呕血与便血病理课件

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,*,Hemetamesis and Hemetochezia(Acute GI Hemorrhage),Hemetamesis and Hemetochezia(,1,Five Ways of GI Bleeding,Hematemesis：vomitting of blood of altered blood（coffee grounds）indicates bleeding proximal to ligament of Treitz,Melena：Tarry stool.Altered（black）blood per rectum（60ml）,Hematochezia：Bright red or maroon rectal,bleeding implies bleeding beyond Lig.T.*,FOB,+,and Iron deficiency anemia,Five Ways of GI BleedingHemate,2,Factors affect the way to manifest,Site of bleeding,Speed of bleeding,Amount of blood loss,Flora of enterocolon,.,Factors affect the way to mani,3,Differentiating Upper from Low GI Bleeding,Hematochezia usually represents a lower GI source bleeding,Upper GI lesion may bleed so briskly that blood doesnt remain in bowl long enough to become melena,Bleeding lesion distal to T Lig.may be either M.or hematochezia,but never manifests hematemesis,Differentiating Upper from Low,4,Common cause of up GI bleeding,Peptic ulcer；,Gastropathy（alcohol，aspirin，NSAIDs，stress）；,GE varices；,Gastric cancer,Common cause of up GI bleeding,5,Less common cause of up GI bleeding,Esophageal or intestinal neoplam,Esophagitis；Malloy-weiss tear，,Hemoptysis:Swallowed blood,Anticoagulant fibrinoloytic therapy:,Telangiectases；aneurysm；vasculitis；Dieulafoy ulcer；AV malformation,Connective tissue disease；,Hemabilia（biliary origin；Crohns disease；amyloidosis,hematological diseases,Less common cause of up GI ble,6,BENIGN GASTRIC ULCER,The classical 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 site in the stomach,but are commonest on the lesser curve away from acid-secreting epithelium.,BENIGN GASTRIC ULCERThe class,7,Duodenum Ulcer,The 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 for it.,Duodenum UlcerThe lesion most,8,GE Varices,A 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.,GE VaricesA number of cutaneou,9,呕血与便血病理课件,10,呕血与便血病理课件,11,呕血与便血病理课件,12,Clinical manifestation of GI Bleeding,Abdominal discomfort,Nausea,Hemadynamic change:reduction in blood volume(syncope,light-headedness,sweating,therst)or shock,Laboratory changes:HCT,BUN,Clinical manifestation of GI B,13,Hematemesis with other symptoms,Hematemesis with upper abdominal pain,Hematemesis with hepatomegly and spleenomegly,Hematemesis with jaundice,Hematemesis with Skin&mucosa hemorrhage,Hematemesis with upper abdominal mass,Others:NSAIDs,Stress,Burning,Brain operation,Trauma,Vomiting,Hematemesis with other sympto,14,Lab.Examination in Localization&Diagnosis of GI Bleeding,Endoscopy,Barium Radiographs,Angiography,Radionuclide imaging,Lab.Examination in Localizatio,15,Approach to the patient with acute upper gastrintesttinal hemorrhage,Acute upper Gastrointestinal Hemorrhage,Rapid assessment Monitor 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,Definitive therapy,Approach to the patient with a,16,呕血与便血病理课件,17,Summary of Acute GI Bleeding,Upper GI source bleeding-Hemetemesis,Major upper GI bleding-Hemetemesis&hemetochezia,The more distant from the rectum,the more likely that melaena occurs,The colon lesion-FOB,+,or hemetochezia,The small bowl lesion-melena or hemetochezia,Summary of Acute GI BleedingUp,18,The questions should be posed,Prior bleeding episode?,Family history of GI diseases,Dose the patient have the illness of ulcer?,Cirrhosis?cancer?bleeding disorder?,Alcohol?NSAIDs?,Any precedes symptoms or signs?,The questions should be posedP,19,2005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PPIs,静脉大剂量PPIs,内镜检查与治疗,出血征象监测、液体复苏并止血治疗,监护病房,中高危(Rockall评分3分),上消化道出血病情严重度分级(Rockall评分,重复内镜治疗经血管造影介入治疗,手术治疗,原发病治疗及随访,成功,成功,失败,失败,2005年中国急性上消化道出血诊治指南中华内科杂志编委会.,20,失血量的评估,急性非静脉曲张性上消化道出血诊治指南,中华内科杂志：2005.1,.,Palmar KR.Guideline Gut 2002,失血量的评估 急性非静脉曲张性上消化道出血诊治指南,21,出血严重程度评估,急性非静脉曲张性上消化道出血诊治指南,中华内科杂志：2005.1,.,Palmar KR.Guideline Gut 2002,出血严重程度评估急性非静脉曲张性上消化道出血诊治指南,22,急性上消化道出血患者Rockall再出血和死亡危险性评估系统,高危：5，中危：34，低危：02,急性上消化道出血患者Rockall再出血和死亡危险性评估系,23,Endoscopic 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 Mallory-W,24,Endoscopic view of a Dieulafoy lesion on the lesser curvature of the stomach,Endoscopic view of a Dieulafoy