1、Diagnosis ofGastrointestinal BleedingProf.Chengwei Tang(唐承薇 教授)Dept.of Gastroenterology,West China HospitalSichuan University Hematemesis and Hematochezia 呕血与便血呕血与便血The approach to gastro-intestinal(GI)bleeding is tailored to the manner of appearance.Is bleeding acute or chronic?Intensive careWhere
2、is the source of bleeding?Empiric therapyDiagnosisTreatment(经验治疗经验治疗 )What is the causes of bleeding?Recognition of hemorrhage Intensive careWhere is the source of bleeding?Empiric therapyDiagnosisTreatment(经验治疗经验治疗 )What is the causes of bleeding?Is bleeding acute or chronic?Recognition of hemorrha
3、geClinical ManifestationsClinical Manifestations1 Manner of bleeding presentation2 Hypovolemia(低血容量)or shock3 Anemia(贫血)Recognition of hemorrhagePatients manifest blood loss1)Hematemesis 呕呕 血血 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)in character
4、 Hemoptysis?Nosebleeding?Manner of bleeding presentationfrom the GI tract in five ways:2)Melena 黑黑 便便 Shiny,black,sticky,foul-smelling stool degradation of blood exogenous stool darkeners iron bismuth(铋剂铋剂)Manner of bleeding presentationManner of bleeding presentation3)Hematochezia 便便 血血 bright red
5、or maroon blood from the rectum pure blood blood intermixed with formed stool bloody diarrheaManner of bleeding presentation4)Occult 隐隐 血血 detected only by testing the stool with a monoclonal antibody for human hemoglobin Estimate amount of bleeding from upper GI tract 510 ml/d OB +5070 ml/d Melena
6、250300 ml in short time Hematemesis Manner of bleeding presentation5)without any objective sign of bleeding with symptoms of blood loss dizziness,dyspnea,angina cordis(心绞痛心绞痛),or even shock digital examination(指检指检)of the rectumHypovolemia or shockSpeed and volume of blood lossWeakness,giddiness(眩晕眩
7、晕),oliguria,(少尿少尿)cold extremity,sweatingVital signs:tachycardia,(心动过速心动过速)hypotention(低血压低血压)Anemiapaledizzinesspalpitationeasy fatigabilitydyspnea angina cordisIs bleeding acute or chronic?1)Bleeding speed Hematemesis of fresh blood generally indicates a more severe bleeding episode than melena,wh
8、ich occurs when bleeding is slow enough to allow time for degradation of blood Is bleeding acute or chronic?2)Hematocrit 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 be low Is bleeding acute or chronic?If blood l
9、oss is acute,the hematocrit 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 7 6 5 4 3 2 1Volume(Liters)45%45%27%ABCIs bleeding acute or chronic?Hematocrit changesA Before bleeding B I
10、mmediately after bleeding C 2472 hours after bleedingIs bleeding acute or chronic?3)Blood pressure and heart ratedepend on u amount of blood lossu suddenness of blood loss u extent of cardiac and vascular compensation postural hypotension -early physical findingtachycardia -greater loss,compensate r
11、ecumbent(卧位卧位)hypotension -final resultsIs bleeding acute or chronic?Is bleeding acute or chronic?Postural hypotension A postural drop in blood pressure of 10 to 15 mm HgIs bleeding acute or chronic?4)Bowel sound Active bowel sound usually be presented in acute bleeding from GI tractEmergent and int
12、ensive care Initially vital signs supine and upright blood pressure pulseIf blood loss is significant,intravenous fluids must be startedSaline or other balanced electrolyte solutions are most rapidly available Blood is sent to the plete blood count clotting studies routine chemistry studies.Blood fo
13、r typing and cross-matching is sent to the blood bank.Where is the source of bleeding?LocalizationUpper GI bleeding:bleeding from a source proximal to the ligament of Treitz.Lower GI bleeding:bleeding from a site distal to the ligament of Treitz.LocalizationTreitz:The ligament of Treitz is an anatom
14、ic landmark for the duodenal-jejunal junction.LocalizationDifferentiating features of upper GI and lower GI bleedingUpper GILower GIManifestationHematemesisHematocheziamelenaNasogastric aspirateBloodyClearBUNElevatedNormalBowel soundHyperactiveNormalUpper GI tract bleeding?I.Clinical manifestationII
