肠胃科病房常见之问题与处理-马偕纪念医院课件

病房常見之消化系

問題與處理馬偕紀念醫院健檢中心主治醫師胃腸內科兼任主治醫師楊安民病房常見之消化系

問題與處理馬偕紀念醫院1GIbleedingNeverforgetthegeneralprincipleofinternalmedicine.Airway,Breathing,CirculationStabilizevitalsignandaggressiveresuscitation.Wellexplanationtothefamily.Acquirethoroughhistoryandpastmedicalhistory.DifferentialdiagnosisofGIbleedingUGI&LGIMakethediagnosisbyyourself!Arrangeadequatediagnosticprocedure.EmpericaltreatmentGIbleedingNeverforgetthege2消化道出血的間接症狀:dizziness,fainting,tachycardia,coldsweating,shock,abdominalfullness,poorappetite,cons.change一旦懷疑,利用vitalsign評估出血量最重耍(occultbleedingorovertbleeding)Orthostatichemodynamicchange–10to20%bloodlossDropinsystolicpressure>10mmHg,raiseinpulserate>15/minSupinehypotension–greaterthan20%bloodloss定位UGIorLGI同時評估medicaltreatmentorsurgicaltreatmentGIbleedingvsNon-GIbleeding:吐血vs.咳血ernalbleeding消化道出血的間接症狀:dizziness,fainti3StudyinGIbleedingDigitalexamforcollectstoolNGaspirationforDDxUGIandLGIPES:PanendoscopyorEGD(esophago-gastro-duodenoscopy):shouldbeperformearlyintheclinicalcourseaftervitalsignstableormanagement.Colonoscopy/rigidsigmoidscopyRBCscan:onlyinTaipeiMMH:>0.1cc/minor6cc/hourAngiography:>0.5cc/minor30cc/hourEnteroscopyorcapsuleendoscopySurgeryStudyinGIbleedingDigitale4WhytheGIbleedingpatientneedNPONoteveryGIbleedingpatientshouldNPOPrepareforemergencystudyormanagementAvoidaspirationWhytheGIbleedingpatientne5GIbleeding處理原則Againandagain:CheckvitalsignEvaluateNPOornotIfNPO,IVFsupplyArrangelaboratorystudyCBC,PT,PTT,Bloodgroupandcrossmatch,liverandrenalfunction.Bloodproduct:Wholebloodvs.packRBC,FFPvs.FP,代用血漿(ex.6HES)MedicationHowtoarrangethestudy:NGirrigation,Bloodsampling,PES,Angiography,Colonofiberscope,RBCscanGIbleeding處理原則Againandagai6VitalsignforGIbleedingOrthostatichypotension:dropSBPover10mmHg,riseinpulserateover15beat/min:bloodloose10-20%Supinehypotension:morethan20%Shockindex:SBP/HR<1whichhintbloodlooseover25%IfthepatientgotInderalusing,thetachycardiamaybedisappear(pacemakeralsocovertherisksign)VitalsignforGIbleedingOrth7IVFsupplyinGIbleedingLarge-boreIVline(14-16gaugecatheter)isbetterthancentralline.Isotonicsolution(NS),LRcanbeinitiatedplusplasmaexpander(ex5%hetastarchor6HES)TheIVFamountisdependenton:hemodynamiccondition,otherCV/renalcondition,ageTheIVFcontentisdependenton:underlinedisease(DM,LC,Uremia,CHF…)SomedrugaddintheIVF(KCL,HRI,st-B..)ortheIVFisfortherapy(PPIorH2RAforPUD;pitression/glypression,sandostadininEV/GV)IVFsupplyinGIbleedingLarge8BloodproductusinginUGIbleedingWhentransfusionisindicated:bleedingismassive,ongoing,orsevereenoughthatcolloidinfusionaloneisnotadequatefortissueoxygenation.