消化道出血 massive bleeding from UGI.ppt

Differential Diagnosis and Management principles of Upper Gastrointestinal Hemorrhage,Chao LIU Sun Yat-sen Memorial Hospital,Upper Gastrointestinal Hemorrhage (uGIH),Bleeding from the mouth to the proximal jejunum (Treitz ligament) A common abdominal emergency A major cause of morbidity and mortality (5% - 10%),Massive uGIH,Blood loss 800 ml or 20% of circulating blood volume,Special symptoms of massive uGIH,Hematemesis Melena: black sticky and foul-smelling stool, liquid or semisolid Hematochezia: passage of bright red rectally,Causes of massive uGIH,Peptic ulcer: about 50% (3/4 duodenal ulcer) Varices: 25% Stress ulcer / Hemorrhagic gastritis / Erosive ulcer: 5% Gastric carcinoma: 5% Hemobilia,Causes of massive uGIH,Others: Esophagitis Mallory-Weiss syndrome esophageal hiatal hernia gastric aneurysm gastric polyps etc,Gastric ulcer,Bleeding,Duodenal ulcer,Esophageal varices,Gastric varices,Hypertensive gastropathy,Stress ulcer,Gastric capiliarectasia,Gastric carcinoma,Differential diagnosis,History Ulcer Cirrhosis (hepatitis, alcohol abuse) Loss of appetite and weight using non-steroidal anti-inflammatory drugs Severe trauma, infection and shock,Differential diagnosis,Physical examination Nasopharygeal site Stigma, jaundice, ascites, splenomegaly Abdominal mass Charcot triad,Differential diagnosis,Laboratory examinations Blood routine test Liver function test Coagulating function test Blood biochemical analysis,Differential diagnosis,Gastric tube Endoscopy Angiography Radiologic contrast studies Radiological scintigraphy,Differential diagnosis,Clinical analysis: speed / amount / period of bleeding Bleeding sites Esophagus or fundus of stomach Stomach and duodenal bulb Below duodenal bulb,Management principles,Initial management Establishing adequate intravenous access Close monitoring of vital signs Replenishing the volume with normal saline or a plasma expander (Plasma/Saline: 3 - 4/1) Prompt blood cross-matching,Management principles (Peptic ulcer ),Medical therapy Histamine (H2)-receptor antagonist Proton pump inhibitors Ice cold saline,Management principles (Peptic ulcer ),Endoscopic hemostasis Injection therapy Coaptive coagulation Laser photocoagulation,Management principles (Peptic ulcer ),Surgical treatment When? How? Oversewing the ulcer bed Ligation of gastroduodenal artery Vagotomy and pyloroplasty Billroth II gastrectomy,Management principles (Varices),Medical therapy Resuscitation with blood and fluid replacement Correction of coagulopathy and thrombocytopenia Treatment of hepatic encephalopathy Vasopressive agents -Blockers (propranolol) Somatostatin Balloon tamponade,Management principles (Varices),Endoscopic therapy Injection sclerotherapy Endoscopic variceal ligation,Management principles (Varices),Surgical treatment When? Endoscopic hemostatis fails to control bleeding Rebleeding occurs soon after nonoperative treatment,Management principles (Varices),Surgical treatment - How? Portosystemic shunts TIPS Selective shunting Noselective shunting Division of collateral vein Splenectomy with periesophagogastric devascularization Esophageal transection liver transplantation,TIPS,Management principles,Stress ulcer Medical therapy Radiological treatment (selective intra-arterial infusion of vasopressin) Subtotal gastrectomy Gastric carcinoma Surgical treatment,Management principles,Hemobilia Antibiotics Correction of coagulopathy Biliary tract endoscope Selective embolization of hepatic artery Selective ligation of hepatic artery Partial hepatectomy,Management principles,Explorative laparotomy Stomach and duodenum Liver and spleen Gallbladder and common bile duct The proximal jejunum Exploration of gastric cavity,Key points,Endoscopy is the optimal investigation almost irrespective of the source of bleeding.,Key points,Peptic ulcer: account for 50% of cases of uGIH, Bleeding from peptic ulcer: first presentation in 10% 15% of theses cases,Key points,80% of bleeding ulcer can stop spontaneously, and the risk factors for poor prognosis are: Recurrent of massive hematemesis Age 60 years（Arteriosclerosis ） Presence of comorbid diseases Onset of GI bleeding after hospital admission for another medical condition; and coagulopathy,Key points,Bleeding from gastroesophageal varices is likely to recur and leads to death during the original admission. Endoscopic sclerotherapy is the m