1、馬偕紀念醫院健檢中心主治醫師胃腸內科兼任主治醫師楊安民lNever forget the general principle of internal medicine.Airway,Breathing,CirculationStabilize vital sign and aggressive resuscitation.Well explanation to the family.Acquire thorough history and past medical history.lDifferential diagnosis of GI bleedingUGI&LGI lMake the d
2、iagnosis by yourself!lArrange adequate diagnostic procedure.lEmperical treatment l消化道出血的間接症狀:dizziness,fainting,tachycardia,cold sweating,shock,abdominal fullness,poor appetite,cons.change l一旦懷疑,利用vital sign評估出血量最重耍(occult bleeding or overt bleeding)Orthostatic hemodynamic change 10 to 20%blood loss
3、lDrop in systolic pressure 10 mmHg,raise in pulse rate 15/minSupine hypotension greater than 20%blood loss l定位 UGI or LGI 同時評估 medical treatment or surgical treatmentlGI bleeding vs Non-GI bleeding:吐血 vs.咳血 vs.internal bleedinglDigital exam for collect stoollNG aspiration for DDx UGI and LGIlPES:Pan
4、endoscopy or EGD(esophago-gastro-duodenoscopy):should be perform early in the clinical course after vital sign stable or management.lColonoscopy/rigid sigmoidscopylRBC scan:only in Taipei MMH:0.1cc/min or 6 cc/hourlAngiography:0.5cc/min or 30 cc/hourlEnteroscopy or capsule endoscopylSurgerylNot ever
5、y GI bleeding patient should NPOlPrepare for emergency study or managementlAvoid aspirationlAgain and again:Check vital signlEvaluate NPO or notlIf NPO,IVF supplylArrange laboratory studyCBC,PT,PTT,Blood group and cross match,liver and renal function.lBlood product:Whole blood vs.pack RBC,FFP vs.FP,
6、代用血漿(ex.6HES)lMedication lHow to arrange the study:NG irrigation,Blood sampling,PES,Angiography,Colonofiberscope,RBC scanlOrthostatic hypotension:drop SBP over 10 mmHg,rise in pulse rate over 15 beat/min:blood loose 10-20%lSupine hypotension:more than 20%lShock index:SBP/HRGPT)with hyperbilirubinemi
7、a,History of alcohol abuse.lThe most important of all:STABILIZED THE VITAL SIGN.WELL EXPLAIN TO THE FAMILY on critical,1/3 mortality in each episode.lPharmacological treatment:Glypressin(Terlipressin):1 amp iv stat and q6h.Sandostadin:2 amp iv drip stat and 12 amp in 500 c.c.D5W run 24 hoursPitressi
8、n:20 amp in 480 c.c.D5W or NS(conc.0.8IU/ml),run 12 cc/hr to 54 cc/hr(0.2IU/min to 0.9IU/min),side-effect:chest pain,peripheral cyanosis combine nitrate-Seldom used in recently years lEndoscopic treatment highly operator dependent,high failure rate in acute bleeding,once the procedure succeeded,the
9、outcome is good.Esophageal varices:band ligationGastric varices:Scleosing therapylSB tube trachea intubation first,the effect is not good.lTIPS-transjugular intrahepatic portosystemic shuntlOperation:Shunt surgery lPrecipitating factors of variceal bleeding-treat the precipitating factorSBPSepsisImp
10、ending hepatic failurelEtiology of peptic ulcer diseaseMucosal defensive factor lMucosal barrier to ion diffusionlTwo component mucous barrierlBicarbonate,PhospholipidslLocal mucosal blood flowlProstaglandins,EGFlIntrinsic mechanism that inhibit gastric secretion.lEtiology of peptic ulcer diseaseAgg
11、ressive factorslGastric acid and pepsinlNSAIDslH.PylorilFree radicall上腹疼痛:燒灼感,悶痛,脹痛慢性:患者常會斷斷續續痛好幾年節律性:每天固定時間疼痛,通常空腹時痛週期性:每年固定一個時期發作lEsophagogastroduodenalscopy(EGD)Gastric ulcer and duodenal ulcer lDescription of PUD in EGDStage:A1,A2,H1,H2,ScarSize:the risk of recurrent bleeding increased if greate
12、r than 2 cmLocation:antrum,body,fundus,anterior wall,posterior wall,great curvature side,lesser curvatyre side SRH(Stigmata of recent hemorrhage)Gastritis and Erosion.lVarix:RCS(red color sign)which hint bleeding:red-whale marking,cherry-red spot,active bleeding;CbCw,F321lUlcer:A1-2(active),H1-2(hea
13、ling)and S1-2(scaring);active bleeding vs SRH(stigmata of recent bleeding)lBleeding with unknown causelPPI(losec/nexium,takepron,pariet,):losec 1Amp+NS 50-100 cc drip over 10 min st and q12h;the 1#qdlH2RA(zantac,tazac,famox):Zantac 3 Amp+500cc IVF run 20cc/hr;then 1#bidlSukit/gelfos 1pk q1h x4-6 tim