(keepHtover25-30%)TheunitisdifferentinTaiwan(1unitisabout250ccbutnot500cc)WholebloodisbetterthanpackRBCifthepatientgotnoriskforfluidoverload(ex.CHF,uremia..)Keepplateletover50000,andcorrectthePTwithvitK,PTTwithFFP(alsoformassivetransfusion)AddBena/DecadroninallergypatientandLasixavoidfluidoverload,SincalaftermassivetransfusionBloodproductusinginUGIble9肠胃科病房常见之问题与处理-马偕纪念医院课件10UGIbleedingDifferentialdiagnosisofVaricealandNon-varicealbleedingHistoryoflivercirrhosiswith/withoutvaricealbleedingMassivehematemesisSignsoflivercirrhosis–Spidernevi,Gynecomastia,Splenomegaly,Ascites,JaundiceLabdatasuggestlivercirrhosis–Hypoalbuminemia,PTprolonged,Mildimpairedliverfunction(GOT>GPT)withhyperbilirubinemia,Historyofalcoholabuse.UGIbleedingDifferentialdiagn11TreatmentofvaricealbleedingThemostimportantofall:STABILIZEDTHEVITALSIGN.WELLEXPLAINTOTHEFAMILY–oncritical,1/3mortalityineachepisode.Pharmacologicaltreatment:Glypressin(Terlipressin):1ampivstatandq6h.Sandostadin:2ampivdripstatand12ampin500c.c.D5Wrun24hoursPitressin:20ampin480c.c.D5WorNS(conc.0.8IU/ml),run12cc/hrto54cc/hr(0.2IU/minto0.9IU/min),side-effect:chestpain,peripheralcyanosis–combinenitrate---SeldomusedinrecentlyyearsTreatmentofvaricealbleeding12TreatmentofvaricealbleedingEndoscopictreatment–highlyoperatordependent,highfailurerateinacutebleeding,oncetheproceduresucceeded,theoutcomeisgood.Esophagealvarices:bandligationGastricvarices:ScleosingtherapySBtube–tracheaintubationfirst,theeffectisnotgood.Treatmentofvaricealbleeding13TIPS--transjugularintrahepaticportosystemicshuntOperation:ShuntsurgeryPrecipitatingfactorsofvaricealbleeding---treattheprecipitatingfactorSBPSepsisImpendinghepaticfailureTIPS--transjugularintrahepa14肠胃科病房常见之问题与处理-马偕纪念医院课件15肠胃科病房常见之问题与处理-马偕纪念医院课件16肠胃科病房常见之问题与处理-马偕纪念医院课件17肠胃科病房常见之问题与处理-马偕纪念医院课件18肠胃科病房常见之问题与处理-马偕纪念医院课件19肠胃科病房常见之问题与处理-马偕纪念医院课件20PepticulcerdiseaseEtiologyofpepticulcerdiseaseMucosaldefensivefactorMucosalbarriertoiondiffusionTwocomponentmucousbarrierBicarbonate,PhospholipidsLocalmucosalbloodflowProstaglandins,EGFIntrinsicmechanismthatinhibitgastricsecretion.PepticulcerdiseaseEtiologyo21PepticulcerdiseaseEtiologyofpepticulcerdiseaseAggressivefactorsGastricacidandpepsinNSAIDsH.PyloriFreeradicalPepticulcerdiseaseEtiologyo22TypicalsymptomsofPUD上腹疼痛:燒灼感,悶痛,脹痛慢性:患者常會斷斷續續痛好幾年節律性:每天固定時間疼痛,通常空腹時痛週期性:每年固定一個時期發作TypicalsymptomsofPUD上腹疼痛:燒23DiagnosisofPUDEsophagogastroduodenalscopy(EGD)GastriculcerandduodenalulcerDescriptionofPUDinEGDStage:A1,A2,H1,H2,ScarSize:theriskofrecurrentbleedingincreasedifgreaterthan2cmLocation:antrum,body,fundus,anteriorwall,posteriorwall,greatcurvatureside,lessercurvatyresideSRH(Stigmataofrecenthemorrhage)GastritisandErosion.DiagnosisofPUDEsophagogastro24肠胃科病房常见之问题与处理-马偕纪念医院课件25肠胃科病房常见之问题与处理-马偕纪念医院课件26肠胃科病房常见之问题与处理-马偕纪念医院课件27RiskysigninthePESdescriptionofUGIbleedingVarix:RCS(redcolorsign)whichhintbleeding:red-whalemarking,cherry-redspot,activebleeding;Cb>Cw,F3>2>1Ulcer:A1-2(active),H1-2(healing)andS1-2(scaring);activebleedingvsSRH(stigmataofrecentbleeding)BleedingwithunknowncauseRiskysigninthePESdescript28Medication/ManagementinUGIbleeding:PUDPPI(losec/nexium,takepron,pariet,):losec1Amp+NS50-100ccdripover10minstandq12h;the