1、咯血、呕血、黑便Hemoptysis、Hematemesis、Hematochezia,湖北医药学院附属太和医院消化内科郜元军 博士 副教授,Intensive care,Where is the source of bleeding?,Empiric therapy,Diagnosis,Treatment,( 经验治疗 ),What is the causes of bleeding?,Is bleeding acute or chronic?,Recognition of hemorrhage,咯 血Hemoptysis,Bleeding below the level of the la
2、rynx that being coughed out Degrees: from blood-tinged sputum to massive gross blood, even leading to airway occlusion (apnea ) & shock. The latter is much less seen.,Definition,定义,咯血(hemoptysis)喉及喉以下呼吸道及肺任何部位出血经口排出者包括大量咯血、血痰或痰中带血大咯血时血液从口鼻涌出,常可阻塞呼吸道,造成窒息死亡,SmallSputum with blood、500ml/d,or 300500ml/
3、d,咯血的量与受损血管的性质与数量有关,与病情严重程度不完全一致,在咯血病人中,其死亡率与单位时间内的咯血量有关:,500ml,大咯血约占整个咯血病人的5,但死亡率高达732,Differentiating 鉴别,Upper airway bleedingHematemesis(呕血),Distinguished hemoptysis from hematemesis,Common causes 常见病因,Tracheobronchial diseases Bronchitis(支气管炎)、bronchiectasia(支扩)、tumorPulmonary diseases Infection
4、:TB(结核)、Pneumonia(肺炎)、Pulmonary abscess(肺脓肿) Immune diseases,Common causes,Cardiovascular disease MS(二狭)、 PE (肺梗死)、 PAH (原发性肺动脉高压)、 deformity of blood vessle (血管畸形) Other less seen disease coagulation abnormalities(凝血功能异常)、endometriosis (子宫内膜异位),Mechanism,肺部的血液来源于两条独立的血液循环系统,肺动脉及其分支 (Pulmonary Arter
5、y)Low pressure95,支气管血管系统(Bronchial Artery)High pressure5,临床的咯血90以上来自支气管循环。肺循环一般很少引起咯血,除非在结核空洞、坏死性的肺栓塞等,病因与发生机制,呼吸系统疾病支气管疾病:支扩、肺癌炎症、肿瘤损伤支气管粘膜病灶处毛细血管通透性增加粘膜下血管破裂肺部疾病:肺结核、肺炎、肺脓肿毛细血管通透性增高,血液渗出-痰中带血丝小血管因病变侵蚀破裂 -中等量出血空洞壁小动脉瘤破裂,或继发性支扩形成的动静脉瘘破裂-大量咯血,病因与发生机制,心血管疾病二尖瓣狭窄、原发性肺动脉高压症、高血压性心脏病、肺梗死肺淤血致肺泡壁或支气管内膜毛细血管破
6、裂出血支气管粘膜下层支气管静脉曲张破裂出血急性肺水肿或急性左心衰竭时,咳浆液性粉红色泡沫样血痰,各种原因在咯血中所占的比重,国外456例患者的病因分布: 结核:44(201) 支气管、肺部炎症:43(197) 肺癌:7(32) 其他:5(26) (Michael L, et al. Crit Care Med 1985;13 -443) : 438,国内917例患者的病因分布: 支气管、肺部炎症:44.1% 肺癌:34.6% 肺结核:8.2% 支扩:4.4%,国内另一组5488例患者病因分布 恶性肿瘤:44.6% 支气管、肺部炎症:35.3% 肺结核:5.8% 支扩:4.3%,在大咯血病人中:
7、 1. 支扩:30 2. 肺癌:20 3. 肺结核:1520,Manifestation 临床表现,1、年龄 2、咯血量 3、颜色和性状,1.年龄,青壮年 常见于肺结核、支气管扩张症、二尖瓣狭窄等40岁以上有长期吸烟史 支气管肺癌儿童 慢性咳嗽伴少量咯血与低色素贫血,须注意特发性含铁血黄素沉着症的可能,痰 中 带 血肺癌、肺结核、慢支、肺炎、 支气管结核、结石少 量 咯 血肺结核、肺脓肿中等量咯血肺结核、支扩、二尖瓣狭窄大 咯 血支扩、肺结核空洞、晚期肿瘤,2.咯血量,临床表现,鲜红色 肺结核、支气管扩张、出血性疾病铁锈色血痰 肺炎链球菌肺炎砖红色胶冻样痰 典型的肺炎克雷伯杆菌肺炎暗红色 二尖
8、瓣狭窄粉红色泡沫痰 左心衰所致肺水肿粘稠暗红色血痰 肺梗死,3.颜色和性状,咯血的伴随症状,发热:肺结核、肺炎、肺脓肿、流行性出血热胸痛:肺炎、肺梗塞、肺癌、肺结核呛咳:肺癌、支原体肺炎脓痰:支扩、肺脓肿、肺结核空洞皮肤粘膜出血: 血液病、风湿病及肺出血型钩端螺旋体病和流行性出血热杵状指: 支气管扩张症、肺脓肿、支气管肺癌黄疸: 钩端螺旋体病、肺炎球菌肺炎、肺梗死,【问诊要点】,确定是否咯血 发病年龄及咯血性状 伴随症状 个人史,呕 血 与 便 血hematemesis and hematochezia,Patients manifest blood loss,1) Hematemesis 呕
9、 血 Bloody vomitus, either fresh and bright red or older and “coffee -ground” (hematin 酸化正铁血红素) in character Hemoptysis? Nosebleeding?,Manner of bleeding presentation,from the GI tract in five ways:,2) Melena 黑 便 Shiny, black, sticky, foul-smelling stool degradation of blood exogenous stool darkeners
