1、Diagnosis ofGastrointestinal BleedingDiagnosis ofGastrointestinal Hematemesis and Hematochezia 嘔血與便血 Hematemesis and HematocheziaThe approach to gastro-intestinal (GI) bleeding is tailored to the manner of appearance.The approach to gastro-intestIs bleeding acute or chronic?Intensive careWhere is th

2、e source of bleeding?Empiric therapyDiagnosisTreatment( 經(jīng)驗(yàn)治療 )What is the causes of bleeding?Recognition of hemorrhage Is bleeding acute or chronic?IIntensive careWhere is the source of bleeding?Empiric therapyDiagnosisTreatment( 經(jīng)驗(yàn)治療 )What is the causes of bleeding?Is bleeding acute or chronic?Reco

3、gnition of hemorrhageIntensive careWhere is the souClinical Manifestations1 Manner of bleeding presentation2 Hypovolemia (低血容量) or shock3 Anemia (貧血) Recognition of hemorrhageClinical Manifestations1 MannPatients manifest blood loss1) Hematemesis 嘔 血 Bloody vomitus, either fresh and bright red or ol

4、der and “coffee -ground” (hematin 酸化正鐵血紅素) in character Hemoptysis? Nosebleeding?Manner of bleeding presentationfrom the GI tract in five ways:Patients manifest blood loss1)2) Melena 黑 便 Shiny, black, sticky, foul-smelling stool degradation of blood exogenous stool darkeners iron bismuth (鉍劑) Manner

5、 of bleeding presentation2) Melena 黑 便Manner of bleManner of bleeding presentation3)Hematochezia 便 血 bright red or maroon blood from the rectum pure blood blood intermixed with formed stool bloody diarrheaManner of bleeding presentatioManner of bleeding presentation4)Occult 隱 血 detected only by test

6、ing the stool with a monoclonal antibody for human hemoglobin Manner of bleeding presentatioEstimate amount of bleeding from upper GI tract 510 ml/d OB + 5070 ml/d Melena 250300 ml in short time Hematemesis Estimate amount of bleeding frManner of bleeding presentationwithout any objective sign of bl

7、eeding with symptoms of blood loss dizziness, dyspnea, angina cordis (心絞痛), or even shock digital examination (指檢) of the rectumManner of bleeding presentatioHypovolemia or shockSpeed and volume of blood lossWeakness, giddiness (眩暈), oliguria, (少尿) cold extremity, sweatingVital signs: tachycardia, (

8、心動(dòng)過(guò)速) hypotention (低血壓)Hypovolemia or shockSpeed and Anemiapaledizzinesspalpitationeasy fatigabilitydyspnea angina cordisAnemiapaleeasy Is bleeding acute or chronic?1) Bleeding speed Hematemesis of fresh blood generally indicates a more severe bleeding episode than melena, which occurs when bleeding

9、 is slow enough to allow time for degradation of blood Is bleeding acute or chronic?1診斷學(xué)-嘔血與便血-英文版課件Is bleeding acute or chronic?2) Hematocrit bleeding slowly hypochromic (血紅蛋白過(guò)少) microcytic (小細(xì)胞) red blood cells mean corpuscular volume (MCV， 平均血球壓積) of the cells may be low Is bleeding acute or chro

10、nic?2Is bleeding acute or chronic? If blood loss is acute, the hematocrit dose not change during the first few hours after hemorrhage About 24 to 72 hours later, plasma volume is larger than normal and the hematocrit is at its lowest point Is bleeding acute or chronic? 7 6 5 4 3 2 1Volume(Liters)45%

11、45%27%ABCIs bleeding acute or chronic?Hematocrit changesA Before bleeding B Immediately after bleeding C 2472 hours after bleeding7 6 5 4 3 2 1VoIs bleeding acute or chronic?3) Blood pressure and heart ratedepend on amount of blood loss suddenness of blood loss extent of cardiac and vascular compens

12、ation Is bleeding acute or chronic?3postural hypotension - early physical findingtachycardia - greater loss, compensate recumbent (臥位) hypotension - final resultsIs bleeding acute or chronic?postural hypotension Is bleediIs bleeding acute or chronic?Postural hypotension A postural drop in blood pres

13、sure of 10 to 15 mm HgIs bleeding acute or chronic?PIs bleeding acute or chronic?4) Bowel sound Active bowel sound usually be presented in acute bleeding from GI tractIs bleeding acute or chronic?4Emergent and intensive care Initially vital signs supine and upright blood pressure pulseEmergent and i

14、ntensive care InIf blood loss is significant, intravenous fluids must be startedSaline or other balanced electrolyte solutions are most rapidly available If blood loss is significant, Blood is sent to the lab. complete blood count clotting studies routine chemistry studies. Blood for typing and cros

15、s- matching is sent to the blood bank. Blood is sent to the lab. Where is the source of bleeding? LocalizationUpper GI bleeding: bleeding from a source proximal to the ligament of Treitz.Lower GI bleeding: bleeding from a site distal to the ligament of Treitz.Where is the source of bleedin Localizat

