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1、上消化道出血Withtheinvertedgastroscopeaspurtinghemorrhagefromafundalvariceisdiscerbnable.HemostasisisachievedwithseverallowvolumeinjectionsofHistoacryl-glue.Therightpictureshowsthetherapeuticsuccess.Thismassivevesselwithactivebleedingwasdiagnosedina58year-oldpatient,whopresentedwith
2、tarystools.Thefirstpictureshowsthelesionafterinjectionoffibringlue.Therightpictureshowsadditionallyappliedhemoclips.Bleedingstoppedattheendoftheprocedure,butreccurredtwicebeforethepatienthadtobetreatedsurgically.Indieu-la-foyulcersanarterialvesselofabnormalsizereachesthemucosa
3、causingatinyulzerationbypermanentcompressionofthemucosallayer.EsophagealvaricesgradeII(right)undgradeIII(left).Cherryredspotsaresignsofimminenthemorrhage(right).Theycorrespondtoareasofespeciallythinandalteredvaricealwall.Thisduodenalulcerattheleftedgeofthefigure,showsanoozing,
4、activebleeding.AccordingtotheForrestclassificationofgastrointestinalhemorrhageoftheupperGI-tract,thisbleedingisgradedasForrestIb.Thevisiblevesselistreatedbyprimaryapplicationofahemoclip.Atthe3weekfollow-up(fig)theClipisstillintheoriginalposition.Theulcershowsaprogressivehealin
5、g.Inoperablecholedochalcancer.Awallstenthadbeeninserted3monthsearlier.Thepatientwasadmittedforseverehemorrhage,whichwasendoscopicallyprovedtooriginatefromthebiliaryduct.Thehemorrhagewasnotamenabletoendoscopyandsurgery.Hugebloodclotsprolapsefromthebiliaryduct.临床表现呕血与黑粪失血性周围循环衰竭
6、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＞5~10ml黑粪50~100ml呕血250~300ml出现全身症状400~500ml周围循环衰竭＞1000ml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HbRBC继续下降,Ret持续升高补
7、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(24~48hr)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＞15~20mmHg,心率上升＞10次/分收缩压＜90mmHg(或较基础下降
8、25%)Hb＜7g/L或Hct＜25%治疗止血措施食管胃底静脉曲张破裂大出血------出血量大,再出血率高,死亡率高治疗
