呕血与便血病理课件.ppt

1、Hemetamesis and Hemetochezia(Acute GI Hemorrhage)Five Ways of GI Bleeding4Hematemesis：vomitting of blood of altered blood（coffee grounds）indicates bleeding proximal to ligament of Treitz4Melena：Tarry stool.Altered（black）blood per rectum（60ml）4Hematochezia：Bright red or maroon rectal,bleeding implies

2、 bleeding beyond Lig.T.*4FOB+and Iron deficiency anemiaFactors affect the way to manifest4Site of bleeding 4Speed of bleeding4Amount of blood loss4Flora of enterocolon.Differentiating Upper from Low GI Bleeding4Hematochezia usually represents a lower GI source bleeding4Upper GI lesion may bleed so b

3、riskly that blood doesnt remain in bowl long enough to become melena 4Bleeding lesion distal to T Lig.may be either M.or hematochezia,but never manifests hematemesis Peptic ulcer；Gastropathy（alcohol，aspirin，NSAIDs，stress）；GE varices；Gastric cancerLess common cause of up GI bleedingEsophageal or inte

4、stinal neoplamEsophagitis；Malloy-weiss tear，Hemoptysis:Swallowed bloodAnticoagulant fibrinoloytic therapy:Telangiectases；aneurysm；vasculitis；Dieulafoy ulcer；AV malformationConnective tissue disease；Hemabilia（biliary origin；Crohns disease；amyloidosis,hematological diseasesBENIGN GASTRIC ULCERThe clas

5、sical presentation of gastric ulcer:with weight loss and indigestion made worse by eating,patients more often describe symptoms that would fit equally well for duodenal ulcer-investigation with barium meal or(preferably)endoscopy is,of course,appropriate for either.Benign ulcers may occur at any sit

6、e in the stomach,but are commonest on the lesser curve away from acid-secreting epithelium.Duodenum Ulcer4The lesion most commonly affecting the duodenum is ulceration,and it is now known that both antral infection with Helicobacter pylori and the presence of gastric acid are virtual prerequisites f

7、or it.GE Varices4A number of cutaneous features(stigmata)may develop in a patient with cirrhosis,and these are important as they aid clinical recognition of chronic liver disease.Clinical manifestation of GI Bleeding4Abdominal discomfort Nausea,4Hemadynamic change:reduction in blood volume(syncope,l

8、ight-headedness,sweating,therst)or shock4Laboratory changes:HCT,BUNHematemesis with other symptoms4Hematemesis with upper abdominal pain4Hematemesis with hepatomegly and spleenomegly4Hematemesis with jaundice4Hematemesis with Skin&mucosa hemorrhage4Hematemesis with upper abdominal mass4Others:NSAIDs

9、,Stress,Burning,Brain operation,Trauma,Vomiting Lab.Examination in Localization&Diagnosis of GI Bleeding4Endoscopy4Barium Radiographs4Angiography4Radionuclide imagingApproach to the patient with acute upper gastrintesttinal hemorrhage Acute upper Gastrointestinal Hemorrhage Rapid assessment Monitor

10、hemodynamic status Fluid resuscitation Gastric lavage(?)self-limited(80%)bleeding(10-20%)Empiric medical therapy Urgent endoscopy recurrent hemorrhage endoscopy Site not localized Localized further assessment enteroscopy,radioisotope s scan,angiography,exploratory surgery Definitive therapy Definiti

11、ve therapy Summary of Acute GI Bleeding4Upper GI source bleeding-Hemetemesis4Major upper GI bleding-Hemetemesis&hemetochezia4The more distant from the rectum,the more likely that melaena occurs4The colon lesion-FOB+or hemetochezia4The small bowl lesion-melena or hemetochezia The questions should be

12、posed4Prior bleeding episode?4Family history of GI diseases4Dose the patient have the illness of ulcer?Cirrhosis?cancer?bleeding disorder?4Alcohol?NSAIDs?4Any precedes symptoms or signs?20052005年中国急性上消化道出血诊治指南年中国急性上消化道出血诊治指南中华内科杂志编委会.急性非静脉曲张性上消化道出血诊治指南（草案）.中华内科杂志2005；44(1):73-76口服口服PPIs静脉大剂量静脉大剂量PPI

13、sPPIs内镜检查与治疗内镜检查与治疗出血征象监测、液体复苏并止血治疗出血征象监测、液体复苏并止血治疗监护病房监护病房中高危中高危(Rockall评分评分3分分)上消化道出血病情严重度分级上消化道出血病情严重度分级(Rockall评分评分重复内镜治疗经血管造影介入治疗重复内镜治疗经血管造影介入治疗手术治疗手术治疗原发病治疗及随访原发病治疗及随访成功成功成功成功失败失败失败失败失血量的评估失血量的评估 失血量失血量伴随症状伴随症状血压和脉搏血压和脉搏化验检查化验检查脉搏脉搏血压血压休克指数休克指数400ml400ml无自觉症状无自觉症状100/min100/min正常正常0.580.58400m

14、l400ml头晕、心慌、头晕、心慌、口干口干1 1800 ml800 ml100100120120SBP70SBP7080mmHg80mmHg脉压差脉压差30mmHg30mmHg1200ml1200ml晕厥、尿少、烦躁晕厥、尿少、烦躁1 1HGB70g/LHGB70g/L肠源性氮质血肠源性氮质血症症1600ml1600ml120120体位低血压体位低血压SBP50SBP5070mmHg70mmHg2000ml2000ml气促、无尿、昏迷气促、无尿、昏迷急性非静脉曲张性上消化道出血诊治指南急性非静脉曲张性上消化道出血诊治指南 中华内科杂志：中华内科杂志：2005.1.Palmar KR.Guid

