上海交大外科學上血pbl

1、上消化道大出血Massive Upper Gastrointestinal Bleeding,上海交通大學醫(yī)學院瑞金臨床醫(yī)學院2009,Introduce Ourselves,Dr. Yang&Dr. Li,Basic Concepts,,What Is Massive Bleeding,>20% (>800ml) blood lossHemodynamic instability血流動力學不穩(wěn)Clin

2、ical signs of poor perfusion組織灌注差,What Is UGI,Esophagus食道Stomach胃Duodenum十二指腸,Jejunum空腸Ileum回腸Ascending Colon升結腸Transverse Colon橫結腸Descending Colon降結腸Sigmoid Colon乙結腸Rectum直腸Anus肛門,,,,,Please Remember,UGIB is no

3、t uncommon in the emergency roomMortality rate is about 10% UGIB is a series of diseases mainly treated by internal medicine.3-15% require a surgical procedure,Let’s have a problem!,,Patient Come,45-yr femalefirst ep

4、isode of hematemesis嘔血transferred from a small hospital2 units of packed erythrocyte紅細胞 tranfusednasogastric tube胃管 introduced with active bleedingpulse 120 bpm, BP 80/40 mmHg,What Is Your Decision,What is your intui

5、tion直覺?,For Reference,Does the patient have life-threatening situation?hypovolemic shock低血容量性休克low body temperature體溫降低anemia/hypoxemia貧血/低氧血癥comorbidities并存病Is it a massive or minor bleeding?Where is the most prob

6、able bleeding site?,Worrisome clinical signs and symptoms,tachycardia心動過速 more than 100 beats per minute (bpm)systolic blood pressure (SBP)收縮壓 ≤ 90mmHgpostural hypotension體位性低血壓 SBP decrease ≥15mmHg or pulse rate incre

7、ase ≥10 bpmcool extremities四肢厥冷syncope暈厥ongoing brisk hematemesis進行性/活躍地嘔血maroon stool棗紅便,Massive or Minor,UGIB or LGIB,,Estimation of Blood Loss,occult blood stool – 5-10ml/24hmelena – 50-100ml/24hhematemesis

8、– 250-300ml in stomachCNS change – >500mlhypovolemia– >1000ml/short period,Child-Pugh Classification,Grade A=5-8 points, Grade B=9-11 points, Grade C= 12-15 points,What Is Your Decision,What are the managem

9、ent priorities優(yōu)先順序 to this patient?,For Reference,Resuscitation復蘇Hemostasis止血Differential diagnosis鑒別診斷Basic disease treatment治療原發(fā)病Comorbidity management處理并存病,Initial Resuscitation,ABCairway保持氣道通暢breathing維持呼吸和供氧c

10、irculation維持循環(huán)bilateral intravenous access (at least)雙路靜脈通路short, large pore短而粗fast fluid replacement快速液體輸入3-for-1 rule: 1ml blood loss, 3ml crystalloid fluidblood transfusion: 2-6 units of packed erythrocyteclose

11、monitoring密切監(jiān)護,Medical Therapy,vasopressin血管加壓素somatostatin or analogs生長抑素或同類物antacid agents制酸劑H2-receptor antagonist H2受體拮抗劑proton pump inhibitor 質子泵抑制劑hemostatic agents & blood coagulation factors止血劑和凝血因子,Naso

12、gastric Tube Introduction,aspiration & lavage吸引和沖洗site of bleedingbile without blood – UGIB not likelygastric fluid & blood – UGIBclear gastric fluid – duodenal bleeding still possiblefalse negative假陰性 appro

13、ximately 10%hemostasis & monitoring止血和監(jiān)控icy saline lavage with epinephrine腎上腺素aspiration color & amountreduce vomiting減少嘔吐, protect the airway,Balloon Tamponade氣囊壓迫,temporary measure during resuscitation (24-

14、48hr)20% complication rateairway obstruction氣道阻塞aspiration誤吸esophagus necrosis食管粘膜壞死arrhythmia心律失常recurrent bleeding after release of balloonfirst inflate gastric balloon to 60mmHg(200ml)then inflate esophagus ba

15、lloon to 40mmHg(150ml)pulling weight 0.25kg using a pulley滑車release for 15min every 4hrs,,,What Is Your Decision,What question would you ask the patient?,For Reference,History of illness病史Precipitating factors誘因Comor

16、bidities并存病,History,history of bleeding出血情況time持續(xù)時間symptoms表現(xiàn)癥狀amount出血量history of related diseasespeptic ulcer消化性潰瘍liver diseases肝臟疾病cholangio-pancreatic diseases膽胰疾病coagulopathy凝血障礙others,Precipitating factors

