上消化道出血-医学知识讲座.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。,定义,(Definition),上消化道出血系指屈氏,(Treitz),韧带以上的消化道，包括食管、胃、十二指肠以及胰腺、胆道引起的出血，也包括胃空肠吻合术后的空肠上段病变出血。,上消化道大量出血：指数小时内失血量,1000ml,，或大于循环血容量的,20,，伴呕血、黑便、急性循环衰竭，死亡率,10,。,上消化道出血最常见病因,消化性溃疡,食管胃底静脉曲张破裂,急性糜烂出血性胃炎,胃癌,病因,(Etiology),食管疾病：,反流性食管炎,食管癌,食管溃疡,食管胃底静脉曲张,食管贲门粘膜撕裂,食管裂孔疝,Reflux Esophagitis(Esophageal erosions),Mid-esophageal diverticulum(traction type),Sherry spots(red color sign),Bleeding Esophageal Varices,Mallory Weiss syndrome,病因,(Etiology),胃疾病：,胃溃疡,急性胃粘膜病变,慢性糜烂性胃炎,胃癌,胃粘膜脱垂,(Prolapse of gastric mucosa),胃淋巴瘤,(Gastric lymphoma),血管瘤,(Angioma of stomach),Dieulafoy syndrome,胃粘膜下恒径动脉综合征又称,Dieulafoy,病,Gastric Angiodysplasias,病因,(Etiology),十二指肠疾病,：,十二指肠溃疡,急性糜烂性十二指肠炎,十二指肠憩室炎,Duodenal ulcer with visible vessel.,Duodenal ulcer with ooze bleeding.Big duodenal ulcer on the posterior wall with hematin pigment at the base and easy bleeding mucosa.,Multiple peptic ulcerations of the duodenal bulb with atypical appearance.,病因,(Etiology),空肠疾病：,胃肠吻合术后的空肠溃疡,(Jejunal ulcer),病因,(Etiology),胆道疾病：,胆管或胆囊结石,胆道蛔虫病,(Biliary,ascriasis),胆囊或胆管癌,胆总管引流造成压迫坏死,病因,Etiology),胰腺疾病：,胰腺癌,急性胰腺炎伴脓肿,-,溃破累及十二指肠,病因,(Etiology),全身性疾病：,血液病,尿毒症,结缔组织病,(Connective,tissue disease),血管性疾病,急性感染如流行性出血热,临床表现,(Clinical Manifestation),呕血,(Hematemesis),与黑便,(Melena),上消化道出血后均有黑粪,幽门以上部位出血，常有呕血,幽门以下部位出血一般只有黑粪,呕血的颜色取决于出血速度和量,黑便呈柏油样，粘稠发亮,失血性周围循环衰竭,(Circulatory failure due to blood loss),出血量大，速度快，循环血容量回心血心排血量,表现：头晕、心悸、出汗、恶心、口渴、晕厥等，脉细、血压、皮肤湿冷、烦躁不安、意识模糊，严重休克，尿量,贫血和血象变化,急性大量出血后,3,4 h,才出现贫血，出血后,24,72 h,血液稀释到最大限度,急性出血患者为正细胞正色素性贫血,出血,24 h,内网织红细胞増高，,4,7,天可高达,5%,15%,上消化道大量出血,2,5 h,，,WBC(10,20),10,9,/L,血止后,2,3,天才恢复正常,发热,(fever),上消化道大量出血后,24h,内发热，,38.5,，持续,3-5,天,可能与周围循环衰竭贫血体温中枢功能障碍有关,氮质血症,1),肠源性氮质血症：上消化道大出血后，数小时开始升高，,24,48,小时达高峰,(5,10ml/,日,黑便：,50-70ml/,日,呕血：胃内储血量,250,300ml,出血量,0.5ml/,分,适应证：,原因不明的急性消化道出血,临床考虑内镜不能到达病变部位,不能接受急诊内镜，又需明确诊断,辅助检查,A,B,C,食道钡透,食道静脉曲张一一虫蚀样或蚯蚓状充盈缺损,A,轻度曲张,B,中度曲张,C,重度曲张,胃底静脉曲张一一菊花样充盈缺损,食道胃底静脉曲张,吞线试验：,100cm,棉线，一端固定于颈部，另一端系金属球，留置,6,8h,后取出，检查血染点和黄染点。血点在黄染点以上为上消化道出血，黄染点以下为下消化道出血。一般进食道,40cm,，胃,60-70cm,，十二指肠,70cm,，有时血染点不明显，可做潜血检查。