上海交大外科学上血pbl课件

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,*,上消化道大出血,Massive Upper Gastrointestinal Bleeding,上海交通大学医学院,瑞金临床医学院,2009,1,Introduce Ourselves,Dr. Yang&,Dr. Li,2,Basic Concepts,3,What Is Massive Bleeding,20% (800ml) blood loss,Hemodynamic instability血流动力学不稳,Clinical signs of poor perfusion组织灌注差,4,What Is UGI,Esophagus食道,Stomach胃,Duodenum十二指肠,Jejunum空肠,Ileum回肠,Ascending Colon升结肠,Transverse Colon横结肠,Descending Colon降结肠,Sigmoid Colon乙结肠,Rectum直肠,Anus肛门,5,6,7,Please Remember,UGIB is not uncommon in the emergency room,Mortality rate is about 10%,UGIB is a series of diseases mainly treated by internal medicine.,3-15% require a surgical procedure,8,Lets have a problem!,9,Patient Come,45-yr female,first episode of hematemesis呕血,transferred from a small hospital,2 units of packed erythrocyte红细胞 tranfused,nasogastric tube胃管 introduced with active bleeding,pulse 120 bpm, BP 80/40 mmHg,10,What Is Your Decision,What is your intuition直觉?,11,For Reference,Does the patient have life-threatening situation?,hypovolemic shock低血容量性休克,low body temperature体温降低,anemia/hypoxemia贫血/低氧血症,comorbidities并存病,Is it a massive or minor bleeding?,Where is the most probable bleeding site?,12,Worrisome clinical signs and symptoms,tachycardia心动过速 more than 100 beats per minute (bpm),systolic blood pressure (SBP)收缩压 90mmHg,postural hypotension体位性低血压 SBP decrease 15mmHg or pulse rate increase 10 bpm,cool extremities四肢厥冷,syncope晕厥,ongoing brisk hematemesis进行性/活跃地呕血,maroon stool枣红便,13,Massive or Minor,Class I,Class II,Class III,Class IV,Blood Loss ml,750,750-1500,1500-2000,2000,Blood Loss %,15,15-30,30-40,40,Pulse Rate bpm,100,100,120,140,Blood Pressure,normal,normal,decrease,decrease,CNS 神经系统症状,Slightly anxious轻度焦虑,Mildly anxious中度焦虑,Anxious, confused焦虑/意识模糊,Confused, lethargic意识模糊/嗜睡,14,UGIB or LGIB,Manifestation症状,UGIB,LGIB,Hematemesis呕血,Almost certain,Rare,Melena黑便,Probable,Possible,Hematochezia 便血,Possible,Probable,Blood-streak stool便中带血丝,Rare,Almost certain,Occult blood stool大便隐血,Possible,Possible,15,Estimation of Blood Loss,occult blood stool 5-10ml/24h,melena 50-100ml/24h,hematemesis 250-300ml in stomach,CNS change 500ml,hypovolemia 1000ml/short period,16,Child-Pugh Classification,No. of Points,1,2,3,Bilirubin(mol/L)总胆红素,51,Albumin(g/L) 白蛋白,35,28-35,Moderate,Encephalopathy 脑病,None,Slight,Moderate,Grade A=5-8 points, Grade B=9-11 points, Grade C= 12-15 points,17,What Is Your Decision,What are the management priorities优先顺序 to this patient?,18,For Reference,Resuscitation复苏,Hemostasis止血,Differential diagnosis鉴别诊断,Basic disease treatment治疗原发病,Comorbidity management处理并存病,19,Initial Resuscitation,ABC,airway保持气道通畅,breathing维持呼吸和供氧,circulation维持循环,bilateral intravenous access (at least)双路静脉通路,short, large pore短而粗,fast fluid replacement快速液体输入,3-for-1 rule: 1ml blood loss, 3ml crystalloid fluid,blood transfusion: 2-6 units of packed erythrocyte,close monitoring密切监护,20,Medical