上海交大外科学上血演示文稿

上(Shang)海交大外科学上(Shang)血演示文稿第一页，共七十九页。（优选）上(Shang)海交大外科学上(Shang)血第二页，共七十九页。BasicConcepts第三页，共七十九页。WhatIsMassiveBleeding>20%(>800ml)bloodlossHemodynamicinstability血流动力学不稳Clinicalsignsofpoorperfusion组织灌(Guan)注差第四页，共七十九页。WhatIsUGIEsophagus食道Stomach胃Duodenum十(Shi)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肛门第五页，共七十九页。第六页，共七十九页。第七页，共七十九页。PleaseRememberUGIBisnotuncommonintheemergencyroomMortalityrateisabout10%UGIBisaseriesofdiseasesmainlytreatedbyinternalmedicine.3-15%requireasurgicalprocedure第八页，共七十九页。Let’shaveaproblem!第九页，共七十九页。PatientCome45-yrfemalefirstepisodeofhematemesis呕血transferredfromasmallhospital2unitsofpackederythrocyte红细胞tranfusednasogastrictube胃(Wei)管introducedwithactivebleedingpulse120bpm,BP80/40mmHg第十页，共七十九页。WhatIsYourDecisionWhatisyourintuition直(Zhi)觉?第十一页，共七十九页。ForReferenceDoesthepatienthavelife-threateningsituation?hypovolemicshock低(Di)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?第十二页，共七十九页。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(Xing)性/活跃地呕血maroonstool枣红便第十三页，共七十九页。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/嗜睡第十四页，共七十九页。UGIBorLGIBManifestation症状UGIBLGIBHematemesis呕血AlmostcertainRareMelena黑便ProbablePossibleHematochezia便血PossibleProbableBlood-streakstool便中带血丝RareAlmostcertainOccultbloodstool大便隐血PossiblePossible第十五页，共七十九页。EstimationofBloodLossoccultbloodstool –5-10ml/24hmelena –50-100ml/24hhematemesis –250-300mlinstomachCNSchange –>500mlhypovolemia –>1000ml/shortperiod第十六页，共七十九页。Child-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=12-15points第十七页，共七十九页。WhatIsYourDecisionWhatarethemanagementpriorities优先顺(Shun)序tothispatient?第十八页，共七十九页。ForReferenceResuscitation复苏Hemostasis止血Differentialdiagnosis鉴别诊断(Duan)Basicdiseasetreatment治疗原发病Comorbiditymanagement处理并存病第十九页，共七十九页。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(Jian)护第二十页，共七十九页。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(Beng)抑制剂hemostaticagents&bloodcoagulationfactors止血剂和凝血因子第二十一页，共七十九页。NasogastricTubeIntroductionaspiration&lavage吸引和冲洗siteofbleedingbilewithoutblood–UGIBnotlikelygastricfluid&blood–UGIBcleargastricfluid–duodenalbleedingstillpossiblefalsenegative假阴(Yin)性approximately10%hemostasis&monitoring止血和监控icysalinelavagewithepinephrine肾上腺素aspirationcolor&amountreducevomiting减少呕吐,protecttheairway第二十二页，共七十九页。BalloonTamponade气囊(Nang)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releasefor15minevery4hrs第二十三页，共七十九页。第二十四页，共七十九页。WhatIsYourDecisionWhatquestionwouldyouaskthepatient?第二十五页，共七十九页。ForReferenceHistoryofillness病史Precipitatingfactors诱因(Yin)Comorbidities并存病第二十六页，共七十九页。Historyhistoryofbleeding出血情(Qing)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others第二十七页，共七十九页。Precipitatingfactorsalcoholabuse酒瘾NSAIDs(nonsteroidanti-inflammatorydrugs)ingestion非甾体类抗炎药物(Wu)应用stress应激:burninjuries–Curling

headinjuries–Cushing第二十八页，共七十九页。FrequentSymptomsHematemesis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(Kun)难-5%Weightloss体重减轻-12%Jaundice黄疸-5.2%第二十九页，共七十九页。WhatIsYourDecisionWhatisthedifferentialDiagnosis鉴别(Bie)诊断?第三十页，共七十九页。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(Yuan)因第三十一页，共七十九页。PepticUlcerhistoryofchroniculcerepigastricpain(nocturnalsymptoms)上(Shang)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,sometimeshematemesis第三十二页，共七十九页。StressGastritishistoryofstress应激病(Bing)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脓毒症第三十三页，共七十九页。StomachNeoplasmsmiddleage中年weightloss体重减轻(Qing)anorexia厌食irregularepigastricpain不规则腹痛abdominalmass腹部包块第三十四页，共七十九页。PortalHypertensionpredisposinghistoryofcirrhosis肝硬化基础疾病hepatitis肝炎Schistosomiasis血吸虫(Chong)病alcoholabuse酒瘾specialfeatures特殊体征jaundice黄疸ascites腹水dilatedveinintheanteriorabdominalwall腹壁静脉怒张rectalhemorrhoids痔第三十五页，共七十九页。