嘔血與便血4課件

嘔血與便血

HematemesisandHematochezia嘔血與便血

HematemesisandHematoch1DefinitionHematemesis

:Bloodyvomitusfromtheuppergastro-intestinal(GI)tract（beforetheligamentofTreitz)Hematochezia:brightred,maroonorblackbloodfromtherectumDefinitionHematemesis:Bloody2Treitz:

TheligamentofTreitzisananatomiclandmarkfortheduodenal-jejunaljunctionTreitz: 3ClinicalManifestation1Mannerofbleedingpresentation2Hypovolemia(低血容量)orshock3Anemia(貧血)ClinicalManifestation1Manne4Patientsmanifestbloodloss(A)

Hematemesis

嘔血

Character

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

infiveways:Patientsmanifestbloodloss(A5causeofdisease90%upperGIbleedingisduetofourlesions:1)pepticulcer(消化性潰瘍)2)esophagealorgastricvarices(食管胃底靜脈曲張破裂)3)hemorrhagicgastritis(急性糜爛性出血性胃炎)4) gastriccancercauseofdisease90%upperGIb6pepticulcerpepticulcer7hemorrhagicgastritishemorrhagicgastritis8esophagealvaricesesophagealvarices9gastriccancergastriccancer10OthercausesofupperGIbleedingMallory-Weisstear食道-賁門(mén)撕裂傷Foreignbodyinesophagus食管異物Ancylostomiasis 鉤蟲(chóng)病Post-sphincterotomy

括約肌切開(kāi)術(shù)后OthercausesofupperGIbleed11

DifferentiationNosebleeding?Hemoptysis?

Differentiation12DifferntiatinghemoptysisandhematemesisHemoptysisHematemesisCauseofdiseaseTB,bronchiectasis,pneumonia,lungcancer,heartdiseasePU,livercirrhosis,acuteerosiveandhemorrhagicgastritisSyptombeforebleedingitchoflaryngeal,dyspnea,coughepigastricdiscomfort,nauseaandvomitMannerofbleedinghawkvomit,spurtingBloodcolourfreshredmaroon,coffee-groundMixtureinbloodsputumfoamfooddebrisgastricjuicePowerofhydrogenalkalityacidityMelenanohaveSputumwithbloodysputumnosputumDifferntiatinghemoptysisand13Mannerofbleedingpresentation(B)

Hematochezia

便血

Character

brightredormaroonbloodfromtherectum

purebloodbloodintermixedwithformedstoolbloodydiarrheaMannerofbleedingpresentatio14(C)

Melena黑便

Character

Shiny,black,sticky,foul-smellingstool

Tarrystool(柏油樣便)(degradationofblood)Differentiation

exogenousstooldarkeners:animalblood,iron,bismuth(鉍劑)

Mannerofbleedingpresentation(C)Melena黑便Mannerofbl15Mannerofbleedingpresentation(D)Stoolwithoccult

blood

隱血便

Detectedonlybytestingthestoolwithamonoclonalantibodyforhumanhemoglobin

Mannerofbleedingpresentatio16EstimateamountofbleedingfromupperGItract5~10ml/dOB+50~70ml/dMelena

250~300mlinshorttimeHematemesis

Estimateamountofbleedingfr17CausesofbleedingColorectalcancerColitisLargehemorrhoid 大痔Rectumtear 肛裂VascularanomaliesHematologicdiseasesCausesofbleedingColorectal18Mannerofbleedingpresentation(E)withoutanyobjectivesignofbleeding,withsymptomsofbloodloss

Mannerofbleedingpresentatio191.HypovolemiaorshockDependingonspeedandvolumeofbloodloss＜1000mL:Weakness,giddiness(眩暈),tachycardia(心動(dòng)過(guò)速),coldextremity,sweatingShock:hypotention(低血壓),oliguria,(少尿)1.HypovolemiaorshockDependi202.Anemiaandhemogramchanging

Ifbloodlossisacute,thehematocrit(紅細(xì)胞比容)dosenotchangeduringthefirstfewhoursafterhemorrhageAbout24to72hourslater,plasmavolumeislargerthannormalandthehematocritisatitslowestpoint

