1 / 23

Upper GI Bleeding and Management

Upper GI Bleeding and Management. 台大醫院小兒肝膽腸胃科 吳嘉峰醫師 2010/07/25. 定義. 上消化道出血 : 於 Treitz 韌帶以上的消化道出血 吐血 Hematemesis : 鮮紅色的血液自口吐出 咖啡色吐出物 Coffee ground emesis : 鮮血經胃酸作用後呈咖啡色吐出物. To be differentiated … . 吐出物是否真的是來自腸胃道出血 ? 紅色食物染色 (Jello,tomatoes,strawberry)? 藥物 (bismuth, iron)? 流鼻血 ?

Jimmy
Download Presentation

Upper GI Bleeding and Management

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Upper GI Bleeding and Management 台大醫院小兒肝膽腸胃科 吳嘉峰醫師 2010/07/25

  2. 定義 • 上消化道出血: 於Treitz韌帶以上的消化道出血 • 吐血 Hematemesis: 鮮紅色的血液自口吐出 • 咖啡色吐出物 Coffee ground emesis: 鮮血經胃酸作用後呈咖啡色吐出物

  3. To be differentiated….. • 吐出物是否真的是來自腸胃道出血? • 紅色食物染色 (Jello,tomatoes,strawberry)? • 藥物 (bismuth, iron)? • 流鼻血? • 來自媽媽的血? • 呼吸道出血?

  4. 如何處理上消化道出血 • 實驗檢查 • CBC with differential • Reticulocyte count(選擇性) • PT, PTT • Blood type & cross match • Albumin, GOT, GPT, BUN, creatinine • 胃液抽取物 • Gilbert et al. report: bleeding source was identified in 16% of patients with negative gastric aspiration

  5. 胃液抽取物

  6. 出血的原因 • 新生兒 吞入母血(APT test) 維生素K缺乏或未施打 壓力性胃炎或潰瘍 凝血功能缺陷 胃酸分泌過多, 藥物 血管異常 牛奶蛋白過敏 病毒感染 Textbook Pediatric Gastrointestinal Disease 4th ed, p259

  7. 出血的原因 • 幼兒(小於三個月) • 壓力性潰瘍 • 胃酸分泌過多 • 食道炎 • 血管異常 • 食道靜脈瘤 • 十二指腸/胃結構異常 • 消化道阻塞 Textbook Pediatric Gastrointestinal Disease 4th ed, p259

  8. 出血的原因 • 孩童及青少年 • 食道撕裂傷 • 胃酸分泌過多 • 靜脈瘤 • 腐蝕性物質誤食 • 血管炎 (Henoch-Schönlein purpura) • 發炎性腸炎 • 消化道阻塞 • 凝血功能異常 Textbook Pediatric Gastrointestinal Disease 4th ed, p259

  9. 血管異常的病兆 • 腫瘤 • 血管瘤 Hemangiomas • 血管內皮瘤 Hemangioendotheliomas • 結構異常 • 微血管性 Capillary • 靜脈性 Venous • 淋巴管性 Lymphatic • 動脈性 Arterial/arteriovenous Textbook Pediatric Gastrointestinal Disease 4th ed, p259

  10. Diagnosis • Radiology Plain X-ray, Barium study, Sonography, CT angiography • Angiography 血流量至少0.5mL/min • Radio-isotope study Technetium-labeled 標記紅血球攝影 • Endoscope Hemoclip, EV Band ligation, ST needle injection (Normal saline, Bosmine, 95% Alcohol, et al)

  11. Management • Medical therapy: Drugs • Balloon tamponade • Endoscopic hemostasis • Angiography: embolization or angiocath with Pitressin infusion • Surgical hemostasis

  12. Medical Therapy • Gastric acid control • Anti-Acid • H2 receptor antagonists • Proton pump inhibitors • Vessel constrictors • Octreotide • Vasopressin • Mucosa protectors • Sucralfate • Misoprostol Textbook Pediatric Gastrointestinal Disease 4th ed, p259

  13. Gastric Acid Control • H2 blockers • Famotidine (Gaster 20mg/tab, 20mg/amp) • 0.5-1 mg/kg/day (max 80mg/day) • Ranitidine (Zantac 150mg/tab, 50mg/amp) • 2-4 mg/kg/day BID po (max 300mg/day); iv q6-8hr (max 50mg q6-8hr) • Proton pump inhibitors • Omeprazole (Losec 40mg/vial) • 1mg/kg/day qd to q12h (adult 40mg/day) • Lansoprazole (Takepron 30mg/cap) • 1-1.2mg/kg/day qd • Esomeprazole (Nexium 40mg/tab) • 1mg/kg/day qd

  14. Vessel Constrictor • Somatostatin (somatosan 3mg/amp) • Prevent postprandial hyperemia or reducing portal pressure by vasoactive peptides • Few side effect: hyperglycemia, abdominal cramping • Stop variceal hemorrhage up to 80% • Adult 250-500mcg/hr for 1-5 days for EV (6-12 Amp in N/S 500cc with 20 cc/hr= 250-500mcg/hr ) • Child 1.5 mcg/kg/hr for 2 days, then up to 3mcg/kg/hr for another 7 days • Octreotide (Sandostatin 0.1mg/amp) • Synthetic analogues of somatostatin • 1-6 mcg/kg/hr (max 50 mcg/hr)

  15. Vessel Constrictor • Vasopressin (Pitressin 20U/1ml/amp) • Reduce splanchnic blood flow & portal pressure • Short half-life (continuous infusion) • Side effect: systemic vasoconstriction (myocardial, mesenteric ischemia/ infarction) • Addition of nitroglycerine to improve efficacy • Initial 0.002-0.005U/kg/min (max 0.01U/kg/min) • Terlipressin (Glypressin 1mg/vial) • Synthetic vasopressin analogue • Fewer side effect & longer half-life • 20-30mcg/kg/dose q6h (adult 1-2 mg q4-6h)

  16. Mucosa Protector • Sucralfate (Sucrate gel 1g/pk) • Aluminum salt of sulfated sucrose forms a paste-like complex adhering to damaged mucosa in the acid PH • Adults 1g qid; child 10-20mg/kg/dose qid, AC • Antacids should not be taken within one-half hour • Misoprostol (Cytotec 200mcg/tab) • Synthetic PGE1 analog (gastric antisecretory agent), reduce acid secretion from parietal cell & stimulation of bicarbonate from gastric & duodenal mucosa • Adults: 200mcg bid / qid (100mcg qid at 8-16y/o)

  17. Balloon Tamponade • Sengstaken-Blakemore tube • 常於停止加壓後復發性出血 • 緊急時使用 • 等待確定治療的橋樑

  18. Sengstaken-Blakemore tube

  19. Sengstaken-Blakemore tube

  20. Endoscopic Hemostasis • Hemoclip: a specific feeding vessel • Banding: Esophageal varix • ST needle injection: epinephrine, normal saline, 95% Alcohol & sclerosants injection • 電燒止血 • Heater probe, monopolar probe, bipolar electocoagulation (BICAP) probe • 雷射止血

  21. Hemoclip

  22. EV Band Ligation

  23. The End

More Related