Upper gastrointestinal bleeding

Introduction to upper gastrointestinal bleeding Upper gastrointestinal bleeding refers to the digestive tract above the ligament of the ligament, including hemorrhage caused by lesions such as esophagus, stomach, duodenum or pancreaticobiliary. The jejunal lesion bleeding after gastrojejunostomy is also in this range. A large amount of bleeding refers to blood loss in excess of 1000ml or circulating blood volume within 20 hours. Its clinical manifestations are hematemesis and/or black feces, often accompanied by acute peripheral circulatory failure caused by decreased blood volume. It is a common emergency. The case fatality rate is as high as 8% to 13.7%. There are many causes of massive bleeding in the upper digestive tract. Commonly, there are peptic ulcers, acute gastric mucosal damage, esophageal varices, and gastric cancer. Acute massive bleeding or bleeding persists, and there are circulatory failures such as palpitations, cold sweats, irritability, pale complexion, damp skin, increased heart rate, decreased blood pressure, and fainting. Treatment consists of two major categories: surgical treatment and non-surgical treatment. Because many diseases and lesions can cause upper gastrointestinal bleeding, the indications for surgical and non-surgical treatment of each disease are not the same. basic knowledge Sickness ratio: 2% Susceptible people: no specific population Mode of infection: non-infectious Complications: hemorrhagic shock peritonitis

Cause of upper gastrointestinal bleeding

Upper gastrointestinal disease (25%):

1, esophageal diseases: esophagitis, esophageal cancer, esophageal peptic ulcer, esophageal injury and so on.

2, gastroduodenal diseases: peptic ulcer, acute gastritis, chronic gastritis, gastric mucosal prolapse, gastric cancer, acute gastric dilatation, duodenitis, Zhuo-Eye syndrome, post-surgical lesions.

3, jejunal disease: jejunal cloning, jejunal ulcer after gastrointestinal anastomosis.

Portal hypertension (22%):

1, a variety of cirrhosis decompensation period.

2, portal vein obstruction portal vein, portal vein thrombosis, portal vein compression by adjacent masses.

3. Hepatic vein occlusion syndrome.

Diseases in the upper gastrointestinal tract adjacent to organs or tissues (15%):

1, biliary bleeding: bile duct or gallbladder stones, gallbladder or cholangiocarcinoma, postoperative biliary drainage tube caused by biliary compression necrosis, liver cancer or hepatic aneurysm broke into the biliary tract.

2, pancreatic disease: involving duodenal pancreatic cancer, acute pancreatitis complicated by abscess ulceration.

3, aneurysm broke into the esophagus, stomach or duodenum, aortic aneurysm, liver or spleen aneurysm rupture.

4. The mediastinal tumor or abscess breaks into the esophagus.

Systemic disease (25%):

1, blood diseases: leukemia, thrombocytopenic purpura, hemophilia, disseminated intravascular coagulation and other coagulation mechanisms.

2, uremia.

3, vascular diseases: atherosclerosis, allergic purpura, hereditary hemorrhagic telangiectasia, elastic pseudo-yellow tumors.

4. Nodular polyarteritis: systemic lupus erythematosus or other vasculitis.

5, stress ulcer sepsis: trauma, burns or major surgery, shock, adrenal glucocorticoid treatment, cerebrovascular accident or other craniocerebral lesions, emphysema and pulmonary heart disease caused by stress.

6, disease factors: 1 esophageal lesions, esophageal tumors, esophageal scar stenosis, etc., resulting in food or small food retention. 2 mediastinal lesions mediastinal tumor or abscess formation lesions, oppression of the esophagus, resulting in esophageal stricture, easy to retain food or small foreign bodies. 3 neurological lesions pharyngeal reflexes or swallowing reflexes are diminished, which may cause accidental swallowing.

Upper gastrointestinal bleeding prevention

1. Actively treat the cause of bleeding.

2, pay attention to living habits, diet, emotional, to avoid stimulating factors.

Upper gastrointestinal bleeding complications Complications, hemorrhagic shock, peritonitis

Hemorrhagic shock can occur in upper gastrointestinal bleeding, secondary peritonitis can also cause complications such as asphyxia.

Upper gastrointestinal bleeding symptoms Common symptoms Hematemesis black face pale pale cold sweat nausea nails suddenly white vagus nerve excitement fecal black with blood ascites fatal upper respiratory tract bleeding

The causes of upper gastrointestinal bleeding are numerous, so their clinical manifestations vary.

Medical history and signs

Medical history enquiries and physical examinations remain the main diagnostic steps.

Small and slow gastrointestinal bleeding, generally no obvious symptoms, or only mild weakness or dizziness, and some are only found in occult blood tests for vomiting or feces. In general, upper gastrointestinal bleeding is Hematemesis or black feces, which depends on the amount of bleeding and its speed, such as large amount of bleeding, fast, vomiting blood is purple or bright red, severe often accompanied by hemorrhagic shock signs, too fast Intestinal peristalsis causes dark red or even bright red blood, which is easy to be confused with lower gastrointestinal bleeding. For example, the blood is stored in the stomach, and it is converted into acidic hemoglobin after contact with gastric acid, so that the vomited blood is brown or coffee ground; If the blood stays in the intestine for a long time, the iron in the blood and the sulfide in the intestine combine with the intestinal sulphide to form iron sulfide, which causes the feces to become black as asphalt, also known as tar-like stool. If the amount of bleeding exceeds 60ml, it can cause black feces. .