16、ionTreitz: The ligament of Treitz is an anatomic landmark for the duodenal-jejunal junction. LocalizationTreitz: LocalizationDifferentiating features of upper GI and lower GI bleedingUpper GILower GIManifestationHematemesisHematocheziamelenaNasogastric aspirateBloodyClearBUNElevatedNormalBowel sound

17、HyperactiveNormal LocalizationDifferentiating Upper GI tract bleeding ?Clinical manifestationBowel soundNasogastric tubeUpper GI tract bleeding ?CliniHematemesisMelenaHematocheziaHematemesisMelenaHematochezia More proximal lesions producehematemesis or melena, whereas more distal lesions are more li

18、kely to produce hematochezia. More proximal lesions pr If hematochezia is from an upper GI source, it usually reflects a massive bleed (i. e. , greater than 1000 ml). If hematochezia is from anWhat is the causes of bleeding?90% upper GI bleeding is due to four lesions: 1) peptic ulcer (消化性潰瘍)2) hemo

19、rrhagic gastritis (胃炎)3) esophageal or gastric varices (靜脈曲張)4) gastric cancerWhat is the causes of bleedingpeptic ulcerpeptic ulcerhemorrhagic gastritishemorrhagic gastritisesophageal varicesesophageal varicesgastric cancergastric cancerCauses of gastrointestinal bleeding Mallory-Weiss tear 食道 - 賁門(mén)

20、撕裂傷Causes of gastrointestinal bleCauses of gastrointestinal bleedingPortal-hypertensive gastropathy 門(mén)脈高壓胃病Ancylostomiasis 鉤蟲(chóng)病Post-sphincterotomy 括約肌切開(kāi)術(shù)后Causes of gastrointestinal bleCauses of gastrointestinal bleeding Colorectal cancer Colitis Large hemorrhoid大痔 Rectum tear肛裂 Vascular anomalies Hema

21、tologic diseasesCauses of gastrointestinal bleDiagnostic approach to gastrointestinal bleeding1 History and physical examination2 Endoscopy 3 Barium radiography4 Angiography5 Nuclear scintigraphyDiagnostic approach to gastroiHistory and physical examination A history of previously docu-mented GI tra

22、ct disease determined by radiography, endoscopy, or surgical procedures is very useful.Diagnostic approach to GI bleedingHistory and physical examinatiDiagnostic approach to GI bleeding Patients with hepatitis B or chronic active liver disease may present with painless hematemesis from esophageal va

23、rices. Diagnostic approach to GI bleeDiagnostic approach to GI bleeding Patients with forceful, retching (干嘔)or multiple episodes of vomiting of food prior to the onset of hematemesismay be bleeding from MalloryWeisstears of the gastroesophageal junction. Diagnostic approach to GI bleeDiagnostic app

24、roach to GI bleeding A history of epigastric (上腹部) burning pain promptly relieved by foodor antacids (抗酸劑) or nocturnal (夜間) pain suggests peptic ulcer disease,particularly duodenal (十二指腸) ulcer. Diagnostic approach to GI bleeDiagnostic approach to GI bleedingColorectal malignancy is often suggeste

25、by a history of gradual weight loss intermittent blood in the stools altered bowel habitsDiagnostic approach to GI bleeDiagnostic approach to GI bleeding Hemorrhoidal bleeding is often suggested by the presence of bright red blood surrounding well-formed, normal-appearing stools.Diagnostic approach

26、to GI bleeDiagnostic approach to GI bleeding Patients with stigmata (特征) of chronic liver disease e.g., spider angioma (蜘蛛痣), ascites (腹水), gynecomastia (男性乳房發(fā)育) and upper GI bleeding often bleed from esophageal varices or erosion (糜爛).Diagnostic approach to GI bleeDiagnostic approach to GI bleeding

27、 Localized epigastric tenderness (觸痛) to palpation may indicate peptic ulcer disease or gastritis. Diagnostic approach to GI bleeDiagnostic approach to GI bleeding Occasionally patients with lower GI tract bleeding from a malignancy have a palpable lower abdominal mass, hepatomegaly (肝腫大)，signs of o

28、bvious weight loss. Diagnostic approach to GI bleeDiagnostic approach to GI bleeding A rectal examination is essen-tial to document stool color as well as to palpate for gross ano-rectal (肛直腸) mass lesions such as polyps, cancers, or large hemorrhoids.Diagnostic approach to GI bleeDiagnostic approac

29、h to GI bleedingEndoscopy (內(nèi)鏡) Endoscopy is the diagnostic procedure of choice because of its high accuracy and immediatetherapeutic potential. Endoscopy , however , must be Performed only following adequate resuscita- tion (復(fù)蘇). Diagnostic approach to GI bleeDiagnostic approach to GI bleedingEndoscopyContraindications：acute myocardial infarction severe chronic lung diseas