呕血的诊断(英文版)

HEMATEMESIScaiqiao yinDepartment of Gastroenterology, Affiliated Minda HospitalMedical College, Hubei University for NationalitiesThe Gastrointestinal System GI tract consists of a hollow muscular tube starting from the oral cavity, going through the rectum and is ended at the anus, where food is expelled. The main function of the GI tract is digestion and absorption of nutrients The movement of the smooth muscles in the GI is called peristasis and propels food in the forward direction Accessory organs that assist the tract by secreting enzymes to help break down food into its component nutrients (salivary glands, liver, pancreas and gall bladder) The Gastrointestinal System digestive tract Starts at mouth pharynx esophagus stomach small intestine large intestine rectum ends at anus digestive gland salivary glands, liver, pancreas gall bladder The Gastrointestinal SystemDigestive and absorptive process take place in the GI tractGastrointestinal Problemsupper gastrointestinal tract disorderDysphagiaNauseaVomitinghematemesishematocheziamelena .lower GI tract hematochezia.jejunumduodenumsuspensory ligament of duodenumduodenojejunal flexureupper gastrointestinal tractlower gastrointestinal tract definition of hematemesis and melaena hematemesis- is vomiting of blood.which can be fresh and red,or degraded by gastric pepsin,when it is dark brown in colour and resembles coffee grounds. melaena-is the passage of tarry,shiny black stools with a characteristic odour and results from upper gastrointestinal bleeding . colour of hematemesis colour of hematemesis depends on the amount and character of the gastric contents at the time blood is vomited and on the length of time the blood has been in the stomach. bright red blood -the source of bleeding is above the gastroesophageal sphincter,e.g.from esophageal varices,actively vomited. Bright red blood in the vomit indicates a fresh hemorrhage and little contact of the blood with gastric juices brownish/ dark brown (coffee-ground) Gastric acids change bright red blood to a brownish color and the vomit is often described as “coffee-ground” in color.colour of melaena colour of melaena is tarry,shiny black stoolsdistinguish melaena from the matt black stools associated with oral iron or bismuth therapy. OB(-) hemoglobin 血红蛋白 胃酸作用 转变为 酸化正铁血红蛋白血红蛋白 细菌作用 所含铁转变为硫化铁amount of hematemesis and melena Evaluation of bleeding amount 5-10ml OB(+) 50-100ml Melena 250-300ml Hematemesis / Hematochezia 400-500ml Symptoms of hypovolemic shock (low circulating blood volume) dizziness, pale complexion, cold sweats, acromegaly damp , dry mouth dysphoria, less urine 1000ml hemorrhagic shock ,SBP90mmHg,P120bpm (20%-30% Systemic circulation blood volume) Causes of hematemesis 1.upper gastrointestinal tract disease peptic ulcer esophagitis,gastritis,duodenitis Mallory -Weiss esphageal tear esophageal varices esophageal or gastric malignancy(cancer) vascular malfomation .2.others:nose bleeding hematological system diseases uremia Diseases of the body system thrombolytics and anticoagulants . vVarises Varises esofagus Varises fundus Dieulafoy haemangiomasv Non varises esofagitis,gastritisduodenitis peptic ulcer Stress ulcer Mallory-Weiss tear Tumor / CarcinomaCauses of hematemesis The most common causes of hematemesis are: peptic ulcer, gastritis, esophageal varices or lesions, and cancer of the stomach. Benign tumors, traumatic postoperative bleeding, and swallowed blood from points in the nose, mouth, and throat can also produce hematemesis. Mallory-Weiss syndromeMallory-Weiss syndrome: bleeding tears in the esophagal mucosa, usually caused by prolonged and vigorous retching.Tumors of esophagus.gastric ulcer (GU)Dieulafoy diseasealcoholdrug: NSAID/steroidsHelicobacter pylorihelicobacter pyloriganstric canceracute erosive and hemorrhagic gastritisalcoholdrug NSAID steroids thrombolytics and anticoagulantsNSAID-induced hemorrhagic gastritis duodenal ulcer( DU)Vascular malfunctions of the gastrointestinal tract, such as bleeding gastric varices or duodenum varicesprediction of the risk