1、1Hemetamesis and Hemetochezia(Acute GI Hemorrhage)2Five Ways of GI Bleeding4Hematemesis：vomitting of blood of altered blood（coffee grounds）indicates bleeding proximal to ligament of Treitz4Melena：Tarry stool.Altered（black）blood per rectum（60ml）4Hematochezia：Bright red or maroon rectal bleeding impli
2、es bleeding beyond Lig.T.*4FOB+and Iron deficiency anemia3Factors affect the way to manifest4Site of bleeding 4Speed of bleeding4Amount of blood loss4Flora of enterocolon.4Differentiating Upper from Low GI Bleeding4Hematochezia usually represents a lower GI source bleeding4Upper GI lesion may bleed
3、so briskly that blood doesnt remain in bowl long enough to become melena 4Bleeding lesion distal to T Lig.may be either M.or hematochezia,but never manifests hematemesis 5 Peptic ulcer；Gastropathy（alcohol，aspirin，NSAIDs，stress）；GE varices；Gastric cancer6Less common cause of up GI bleedingEsophageal
4、or intestinal neoplamEsophagitis；Malloy-weiss tear，Hemoptysis:Swallowed bloodAnticoagulant fibrinoloytic therapy:Telangiectases；aneurysm；vasculitis；Dieulafoy ulcer；AV malformationConnective tissue disease；Hemabilia（biliary origin；Crohns disease；amyloidosis,hematological diseases7BENIGN GASTRIC ULCER
5、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
6、 any site in the stomach,but are commonest on the lesser curve away from acid-secreting epithelium.8 Location of benign gastric ulcers in relationship to the distance from the pylorus.The majority of benign ulcers will be found on the lesser curvature within 3 cm of the angulus.910Duodenum Ulcer4The
7、 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.11Bleeding From EV4A number of cutaneous features(stigmata)may develop in a patient with cirrhosis,and
8、these are important as they aid clinical recognition of chronic liver disease.12131415Bleeding Survey:Endoscopic Findings in 214 Patients With Clear Nasogastric AspiratesFINDING NUMBER OF PATIENTS INCIDENCE(%)Duodenaal ulcer 64 29.8Gastric erosions 57 6.5Gastric ulcer 47 21.9Esophagitis 23 10.7Duode
9、nitis 21 9.8Varices 11 5.1Mallory-Weiss tear 10 4.7Neoplasm 8 3.7Stomal ulcer 7 3.3Esophageal ulcer 2 0.9Telangiectasia 0Other 18 8.416Clinical manifestation of GI Bleeding4Abdominal disconfortNausea,4Hemadynamic change:reduction in blood volume(syncope,light-headedness,sweating,therst)or shock4Labo
10、ratory changes:HCT,BUN17Hematemesis with other symptoms4Hematemesis with upper abdominal pain4Hematemesis with hepatomegly and spleenomegly4Hematemesis with jaundice4Hematemesis with Skin&mucosa hemorrhage4Hematemesis with upper abdominal mass4Others:NSAIDs,Stress,Burning,Brain operation,Trauma,Vomi
11、ting 18Lab.Examination in Localization&Diagnosis of GI Bleeding4Endoscopy4Barium Radiographs4Angiography4Radionuclide imaging19Approach to the patient with acute upper gastrintesttinal hemorrhage Acute upper Gastrointestinal Hemorrhage Rapid assessment Monitor hemodynamic status Fluid resuscitation
12、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 2021Endoscopic view of a Mal
13、lory-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).22Endoscopic view of a Dieulafoy lesion on the lesser curvature of the stomach23Endoscopic view of a vascular ectasia(angiodyspl
14、asia)in the duodenum.24Endoscopic view of the gastric antrum with watermelon stomach.The pylorus is at top center.Note the linear distribution pattern of the vascular lesions arranged radially around the pylorus.25Endoscopic views of ulcers with stigmata of recent hemorrhage.A,Duodenal ulcer with a
15、visible vessel.B,Gastric ulcer with a red spot in the center of the crater.C,Duodenal ulcer with a red spot in the center of the crater.D,Purplish clot adherent to a gastric ulcer.2627Typical picture of a trivial nonsteroidal anti-inflammatory drug(NSAID)-induced injury to the gastric mucosa.There a
16、re multiple small erosions with brown-black staining of the center as a result of local bleeding and petechiae.28Typical round gastric ulcer at the angulus(incisura)of the stomach.29ESOPHAGUS STOMACHDUODENUMJEJUNUM ILEUMCOLORECTUMEsophageal varicesAV malformationsAngiodysplasiaEsophagitisAngiodyspla
17、siaAV malformationsGastritisUlcersUlcerative colitisGastric varices AnastomoticDiverticulosisMallory-Weiss tears SimpleCancerPeptic ulcerDiverticulaPolypsAV malformationsMeckelsHemorrhoidsCancerAcquiredAnal fissurePolypsCrohns diseaseStomal varicesLeiomyomaVaricesPostoperativeSarcomaIschemic ulcerPo
18、stpolypectomyBrunners adenomaTuberculosisAnastomoticAngiodysplasiaArteritisTraumaPancreatic restBlind loopUlcersTraumaAngiomaSimplePostoperativeLeiomyomaStercoralRetained ulcerCancerTyphoidResidual gastritisSarcomaAmebicAnastomotic ulcerPolyps Uremic ulcer Stomal varices Lymphoid hyperplasia TraumaC
19、auses of Low GI Bleeding 30Differentiating Upper from Low GI Bleeding4Hematochezia usually represents a lower GI source bleeding4Upper GI lesion may bleed so briskly that blood doesnt remain in bowl long enough to become melena 4Bleeding lesion distal to T.Lig.may be either M.or hematochezia,but nev
20、er manifests hematemesis 31Hematochezia with other symptoms4Abdominal pain4Fever4Tenesmus4Systemic Hemorrhage 4Dermal sign4Abdominal mass32Lab.Examination For detecting Low GI Bleeeding4Anoscopy&sigmoidoscopy4Barium Edema(BE)4Angiography4Radionuclide scanning333435A,Linear ulcers of Crohns colitis.B
21、,Mucosa surrounding the ulcers is nodular(cobblestoning).36Shigella colitis.Patchy areas of erythema,spontaneous bleeding,and loss of the normal vascular pattern are evident37Salmonella colitis.Diffuse erythema,spontaneous bleeding,and loss of the vascular pattern with formation of telangiectasis ar
22、e present.38Tuberculosis.Linear ulceration runs circumferentially along the interhaustral septum with tiny satellite ulcerations.This must be distinguished from the longitudinal linear ulcerations seen in inflammatory bowel disease.39Pseudomembranous(antibiotic-associated)colitis.Numerous elevated y
23、ellowish plaques are present on the mucosal surface.40Amebiasis.Discrete punched-out ulcers are present in the right colon.41Severe acute ulcerative colitis.No vascular pattern is discernible.A severe degree of spontaneous bleeding is present42Large colonic ulcer in a patient with ischemic colitis.4
24、3Advantage colon carcinoma44Barium enema appearance of an ischemic stricture with features of carcinoma:asymmetry,mucosal destruction,and shouldering.45Summary of Acute GI Bleeding4Upper GI source bleeding-Hemetemesis4Major upper GI bleding-Hemetemesis&hemetochezia4The more distant from the rectum,the more likely that melaena occurs4The colon lesion-FOB+or hemetochezia4The small bowl lesion-melena or hemetochezia