Therapy,vasopressin血管加压素,somatostatin or analogs生长抑素或同类物,antacid agents制酸剂,H2-receptor antagonist H2受体拮抗剂,proton pump inhibitor 质子泵抑制剂,hemostatic agents & blood coagulation factors止血剂和凝血因子,21,Nasogastric Tube Introduction,aspiration & lavage吸引和冲洗,site of bleeding,bile without blood UGIB not likely,gastric fluid & blood UGIB,clear gastric fluid duodenal bleeding still possible,false negative假阴性 approximately 10%,hemostasis & monitoring止血和监控,icy saline lavage with epinephrine肾上腺素,aspiration color & amount,reduce vomiting减少呕吐, protect the airway,22,Balloon Tamponade气囊压迫,temporary measure during resuscitation (24-48hr),20% complication rate,airway obstruction气道阻塞,aspiration误吸,esophagus necrosis食管粘膜坏死,arrhythmia心律失常,recurrent bleeding after release of balloon,first inflate gastric balloon to 60mmHg(200ml),then inflate esophagus balloon to 40mmHg(150ml),pulling weight 0.25kg using a pulley滑车,release for 15min every 4hrs,23,24,What Is Your Decision,What question would you ask the patient?,25,For Reference,History of illness病史,Precipitating factors诱因,Comorbidities并存病,26,History,history of bleeding出血情况,time持续时间,symptoms表现症状,amount出血量,history of related diseases,peptic ulcer消化性溃疡,liver diseases肝脏疾病,cholangio-pancreatic diseases胆胰疾病,coagulopathy凝血障碍,others,27,Precipitating factors,alcohol abuse酒瘾,NSAIDs (nonsteroid anti-inflammatory drugs) ingestion非甾体类抗炎药物应用,stress应激: burn injuries Curling head injuries Cushing,28,Frequent Symptoms,Hematemesis呕血 - 40-50%,Melena黑便 - 70-80%,Hematochezia便血 - 15-20%,Either hematochezia or melena - 90-98%,Syncope晕厥 - 14.4%,Presyncope晕厥前期 - 43.2%,Dyspepsia消化不良 - 18%,Epigastric pain上腹痛 - 41%,Heartburn胃灼热 - 21%,Diffuse abdominal pain弥漫性腹痛 - 10%,Dysphagia吞咽困难 - 5%,Weight loss体重减轻 - 12%,Jaundice黄疸 - 5.2%,29,What Is Your Decision,What is the differential Diagnosis鉴别诊断?,30,For Reference,Peptic ulcer消化性溃疡,Stress gastritis应激性胃炎,Stomach neoplasms胃肿瘤,Portal hypertension门脉高压,Hemobilia胆道出血,Miscellaneous其他少见原因,31,Peptic Ulcer,history of chronic ulcer,epigastric pain (nocturnal symptoms) 上腹痛（夜间痛）,dyspepsia消化不良,satiety饱胀,history of mucosa damage,diet,smoking,NSAIDs 非甾体类抗炎药物,Adrenal cortical hormone肾上腺皮质激素,usually melena, sometimes hematemesis,32,Stress Gastritis,history of stress应激病史,burn injuries,head injuries,predisposing clinical conditions可导致应激的临床情况,shock休克,multiple trauma多发伤,ARDS (acute respiratory distress syndrome)急性呼吸窘迫综合征,SIRS (systemic inflammatory response syndrome)全身炎症反应综合征,MODS (multiple organ dysfunction syndrome)多脏器功能障碍综合征,sepsis脓毒症,33,Stomach Neoplasms,middle age中年,weight loss体重减轻,anorexia厌食,irregular epigastric pain不规则腹痛,abdominal mass腹部包块,34,Portal Hypertension,predisposing history of cirrhosis肝硬化基础疾病,hepatitis肝炎,Schistosomiasis血吸虫病,alcohol abuse酒瘾,special features特殊体征,jaundice黄疸,ascites腹水,dilated vein in the anterior abdominal wall腹壁静脉怒张,rectal hemorrhoids痔,35,Formation of Portal System,3 inflow vein collect blood from