简介常见病因* * 上消化道出血中山大学附属第一医院高翔上消化道出血: Treitz 韧带以上的消化道引起的出血:食管,胃,十二指肠,胰,胆,胃空肠吻合术后的空肠病变下消化道出血: Treitz 韧带以下的消化道引起的出血上消化道出血引起的大量出血较下消化道更为常见大量出血:短期内失血超过1000 ml 或循环血量20% 消化性溃疡(十二指肠和胃) 33-51% 食管和胃静脉曲张23-33% Mallory-Weiss 综合征	3-10% 胃或十二指肠糜烂		1-19% 血管瘤				0-7% 肿瘤		  		 1-5% With the inverted gastroscope a spurting hemorrhage from a fundal varice is discerbnable. Hemostasis is achieved with several low volume injections of Histoacryl - glue. The right picture shows the therapeutic success. There are blood covered errosions throughout the whole stomach. This has led to a upper GI hemorrhage compromising the patient hemodynamically. The sole reason was a single ingestion of 400 mg of ibuprofen This massive vessel with active bleeding was diagnosed in a 58 year- old patient, who presented with tary stools. The first picture shows the lesion after injection of fibrin glue. The right picture shows additionally applied hemoclips. Bleeding stopped at the end of the procedure, but reccurred twice before the patient had to be treated surgically. In dieu-la-foy ulcers an arterial vessel of abnormal size reaches the mucosa causing a tiny ulzeration by permanent compression of the mucosal layer.  Esophageal varices grade II (right) und grade III (left). Cherry red spots are signs of imminent hemorrhage (right). They correspond to areas of especially thin and altered variceal wall.  This duodenal ulcer at the left edge of the figure, shows an oozing, active bleeding. According to the Forrest classification of gastrointestinal hemorrhage of the upper GI- tract, this bleeding is graded as Forrest Ib. The visible vessel is treated by primary application of a hemoclip. At the 3 week follow- up (fig )the Clip is still in the original position. The ulcer shows a progressive healing.  Inoperable choledochal cancer. A wall stent had been inserted 3 months earlier. The patient was admitted for severe hemorrhage, which was endoscopically proved to originate from the biliary duct. The hemorrhage was not amenable to endoscopy and surgery. Huge blood clots prolapse from the biliary duct. 临床表现呕血与黑粪失血性周围循环衰竭血象变化发热氮质血症诊断思路是上消化道出血吗? 出了多少血? 出血停止了吗? 什么原因引起的出血? 上消化道出血的确立呕血和黑粪,失血性周围循环衰竭,血和粪便的检查早期识别:直肠指诊排除消化道以外的病因:咯血、口鼻咽出血、事物或药物出血量的估计粪便隐血试验阳性每日消化道出血＞5~10 ml 黑粪50~100 ml  呕血250~300 ml 出现全身症状400~500 ml 周围循环衰竭＞1000 ml 最有价值的标准:周围循环衰竭的临床表现动态观察血压和心率出血是否停止继续出血或再出血的表现: 反复呕血或黑粪周围循环衰竭经治疗后无改善或波动Hb\RBC 继续下降, Ret 持续升高补液与尿量足够的情况下,血尿素氮持续或再次升高出血后48小时以上未再继续出血,再出血可能性小; 既往有大出血史、本次出血量大、24小时内反复大量出血、食管胃底静脉曲张出血、有明显的高血压或动脉硬化者,再出血可能性大出血的病因病史实验室检查胃镜:首选;推畅急诊胃镜检查(24~48 hr) X 线钡餐其他:选择性动脉造影治疗原则: 抗休克,积极补充血容量一般的急救措施: 禁食,卧床休息,保持呼吸道通畅严密监测生命体征积极补充血容量:立即配血,输足量全血紧急输血指征: 改变体位出现晕厥,血压下降＞15~20 mmHg, 心率上升＞10次/分收缩压＜90 mmHg( 或较基础下降25%)  Hb＜7g/L 或Hct＜25%  治疗*