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【医学PPT课件】上消化道出血

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单击此处编辑母版标题样式 单击此处编辑母版副标题样式 *1 上消化道出血 •消化内科 •胡阳黔 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 讲授目的和要求 •1、掌握上消化道出血的常见病因、临床 表现、诊断及治疗原则。 •2、熟悉本病的鉴别诊断。 •3、了解上消化道出血的主要诊断方法 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 上消化道出血 下消化道出血 系指屈氏韧带以上的 消化道出血,常表现 为呕血、黑便、便血 :食管、胃、肝胆、 胰腺、十二指肠 屈氏韧带以下的消化 道出血,常表现为便 血:小肠、结肠、直 肠、肛管 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 上消化道大量出血 出血量:短期内超过1000ml 或循环血量的20%。 临床表现:呕血、黑粪、便血 急性失血性周围循环衰竭。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 病 因 • 上消化道疾病 • 门脉高压引起的食管胃底静脉曲张破裂 或门脉高压性胃病 • 上消化道邻近器官或组织的疾病 • 全身性疾病 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 食管疾病:食管炎、食管癌、食管溃疡、食管损伤(Mallory- Weiss综合征、放射及化学损伤等) 胃十二指肠疾病: • 消化性溃疡 • Zollinger-Ellison综合征 • 急性胃黏膜损害 • 胃癌 • 胃血管异常(血管瘤、动静脉畸形、胃黏膜下恒径动脉破裂又 称Dieulafoy病等) • 其他肿瘤(间质瘤、平滑肌瘤、平滑肌肉瘤、息肉、淋巴瘤) (一)上消化道疾病 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 食管溃疡 食管炎 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 食管癌 食管异物损伤 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. Mallory-Weiss tear (食管贲门粘膜撕裂综合征) Dieulafoy's Lesion (胃粘膜下恒径动脉破裂) Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 胃角溃疡 胃体溃疡射血 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 胃溃疡并血痂附着 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 胃癌 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 胃息肉 胃间质瘤 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 急性胃粘膜病变 胃毛细血 管扩张症 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 十二指肠球部溃疡 十二指肠球 部对吻溃疡 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 十二指肠降部溃疡出血 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 门静脉高压 食管胃底静脉曲张破裂 门脉高压性胃病 (二)门静脉高压 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 食管静脉曲张 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 食管静脉曲张 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 胃底静脉曲张 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 门脉高压性胃病 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. (三)上消化道邻近器官或组织的疾病 1、胆道出血 2、胰腺疾病累及十二指肠 3、主动脉瘤破入食管、胃或十二指肠 4、纵隔肿瘤或脓肿破入食管 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. (四)全身性疾病 血管性疾病:过敏性紫癜,遗传性出血性毛细血管 扩张等 血液病:血友病、ITP、白血病 尿毒症 结缔组织病 急性感染:流行性出血热,钩体病等 应激相关胃粘膜损伤:急性糜烂出血性胃炎, 应激性溃疡 抗凝剂过量等 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 临床上最常见的病因: •消化性溃疡:占30~50%; •急性糜烂出血性胃炎:占20%~30%; •食管胃底静脉曲张破裂: 占20%; •胃癌: 占5% Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 二、临床表现 1、呕血与黑便 2、失血性周围循环衰竭 3、发热 4、氮质血症 5、血象 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 1、呕血与黑便 •是上消化道出血的特征性表现 •均有黑便,但不一定有呕血,取决于出血部位 、量及速度 食管、胃出血:多为呕血和黑便。但如出血量 小,速度慢,亦可无呕血。 十二指肠出血:多仅有黑粪。但如出血量大, 速度快, 亦可有呕血。 •呕血多为咖啡色或棕褐色,量大可为鲜红色或 伴血凝块。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 呕血多呈咖啡色 血红素 正铁血红素 黑粪呈柏油样,粘稠而发亮 血红蛋白的铁 硫化铁 胃酸 肠内硫化物 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 2、失血性周围循环衰竭表现 头晕 肢体冷感 乏力 心率加快 晕觉 血压偏低 一般表现 烦躁不安 面色苍白 四肢湿冷 口唇发绀 呼吸急促 血压下降 心率加快 尿量减少 严重时呈休克状态 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 注意:出血后常有便意, 上厕所时常发生晕厥。 ! Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 血象 •失血性贫血 •出血早期可无明显变化,经3~4小时以上才出 现贫血 •正细胞正色素性贫血 •出血24小时内网织红细胞即升高,如持续升高 ,提示出血未停止 •出血后2~5小时,因应激反应,白细胞可达10 ~20ⅹ109 /L,血止后2~3天恢复正常 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 氮质血症 •可分肠源性、肾前性、肾性氮质血症. •肠源性:出血后血液中蛋白分解产物在肠道吸收,致血 中氮质升高 •肾前性:失血后外周循环衰竭,肾血流减少,肾小球滤 过率下降,氮质储留 •出血后数小时血尿素氮开始上升,24~48小时达高峰, 3~4天后恢复正常。如持续升高,提示出血未停止。 •如出血纠正,血容量补足,尿素氮仍持续升高,提示肾 性氮质血症,肾功能衰竭 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 发热 •大量出血后,24小时内常出现低热一般不超 过38℃,可持续3~5天; •机制:尚不清楚,可能为循环血量减少、周 围循环衰竭,致体温调节中枢功能障碍; •发热超过39℃,持续7天以上,应考虑有并 发症存在。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 诊断思路 1.上消化道出血诊断的确立 2.出血严重程度的估计和周围循环 状态的判断 3.出血是否停止的判断 4.出血的病因诊断 5.预后估计 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. (一)上消化道出血诊断的确立 1、诊断根据 (1)呕血、黑便 (2)失血性周围循环衰竭表现 (3)呕吐物或粪便隐血试验强阳性 (4)Hb↓、RBC↓的实验室证据 确诊:急诊胃镜 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 注意:上消化道大量出血的早期识别 少数患者因出血速度快,早期可无 呕血及黑便,仅有周围循环衰竭表现。 直肠指检可发现尚未排出的黑便, 有助于早期诊断。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 1)、排除消化道以外的出血因素 (1)排除来自呼吸道出血:因大量咯血时,可吞 咽入消化道而引起呕血或黑便。 (2)排除口鼻部、咽喉部出血:注意询问病史及 局部检查鉴别 (3)排除进食动物血、活性碳及铋剂、铁剂、中 草药等药物引起的黑便:注意询问病史及观察大便 情况鉴别,一般药物所致的黑便,缺乏光泽。 2)、判断上消化道还是下消化道出血 2、鉴别诊断: Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 判断上消化道还是下消化道出血判断上消化道还是下消化道出血 鉴别要点上消化道出血下消化道出血 既往史 多曾有溃疡病、肝、胆 疾病史或有呕血史。 多曾有下腹部疾病、包块 及排便异常、便秘、腹痛 及便血史。 出血先兆 上腹部闷胀,疼痛或绞 痛发作,恶心,反胃。 中下腹不适或下坠,欲排 大便 出血方式 呕血伴柏油样便。 便血,无呕血 便血特点 柏油样便,稠或成形, 无血块。 暗红或鲜红,稀多不成形 ,大量出血时可有血块。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. (二)出血严重程度的估计和周围循环状态的判断 1、根据临床表现 粪便隐血(+) 黑便 呕血 全身症状 周围循环衰竭1000ml 400~500ml 250~300ml/次 50~100ml/日 5~10ml/日 出血量 出血量 胃内积血 出血量 出血量 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 2、根据Bp、P动态观察 3、根据输血、输液后的患者病情稳定情况 4、体位变化:平卧→坐位 BP↓15∽20mmHg、P↑10次/分 示血容量明显不足,需紧急输血。 SBP120次/分,伴休克表现 示严重大量出血,需积极抢救。 5、Hb、RBC变化:但不能反应早期急性出血, 且受出血前有无贫血的影响。 最有价值的标准:周围循环衰竭的临床表现 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 肠道内积血需经数日(一般3天) 才能排尽,下列情 况应考虑继续/再出血: (1)呕血、黑粪情况:(反复呕血,或黑粪次数 增多或转为暗红色、粪质稀薄,伴有肠鸣音亢进) (2)周围循环衰竭的表现:经充分补液及输血后 未见明显改善,或虽暂时好转又恶化 (3)实验室指标1(红细胞计数、血红蛋白、红细 胞压积测定继续下降,网织红计数持续升高) (4)实验室指标2(补液与尿量足够的情况下,血 尿素氮仍持续升高或再次增高) (三)、出血是否停止的判断 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. Ø 出血后48小时以上未再继续出血,再出血可能性 小; Ø 既往有大出血史、本次出血量大、24小时内反 复大量出血、食管胃底静脉曲张出血、有明显的 高血压或动脉硬化者,再出血可能性大。 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. • 1、既往史、临床症状与体征提供重要线索 • 2、胃镜检查:首选,病变部位、病因、出血 情况;出血后24~48h内进行。 • 3、X线钡餐检查。 • 4、其他检查:选择性动脉造影、ECT、吞线试 验及小肠镜检查、胶囊内镜—小肠出血。 (四)、出血的病因诊断 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 消化性溃疡出血 •居消化道出血首位,青壮年人好发; •球部溃疡更易出血,提示病变具有高度活动性; •常有慢性、周期性、节律性上疼痛,出血前数日疼痛加重 ,部分患者出血后疼痛缓解; •溃疡出血后疼痛减轻机制:出血后溃疡及其周充血、水肿 消退;痛觉神经末梢覆以血液,脱离胃
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