15、eline Gut 2002出血严重程度评估出血严重程度评估分级分级 年龄年龄伴发伴发病病失血量失血量(ml)(ml)血压血压(mmHg)(mmHg)脉搏脉搏(次次/分分)血红蛋白血红蛋白(g/L)(g/L)症状症状轻度轻度6060 无无500500基本正常基本正常正常正常无变化无变化头昏头昏中度中度6060 无无50010005001000下降下降1001007070100100晕厥、口渴、少尿晕厥、口渴、少尿重度重度6060 有有15001500收缩压收缩压8080 1201207070肢冷、少尿、意识模肢冷、少尿、意识模糊糊急性非静脉曲张性上消化道出血诊治指南急性非静脉曲张性上消化道出血

16、诊治指南 中华内科杂志：中华内科杂志：2005.1.Palmar KR.Guideline Gut 2002急性上消化道出血患者急性上消化道出血患者RockallRockall再出血和死亡危险性评估系统再出血和死亡危险性评估系统变量评 分0123年龄(岁)60607980休克无休克（收缩压100mmHg，脉率100次分）心动过速（脉率100次分，收缩压100mmHg）低血压（收缩压100mmHg），脉率100次分伴发病无心力衰竭、缺血性心脏病及其他重要伴发病肝衰竭、肾衰竭和癌肿播散内镜诊断Mallory-Weiss撕裂，无病变溃疡等其他病变上消化道恶性疾病内镜下出血征象无或有黑斑上消化道血液潴

17、留、黏附血凝块，血管显露或喷血高危：高危：5，中危：中危：34，低危：低危：02Endoscopic view of a Mallory-Weiss tear with active bleeding(gastric lumen is at top left).B,Endoscopic view of an organized clot adherent to a Mallory-Weiss tear(gastric lumen is at bottom left).Endoscopic view of a Dieulafoy lesion on the lesser curvature of

18、 the stomachEndoscopic view of a vascular ectasia(angiodysplasia)in the duodenum.Endoscopic view of the gastric antrum with watermelon stomach.The pylorus is at top center.Note the linear distribution pattern of the vascular lesions arranged radially around the pylorus.Endoscopic views of ulcers wit

19、h stigmata of recent hemorrhage.A,Duodenal ulcer with a visible vessel.B,Gastric ulcer with a red spot in the center of the crater.C,Duodenal ulcer with a red spot in the center of the crater.D,Purplish clot adherent to a gastric ulcer.Typical picture of a trivial nonsteroidal anti-inflammatory drug

20、(NSAID)-induced injury to the gastric mucosa.There are multiple small erosions with brown-black staining of the center as a result of local bleeding and petechiae.Typical round gastric ulcer at the angulus(incisura)of the stomach.ESOPHAGUS STOMACHDUODENUMJEJUNUM ILEUMCOLORECTUMEsophageal varicesAV m

21、alformationsAngiodysplasiaEsophagitisAngiodysplasiaAV malformationsGastritisUlcersUlcerative colitisGastric varices AnastomoticDiverticulosisMallory-Weiss tears SimpleCancerPeptic ulcerDiverticulaPolypsAV malformationsMeckelsHemorrhoidsCancerAcquiredAnal fissurePolypsCrohns diseaseStomal varicesLeio

22、myomaVaricesPostoperativeSarcomaIschemic ulcerPostpolypectomyBrunners adenomaTuberculosisAnastomoticAngiodysplasiaArteritisTraumaPancreatic restBlind loopUlcersTraumaAngiomaSimplePostoperativeLeiomyomaStercoralRetained ulcerCancerTyphoidResidual gastritisSarcomaAmebicAnastomotic ulcerPolyps Uremic u

23、lcer Stomal varices Lymphoid hyperplasia TraumaCauses of Low GI Bleeding Differentiating Upper from Low GI Bleeding4Hematochezia usually represents a lower GI source bleeding4Upper GI lesion may bleed so briskly that blood doesnt remain in bowl long enough to become melena 4Bleeding lesion distal to

24、 T.Lig.may be either M.or hematochezia,but never manifests hematemesis Hematochezia with other symptoms4Abdominal pain4Fever4Tenesmus4Systemic Hemorrhage 4Dermal sign4Abdominal massLab.Examination For detecting Low GI Bleeeding4Anoscopy&sigmoidoscopy4Barium Edema(BE)4Angiography4Radionuclide scannin

25、gA,Linear ulcers of Crohns colitis.B,Mucosa surrounding the ulcers is nodular(cobblestoning).Shigella colitis.Patchy areas of erythema,spontaneous bleeding,and loss of the normal vascular pattern are evidentSalmonella colitis.Diffuse erythema,spontaneous bleeding,and loss of the vascular pattern wit

26、h formation of telangiectasis are present.Tuberculosis.Linear ulceration runs circumferentially along the interhaustral septum with tiny satellite ulcerations.This must be distinguished from the longitudinal linear ulcerations seen in inflammatory bowel disease.Pseudomembranous(antibiotic-associated

27、)colitis.Numerous elevated yellowish plaques are present on the mucosal surface.Amebiasis.Discrete punched-out ulcers are present in the right colon.Severe acute ulcerative colitis.No vascular pattern is discernible.A severe degree of spontaneous bleeding is presentLarge colonic ulcer in a patient with ischemic colitis.Advantage colon carcinoma