G.I._Bleeding上消化道出血

1、Presented by:Ahmed T. Al-SuwaidiMohamed S. Al-Hoqani 50 yrs, Pakistani, male C/O: Bleeding/rectum & Abd. pain Painless bleeding, 1 yr excess bleeding, 1 month Black, 4-5 times/day, little quant. Abd. pain Vomiting, 1 week M.H:* no peptic ulcer disease* no medications (NSAIDs)* no urinary symptom

2、s* not known DM, HPTN, IHD* weight loss O/E:* Afebrile* no pallor* not dyspneaic* no lymphoadenopathies* no S.C.L.N Vital Signs:* Pulse: 78 bts/min* BP: 130/80* RR: 18 br/min Heart: NAD Lung: NAD Abd.:* not distended* no epigast. tenderness* tender, firm, partly mobile mass at Rt lumbar region.* spl

3、een not palpable* Lt lobe liver palpable, mildly tender* bowel sounds present PR:* no enlarged piles* no active bleeding* no palpable mass* no blood on finger ECG, CBC, Sr Amylase, Bleeding profile, Abd X-ray, fecal loading ascending colon Lab Results:* Hb: 14.1 g/dl* Plt: 252 * 103* Hypochromic, mi

4、crocytic* PT: 17.3 sec* aPTT: 35.4 sec* Sr Amy: 129 U/l 106 U/l* Na+: 140 mmol/l* K+: 4.1 mmol/l* BUN: 17 mg/dl Acute Vs Chronic Acute Upper G.I.Bleeding: Acute Lower G.I.Bleeding: Haematemesis Melaena Site & Time Aetiology: 1. Drugs (Aspirin & NSAIDs) 2. Alcohol 3.Chronic peptic ulceration

5、(50% of GI hemorrhage) 4.Others: reflux esophagitis, varices, gastric carcinoma, acute gastric ulcers & erosions. Clinical approach: 1. recent (24 hrs), then hospitalized. 2. if small amount, no immediate Tx, because CVS can compensate 3. 85% stop bleeding during 48 hrs 4. history helps in diagn

6、osing the cause of the hemorrhage, eg: long history of indigestion, or previous hem. from ulcers. Clinical approach: 5. factors include: age (60 +) amount of bld lost continuing visible bld loss. signs of chronic liver disease classical clinical features of shock Clinical approach:6. liver disease s

7、evere, recurrent bleeding (if from varices)7. splenomegaly portal hypertension Immediate management:* Emergency management: History + exam. Monitor: pulse & BP /30 min Bld sample: haemoglobin, urea, electrolytes, grouping & cross-matching I.v. access * Emergency management (cntd): Bld transf

8、usion in case of 1) shock 2) haemoglobin 1 ml/minute Radionuclide scanning Uses technetium-99m labeled red blood cellsIf source of colonic bleeding unclear perform a subtotal colectomy and end-ileostomy Acute bleeding tends to be self limiting Consider selective mesenteric embolisation if life threatening haemorrhage If bleeding persists perform endoscopy to exclude upper GI cause Proceed to laparotomy and consider on-table lavage an