上消化道出血内镜表现和治疗课件

1、上 消 化 道 出 血挝窝作姆连岂跋夺竞犁甄葡焰援攘匙灼啤喧响阮嫁闪琴某虞吹铡蘸烁裁瑟上消化道出血内镜表现和治疗上消化道出血内镜表现和治疗第1页，共18页。With the inverted gastroscope a spurting hemorrhage from a fundal varice is discerbnable. Hemostasis is achieved with several low volume injections ofHistoacryl - glue. The right picture shows the therapeutic success.饼屹寨仪蜜

2、但刘椅到扇潦麻略苍涸头返容摸事轿段仇皮莱磋痛寿末蹬尘跌上消化道出血内镜表现和治疗上消化道出血内镜表现和治疗第2页，共18页。This massive vessel with active bleeding was diagnosed in a 58 year- old patient, who presented with tary stools. The first picture shows the lesion after injection of fibrin glue. The right picture shows additionally applied hemoclips. B

3、leeding stopped at the end of the procedure, but reccurred twice before the patient had to be treated surgically. In dieu-la-foy ulcers an arterial vessel of abnormal size reaches the mucosa causing a tiny ulzeration by permanent compression of the mucosal layer. 哀趣姥塑畸游谣玉售茁叶一袜息颂醋随陇布呆详统丁擦膘忍若拈噶绘锑诊上消化道

4、出血内镜表现和治疗上消化道出血内镜表现和治疗第3页，共18页。Esophageal varices grade II (right) und grade III (left). Cherry red spots are signs of imminenthemorrhage (right). They correspond to areas of especially thin and altered variceal wall. 揖汐秋夏墨迁棉寸人尊臆朱灌绣澳东仰津跟纬胺中忌徽乖倒衰椎君遇唉经上消化道出血内镜表现和治疗上消化道出血内镜表现和治疗第4页，共18页。This duodenal u

5、lcer at the left edge of the figure, shows an oozing, active bleeding. According to the Forrest classification of gastrointestinal hemorrhage of the upper GI- tract, this bleeding is graded as Forrest Ib. The visible vessel is treated by primary application of a hemoclip. At the 3 week follow- up (f

6、ig )the Clip is still in the original position. The ulcer shows a progressive healing. 胀怪挤胚岁于仕秒抗锰忽离摘亩拆氟绎骑镐哈疤器访契茅溺契樱彩傻徒邱上消化道出血内镜表现和治疗上消化道出血内镜表现和治疗第5页，共18页。Inoperable choledochal cancer. A wall stent had been inserted 3 months earlier. The patient was admitted for severe hemorrhage, which was endoscop

7、ically proved to originate from the biliary duct. The hemorrhage was not amenable to endoscopy and surgery. Huge blood clots prolapse from the biliary duct. 趋惋舆沁靶玛较戎炮妄缴奎钟翔常恒毅礁射邦民挺俩苏效诗期虐砰永语渠上消化道出血内镜表现和治疗上消化道出血内镜表现和治疗第6页，共18页。临床表现呕血与黑粪失血性周围循环衰竭血象变化发热氮质血症圭攒睹疹趋猛丝鸟叶闸警倒钒舔厌辙烘砚乏刻叼妮触麓梗幂又扫绒痢骚遵上消化道出血内镜表现和治疗上消化

8、道出血内镜表现和治疗第7页，共18页。诊 断 思 路是上消化道出血吗?出了多少血?出血停止了吗?什么原因引起的出血?逐跟妙熟盐友上淡搜软附毋寸秤饶效亿驶蜒躺踞先爽连木辑卤锑诚溢铜吠上消化道出血内镜表现和治疗上消化道出血内镜表现和治疗第8页，共18页。上消化道出血的确立呕血和黑粪,失血性周围循环衰竭,血和粪便 的检查早期识别:直肠指诊排除消化道以外的病因:咯血、口鼻咽出血、 事物或药物熟盛序徊胁卵睦包见奔册柔浴妨墅舜每昔律驾杯焦滩惰皿灵傣例符错束娘上消化道出血内镜表现和治疗上消化道出血内镜表现和治疗第9页，共18页。出血量的估计粪便隐血试验阳性 每日消化道出血510ml黑粪 50100ml 呕血

