1、Diagnosis of Gastrointestinal Bleeding,Hematemesis and Hematochezia 呕血与便血,The approach to gastro-intestinal (GI) bleeding is tailored to the manner of appearance.,Is bleeding acute or chronic?,Intensive care,Where is the source of bleeding?,Empiric therapy,Diagnosis,Treatment,( 经验治疗 ),What is the ca
2、uses of bleeding?,Recognition of hemorrhage,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,Clinical Manifestations,1 Manner of bleeding presentation 2 Hypovolemia (低血
3、容量) or shock 3 Anemia (贫血),Recognition of hemorrhage,Patients manifest blood loss,1) Hematemesis 呕 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) M
4、elena 黑 便Shiny, black, sticky, foul-smelling stool degradation of blood exogenous stool darkenersiron bismuth (铋剂),Manner of bleeding presentation,Manner of bleeding presentation,3) Hematochezia 便 血bright red or maroon blood from the rectumpure bloodblood intermixed with formed stool bloody diarrhea
5、,Manner of bleeding presentation,4) Occult 隐 血detected only by testing the stool with a monoclonal 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 sig
6、n of bleeding with symptoms of blood lossdizziness, dyspnea, angina cordis (心绞痛), or even shock digital examination (指检) ofthe rectum,Hypovolemia or shock,Speed and volume of blood lossWeakness, giddiness (眩晕), oliguria, (少尿) cold extremity, sweatingVital signs: tachycardia, (心动过速) hypotention (低血压)
7、,Anemia,pale dizziness palpitation,easy fatigability dyspnea angina cordis,Is bleeding acute or chronic?,1) Bleeding speed Hematemesis of fresh blood generally indicates a more severe bleeding episode than melena, which occurs when bleeding is slow enough to allow time for degradation of blood,Is bl
8、eeding acute or chronic?,2) Hematocrit bleeding slowly hypochromic (血红蛋白过少)microcytic (小细胞) red blood cells mean corpuscular volume (MCV， 平均血球压积) of the cells may be low,Is bleeding acute or chronic?,If blood loss is acute, the hematocrit dose not change during the first few hours after hemorrhage A
9、bout 24 to 72 hours later, plasma volume is larger than normal and the hematocrit is at its lowest point,Is bleeding acute or chronic?,Hematocrit changes A Before bleeding B Immediately after bleeding C 2472 hours after bleeding,Is bleeding acute or chronic?,3) Blood pressure and heart rate depend o
10、n amount of blood losssuddenness of blood loss extent of cardiac and vascularcompensation,postural hypotension - early physical finding tachycardia - greater loss, compensate recumbent (卧位) hypotension - final results,Is bleeding acute or chronic?,Is bleeding acute or chronic?,Postural hypotension A
11、 postural drop in blood pressure of 10 to 15 mm Hg,Is bleeding acute or chronic?,4) Bowel sound Active bowel sound usually be presented in acute bleeding from GI tract,Emergent and intensive care,Initiallyvital signssupine and upright blood pressure pulse,If blood loss is significant, intravenous fl
12、uids must be started,Saline or other balanced electrolyte solutions are most rapidly available,Blood is sent to the lab. complete blood countclotting studiesroutine chemistry studies. Blood for typing and cross- matching is sent to the blood bank.,Where is the source of bleeding? Localization,Upper
13、GI bleeding: bleeding from a source proximal to the ligament of Treitz. Lower GI bleeding: bleeding from a site distal to the ligament of Treitz.,Localization,Treitz: The ligament of Treitz is an anatomic landmark for the duodenal-jejunal junction.,Localization,Differentiating features of upper GI a
14、nd lower GI bleedingUpper GI Lower GI Manifestation Hematemesis Hematochezia melena Nasogastricaspirate Bloody Clear BUN Elevated Normal Bowel sound Hyperactive Normal,Upper GI tract bleeding ?,Clinical manifestation Bowel sound Nasogastric tube,Hematemesis,Melena,Hematochezia,More proximal lesions
