上海交大外科学上血pbl 课件

上消化道大出血

MassiveUpperGastrointestinalBleeding上海交通大学医学院瑞金临床医学院2009IntroduceOurselvesDr.Yang

&Dr.LiBasicConceptsWhatIsMassiveBleeding>20%(>800ml)bloodlossHemodynamicinstability血流动力学不稳Clinicalsignsofpoorperfusion组织灌注差WhatIsUGIEsophagus食道Stomach胃Duodenum十二指肠Jejunum空肠Ileum回肠AscendingColon升结肠TransverseColon横结肠DescendingColon降结肠SigmoidColon乙结肠Rectum直肠Anus肛门PleaseRememberUGIBisnotuncommonintheemergencyroomMortalityrateisabout10%UGIBisaseriesofdiseasesmainlytreatedbyinternalmedicine.3-15%requireasurgicalprocedureLet’shaveaproblem!PatientCome45-yrfemalefirstepisodeofhematemesis呕血transferredfromasmallhospital2unitsofpackederythrocyte红细胞tranfusednasogastrictube胃管introducedwithactivebleedingpulse120bpm,BP80/40mmHgWhatIsYourDecisionWhatisyourintuition直觉?ForReferenceDoesthepatienthavelife-threateningsituation?hypovolemicshock低血容量性休克lowbodytemperature体温降低anemia/hypoxemia贫血/低氧血症comorbidities并存病Isitamassiveorminorbleeding?Whereisthemostprobablebleedingsite?Worrisomeclinicalsignsandsymptomstachycardia心动过速morethan100beatsperminute(bpm)systolicbloodpressure(SBP)收缩压≤90mmHgposturalhypotension体位性低血压SBPdecrease≥15mmHgorpulserateincrease≥10bpmcoolextremities四肢厥冷syncope晕厥ongoingbriskhematemesis进行性/活跃地呕血maroonstool枣红便MassiveorMinorClassIClassIIClassIIIClassIVBloodLossml≤750750-15001500-2000＞2000BloodLoss%≤1515-3030-40＞40PulseRatebpm≤100＞100＞120＞140BloodPressurenormalnormaldecreasedecreaseCNS神经系统症状Slightlyanxious轻度焦虑Mildlyanxious中度焦虑Anxious,confused焦虑/意识模糊Confused,lethargic意识模糊/嗜睡UGIBorLGIBManifestation症状UGIBLGIBHematemesis呕血AlmostcertainRareMelena黑便ProbablePossibleHematochezia便血PossibleProbableBlood-streakstool便中带血丝RareAlmostcertainOccultbloodstool大便隐血PossiblePossibleEstimationofBloodLossoccultbloodstool –5-10ml/24hmelena –50-100ml/24hhematemesis –250-300mlinstomachCNSchange –>500mlhypovolemia –>1000ml/shortperiodChild-PughClassificationNo.ofPoints123Bilirubin(μmol/L)总胆红素<3434-51>51Albumin(g/L)白蛋白>3528-35<28ProthrombinTime凝血酶原时间(s)≤1415-17≥18Ascites腹水NoneSlight>ModerateEncephalopathy脑病NoneSlight>ModerateGradeA=5-8points,GradeB=9-11points,GradeC=12-15pointsWhatIsYourDecisionWhatarethemanagementpriorities优先顺序tothispatient?ForReferenceResuscitation复苏Hemostasis止血Differentialdiagnosis鉴别诊断Basicdiseasetreatment治疗原发病Comorbiditymanagement处理并存病InitialResuscitationABCairway保持气道通畅breathing维持呼吸和供氧circulation维持循环bilateralintravenousaccess(atleast)双路静脉通路short,largepore短而粗fastfluidreplacement快速液体输入3-for-1rule:1mlbloodloss,3mlcrystalloidfluidbloodtransfusion:2-6unitsofpackederythrocyteclosemonitoring密切监护MedicalTherapyvasopressin血管加压素somatostatinoranalogs生长抑素或同类物antacidagents制酸剂H2-receptorantagonistH2受体拮抗剂protonpumpinhibitor质子泵抑制剂hemostaticagents&bloodcoagulationfactors止血剂和凝血因子NasogastricTubeIntroductionaspiration&lavage吸引和冲洗siteofbleedingbilewithoutblood–UGIBnotlikelygastricfluid&blood–UGIBcleargastricfluid–duodenalbleedingstillpossiblefalsenegative假阴性approximately10%hemostasis&monitoring止血和监控icysalinelavagewithepinephrine肾上腺素aspirationcolor&amountreducevomiting减少呕吐,protecttheairwayBalloonTamponade气囊压迫temporarymeasureduringresuscitation(24-48hr)20%complicationrateairwayobstruction气道阻塞aspiration误吸esophagusnecrosis食管粘膜坏死arrhythmia心律失常recurrentbleedingafterreleaseofballoonfirstinflategastricballoonto60mmHg(200ml)theninflateesophagusballoonto40mmHg(150ml)pullingweight0.25kgusingapulley滑车releasefor15minevery4hrsWhatIsYourDecisionWhatquestionwouldyouaskthepatient?ForReferenceHistoryofillness病史Precipitatingfactors诱因Comorbidities并存病Historyhistoryofbleeding出血情况time持续时间symptoms表现症状amount出血量historyofrelateddiseasespepticulcer消化性溃疡liverdiseases肝脏疾病cholangio-pancreaticdiseases胆胰疾病coagulopathy凝血障碍othersPrecipitatingfactorsalcoholabuse酒瘾NSAIDs(nonsteroidanti-inflammatorydrugs)ingestion非甾体类抗炎药物应用stress应激:burninjuries–Curling

headinjuries–CushingFrequentSymptomsHematemesis呕血-40-50%Melena黑便-70-80%Hematochezia便血-15-20%Eitherhematocheziaormelena-90-98%Syncope晕厥-14.4%Presyncope晕厥前期-43.2%Dyspepsia消化不良-18%Epigastricpain上腹痛-41%Heartburn胃灼热-21%Diffuseabdominalpain弥漫性腹痛-10%Dysphagia吞咽困难-5%Weightloss体重减轻-12%Jaundice黄疸-5.2%WhatIsYourDecisionWhatisthedifferentialDiagnosis鉴别诊断?ForReferencePepticulcer消化性溃疡Stressgastritis应激性胃炎Stomachneoplasms胃肿瘤Portalhypertension门脉高压Hemobilia胆道出血Miscellaneous其他少见原因PepticUlcerhistoryofchroniculcerepigastricpain(nocturnalsymptoms)上腹痛（夜间痛）dyspepsia消化不良satiety饱胀historyofmucosadamagedietsmokingNSAIDs非甾体类抗炎药物Adrenalcorticalhormone肾上腺皮质激素usuallymelena,sometimeshematemesisStressGastritishistoryofstress应激病史burninjuriesheadinjuriespredisposingclinicalconditions可导致应激的临床情况shock休克multipletrauma多发伤ARDS(acuterespiratorydistresssyndrome)急性呼吸窘迫综合征SIRS(systemicinflammatoryresponsesyndrome)全身炎症反应综合征MODS(multipleorgandysfunctionsyndrome)多脏器功能障碍综合征sepsis脓毒症StomachNeoplasmsmiddleage中年weightloss体重减轻anorexia厌食irregularepigastricpain不规则腹痛abdominalmass腹部包块PortalHypertensionpredisposinghistoryofcirrhosis肝硬化基础疾病hepatitis肝炎Schistosomiasis血吸虫病alcoholabuse酒瘾specialfeatures特殊体征jaundice黄疸ascites腹水dilatedveinintheanteriorabdominalwall腹壁静脉怒张rectalhemorrhoids痔FormationofPortalSystem3inflowveincollectbloodfromspleen,pancreas,stomach,intestine,colon,andrectumsplenicveinsuperiormesentericveininferiormesentericvein2branchesintoleft&righthepaticlobethroughhepaticsinustohepaticveintoIVC75%bloodsupply,50%oxygensupplyofliverCollateralVascularSystem侧支循环esophageal-fundussubmucosalvenousplexus食管下段-胃底交通支rectalhemorrhoidalsystem直肠下段肛管交通支retroperitonealsystem后腹膜交通支anteriorabdominalwallsystem前腹壁交通支DefinitionofPortalHypertensionnormalportalpressure:13-24cmH2Onormalhepaticveinpressuregradient(HVPG):5-9cmH2Oportalhypertension:30-50cmH2OHVPG>12mmHgleadstoUGIBCauseofHypertensioncirrhosishepaticsinusnarrownessportalbloodinflowblockedhighpressurehepaticarteryflowtolowpressureportalveinPathophysiologyofPortalHypertensionsplenemegaly&hypersplenism脾肿大/脾功能亢进peripheraltotalbloodcountdecreasecollateralvascularvarix侧支静脉曲张esophageal-fundussubmucosalvenousplexushasgreatestgradient,causemassiveUGIBhemorrhoidCaputMedusae海蛇头ascitescapillaryfiltrationpressureincrease毛细血管渗透压增加hypoalbuminemia