1、消化道出血,呕血,消化道出血-呕血,呕血(hematemesis):是由上消化道疾病或全身性疾病所致的急性上消化道出血.上消化道指屈氏韧带以上的消化器官, 包括食管, 胃, 十二指肠, 肝, 胆, 胰及部分空肠.,呕血,上消化道出血的死亡率在最近的40年中仍维持在8%-10%。The mortality rates from upper GI hemorrhage have remained stable at 8% to 10% during the last 40 years.,内窥镜及其治疗技术的出现使严重出血得到早期诊断及治疗，使死亡率降低。Early and accurate dia
2、gnosis of patients with severe bleeding can facilitate therapeutic maneuvers, leading to lower mortality rates.This trend appears to have occurred with the use of therapeutic endoscopic techniques.,对出血的诊断、治疗及预防之前，病人的血液动力学必须稳定。Despite the increasing armamentarium of the therapeutic endoscopist and an
3、giographer（血管造影）, the cornerstone of management for GI hemorrhage remains rapid assessment of the patient with appropriate resuscitation. The patient must be hemodynamically stabilized before diagnosis, therapy, and prevention of rebleeding can begin.,病因,1.食管疾病2.胃及十二指肠疾病3.肝、胆道疾病4.胰腺5.血液疾病6.急性传染病7.其它
4、,病 因,1. 食管疾病 食管静脉破裂 食管炎 食管癌 食管异物 Mallory-weiss 综合征,病因,2.胃及十二指肠疾病 消化性溃疡 慢性胃炎 急性胃粘膜病变 胃癌 胃粘膜脱垂 胃动脉硬化,Dieulafoy病 十二指肠炎等,病因,3. 肝, 胆道疾病 胃底及食管静脉曲张破裂出血 肝脏及胆道疾病引起的出血, 大量血液流入十二指肠, 造成呕血或便血. 如: 肝癌, 肝脓肿或肝动脉瘤破裂出血; 胆囊, 胆道结石, 胆道寄生虫(蛔虫), 胆囊癌, 胆管癌及壶腹癌均可引起出血.,病因,4.胰腺疾病 急性胰腺炎合并脓肿破裂出血, 胰腺癌.5.血液疾病 遗传性毛细血管扩张症, 抗凝药过量等.6.急
5、性传染病 流行性出血热, 钩短螺旋体病, 登革热, 暴发性肝炎.7.其他 尿毒症, 结节性多动脉炎,一消化性溃疡（Peptic Ulcers ）,胃、十二指肠球部溃疡NASAIDs (non-steroidal antiinflammatory drugs (NSAIDs), including aspirin.) 占上消化道出血的50%，占急性上消化道出血死亡率的6%。,二. 门脉高压症（Portal Hypertension）,胃底食管静脉曲张破裂出血门脉高压性胃病,食管静脉曲张出血约占急性上消化道出血的10%，死亡率占急性上消化道出血的15%。如果不治疗，再出血率占50%1年的死亡率占6
6、0%。门脉高压性胃病出血占肝硬化病人的20%。,三食管喷门粘膜撕裂综合征Mallory-weiss syndrome,剧烈干呕, 呕吐, 和腹内压骤然增加的情况下, 可造成胃的贲门,食管远端的粘膜和粘膜下层撕裂, 并发大量出血. 主要病理所见是食管和胃的交接处和食管远端粘膜和下层的纵行裂伤. 裂伤多为单发, 但也可为多发. 裂伤一般长3-20mm, 宽2-3mm.,食管喷门粘膜撕裂综合征Mallory-weiss syndrome,因为是动脉出血, 所以出血量大, 严重时可引起休克和死亡. 但有些病例出血很少, 甚至仅在呕吐物含有血丝, 或仅有黑便而无呕血.,五胃肿瘤,胃黏膜损伤,NSAIDs
