上海交大外科學(xué)上血演示文稿

上(Shang)海交大外科學(xué)上(Shang)血演示文稿第一頁，共七十九頁。（優(yōu)選）上(Shang)海交大外科學(xué)上(Shang)血第二頁，共七十九頁。BasicConcepts第三頁，共七十九頁。WhatIsMassiveBleeding>20%(>800ml)bloodlossHemodynamicinstability血流動力學(xué)不穩(wěn)Clinicalsignsofpoorperfusion組織灌(Guan)注差第四頁，共七十九頁。WhatIsUGIEsophagus食道Stomach胃Duodenum十(Shi)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肛門第五頁，共七十九頁。第六頁，共七十九頁。第七頁，共七十九頁。PleaseRememberUGIBisnotuncommonintheemergencyroomMortalityrateisabout10%UGIBisaseriesofdiseasesmainlytreatedbyinternalmedicine.3-15%requireasurgicalprocedure第八頁，共七十九頁。Let’shaveaproblem!第九頁，共七十九頁。PatientCome45-yrfemalefirstepisodeofhematemesis嘔血transferredfromasmallhospital2unitsofpackederythrocyte紅細(xì)胞tranfusednasogastrictube胃(Wei)管introducedwithactivebleedingpulse120bpm,BP80/40mmHg第十頁，共七十九頁。WhatIsYourDecisionWhatisyourintuition直(Zhi)覺?第十一頁，共七十九頁。ForReferenceDoesthepatienthavelife-threateningsituation?hypovolemicshock低(Di)血容量性休克lowbodytemperature體溫降低anemia/hypoxemia貧血/低氧血癥comorbidities并存病Isitamassiveorminorbleeding?Whereisthemostprobablebleedingsite?第十二頁，共七十九頁。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(Xing)性/活躍地嘔血maroonstool棗紅便第十三頁，共七十九頁。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/嗜睡第十四頁，共七十九頁。UGIBorLGIBManifestation癥狀UGIBLGIBHematemesis嘔血AlmostcertainRareMelena黑便ProbablePossibleHematochezia便血PossibleProbableBlood-streakstool便中帶血絲RareAlmostcertainOccultbloodstool大便隱血PossiblePossible第十五頁，共七十九頁。EstimationofBloodLossoccultbloodstool –5-10ml/24hmelena –50-100ml/24hhematemesis –250-300mlinstomachCNSchange –>500mlhypovolemia –>1000ml/shortperiod第十六頁，共七十九頁。Child-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=12-15points第十七頁，共七十九頁。WhatIsYourDecisionWhatarethemanagementpriorities優(yōu)先順(Shun)序tothispatient?第十八頁，共七十九頁。ForReferenceResuscitation復(fù)蘇Hemostasis止血Differentialdiagnosis鑒別診斷(Duan)Basicdiseasetreatment治療原發(fā)病Comorbiditymanagement處理并存病第十九頁，共七十九頁。InitialResuscitationABCairway保持氣道通暢breathing維持呼吸和供氧circulation維持循環(huán)bilateralintravenousaccess(atleast)雙路靜脈通路short,largepore短而粗fastfluidreplacement快速液體輸入3-for-1rule:1mlbloodloss,3mlcrystalloidfluidbloodtransfusion:2-6unitsofpackederythrocyteclosemonitoring密切監(jiān)(Jian)護第二十頁，共七十九頁。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(Beng)抑制劑hemostaticagents&bloodcoagulationfactors止血劑和凝血因子第二十一頁，共七十九頁。NasogastricTubeIntroductionaspiration&lavage吸引和沖洗siteofbleedingbilewithoutblood–UGIBnotlikelygastricfluid&blood–UGIBcleargastricfluid–duodenalbleedingstillpossiblefalsenegative假陰(Yin)性approximately10%hemostasis&monitoring止血和監(jiān)控icysalinelavagewithepinephrine腎上腺素aspirationcolor&amountreducevomiting減少嘔吐,protecttheairway第二十二頁，共七十九頁。BalloonTamponade氣囊(Nang)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releasefor15minevery4hrs第二十三頁，共七十九頁。第二十四頁，共七十九頁。WhatIsYourDecisionWhatquestionwouldyouaskthepatient?第二十五頁，共七十九頁。ForReferenceHistoryofillness病史Precipitatingfactors誘因(Yin)Comorbidities并存病第二十六頁，共七十九頁。Historyhistoryofbleeding出血情(Qing)況time持續(xù)時間symptoms表現(xiàn)癥狀amount出血量historyofrelateddiseasespepticulcer消化性潰瘍liverdiseases肝臟疾病cholangio-pancreaticdiseases膽胰疾病coagulopathy凝血障礙others第二十七頁，共七十九頁。Precipitatingfactorsalcoholabuse酒癮NSAIDs(nonsteroidanti-inflammatorydrugs)ingestion非甾體類抗炎藥物(Wu)應(yīng)用stress應(yīng)激:burninjuries–Curling

headinjuries–Cushing第二十八頁，共七十九頁。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(Kun)難-5%Weightloss體重減輕-12%Jaundice黃疸-5.2%第二十九頁，共七十九頁。WhatIsYourDecisionWhatisthedifferentialDiagnosis鑒別(Bie)診斷?第三十頁，共七十九頁。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(Yuan)因第三十一頁，共七十九頁。PepticUlcerhistoryofchroniculcerepigastricpain(nocturnalsymptoms)上(Shang)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,sometimeshematemesis第三十二頁，共七十九頁。StressGastritishistoryofstress應(yīng)激病(Bing)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膿毒癥第三十三頁，共七十九頁。StomachNeoplasmsmiddleage中年weightloss體重減輕(Qing)anorexia厭食irregularepigastricpain不規(guī)則腹痛abdominalmass腹部包塊第三十四頁，共七十九頁。