1#qdH2RA(zantac,tazac,famox):Zantac3Amp+500ccIVFrun20cc/hr;then1#bidSukit/gelfos1pkq1hx4-6timesSucrategel1Pkbidorulsanic1#qid(avoidusingwithantiacid,H2RAorPPI)Therapeuticendoscopywithbosmininjection,heatprobe,hemoclip,laser..Sometimes,surgicalinterventionstillindicatedMedication/ManagementinUGIb29肠胃科病房常见之问题与处理-马偕纪念医院课件30Medication/ManagementinUGIbleeding:SurgicalinterventioninPUDorotherDxHypovolemicshockcannotcontrolbymedicaltreatmentMassivetransfusionover4-6U/8U(2000cc)in24hoursorover10U(2500-5000cc)overallRecurrentorintractablebleedingafternon-surgicaltreatmentRiskfactorforOP:over60y/o,transfusionover5unit,shock,hematemesiswithhypotension,coagulopathy,largeulcerover2cm,emergencyOp,comorbidillness,rebleedingwithin72hoursMedication/ManagementinUGIb31處理較特殊之處一般內科病患需在最短時間內判斷病況是否危急(critical);但面對腸胃科病患時,必須同時找出有緊急手術適應症的患者判斷是否有緊急檢查的適應症某些特殊的狀況(ex.Severepancreatitis,hepaticfailure,hypovolemicshock..)處置必須移入ICU處理(ex.SBtube,plasmaphrosis)檢查前的預備工作CallGICRforemergentendoscopy!各護理站皆有oncallCR的電話,若找不到CR,直接找VS,切勿猶豫處理較特殊之處一般內科病患需在最短時間內判斷病況是否危急(c32LowGIbleedingHemorrhoid,analfistula,angiodysplasia,radiationproctitis/colitis,aortoentericfistula,tumorUrgentcolonoscopy:difficultduetopoorpreparationConsultProctologistforthesurgicalinterventionFortunately,mostcommonLGIbleedingmaystoppedspontaneously.LowGIbleedingHemorrhoid,ana33肠胃科病房常见之问题与处理-马偕纪念医院课件34肠胃科病房常见之问题与处理-马偕纪念医院课件35IleusVerydangerousdiagnosiswhennewpatientarrivewiththisdiagnosisParalyticvsMechanicalNPOinmostcasesIVFsupplyOverlappingwithacuteabdomenSeriesF/UthesamekindxrayfilmIleusVerydangerousdiagnosis36肠胃科病房常见之问题与处理-马偕纪念医院课件37肠胃科病房常见之问题与处理-马偕纪念医院课件38肠胃科病房常见之问题与处理-马偕纪念医院课件39肠胃科病房常见之问题与处理-马偕纪念医院课件40Nauseaandvomiting(1)Bowelobstructionorpregnancymustexcludefirst.Besides,extra-abdominalproblem(IICP,metabolicproblem..)alsoneedexclude.ThevomitusalsohelpforidentifiedtheobstructionlevelbycolorNGdecompressionamountisanotherkeyforevaluatethedegreeforobstructionNauseaandvomiting(1)Bowelob41Nauseaandvomiting(2)Novamin(proclorperazine):ADR-drowsiness,acutedystonicreaction,EPS,posturalhypotension..Dopamineantagonist-primperan(metoclopramide-EPSisnotoriousADR)andmotilium(domperidone).CisparideisnotapproveinFDAnowOndansteron(zofran)andGranisetron(kytril)are5HT3(serotonin)receptorinhibitorforC/TNauseaandvomiting(2)Novamin42Diarrhea(1)ThedefinitionofdiarrheaincludetheBMincreaseover3timesperdayandtheamountincreaseAcutediarrheavschronicdiarrhea:2weekNPOisthefirststepinDDxthesecretaryandosmoticdiarrhea(butIVFsupplyalsoindicatedafterNPOespeciallyinDMpatient)Stoolstudy:stoolOB,puscellandculturewheninfectiousdiarrheaissuspectedesp.inbacterialinfection).PMCneedspecialagarforculture.Amebaandparasiteovainchronicdiarrheaalsoneedconsidered.Diarrhea(1)Thedefinitionofd43Diarrhea(2)Drugmaybethemostcommoncauseofdiarrheainhospital(senokot,MgO,antacids,digitalis,quinidine,colchicine,antibiotic..)PMC(pseudomembranouscolitis)mustbecarefullymonitorwhenantibioticusingParasitestillneedconsideresp.inMMHTaitungbranch.MostAGEiscausedbyvirusandself-limiting.Diarrheaincancerpatientspostradiotherapyisdangerous.Diarrhea(2)Drugmaybethemo44Diarrhea(3)ReviewthedrugsheetEvaluatetheriskysign:BMover6times,bloodystoolortenesmus,fever,severeabdpain,dehydrationHydrationbyenteralfeedingifpossibleSymptomatictreatmentwith:Kaopetin15-20cc/Tannalbinforloosestool,Anti-muscarinics(buscopan-scopolamine,trancolon-mepenzolate,bentyl-dicyclomine,esperan-oxapium),Smoothmusclerelaxant(Spasmonal-alverine,Cospanon-Flopropione,Duspatalin-Mebeverine)Imodium2#stCodeineandMorphineAntibioticinInfectiousdiarrheaafterstoolcultureandstudy:FQandsulfadrugDiarrhea(3)Reviewthedrugsh45PMCorAACPseudomenbranouscolitisorantibiotic-associatedcolitisC.difficleisnottheonlycauseCleocinismostnotoriousdrug.PCNandCephagotmostpatient!Dx:scope,toxin,culture(inanaerobiccondition)Tx:stopantibiotic,symptomaticcontrol,oralantibiotic(metronidazole,vancomycine),IVantibioticmaybethelastchoice.InferonBernaenema…PMCorAACPseudomenbranouscol46Constipation(1)Medicationalsothemaincauseofconstipation(Calciumchannelblocker,opiates,anticholinergic,iron,bariumsulfate)Besides,oldageandseveraldisease(DM,hypothyroidism,scleroderma,myotonicdystrophy..)patientalsogotconstipationtendencyIntestinalobstructionmustexcludefirstConstipation(1)Medicationalso47Constipation(2)Fibersupplementation:KonsylorNormacolEmollientlaxative:MineraloilStimulantcathartics:Castoroil,Anthraquinones(senokot1-2#qhs),Bisacodyl(dulcolax1-2#qhsorsupp)Osmoticcathartic:Mgcitrate,lactulose..FleetenemaConstipation(2)Fibersuppleme48TPNIndication:不能吃,不想吃,吃不下Time:notover7daysNPOHowtoorder:graduallyincreasethedoseandconcentrationHowtocalculatethewateramountHowtocalculatethecaloridemandHowtocalculatetheproteindemandHowtocalculatethefatsupplyHowtosupplythetraceelement,Vit…TPNIndication:不能吃,不想吃,吃不下49TPN(2)ComplicationofTPNMechanicalproblem:causedbyCVPinsertionChemicalproblem:BS,electrolytebalance..InfectionproblemOtherproblem:GBstasisandstone,LFTimpairment,druginteractionTPN(2)ComplicationofTPN50ComplicationofhepaticinsufficiencyFulminanthepaticfailureHepaticencephalopathyHepato-pulmonarysyndromeHepato-renalsyndromePortalhypertensionAscitesSBPCoagulopathyComplicationofhepaticinsuff51HepaticfailureHowtoidentifiedthehepaticfailure?PTismoreimportantthanAST/ALTBilirubinalsoveryimportantparameterHypoglycemiaandhypocholesterolalsoriskysignCons.LevelmustevaluatecarefullyandcloselyTheNH3levelisnotparalleltocons.LevelVeryhighmortalityifnochanceforlivertransplantTheChild-Turcott-Pughscore(A:2.8-3.5,A:slightly,Bil:2-3,Encephalopathy1-2,PT4-6)–A:5,6;B:7-9;C:10-15HepaticfailureHowtoidentif52Hepaticencephalopaghy(HE)Correcttheprecipitatingfactor:azotemia,tranquilizer,opioid,sedative-hyponotic,GIbleeding,hypokalemia,alkalosis,constipation,infection,diarrhea,porto-systemicshuntMedication:lactulosepoandenema;Neomycinepoandenema,Metronidazolepo,BCAAchainsupply(aminopoly-H)Thepossibilityofintra-craniallesionmustexclude(ex.ICH,SDH,braintumor)Hepaticencephalopaghy(HE)Co53Hepato-pulmonarysndromeIntra-pulmonaryshuntincreaseHypoxiaProvebyangiographyorcontrastheartecho.Hepato-pulmonarysndromeIntra-54Hepato-renalsyndromeSimilartopre-renalazotemiaDifficultinDDxCheckUrineNaAlsocausedbyperipherialarterioldilatationAcutevs.ChronicThekidneyisnormal!!Hepato-renalsyndromeSimilart55PortalHTNPE:caputmedusa,hemorrhoid…Normalportalpresssure:7mmHg(about10cmH2O)PortalHTN:over10mmHg(gotS/Sifover12-15mmHg)EVorGVbleeding(dependentonwhichcollateralcirculation)PortalHTNPE:caputmedusa,he56AscitesandSBPAldactoneisthefirstchoicefordiureticinLCrelatedascitesAnyLCpatientwithfever,abdominalpainneedscreentheSBPNeutrophileover250/ulEcoli,KPandStreppneumoniaeEmpiricantibiotic:3rdcephalosporineor1st+aminoglycoside(riskforrenaltoxicity)Norfloxcin400mgqdcanreducetherecurrenceforSBPAscitesandSBPAldactoneisth57CoagulopathyPTprolongThrombocytopeniaPTTprolongiftheconditionworsenorcomplicationCoagulopathyPTprolong58PancreatitisLabdatacannotcompleteexcludeorincludeallcasesCTismostsensitivediagnosistoolinseverepancreatitisHydrationisthekeypointfortreatmentBiliarypancreatitisismorecommoninTaiwanandfemalepatient.AlcrelatedpancreatitisismostcommoncauseinUSAandincreaseinTaiwanHypertriglycemiavs.DMvs.pancreatitisPancreatitisLabdatacannotc59Pancreatitis(2)BiliarypancreatitisneeddrainageASAPRansoncriteriaandAPACHEII:ifRansonover3pointorAPACHEover5,thepatientgotseverepancreatitisIdentifiedtheseverevsmildpancreatitis:clinicalcourse(CV,chest,GI,nephrocomplication),scoringsystem,CTstagingPancreatitis(2)Biliarypancre60RansoncriteriaOnadmission:Alcoholic(Non-alcoholic)WBC:>16000(18000)Bloodsugar:>200(220)LDH:>350(400)AST:>250(440)Age:>55(70)Duringthefirst48hoursofadmissionFallinhematocrit:>10%(10%)Serumcalcium:<8mg/dl(8mg/dl)Basedeficit:>4mEq/L(5mEg/L)IncreaseinBUN:>5mg/dl(2mg/dl)Fluidsequestration:>6L(6L)ArterialPO2:<60mmHg(60mmHg)RansoncriteriaOnadmission:61Pancreatitis(3)Naturecourse:AcuterenalfailureandM.acidosisLungcomplication(ARDS..)IleusandGIbleeding2ndinfectionofnecrotictissue(2week)Pseudocyst(6weeek)Pancreatitis(3)Naturecourse:62AcutecholangitisvscholecystitisComparisonofthetriade:RUQpain+fever+leucocytosisRUQpain+fever+jaundice(Charcottriade)+shock+conschange(Raynoldpentade)Acutecholangitisvscholecyst63ThankYouforYourAttention!ThankYouforYourAttention!64病房常見之消化系

問題與處理馬偕紀念醫院健檢中心主治醫師胃腸內科兼任主治醫師楊安民病房常見之消化系

