1、Diagnosis ofGastrointestinal Bleeding 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 is the source of bleeding?Empiric therapyDiagnosisTreatment(经验治疗)What is the causes of b
2、leeding?Recognition of hemorrhage Intensive careWhere is the source of bleeding?Empiric therapyDiagnosisTreatment(经验治疗)What is the causes of bleeding?Is bleeding acute or chronic?Recognition of hemorrhageClinical ManifestationsClinical Manifestations1 Manner of bleeding presentation2 Hypovolemia(低血容
3、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 Hemoptysis?Nosebleeding?Manner of bleeding presentationfrom the GI tract in five ways:n2)Melena 黑
4、黑 便便n Shiny,black,sticky,foul-smelling stool n degradation of blood n exogenous stool darkenersn iron n bismuth(铋剂铋剂)Manner of bleeding presentationManner of bleeding presentationn3)Hematochezia 便便 血血n bright red or maroon blood from the rectumn pure bloodn blood intermixed with formed stool bloody
5、diarrheaManner of bleeding presentationn4)Occult 隐隐 血血n detected only by testing the stool nwith a monoclonal antibody for human nhemoglobin Estimate amount of bleeding from upper GI tractn 510 ml/d OB +n 5070 ml/d Melena n250300 ml in short time Hematemesis Manner of bleeding presentationnwithout a
6、ny objective sign of bleeding with symptoms of n blood lossn dizziness,dyspnea,angina cordis(心绞痛心绞痛),or even shock nn digital examination(指检指检)ofn the rectumHypovolemia or shockSpeed and volume of blood lossWeakness,giddiness(眩晕眩晕),oliguria,(少尿少尿)cold extremity,sweatingVital signs:tachycardia,(心动过速心
7、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,which occurs when bleeding is slow enough to allow time for degradation o
8、f 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 loss is acute,the hematocrit dose not change during the first few hours
9、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 Immediately after bleeding C 2472 hours after bleedingIs bleeding acute
10、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 recumbent(卧位卧位)hypotension -final resultsIs bleeding acute or chronic?Is
11、 bleeding acute or chronic?nPostural hypotension n 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 intensive care Initially vital signs supine and upright blood pressure
12、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 for typing and cross-matching is sent to the blood bank.Where is the s
13、ource 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 anatomic landmark for the duodenal-jejunal junction.LocalizationDifferenti
14、ating features of upper GI and lower GI bleedingUpper GILower GIManifestation Hematemesis HematocheziamelenaNasogastric aspirateBloodyClearBUNElevatedNormalBowel sound HyperactiveNormalUpper GI tract bleeding?A.Clinical manifestationB.Bowel soundC.Nasogastric tubeHematemesisMelenaHematochezia More p
15、roximal 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 causes of bleeding?90%upper GI bleeding is due to four lesions:1)pept
16、ic 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 -贲门撕裂伤贲门撕裂伤Causes of gastrointestinal bleedingPortal-hypertensive g
17、astropathy 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 approach to gastrointestinal bleeding1 History and physical examination2
18、 Endoscopy 3 Barium radiography4 Angiography5 Nuclear scintigraphyHistory and physical examinationn A history of previously docu-mented GI tract disease determined by radiography,endoscopy,or surgical procedures is very useful.Diagnostic approach to GI bleedingDiagnostic approach to GI bleedingn Pat
19、ients with hepatitis B or nchronic active liver disease may npresent with painless hematemesis nfrom esophageal varices.Diagnostic approach to GI bleedingn Patients with forceful,retching(干呕干呕)nor multiple episodes of vomiting of food prior to the onset of hematemesismay be bleeding from MalloryWeis
20、stears of the gastroesophageal junction.Diagnostic approach to GI bleedingn A history of epigastric(上腹部上腹部)nburning 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(十二十二n指肠指肠)ulcer.Diagnostic approach to GI bleedingnColorecta
21、l malignancy nis often suggeste by a history of n gradual weight lossn intermittent blood in the stoolsn altered bowel habitsDiagnostic approach to GI bleedingn Hemorrhoidal bleeding is often suggested by the presence of bright red blood surrounding well-formed,normal-appearing stools.Diagnostic app
22、roach to GI bleedingn Patients with stigmata(特征特征)of chronic liver disease e.g.,spider angioma(蜘蛛痣蜘蛛痣),ascites(腹水腹水),gynecomastia(男性乳房发男性乳房发育育)and upper GI bleeding often bleed from esophageal varices or erosion(糜烂糜烂).Diagnostic approach to GI bleedingn Localized epigastric tenderness n(触痛触痛)to palp
23、ation may indicate peptic nulcer disease or gastritis.Diagnostic approach to GI bleedingn Occasionally patients with lower GI tract bleeding from a malignancy have a palpable lower abdominal mass,hepatomegaly(肝肿肝肿大大)，signs of obvious weight loss.Diagnostic approach to GI bleedingn A rectal examinati
24、on 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 bleedingnEndoscopy(内镜内镜)n Endoscopy is the diagnosticn procedure of choice because ofn its high accuracy and immediatentherape
25、utic potential.n Endoscopy ,however,must n be Performed only following n adequate resuscita-tion(复苏复苏).Diagnostic approach to GI bleedingnEndoscopynContraindications：nacute myocardial infarction severe chronic lung disease nhemodynamic instabilitynpatient agitation(焦虑不安焦虑不安)nterminal malignancyDiagn
26、ostic approach to GI bleedingnBarium radiography(钡餐钡餐)nBarium radiography is noninvasivenbut has significant disadvantages,nparticularly in patients who are bleeding nbriskly(actively).Diagnostic approach to GI bleedingnAngiography(血管造影血管造影)n Angiography may localize the site of bleeding.Diagnostic
27、approach to GI bleedingnAngiographyn Bleeding must be active because angiography detects only extravasation(外外渗渗)of contrast (造影剂造影剂)into the GI tract.思考题：思考题：A.胃肠道出血有哪些表现形式？胃肠道出血有哪些表现形式？B.胃肠道出血的病因有哪些？胃肠道出血的病因有哪些？C.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