2.Anemiaandhemogramchangin21

bleedingslowly

hypochromic(血紅蛋白過(guò)少)microcytic(小細(xì)胞)redbloodcells

meancorpuscularvolume(MCV，

平均血球壓積)ofthecellsmaybelow

bleedingslowly227654321Volume(Liters)45%45%27%ABCHematocritchangesABeforebleedingBImmediatelyafterbleedingC24~72hoursafterbleeding7654321Vo233.Feverlowgradefeverin24hoursafterbleeding3.Feverlowgradefeverin24h244.Azotemia(氮質(zhì)血癥)

DegradationofproteininintestinaltractBUN

↗

inseveralhoursafterbleeding

uptothepeakinabout24-48hours

↘normal

after3-4days4.Azotemia(氮質(zhì)血癥)Degradati255.Bowelsound

ActivebowelsoundusuallybepresentedinacutebleedingfromGItract5.Bowelsound 26Whereisthesourceofbleeding?

Localization

UpperGIbleeding:bleedingfromasourceproximaltotheligamentofTreitzLowerGIbleeding:bleedingfromasitedistaltotheligamentofTreitzWhereisthesourceofbl27

Localization

DifferentiatingfeaturesofupperGIandlowerGIbleeding

UpperGI LowerGI Manifestation Hematemesis Hematochezia melena Nasogastric

aspirate

Bloody Clear BUN

Elevated Normal Bowelsound Hyperactive NormalLocalization Differentiating28UpperGItractbleeding?Clinicalmanifestation(hematemesis melena) BowelsoundNasogastrictubeUpperGItractbleeding?Clini29HematemesisMelenaHematocheziaMoreproximallesionsproducehematemesisormelena,whereasmoredistallesionsaremorelikelytoproducehematocheziaHematemesisMelenaHematocheziaM30Diagnosticapproach

1.Historyandphysicalexamination2.Laboratoryexamination3.AuxiliaryexaminationDiagnosticapproach

1.Histor31HistoryandphysicalexaminationAhistoryofpreviouslydocumentedGItractdiseasedeterminedbyradiography,endoscopy,orsurgicalproceduresisveryusefulDiagnosticapproachtoGIbleedingHistoryandphysicalexaminati32DiagnosticapproachtoGIbleeding

Ahistoryofepigastric(上腹部)burningpainpromptlyrelievedbyfoodorantacids(抗酸劑)

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

ulcer?DiagnosticapproachtoGIblee33DiagnosticapproachtoGIbleeding

Patientswithstigmata

(特征)

ofhepatitisBorotherchronicactiveliverdisease[e.gspiderangioma

(蜘蛛痣),ascites(腹水),gynecomastia(男性乳房發(fā)育)]maypresentwithpainlesshematemesisfromesophagealvaricesⅡDiagnosticapproachtoGIblee34DiagnosticapproachtoGIbleeding

Patientswithforceful,retching

(干嘔)ormultipleepisodesofvomitingoffoodpriortotheonsetofhematemesismaybebleedingfrom

Mallory－Weisstears

ofthegastro-esophagealjunctionⅢDiagnosticapproachtoGIblee35DiagnosticapproachtoGIbleeding

Ahistoryof

gradualweightlossintermittentbloodinthestoolsalteredbowelhabitsoftensuggests

colorectalmalignancy

ⅣDiagnosticapproachtoGIblee36DiagnosticapproachtoGIbleeding

Hemorrhoidalbleedingisoftensuggestedbythepresenceofbrightredbloodsurroundingwell-formed,normal-appearingstoolsⅤDiagnosticapproachtoGIblee37DiagnosticapproachtoGIbleeding

A

rectalexamination

isessentialtodocumentstoolcoloraswellastopalpateforgrossanorectal

(肛直腸)

masslesionssuchaspolyps(息肉),cancers,orlargehemorrhoids.DiagnosticapproachtoGIblee38DiagnosticapproachtoGIbleeding

AuxiliaryexaminationEndoscopy(內(nèi)鏡)Endoscopyisthediagnosticprocedureofchoicebecauseofitshighaccuracyandimmediatetherapeuticpotential.

Endoscopy,however,mustbeperformedonlyfollowingadequate