7、酒精应急,应激性病变,1.颅内疾病与严重损伤. Cushing溃疡2.烧伤. Curling溃疡3.多器官功能衰竭,食管损伤,慢性胃食管反流,四The Dieulafoys,lesion is defined as a ruptured, thick-walled artery that is larger than other surrounding submucosal vessels, with little or no associated ulceration.,呕血的原因以消化性溃疡引起最为多见.其次为胃底或食道静脉曲张破裂再次为急性胃粘膜病变.,临床表现,1呕血（hemateme
8、sis)：黑便(melena):3出血量的估计：伴随症状：,临床表现,呕血（HEMATEMESIS）： 血色为鲜红或混有凝血块 bright red blood 或为咖啡渣样棕褐色 or coffee grounds,临床表现,酸化正铁血红蛋白(hematin),临床表现,黑便 (menela): 血红蛋白在肠道内与硫化物结合形 成硫化亚铁,故粪便成黑色,更由于附有粘液而发亮,类似柏油, 故又称柏油样便 (tarry stool).,出血量的估计:,出血量为10%-15%的血容量时,除头晕、畏寒外，多无血压、脉搏等的变化。,出血量的估计,急性失血症状:出血量达20%以上血容量时，则有头晕, 乏
9、力, 出汗, 四肢冷厥, 心慌, 脉搏增快等.急性周围循环衰竭的表现: 出血量在30%以上，出现脉搏频数微弱, 血压下降, 呼吸急促, 及休克等.,临床表现,血液学改变: 血红蛋白及红细胞可逐渐降 低. 出血早期不能仅靠血液学改变来判断出血量.,临床表现,氮质血症1.肠道性氮质血症2.肾性氮质血症 在严重失水和血压降低的情况下, 由于缺血、缺氧和低血容量,肾血流量、肾小球滤过率肾排泄功能均降低,因而产生氮质血症. 急性肾功能衰竭,伴随症状:,1.上腹痛: 消化性溃疡 胃癌2.肝脾肿大: 胃底食道静脉破裂 肝癌,伴随症状,3.黄疸: 肝胆疾病, 感染性疾病, 如败血症, 及钩端螺旋体病.4.皮肤
10、粘膜出血: 血液及凝血功能障碍的疾病5.其他: 急性胃粘膜病变, Mallory-weiss综合征.,在诊断上消化道出血的诊断过程中,必须注意以下几个问题: 排除消化道以外的出血因素 排除来自呼吸道出血: 大量咯血时, 可吞咽 入消化道,而引起呕血或黑便. 排除口、鼻、咽喉部出血:注意病史询问和 局部检查. 排除进食引起黑便:如动物血, 炭粉, 含铁剂 的药物或含铋剂的药物.,问诊要点,1.确定是否呕血2.呕血的原因3.颜色4.呕血量5.一般情况6.既往史、用药情况。,便血(hematochezia),消化道出血, 血液由肛门排出成为便血. 便血颜色可以实现红, 暗红或黑色(柏油便), 须经隐
11、血试验才能确定者, 称为隐血便(stool with occult blood).,病 因,1. 上消化道疾病2. 小肠疾病 肠结核 , 肠伤寒, 急性出血性坏死性胰腺炎, 小肠肿瘤, Crohn病, 小肠血管瘤, 空肠憩室炎或溃疡, 肠套叠,.,病因,3. 结肠疾病 急性细菌性痢疾, 阿米巴性痢疾, 非特异性溃疡性结肠炎, 结肠憩室炎, 结肠癌, 结肠息肉病, 缺血性肠炎.4. 直肠肛管疾病 直肠肛管损伤, 非特异性直肠炎, 直肠息肉, 直肠癌, 痔, 肛裂, 肛瘘.,病因,5. 感染出血 肠伤寒, 副伤寒, 钩端螺旋体病, 流行性出血热, 重症肝炎, 败血症, 血吸虫病, 钩虫病等.6.