問題與處理馬偕紀念醫院65GIbleedingNeverforgetthegeneralprincipleofinternalmedicine.Airway,Breathing,CirculationStabilizevitalsignandaggressiveresuscitation.Wellexplanationtothefamily.Acquirethoroughhistoryandpastmedicalhistory.DifferentialdiagnosisofGIbleedingUGI&LGIMakethediagnosisbyyourself!Arrangeadequatediagnosticprocedure.EmpericaltreatmentGIbleedingNeverforgetthege66消化道出血的間接症狀:dizziness,fainting,tachycardia,coldsweating,shock,abdominalfullness,poorappetite,cons.change一旦懷疑,利用vitalsign評估出血量最重耍(occultbleedingorovertbleeding)Orthostatichemodynamicchange–10to20%bloodlossDropinsystolicpressure>10mmHg,raiseinpulserate>15/minSupinehypotension–greaterthan20%bloodloss定位UGIorLGI同時評估medicaltreatmentorsurgicaltreatmentGIbleedingvsNon-GIbleeding:吐血vs.咳血ernalbleeding消化道出血的間接症狀:dizziness,fainti67StudyinGIbleedingDigitalexamforcollectstoolNGaspirationforDDxUGIandLGIPES:PanendoscopyorEGD(esophago-gastro-duodenoscopy):shouldbeperformearlyintheclinicalcourseaftervitalsignstableormanagement.Colonoscopy/rigidsigmoidscopyRBCscan:onlyinTaipeiMMH:>0.1cc/minor6cc/hourAngiography:>0.5cc/minor30cc/hourEnteroscopyorcapsuleendoscopySurgeryStudyinGIbleedingDigitale68WhytheGIbleedingpatientneedNPONoteveryGIbleedingpatientshouldNPOPrepareforemergencystudyormanagementAvoidaspirationWhytheGIbleedingpatientne69GIbleeding處理原則Againandagain:CheckvitalsignEvaluateNPOornotIfNPO,IVFsupplyArrangelaboratorystudyCBC,PT,PTT,Bloodgroupandcrossmatch,liverandrenalfunction.Bloodproduct:Wholebloodvs.packRBC,FFPvs.FP,代用血漿(ex.6HES)MedicationHowtoarrangethestudy:NGirrigation,Bloodsampling,PES,Angiography,Colonofiberscope,RBCscanGIbleeding處理原則Againandagai70VitalsignforGIbleedingOrthostatichypotension:dropSBPover10mmHg,riseinpulserateover15beat/min:bloodloose10-20%Supinehypotension:morethan20%Shockindex:SBP/HR<1whichhintbloodlooseover25%IfthepatientgotInderalusing,thetachycardiamaybedisappear(pacemakeralsocovertherisksign)VitalsignforGIbleedingOrth71IVFsupplyinGIbleedingLarge-boreIVline(14-16gaugecatheter)isbetterthancentralline.Isotonicsolution(NS),LRcanbeinitiatedplusplasmaexpander(ex5%hetastarchor6HES)TheIVFamountisdependenton:hemodynamiccondition,otherCV/renalcondition,ageTheIVFcontentisdependenton:underlinedisease(DM,LC,Uremia,CHF…)SomedrugaddintheIVF(KCL,HRI,st-B..)ortheIVFisfortherapy(PPIorH2RAforPUD;pitression/glypression,sandostadininEV/GV)IVFsupplyinGIbleedingLarge72BloodproductusinginUGIbleedingWhentransfusionisindicated:bleedingismassive,ongoing,orsevereenoughthatcolloidinfusionaloneisnotadequatefortissueoxygenation.(keepHtover25-30%)TheunitisdifferentinTaiwan(1unitisabout250ccbutnot500cc)WholebloodisbetterthanpackRBCifthepatientgotnoriskforfluidoverload(ex.CHF,uremia..)Keepplateletover50000,andcorrectthePTwithvitK,PTTwithFFP(alsoformassivetransfusion)AddBena/DecadroninallergypatientandLasixavoidfluidoverload,SincalaftermassivetransfusionBloodproductusinginUGIble73肠胃科病房常见之问题与处理-马偕纪念医院课件74UGIbleedingDifferentialdiagnosisofVaricealandNon-varicealbleedingHistoryoflivercirrhosiswith/withoutvaricealbleedingMassivehematemesisSignsoflivercirrhosis–Spidernevi,Gynecomastia,Splenomegaly,Ascites,JaundiceLabdatasuggestlivercirrhosis–Hypoalbuminemia,PTprolonged,Mildimpairedliverfunction(GOT>GPT)withhyperbilirubinemia