上海交大外科学上血演示文稿

上海交大外科学上血演示文稿现在是1页\一共有79页\编辑于星期六（优选）上海交大外科学上血现在是2页\一共有79页\编辑于星期六BasicConcepts现在是3页\一共有79页\编辑于星期六WhatIsMassiveBleeding>20%(>800ml)bloodlossHemodynamicinstability血流动力学不稳Clinicalsignsofpoorperfusion组织灌注差现在是4页\一共有79页\编辑于星期六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肛门现在是5页\一共有79页\编辑于星期六现在是6页\一共有79页\编辑于星期六现在是7页\一共有79页\编辑于星期六PleaseRememberUGIBisnotuncommonintheemergencyroomMortalityrateisabout10%UGIBisaseriesofdiseasesmainlytreatedbyinternalmedicine.3-15%requireasurgicalprocedure现在是8页\一共有79页\编辑于星期六Let’shaveaproblem!现在是9页\一共有79页\编辑于星期六PatientCome45-yrfemalefirstepisodeofhematemesis呕血transferredfromasmallhospital2unitsofpackederythrocyte红细胞tranfusednasogastrictube胃管introducedwithactivebleedingpulse120bpm,BP80/40mmHg现在是10页\一共有79页\编辑于星期六WhatIsYourDecisionWhatisyourintuition直觉?现在是11页\一共有79页\编辑于星期六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?现在是12页\一共有79页\编辑于星期六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枣红便现在是13页\一共有79页\编辑于星期六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/嗜睡现在是14页\一共有79页\编辑于星期六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现在是15页\一共有79页\编辑于星期六EstimationofBloodLossoccultbloodstool –5-10ml/24hmelena –50-100ml/24hhematemesis –250-300mlinstomachCNSchange –>500mlhypovolemia –>1000ml/shortperiod现在是16页\一共有79页\编辑于星期六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现在是17页\一共有79页\编辑于星期六WhatIsYourDecisionWhatarethemanagementpriorities优先顺序tothispatient?现在是18页\一共有79页\编辑于星期六ForReferenceResuscitation复苏Hemostasis止血Differentialdiagnosis鉴别诊断Basicdiseasetreatment治疗原发病Comorbiditymanagement处理并存病现在是19页\一共有79页\编辑于星期六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密切监护现在是20页\一共有79页\编辑于星期六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止血剂和凝血因子现在是21页\一共有79页\编辑于星期六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,protecttheairway现在是22页\一共有79页\编辑于星期六BalloonTamponade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releasefor15minevery4hrs现在是23页\一共有79页\编辑于星期六现在是24页\一共有79页\编辑于星期六WhatIsYourDecisionWhatquestionwouldyouaskthepatient?现在是25页\一共有79页\编辑于星期六ForReferenceHistoryofillness病史Precipitatingfactors诱因Comorbidities并存病现在是26页\一共有79页\编辑于星期六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others现在是27页\一共有79页\编辑于星期六Precipitatingfactorsalcoholabuse酒瘾NSAIDs(nonsteroidanti-inflammatorydrugs)ingestion非甾体类抗炎药物应用stress应激:burninjuries–Curling

headinjuries–Cushing现在是28页\一共有79页\编辑于星期六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吞咽困难-5%Weightloss体重减轻-12%Jaundice黄疸-5.2%现在是29页\一共有79页\编辑于星期六WhatIsYourDecisionWhatisthedifferentialDiagnosis鉴别诊断?现在是30页\一共有79页\编辑于星期六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其他少见原因现在是31页\一共有79页\编辑于星期六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,sometimeshematemesis现在是32页\一共有79页\编辑于星期六StressGastritishistoryofstress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脓毒症现在是33页\一共有79页\编辑于星期六StomachNeoplasmsmiddleage中年weightloss体重减轻anorexia厌食irregularepigastricpain不规则腹痛abdominalmass腹部包块现在是34页\一共有79页\编辑于星期六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痔现在是35页\一共有79页\编辑于星期六FormationofPortalSystem3inflowveincollectbloodfromspleen,pancreas,stomach,intestine,colon,andrectumsplenicveinsuperiormesentericveininferiormesentericvein2branchesintoleft&righthepaticlobethroughhepaticsinustohepaticveintoIVC75%bloodsupply,50%oxygensupplyofliver现在是36页\一共有79页\编辑于星期六现在是37页\一共有79页\编辑于星期六CollateralVascularSystem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前腹壁交通支现在是38页\一共有79页\编辑于星期六现在是39页\一共有79页\编辑于星期六DefinitionofPortalHypertensionnormalportalpressure:13-24cmH2Onormalhepaticveinpressuregradient(HVPG):5-9cmH2Oportalhypertension:30-50cmH2OHVPG>12mmHgleadstoUGIB现在是40页\一共有79页\编辑于星期六现在是41页\一共有79页\编辑于星期六CauseofHypertensioncirrhosishepaticsinusnarrownessportalbloodinflowblockedhighpressurehepaticarteryflowtolowpressureportalvein现在是42页\一共有79页\编辑于星期六现在是43页\一共有79页\编辑于星期六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门脉性胃病/脑病stomachmucousedema胃粘膜水肿portalsystemicshunt门体分流现在是44页\一共有79页\编辑于星期六CaputMedusae现在是45页\一共有79页\编辑于星期六Hemobiliahemobiliatriad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胆道结石现在是46页\一共有79页\编辑于星期六MiscellaneousMallory-Weisssyndrome:linearmucosallacerationnearcardia贲门asaresultofforcefulvomiting,retching干呕orcoughingDieulafoylesion:vascularmalformationinstomachAngiodysplasia血管发育不良:abnormaldilated,thin-walledmucosalorsubmucosalvessels粘膜/粘膜下血管现在是47页\一共有79页\编辑于星期六WhatIsYourDecisionWhatphysicalexamination体格检查findingswouldyousearchfor?现在是48页\一共有79页\编辑于星期六ForReferenceSignsofshockandbloodlossSignsofchronicliverdiseaseSignsoftumor现在是49页\一共有79页\编辑于星期六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结膜甲床苍白signsofpoorperfusion:coldextremities四肢厥冷,coldsweating冷汗,oliguria少尿,chestpain胸痛现在是50页\一共有79页\编辑于星期六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海蛇头现在是51页\一共有79页\编辑于星期六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）陷凹结节现在是52页\一共有79页\编辑于星期六WhatIsYourDecisionWhatdiagnosticstudieswouldyouorder?现在是53页\一共有79页\编辑于星期六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内镜现在是54页\一共有79页\编辑于星期六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脏器穿孔现在是55页\一共有79页\编辑于星期六现在是56页\一共有79页\编辑于星期六UlcerwithBlackSpot10%Rebleeding现在是57页\一共有79页\编辑于星期六UlcerwithBloodClot22%Rebleeding现在是58页\一共有79页\编辑于星期六UlcerwithVisibleVessel43%Rebleeding现在是59页\一共有79页\编辑于星期六UlcerwithActiveBleeding55%Rebleeding现在是60页\一共有79页\编辑于星期六EsophagusVarices现在是61页\一共有79页\编辑于星期六现在是62页\一共有79页\编辑于星期六HypertensivePortalGastropathy现在是63页\一共有79页\编辑于星期六InjectionofSclerosant硬化剂现在是64页\一共有79页\编辑于星期六BandLigation皮圈套扎现在是65页\一共有79页\编辑于星期六Hemoclip止血夹现在是66页\一共有79页\编辑于星期六LaserApplication激光止血现在是67页\一共有79页\编辑于星期六HeaterProbe加热探针现在是68页\一共有79页\编辑于星期六WhatIsYourDecisionWhatarethetherapeuticoptionsforeachcommonetiology病因ofmassiveUGIBafterinitialresuscitation?现在是69页\一共有79页\编辑于星期六ForReferenceMedicineEndoscopeSurgery现在是70页\一共有79页\编辑于星期六Non-VaricealBleedingtherapeuticendoscopewith/withoutmedicineifeffectivethencontinuedrugtherapyeradicationofH.pylorimucousprotection2attemptsofendoscopicfailurepursuesurgeryothersurgicalindicationsseverelife-threateningbleedingnotresponsivetoresuscitationcoexistingreasonofperforation,obstructionormalignanciessecondhospitalizationofpepticulcer现在是71页\一共有79页\编辑于星期六VaricealBleedingdrugtherapywith/withoutballoontemponadeendoscopicbindingorsclerotherapytransjugularintrahepaticportosystemicshunt(TIPS)经颈静脉肝内门体分流术effectiverate90%rebleedingrateinoneyear16-30%shuntdisfunctionratein6months50-60%inducingencephalopathyra