15、produce hematemesis or melena, whereas more distal lesions are more likely to produce hematochezia.,If hematochezia is from an upper GI source, it usually reflects a massive bleed (i. e. , greater than 1000 ml).,What is the causes of bleeding?,90% upper GI bleeding is due to four lesions: 1) peptic
16、ulcer (消化性溃疡) 2) hemorrhagic gastritis (胃炎) 3) esophageal or gastric varices ( 静脉曲张) 4) gastric cancer,peptic ulcer,hemorrhagic gastritis,esophageal varices,gastric cancer,Causes of gastrointestinal bleeding,Mallory-Weiss tear食道 - 贲门撕裂伤,Causes of gastrointestinal bleeding,Portal-hypertensive gastrop
17、athy 门脉高压胃病 Ancylostomiasis 钩虫病 Post-sphincterotomy 括约肌切开术后,Causes of gastrointestinal bleeding,Colorectal cancerColitisLarge hemorrhoid 大痔Rectum tear 肛裂Vascular anomaliesHematologic diseases,Diagnostic approach to gastrointestinal bleeding,1 History and physical examination 2 Endoscopy 3 Barium rad
18、iography 4 Angiography 5 Nuclear scintigraphy,History and physical examination,A history of previously docu-mented GI tract disease determined by radiography, endoscopy, or surgical procedures is very useful.,Diagnostic approach to GI bleeding,Diagnostic approach to GI bleeding,Patients with hepatit
19、is B or chronic active liver disease may present with painless hematemesis from esophageal varices.,Diagnostic approach to GI bleeding,Patients with forceful, retching (干呕) or multiple episodes of vomiting of food prior to the onset of hematemesismay be bleeding from MalloryWeisstears of the gastroe
20、sophageal junction.,Diagnostic approach to GI bleeding,A history of epigastric (上腹部) burning pain promptly relieved by foodor antacids (抗酸剂) or nocturnal (夜间) pain suggests peptic ulcer disease,particularly duodenal (十二 指肠) ulcer.,Diagnostic approach to GI bleeding,Colorectal malignancy is often sug
21、geste by a history of gradual weight lossintermittent blood in the stoolsaltered bowel habits,Diagnostic approach to GI bleeding,Hemorrhoidal bleeding is often suggested by the presence of bright red blood surrounding well-formed, normal-appearing stools.,Diagnostic approach to GI bleeding,Patients
22、with stigmata (特征) of chronic liver disease e.g., spider angioma (蜘蛛痣), ascites (腹水), gynecomastia (男性乳房发育) and upper GI bleeding often bleed from esophageal varices or erosion (糜烂).,Diagnostic approach to GI bleeding,Localized epigastric tenderness (触痛) to palpation may indicate peptic ulcer diseas
23、e or gastritis.,Diagnostic approach to GI bleeding,Occasionally patients with lower GI tract bleeding from a malignancy have a palpable lower abdominal mass, hepatomegaly (肝肿大)，signs of obvious weight loss.,Diagnostic approach to GI bleeding,A rectal examination is essen-tial to document stool color
24、 as well as to palpate for gross ano-rectal (肛直肠) mass lesions such as polyps, cancers, or large hemorrhoids.,Diagnostic approach to GI bleeding,Endoscopy (内镜)Endoscopy is the diagnosticprocedure of choice because ofits high accuracy and immediate therapeutic potential. Endoscopy , however , must be
25、 Performed only following adequate resuscita- tion (复苏).,Diagnostic approach to GI bleeding,EndoscopyContraindications：acute myocardial infarction severe chronic lung disease hemodynamic instabilitypatient agitation (焦虑不安)terminal malignancy,Diagnostic approach to GI bleeding,Barium radiography (钡餐)
26、Barium radiography is noninvasive but has significant disadvantages, particularly in patients who are bleeding briskly (actively).,Diagnostic approach to GI bleeding,Angiography (血管造影)Angiography may localize the site of bleeding.,Diagnostic approach to GI bleeding,AngiographyBleeding must be active
27、 because angiography detects only extravasation (外渗) of contrast (造影剂) into the GI tract.,思考题：,胃肠道出血有哪些表现形式？ 胃肠道出血的病因有哪些？ 对胃肠道出血的诊断通常采用哪些方式？,References： Textbook of physical diagnosis. 4th edition. MH Swartz.Elsevier science. 2002. Sleisenger & Fordtrans Gastrointestinal and liver disease. 6th edition. M Feldman, BF Scharschmidt, MH Sleisenger.W.B.Saunders, 2001. physical Diagnosis ， Fourth Edition, Jo-Ann Reteguiz,M.D., McGraw-Hill,
