上消化道出血课件(同名1)

Hematemesis 呕血UPPER GASTROINTESTINAL BLEEDINGDepartment of Gastroenterology Xuanwu hospital Hematemesi1Overview Definition Etiology Clinical manifestation Differential diagnosis Diagnostic approach TreatmentOverview 2DefinitionIndicates an upper gastro-intestinal site of bleedingDefinitionIndicates an upper 3Classfication of EtiologyEsophageal diseasesGastroduodenal dieasesBiliary and Pancreatic diseasesSystemic diseasesClassfication of EtiologyEsop4Classfication of EtiologyClassfication of Etiology5Classfication of EtiologyClassfication of Etiology6Etiology1Esophageal diseasesVarices ruptureReflux esophagitisMallory-Weiss tearEsophageal cancerEtiology1Esophageal diseasesVa7Esophageal VaricesEsophageal Varices8Mallory-Weiss tear Mallory-Weiss tear 9Etiology2Gastroduodenal dieasesn n Gastric ulcern n Duodenal ulcern n Dieulafoy lesionn n Stress ulcer n n CancerEtiology2Gastroduodenal diease10Peptic ulcerPeptic ulcer11Etiology(3)Biliary diseasesn n Gallstones cholecystitisGallstones cholecystitisn n Carcinoma of gallbladder Carcinoma of gallbladder n n Carcinoma of bile duct Carcinoma of bile duct Pancreatic cancer Pancreatitis Pancreatic diseases Etiology(3)Biliary disease12Etiology(4)Systemic diseases Anaphylactoid purpura Epidemic hemorrhagic fever(EHF)Disseminated intravascular-Coagulation(DIC)Etiology(4)Systemic diseases13 Clinical manifestation上消化道出血课件(同名1)14Case report1n nA 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.n nHe had a regular epigastric pain in the past two weeks.He also feels dizzinessfatigability and thirst physical n nExamination reveals BP90/60mmHg HR 102/min,pale skinCase report1A thirty-year-old 15Case report2A 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 a history of chronic liver disease.Examination reveals BP70/50mmHg HR 124/min,lethargy、moist cold skin、jaundice、spider angioma、splenomegaliaCase report2A 42-year-old man 16Key point&AimAssess ofAssess of severity of Hypovolemia severity of HypovolemiaDetermine the causeDetermine the causeKey point&AimAssess ofDetermi17HistoryDuration:from onset to presentPrior symptomsPrior bleedingPrior gastrointestinal diseaseHistoryDuration:from onset to18Color&Character -Fresh red -Dark red -Coffee-ground -Clots Color&Character -Fresh re19Amount of bleeding How to assess:1.-cup -bottle?-basin -pile?whats the volume of these vessels 2.how many times?3.total Amount?Amount of bleeding How to as20Amount versus Signs MinimalMinimal amount of bleeding with amount of bleeding with symptomssymptoms 250300 ml 250300 ml HematemesisHematemesis5070 ml/d 5070 ml/d MelenaMelena 2-5 ml/d 2-5 ml/d OB +OB +Amount versus Signs Minimal 21Melena-Melena is defined as passage of black,tarry(柏油)stool-Melena always follows hematemesisMelena-Melena is defined as 22Mild Hypovolemia 1.Blood loss500ml 2.Light headed、weakness palpitation、thirst 3.Rapid pulseMild Hypovolemia 1.Blood los23 1.Blood loss1000ml 2.Syncope(晕厥)anxiety sweating 3.Postural hypotension(recumbent to upright)drop15-20mmHg TachycardiaModerate Hypovolemia 1.Blood loss1000mlModerate24Shock 1.blood loss1500ml 2.lethargy,pale cold moist skin,oliguria,(少尿)dyspnea 3.hypotension TachycardiaShock 1.blood loss1500ml25Rate of blood loss A case analysis:a 45-year old man who fainted in a bathroom at 6am while vomiting red blood,then has systolic pressure of 70mmHg at 9am is estimated to have lost 1500ml of blood in 3 hours The rate is 500ml/hourRate of blood loss A 26Hemodynamics and Blood LossHemodynamics Hemodynamics Blood Loss(%)Blood Loss(%)Severity of BleedSeverity of BleedVital SignsVital SignsFraction of Intravascular Fraction of Intravascular VolumeVolumeShockShock20-3020-30massivemassivePostural-hypotensionPostural-hypotension tachycardiatachycardia10-2010-20Moderate Moderate normalnormal1010minorminorHemodynamics and Blood LossHem27It reflects a massive arterial bleed spraying (greater than 1000 ml).Massive bleeding It reflects a massive arterial28Hematocrit（红细胞压积）（红细胞压积）If blood loss is acute,the hematocrit dose not change during the first few hours after hemorrhage（出血）About 24 to 72 hours later,plasma volume is larger than normal and the hematocrit is at its lowest point Hematocrit（红细胞压积）If blo29Hematocrit（红细胞压积）Hematocrit changes A A Before bleeding Before bleeding B B Immediately after bleeding Immediately after bleeding C C 2472 hours after bleeding 2472 hours after bleeding7 6 5 4 3 2 1Volume(Liters)45%45%27%ABCHematocrit（红细胞压积）Hematocrit ch30clinical manifestationBowel sound Active bowel sound usually be presented in active bleedingclinical manifestationBowel so31clinical manifestation Fever:bigin within 24 hours,moderate38.5。