消化道出血（ppt61）课件

Gastrointestinal Hemorrhage 消化道出血 武汉大学人民医院消化内科 于红刚 副教授 消化道以屈氏韧带消化道以屈氏韧带( (the ligament of Treitz)为界，其上的消化道出血称上为界，其上的消化道出血称上 消化道出血，其下的消化道出血称为消化道出血，其下的消化道出血称为 下消化道出血下消化道出血 Supper Gastrointestinal Hemorrhage 上消化道出血 Etiology Upper gastrointestinal bleeding is most commonly caused by peptic ulceration, gastroesophageal varices, acute erosive and hemorrhagic gastritis, and gastric cancer 病因 消化性溃疡 食管胃底静脉曲张破裂 急性糜烂出血性胃炎 胃癌 最常见 Etiology Esophageal Diseases Duodenal and Gastric Diseases Portal Hypertension-Related Causes Hemobilia Hemosuccus Pancreaticus Systemic Diseases Esophageal Diseases Esophagitis Esophageal ulceration Tumor of the esophagus Esophagus diverticulitis Esophagus injury: physical (Mallory- Weiss Tear); chemical (strong acid or alkali); radioactive Duodenal and Gastric Diseases Gastric Ulcer; Acute erosive and hemorrhagic gastritis; Gastric cancer; Gastric polyp; Zollinger- Ellison Syndrome; MALToma; Neurofibromatosis; Gastric vascular abnormity (Vascular Ectasia, Arteriovenous Malformations, Dieulafoys Lesion); Prolapse of gastric mucosa; Gastritis after operation; stoma ulcer Duodenal Ulcers; Duodenal diverticulitis; Acute erosive duodenitis; Crohns disease; Duodenal tuberculosis Portal Hypertension-Related Causes Esophageal varices Gastric varices Portal hypertensive gastropathy Hemobilia Including trauma, gallstones, cholecystic carcinoma, cholangiocarcinoma, ascariasis of biliary tract, liver cancer, liver abscess, hepatic hemangioma Hemosuccus Pancreaticus Pancreatic cancer Erosion of a pseudocyst into the splenic or peripancreatic artery or formation of an arterial aneurysm in the course of chronic pancreatitis Systemic Diseases Vascular Diseases: hypersusceptible purpura hereditary hemorrhagic telangiectasia Hematic Diseases: haemophilia; thrombocytopenic purpura Uremia Connective Tissue Diseases: polyarteritis nodosa; systemic lupus erythematosus Stress-related gastric mucosal injury （一）上消化道疾病 1食管疾病 2胃十二指肠溃疡疾病 （二）门静脉高压引起的食管胃底静脉 曲张破裂或门脉高压性胃病 （三）上消化道邻近器官或组织的疾病 （1）胆道出血 （2）胰腺疾病累及十二指肠 （3）主动脉瘤破入食管、胃或十二指肠 （4）纵隔肿瘤或脓肿破入食管 （四）全身性疾病 1血管性疾病 2血液病 3尿毒症 4结缔组织病 5急性感染 6应激相关胃粘膜损伤 Clinical Presentation Hematemesis Melena Hematochezia Symptoms of blood loss Anemia and Change of hemogram Elevation in the BUN level 临床表现 1呕血与黑粪 2失血性周围循环衰竭 3贫血和血象变化 4发热 5氮质血症 Hematemesis Be defined as the vomiting of blood and indicates an upper gastrointestinal site of bleeding blood may be either fresh, bright red, or it may be old and take on the appearance of coffee grounds bright red blood often from varices or arterial lesion; Patients with coffee ground emesis are not usually bleeding actively but have had a recent or even remote bleeding Melena Be defined as passage of black, tarry, and foul- smelling stool Character of melena is