15、.Bowel soundIII.Nasogastric tubeHematemesisMelenaHematochezia More proximal lesions producehematemesis or melena,whereas more distal lesions are more likely to produce hematochezia.If hematochezia is from an upper GI source,it usually reflects a massive bleed(i.e.,greater than 1000 ml).What is the c
16、auses of bleeding?90%upper GI bleeding is due to four lesions:1)peptic ulcer(消化性溃疡消化性溃疡)2)hemorrhagic gastritis(胃炎胃炎)3)esophageal or gastric varices (静脉曲张静脉曲张)4)gastric cancerpeptic ulcerhemorrhagic gastritisesophageal varicesgastric cancerCauses of gastrointestinal bleedingn Mallory-Weiss tear 食道食道
17、 -贲门撕裂伤贲门撕裂伤Causes of gastrointestinal bleedingPortal-hypertensive gastropathy 门脉高压胃病门脉高压胃病Ancylostomiasis 钩虫病钩虫病Post-sphincterotomy 括约肌切开术后括约肌切开术后Causes of gastrointestinal bleeding Colorectal cancer Colitis Large hemorrhoid大痔大痔 Rectum tear肛裂肛裂 Vascular anomalies Hematologic diseasesDiagnostic appr
18、oach to gastrointestinal bleeding1 History and physical examination2 Endoscopy 3 Barium radiography4 Angiography5 Nuclear scintigraphyHistory and physical examination A history of previously docu-mented GI tract disease determined by radiography,endoscopy,or surgical procedures is very useful.Diagno
19、stic approach to GI bleedingDiagnostic approach to GI bleeding Patients with hepatitis B or chronic active liver disease may present with painless hematemesis from esophageal varices.Diagnostic approach to GI bleeding Patients with forceful,retching(干呕干呕)or multiple episodes of vomiting of food prio
20、r to the onset of hematemesismay be bleeding from MalloryWeisstears of the gastroesophageal junction.Diagnostic approach to GI bleeding A history of epigastric(上腹部上腹部)burning pain promptly relieved by foodor antacids(抗酸剂抗酸剂)or nocturnal(夜间夜间)pain suggests peptic ulcer disease,particularly duodenal(十
21、二十二指肠指肠)ulcer.Diagnostic approach to GI bleedingColorectal malignancy is often suggeste by a history of gradual weight loss intermittent blood in the stools altered bowel habitsDiagnostic approach to GI bleeding Hemorrhoidal bleeding is often suggested by the presence of bright red blood surrounding
22、 well-formed,normal-appearing stools.Diagnostic approach to GI bleeding Patients with stigmata(特征特征)of chronic liver disease e.g.,spider angioma(蜘蛛蜘蛛痣痣),ascites(腹水腹水),gynecomastia(男性乳房发育男性乳房发育)and upper GI bleeding often bleed from esophageal varices or erosion(糜烂糜烂).Diagnostic approach to GI bleedi
23、ng Localized epigastric tenderness(触痛触痛)to palpation may indicate peptic ulcer disease or gastritis.Diagnostic approach to GI bleeding Occasionally patients with lower GI tract bleeding from a malignancy have a palpable lower abdominal mass,hepatomegaly(肝肿大肝肿大)，signs of obvious weight loss.Diagnosti
24、c approach to GI bleeding A rectal examination is essen-tial to document stool color as well as to palpate for gross ano-rectal(肛直肠肛直肠)mass lesions such as polyps,cancers,or large hemorrhoids.Diagnostic approach to GI bleedingEndoscopy(内镜内镜)Endoscopy is the diagnostic procedure of choice because of
25、its high accuracy and immediatetherapeutic potential.Endoscopy ,however,must be Performed only following adequate resuscita-tion(复苏复苏).Diagnostic approach to GI bleedingEndoscopyContraindications：acute myocardial infarction severe chronic lung disease hemodynamic instabilitypatient agitation(焦虑不安焦虑不
26、安)terminal malignancyDiagnostic approach to GI bleedingBarium radiography(钡餐钡餐)Barium radiography is noninvasivebut has significant disadvantages,particularly in patients who are bleeding briskly(actively).Diagnostic approach to GI bleedingAngiography(血管造影血管造影)Angiography may localize the site of bl
27、eeding.Diagnostic approach to GI bleedingAngiography Bleeding must be active because angiography detects only extravasation(外渗外渗)of contrast (造影剂造影剂)into the GI tract.思考题：思考题：I.胃肠道出血有哪些表现形式？胃肠道出血有哪些表现形式？II.胃肠道出血的病因有哪些？胃肠道出血的病因有哪些？III.对胃肠道出血的诊断通常采用哪些方式？对胃肠道出血的诊断通常采用哪些方式？References：Textbook of physical diagnosis.4th edition.MH Swartz.Elsevier science.2002.Sleisenger&Fordtrans Gastrointestinal and liver disease.6th edition.M Feldman,BF Scharschmidt,MH Sleisenger.W.B.Saunders,2001.physical Diagnosis，Fourth Edition,Jo-Ann Reteguiz,M.D.,McGraw-Hill