,Historyofalcoholabuse.UGIbleedingDifferentialdiagn75TreatmentofvaricealbleedingThemostimportantofall:STABILIZEDTHEVITALSIGN.WELLEXPLAINTOTHEFAMILY–oncritical,1/3mortalityineachepisode.Pharmacologicaltreatment:Glypressin(Terlipressin):1ampivstatandq6h.Sandostadin:2ampivdripstatand12ampin500c.c.D5Wrun24hoursPitressin:20ampin480c.c.D5WorNS(conc.0.8IU/ml),run12cc/hrto54cc/hr(0.2IU/minto0.9IU/min),side-effect:chestpain,peripheralcyanosis–combinenitrate---SeldomusedinrecentlyyearsTreatmentofvaricealbleeding76TreatmentofvaricealbleedingEndoscopictreatment–highlyoperatordependent,highfailurerateinacutebleeding,oncetheproceduresucceeded,theoutcomeisgood.Esophagealvarices:bandligationGastricvarices:ScleosingtherapySBtube–tracheaintubationfirst,theeffectisnotgood.Treatmentofvaricealbleeding77TIPS--transjugularintrahepaticportosystemicshuntOperation:ShuntsurgeryPrecipitatingfactorsofvaricealbleeding---treattheprecipitatingfactorSBPSepsisImpendinghepaticfailureTIPS--transjugularintrahepa78肠胃科病房常见之问题与处理-马偕纪念医院课件79肠胃科病房常见之问题与处理-马偕纪念医院课件80肠胃科病房常见之问题与处理-马偕纪念医院课件81肠胃科病房常见之问题与处理-马偕纪念医院课件82肠胃科病房常见之问题与处理-马偕纪念医院课件83肠胃科病房常见之问题与处理-马偕纪念医院课件84PepticulcerdiseaseEtiologyofpepticulcerdiseaseMucosaldefensivefactorMucosalbarriertoiondiffusionTwocomponentmucousbarrierBicarbonate,PhospholipidsLocalmucosalbloodflowProstaglandins,EGFIntrinsicmechanismthatinhibitgastricsecretion.PepticulcerdiseaseEtiologyo85PepticulcerdiseaseEtiologyofpepticulcerdiseaseAggressivefactorsGastricacidandpepsinNSAIDsH.PyloriFreeradicalPepticulcerdiseaseEtiologyo86TypicalsymptomsofPUD上腹疼痛:燒灼感,悶痛,脹痛慢性:患者常會斷斷續續痛好幾年節律性:每天固定時間疼痛,通常空腹時痛週期性:每年固定一個時期發作TypicalsymptomsofPUD上腹疼痛:燒87DiagnosisofPUDEsophagogastroduodenalscopy(EGD)GastriculcerandduodenalulcerDescriptionofPUDinEGDStage:A1,A2,H1,H2,ScarSize:theriskofrecurrentbleedingincreasedifgreaterthan2cmLocation:antrum,body,fundus,anteriorwall,posteriorwall,greatcurvatureside,lessercurvatyresideSRH(Stigmataofrecenthemorrhage)GastritisandErosion.DiagnosisofPUDEsophagogastro88肠胃科病房常见之问题与处理-马偕纪念医院课件89肠胃科病房常见之问题与处理-马偕纪念医院课件90肠胃科病房常见之问题与处理-马偕纪念医院课件91RiskysigninthePESdescriptionofUGIbleedingVarix:RCS(redcolorsign)whichhintbleeding:red-whalemarking,cherry-redspot,activebleeding;Cb>Cw,F3>2>1Ulcer:A1-2(active),H1-2(healing)andS1-2(scaring);activebleedingvsSRH(stigmataofrecentbleeding)BleedingwithunknowncauseRiskysigninthePESdescript92Medication/ManagementinUGIbleeding:PUDPPI(losec/nexium,takepron,pariet,):losec1Amp+NS50-100ccdripover10minstandq12h;the1#qdH2RA(zantac,tazac,famox):Zantac3Amp+500ccIVFrun20cc/hr;then1#bidSukit/gelfos1pkq1hx4-6timesSucrategel1Pkbidorulsanic1#qid(avoidusingwithantiacid,H2RAorPPI)Therapeuticendoscopywithbosmininjection,heatprobe,hemoclip,laser..Sometimes,surgicalinterventionstillindicatedMedication/ManagementinUGIb93肠胃科病房常见之问题与处理-马偕纪念医院课件94Medication/ManagementinUGIbleeding:SurgicalinterventioninPUDorotherDxHypovolemicshockcannotcontrolbymedicaltreatmentMassivetransfusionover4-6U/8U(2000cc)in24hoursorover10U(2500-5000cc)overallRecurrentorintractablebleedingafternon-surgicaltreatmentRiskfactorforOP:over60y/o,transfusionover5unit,shock,hematemesiswithhypotension,coagulopathy,largeulcerover2cm,emergencyOp,comorbidillness,rebleedingwithin72hoursMedication/ManagementinUGIb95處理較特殊之處一般內科病患需在最短時間內判斷病況是否危急(critical);但面對腸胃科病患時,必須同時找出有緊急手術適應症的患者判斷是否有緊急檢查的適應症某些特殊的狀況(ex.Severepancreatitis,hepaticfailure,hypovolemicshock..)處置必須移入ICU處理(ex.SBtube,plasmaphrosis)檢查前的預備工作CallGICRforemergentendoscopy!各護理站皆有oncallCR的電話,若找不到CR,直接找VS,切勿猶豫處理較特殊之處一般內科病患需在最短時間內判斷病況是否危急(c96LowGIbleedingHemorrhoid,analfistula,angiodysplasia,radiationproctitis/colitis,aortoentericfistula,tumorUrgentcolonoscopy:difficultduetopoorpreparationConsultProctologistforthesurgicalinterventionFortunately,mostcommonLGIbleedingmaystoppedspontaneously.LowGIbleedingHemorrhoid,ana97肠胃科病房常见之问题与处理-马偕纪念医院课件98肠胃科病房常见之问题与处理-马偕纪念医院课件99IleusVerydangerousdiagnosiswhennewpatientarrivewiththisdiagnosisParalyticvsMechanicalNPOinmostcasesIVFsupplyOverlappingwithacuteabdomenSeriesF/UthesamekindxrayfilmIleusVerydangerousdiagnosis100肠胃科病房常见之问题与处理-马偕纪念医院课件101肠胃科病房常见之问题与处理-马偕纪念医院课件102肠胃科病房常见之问题与处理-马偕纪念医院课件103肠胃科病房常见之问题与处理-马偕纪念医院课件104Nauseaandvomiting(1)Bowelobstructionorpregnancymustexcludefirst.Besides,extra-abdominalproblem(IICP,metabolicproblem..)alsoneedexclude.ThevomitusalsohelpforidentifiedtheobstructionlevelbycolorNGdecompressionamountisanotherkeyforevaluatethedegreeforobstructionNauseaandvomiting(1)Bowelob105Nauseaandvomiting(2)Novamin(proclorperazine):ADR-drowsiness,acutedystonicreaction,EPS,posturalhypotension..Dopamineantagonist-primperan(metoclopramide-EPSisnotoriousADR)andmotilium(domperidone).CisparideisnotapproveinFDAnowOndansteron(zofran)andGranisetron(kytril)are5HT3(serotonin)receptorinhibitorforC/TNauseaandvomiting(2)Novamin106Diarrhea(1)ThedefinitionofdiarrheaincludetheBMincreaseover3timesperdayandtheamountincreaseAcutediarrheavschronicdiarrhea:2weekNPOisthefirststepinDDxthesecretaryandosmoticdiarrhea(butIVFsupplyalsoindicatedafterNPOespeciallyinDMpatient)Stoolstudy:stoolOB,puscellandculturewheninfectiousdiarrheaissuspectedesp.inbacterialinfection).PMCneedspecialagarforculture.Amebaandparasiteovainchronicdiarrheaalsoneedconsidered.Diarrhea(1)Thedefinitionofd107Diarrhea(2)Drugmaybethemostcommoncauseofdiarrheainhospital(senokot,MgO,antacids,digitalis,quinidine,colchicine,antibiotic..)PMC(pseudomembranouscolitis)mustbecarefullymonitorwhenantibioticusingParasitestillneedconsideresp.inMMHTaitungbranch.MostAGEiscausedbyvirusandself-limiting.Diarrheaincancerpatientspostradiotherapyisdangerous.Diarrhea(2)Drugmaybethemo108Diarrhea(3)ReviewthedrugsheetEvaluatetheriskysign:BMover6times,bloodystoolortenesmus,fever,severeabdpain,dehydrationHydrationbyenteralfeedingifpossibleSymptomatictreatmentwith:Kaopetin15-2