上消化道大量出血

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,*,科室学习,-,小讲课,上消化道大量出血的诊断与鉴别诊断,A common medical condition,250,000,500,000 admissions/year US,UGI bleeding incidence 100/100,000 adults,Incidence increases 20-30 fold from third to ninth decade of life,LGI bleeding incidence 20/100,000 adults,Overwhelmingly disease of the elderly,GI bleeding stops spontaneously in 80%,Morbidity Data,Majority will receive blood transfusions,2,10%require urgent surgery to arrest bleeding,Average LOS 4,7 days,Mortality rates for UGI bleeding 2,15%,Mortality for patients who develop bleeding after admission to hospital for another reason is 20,30%,Costs,Average hospital costs exceed$5,000 per admission,Most of this for hospital bed and ICU stays rather than physician fees,blood products,diagnostic tests,or medications,Reduction of hospital admissions and LOS has greatest potential to reduce costs,一、概念,上消化道概念,?,一、概念,上消化道大量出血概念,部位,出血量,：,指出血达全身血量的,30%50%,时（,15002000ml,），临床上出现低血容量性休克，收缩压,10.7kPa(80mmHg),，脉压差,3.34.0kPa(2530mmHg,）及脉搏快而弱（脉搏,120,次,/min,），血红蛋白,70g/L,，红细胞计数,3,10,12,/L,。,出血速度,?,UGI bleeding:Nomenclature,Hematemesis 25%,Melena alone 25%,50,100 cc of blood will render stool melenic,Hematochezia 15%,seen in massive UGI hemorrhage,“,Red blood,”,hematemesis,“,Coffee ground,”,emesis,二、病因,按照发病机制可分为以下五类,炎症性疾患：,机械性疾患：,血管性疾患：,赘生物：,全身性疾患：,炎症性疾患,机械性疾患,血管性疾患,赘生物,全身性疾患,三、临床表现,呕血与黑粪：,急性失血所致的表现,发热,氮质血症,血象变化,原发病表现,四、出血量和休克的估计,1,、临床判断：,粪便潜血阳性：,510ml,柏油便：,60100ml,呕血：,250300ml,中等量失血：出血占全身血容量的,15%,，约,800ml,大量失血：出血占全身血量的,30%50%,，约,15002000ml,呕血,黑粪,胃管内引流出血性液体,2,、判断上消化道出血的血液学指标,失血量（,%,）,血红蛋白（,g/L,）,红细胞计数（,10,12/L,）,血细胞比容,1015,100,4,0.4,20,70100,34,0.350.4,30,70,3,0.3,3,、休克指数,休克指数,=,脉搏,/,收缩压（,mmHg,），正常为,0.54,。,休克指数,=1,，失血量为血容量的,20%30%,休克指数,=1.52,，失血量为血容量的,30%50%,4,、中心静脉压（,CVP,）测定：,能反映患者血容量和活动性出血。,正常范围：,0.591.18kPa,0.49kPa,或波动不稳，应考虑有活动性出血及液体量不足,五、判断出血是否停止或再出血,继续出血或再出血的指征：,反复呕血,黑便次数增多,外周循环衰竭的表现,CPV,或波动,血常规：,RBC,、,Hb,、,MCV,、网织红细胞,在补液量和排尿量足够的情况下，,BUN,持续下降或再次升高,内镜下见病灶部位或边缘有新鲜血或渗血,选择性动脉造影见病变处有多染色区,五、判断出血是否停止或再出血,再出血可能的征兆：,呕血者仅有黑便者,首次出血量大,动脉破裂,老年人伴有明显动脉硬化,食管胃底静脉曲张破裂出血,内镜下见病灶处隆起的红色小斑点或小血管，或假动脉瘤形成,Scoring System for Predicting Rebleeding and Mortality,Variable,Score,Age,79,2,Shock,None,0,Tachycardia,1,Hypotension,2,Comorbidity,None,0,CAD,CHF,other major comorbidity,1,Renal failure,liver failure,malignancy,2,Diagnosis,Mallory Weiss tear or no lesion observed,0,All ot,her diagnoses,1,Malignant lesion,2,Stigmas of recent hemorrhage,None or spot in ulcer base,0,Blood in the GI tract,clot,visible vessel,in ulcer base,2,Scoring is not Boring,Score,Rebleeding%,Mortality%,1,3,0,2,5,0,3,12,2,4,13,4,5,17,8,6,30,15,7,40,20,8,48,39,六、诊断,出血的病因诊断,病史、症状、体征,实验室检查：粪潜血、血常规,急诊内镜检查：,80%,线钡餐检查：病情稳定,37,日后再作此项检查,选择性动脉造影：动脉出血量在,0.5ml/min,，诊断率可达,70%95%,锝,99m,Tc,腹部扫描：出血速度为,0.050.1ml/min,，敏感性为,97%,，特异性为,85%,超声内镜检查,超、检查,术中胃镜,诊断流程,呕血、黑便,血红蛋白、红细胞计数、血细胞比容测定,大便常规,+,潜血,胃镜检查,对症处理,结肠镜检查,胶囊内镜、小肠镜、,DSA,、,99m,Tc,核素腹部扫描,（,+,）,（,+,）,（,+,）,（,+,）,（,-,）,（,-,）,七、鉴别诊断（一）,排除消化道以外的出血,排除来自呼吸道出血：,排除口、鼻、咽喉部出血：,排除进食引起的黑便,七、鉴别诊断（二）,鉴别要点,上消化道出血,下消化道出血,既往史,多有溃疡病、肝胆疾病史或有呕血史,多有下腹部疼痛、包块及排便异常（便秘或腹泻）病史或便血史,出血征兆,上腹部闷胀、疼痛或绞痛发作，恶心、反酸,中下腹不适或下坠，欲排便,出血方式,呕血伴柏油样便,便血无呕血,便血特点,柏油样便，稠或成形，无血,暗红或鲜血，稀，多不成形,直肠指诊,黑色或酱紫色粪便（大量出血）,大量出血时可有血块，呈酱紫色或鲜红色,七、鉴别诊断（三）,罕见病因不应忽视,反复钩虫感染者,胆道出血,出血性疾病,败血症、重症肝炎、钩端螺旋体病、流行性出血热,胃肠道血管畸形,八、治疗,一般急救治疗：,休息、镇静、严密观察生命体征,积极补充血容量,止血措施,生长抑素及 其类似物,双气囊三腔管压迫止血,内镜下治疗,线引导下的介入治疗,手术治疗,