上海交大外科學(xué)上血pbl課件

上消化道大出血

MassiveUpperGastrointestinalBleeding2009IntroduceOurselvesDr.Yang

&Dr.LiBasicConceptsWhatIsUGIEsophagus食道Stomach胃Duodenum十二指腸Jejunum空腸Ileum回腸AscendingColon升結(jié)腸TransverseColon橫結(jié)腸DescendingColon降結(jié)腸SigmoidColon乙結(jié)腸Rectum直腸Anus肛門Let’shaveaproblem!PatientCome45-yrfemalefirstepisodeofhematemesis嘔血transferredfromasmallhospital2unitsofpackederythrocyte紅細(xì)胞tranfusednasogastrictube胃管introducedwithactivebleedingpulse120bpm,BP80/40mmHgWhatIsYourDecisionWhatisyourintuition直覺?Worrisomeclinicalsignsandsymptomstachycardia心動過速morethan100beatsperminute(bpm)systolicbloodpressure(SBP)收縮壓≤90mmHgposturalhypotension體位性低血壓SBPdecrease≥15mmHgorpulserateincrease≥10bpmcoolextremities四肢厥冷syncope暈厥ongoingbriskhematemesis進(jìn)行性/活躍地嘔血maroonstool棗紅便MassiveorMinorClassIClassIIClassIIIClassIVBloodLossml≤750750-15001500-2000＞2000BloodLoss%≤1515-3030-40＞40PulseRatebpm≤100＞100＞120＞140BloodPressurenormalnormaldecreasedecreaseCNS神經(jīng)系統(tǒng)癥狀Slightlyanxious輕度焦慮Mildlyanxious中度焦慮Anxious,confused焦慮/意識模糊Confused,lethargic意識模糊/嗜睡UGIBorLGIBManifestation癥狀UGIBLGIBHematemesis嘔血AlmostcertainRareMelena黑便ProbablePossibleHematochezia便血PossibleProbableBlood-streakstool便中帶血絲RareAlmostcertainOccultbloodstool大便隱血PossiblePossibleChild-PughClassificationNo.ofPoints123Bilirubin(μmol/L)總膽紅素<3434-51>51Albumin(g/L)白蛋白>3528-35<28ProthrombinTime凝血酶原時間(s)≤1415-17≥18Ascites腹水NoneSlight>ModerateEncephalopathy腦病NoneSlight>ModerateGradeA=5-8points,GradeB=9-11points,GradeC=12-15pointsWhatIsYourDecisionWhatarethemanagementpriorities優(yōu)先順序tothispatient?ForReferenceResuscitation復(fù)蘇Hemostasis止血Differentialdiagnosis鑒別診斷Basicdiseasetreatment治療原發(fā)病Comorbiditymanagement處理并存病MedicalTherapyvasopressin血管加壓素somatostatinoranalogs生長抑素或同類物antacidagents制酸劑H2-receptorantagonistH2受體拮抗劑protonpumpinhibitor質(zhì)子泵抑制劑hemostaticagents&bloodcoagulationfactors止血劑和凝血因子NasogastricTubeIntroductionaspiration&lavage吸引和沖洗siteofbleedingbilewithoutblood–UGIBnotlikelygastricfluid&blood–UGIBcleargastricfluid–duodenalbleedingstillpossiblefalsenegative假陰性approximately10%hemostasis&monitoring止血和監(jiān)控icysalinelavagewithepinephrine腎上腺素aspirationcolor&amountreducevomiting減少嘔吐,protecttheairwayBalloonTamponade氣囊壓迫temporarymeasureduringresuscitation(24-48hr)20%complicationrateairwayobstruction氣道阻塞aspiration誤吸esophagusnecrosis食管粘膜壞死arrhythmia心律失常recurrentbleedingafterreleaseofballoonfirstinflategastricballoonto60mmHg(200ml)theninflateesophagusballoonto40mmHg(150ml)pullingweight0.25kgusingapulley滑車releasefor15minevery4hrsWhatIsYourDecisionWhatquestionwouldyouaskthepatient?ForReferenceHistoryofillness病史Precipitatingfactors誘因Comorbidities并存病FrequentSymptomsHematemesis嘔血-40-50%Melena黑便-70-80%Hematochezia便血-15-20%Eitherhematocheziaormelena-90-98%Syncope暈厥-14.4%Presyncope暈厥前期-43.2%Dyspepsia消化不良-18%Epigastricpain上腹痛-41%Heartburn胃灼熱-21%Diffuseabdominalpain彌漫性腹痛-10%Dysphagia吞咽困難-5%Weightloss體重減輕-12%Jaundice黃疸-5.2%WhatIsYourDecisionWhatisthedifferentialDiagnosis鑒別診斷?ForReferencePepticulcer消化性潰瘍Stressgastritis應(yīng)激性胃炎Stomachneoplasms胃腫瘤Portalhypertension門脈高壓Hemobilia膽道出血Miscellaneous其他少見原因PepticUlcerhistoryofchroniculcerepigastricpain(nocturnalsymptoms)上腹痛（夜間痛）dyspepsia消化不良satiety飽脹historyofmucosadamagedietsmokingNSAIDs非甾體類抗炎藥物Adrenalcorticalhormone腎上腺皮質(zhì)激素usuallymelena,sometimeshematemesisStressGastritishistoryofstress應(yīng)激病史burninjuriesheadinjuriespredisposingclinicalconditions可導(dǎo)致應(yīng)激的臨床情況shock休克multipletrauma多發(fā)傷ARDS(acuterespiratorydistresssyndrome)急性呼吸窘迫綜合征SIRS(systemicinflammatoryresponsesyndrome)全身炎癥反應(yīng)綜合征MODS(multipleorgandysfunctionsyndrome)多臟器功能障礙綜合征sepsis膿毒癥StomachNeoplasmsmiddleage中年weightloss體重減輕anorexia厭食irregularepigastricpain不規(guī)則腹痛abdominalmass腹部包塊PortalHypertensionpredisposinghistoryofcirrhosis肝硬化基礎(chǔ)疾病hepatitis肝炎Schistosomiasis血吸蟲病alcoholabuse酒癮specialfeatures特殊體征jaundice黃疸ascites腹水dilatedveinintheanteriorabdominalwall腹壁靜脈怒張rectalhemorrhoids痔FormationofPortalSystem3inflowveincollectbloodfromspleen,pancreas,stomach,intestine,colon,andrectumsplenicveinsuperiormesentericveininferiormesentericvein2branchesintoleft&righthepaticlobethroughhepaticsinustohepaticveintoIVC75%bloodsupply,50%oxygensupplyofliverCollateralVascularSystem側(cè)支循環(huán)esophageal-fundussubmucosalvenousplexus食管下段-胃底交通支rectalhemorrhoidalsystem直腸下段肛管交通支retroperitonealsystem后腹膜交通支anteriorabdominalwallsystem前腹壁交通支DefinitionofPortalHypertensionnormalportalpressure:13-24cmH2Onormalhepaticveinpressuregradient(HVPG):5-9cmH2Oportalhypertension:30-50cmH2OHVPG>12mmHgleadstoUGIBCauseofHypertensioncirrhosishepaticsinusnarrownessportalbloodinflowblockedhighpressurehepaticarteryflowtolowpressureportalveinPathophysiologyofPortalHypertensionsplenemegaly&hypersplenism脾腫大/脾功能亢進(jìn)peripheraltotalbloodcountdecreasecollateralvascularvarix側(cè)支靜脈曲張esophageal-fundussubmucosalvenousplexushasgreatestgradient,causemassiveUGIBhemorrhoidCaputMedusae海蛇頭ascitescapillaryfiltrationpressureincrease毛細(xì)血管滲透壓增加hypoalbuminemia低白蛋白血癥excessivelymphaticfluidgeneration淋巴液生成過多hyperaldosteronemia高醛固酮血癥portalgastropathy/encephalopathy門脈性胃病/腦病stomachmucousedema胃粘膜水腫portalsystemicshunt門體分流CaputMedusaeHemobiliahemobiliatriad膽道出血三聯(lián)癥biliarycolic膽絞痛obstructivejaundice梗阻性黃疸gastrointestinalbleeding消化道出血livertrauma肝外傷hepatichemangioma肝血管瘤hepaticneoplasm肝腫瘤hepaticabscess肝膿腫biliarytractstone膽道結(jié)石MiscellaneousMallory-Weisssyndrome:linearmucosallacerationnearcardia賁門asaresultofforcefulvomiting,retching干嘔orcoughingDieulafoylesion:vascularmalformationinstomachAngiodysplasia血管發(fā)育不良:abnormaldilated,thin-walledmucosalorsubmucosalvessels粘膜/粘膜下血管WhatIsYourDecisionWhatphysicalexamination體格檢查findingswouldyousearchfor?ForReferenceSignsofshockandbloodlossSignsofchronicliverdiseaseSignsoftumorShock&BloodLosspulseandbloodpressure脈率血壓posturalhypotension體位性低血壓mentaldisorder:anxious焦慮,confusion意識模糊,delirium譫妄,lethargy嗜睡,presyncope暈厥前期,syncope暈厥signsofanemia:paleconjunctivaandnailbed結(jié)膜甲床蒼白signsofpoorperfusion:coldextremities四肢厥冷,coldsweating冷汗,oliguria少尿,chestpain胸痛ChronicLiverDiseasesspiderangiomata蜘蛛痣palmaerythema肝掌gynecomastia男性乳房發(fā)育splenomegaly脾腫大ascites腹水pedaledema足部水腫asterixis撲翼樣震顫CaputMedusae海蛇頭Tumorupperabdominalmass上腹包塊leftsupraclavicularlymphnode(Virchow’snode)左鎖骨上淋巴結(jié)腫大umbilicalnodular(SisterMaryJoseph’snode)臍周結(jié)節(jié)Douglaspouchnodular(Bloomer’sshelf)直腸子宮（膀胱）陷凹結(jié)節(jié)WhatIsYourDecisionWhatdiagnosticstudieswouldyouorder?ForReferenceCompletebloodcount(CBC)全血細(xì)胞計(jì)數(shù)Bloodcrossmatch交叉配血Coagulationprofile凝血功能Liver&Renalfunction肝腎功能Calciumlevel血鈣Gastrinlevel血胃泌素CTscan計(jì)算機(jī)斷層掃描orUltrasonography超聲檢查DigitalSubtractionAngiography(DSA)數(shù)字減影血管造影Endoscope內(nèi)鏡EndoscopicExplorediagnosis&treatment診斷/治療雙重作用mostreliable&effectivemethod最可靠最有效within24-48hrsafterbleeding應(yīng)在出血后24-48小時內(nèi)進(jìn)行contraindication反指征hemodynamicinstablility血流動力學(xué)不穩(wěn)定severecardiacdecompensation嚴(yán)重心功能失代償acutemyocardialinfarction急性心肌梗塞perforatedviscus臟器穿孔UlcerwithBlackSpot10%RebleedingUlcerwithBloodClot22%RebleedingUlcerwithVisibleVessel43%RebleedingUlcerwithActiveBleeding55%RebleedingEsophagusVaricesHypertensivePortalGastropathyInjectionofSclerosant硬化劑BandLigation皮圈套扎Hemoclip止血夾LaserApplication激光止血HeaterProbe加熱探針WhatIsYourDecisionWhatarethetherapeuticoptionsforeachcommonetiology病因ofmassiveUGIBafterinitialresuscitation?ForReferenceMedicineEndoscopeSurgeryNon-VaricealBleedingtherapeuticendoscopewith/withoutmedicineifeffectivethencontinuedrugtherapyeradicationofH.pylorimucousprotection2attemptsofendoscopicfailurepursuesurgeryothersurgicalindicationsseverelife-threateningbleedingnotresponsivetoresuscitationcoexistingreasonofperforation,obstructionormalignanciessecondhospitalizationofpepticulcerVaricealBleedingdrugtherapywith/withoutballoontemponadeendoscopicbindingorsclerotherapytransjugularintrahepaticportosystemicshunt(TIPS)經(jīng)頸靜脈肝內(nèi)門體分流術(shù)effectiverate90%rebleedingrateinoneyear16-30%shuntdisfunctionratein6months50-60%inducingencephalopathyrate25-35%30daymortalityrate14-16%canbeusedasatemporarymethodbeforetransplantationChildA&B–surgeryChildC–transplantationTIPS8-12mmWhatIsYourDecisionHowtoperformtheoperation?ForReferenceExploration探查Hemostasis止血RadicalOperation根治ExplorationSequencemostpopularsite:sto