便血病理课件-

1、Hemetamesis and Hemetochezia(Acute GI Hemorrhage)1Hemetamesis and Hemetochezia(Five Ways of GI BleedingHematemesis：vomitting of blood of altered blood（coffee grounds） indicates bleeding proximal to ligament of TreitzMelena：Tarry stool. Altered （black） blood per rectum （60ml）Hematochezia： Bright red

2、or maroon rectal bleeding implies bleeding beyond Lig.T.*FOB+ and Iron deficiency anemia2Five Ways of GI BleedingHemateFactors affect the way to manifestSite of bleeding Speed of bleedingAmount of blood lossFlora of enterocolon. 3Factors affect the way to maniDifferentiating Upper from Low GI Bleedi

3、ngHematochezia usually represents a lower GI source bleedingUpper GI lesion may bleed so briskly that blood doesnt remain in bowl long enough to become melena Bleeding lesion distal to T Lig.may be either M.or hematochezia, but never manifests hematemesis 4Differentiating Upper from Low Peptic ulcer

4、 ；Gastropathy （alcohol， aspirin， NSAIDs， stress）；GE varices； Gastric cancer5 Peptic ulcer ；5Less common cause of up GI bleedingEsophageal or intestinal neoplamEsophagitis； Malloy-weiss tear，Hemoptysis: Swallowed bloodAnticoagulant fibrinoloytic therapy:Telangiectases； aneurysm ；vasculitis；Dieulafoy

5、ulcer； AV malformationConnective tissue disease；Hemabilia（biliary origin；Crohns disease；amyloidosis , hematological diseases6Less common cause of up GI bleBENIGN GASTRIC ULCERThe classical presentation of gastric ulcer :with weight loss and indigestion made worse by eating, patients more often descr

6、ibe symptoms that would fit equally well for duodenal ulcer - investigation with barium meal or (preferably) endoscopy is, of course, appropriate for either. Benign ulcers may occur at any site in the stomach, but are commonest on the lesser curve away from acid-secreting epithelium. 7BENIGN GASTRIC

7、 ULCERThe class Location of benign gastric ulcers in relationship to the distance from the pylorus. The majority of benign ulcers will be found on the lesser curvature within 3 cm of the angulus.8 Location of benign gastric ul大家有疑问的，可以询问和交流可以互相讨论下，但要小声点9大家有疑问的，可以询问和交流可以互相讨论下，但要小声点9Duodenum UlcerThe

8、lesion most commonly affecting the duodenum is ulceration, and it is now known that both antral infection with Helicobacter pylori and the presence of gastric acid are virtual prerequisites for it. 10Duodenum UlcerThe lesion most Bleeding From EVA number of cutaneous features (stigmata) may develop

9、in a patient with cirrhosis, and these are important as they aid clinical recognition of chronic liver disease. 11Bleeding From EVA number of cu121213131414Bleeding Survey: Endoscopic Findings in 214 Patients With Clear Nasogastric AspiratesFINDING NUMBER OF PATIENTS INCIDENCE (%)Duodenaal ulcer 64

10、29.8Gastric erosions 57 6.5Gastric ulcer 47 21.9Esophagitis 23 10.7Duodenitis 21 9.8Varices 11 5.1Mallory-Weiss tear 10 4.7Neoplasm 8 3.7Stomal ulcer 7 3.3Esophageal ulcer 2 0.9Telangiectasia 0Other 18 8.415Bleeding Survey: Endoscopic FiClinical manifestation of GI BleedingAbdominal disconfortNausea

11、, Hemadynamic change: reduction in blood volume (syncope,light-headedness, sweating,therst) or shockLaboratory changes: HCT, BUN16Clinical manifestation of GI BHematemesis with other symptomsHematemesis with upper abdominal painHematemesis with hepatomegly and spleenomeglyHematemesis with jaundiceHe

