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1、上 消 化 道 出 血中山大学附属第一医院高翔简 介n上消化道出血: Treitz 韧带以上的消化道 引起的出血:食管,胃,十二指肠,胰,胆,胃空 肠吻合术后的空肠病变n下消化道出血: Treitz 韧带以下的消化道 引起的出血n上消化道出血引起的大量出血较下消化 道更为常见n大量出血:短期内失血超过1000ml或循环 血量20%常见病因n消化性溃疡 (十二指肠和胃) 33-51%n食管和胃静脉曲张 23-33%nMallory-Weiss 综合征3-10%n胃或十二指肠糜烂 1-19%n血管瘤 0-7%n肿瘤 1-5%With the inverted gastroscope a spurt
2、ing hemorrhage from a fundal varice is discerbnable. Hemostasis is achieved with several low volume injections of Histoacryl - glue. The right picture shows the therapeutic success.There are blood covered errosions throughout the whole stomach. This has led to a upper GI hemorrhage compromising the
3、patienthemodynamically. The sole reason was a single ingestion of 400 mg of ibuprofenThis massive vessel with active bleeding was diagnosed in a 58 year- oldpatient, who presented with tary stools. The first picture shows the lesion after injection of fibrin glue. The right picture shows additionall
4、y applied hemoclips. Bleeding stopped at the end of the procedure, but reccurredtwice before the patient had to be treated surgically. In dieu-la-foy ulcersan arterial vessel of abnormal size reaches the mucosa causing a tinyulzeration by permanent compression of the mucosal layer. Esophageal varice
5、s grade II (right) und grade III (left). Cherry red spots are signs of imminent hemorrhage (right). They correspond to areas of especially thin and altered variceal wall. This duodenal ulcer at the left edge of the figure, shows an oozing, active bleeding. According to the Forrest classification of
6、gastrointestinalhemorrhage of the upper GI- tract, this bleeding is graded as Forrest Ib. The visible vessel is treated by primary application of a hemoclip. At the 3 week follow- up (fig )the Clip is still in the original position. The ulcer shows a progressive healing. Inoperable choledochal cance
7、r. A wall stent had been inserted 3 months earlier. The patient was admitted for severe hemorrhage, which was endoscopically proved to originate from the biliary duct. The hemorrhage was not amenable to endoscopy and surgery. Huge blood clots prolapse from the biliary duct. 临床表现v呕血与黑粪v失血性周围循环衰竭v血象变化
8、v发热v氮质血症诊 断 思 路是上消化道出血吗?出了多少血?出血停止了吗?什么原因引起的出血?上消化道出血的确立 呕血和黑粪,失血性周围循环衰竭,血和粪便的检查 早期识别:直肠指诊 排除消化道以外的病因:咯血、口鼻咽出血、事物或药物出血量的估计粪便隐血试验阳性 每日消化道出血510ml 黑粪 50100ml 呕血 250300ml 出现全身症状 400500ml 周围循环衰竭 1000mlv最有价值的标准:周围循环衰竭的临床表现 v动态观察血压和心率出血是否停止继续出血或再出血的表现: 反复呕血或黑粪 周围循环衰竭经治疗后无改善或波动 HbRBC继续下降,Ret持续升高 补液与尿量足够的情况下
9、,血尿素氮持续或再次升高 出血后48小时以上未再继续出血,再出血可能性小; 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,再出血可能性大出血的病因v病史v实验室检查v胃镜:首选;推畅急诊胃镜检查(2448hr)vX线钡餐 v其他:选择性动脉造影治 疗原则: 抗休克,积极补充血容量v一般的急救措施:禁食,卧床休息,保持呼吸道通畅严密监测生命体征v积极补充血容量:立即配血,输足量全血q紧急输血指征:改变体位出现晕厥,血压下降1520mmHg,心率上升10次/分收缩压90mmHg(或较基础下降25%)Hb7g/L或Hct25%治 疗v止血措施
10、q食管胃底静脉曲张破裂大出血-出血量大,再出血率高,死亡率高治 疗 药物止血 血管加压素(vasopressin) 机制:收缩内脏血管,减少门静脉血流,降低门静 脉及侧枝循环压力 用量:0.2U/分持续静脉滴注 不良反应:腹痛,血压升高,心律失常,心绞痛,心 肌梗死 建议:与硝酸甘油同时用 禁忌:有冠心病者 药物止血 生长抑素(somatostatin) 机制:减少内脏血流,减少奇静脉血流 优点:疗效确实,无全身血流动力学改变 缺点:价格昂贵 用量: 14肽天然生长抑素:首剂250ug静脉缓注,继以250ug/h静脉滴注 o 注意:该药半衰期短,中断超过5分钟须再次首剂 8肽生长抑素:首剂10
11、0ug静脉缓注,继以2550ug/h持续静脉滴注治疗 气囊压迫止血治 疗三腔二囊管食管囊 (3545mmHg)胃囊 (5070mmHg) 优点:止血确实 缺点: 痛苦并发症多(吸入性肺炎,窒息,食管粘膜坏死,心律失常等)早期再出血率高v不推荐作为首选治疗措施 内镜治疗 硬化剂注射 皮圈套扎 硬化剂注射+皮圈套扎治 疗 优点: 止血确实 可有效防止早期再出血 v是治疗食管胃底静脉曲张的重要手段 并发症:局部溃疡,出血,穿孔,瘢痕狭窄等 时机:大出血基本控制,患者基本情况稳定 外科治疗外科手术 o适应症:内科治疗无效 o应尽量避免经颈静脉门体静脉分流术 o尤其适用于准备肝移植的患者治疗v止血措施q非曲张静脉上消化道出血-消化性溃疡胃最常见病因治 疗 抑制胃酸分泌 H2受体拮抗剂 质子泵抑制剂(优于H2受体拮抗剂) 内镜治疗:活动性出血;暴露血管的溃疡 方法:激光,热探头,高频电灼,微波,注射疗法 手术治疗 介入治疗