due to degradation of blood to hematin or other hemochromes by bacteria Instillation of 50 to 100 mL of blood into the stomach is required to produce melena consistently, tests for fecal occult blood become positive when about 5 mL is lost per day Hematochezia Refers to passage of bright red blood from the rectum that may or may not be mixed with stool It is happen when patients have gastro- intestinal lesions that bleed massively Symptoms of blood loss Including lightheadedness; tachycardia; angina pectoris; postural hypotension (the blood pressure is maintained on recumbency but falls more than 15 to 20 mmHg when the patient sits up) or even shock (pale to ashen, dyspnea, sweating and distressed, syncope) Anemia and Change of hemogram Patients who bleed small amounts of blood over long periods of time develop iron deficiency anemia, a low mean corpuscular volume (MCV), hypochromic, microcytic red blood cell and detection of occult blood in the stool with standard fecal occult blood tests If blood loss is acute, hematocrit value may not reflect blood loss accurately and the MCV, hemoglobin concentration is normal, Because equilibration with extra-vascular fluid and subsequent hemodilution requires several hours Elevation in the BUN level The blood urea nitrogen (BUN) level may be mildly elevated in patients with upper GI bleeding Due to breakdown of blood proteins to urea by intestinal bacteria and its absorption, as well as from a mild reduction in glomerular filtration rate BUN less than 14.3 mmol/L 诊断 （一）上消化道出血诊断的确立 1排除消化道以外的出血因素 （1）排除来自呼吸道出血 （2）排除口、鼻、咽喉部出血 （3）排除进食引起的黑粪 2判断上消化道还是下消化道出血 Clinical Localization of Bleeding Hematemesis is from an upper gastrointestinal source of bleeding Melena is usually the result of upper gastrointestinal bleeding and should not be confused with components of the diet (such as red meat and vegetables containing peroxidases) or the dark-green character of ingested iron or the black, nonfoul-smelling stool caused by ingestion of bismuth (such as bismuth subsalicylate) Hematochezia is usually the result of lower gastrointestinal bleeding but approximately 10% of the patients with rapid bleeding from an upper source present with hematochezia The nasogastric lavage has been used extensively to help differentiate upper from lower gastrointestinal bleeding, but now, the use is discouraged Other clues to an upper gastrointestinal source of bleeding include hyperactive bowel sounds and an elevation in the BUN level out of proportion to creatinine （二）出血严重程度的估计和周围循环状态的判断 （三）出血是否停止的判断 临床上出现下列情况应考虑继续出血或再出血： 反复呕血，或黑粪次数增多、粪质稀薄，伴有 肠鸣音亢进； 周围循环衰竭的表现经充分补液输血而未见明 显改善，或虽暂时好转而又恶化； 血红蛋白浓度、红细胞计数与红细胞压积继续 下降，网织红细胞计数持续增高 （四）出血的病因诊断 1临床与实验室检查提供的线 索 2胃镜检查 3X线钡餐检查 4其他检查 （五）危险性预测 提示预后不良危险性增高的主要因素有： 高龄患者（60岁）； 有严重伴随病（心、肺、肝、肾功能不全、脑 