C,the cause is unknow.BUN:useful measurement of bleeding often elevated by absorption of ammonia from ingested blood clinical manifestation Fever:32Differential diagnosis Upper GI Upper GILower GILower GIManifestationManifestationHematemesisHematemesisHematocheziaHematocheziamelenamelenaNasogastricNasogastric aspirate aspirateBloodyBloodyClearClear BUN BUNElevatedElevatedNormalNormalBowel soundBowel soundHyperactiveHyperactiveNormalNormalDifferential diagnosis33Differential diagnosis hematemesis hemoptysis hematemesis hemoptysis（咯血）（咯血）（咯血）（咯血）Symptom Symptom vomiting cough vomiting cough&nausea stethocatharsis nausea stethocatharsis PH PH value 4.0value 6.0 6.0 MixtureMixture food food foamfoam&sputumsputum Differential diagnosis 34Differential diagnosisn nBlood in the nose or trickling down the pharynx suggests the nasopharynx（鼻咽）as the source n nTraditional Chinese drug（中药）n nbismuth(铋)、iron(铁)n nAnimals blood(liver)Differential diagnosisBlood in35Diagnostic test上消化道出血课件(同名1)36Retaining of nasogastric tube 1.Determine the site of bleeding 2.Dynamic monitoring 3.therpyNasogastric tubeNasogastric tube37Endoscopy(内镜内镜)Endoscopy is the diagnostic procedure of choice of accuracy immediatetherapeutic potential.Endoscopy ,however,must be Performed only following adequate resuscita-tion(复苏).Endoscopy(内镜)Endoscopy 38Barium radiography(钡餐钡餐)Barium radiography is noninvasivebut has significant disadvantages,particularly in patients who are bleeding briskly(actively).Barium radiography(钡餐)Bari39Angiography(血管造影)Angiography may localize the site of bleeding Using in a obscure bleedingAngiography(血管造影)40Angiography Bleeding must be active because angiography detects only extravasation(外渗)of contrast (造影剂)into the GI tract.Angiography41radionuclide imaging1.Useful for the obscure bleedingif endoscopy examination is negative2.Active bleeding is need to be existing with a rate0.5ml/minradionuclide imaging1.Useful f42 Prognosis&Treament上消化道出血课件(同名1)43Prognostic factors:endoscopic80%60%40%20%0%Clean baseFlat spotAdherent clot%of patients rebleedingIncidence of rebleeding by appearance of ulcer at endoscopy Nonbleeding visible vesselActive bleeding510224355Prognostic factors:endoscopic44Ulcers of bleedingUlcers of bleeding45Outcome of Acute G I BleedingOutcome of Acute G I Bleeding46Influence of Diagnosis on OutcomeInfluence of Diagnosis on Outc47Vascular AnatomyVascular Anatomy48Vascular Anatomy-Relationship to TherapyVascular Anatomy-49Role of EndoscopyRole of Endoscopy50Stigmata of Recent Haemorrhage-PrevalenceStigmata of Recent Haemorrhage51Nature of the visible vesselNature of the visible vessel52Overview of managementn n Initial management n n Endoscopic therapyn n Surgical therapyn n Pharmacological therapyOverview of management Initial53Initial Managementn n Assess haemodynamic instabilityn n Resuscitation n n Haemogram and coagulation studiesn n Nasogastric tube(in/out)n n Monitoring of vital signs and urine outputInitial Management Assess haem54Endoscopic therapyn nPerform early(ideally within 24 h)Perform early(ideally within 24 h)n nIndications for haemostatic therapyIndications for haemostatic therapy1 1n n 1.+/-Adherent clot 1.