Acute massive hemorrhage or bleeding persists, and there are palpitations, cold sweats, irritability, pale complexion, dry skin, increased heart rate, decreased blood pressure, and fainting such as fainting. If the blood loss exceeds 1/3 of the total circulating blood volume in a short period of time, It can be life-threatening. Within a few hours after hemorrhage, hemoglobin, red blood cell count and hematocrit may not change much. It cannot be used to assess the severity of bleeding. Within 3 to 4 hours to several days after hemorrhage, tissue fluid enters the circulating blood to compensate. Its blood volume, even if bleeding has stopped, visible hemoglobin, red blood cell count and hematocrit continue to decline, and see signs of bone marrow stimulation, manifested as late red blood cells, polychromatic red blood cells and reticulocytes. The latter can reach 5-15% 4 to 5 days after hemorrhage. For example, 2 weeks after hemorrhage, reticulocytes continue to increase, suggesting that hemorrhage continues. The number of white blood cells increases several hours after major hemorrhage, and returns to normal after about 3-4 days. , blood urea nitrogen increased, up to 40mg / dl, due to absorption of intestinal blood protein digestion products and renal blood flow and glomerular filtration rate after shock, bleeding stopped, blood urea nitrogen within 2 to 3 days Down to normal, such as patients without vomiting or loss of water, kidney function is good, blood urea nitrogen is constantly increasing, often prompted to continue bleeding.

Examination of upper gastrointestinal bleeding

First, laboratory tests:

In acute gastrointestinal bleeding, the key tests should include blood routine, blood type, clotting time, stool or vomit blood test (conditional for radionuclide or immunological blood test), liver function and serum creatinine, Urea nitrogen, etc., conditions should be measured blood cell volume.

Second, special inspection methods:

1, the lower gastrointestinal bleeding first with hard sigmoidoscopy: proctitis, rectal cancer and perianal lesions caused by bleeding can be quickly identified, a large number of blood in the stool for emergency fiber colonoscopy is often not easy to succeed, because of a large number of blood and Blood clots are difficult to remove, affecting operation and observation. If there is not much bleeding or chronic bleeding, fiber colonoscopy can be performed after intestinal preparation.

2, selective angiography: when gastrointestinal bleeding and endoscopic and X-ray examination can not find the lesion, should do selective angiography, this examination has high diagnostic value for intestinal vascular malformation, small intestinal leiomyoma, etc. Moreover, it is still possible to stop bleeding by injecting a vasoconstrictor through a catheter or by injecting a artificial embolus. According to foreign animal experiments, if the contrast agent is extravasated, the bleeding site can be displayed, and the bleeding rate is at least 0.5-1.0 ml/min (750~). 1500ml / d), it is most suitable for active bleeding when the examination, the positive rate can reach 50% ~ 77%, generally choose superior mesenteric artery and celiac artery angiography is enough to show the desired range, contraindications are iodine allergy or renal function In patients with severe arteriosclerosis, intubation is also very difficult and difficult to achieve.

3, X-ray barium angiography: Although the diagnostic value of endoscopy is superior to X-ray barium angiography, it can not be replaced, because some of the intestinal anatomy can not be seen by general endoscopy, and because some endoscopy physicians Insufficient experience, sometimes missed lesions, these can be remedied by X-ray barium examination, but it is not appropriate to perform barium angiography too early after active bleeding, otherwise it will cause rebleeding or aggravate bleeding due to pressing the abdomen. Bleeding stopped, and the condition was stable after 3 days. Careful operation. For some cases with difficult diagnosis, Miller-Abbot can be used to reach the small intestine, and the intestinal fluid can be sucked in sections. Injecting the sputum into the bloody intestinal fluid can sometimes improve the diagnostic positive rate. Note that residual sputum can interfere with selective angiography and endoscopy.

4. Radionuclide scanning: radionuclide scanning can be performed by endoscopic and X-ray negative cases. The method is to label the patient's red blood cells with a nuclides (eg 99m) and then inject them into the patient from the vein. There is active bleeding, and the bleeding rate can reach 0.1ml/min. The radionuclide can show the bleeding site. Injection of 99m marked red blood cells can monitor the patient's gastrointestinal bleeding for 24h. Experience has proved that if the test is negative, then Selective angiography is also often negative.

Diagnosis and diagnosis of upper gastrointestinal bleeding

diagnosis

Can be diagnosed based on clinical symptoms and laboratory tests.

Differential diagnosis

Upper gastrointestinal bleeding is more common, mainly need to pay attention to the identification of lower gastrointestinal bleeding.

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