FormationofPortalSystem3inflowveincollectbloodfromspleen,pancreas,stomach,intestine,colon,andrectumsplenicveinsuperiormesentericveininferiormesentericvein2branchesintoleft&righthepaticlobethroughhepaticsinustohepaticveintoIVC75%bloodsupply,50%oxygensupplyofliver第三十六页，共七十九页。第三十七页，共七十九页。CollateralVascularSystem侧支(Zhi)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前腹壁交通支第三十八页，共七十九页。第三十九页，共七十九页。DefinitionofPortalHypertensionnormalportalpressure:13-24cmH2Onormalhepaticveinpressuregradient(HVPG):5-9cmH2Oportalhypertension:30-50cmH2OHVPG>12mmHgleadstoUGIB第四十页，共七十九页。第四十一页，共七十九页。CauseofHypertensioncirrhosishepaticsinusnarrownessportalbloodinflowblockedhighpressurehepaticarteryflowtolowpressureportalvein第四十二页，共七十九页。第四十三页，共七十九页。PathophysiologyofPortalHypertensionsplenemegaly&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(Men)脉性胃病/脑病stomachmucousedema胃粘膜水肿portalsystemicshunt门体分流第四十四页，共七十九页。CaputMedusae第四十五页，共七十九页。Hemobiliahemobiliatriad胆道出血三联症biliarycolic胆绞痛obstructivejaundice梗(Geng)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胆道结石第四十六页，共七十九页。MiscellaneousMallory-Weisssyndrome:linearmucosallacerationnearcardia贲门asaresultofforcefulvomiting,retching干呕orcoughingDieulafoylesion:vascularmalformationinstomachAngiodysplasia血管发(Fa)育不良:abnormaldilated,thin-walledmucosalorsubmucosalvessels粘膜/粘膜下血管第四十七页，共七十九页。WhatIsYourDecisionWhatphysicalexamination体(Ti)格检查findingswouldyousearchfor?第四十八页，共七十九页。ForReferenceSignsofshockandbloodlossSignsofchronicliverdiseaseSignsoftumor第四十九页，共七十九页。Shock&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(Chuang)苍白signsofpoorperfusion:coldextremities四肢厥冷,coldsweating冷汗,oliguria少尿,chestpain胸痛第五十页，共七十九页。ChronicLiverDiseasesspiderangiomata蜘蛛痣(Zhi)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海蛇头第五十一页，共七十九页。Tumorupperabdominalmass上腹包块leftsupraclavicularlymphnode(Virchow’snode)左锁骨上淋(Lin)巴结肿大umbilicalnodular(SisterMaryJoseph’snode)脐周结节Douglaspouchnodular(Bloomer’sshelf)直肠子宫（膀胱）陷凹结节第五十二页，共七十九页。WhatIsYourDecisionWhatdiagnosticstudieswouldyouorder?第五十三页，共七十九页。ForReferenceCompletebloodcount(CBC)全血细胞计(Ji)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内镜第五十四页，共七十九页。EndoscopicExplorediagnosis&treatment诊断/治疗双重作用mostreliable&effectivemethod最可靠最有效within24-48hrsafterbleeding应在(Zai)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脏器穿孔第五十五页，共七十九页。第五十六页，共七十九页。UlcerwithBlackSpot10%Rebleeding第五十七页，共七十九页。UlcerwithBloodClot22%Rebleeding第五十八页，共七十九页。UlcerwithVisibleVessel43%Rebleeding第五十九页，共七十九页。UlcerwithActiveBleeding55%Rebleeding第六十页，共七十九页。EsophagusVarices第六十一页，共七十九页。第六十二页，共七十九页。HypertensivePortalGastropathy第六十三页，共七十九页。InjectionofSclerosant硬化(Hua)剂第六十四页，共七十九页。BandLigation皮圈套(Tao)扎第六十五页，共七十九页。Hemoclip止血(Xue)夹第六十六页，共七十九页。LaserApplication激光(Guang)止血第六十七页，共七十九页。HeaterProbe加热(Re)探针第六十八页，共七十九页。WhatIsYourDecisionWhatarethetherapeuticoptionsforeachcommonetiology病(Bing)因ofmassiveUGIBafterinitialresuscitation?第六十九页，共七十九页。ForReferenceMedicineEndoscopeSurgery第七十页，共七十九页。Non-VaricealBleedingtherapeuticendoscopewith/withoutmedicineifeffectivethencontinuedrugtherapyeradicationofH.pylorimucousprotection2attemptsofendoscopicfailurepursuesurgeryothersurgicalindicationsseverelife-threateningbleedingnotresponsivetoresuscitationcoexistingreasonofperforation,obstructionormalignanciessecondhospitalizationofpepticulcer第七十一页，共七十九页。VaricealBleedingdrugtherapywith/withoutballoontemponadeendoscopicbindingorsclerotherapytransjugularintrahepaticportosystemicshunt(TIPS)经颈静脉肝内门体分流(Liu)术effectiverate90%rebleedingrateinoneyear16-30%shuntdisfunctionratein6months50-60%inducingencephalop