《gi_bleeding上消化道出血》由会员分享，可在线阅读，更多相关《gi_bleeding上消化道出血（25页珍藏版）》请在金锄头文库上搜索。
1、G.I. Bleeding,Presented by: Ahmed T. Al-Suwaidi Mohamed S. Al-Hoqani,G.I. Bleeding Case,50 yrs, Pakistani, male C/O: Bleeding/rectum & Abd. pain Painless bleeding, 1 yr excess bleeding, 1 month Black, 4-5 times/day, little quant. Abd. pain Vomiting, 1 week,G.I. Bleeding Case,M.H: * no peptic ulcer d
2、isease * no medications (NSAIDs) * no urinary symptoms * not known DM, HPTN, IHD * weight loss,G.I. Bleeding Case,O/E: * Afebrile * no pallor * not dyspneaic * no lymphoadenopathies * no S.C.L.N,G.I. Bleeding Case,Vital Signs: * Pulse: 78 bts/min * BP: 130/80 * RR: 18 br/min Heart: NAD Lung: NAD,G.I
3、. Bleeding Case,Abd.: * not distended * no epigast. tenderness * tender, firm, partly mobile mass at Rt lumbar region. * spleen not palpable * Lt lobe liver palpable, mildly tender * bowel sounds present,G.I. Bleeding Case,PR: * no enlarged piles * no active bleeding * no palpable mass * no blood on
4、 finger ECG, CBC, Sr Amylase, Bleeding profile, Abd X-ray, fecal loading ascending colon,G.I. Bleeding Case,Lab Results: * Hb: 14.1 g/dl * Plt: 252 * 103 * Hypochromic, microcytic * PT: 17.3 sec * aPTT: 35.4 sec * Sr Amy: 129 U/l 106 U/l * Na+: 140 mmol/l * K+: 4.1 mmol/l * BUN: 17 mg/dl,G.I. Bleedi
5、ng,Acute Vs Chronic Acute Upper G.I.Bleeding: Acute Lower G.I.Bleeding:,Acute Upper G.I. Bleeding,Haematemesis Melaena Site & Time,Acute U.G.I. Bleeding, Aetiology: 1. Drugs (Aspirin & NSAIDs) 2. Alcohol 3.Chronic peptic ulceration (50% of GI hemorrhage) 4.Others: reflux esophagitis, varices, gastri
6、c carcinoma, acute gastric ulcers & erosions.,Acute U.G.I. Bleeding, Clinical approach: 1. recent (24 hrs), then hospitalized. 2. if small amount, no immediate Tx, because CVS can compensate 3. 85% stop bleeding during 48 hrs 4. history helps in diagnosing the cause of the hemorrhage, eg: long histo
7、ry of indigestion, or previous hem. from ulcers.,Acute U.G.I. Bleeding, Clinical approach: 5. factors include: age (60 +) amount of bld lost continuing visible bld loss. signs of chronic liver disease classical clinical features of shock,Acute U.G.I. Bleeding, Clinical approach: 6. liver disease sev
8、ere, recurrent bleeding (if from varices) 7. splenomegaly portal hypertension,Acute U.G.I. Bleeding, Immediate management: * Emergency management: History + exam. Monitor: pulse & BP /30 min Bld sample: haemoglobin, urea, electrolytes, grouping & cross-matching I.v. access,Acute U.G.I. Bleeding,* Em
9、ergency management (cntd): Bld transfusion in case of 1) shock 2) haemoglobin 10 g/dl Urgent endoscopy Surgery when recommended,Acute U.G.I. Bleeding,*Shock management: ABC Airway: endotracheal tube, oropharyngeal airway. *Give oxygen,Acute U.G.I. Bleeding,*Shock management (cntd): Breathing: suppor
10、t respiratory function * Monitor: resp. rate, bld gases, chest radiograph Circulation: expand circulating volume: blood, colloids, crystalloids support CVS function: vasodilators * Monitor: skin color, peripheral temp., urine flow, BP, ECG,Acute U.G.I. Bleeding, General Investigations: 1. Hb, PCV 2.
11、 CBC (WBC etc) 3. Bld glucose 4. Platelets, coagulation 5. Urea, creatinine, electrolytes 6. Liver biochem. 7. Acid-base state 8. Imaging: chest & abd. radiography, US, CT,Acute U.G.I. Bleeding,*General management: Blood volume 1. restore volume to normal 2. transfusion Endoscopy 1. shock, suspected
12、 liver disease or continued bleeding 2. control varices or ulcers to reduce re-bleeding,Acute U.G.I. Bleeding,*General management: Drug therapy 1. H2 receptor antagonists 2. proton pump inhibitors Factors in reassessment 1. age: 60 + greater mortality 2. recurrent hemorrhage: + mortality 3. re-bleed
13、ing: mostly within the 1st 48 hrs 4. surgical procedures in case of severe bleeding.,Lower gastrointestinal haemorrhage,Causes,Diverticular disease,Angiodysplasia,Inflammatory bowel disease,Ischaemic colitis,Infective colitis,Colorectal carcinoma,Investigation,May show angiodysplastic lesions even o
14、nce bleeding has ceased,Most patients are stable and can be investigated once bleeding has stopped,In the actively bleeding patient consider,Colonoscopy - can be difficult,Selective mesenteric angiography,Requires continued bleeding of 1 ml/minute,Radionuclide scanning Uses technetium-99m labeled re
15、d blood cells,Management,If source of colonic bleeding unclear perform a subtotal colectomy and end-ileostomy,Acute bleeding tends to be self limiting,Consider selective mesenteric embolisation if life threatening haemorrhage,If bleeding persists perform endoscopy to exclude upper GI cause,Proceed to laparotomy and consider on-table lavage an panendoscopy,If right-sided angiodysplasia perform a right hemicolectomy,If bleeding diverticular disease perform a sigmoid colectomy,