12、全身性疾病 白血病, 血小板减少性紫癜, 过敏性紫癜, 血友病, 遗传性毛细血管扩张症, 维生素C及K缺乏症, 肝脏疾病等.,The most common causes of chronic lower GI bleeding are hemorrhoids （痔）and colonic neoplasia（结肠新生物）. As is the case with upper GI bleeding, 80% of bleeding episodes resolve spontaneously. Among the patients in whom bleeding ceases, 25% h
13、ave recurrent bleeding. Unlike upper GI bleeding, most lower GI bleeding is slow and intermittent and does not require hospitalization.,Final Diagnoses of acute lower GI bleeding of Major Lower Gastrointestinal Bleeding DIAGNOSIS PERCENT OF TOTAL DIAGNOSISDiverticulosis（憩室） 43Angiodysplasia（血管发育不良）
14、20Undetermined（不明原因） 12Neoplasia（肿瘤） 9Colitis（结肠炎） 9 Radiation 6 Ischemic缺血性 2 Ulcerative 1Other（其它） 7,Diverticular Bleeding,Diverticular bleeding occurs in only 3% of patients with diverticulosis. angiographic studies demonstrated that, despite the left-sided preponderance of diverticula, 70% of bl
15、eeding diverticula occur in the right colon.,Diverticular Bleeding,Diverticular bleeding presents with acute, painless, maroon栗色的 to bright red hematochezia, although melanic stools may occur.The degree of blood loss is often significant and may not be well tolerated by the elderly population at ris
16、k.,Diverticular Bleeding,Among the 80% of patients in whom bleeding ceases, 75% will not have a recurrence, and 25% will have repeated episodes of diverticular hemorrhage.,Angiodysplasia,Vascular ectasias, or angiodysplasias, are common causes associated with aging. 2/370years。Angiodysplastic lesion
17、s are usually multiple, less than 5 mm in diameter, and involve primarily the cecum and right colon The pathogenesis of angiodysplasias is unknown.,Angiodysplasia,46% of 80 patients with lower GI angiodysplasia presented with acute hemorrhage, and 54% presented with chronic or occult blood loss.,Neo
18、plasms,usually present with small degrees of intermittent bleeding or hemoccult-positive stools.,Perianal Disease 肛周疾病,Hemorrhoids and anal fissures （痔和肛裂）are probably the most common causes of minor intermittent lower GI bleeding.,Meckels Diverticulum shows gastric mucosa,Meckels Diverticulum,. Mos
19、t Meckels diverticula remain asymptomatic common complication, usually occurs in childhood.Patients present with painless bleeding described as currant jelly.,Meckels Diverticulum,The diagnosis can be made by radiolabeled technetium scanning. but false-negative scans are not uncommon, and false-posi
20、tive scans have also been reported.,Inflammatory Bowel Disease,The blood is usually mixed in with the stool and is associated with other symptoms of the disease such as diarrhea, tenesmus里急后重, and pain.,Colitis due to Ischemia, Infections, or Irradiation,临床表现,便血 下消化道出血, 如出血量多则呈现红, 若停留时间较长, 则为暗红色. 肛门
21、或肛管疾病出血, 如痔, 肛裂或直肠肿瘤引起的出血, 表现为血色鲜红不与粪便混合, 仅粘附于粪便表面或于排便后有鲜血滴出或喷射者.,临床表现,出血量不多则全身症状不明显如短期内出血量多, 则可出现贫血及周围循环衰竭症状.,临床表现,上消化道出血或小肠出血并在肠道停留时间较长, 表现为黑便或柏油样便. 阿米巴痢疾为暗红色果酱样的脓血便. 急性细菌性痢疾为粘液脓性血便. 急性出血性坏死性肠炎可排出洗肉水养粪便, 并有特殊的腥臭味.,伴随症状,1. 腹痛 上腹绞痛: 肝胆道出血. 腹痛伴便血: 急性出血性坏死性肠炎. 慢性反复上腹痛, 且呈周期性与规律性, 出血后痛减轻者, 见于消化性溃疡. 腹痛时
22、排脓血便, 便后腹痛减轻者, 见于细菌性或阿米巴性痢疾, 也见于溃疡性结肠炎. 排血便后腹痛不减轻者, 常为小肠疾病.,伴随症状,2.里急后重(tenesmus),提示肛门, 直肠疾 病, 见于痢疾, 直肠炎及直肠癌.3.发热 传染性疾病或恶性肿瘤, 如败血症, 流行性出血热, 钩端螺旋体病, 胃 癌, 结肠癌等.4.全身出血倾向,5.皮肤改变 蜘蛛痣及肝掌者, 可能与肝硬化门脉高压有关. 皮肤与粘膜出现成簇的, 细小的呈紫红色或鲜红色的毛细血管扩张症.6.腹部肿块 小肠恶性淋巴瘤, 结肠癌, 肠结核, 肠套叠及Crohn病等.,判断上消化道还是下消化道出血鉴别要点 上消化道出血 下消化道出血 既往史 多曾有溃疡病, 多曾有下腹部疼痛 肝,胆疾患病史 包块及排便异常 或有呕血史. 病史或便血史.出血先兆 上腹部闷胀,疼 中、下腹不适或 痛或绞痛,呕心 下坠, 欲排大便 反胃出血方式 呕血伴柏油样便 便血,无呕血便血特点 柏油样便,稠或 暗红或鲜红,稀 成形,无血块. 多不成形,大量出 血时可有血块.,急性上消化道出血的临床表现?如何估计急性上消化道出血的出血量?上消化道出血的常见原因有哪些?如何确定出血的部位与原因?,问题:,便血有哪些表现?柏油样便是怎样形成的?,