14、eslSucrate gel 1Pk bid or ulsanic 1#qid(avoid using with antiacid,H2RA or PPI)lTherapeutic endoscopy with bosmin injection,heat probe,hemoclip,laser.lSometimes,surgical intervention still indicatedlHypovolemic shock can not control by medical treatmentlMassive transfusion over 4-6U/8U(2000cc)in 24 h
15、ours or over 10U(2500-5000cc)overalllRecurrent or intractable bleeding after non-surgical treatment lRisk factor for OP:over 60y/o,transfusion over 5 unit,shock,hematemesis with hypotension,coagulopathy,large ulcer over 2 cm,emergency Op,co morbid illness,rebleeding within 72 hoursl一般內科病患需在最短時間內判斷病況
16、是否危急(critical);但面對腸胃科病患時,必須同時找出有緊急手術適應症的患者l判斷是否有緊急檢查的適應症l某些特殊的狀況(ex.Severe pancreatitis,hepatic failure,hypovolemic shock.)處置必須移入ICU處理(ex.SB tube,plasmaphrosis)l檢查前的預備工作lCall GI CR for emergent endoscopy!各護理站皆有on call CR 的電話,若找不到CR,直接找VS,切勿猶豫lHemorrhoid,anal fistula,angiodysplasia,radiation proctiti
17、s/colitis,aortoenteric fistula,tumorlUrgent colonoscopy:difficult due to poor preparationlConsult Proctologist for the surgical interventionlFortunately,most common LGI bleeding may stopped spontaneously.lVery dangerous diagnosis when new patient arrive with this diagnosislParalytic vs Mechanical lN
18、PO in most caseslIVF supplylOverlapping with acute abdomen lSeries F/U the same kind x ray filmlBowel obstruction or pregnancy must exclude first.Besides,extra-abdominal problem(IICP,metabolic problem.)also need exclude.lThe vomitus also help for identified the obstruction level by colorlNG decompre
19、ssion amount is another key for evaluate the degree for obstructionlNovamin(proclorperazine):ADR-drowsiness,acute dystonic reaction,EPS,postural hypotension.lDopamine antagonist-primperan(metoclopramide-EPS is notorious ADR)and motilium(domperidone).Cisparide is not approve in FDA nowlOndansteron(zo
20、fran)and Granisetron(kytril)are 5HT3(serotonin)receptor inhibitor for C/TlThe definition of diarrhea include the BM increase over 3 times per day and the amount increaselAcute diarrhea vs chronic diarrhea:2 weeklNPO is the first step in DDx the secretary and osmotic diarrhea(but IVF supply also indi
21、cated after NPO especially in DM patient)lStool study:stool OB,pus cell and culture when infectious diarrhea is suspected esp.in bacterial infection).PMC need special agar for culture.Ameba and parasite ova in chronic diarrhea also need considered.lDrug may be the most common cause of diarrhea in ho
22、spital(senokot,MgO,antacids,digitalis,quinidine,colchicine,antibiotic.)lPMC(pseudomembranous colitis)must be carefully monitor when antibiotic usinglParasite still need consider esp.in MMH Taitung branch.lMost AGE is caused by virus and self-limiting.lDiarrhea in cancer patients post radiotherapy is
23、 dangerous.lReview the drug sheetlEvaluate the risky sign:BM over 6 times,bloody stool or tenesmus,fever,severe abd pain,dehydrationlHydration by enteral feeding if possiblelSymptomatic treatment with:Kaopetin 15-20 cc/Tannalbin for loose stool,Anti-muscarinics(buscopan-scopolamine,trancolon-mepenzo
24、late,bentyl-dicyclomine,esperan-oxapium),Smooth muscle relaxant(Spasmonal-alverine,Cospanon-Flopropione,Duspatalin-Mebeverine)lImodium 2#stlCodeine and MorphinelAntibiotic in Infectious diarrhea after stool culture and study:FQ and sulfa druglPseudomenbranous colitis or antibiotic-associated colitis
25、lC.difficle is not the only cause lCleocin is most notorious drug.PCN and Cepha got most patient!lDx:scope,toxin,culture(in anaerobic condition)lTx:stop antibiotic,symptomatic control,oral antibiotic(metronidazole,vancomycine),IV antibiotic may be the last choice.Inferon Berna enemalMedication also