PortalHypertensionpredisposinghistoryofcirrhosis肝硬化基礎(chǔ)疾病hepatitis肝炎Schistosomiasis血吸蟲(Chong)病alcoholabuse酒癮specialfeatures特殊體征jaundice黃疸ascites腹水dilatedveinintheanteriorabdominalwall腹壁靜脈怒張rectalhemorrhoids痔第三十五頁，共七十九頁。FormationofPortalSystem3inflowveincollectbloodfromspleen,pancreas,stomach,intestine,colon,andrectumsplenicveinsuperiormesentericveininferiormesentericvein2branchesintoleft&righthepaticlobethroughhepaticsinustohepaticveintoIVC75%bloodsupply,50%oxygensupplyofliver第三十六頁，共七十九頁。第三十七頁，共七十九頁。CollateralVascularSystem側(cè)支(Zhi)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前腹壁交通支第三十八頁，共七十九頁。第三十九頁，共七十九頁。DefinitionofPortalHypertensionnormalportalpressure:13-24cmH2Onormalhepaticveinpressuregradient(HVPG):5-9cmH2Oportalhypertension:30-50cmH2OHVPG>12mmHgleadstoUGIB第四十頁，共七十九頁。第四十一頁，共七十九頁。CauseofHypertensioncirrhosishepaticsinusnarrownessportalbloodinflowblockedhighpressurehepaticarteryflowtolowpressureportalvein第四十二頁，共七十九頁。第四十三頁，共七十九頁。PathophysiologyofPortalHypertensionsplenemegaly&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(Men)脈性胃病/腦病stomachmucousedema胃粘膜水腫portalsystemicshunt門體分流第四十四頁，共七十九頁。CaputMedusae第四十五頁，共七十九頁。Hemobiliahemobiliatriad膽道出血三聯(lián)癥biliarycolic膽絞痛obstructivejaundice梗(Geng)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)石第四十六頁，共七十九頁。MiscellaneousMallory-Weisssyndrome:linearmucosallacerationnearcardia賁門asaresultofforcefulvomiting,retching干嘔orcoughingDieulafoylesion:vascularmalformationinstomachAngiodysplasia血管發(fā)(Fa)育不良:abnormaldilated,thin-walledmucosalorsubmucosalvessels粘膜/粘膜下血管第四十七頁，共七十九頁。WhatIsYourDecisionWhatphysicalexamination體(Ti)格檢查findingswouldyousearchfor?第四十八頁，共七十九頁。ForReferenceSignsofshockandbloodlossSignsofchronicliverdiseaseSignsoftumor第四十九頁，共七十九頁。Shock&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(Chuang)蒼白signsofpoorperfusion:coldextremities四肢厥冷,coldsweating冷汗,oliguria少尿,chestpain胸痛第五十頁，共七十九頁。ChronicLiverDiseasesspiderangiomata蜘蛛痣(Zhi)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海蛇頭第五十一頁，共七十九頁。Tumorupperabdominalmass上腹包塊leftsupraclavicularlymphnode(Virchow’snode)左鎖骨上淋(Lin)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)第五十二頁，共七十九頁。WhatIsYourDecisionWhatdiagnosticstudieswouldyouorder?第五十三頁，共七十九頁。ForReferenceCompletebloodcount(CBC)全血細(xì)胞計(Ji)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計算機斷層掃描orUltrasonography超聲檢查DigitalSubtractionAngiography(DSA)數(shù)字減影血管造影Endoscope內(nèi)鏡第五十四頁，共七十九頁。EndoscopicExplorediagnosis&treatment診斷/治療雙重作用mostreliable&effectivemethod最可靠最有效within24-48hrsafterbleeding應(yīng)在(Zai)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臟器穿孔第五十五頁，共七十九頁。第五十六頁，共七十九頁。UlcerwithBlackSpot10%Rebleeding第五十七頁，共七十九頁。UlcerwithBloodClot22%Rebleeding第五十八頁，共七十九頁。UlcerwithVisibleVessel43%Rebleeding第五十九頁，共七十九頁。UlcerwithActiveBleeding55%Rebleeding第六十頁，共七十九頁。EsophagusVarices第六十一頁，共七十九頁。第六十二頁，共七十九頁。HypertensivePortalGastropathy第六十三頁，共七十九頁。InjectionofSclerosant硬化(Hua)劑第六十四頁，共七十九頁。BandLigation皮圈套(Tao)扎第六十五頁，共七十九頁。Hemoclip止血(Xue)夾第六十六頁，共七十九頁。LaserApplication激光(Guang)止血第六十七頁，共七十九頁。HeaterProbe加熱(Re)探針第六十八頁，共七十九頁。WhatIsYourDecisionWhatarethetherapeuticoptionsforeachcommonetiology病(Bing)因ofmassiveUGIBafterinitialresuscitation?第六十九頁，共七十九頁。ForReferenceMedicineEndoscopeSurgery第七十頁，共七十九頁。Non-VaricealBleedingtherapeuticendoscopewith/withoutmedicineifeffectivethencontinuedrugtherapyeradicationofH.pylorimucousprotection2attemptsofendoscopicfailurepursuesurgeryothersurgicalindicationsseverelife-threateningbleedingnotresponsivetoresuscitationcoexistingreasonofperforation,obstructionormalignanciessecondhospitalizationofpepticulcer第七十一頁，共七十九頁。VaricealBleedingdrugtherapywith/withoutballoontemponadeendoscopicbindingorsclerotherapytransjugularintrahepaticportosystemicshunt(TIPS)經(jīng)頸靜脈肝內(nèi)門體分流(Liu)術(shù)effectiverate90%rebleedingrateinoneyear16-30%shuntdisfunctionratein6months50-60%inducingencephalop