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1、Gastrointestinal Hemorrhage 消化道出血,消化道以屈氏韧带(the ligament of Treitz)为界，其上的消化道出血称上消化道出血，其下的消化道出血称为下消化道出血,Supper Gastrointestinal Hemorrhage上消化道出血,Etiology,Upper gastrointestinal bleeding is most commonly caused by peptic ulceration, gastroesophageal varices, acute erosive and hemorrhagic gastritis, and
2、 gastric cancer,病因,消化性溃疡食管胃底静脉曲张破裂急性糜烂出血性胃炎胃癌,最常见,Etiology,Esophageal Diseases Duodenal and Gastric Diseases Portal Hypertension-Related Causes Hemobilia Hemosuccus Pancreaticus Systemic Diseases,Esophageal Diseases,Esophagitis Esophageal ulceration Tumor of the esophagus Esophagus diverticulitis Es
3、ophagus injury: physical (Mallory-Weiss Tear); chemical (strong acid or alkali); radioactive,Duodenal and Gastric Diseases,Gastric Ulcer; Acute erosive and hemorrhagic gastritis; Gastric cancer; Gastric polyp; Zollinger-Ellison Syndrome; MALToma; Neurofibromatosis; Gastric vascular abnormity (Vascul
4、ar Ectasia, Arteriovenous Malformations, Dieulafoys Lesion); Prolapse of gastric mucosa; Gastritis after operation; stoma ulcerDuodenal Ulcers; Duodenal diverticulitis; Acute erosive duodenitis; Crohns disease; Duodenal tuberculosis,Portal Hypertension-Related Causes,Esophageal varices Gastric varic
5、es Portal hypertensive gastropathy,Hemobilia,Including trauma, gallstones, cholecystic carcinoma, cholangiocarcinoma, ascariasis of biliary tract, liver cancer, liver abscess, hepatic hemangioma,Hemosuccus Pancreaticus,Pancreatic cancer Erosion of a pseudocyst into the splenic or peripancreatic arte
6、ry or formation of an arterial aneurysm in the course of chronic pancreatitis,Systemic Diseases,Vascular Diseases: hypersusceptible purpurahereditary hemorrhagic telangiectasia Hematic Diseases: haemophilia; thrombocytopenic purpura Uremia Connective Tissue Diseases:polyarteritis nodosa; systemic lu
7、pus erythematosus Stress-related gastric mucosal injury,（一）上消化道疾病1食管疾病2胃十二指肠溃疡疾病（二）门静脉高压引起的食管胃底静脉曲张破裂或门脉高压性胃病（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,（四）全身性疾病1血管性疾病2血液病3尿毒症4结缔组织病5急性感染6应激相关胃粘膜损伤,Clinical Presentation,Hematemesis Melena Hematochezia Symptoms of blood loss
8、Anemia and Change of hemogram Elevation in the BUN level,临床表现,1呕血与黑粪 2失血性周围循环衰竭 3贫血和血象变化 4发热 5氮质血症,Hematemesis,Be defined as the vomiting of blood and indicates an upper gastrointestinal site of bleedingblood may be either fresh, bright red, or it may be old and take on the appearance of coffee grou
9、ndsbright red blood often from varices or arterial lesion; Patients with coffee ground emesis are not usually bleeding actively but have had a recent or even remote bleeding,Melena,Be defined as passage of black, tarry, and foul-smelling stoolCharacter of melena is due to degradation of blood to hem
10、atin or other hemochromes by bacteriaInstillation of 50 to 100 mL of blood into the stomach is required to produce melena consistently, tests for fecal occult blood become positive when about 5 mL is lost per day,Hematochezia,Refers to passage of bright red blood from the rectum that may or may not
11、be mixed with stoolIt is happen when patients have gastro- intestinal lesions that bleed massively,Symptoms of blood loss,Including lightheadedness; tachycardia; angina pectoris; postural hypotension (the blood pressure is maintained on recumbency but falls more than 15 to 20 mmHg when the patient s
12、its up) or even shock (pale to ashen, dyspnea, sweating and distressed, syncope),Anemia and Change of hemogram,Patients who bleed small amounts of blood over long periods of time develop iron deficiency anemia, a low mean corpuscular volume (MCV), hypochromic, microcytic red blood cell and detection
13、 of occult blood in the stool with standard fecal occult blood testsIf blood loss is acute, hematocrit value may not reflect blood loss accurately and the MCV, hemoglobin concentration is normal, Because equilibration with extra-vascular fluid and subsequent hemodilution requires several hours,Eleva
14、tion in the BUN level,The blood urea nitrogen (BUN) level may be mildly elevated in patients with upper GI bleeding Due to breakdown of blood proteins to urea by intestinal bacteria and its absorption, as well as from a mild reduction in glomerular filtration rateBUN less than 14.3 mmol/L,诊断,（一）上消化道
15、出血诊断的确立1排除消化道以外的出血因素（1）排除来自呼吸道出血（2）排除口、鼻、咽喉部出血（3）排除进食引起的黑粪2判断上消化道还是下消化道出血,Clinical Localization of Bleeding,Hematemesis is from an upper gastrointestinal source of bleeding Melena is usually the result of upper gastrointestinal bleeding and should not be confused with components of the diet (such as
16、 red meat and vegetables containing peroxidases) or the dark-green character of ingested iron or the black, nonfoul-smelling stool caused by ingestion of bismuth (such as bismuth subsalicylate),Hematochezia is usually the result of lower gastrointestinal bleeding but approximately 10% of the patient
17、s with rapid bleeding from an upper source present with hematochezia The nasogastric lavage has been used extensively to help differentiate upper from lower gastrointestinal bleeding, but now, the use is discouraged Other clues to an upper gastrointestinal source of bleeding include hyperactive bowel sounds and an elevation in the BUN level out of proportion to creatinine,