26、the main cause of constipation(Calcium channel blocker,opiates,anticholinergic,iron,barium sulfate)lBesides,old age and several disease(DM,hypothyroidism,scleroderma,myotonic dystrophy.)patient also got constipation tendencylIntestinal obstruction must exclude firstlFiber supplementation:Konsyl or N
27、ormacollEmollient laxative:Mineral oillStimulant cathartics:Castor oil,Anthraquinones(senokot 1-2#qhs),Bisacodyl(dulcolax 1-2#qhs or supp)lOsmotic cathartic:Mg citrate,lactulose.lFleet enema lIndication:不能吃,不想吃,吃不下lTime:not over 7 days NPOlHow to order:gradually increase the dose and concentrationlH
28、ow to calculate the water amountlHow to calculate the calori demandlHow to calculate the protein demandlHow to calculate the fat supplylHow to supply the trace element,VitComplication of TPN1.Mechanical problem:caused by CVP insertion2.Chemical problem:BS,electrolyte balance.3.Infection problem4.Oth
29、er problem:GB stasis and stone,LFT impairment,drug interaction lFulminant hepatic failurelHepatic encephalopathylHepato-pulmonary syndromelHepato-renal syndromelPortal hypertensionlAsciteslSBPlCoagulopathylHow to identified the hepatic failure?lPT is more important than AST/ALTlBilirubin also very i
30、mportant parameterlHypoglycemia and hypocholesterol also risky signlCons.Level must evaluate carefully and closelylThe NH3 level is not parallel to cons.LevellVery high mortality if no chance for liver transplantlThe Child-Turcott-Pugh score(A:2.8-3.5,A:slightly,Bil:2-3,Encephalopathy 1-2,PT 4-6)A:5
31、,6;B:7-9;C:10-15lCorrect the precipitating factor:azotemia,tranquilizer,opioid,sedative-hyponotic,GI bleeding,hypokalemia,alkalosis,constipation,infection,diarrhea,porto-systemic shuntlMedication:lactulose po and enema;Neomycine po and enema,Metronidazole po,BCAA chain supply(aminopoly-H)lThe possib
32、ility of intra-cranial lesion must exclude(ex.ICH,SDH,brain tumor)lIntra-pulmonary shunt increaselHypoxialProve by angiography or contrast heart echo.lSimilar to pre-renal azotemialDifficult in DDxlCheck Urine Na lAlso caused by peripherial arteriol dilatationlAcute vs.ChroniclThe kidney is normal!l
33、PE:caput medusa,hemorrhoidlNormal portal presssure:7 mmHg(about 10 cm H2O)lPortal HTN:over 10 mmHg(got S/S if over 12-15 mmHg)lEV or GV bleeding(dependent on which collateral circulation)lAldactone is the first choice for diuretic in LC related asciteslAny LC patient with fever,abdominal pain need s
34、creen the SBPlNeutrophile over 250/ul lE coli,KP and Strep pneumoniae lEmpiric antibiotic:3rd cephalosporine or 1st+aminoglycoside(risk for renal toxicity)lNorfloxcin 400 mg qd can reduce the recurrence for SBPlPT prolong lThrombocytopenialPTT prolong if the condition worsen or complicationlLab data
35、 can not complete exclude or include all caseslCT is most sensitive diagnosis tool in severe pancreatitislHydration is the key point for treatmentlBiliary pancreatitis is more common in Taiwan and female patient.lAlc related pancreatitis is most common cause in USA and increase in TaiwanlHypertrigly
36、cemia vs.DM vs.pancreatitislBiliary pancreatitis need drainage ASAPlRanson criteria and APACHE II:if Ranson over 3 point or APACHE over 5,the patient got severe pancreatitislIdentified the severe vs mild pancreatitis:clinical course(CV,chest,GI,nephro complication),scoring system,CT stagingOn admiss
37、ion:Alcoholic(Non-alcoholic)WBC:16000(18000)Blood sugar:200(220)LDH:350(400)AST:250(440)Age:55(70)During the first 48 hours of admissionFall in hematocrit:10%(10%)Serum calcium:4 mEq/L(5 mEg/L)Increase in BUN:5 mg/dl(2 mg/dl)Fluid sequestration:6L(6L)Arterial PO2:60 mmHg(60 mmHg)Nature course:lAcute renal failure and M.acidosislLung complication(ARDS.)lIleus and GI bleeding l2nd infection of necrotic tissue(2week)lPseudocyst(6weeek)Comparison of the triade:RUQ pain+fever+leucocytosisRUQ pain+fever+jaundice(Charcot triade)+shock+cons change(Raynold pentade)
