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1、HEMATEMESIScaiqiaoyinDepartmentofGastroenterology,AffiliatedMindaHospitalMedicalCollege,HubeiUniversityforNationalitiesTheGastrointestinalSystemGI tract consists of a hollow muscular tube starting from the oral cavity, going through the rectum and is ended at the anus, where food is expelled. The ma
2、in function of the GI tract is digestion and absorption of nutrientsThe movement of the smooth muscles in the GI is called peristasis and propels food in the forward directionAccessory organs that assist the tract by secreting enzymes to help break down food into its component nutrients (salivary gl
3、ands, liver, pancreas and gall bladder) TheGastrointestinalSystemdigestive tract Startsatmouthpharynxesophagusstomachsmallintestinelargeintestinerectumendsatanusdigestive gland salivary glands, liver, pancreas gall bladderTheGastrointestinalSystemDigestiveandabsorptiveprocesstakeplaceintheGItractGas
4、trointestinalProblemsuppergastrointestinaltractdisorderDysphagiaNauseaVomitinghematemesishematocheziamelena.lowerGItracthematochezia.jejunumduodenumsuspensoryligamentofduodenumduodenojejunalflexureuppergastrointestinaltractlowergastrointestinaltract definitionofhematemesisandmelaenahematemesis- isvo
5、mitingofblood.whichcanbefreshandred,ordegradedbygastricpepsin,whenitisdarkbrownincolourandresemblescoffeegrounds.melaena-isthepassageoftarry,shinyblackstoolswithacharacteristicodourandresultsfromuppergastrointestinalbleeding.colourofhematemesiscolourofhematemesisdependsontheamountandcharacterofthega
6、striccontentsatthetimebloodisvomitedandonthelengthoftimethebloodhasbeeninthestomach.brightredblood-thesourceofbleedingisabovethegastroesophagealsphincter,e.g.fromesophagealvarices,activelyvomited.Brightredbloodinthevomitindicatesafreshhemorrhageandlittlecontactofthebloodwithgastricjuicesbrownish/dar
7、kbrown(coffee-ground)Gastricacidschangebrightredbloodtoabrownishcolorandthevomitisoftendescribedas“coffee-ground”incolor.colourofmelaenacolourofmelaenaistarry,shinyblackstoolsdistinguishmelaenafromthemattblackstoolsassociatedwithoralironorbismuththerapy.OB(-)hemoglobin 血红蛋白 胃酸作用 转变为 酸化正铁血红蛋白血红蛋白 细菌作
8、用 所含铁转变为硫化铁amountofhematemesisandmelenaEvaluationofbleedingamount5-10mlOB(+)50-100mlMelena250-300mlHematemesis/Hematochezia400-500mlSymptomsofhypovolemicshock(lowcirculatingbloodvolume)dizziness,palecomplexion,coldsweats,acromegalydamp,drymouthdysphoria,lessurine1000mlhemorrhagicshock,SBP90mmHg,P120
9、bpm(20%-30%Systemiccirculationbloodvolume)Causesofhematemesis1.uppergastrointestinaltractdiseasepepticulceresophagitis,gastritis,duodenitisMallory-Weissesphagealtearesophagealvaricesesophagealorgastricmalignancy(cancer)vascularmalfomation.2.others:nosebleedinghematologicalsystemdiseasesuremiaDisease
10、softhebodysystemthrombolyticsandanticoagulants.vVarisesVarisesesofagusVarisesfundusDieulafoyhaemangiomasvNonvarisesesofagitis,gastritisduodenitispepticulcerStressulcerMallory-WeisstearTumor/CarcinomaCausesofhematemesisThemostcommoncausesofhematemesisare:pepticulcer,gastritis,esophagealvaricesorlesio
11、ns,andcancerofthestomach.Benigntumors,traumaticpostoperativebleeding,andswallowedbloodfrompointsinthenose,mouth,andthroatcanalsoproducehematemesis.esophageal varicesMallory-WeisssyndromeMallory-Weisssyndrome:bleedingtearsintheesophagalmucosa,usuallycausedbyprolongedandvigorousretching.esophagal canc
12、erTumorsofesophagus.gastriculcer(GU)Dieulafoydiseasealcoholdrug:NSAID/steroidsHelicobacter pylorihelicobacterpyloriganstriccanceracute erosive and hemorrhagic gastritisalcoholdrugNSAIDsteroidsthrombolyticsandanticoagulantsNSAID-induced hemorrhagic gastritis duodenalulcer(DU)Vascularmalfunctionsofthe