10、 iron bismuth (铋剂),Manner of bleeding presentation,Manner of bleeding presentation,3)Hematochezia 便 血 bright red or maroon blood from the rectum pure blood blood intermixed with formed stool bloody diarrhea,Manner of bleeding presentation,4)Occult 隐 血 detected only by testing the stool with a monocl
11、onal antibody for human hemoglobin,Estimate amount of bleeding from upper GI tract,510 ml/d OB + 5070 ml/d Melena 250300 ml in short time Hematemesis,Manner of bleeding presentation,without any objective sign of bleeding with symptoms of blood loss dizziness, dyspnea, angina cordis (心绞痛), or even sh
12、ock digital examination (指检) of the rectum,呕 血 hematemesis,一、定义(Definition),Bleeding that being vomited, with upper gastrointestinal or systemic diseases Often with melena(黑便)Acute circulatory failure (急性周围循环衰竭),假性呕血药物及食物 呕血与咯血的鉴别,Differentiating(鉴别),二、病因(causees),What is the causes of upper GI blee
13、ding?,90% upper GI bleeding is due to four lesions in China: 1) peptic ulcer (消化性溃疡)2) acute gastric mucosal lesion (急性胃粘膜病变)3) esophageal or gastric varices (静脉曲张) 4) gastric cancer,(一)食管疾病 食管静脉曲张破裂(esophageal or gastric varices) 食道贲门粘膜撕裂(Malloy-Weiss tear) 食管裂孔疝 反流性食管炎 食管癌,(二)胃及十二指肠疾病,(三)胆道出血,(四)胰
14、腺疾病,1、慢性胰腺炎 2、急性胰腺炎 3、胃泌素瘤(Zollinger-EllisonS) 4、胰腺癌,(五)全身性疾病 (六)急性传染病 血液系统疾病 流行性出血热 尿毒症 钩体病 重症肝炎,三、临床表现(Manifestation),(一)消化道局部症状 Abdominal discomfort Nausea, hematemesis, malena,1.上消化道出血是否呕血取决于出血量:300ml部 位:幽门以上部位出血量小或速度较慢可不呕血幽门以下病变如十二指肠病变出血量大、速度快,血液可反流入胃而呕出,2、上消化道出血呕血的颜色取决于量和时间 量小、时间长为咖啡色 量大、时间短为鲜
15、红色Hb+HCl 正铁血红蛋白 咖啡色3、呕血后4小时即可出现黑便 结肠段Hb+硫化物 硫化亚铁 柏油样,(二) 全身症状,1、失血性贫血Anemia,paledizzinesspalpitation,easy fatigabilitydyspnea angina cordis,2、循环衰竭失血性休克Hypovolemia or shock,Speed and volume of blood lossWeakness, giddiness (眩晕), oliguria, (少尿) cold extremity(四肢阙冷), sweatingVital signs: tachycardia (心
16、动过速) , hypotention (低血压),(三)血象变化及氮质血症,早期可无明显变化3-4h 后,Hb和Hct下降BUN和Cr渐升高,四、 伴随症状(accompanying symptom),1.上腹痛中青年人慢性反复发作周期性,节律性消化性溃疡(Peptic ulcer)?中老年人慢性上腹痛无规律,厌食,消瘦胃癌(gastric cancer)?,2、肝脾肿大 蜘蛛痣,肝掌 腹壁静脉曲张 脾大,腹水 肝硬化(cirrhosis)? 肝大,肝区痛 肝区结节,质硬肝癌(hepatic carcinoma)?,3.黄疸 黄疸、寒战,发热伴右上腹绞痛 胆道疾病? 黄疸、发热,全身皮肤出血倾
17、向 感染性疾病? 4、皮肤黏膜出血血液病,5、其他: 非甾类药 大面积烧伤 颅脑手术 严重外伤伴呕血急性胃粘膜病变AGML 剧烈呕吐后呕血贲门粘膜撕裂Malorry Weiss Syndrome,6、头晕、黑朦、口渴、冷汗 血容量不足 肠鸣、黑便或便血 活动性出血,五 问诊要点,确定是否呕血 呕血的诱因 呕血的颜色 伴随症状 既往病史,便 血 Hematochezia,便血指消化道出血,血液由肛门排出,颜色可呈鲜红、暗红、或柏油样隐血:消化道出血量小,肉眼看不到粪便颜色的改变,须隐血试验确定,上消化道疾病小肠疾病肠结核、肠伤寒、急性出血坏死性肠炎、小肠肿瘤、肠套叠结肠疾病急性菌痢、阿米巴痢疾、
18、溃疡性结肠炎、结肠癌直肠肛管疾病直肠息肉、直肠癌、痔疮、肛裂全身性疾病肝病、血液病、传染病,一、病 因,痔疮,溃疡性结肠炎,大肠癌,憩室炎,肠道息肉,血管畸形,二、临床表现,便血颜色 出血部位 出血量 血液在肠腔停留时间长短性状 柏油便 潜血试验 OB 抗人Hb单克隆抗体,几种特殊性状的血便,黏液脓血便急性菌痢暗红色果酱样脓血便阿米巴痢疾洗肉水样血便,并有特殊腥臭味急性出血坏死性肠炎血色鲜红不与粪便混合 痔疮、肛裂、直肠肿瘤,(三)伴随症状,1.腹痛慢性、周期性、节律性,出血后疼痛减轻 消化性溃疡上腹绞痛、黄疸伴便血 胆道出血腹痛时排血便或脓血便,便后腹痛减轻 痢疾、溃结其他急性出血性坏死性肠