spleen, pancreas, stomach, intestine, colon, and rectum,splenic vein,superior mesenteric vein,inferior mesenteric vein,2 branches into left & right hepatic lobe,through hepatic sinus to hepatic vein to IVC,75% blood supply, 50% oxygen supply of liver,36,37,Collateral Vascular System侧支循环,esophageal-fundus submucosal venous plexus食管下段-胃底交通支,rectal hemorrhoidal system直肠下段肛管交通支,retroperitoneal system后腹膜交通支,anterior abdominal wall system前腹壁交通支,38,39,Definition of Portal Hypertension,normal portal pressure: 13-24cmH,2,O,normal hepatic vein pressure gradient (HVPG) : 5-9cmH,2,O,portal hypertension: 30-50cmH,2,O,HVPG 12mmHg leads to UGIB,40,41,Cause of Hypertension,cirrhosis,hepatic sinus,narrowness,portal blood inflow blocked,high pressure hepatic artery,flow to low pressure portal vein,42,43,Pathophysiology of Portal Hypertension,splenemegaly & hypersplenism脾肿大/脾功能亢进,peripheral total blood count decrease,collateral vascular varix侧支静脉曲张,esophageal-fundus submucosal venous plexus has greatest gradient, cause massive UGIB,hemorrhoid,Caput Medusae海蛇头,ascites,capillary filtration pressure increase毛细血管渗透压增加,hypoalbuminemia低白蛋白血症,excessive lymphatic fluid generation淋巴液生成过多,hyperaldosteronemia高醛固酮血症,portal gastropathy/encephalopathy门脉性胃病/脑病,stomach mucous edema胃粘膜水肿,portal systemic shunt门体分流,44,Caput Medusae,45,Hemobilia,hemobilia triad胆道出血三联症,biliary colic胆绞痛,obstructive jaundice梗阻性黄疸,gastrointestinal bleeding消化道出血,liver trauma肝外伤,hepatic hemangioma肝血管瘤,hepatic neoplasm肝肿瘤,hepatic abscess肝脓肿,biliary tract stone胆道结石,46,Miscellaneous,Mallory-Weiss syndrome: linear mucosal laceration near cardia贲门 as a result of forceful vomiting, retching干呕 or coughing,Dieulafoy lesion: vascular malformation in stomach,Angiodysplasia血管发育不良: abnormal dilated, thin-walled mucosal or submucosal vessels粘膜/粘膜下血管,47,What Is Your Decision,What physical examination体格检查 findings would you search for?,48,For Reference,Signs of shock and blood loss,Signs of chronic liver disease,Signs of tumor,49,Shock & Blood Loss,pulse and blood pressure脉率血压,postural hypotension体位性低血压,mental disorder: anxious焦虑, confusion意识模糊, delirium谵妄, lethargy嗜睡, presyncope晕厥前期, syncope晕厥,signs of anemia: pale conjunctiva and nail bed结膜甲床苍白,signs of poor perfusion: cold extremities四肢厥冷, cold sweating冷汗, oliguria少尿, chest pain胸痛,50,Chronic Liver Diseases,spider angiomata蜘蛛痣,palma erythema肝掌,gynecomastia男性乳房发育,splenomegaly脾肿大,ascites腹水,pedal edema足部水肿,asterixis扑翼样震颤,Caput Medusae海蛇头,51,Tumor,upper abdominal mass上腹包块,left supraclavicular lymph node (Virchows node)左锁骨上淋巴结肿大,umbilical nodular (Sister Mary Josephs node)脐周结节,Douglas pouch nodular (Bloomers shelf)直肠子宫（膀胱）陷凹结节,52,What Is Your Decision,What diagnostic studies would you order?,53,For Reference,Complete blood count (CBC)全血细胞计数,Blood cross match交叉配血,Coagulation profile凝血功能,Liver & Renal function肝肾功能,Calcium level血钙,Gastrin level血胃泌素,CT scan计算机断层扫描 or Ultrasonography超声检查,Digital