低白蛋白血症excessivelymphaticfluidgeneration淋巴液生成过多hyperaldosteronemia高醛固酮血症portalgastropathy/encephalopathy门脉性胃病/脑病stomachmucousedema胃粘膜水肿portalsystemicshunt门体分流CaputMedusaeHemobiliahemobiliatriad胆道出血三联症biliarycolic胆绞痛obstructivejaundice梗阻性黄疸gastrointestinalbleeding消化道出血livertrauma肝外伤hepatichemangioma肝血管瘤hepaticneoplasm肝肿瘤hepaticabscess肝脓肿biliarytractstone胆道结石MiscellaneousMallory-Weisssyndrome:linearmucosallacerationnearcardia贲门asaresultofforcefulvomiting,retching干呕orcoughingDieulafoylesion:vascularmalformationinstomachAngiodysplasia血管发育不良:abnormaldilated,thin-walledmucosalorsubmucosalvessels粘膜/粘膜下血管WhatIsYourDecisionWhatphysicalexamination体格检查findingswouldyousearchfor?ForReferenceSignsofshockandbloodlossSignsofchronicliverdiseaseSignsoftumorShock&BloodLosspulseandbloodpressure脉率血压posturalhypotension体位性低血压mentaldisorder:anxious焦虑,confusion意识模糊,delirium谵妄,lethargy嗜睡,presyncope晕厥前期,syncope晕厥signsofanemia:paleconjunctivaandnailbed结膜甲床苍白signsofpoorperfusion:coldextremities四肢厥冷,coldsweating冷汗,oliguria少尿,chestpain胸痛ChronicLiverDiseasesspiderangiomata蜘蛛痣palmaerythema肝掌gynecomastia男性乳房发育splenomegaly脾肿大ascites腹水pedaledema足部水肿asterixis扑翼样震颤CaputMedusae海蛇头Tumorupperabdominalmass上腹包块leftsupraclavicularlymphnode(Virchow’snode)左锁骨上淋巴结肿大umbilicalnodular(SisterMaryJoseph’snode)脐周结节Douglaspouchnodular(Bloomer’sshelf)直肠子宫（膀胱）陷凹结节WhatIsYourDecisionWhatdiagnosticstudieswouldyouorder?ForReferenceCompletebloodcount(CBC)全血细胞计数Bloodcrossmatch交叉配血Coagulationprofile凝血功能Liver&Renalfunction肝肾功能Calciumlevel血钙Gastrinlevel血胃泌素CTscan计算机断层扫描orUltrasonography超声检查DigitalSubtractionAngiography(DSA)数字减影血管造影Endoscope内镜EndoscopicExplorediagnosis&treatment诊断/治疗双重作用mostreliable&effectivemethod最可靠最有效within24-48hrsafterbleeding应在出血后24-48小时内进行contraindication反指征hemodynamicinstablility血流动力学不稳定severecardiacdecompensation严重心功能失代偿acutemyocardialinfarction急性心肌梗塞perforatedviscus脏器穿孔UlcerwithBlackSpot10%RebleedingUlcerwithBloodClot22%RebleedingUlcerwithVisibleVessel43%RebleedingUlcerwithActiveBleeding55%RebleedingEsophagusVaricesHypertensivePortalGastropathyInjectionofSclerosant硬化剂BandLigation皮圈套扎Hemoclip止血夹LaserApplication激光止血HeaterProbe加热探针WhatIsYourDecisionWhatarethetherapeuticoptionsforeachcommonetiology病因ofmassiveUGIBafterinitialresuscitation?ForReferenceMedicineEndoscopeSurgeryNon-VaricealBleedingtherapeuticendoscopewith/withoutmedicineifeffectivethencontinuedrugtherapyeradicationofH.pylorimucousprotection2attemptsofendoscopicfailurepursuesurgeryothersurgicalindicationsseverelife-threateningbleedingnotresponsivetoresuscitationcoexistingreasonofperforation,obstructionormalignanciessecondhospitalizationofpepticulcerVaricealBleedingdrugtherapywith/withoutballoontemponadeendoscopicbindingorsclerotherapytransjugularintrahepaticportosystemicshunt(TIPS)经颈静脉肝内门体分流术effectiverate90%rebleedingrateinoneyear16-30%shuntdisfunctionratein6months50-60%inducingencephalopathyrate25-35%30daymortalityrate14-16%canbeusedasatemporarymethodbeforetransplantationChildA&B–surgeryChildC–transplantationTIPS8-12mmWhatIsYourDec