血管意外等）； 本次出血量大或短期内反复出血； 特殊病因和部位的出血（如食管胃底静脉曲张 破裂出血）； 消化性溃疡伴有内镜下活动性出血，或近期出 血征象如暴露血管或溃疡面上有血痂 治疗 （一）一般急救措施 （二）积极补充血容量 （三）止血措施 1食管、胃底静脉曲张破裂大出血的止血措施 2其他病因所致上消化道大量出血的止血措施 （1）抑制胃酸分泌的药物 （2）内镜治疗 （3）手术治疗 （4）介入治疗 Algorithm for management of upper gastrointestinal bleeding Lower digestive Hemorrhage 下消化道出血 Definition Lower digestive hemorrhage refers to bleeding (hemorrhage) that arises in the digestive tract below the ligament of Treitz 定义 下消化道出血是Treitz韧带远端的肠段，包 括空肠、回肠、结肠、直肠以及肛门病变引 起的出血，其临床表现以便血为主，轻者仅 呈粪便潜血或黑粪，出血量大则排出鲜血便 ，重者出现休克。 下消化道出血主要来源于大肠，小肠病变 相对较少见 病因 （一）肠道肿瘤：恶性肿瘤有癌，类癌，恶性 淋巴瘤，平滑肌肉瘤，纤维肉瘤，神经纤维肉 瘤；良性肿瘤有平滑肌瘤，脂肪瘤，血管瘤， 神经纤维瘤，粘液瘤等 （二）息肉病变：分为腺瘤性，错构瘤性，炎 性和增生性 （三）炎症性肠病：感染性肠炎有结核，伤 寒，菌痢和其他细菌性肠炎；寄生虫感染有 阿米巴，血吸虫，钩虫，鞭虫等；非特异性 肠炎有溃疡性结肠炎，克罗恩病；还包括药 物性肠炎，放射性肠炎，坏死性小肠炎，缺 血性肠炎等 （四）血管性疾病：肠血管畸形，肠系膜动 脉栓塞，肠系膜血管血栓形成，先天性毛细 血管扩张症，结肠静脉曲张，小肠海绵状血 管瘤，毛细血管瘤 （五）肠壁结构性病变：肠道憩室病， Meckel憩室，消化道重复畸形，肠套叠，肠 扭转，肠气囊肿病等 （六）全身性疾病： 1. 血液系统疾病：白血病，过敏性紫癜，血 小板减少性紫癜，再生障碍性贫血，血友病 ，恶性网状细胞增多症 2. 风湿性疾病：系统性红斑狼疮，结节性多 动脉炎等 3. 维生素C、K缺乏，食物中毒，药物中毒 （七）医源性出血 （八）其他：如肿瘤侵犯，子宫内膜异位症 ，腹内疝，腹外伤等。 （九）原因不明 据统计，国内引起下消化道出血的原因依 次为：大肠癌、息肉、炎症性肠病、痔和肛 裂 血管畸形等 诊断 完整系统的下消化道出血的诊断包括下消 化道出血的确立，出血速度，出血量和出血 部位的判断，以及明确出血的病因。必须详 细询问病史，细致体检，和实验室检查，包 括三大常规，肝肾功能，凝血功能血尿素氮 肌酐等，并根据具体情况相应选择内镜，系 统钡餐，核素扫描，选择性动脉造影等辅助 检查 判断上消化道还是下消化道出血 鉴别要点 上消化道出血 下消化道出血 既往史 多有消化性溃疡,肝胆 多曾有下腹疼痛，腹部包块 疾病，呕血，饮酒史 排便异常，或便血史 出血先兆 上腹胀,疼痛恶心反胃 中下腹不适，坠胀, 欲排便 出血方式 黑粪或呕血 便血,无呕血 便血特点 柏油样便,较稠 暗红或鲜红，稀，多不成形 可成形,无血块. 大量出血时可有血块. 血尿素氮与 增高 略增高或正常 肌酐比值 下消化道出血的定位和病因诊断 1 病史 1.1 年龄 老年患者多为大肠癌、息肉；中青年多为息肉 、炎症性肠病、痔；儿童多为先天性疾病，以Meckel憩室最 多见。 1.2 出血前病史 寄生虫、肠道和全身性疾病、药物史等 1.3 粪便颜色和症状 血色鲜红与粪便相混杂，应考虑结 肠癌、结肠息肉病、慢性溃疡性结肠炎；粘液脓血便，应考 虑菌痢、结肠血吸虫病、慢性结肠炎、结肠结核等 ；果酱 色大便应考虑阿米巴痢疾；柏油样便应考虑右半结肠或小肠 出血 1.4 伴随症状 伴发热常见于肠道炎症性病变； 伴有剧烈腹痛，应考虑肠系膜血管栓塞、出血性 坏死性肠炎、缺血性结肠炎、肠套叠等；不伴腹 痛者考虑息肉、血管病变等；伴有不完全梗阻者 ，应考虑结癌、克罗恩病、肠结核、肠套叠等； 伴有皮肤或其他器官出血征象者，要注意血液系 统疾病、重症肝病、尿毒症、维生素C缺乏症等 情况 2 体格检查 皮肤粘膜：皮疹、出血点、毛细血管扩张等 腹部体检：压痛及包块 肛门直肠指检：注意痔、肛裂、瘘管、肿物等 3 实验室检查 三大常规 生化检查、凝血功能 怀疑伤寒作血培养和肥达试验 怀疑结核作PPD实验 怀疑全身性疾病作相应检查 4 影像学检查 4.1 结肠镜（colonoscopy）：是诊断大肠和回 肠末端病变的首选检查方法。 具有直视的优点，诊断敏感性高，可发现活 动性出血，也可发现轻微的炎性病变和浅表溃 疡。能在检查过程中作活检判断病变性质，并 可行息肉摘除、血管套扎等治疗。 在急性出血期间仍可进行该项检查，但在严 重出血伴休克病例宜稍推迟待病情稳定后再进 行 4.2 X线钡剂造影（Barium radiographs）：由于 小肠镜检病人较痛苦，花费较高，小肠X线气 钡双重对比造影仍然是诊断小肠出血性疾病最 常用的检查手法 对小肠肿瘤、憩室及小肠畸形等小肠疾病的 诊断具有重要价值 急性活动性出血及出血停止48小时内不宜行 此检查 4.3 放射性核素扫描或选择性动脉造影 必须在活动性出血时进行 适用于：内镜检查和X线钡剂造影不能确定 出血来源，严重急性大出血或其他原因不能 行内镜检查 放射性核素扫描在出血速度0.1ml/min时 可判断出血部位 选择性动脉造影在出血量0.5ml/min时有 定位价值，并对某些血管畸形有定性价值 Radionuclide imaging Radionuclide imaging (such as Tagged Red Blood Cell Scintigraphy) is mainly adopted in patients with lower gastrointestinal bleeding Advantages (1) sensitivity to low rates of bleeding (0.1 to 0.5 mL/min); (2) safety; (3) it is noninvasive; (5) low cost Disadvantages include its lack of therapeutic capability and doubt about its accuracy Angiography Angiogra