Subtraction Angiography (DSA)数字减影血管造影,Endoscope内镜,54,Endoscopic Explore,diagnosis & treatment诊断/治疗双重作用,most reliable & effective method最可靠最有效,within 24-48hrs after bleeding应在出血后24-48小时内进行,contraindication反指征,hemodynamic instablility血流动力学不稳定,severe cardiac decompensation严重心功能失代偿,acute myocardial infarction急性心肌梗塞,perforated viscus脏器穿孔,55,56,Ulcer with Black Spot,10% Rebleeding,57,Ulcer with Blood Clot,22% Rebleeding,58,Ulcer with Visible Vessel,43% Rebleeding,59,Ulcer with Active Bleeding,55% Rebleeding,60,Esophagus Varices,61,62,Hypertensive Portal Gastropathy,63,Injection of Sclerosant硬化剂,64,Band Ligation皮圈套扎,65,Hemoclip止血夹,66,Laser Application激光止血,67,Heater Probe加热探针,68,What Is Your Decision,What are the therapeutic options for each common etiology病因 of massive UGIB after initial resuscitation?,69,For Reference,Medicine,Endoscope,Surgery,70,Non-Variceal Bleeding,therapeutic endoscope with/without medicine,if effective then continue drug therapy,eradication of H. pylori,mucous protection,2 attempts of endoscopic failure pursue surgery,other surgical indications,severe life-threatening bleeding not responsive to resuscitation,coexisting reason of perforation,obstruction or malignancies,second hospitalization of peptic ulcer,71,Variceal Bleeding,drug therapy with/without balloon temponade,endoscopic binding or sclerotherapy,transjugular intrahepatic portosystemic shunt (TIPS) 经颈静脉肝内门体分流术,effective rate 90%,rebleeding rate in one year 16-30%,shunt disfunction rate in 6 months 50-60%,inducing encephalopathy rate 25-35%,30 day mortality rate 14-16%,can be used as a temporary method before transplantation,Child A & B surgery,Child C transplantation,72,TIPS,8-12mm,73,What Is Your Decision,How to perform the operation?,74,For Reference,Exploration探查,Hemostasis止血,Radical Operation根治,75,Exploration Sequence,most popular site: stomach & duodenum胃十二指肠,cirrhosis or not: liver and spleen肝脾,gallbladder and common bile duct胆道系统,upper portion of jejunum上段空肠,76,Non-Variceal Bleeding,peptic ulcer or stress gastritis消化性溃疡和应激性胃炎,vagotomy迷走神经切除术,gastrectomy胃切除,sewing of bleeding ulcer溃疡缝扎,stomach neoplasm胃肿瘤,gastrectomy胃切除,hemobilia胆道出血,self-limited, seldom needs operation自限性，很少需要手术,77,Variceal Bleeding,emergency: devascularization procedure断流术,splenectomy脾切除,gastroesophageal devascularization胃底食管血管离断,esophageal transection食管下段横断,Child A/B: decompressive shunt分流术,total portal systemic shunt非选择性分流,excellent control of bleeding止血效果好,40-50% encephalopathy肝性脑病发生率高,selective portal systemic shunt选择性分流,maintain portal flow to liver保持门脉入肝血流,10-15% encephalopathy肝性脑病发生率低,produce ascites可产生腹水,Child C: transplantation肝移植,78,Esophageal Transection,79,Porto-Cava Shunt,80,Distal Splenorenal Shunt,81,Conclusion,Save life first,Bleeding site not so important,Primary choice endoscope,Operation usually not necessary,82,We have the gun,but dont want to shoot,83,Thank You,84,