17、,alcohol abuse酒癮NSAIDs (nonsteroid anti-inflammatory drugs) ingestion非甾體類抗炎藥物應用stress應激: burn injuries – Curling head injuries – Cushing,Frequent Symptoms,Hematemesis嘔血 - 40-50% Melena黑便 - 70-80% Hem

18、atochezia便血 - 15-20% Either hematochezia or melena - 90-98% Syncope暈厥 - 14.4% Presyncope暈厥前期 - 43.2% Dyspepsia消化不良 - 18% Epigastric pain上腹痛 - 41% Heartburn胃灼熱 - 21% Diffuse abdominal pain彌漫性腹痛 - 10% Dysphagia吞咽困

19、難 - 5% Weight loss體重減輕 - 12% Jaundice黃疸 - 5.2%,What Is Your Decision,What is the differential Diagnosis鑒別診斷?,For Reference,Peptic ulcer消化性潰瘍Stress gastritis應激性胃炎Stomach neoplasms胃腫瘤Portal hypertension門脈高壓Hemobilia膽

20、道出血Miscellaneous其他少見原因,Peptic Ulcer,history of chronic ulcerepigastric pain (nocturnal symptoms) 上腹痛（夜間痛）dyspepsia消化不良satiety飽脹history of mucosa damage dietsmokingNSAIDs 非甾體類抗炎藥物Adrenal cortical hormone腎上腺皮質激素u

21、sually melena, sometimes hematemesis,Stress Gastritis,history of stress應激病史burn injurieshead injuriespredisposing clinical conditions可導致應激的臨床情況shock休克multiple trauma多發(fā)傷ARDS (acute respiratory distress syndrome)急性呼吸

22、窘迫綜合征SIRS (systemic inflammatory response syndrome)全身炎癥反應綜合征MODS (multiple organ dysfunction syndrome)多臟器功能障礙綜合征sepsis膿毒癥,Stomach Neoplasms,middle age中年weight loss體重減輕anorexia厭食irregular epigastric pain不規(guī)則腹痛abdomi

23、nal mass腹部包塊,Portal Hypertension,predisposing history of cirrhosis肝硬化基礎疾病hepatitis肝炎Schistosomiasis血吸蟲病alcohol abuse酒癮special features特殊體征jaundice黃疸ascites腹水dilated vein in the anterior abdominal wall腹壁靜脈怒張rectal

24、 hemorrhoids痔,Formation of Portal System,3 inflow vein collect blood from spleen, pancreas, stomach, intestine, colon, and rectumsplenic veinsuperior mesenteric veininferior mesenteric vein2 branches into left &

25、right hepatic lobethrough hepatic sinus to hepatic vein to IVC75% blood supply, 50% oxygen supply of liver,,,Collateral Vascular System側支循環(huán),esophageal-fundus submucosal venous plexus食管下段-胃底交通支rectal hemorrhoidal syste

26、m直腸下段肛管交通支retroperitoneal system后腹膜交通支anterior abdominal wall system前腹壁交通支,,,Definition of Portal Hypertension,normal portal pressure: 13-24cmH2Onormal hepatic vein pressure gradient (HVPG) : 5-9cmH2Oportal hypertens

27、ion: 30-50cmH2OHVPG > 12mmHg leads to UGIB,,,Cause of Hypertension,,,Pathophysiology of Portal Hypertension,splenemegaly & hypersplenism脾腫大/脾功能亢進peripheral total blood count decreasecollateral vascular varix側支靜

28、脈曲張esophageal-fundus submucosal venous plexus has greatest gradient, cause massive UGIBhemorrhoidCaput Medusae海蛇頭ascitescapillary filtration pressure increase毛細血管滲透壓增加hypoalbuminemia低白蛋白血癥excessive lymphatic fluid

29、 generation淋巴液生成過多hyperaldosteronemia高醛固酮血癥 portal gastropathy/encephalopathy門脈性胃病/腦病stomach mucous edema胃粘膜水腫portal systemic shunt門體分流,Caput Medusae,,Hemobilia,hemobilia triad膽道出血三聯(lián)癥biliary colic膽絞痛obstructive jau

30、ndice梗阻性黃疸gastrointestinal bleeding消化道出血liver trauma肝外傷hepatic hemangioma肝血管瘤hepatic neoplasm肝腫瘤hepatic abscess肝膿腫biliary tract stone膽道結石,Miscellaneous,Mallory-Weiss syndrome: linear mucosal laceration near cardia賁

31、門 as a result of forceful vomiting, retching干嘔 or coughing Dieulafoy lesion: vascular malformation in stomachAngiodysplasia血管發(fā)育不良: abnormal dilated, thin-walled mucosal or submucosal vessels粘膜/粘膜下血管,What Is Your Decisi