12、matemesis with Skin & mucosa hemorrhageHematemesis with upper abdominal massOthers: NSAIDs, Stress, Burning, Brain operation, Trauma, Vomiting 17Hematemesis with other symptoLab.Examination in Localization & Diagnosis of GI BleedingEndoscopyBarium RadiographsAngiographyRadionuclide imaging18Lab.Exam

13、ination in LocalizatioApproach to the patient with acute upper gastrintesttinal hemorrhage Acute upper Gastrointestinal Hemorrhage Rapid assessment Monitor hemodynamic status Fluid resuscitation Gastric lavage(?) self-limited (80%) bleeding (10-20%) Empiric medical therapy Urgent endoscopy recurrent

14、 hemorrhage endoscopy Site not localized Localized further assessment enteroscopy, radioisotope s scan, angiography, exploratory surgery Definitive therapy Definitive therapy 19Approach to the patient with a2020Endoscopic view of a Mallory-Weiss tear with active bleeding (gastric lumen is at top lef

15、t). B, Endoscopic view of an organized clot adherent to a Mallory-Weiss tear (gastric lumen is at bottom left ).21Endoscopic view of a Mallory-WEndoscopic view of a Dieulafoy lesion on the lesser curvature of the stomach22Endoscopic view of a DieulafoyEndoscopic view of a vascular ectasia (angiodysp

16、lasia) in the duodenum. 23Endoscopic view of a vascular Endoscopic view of the gastric antrum with watermelon stomach. The pylorus is at top center. Note the linear distribution pattern of the vascular lesions arranged radially around the pylorus.24Endoscopic view of the gastricEndoscopic views of u

17、lcers with stigmata of recent hemorrhage. A, Duodenal ulcer with a visible vessel. B, Gastric ulcer with a red spot in the center of the crater. C, Duodenal ulcer with a red spot in the center of the crater. D, Purplish clot adherent to a gastric ulcer. 25Endoscopic views of ulcers wit2626Typical pi

18、cture of a trivial nonsteroidal anti-inflammatory drug (NSAID)-induced injury to the gastric mucosa. There are multiple small erosions with brown-black staining of the center as a result of local bleeding and petechiae.27Typical picture of a trivial nTypical round gastric ulcer at the angulus (incis

19、ura) of the stomach.28Typical round gastric ulcer atCauses of Low GI Bleeding 29Causes of Low GI Bleeding 29Differentiating Upper from Low GI BleedingHematochezia usually represents a lower GI source bleedingUpper GI lesion may bleed so briskly that blood doesnt remain in bowl long enough to become

20、melena Bleeding lesion distal to T. Lig. may be either M.or hematochezia, but never manifests hematemesis 30Differentiating Upper from LowHematochezia with other symptomsAbdominal painFeverTenesmusSystemic Hemorrhage Dermal signAbdominal mass31Hematochezia with other symptLab. Examination For detect

21、ing Low GI BleeedingAnoscopy & sigmoidoscopyBarium Edema (BE)AngiographyRadionuclide scanning32Lab. Examination For detecting33333434A, Linear ulcers of Crohns colitis. B, Mucosa surrounding the ulcers is nodular (cobblestoning).35A, Linear ulcers of Crohns coShigella colitis. Patchy areas of erythe

22、ma, spontaneous bleeding, and loss of the normal vascular pattern are evident36Shigella colitis. Patchy areasSalmonella colitis. Diffuse erythema, spontaneous bleeding, and loss of the vascular pattern with formation of telangiectasis are present.37Salmonella colitis. Diffuse erTuberculosis. Linear

23、ulceration runs circumferentially along the interhaustral septum with tiny satellite ulcerations. This must be distinguished from the longitudinal linear ulcerations seen in inflammatory bowel disease. 38Tuberculosis. Linear ulceratioPseudomembranous (antibiotic-associated) colitis. Numerous elevated yellowish plaques are present on the mucosal surface.39Pseudomembranous (antibiotic-aAmebiasis. Discrete punched-out ulcers are present in the right colo