19、炎、肠套叠、肠系膜血栓形成或栓塞等,伴随症状,2.里急后重 肛门、直肠疾病 痢疾、直肠炎、直肠癌3.发热 传染性疾病:败血症、流行性出血热、钩体病肿瘤:肠道淋巴瘤、白血病,伴随症状,4.全身出血倾向 急性传染病及血液病5.皮肤改变 蜘蛛痣、肝掌、毛细血管扩张6.腹块 肿瘤、肠结核、肠套叠、Crohn,四、问诊要点,1.便血的病因和诱因2.便血量3.患者一般情况4.过去有否腹泻、腹痛、痔疮、肛裂、抗凝药物、胃肠手术,Differentiating features of upper GI and lower GI bleedingUpper GILower GIManifestationHema
20、temesisHematocheziamelenaNasogastric aspirateBloodyClearBUNElevatedNormalBowel soundHyperactiveNormal,医源性出血(iatrogenic bleeding),Diagnostic(诊断)Therapeutic(治疗),便 秘Constipation,Definition-simple,Frequency Stools less frequent than 3 per weekProcess Straining(费力)Stool signature Hard or lumpy(多块状) stool
21、s,Definition-complicated,Straining in 25% of movementsFeeling of incomplete evacuation(不尽感) after 25% Sense of anorectal obstruction / blockade in 25% Manual manoeuvres(人工) to help in 25%Hard or lumpy stools in 25%Stools less frequent than 3 per week(2+ for at least 3months during the last year),Epi
22、demiology(流行病学),Chronic constipation is commonSlightly more common in women F/M ratio = range 1.3 to 2.5Affects all age groups,Causes(病因),Functional(功能性)Organic (器质性),Functional,Decreased exercise(锻炼)Not eating enough fibre(纤维)Not drinking enough fluid(液体)Depression / grief / anxiety(抑郁、悲伤、焦虑)Motili
23、ty(动力) disorder: IBS(肠易激综合征),Organic,Anal sphincter spasm: proctitis(直肠炎), anal fissure(肛裂)Powerless evacuation: ascites(腹水), systemic sclerosis (硬皮病)Obstruction: Benign stricture(良性狭窄), malignancy(恶性疾病)Systemic diseasesDrugs,Systemic diseases,Peripheral neurogenic Hirschsprungs(先天性巨结肠), autonomic n
24、europathy(自主神经疾病), Diabetes(糖尿病), pseudo-obstruction(假性肠梗阻)Central neurogenic Parkinsons(帕金森病), multiple sclerosis(多发性硬化), spinal cord injury(脊髓损伤)Non-neurogenicHypothyroidism(甲减), hypercalcaemia(高钙血症), panhypopituitarism(垂体功能减退), pregnancy(怀孕), anorexia nervosa(神经性厌食), systemic sclerosis(硬皮病),Drugs
25、,ANALGESICS(镇痛药)Opiates! (this includes tramadol)ANTICHOLINERGICS(抗胆碱药)Antispasmodics, antidepressants, antipsychoticsCATION-CONTAINING(阳离子结合剂)Iron supplements, antacids, NEURALLY ACTIVE(神经活性药)Ca+blockers, 5HT3 antagonists,Constipation Is a Constellation of Symptoms,Most commonly reported symptomsHa
26、rd, lumpy stoolsIncreased strainingInfrequent bowel movementsSensation of incomplete evacuationBloating/fullness(腹胀)Chronic constipationMore persistent than intermittent or episodicSeveral months duration,Accompanying symptoms,Vomiting, abdominal blotting, intestinal colic: intestinal obstruction(肠梗阻)Abdominal mass: tumor, TB(结核), Crohn disease(克罗恩病)Alternating of diarrhea and constipation: intestinal TB, UC(溃疡性结肠炎), IBSDepression / grief / anxiety: functional,Main points of inquiring,Stool signature and the process of passageDrug usageOther diseases,谢谢,
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