32、on,What physical examination體格檢查 findings would you search for?,For Reference,Signs of shock and blood lossSigns of chronic liver diseaseSigns of tumor,Shock & Blood Loss,pulse and blood pressure脈率血壓postural hypot

33、ension體位性低血壓mental disorder: anxious焦慮, confusion意識模糊, delirium譫妄, lethargy嗜睡, presyncope暈厥前期, syncope暈厥signs of anemia: pale conjunctiva and nail bed結膜甲床蒼白 signs of poor perfusion: cold extremities四肢厥冷, cold sweating

34、冷汗, oliguria少尿, chest pain胸痛,Chronic Liver Diseases,spider angiomata蜘蛛痣palma erythema肝掌gynecomastia男性乳房發(fā)育splenomegaly脾腫大ascites腹水pedal edema足部水腫asterixis撲翼樣震顫Caput Medusae海蛇頭,Tumor,upper abdominal mass上腹包塊left su

35、praclavicular lymph node (Virchow’s node)左鎖骨上淋巴結腫大umbilical nodular (Sister Mary Joseph’s node)臍周結節(jié)Douglas pouch nodular (Bloomer’s shelf)直腸子宮（膀胱）陷凹結節(jié),What Is Your Decision,What diagnostic studies would you order?,For

36、Reference,Complete blood count (CBC)全血細胞計數(shù)Blood cross match交叉配血Coagulation profile凝血功能Liver & Renal function肝腎功能Calcium level血鈣Gastrin level血胃泌素CT scan計算機斷層掃描 or Ultrasonography超聲檢查Digital Subtraction Angiogra

37、phy (DSA)數(shù)字減影血管造影Endoscope內鏡,Endoscopic Explore,diagnosis & treatment診斷/治療雙重作用most reliable & effective method最可靠最有效within 24-48hrs after bleeding應在出血后24-48小時內進行contraindication反指征hemodynamic instablility血流動

38、力學不穩(wěn)定severe cardiac decompensation嚴重心功能失代償acute myocardial infarction急性心肌梗塞perforated viscus臟器穿孔,,,Ulcer with Black Spot10% Rebleeding,,Ulcer with Blood Clot22% Rebleeding,,Ulcer with Visible Vessel43% Rebleeding,,

39、Ulcer with Active Bleeding55% Rebleeding,,,Esophagus Varices,,,,,Hypertensive Portal Gastropathy,Injection of Sclerosant硬化劑,,Band Ligation皮圈套扎,,Hemoclip止血夾,,Laser Application激光止血,,Heater Probe加熱探針,,What Is Your Decision

40、,What are the therapeutic options for each common etiology病因 of massive UGIB after initial resuscitation?,For Reference,MedicineEndoscopeSurgery,Non-Variceal Bleeding,therapeutic endoscope with/without medicineif effe

41、ctive then continue drug therapyeradication of H. pylorimucous protection2 attempts of endoscopic failure pursue surgeryother surgical indicationssevere life-threatening bleeding not responsive to resuscitationcoex

42、isting reason of perforation,obstruction or malignanciessecond hospitalization of peptic ulcer,Variceal Bleeding,drug therapy with/without balloon temponadeendoscopic binding or sclerotherapytransjugular intrahepatic

43、portosystemic shunt (TIPS) 經(jīng)頸靜脈肝內門體分流術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 tem

44、porary method before transplantationChild A & B – surgeryChild C – transplantation,TIPS,,8-12mm,,What Is Your Decision,How to perform the operation?,For Reference,Exploration探查Hemostasis止血Radical Operation根治,Expl

45、oration Sequence,most popular site: stomach & duodenum胃十二指腸cirrhosis or not: liver and spleen肝脾gallbladder and common bile duct膽道系統(tǒng)upper portion of jejunum上段空腸,Non-Variceal Bleeding,peptic ulcer or stress gastriti

46、s消化性潰瘍和應激性胃炎vagotomy迷走神經(jīng)切除術gastrectomy胃切除sewing of bleeding ulcer潰瘍縫扎stomach neoplasm胃腫瘤gastrectomy胃切除hemobilia膽道出血self-limited, seldom needs operation自限性，很少需要手術,Variceal Bleeding,emergency: devascularization proc

47、edure斷流術splenectomy脾切除gastroesophageal devascularization胃底食管血管離斷esophageal transection食管下段橫斷Child A/B: decompressive shunt分流術total portal systemic shunt非選擇性分流excellent control of bleeding止血效果好40-50% encephalopathy

48、肝性腦病發(fā)生率高selective portal systemic shunt選擇性分流maintain portal flow to liver保持門脈入肝血流10-15% encephalopathy肝性腦病發(fā)生率低produce ascites可產生腹水Child C: transplantation肝移植,Esophageal Transection,,Porto-Cava Shunt,,Distal Splenore