acute gastrointestinal and genitourinary disorders课件

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1、AcuteGastrointestinalandGenitourinaryDisordersChristianaE.Hall,MDMSDivisionofNeurocriticalCareUniversityofTexasSouthwesternMedicalCenterDallas,TexasUpper&LowerGIbleedingUGIBCAUSESPepticulcerdiseasemostcommonVaricealhemorrhagemostfearedAortoentericfistuladeadlyOthercauses:esophagitis,mallory-w

2、eisstear,Dieulafoy’slesion,angiodysplasia,tumorsUpper&LowerGIbleedingLGIBCAUSESDiverticularDzmostcommonAngiodysplasiasecondmostcommonIschemiccolitismostfearedPostpolypectomybleedsmostannoyingOthercauses:(LGIB)Colitis,Dieulafoy’slesion,tumors,anorectalfissures/varices/hemorrhoids.**Meckel’sdiver

3、ticulum–rare,smallbowel,ALWAYSruleoutinyoungpeopleUpper&LowerGIbleedingInitialapproach&managementUGIBmorelikelyhemodynamicallyunstablethanLGIBAdequateIVaccessie2largeboreIVsStattype&cross,CBC,coags,chemistry,LFTUpto2literscrystalloid;considerO(-)Transfuseasappropriatecorrectcoagulopathyandconsi

4、derholdingadditionalPRBCunitsNGTforroomtempsalinelavageunlessclearlyLGIBConsultGIendoscopistIfmassive,initiatemassivebleedingtransfusionprotocoltoincludeFFP&Pltsetc;rapidinfuser/warmertoBSDUpper&LowerGIbleedingUGIBNon-varicealBeginresuscitationHgb>7Arrangeendoscopyfordxandtx(w/in24hrs)Considerp

5、re-endoscopyPPI;definitePPIposttreatmentNopromotilityagents,nosomatostatin,noH2antagonistsSurgeryorintravasculartxwhenendoscopyfailsF/UtestingforHpyloriHomeonPPIantipltorNSAIDtxsaferwithPPIUGIBVaricealPromptattn.Hgb~8Urgentendoscopyfordx&tx(w/in12hrs)ConsiderprotectiveintubationBalloonTamponade

6、–temporize(Sengstaken-BlakemoreTube)somatostatinimmediately3-5d*TIPSifendoscopy+pharmaco-therapyunsuccessfulCirrhotics:IweekSBPprophylaxisw/quinoloneorCeftriaxone*TIPS–transjugularintrahepaticportosystemicShuntAnnInternMed.2010;152(2):101-13.AnnInternMed.2003Nov18;139(10):843-57AmJGastroentero

7、l.2007Sep;102(9):2086-102.Upper&LowerGIbleedingLGIBPEARLSAcute&FulminantHepaticFailureAcuteLiverFailure=onsetofhepaticencephalopathyandcoagulopathy(INR>1.5)within26weeksofinitialjaundiceinapatientwithoutpreexistingliverdz:Fulminan