,外科手术探查：,适应证：,不能明确出血原因、部位,出血不止、进行性贫血、血压下降,明显大出血、快速输血、血压不上升,辅助检查,鉴别诊断,判断上消化道还是下消化道出血,鉴别要点,上消化道出血,下消化道出血,既往史,多曾有溃疡病肝,胆疾患病史或有呕血史,多曾有下腹部疼痛包块及排便异常病史或便血史,.,出血先兆,上腹部闷胀,疼痛或绞痛,呕心、反胃,中、下腹不适下坠,欲排大便,出血方式,呕血伴柏油样便,便血,无呕血,便血特点,柏油样便,稠或成形,无血块,暗红或鲜红,稀多不成形,大量出血时可有血块,病史,出血方式,出血前症状,血内混有物,颜色,血液反应,黑便,咯血,肺结核、支扩、心脏病,咳出,常有喉痒、咳嗽、胸闷,气泡及痰,鲜红,碱性,无,(,咽下后有,),呕血,溃疡病、肝硬化,呕出,恶心、呕吐、上腹不适或痛,食物及胃液,暗红或咖啡色,酸性,有,呕血与咯血鉴别,上消化道出血,动物血,猪肝,铋剂,铁剂,炭粉,中药,黑便,(Melena),治疗原则,补充血容量,抗休克,止血治疗,病因治疗,一般治疗,禁食,，,卧位休息,保持呼吸道通畅，必要时吸氧,立即建立输液通道,心电监护,，,监测,P,、,Bp,、,R,、尿量及神志变化,观察呕血与黒粪情况,备血、,査,Hb,、,RBC,、红细胞压积与,BUN,必要时行中心静脉压测定,禁食,Fasting,食道胃底静脉曲张破裂：禁食，呕血停止后,2,3,天进食,溃疡病出血：有呕血者，禁食，呕血停止后,12,24,小时进食,无呕血者，一般不禁食,补充血容量,紧急输血指征,:,改变体位出现晕厥、血压下降和心率加快,失血性休克,血红蛋白低于,70g/L 或 血细胞比容低于,25%,补液量是否充分的判断指标,临床表现：,Bp,、,P,、尿量、口渴、颈静脉充盈,补足,-,颈静脉充盈良好,不足,-,颈静脉完全塌陷,中心静脉压：正常,8,12cm H2O,15,输液过量,尿量：正常人酶小时尿量,25,50ml,达到,-,入量足够,仍少,-,补液不足,药物止血治疗,血管加压素,(vasopressin),作用机制是通过对内脏血管的收缩作用，减少门脉血流量，降低门脉及其侧支循环的压力，从而控制食管、胃底静脉曲张出血。,推荐疗法是,0.2-0.4U/min 静脉持续滴注,不良反应有腹痛、血压升高、心律失常、心绞痛，严重者可发生心肌梗死。,硝酸甘油静脉滴注,或舌下含服硝酸甘油,0.6mg,毎,30 分钟,1 次,药物止血治疗,生长抑素,(somatostatin),用法为首剂,250,g 静脉缓注,继以,250,g/h 持续静脉滴注,奥曲肽,(octreotide),首剂,100,g 静脉缓注,继以,2550,g/h 持续静脉滴,药物止血治疗口服或胃内灌注止血药,去甲肾上腺素胃内灌注或口服,使胃壁小动、静脉收缩而止血，在碱性环境中易氧化失活，适于微酸环境,口服：,8mg+100ml NS,，每次,50ml,，应用,2-3,次,灌洗：,8mg+100ml NS,，每次,50ml,，,30,分钟后抽出，,1-2,次 无效换药,凝血酶：使纤维蛋白原变为纤维蛋白,500,1000U,，口服或灌注,孟氏液：碱式硫酸亚铁，有收敛、凝固作用，灌注或口服，每次,50ml,药物止血治疗,抑制胃酸分泌,机理：,pH6,时易止血；,适于消化性溃疡、出血糜烂性胃炎,药物：,H2,受体阻断剂：,Cimetidine,，,Ranitidine,，,Famotidine,。,质子泵抑制剂（,PPI,）：,Omeprazole(Losec),，,Lansoprazole(Takepron),等,抑酸治疗,H,2,Receptor antagonists(H2RA),Drugs,Intensity,Direction,Cimetidine,1,400mg,qid,IV,Ranitidine,4-10,50mg,qid,IV,Famotidine,20-50,20mg,qid,IV,Nizatidine,4-10,150mg,qid,IV,Proton pump inhibitor(PPI),Drugs,Direction,Omeprazole,40 mg,bid,IV,Pantoprazole,80 mg,bid,IV,Esomeprazole,40 mg,bid,IV,抑酸治疗,内镜下止血（,Urgent endoscopy therapy,）,向出血处喷洒药物：,去甲,(4-8mg+100ml),凝血酶,(1000-2000U+10-20ml),孟氏液,(5-10%),向出血处注入药物：,肾上腺素,1mg,稀释为,10ml,，每次注射,0.5-2.0ml,，总量,20ml,。,无水酒精：每点,0.1-0.2ml,，总量,1-2ml,。,硬化剂：,5,鱼甘油酸钠,0.5-1%,乙氧硬化醇,血管内或血管旁注射，每次,2-3ml,内镜下止血Urgent endoscopy therapy,）,The use of a metallic hemoclip as a mechanical method to prevent re-bleeding can be a good alternative for visible vessels.,Left:,A small vessel with an adherent clot seen at the GE junction in a patient presenting with hematemesis.,Right:,The lesion was coagulated with the heater probe with formation of a superficial iatrogenic ulcer thereafter.,Ooze bleeding during the initial treatment with the heater probe of this angiodysplasia.,Hemoclipping,A,Dieulafoy lesion,on the anterior wall of the antrum with active bleeding,Hemoclipping,Sequential images demonstrating the hemoclipping technique in this case used to prevent further bleeding from a post-polypectomy ulcer in the stomach.,EIS,EIS,EVL,其他治疗,微波止血,激光止血,电凝止血,三腔二囊管压迫止血,适于食管胃底静脉曲张破裂出血。