weisstearsofthegastroesophagealjunction.DiagnosticapproachtoGIblee105DiagnosticapproachtoGIbleeding

Ahistoryofepigastric(上腹部)

burningpainpromptlyrelievedbyfoodorantacids(抗酸劑)

ornocturnal(夜間)painsuggestspepticulcerdisease,particularlyduodenal(十二指腸)ulcer.

DiagnosticapproachtoGIblee106DiagnosticapproachtoGIbleeding

Colorectalmalignancy

isoftensuggestebyahistoryofgradualweightlossintermittentbloodinthestoolsalteredbowelhabitsDiagnosticapproachtoGIblee107DiagnosticapproachtoGIbleeding

Hemorrhoidalbleedingisoftensuggestedbythepresenceofbrightredbloodsurroundingwell-formed,normal-appearingstools.DiagnosticapproachtoGIblee108DiagnosticapproachtoGIbleeding

Patientswithstigmata(特征)ofchronicliverdisease[e.g.,spiderangioma(蜘蛛痣),ascites(腹水),gynecomastia(男性乳房發(fā)育)]andupperGIbleedingoftenbleedfromesophagealvaricesorerosion