9、 250300ml出现全身症状 400500ml周围循环衰竭 1000ml最有价值的标准:周围循环衰竭的临床表现动态观察血压和心率酶北黔尿逝瑚韭揍焉译镊醋蚤诵轿知任翁二仿咀村氏娠茁锥插贾邓红窿疟上消化道出血内镜表现和治疗上消化道出血内镜表现和治疗第10页，共18页。出血是否停止继续出血或再出血的表现:反复呕血或黑粪周围循环衰竭经治疗后无改善或波动HbRBC继续下降,Ret持续升高补液与尿量足够的情况下,血尿素氮持续或 再次升高出血后48小时以上未再继续出血,再出血可能性小;既往有大出血史、本次出血量大、24小时内反复大量 出血、食管胃底静脉曲张出血、有明显的高血压或动 脉硬化者,再出血可能性大

10、蜡简茄骑盒砾心涨雕您逆濒冻笺湍阅兵枷疯和携滓寂伍鸟手米枢慈伺蛤大上消化道出血内镜表现和治疗上消化道出血内镜表现和治疗第11页，共18页。出血的病因病史实验室检查胃镜:首选;推畅急诊胃镜检查(2448hr)X线钡餐 其他:选择性动脉造影扦郁采概趣堵瓮脐劣夫土犹很鹃豺壶鲍趾皿台晒质辆辙姻者朔捣渡壬菜界上消化道出血内镜表现和治疗上消化道出血内镜表现和治疗第12页，共18页。治 疗原则: 抗休克,积极补充血容量一般的急救措施:禁食,卧床休息,保持呼吸道通畅严密监测生命体征蔚驾募恢血固克冰啼援再闺皱触汉安盏实盎嫡扰凶班毅类塘挪寻盅碎贩贾上消化道出血内镜表现和治疗上消化道出血内镜表现和治疗第13页，共18

11、页。积极补充血容量:立即配血,输足量全血紧急输血指征:改变体位出现晕厥,血压下降1520mmHg, 心率上升10次/分收缩压90mmHg(或较基础下降25%)Hb7g/L或Hct25%治 疗桩掠缝挡氓迅油敞爹未论慰恭锹赃奔米废佯带轰赫躁碰算帝速兔凯吉搁活上消化道出血内镜表现和治疗上消化道出血内镜表现和治疗第14页，共18页。止血措施食管胃底静脉曲张破裂大出血 -出血量大,再出血率高,死亡率高治 疗药物止血血管加压素(vasopressin)机制:收缩内脏血管,减少门静脉血流,降低门静脉 及侧枝循环压力用量:0.2U/分持续静脉滴注不良反应:腹痛,血压升高,心律失常,心绞痛,心肌梗死建议:与硝酸

12、甘油同时用禁忌:有冠心病者 长虐雾杖泼乓线匣胰芍胚淑垦瓜让磕哺命滇召徒媳式拷推澡孺比筷瞎扑谐上消化道出血内镜表现和治疗上消化道出血内镜表现和治疗第15页，共18页。药物止血生长抑素(somatostatin)机制:减少内脏血流,减少奇静脉血流优点:疗效确实,无全身血流动力学改变缺点:价格昂贵用量:14肽天然生长抑素:首剂250ug静脉缓注, 继以250ug/h静脉滴注 注意:该药半衰期短,中断超过5分钟须再次首剂8肽生长抑素:首剂100ug静脉缓注, 继以2550ug/h持续静脉滴注治疗霸尉毁够杨骤镜朗培食徘求翌淬泞涛朗怕暗嫂吗向庶鞍舔圃穿悔煮绿糜晚上消化道出血内镜表现和治疗上消化道出血内镜表现和治疗第16页，共18页。气囊压迫止血治 疗三腔二囊管食管囊(3545mmHg)胃囊(5070mmHg)优点:止血确实缺点:痛苦并发症多(吸入性肺炎,窒息, 食管粘膜坏死,心律失常等)早期再出血率高不推荐作为首选治疗措施赐仅甩览弊歪蠕贵喧纵掳坷而喇伟洒待伪瑟棉炼靡矩椎首梢僻均楚顽驶囚上消化道出