,解释工作,准备石蜡油、检查漏气、注气量、压力,压迫方法：先压胃囊，后压食管囊,放置,24,小时需放气,15,分钟，必要时再充气；如出血停止,24,小时可放气，如,24,小时内未再出血可拔管，放管最长不超过,72,小时,并发症：窒息、食管下段溃疡、肺部感染,Balloon,tamponade,modified,Sengstakan-Blakemore tube:,Immediate cessation of bleeding more than 85%of patients,Widespread available,Recurrent hemorrhage up to 50%after deflation,A stopgap of definite treatment,From Rikkers LF:Portal hypertension.In Goldsmith H ed:Practice of Surgery.Philadelphia,Harper&Row,1981,pp 1-37.,200ml,150ml,其他治疗,腹腔动脉造影（,Therapeutic angiography,）检查同时进行治疗。,外科手术：内科保守治疗无效者,(24,小时以上,),，急诊外科手术治疗。,病因治疗：针对前面所述的上消化道出血原因进行治疗。,介入治疗,严重消化道大出血,无法进行内镜治疗,不能耐受手术,选择性肠系膜动脉造影,进行血管栓塞治疗,Endoscopic variceal ligation,After identifying the target varix,endoscopic suction is activated and the varix suctioned into the ligating cylinder to finally release the elastic ring.,Active bleeding from a varix in the distal esophagus(left).The bleeding was stopped after rubber-band ligation(right).,Superficial ulcerations appearing a few days after ligation therapy.Elastic rings still remaining in necrosed areas.,Scarring of the esophagus as a result of endoscopic variceal treatment.A small remaining varix is seen on the lower right picture.,Injection Sclerotherapy of Esophageal Varices,At present,injection sclerotherapy is less frequently used.It is a good alternative in cases of active and profuse bleeding where endoscopic view is diminished or,as in this case,to the inability to pass the upper esophageal sphincter with the mounted ligating cylinder.,Post-sclerotherapy Esophageal Ulcers,Two relatively deep ulcers are seen along the esophagus a few days after sclerotherapy.,Gastric varices seen as tortuous dilated venous channels on the fornix.,Variceal band ligation.,Variceal protrusions around the cardia(upper left).Ligatures in place are seen through the ligating cylinder.,TIPS,Transjugular intrahepatic portosystemic shunt,手术治疗,内科保守治疗无效者,(24,小时以上,),分流术,From Sarfen IJ Rypins EB,Mason GR:A systemic appraisal of portocaval H-graft diameters:Clinical and hemodynamic perspectives.Ann Surg 204:356-363,1986.,分流术,Modified From Sugiura M,Futagawa S:Further evaluation of the Sugiura procedure in the treatment of esophageal varices.Arch Surg 112:1317,1977.,断流术,