of mortality in patients with upper GI bleeding -Rockall Score criterion score age : 60/60-79/ 80 0 1 2shock : none/pulse 100 bpm SBp100mmHg /SBp 100mmHg 0 1 2comorbidity :none/heart failure/ischaemic heart disease or other major disease/ renal failure or disseminated malignancy 0 2 3endoscopic findings:Mallory-Weiss tear and no visible bleeding/all other diagnoses/upper gastrointestinal malignancy 0 1 2major stigmata of recent haemorrhage:none/visible bleeding vessel or adherent clot 0 2 total score pre-endoscopy score 4=25% mortality (maximum score=7) pre-endoscopy postendoscopy score 8+=40% mortality (maximum score=11) postendoscopyprediction of the risk of mortality in patients with upper GI bleeding -Rockall Score differential diagnosis hemoptysis - is spitting or coughing of blood,the bleeding lesions may be anywhere from nose to lung. hemoptysis hematemesis pathogenesis respiratory tract disease upper GI tract disease (causes) bronchitis /pneumonia) PU/ liver cirrhosis/ cancer tuberculosis/carcinoma gastritis/ esophageal varices heart failure bleeding disorder complaints larynx(throat) itch abdominal discomfortable (before bleeding ) chest pain/ distress,cough nasea ,vomit style of bleeding spitting/coughing out vomiting out PH alkline 7 acidity7 melena - + + sputum after bleeding + - + clinical occurance symptoms-history takingdepend on the amount and speed of bleeding chief complaints:hematemesis / melena/ Hematochezia accompany complaints:abodominal pain/dizzy/sweat / conscious/short of breath/ past history: Is there a previous history of PU or liver disease? Is there a history of alcohol,NSAID or corticosteroid ingestion? Did the vomitus comprise fresh blood or coffeeground-stained fluid? Was the hnatemesis preceded by intense retching? Was blood stainning of the vomitus apparent in the first vomit? clinical occurance physical examination (signs)Vitals : T, P,R,Bp (Tachycardia, hypotension) Skin examination jaundice/ spider naevi/caput medusae/palmar erythema/mucotutaneous hemorrhage pallor/hydration/edma palmar erythemadistended veinsclinical occurance physical examination (signs) Abdominal examination inspection:scars/swellings/distended veins/varices of abdominal wall palpation:tnderness/hepatomegaly/splenomegalypercussion:ascitesausculation:bowel sounds/bruits clinical occuranceLaboratory examinationblood routine examination (RBC/hemoglobin/Hct/WBC /PLT count)coagulation function: PT/APTTliver function: TBil(total bilirubin) : direct bilirubin (DBIL), indirect bilirubin(IBIL) albumin enzymology (AST/ALT/GGT/ALP)renal function: BUN and creatinine clinical occurance endoscopy examination clinical occurance diagnosis history taking -complaints physical exaimation-signs Laboratory examination endoscopy examinationClinical Scenario67 yo M with history of HTN and osteoarthritis who presents to the ED with 3 episodes of coffee ground emesis today. No abdominal pain, melena or hematochezia. No history of liver disease or coagulopathy, +occasional ETOH use.Medications include HCTZ, Lisinopril, and Ibuprofen PRN for joint pain VS on arrival: T 37, HR 102, BP 108/72, similar BP standing , Pox 99% RAExamination: AOx3. No scleral icterus. Abdomen soft, non-tender, no HSM. Rectal with dark brown stool, guiac +. Labs: Hgb 9.8, Plt 245, INR 1, LFTs nl, BUN 28/Cr 1.4. What is the likely etiology of the bleeding?Clinical Scenario conculsion 67yo M on NSAIDS with 3 episodes of coffee ground emesis, anemia, and tachycardia What is the likely etiology of the bleeding? Suspect peptic ulcer disease or gastritissummary- Learning Objectives the definition of hematemesis is vomiting of blood.which can be fresh and red,or degraded by gastric pepsin,when it is dark brown in colour and resembles coffee grounds. the major causes of hematemesis The most common causes of hematemesis are peptic ulcer, gastritis, esophageal varices or lesions, and cancer of the stomach evaluation of hematemesis and melena-colour/amount/accompany complaints/past history/physical examination differentitation of hematemesis and hemoptysis