1、呕血与便血呕血与便血Hematemesis and HematocheziaDefinitionHematemesis:Bloody vomitus from the upper gastro-intestinal(GI)tract（before the ligament of Treitz)Hematochezia:bright red,maroon or black blood from the rectumTreitz:The ligament of Treitz is an anatomic landmark for the duodenal-jejunal junctionClini
2、cal Manifestation1 Manner of bleeding presentation2 Hypovolemia(低血容量)or shock3 Anemia(贫血)Patients manifest blood loss(A)Hematemesis 呕呕 血血 Character Bloody vomitus,either fresh and bright red or older and “coffee-ground”(hematin 酸化正铁血红素酸化正铁血红素)Manner of bleeding presentationfrom the GI tract in five
3、ways:cause of disease90%upper GI bleeding is due to four lesions:1)peptic ulcer (消化性溃疡消化性溃疡)2)esophageal or gastric varices (食管胃底静脉曲张破裂食管胃底静脉曲张破裂)3)hemorrhagic gastritis (急性糜烂性出血性胃炎急性糜烂性出血性胃炎)4)gastric cancerpeptic ulcerhemorrhagic gastritisesophageal varicesgastric cancerOther causes of upper GI bl
4、eedingMallory-Weiss tear食道食道-贲门撕裂伤贲门撕裂伤 Foreign body in esophagus 食管异物食管异物 Ancylostomiasis 钩虫病钩虫病 Post-sphincterotomy 括约肌切开术后括约肌切开术后 Differentiation Nosebleeding?Hemoptysis?Differntiating hemoptysis and hematemesisHemoptysisHematemesisCause of diseaseTB,bronchiectasis,pneumonia,lung cancer,heart dis
5、easePU,liver cirrhosis,acute erosive and hemorrhagic gastritisSyptom before bleedingitch of laryngeal,dyspnea,coughepigastric discomfort,nausea and vomitManner of bleedinghawkvomit,spurtingBlood colourfresh redmaroon,coffee-groundMixture in bloodsputumfoamfood debrisgastric juicePower of hydrogenalk
6、alityacidityMelenanohaveSputumwith bloody sputumno sputumManner of bleeding presentation(B)Hematochezia 便便 血血 Character u bright red or maroon blood from the rectumu pure bloodu blood intermixed with formed stool u bloody diarrhea(C)Melena 黑黑 便便 Character Shiny,black,sticky,foul-smelling stool Tarry
7、 stool(柏油样便柏油样便)(degradation of blood)Differentiation exogenous stool darkeners:animal blood,iron,bismuth(铋剂铋剂)Manner of bleeding presentationManner of bleeding presentation(D)Stool with occult blood 隐血便隐血便 Detected only by testing the stool with a monoclonal antibody for human hemoglobin Estimate a
8、mount of bleeding from upper GI tract 510 ml/d OB +5070 ml/d Melena 250300 ml in short time Hematemesis Causes of bleeding一一 Colorectal cancer二二 Colitis三三 Large hemorrhoid 大痔大痔四四 Rectum tear 肛裂肛裂五五 Vascular anomalies六六 Hematologic diseasesManner of bleeding presentation(E)without any objective sign
9、of bleeding,with symptoms of blood loss 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)2.Anemia and hemogram changing If blood loss is acute,the hematocrit(红细红细胞比容胞
10、比容)dose not change during the first few hours after hemorrhage 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)of the cells may
11、 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 bleeding up to the peak
12、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?LocalizationUpper GI bleeding:bleeding from a source proximal to the ligament of TreitzLower GI bleeding:bleeding from a site distal to the
13、ligament of Treitz LocalizationDifferentiating features of upper GI and lower GI bleedingUpper GILower GIManifestationHematemesisHematocheziamelenaNasogastric aspirateBloodyClearBUNElevatedNormalBowel soundHyperactiveNormalUpper GI tract bleeding?I.Clinical manifestation (hematemesismelena)一一 Bowel
14、sound二二 Nasogastric 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 examinationHistory and physical examin
15、ation 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 bleeding A history of epigastric(上腹部上腹部)burning pain promptly relieved by food or antacids(抗酸剂抗酸剂)or nocturna
16、l(夜间夜间)pain suggests peptic ulcer disease,particularly duodenal(十二指肠十二指肠)ulcerDiagnostic approach to GI bleeding 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发育)may present with painless hematemesis f
17、rom esophageal varicesDiagnostic approach to GI bleeding 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 approach to GI bleedingA history of gradual weig
18、ht loss intermittent blood in the stools altered bowel habitsoften suggests colorectal malignancy Diagnostic approach to GI bleeding Hemorrhoidal bleeding is often suggested by the presence of bright red blood surrounding well-formed,normal-appearing stoolsDiagnostic approach to GI bleeding A rectal
19、 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 examinationEndoscopy(内镜内镜)Endoscopy is the diagnostic procedure of choice because of its high
20、accuracy and immediate therapeutic potential.Endoscopy ,however,must be performed only following adequate resuscitation(复苏复苏)Diagnostic approach to GI bleedingBarium radiography(钡餐钡餐)Barium radiography is noninvasivebut has significant disadvantages,particularly in patients who are bleeding actively
21、Diagnostic approach to GI bleedingAngiography(血管造影血管造影)Angiography may localize the site of bleeding 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 隐血便隐血便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)
