上消化道出血(修改)VIP专享VIP免费

上消化道出血乐亭县医院洪素妹简介上消化道出血上消化道出血::TreitzTreitz韧带以上的消化道引起的韧带以上的消化道引起的出血出血::食管食管,,胃胃,,十二指肠十二指肠,,胰胰,,胆胆,,胃空肠吻合胃空肠吻合术后的空肠病变术后的空肠病变下消化道出血下消化道出血::TreitzTreitz韧带以下的消化道引起的韧带以下的消化道引起的出血出血上消化道出血引起的大量出血较下消化道更为常上消化道出血引起的大量出血较下消化道更为常见见大量出血大量出血::短期内失血超过短期内失血超过10001000mlml或循环血量或循环血量220%0%常见病因消化性溃疡消化性溃疡((十二指肠和胃十二指肠和胃)33-51%)33-51%食管和胃静脉曲张食管和胃静脉曲张23-33%23-33%Mallory-WeissMallory-Weiss综合征综合征3-10%3-10%胃或十二指肠糜烂胃或十二指肠糜烂1-1-19%19%血管瘤血管瘤0-7%0-7%肿瘤肿瘤1-5%1-5%Withtheinvertedgastroscopeaspurtinghemorrhagefromafundalvariceisdiscerbnable.HemostasisisachievedwithseverallowvolumeinjectionsofHistoacryl-glue.Therightpictureshowsthetherapeuticsuccess.Therearebloodcoverederrosionsthroughoutthewholestomach.ThishasledtoaupperGIhemorrhagecompromisingthepatienthemodynamically.Thesolereasonwasasingleingestionof400mgofibuprofenThismassivevesselwithactivebleedingwasdiagnosedina58year-oldpatient,whopresentedwithtarystools.Thefirstpictureshowsthelesionafterinjectionoffibringlue.Therightpictureshowsadditionallyappliedhemoclips.Bleedingstoppedattheendoftheprocedure,butreccurredtwicebeforethepatienthadtobetreatedsurgically.Indieu-la-foyulcersanarterialvesselofabnormalsizereachesthemucosacausingatinyulzerationbypermanentcompressionofthemucosallayer.EsophagealvaricesgradeII(right)undgradeIII(left).Cherryredspotsaresignsofimminenthemorrhage(right).Theycorrespondtoareasofespeciallythinandalteredvaricealwall.Thisduodenalulcerattheleftedgeofthefigure,showsanoozing,activebleeding.AccordingtotheForrestclassificationofgastrointestinalhemorrhageoftheupperGI-tract,thisbleedingisgradedasForrestIb.Thevisiblevesselistreatedbyprimaryapplicationofahemoclip.Atthe3weekfollow-up(fig)theClipisstillintheoriginalposition.Theulcershowsaprogressivehealing.Inoperablecholedochalcancer.Awallstenthadbeeninserted3monthsearlier.Thepatientwasadmittedforseverehemorrhage,whichwasendoscopicallyprovedtooriginatefromthebiliaryduct.Thehemorrhagewasnotamenabletoendoscopyandsurgery.Hugebloodclotsprolapsefromthebiliaryduct.临床表现呕血与黑粪失血性周围循环衰竭血象变化发热氮质血症失血量和休克的估计诊断思路是上消化道出血吗?出了多少血?出血停止了吗?什么原因引起的出血?上消化道出血的确立呕血和黑粪,失血性周围循环衰竭,血和粪便的检查早期识别:直肠指诊排除消化道以外的病因:咯血、口鼻咽出血、事物或药物出血量的估计•粪便隐血试验阳性每日消化道出血＞5~10ml•黑粪50~100ml•呕血250~300ml•出现全身症状400~500ml•周围循环衰竭＞1000ml最有价值的标准:周围循环衰竭的临床表现动态观察血压和心率出血是否停止继续出血或再出血的表现:•反复呕血或黑粪•周围循环衰竭经治疗后无改善或波动•Hb\RBC继续下降,Ret持续升高•补液与尿量足够的情况下,血尿素氮持续或再次升高出血后48小时以上未再继续出血,再出血可能性小;既往有大出血史、本次出血量大、24小时内反复大量出血、食管胃底静脉曲张出血、有明显的高血压或动脉硬化者,再出血可能性大出血的病因病史实验室检查胃镜:首选;推畅急诊胃镜检查(24~48hr)X线钡餐其他:选择性动脉造影治疗原则:抗休克,积极补充血容量一般的急救措施:禁食,卧床休息,保持呼吸道通畅严密监测生命体征积极补充血容量:立即配血,输足量全血紧急输血指征:改变体位出现晕厥,血...