+/-Adherent clotn n 2.Nonbleeding visible vessel 2.Nonbleeding visible vesseln n 3.Active bleeding(oozing,spurting)3.Active bleeding(oozing,spurting)n nHeater probe,bipolar electrocoagulation or Heater probe,bipolar electrocoagulation or injection therapyinjection therapyn nDecreases in rebleeding,surgery and Decreases in rebleeding,surgery and mortalitymortality2,32,31.Laine&Peterson;19942.Cook et al;19923.Sacks et al;1990Endoscopic therapyPerform earl55上消化道出血课件(同名1)56Effect of Therapy on re-bleeding rates(Visible Vessel)Effect of Therapy on re-bleedi57Effect of Therapy on re-bleeding rates(Active Bleeding)Effect of Therapy on re-bleedi58Role of acid in haemostasisn nImpairs clot formationImpairs clot formation n n Impairs platelet aggregation and causes Impairs platelet aggregation and causes disaggregation disaggregationn nAccelerates clot lysisAccelerates clot lysis n n Predominantly acid-stimulated pepsin Predominantly acid-stimulated pepsinn nMay impair integrity of mucus/bicarbonate May impair integrity of mucus/bicarbonate barrierbarrierRole of acid in haemostasisImp59pH=7.4 Aggregation(%)Effect of plasma pH on platelet aggregationGreen et al;1978Time(minutes)0204060801000 1 2 3 4 5pH=5.9pH=6.8A ADP pH=7.4 Aggregation(%)Effect60Effect of PPI on gastric pHn nIncrease intragastric pHIncrease intragastric pHn n pH6.0 for 84-99%of daypH6.0 for 84-99%of dayn nNo reported toleranceNo reported tolerancen nContinuous infusion(CI)superior to intermittent bolusContinuous infusion(CI)superior to intermittent bolusadministration administration n nClinical improvements in rebleeding and/or surgery with:Clinical improvements in rebleeding and/or surgery with:Bolus 80mg+CI 8mg/h Bolus 80mg+CI 8mg/hEffect of PPI on gastric pHInc61Omeprazole in the Upper GI Bleeding Patients with Stigmata of recent haemorrhageOmeprazole in the Upper GI Ble62Omeprazole therapy in the treatment of upper GI bleeding from specific lesions Omeprazole therapy in the tre63Prevention of Recurrent Upper GI BleedingPrevention of Recurrent Upper64Stress Bleeding prophylaxis-IndicationsStress Bleeding prophylaxis-65Stress Prophylaxis-TreatmentStress Prophylaxis-Treatment66 Oesophageal varices cause+10%of cases of acute upper GI bleeding admitted to hospitalsVariceal Haemorrhage Mortality rate 30-50%Oesophageal varices cause+167Gastro-oesophageal varices are present in+50%of cirrhotic patients.Their presence correlates with severity of liver diseaseVariceal HaemorrhageBleeding from oesophageal varices ceases spontaneously in up to 40%of patientsGastro-oesophageal varices are68 Control of hemorrhageTreatment of Acute Variceal Hemorrhage Prevention of early recurrence Control of hemorrhageTreatme69 High rate of major complications Pharmacotherapy Vasoactive therapy-Vasopressin Conflicting results with Terlipressin and Nitroglycerin High rate of major complicat70 Native Somatostatin Reduces splanchnic blood flow and azygos blood flow Use is restricted due to its short half life (1-2 min)Pharmacotherapy Native SomatostatinPharmacot71 Is as effective as endoscopic sclerotherapy and is a safe treatment for acute variceal bleedingPharmacotherapy Synthetic somatostatin analogue-OctreotideHalf life 1-2 hoursMore effective than placebo,vasopressin and balloon tamponade Is as effective as endosc72 Non selective-adrenergic blockers-propranolol,nadolol or timolol PharmacotherapyThey decrease portal venous inflow by two mechanisms -decreasing cardiac output(1 blockade)-splanchnic vasoconstriction(2 blockade and unopposed alpha adrenergic activity)Non selective-adrenergic b73 Antibiotic prophilaxis is mandatoryPharmacotherapy-Reduces rate of bacterial infections-Increases survival Avoid intravascular over expansion Blood replacement to target Hematocrit of 25-30%Antibiotic prophilaxis is ma74 Octreotide as adjunct to endoscopic therapy appears to be the most promising approach in the treatment of acute variceal hemorrhage Octreotide as adjunct to end75Endoscopic View of Oesophageal VaricesEndoscopic View of Oesophageal76上消化道出血课件(同名1)77Oesophageal Varices-SclerotherapyOesophageal Varices-Scleroth78Oesophageal Varices-BandingOesophageal Varices-Banding79 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 therapyShunt Therapy Shunt surgery(distal spleno80 prevents rebleedingShunt Surgery increases risk of portosystemic encephalopathy no effect on survival prevents rebleedingShunt Sur81 reduces rebleeding encephalopathy no effect on survival shunt dysfunctionT I P S reduces rebleedingT I P S82TIPS-stent positioned between the hepatic and portal veinsTIPS-stent positioned betwee83Summary1.Common causes for hematemesis2.The ways to assess the severity of hematemesis3.Search for source of bleedingSummary1.Common causes for 84HematemesisHematemesisMelenaHematocheziaHematemesisMelenaHematochezia85谢谢谢谢86