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1、DefinitionHematemesis :Bloody vomitus from the upper gastro-intestinal(GI) tract（before the ligament of Treitz)Hematochezia: bright red , maroon or black blood from the rectumesophageal varicesgastric cancerOther causes of upper GI bleedingMallory-Weiss tear食道食道 - 贲门撕裂伤贲门撕裂伤n Foreign body in esophag
2、usn 食管异物食管异物n Ancylostomiasis 钩虫病钩虫病n Post-sphincterotomy 1. 括约肌切开术后括约肌切开术后 nDifferentiationn Nosebleeding?n Hemoptysis? n Differntiating hemoptysis and hematemesisHemoptysisHematemesisCause of diseaseTB, bronchiectasis, pneumonia, lung cancer,heart diseasePU, liver cirrhosis, acute erosive and hemo
3、rrhagic gastritisSyptom before bleedingitch of laryngeal, dyspnea, coughepigastric discomfort, nausea and vomitManner of bleedinghawkvomit , spurtingBlood colourfresh redmaroon, coffee-groundMixture in bloodsputumfoamfood debrisgastric juicePower of hydrogenalkalityacidityMelenanohaveSputumwith bloo
4、dy sputumno sputumManner of bleeding presentationn(B)Hematochezia 便便 血血n Character u bright red or maroon blood from the rectumu pure bloodu blood intermixed with formed stool u bloody diarrhean(C) Melena 黑黑 便便n Charactern Shiny, black, sticky, foul-smelling stool n Tarry stool(柏油样便柏油样便)(degradation
5、 of blood)n Differentiation n exogenous stool darkeners :n animal blood, iron , bismuth (铋剂铋剂) Manner of bleeding presentationManner of bleeding presentationn(D) Stool with occult blood 隐血便隐血便n Detected only by testing the stool nwith a monoclonal antibody for human nhemoglobin Estimate amount of bl
6、eeding from upper GI tractn 510 ml/d OB +n 5070 ml/d Melena n250300 ml in short time Hematemesis Causes of bleeding Colorectal cancer Colitis Large hemorrhoid 大痔大痔 Rectum tear 肛裂肛裂 Vascular anomalies Hematologic diseasesManner of bleeding presentation (E) without any objective sign of bleeding , wit
7、h symptoms of blood lossn n 1. Hypovolemia or shockDepending on speed and volume of blood loss1000mL: Weakness, giddiness (眩晕眩晕), tachycardia(心动过速心动过速) , cold extremity, sweatingShock: hypotention (低血压低血压), oliguria, (少少尿尿)n2. Anemia and hemogram changingn If blood loss is acute, the hematocrit (红细红
8、细胞比容胞比容)dose not change during the first few hours after hemorrhage n About 24 to 72 hours later, plasma volume is larger than normal and the hematocrit is at its lowest point bleeding slowly hypochromic (血红蛋白过少血红蛋白过少) microcytic (小细胞小细胞) red blood cells mean corpuscular volume (MCV， 平均血球压积平均血球压积) o
9、f the cells may be low 7 6 5 4 3 2 1Volume (Liters)45%45%27%ABCHematocrit changesA Before bleedingB Immediately after bleedingC 2472 hours after bleeding3.Feverlow grade fever in 24 hours after bleeding4. Azotemia(氮质血症氮质血症) Degradation of protein in intestinal tract BUN in several hours after bleedi
10、ng up to the peak in about 24-48 hours normal after 3-4days 5. Bowel sound Active bowel sound usually be presented in acute bleeding from GI tract Where is the source of bleeding? LocalizationnUpper GI bleeding: bleeding from a source proximal to the ligament of TreitzLower GI bleeding: bleeding fro
11、m a site distal to the ligament of Treitz LocalizationnDifferentiating features of upper GI and lower GI bleedingUpper GILower GIManifestationHematemesisHematocheziamelenaNasogastric aspirateBloodyClearBUNElevatedNormalBowel soundHyperactiveNormalUpper GI tract bleeding ?Clinical manifestation (hema
12、temesismelena)Bowel soundNasogastric tubeHematemesisMelenaHematocheziaMore proximal lesions produce hematemesis or melena, whereas more distal lesions are more likely to produce hematocheziaDiagnostic approach 1. History and physical examination2. Laboratory examination3. Auxiliary examinationHistor
13、y and physical examinationn A history of previously documented GI tract disease determined by radiography, endoscopy, or surgical procedures is very usefulDiagnostic approach to GI bleedingDiagnostic approach to GI bleedingn A history of epigastric (上腹部上腹部) burning pain promptly relieved by food or
14、antacids (抗酸剂抗酸剂) or nocturnal (夜间夜间) pain suggests peptic ulcer disease, particularly duodenal (十二指肠十二指肠) ulcerDiagnostic approach to GI bleedingn Patients with stigmata (特征特征) of hepatitis B or other chronic active liver disease e.g spider angioma (蜘蛛痣蜘蛛痣), ascites (腹水腹水), gynecomastia (男性乳男性乳房发育房
15、发育) may present with painless hematemesis from esophageal varicesDiagnostic approach to GI bleedingn Patients with forceful, retching (干呕干呕)or multiple episodes of vomiting of food prior to the onset of hematemesis may be bleeding from MalloryWeisstears of the gastro-esophageal junctionDiagnostic ap
16、proach to GI bleedingnA history of n gradual weight lossn intermittent blood in the stoolsn altered bowel habitsnoften suggests colorectal malignancy Diagnostic approach to GI bleedingn Hemorrhoidal bleeding is often suggested by the presence of bright red blood surrounding well-formed, normal-appea
17、ring stoolsDiagnostic approach to GI bleedingn A rectal examination is essential to document stool color as well as to palpate for gross anorectal (肛直肠肛直肠) mass lesions such as polyps(息肉息肉), cancers, or large hemorrhoids.Diagnostic approach to GI bleedingAuxiliary examinationnEndoscopy (内镜内镜)n Endos
18、copy is the diagnostic procedure of choice because of its high accuracy and immediate therapeutic potential. n Endoscopy , however , must be performed only following adequate resuscitation (复苏复苏)Diagnostic approach to GI bleedingnBarium radiography (钡餐钡餐)n Barium radiography is noninvasivenbut has s
19、ignificant disadvantages, nparticularly in patients who are bleeding nactivelyDiagnostic approach to GI bleedingnAngiography (血管造影血管造影)n Angiography may localize the site of bleedingn Bleeding must be active because angiography detects only extravasation (外外渗渗) of contrast (造影剂造影剂) into the GI tractIs bleeding acute or chronic?Intensive careWhere is the source of bleeding?Empiric therapyDiagnosisTreatment( ( 经验治疗经验治疗 ) )What is the causes of bleeding?Recognition of hemorrhage Diagnostic approachQuestions1. 名词解释名词解释: 呕血呕血 便血便血 隐隐血便血便2. 呕血最常见原因有哪些呕血最常见原因有哪些?(至少至少4种种)44 结束语结束语