消化道出血呕血消化道出血-----呕血呕血病因病因病因病因病因一．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三．食管喷门粘膜撕裂综合征Mallory-weiss syndrome 食管喷门粘膜撕裂综合征Mallory-weiss syndrome 五．胃肿瘤胃黏膜损伤应激性病变食管损伤慢性胃食管反流四．The Dieulafoy's lesion is defined as a ruptured, thick-walled artery that is larger than other surrounding submucosal vessels, with little or no associated ulceration.  临床表现临床表现临床表现临床表现出血量的估计: 出血量的估计临床表现临床表现伴随症状: 伴随症状问诊要点便血( hematochezia) 病因病因病因Diverticular Bleeding   Diverticular Bleeding   Diverticular Bleeding   Angiodysplasia   Angiodysplasia   Neoplasms   Perianal Disease  肛周疾病Meckel's Diverticulum shows gastric mucosa  Meckel's Diverticulum  Meckel's Diverticulum  Inflammatory Bowel Disease   Colitis due to Ischemia, Infections, or Irradiation  临床表现临床表现临床表现伴随症状伴随症状问题: 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: ㈠排除消化道以外的出血因素⑴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. ⑵排除口、鼻、咽喉部出血:注意病史询问和局部检查. ⑶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. 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。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), 须经隐血试验才能确定者, 称为隐血便( stool with occult blood).  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,. 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. 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. 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% have 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 DIAGNOSIS Diverticulosis（憩室）43 Angiodysplasia（血管发育不良）20 Undetermined（不明原因） 12 Neoplasia（肿瘤） 9 Colitis（结肠炎）9  Radiation	 6  Ischemic 缺血性 2  Ulcerative	 1 Other（其它）7 Diverticular bleeding occurs in only 3% of patients with diverticulosis.  angiographic studies demonstrated that, despite the left-sided preponderance of diverticula, 70% of bleeding diverticula occur in the right colon. 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 risk. Among the 80% of patients in whom bleeding ceases, 75% will not have a recurrence, and 25% will have repeated episodes of diverticular hemorrhage. Vascular ectasias, or angiodysplasias, are common causes associated with aging. 2/3》70years。Angiodysplastic lesions are usually multiple, less than 5 mm in diameter, and involve primarily the cecum and right colon The pathogenesis of angiodysplasias is unknown.  46% of 80 patients with lower GI angiodysplasia presented with acute hemorrhage, and 54% presented with chronic or occult blood loss.  usually present with small degrees of intermittent bleeding or hemoccult-positive stools. Hemorrhoids and anal fissures （痔和肛裂）are probably the most common causes of minor intermittent lower GI bleeding. . Most Meckel's diverticula remain asymptomatic common complication, usually occurs in childhood. Patients present with painless bleeding described as "currant jelly." The diagnosis can be made by radiolabeled technetium scanning. but false-negative scans are not uncommon, and false-positive scans have also been reported. 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. 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. * * 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. 	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 diagnosis 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 angiographer（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. 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. 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60%。门脉高压性胃病出血占肝硬化病人的20%。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3-20 mm, 宽2-3 mm.  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.  NSAIDs 酒精应急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. 1．呕血（hematemesis)：２．黑便( melena): 3．出血量的估计：４．伴随症状：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"  酸化正铁血红蛋白( hematin)  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). 出血量为10%-15%的血容量时,除头晕、畏寒外，多无血压、脉搏等的变化。急性失血症状:出血量达20%以上血容量时，则有头晕, 乏力, 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. 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. * * * * *