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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.臨床表現(xiàn)嘔血與黑糞失血性周圍循環(huán)衰竭
6、血象變化發(fā)熱氮質(zhì)血癥診斷思路是上消化道出血嗎?出了多少血?出血停止了嗎?什么原因引起的出血?上消化道出血的確立嘔血和黑糞,失血性周圍循環(huán)衰竭,血和糞便的檢查早期識別:直腸指診排除消化道以外的病因:咯血、口鼻咽出血、事物或藥物出血量的估計(jì)糞便隱血試驗(yàn)陽性每日消化道出血>5~10ml黑糞50~100ml嘔血250~300ml出現(xiàn)全身癥狀400~500ml周圍循環(huán)衰竭>1000ml最有價(jià)值的標(biāo)準(zhǔn):周圍循環(huán)衰竭的臨床表現(xiàn)動態(tài)觀察血壓和心率出血是否停止繼續(xù)出血或再出血的表現(xiàn):反復(fù)嘔血或黑糞周圍循環(huán)衰竭經(jīng)治療后無改善或波動HbRBC繼續(xù)下降,Ret持續(xù)升高補(bǔ)
7、液與尿量足夠的情況下,血尿素氮持續(xù)或再次升高出血后48小時(shí)以上未再繼續(xù)出血,再出血可能性小;既往有大出血史、本次出血量大、24小時(shí)內(nèi)反復(fù)大量出血、食管胃底靜脈曲張出血、有明顯的高血壓或動脈硬化者,再出血可能性大出血的病因病史實(shí)驗(yàn)室檢查胃鏡:首選;推暢急診胃鏡檢查(24~48hr)X線鋇餐其他:選擇性動脈造影治療原則:抗休克,積極補(bǔ)充血容量一般的急救措施:禁食,臥床休息,保持呼吸道通暢嚴(yán)密監(jiān)測生命體征積極補(bǔ)充血容量:立即配血,輸足量全血緊急輸血指征:改變體位出現(xiàn)暈厥,血壓下降>15~20mmHg,心率上升>10次/分收縮壓<90mmHg(或較基礎(chǔ)下降
8、25%)Hb<7g/L或Hct<25%治療止血措施食管胃底靜脈曲張破裂大出血------出血量大,再出血率高,死亡率高治療