13、gastrointestinaltract,suchasbleedinggastricvaricesorduodenumvaricespredictionoftheriskofmortalityinpatientswithupperGIbleeding-RockallScorecriterionscoreage:60/60-79/80012shock:none/pulse100bpmSBp100mmHg/SBp100mmHg012comorbidity:none/heartfailure/ischaemicheartdiseaseorothermajordisease/renalfailure
14、ordisseminatedmalignancy023endoscopicfindings:Mallory-Weisstearandnovisiblebleeding/allotherdiagnoses/uppergastrointestinalmalignancy012majorstigmataofrecenthaemorrhage:none/visiblebleedingvesseloradherentclot02totalscorepre-endoscopyscore4=25%mortality(maximumscore=7)pre-endoscopypostendoscopyscore
15、8+=40%mortality(maximumscore=11)postendoscopypredictionoftheriskofmortalityinpatientswithupperGIbleeding-RockallScoredifferentialdiagnosishemoptysis-isspittingorcoughingofblood,thebleedinglesionsmaybeanywherefromnosetolung.hemoptysishematemesispathogenesis respiratorytractdiseaseupperGItractdisease(
16、causes) bronchitis/pneumonia)PU/livercirrhosis/cancertuberculosis/carcinomagastritis/esophagealvaricesheartfailurebleedingdisorder complaints larynx(throat)itchabdominaldiscomfortable(beforebleeding)chestpain/distress,coughnasea,vomit style of bleeding spitting/coughingoutvomitingout PH alkline7acid
17、ity7melena -+ sputum after bleeding+-+clinicaloccurancesymptoms-historytakingdependontheamountandspeedofbleedingchief complaints:hematemesis/melena/Hematocheziaaccompany complaints:abodominalpain/dizzy/sweat/conscious/shortofbreath/past history:IsthereaprevioushistoryofPUorliverdisease?Isthereahisto
18、ryofalcohol,NSAIDorcorticosteroidingestion?Didthevomituscomprisefreshbloodorcoffeeground-stainedfluid?Wasthehnatemesisprecededbyintenseretching?Wasbloodstainningofthevomitusapparentinthefirstvomit?clinicaloccurancephysicalexamination(signs)Vitals:T,P,R,Bp(Tachycardia,hypotension)Skin examinationjaun
19、dice/spidernaevi/caputmedusae/palmarerythema/mucotutaneoushemorrhagepallor/hydration/edmapalmarerythemadistendedveinsclinicaloccurancephysicalexamination(signs) Abdominal examinationinspection:scars/swellings/distendedveins/varicesofabdominalwallpalpation:tnderness/hepatomegaly/splenomegalypercussio
20、n:ascitesausculation:bowelsounds/bruitsclinicaloccuranceLaboratoryexaminationbloodroutineexamination(RBC/hemoglobin/Hct/WBC/PLTcount)coagulationfunction:PT/APTTliverfunction:TBil(totalbilirubin):directbilirubin(DBIL),indirectbilirubin(IBIL)albuminenzymology(AST/ALT/GGT/ALP)renalfunction:BUNandcreati
21、nineclinicaloccuranceendoscopyexaminationclinicaloccurancediagnosishistorytaking-complaintsphysicalexaimation-signsLaboratoryexaminationendoscopyexaminationClinicalScenario67yoMwithhistoryofHTNandosteoarthritiswhopresentstotheEDwith3episodesofcoffeegroundemesistoday.Noabdominalpain,melenaorhematoche
22、zia.Nohistoryofliverdiseaseorcoagulopathy,+occasionalETOHuse.MedicationsincludeHCTZ,Lisinopril,andIbuprofenPRNforjointpainVSonarrival:T37,HR102,BP108/72,similarBPstanding,Pox99%RAExamination:AOx3.Noscleralicterus.Abdomensoft,non-tender,noHSM.Rectalwithdarkbrownstool,guiac+.Labs:Hgb9.8,Plt245,INR1,LF
23、Tsnl,BUN28/Cr1.4.Whatisthelikelyetiologyofthebleeding?ClinicalScenarioconculsion67yoMonNSAIDSwith3episodesofcoffeegroundemesis,anemia,andtachycardiaWhatisthelikelyetiologyofthebleeding?Suspectpepticulcerdiseaseorgastritissummary-LearningObjectivesthedefinitionofhematemesis isvomitingofblood.whichcan
24、befreshandred,ordegradedbygastricpepsin,whenitisdarkbrownincolourandresemblescoffeegrounds.themajorcausesofhematemesisThemostcommoncausesofhematemesisarepepticulcer,gastritis,esophagealvaricesorlesions,andcancerofthestomachevaluationofhematemesisandmelena-colour/amount/accompanycomplaints/pasthistory/physicalexaminationdifferentitationofhematemesisandhemoptysis
