1、,Hematemesis 嘔血,UPPER GASTROINTESTINAL BLEEDING,Department of Gastroenterology Xuanwu hospital,Overview,Definition,Etiology,Clinical manifestation,Differential diagnosis,Diagnostic approach,Treatment,Definition,Indicates an upper gastro-intestinal site of bleeding,Classfication of Etiology,Esophagea

2、l diseases Gastroduodenal dieases Biliary and Pancreatic diseases Systemic diseases,Classfication of Etiology,Classfication of Etiology,Etiology1,Esophageal diseases,Varices rupture,Reflux esophagitis,Mallory-Weiss tear,Esophageal cancer,Esophageal Varices,Mallory-Weiss tear,Etiology2,Gastroduodenal

3、 dieases Gastric ulcer Duodenal ulcer Dieulafoy lesion Stress ulcer Cancer,Peptic ulcer,Etiology(3),Biliary diseases Gallstones cholecystitis Carcinoma of gallbladder Carcinoma of bile duct,Pancreatic cancer Pancreatitis,Pancreatic diseases,Etiology(4),Systemic diseases Anaphylactoid purpura Epidemi

4、c hemorrhagic fever (EHF) Disseminated intravascular- Coagulation(DIC),Clinical manifestation,Case report1,A thirty-year-old man presents with three episodes of vomiting red blood in the two days ,the amount is estimated three bottles, meanwhile he passed black stool six times. He had a regular epig

5、astric pain in the past two weeks. He also feels dizzinessfatigability and thirst physical Examination reveals BP90/60mmHg HR 102/min, pale skin,Case report2,A 42-year-old man present with vomiting a large mount of fresh blood and clots for two hours, He complains of faint、sweating、palpitation. with

6、 a history of chronic liver disease. Examination reveals BP70/50mmHg HR 124/min,lethargy、moist cold skin、jaundice、 spider angioma 、splenomegalia,Key point 1978,Time (minutes),0 20 40 60 80 100,0 1 2 3 4 5,pH = 5.9,pH = 6.8,A, ADP,Effect of PPI on gastric pH,Increase intragastric pH pH6.0 for 84-99%

7、of day No reported tolerance Continuous infusion (CI) superior to intermittent bolus administration Clinical improvements in rebleeding and/or surgery with: Bolus 80mg + CI 8mg/h,Omeprazole in the Upper GI Bleeding Patients with Stigmata of recent haemorrhage,Omeprazole therapy in the treatment of u

8、pper GI bleeding from specific lesions,Prevention of Recurrent Upper GI Bleeding,Stress Bleeding prophylaxis - Indications,Stress Prophylaxis - Treatment,Oesophageal varices cause + 10% of cases of acute upper GI bleeding admitted to hospitals,Variceal Haemorrhage,Mortality rate 30-50%,Gastro-oesoph

9、ageal varices are present in + 50% of cirrhotic patients. Their presence correlates with severity of liver disease,Variceal Haemorrhage,Bleeding from oesophageal varices ceases spontaneously in up to 40% of patients,Control of hemorrhage,Treatment of Acute Variceal Hemorrhage,Prevention of early rec

10、urrence,High rate of major complications,Pharmacotherapy,Vasoactive therapy - Vasopressin,Conflicting results with Terlipressin and Nitroglycerin,Native Somatostatin Reduces splanchnic blood flow and azygos blood flow Use is restricted due to its short half life (1-2 min),Pharmacotherapy,Is as effec

11、tive as endoscopic sclerotherapy and is a safe treatment for acute variceal bleeding,Pharmacotherapy,Synthetic somatostatin analogue - Octreotide,Half life 1-2 hours,More effective than placebo, vasopressin and balloon tamponade,Non selective -adrenergic blockers - propranolol, nadolol or timolol,Ph

12、armacotherapy,They decrease portal venous inflow by two mechanisms - decreasing cardiac output (1 blockade),- splanchnic vasoconstriction (2 blockade and unopposed alpha adrenergic activity),Antibiotic prophilaxis is mandatory,Pharmacotherapy,- Reduces rate of bacterial infections - Increases surviv

13、al,Avoid intravascular over expansion,Blood replacement to target Hematocrit of 25-30%,Octreotide as adjunct to endoscopic therapy appears to be the most promising approach in the treatment of acute variceal hemorrhage,Endoscopic View of Oesophageal Varices,Oesophageal Varices - Sclerotherapy,Oesoph

14、ageal Varices - Banding,Shunt surgery (distal spleno-renal) in well compensated liver disease (Child A) or TIPS are of proven clinical efficacy as salvage therapy for patients not responding to endoscopic or pharmacologic therapy,Shunt Therapy,prevents rebleeding,Shunt Surgery,increases risk of portosystemic encephalopathy,no effect on survival,reduces rebleeding encephalopathy no effect on survival shunt dysfunction