Upper gastrointestinal bleeding in the elderly
Introduction
Introduction to upper gastrointestinal bleeding in the elderly Hemorrhageofdigestivetract is a hemorrhage from the esophagus, stomach, intestines, and biliary tract, pancreatic duct, etc. Among them, the esophagus, stomach, duodenum, and biliary tract and pancreatic duct above the Treitz ligament For upper gastrointestinal bleeding, bleeding in the jejunum, ileum, colon, rectum, etc. below the flexural ligament is lower gastrointestinal bleeding; jejunal bleeding after gastric-jejunal anastomosis is attributed to upper gastrointestinal bleeding, the incidence of gastrointestinal bleeding in the elderly The rate is high, the mortality rate is high, and it is easily covered by other diseases such as cardiovascular diseases, and often becomes a diagnostic clue for other diseases such as tumors. It is often necessary to take into account the treatment of hemostasis, complications, primary disease treatment, and cardiovascular disease. basic knowledge The proportion of illness: 0.001% (more common in gastric ulcer, portal hypertension, cirrhosis, etc.) Susceptible people: the elderly Mode of infection: non-infectious Complications: shock anemia upper gastrointestinal bleeding blood in the stool
Cause
The cause of upper gastrointestinal bleeding in the elderly
Upper gastrointestinal bleeding (35%):
(1) Common: peptic ulcer, acute gastric mucosal lesions, gastric cancer, esophageal cancer, esophageal and gastric varices, esophageal and gastric mucosal tears.
(2) Other:
1 esophagus: reflux esophagitis, esophageal hiatal hernia, esophageal diverticulitis, esophageal ulcer, Barrett's esophagus, esophageal foreign body injury, esophageal chemical injury, esophageal radiation injury.
2 stomach: chronic gastritis, gastric mucosal prolapse, acute gastric dilatation, post-stomach lesions (biliary reflux anastomotic stomatitis and residual gastritis, recurrent peptic ulcer, residual gastric cancer, etc.), leiomyoma, leiomyosarcoma, lymph Tumor, neurofibromatosis, gastric polyps, etc.), gastric vascular changes (vasodilation of the antrum, gastroduodenal arteriovenous malformations, etc.).
3 duodenum: duodenitis, hookworm disease, duodenal diverticulitis.
4 hepatobiliary pancreas: biliary calculi, biliary ascariasis, gallbladder or cholangiocarcinoma, liver cancer, pancreatic cancer, acute pancreatitis.
Lower gastrointestinal bleeding (30%):
(1) common: sputum or anal fissure, intestinal polyps or polyposis, rectal cancer, colon cancer, ulcerative colitis, intestinal vascular malformations.
(2) Other:
1 rectum and anal canal: trauma, ulcers, idiopathic ulcerative proctitis, rectal carcinoid.
2 colon: radiation enteritis, ischemic colitis, toxic enteritis, drug enteritis, infectious inflammation (bacteria, amoeba, fungi, parasites, tuberculosis, syphilis, etc.), other tumors (sarcoma, lymphoma, smoothing) Fibroids, lipomas, etc.), advanced schistosomiasis, vascular disease (mesenteric vascular embolization, hemangioma, vascular dysplasia, etc.), intussusception, intestinal torsion, etc.
3 small intestine: acute hemorrhagic necrotic enteritis, ischemic bowel disease, small intestine tumor (lymphoma, leiomyoma, leiomyosarcoma, adenoma, etc.).
Bleeding from systemic disease or total digestive tract disease (20%):
Can be upper gastrointestinal bleeding, lower gastrointestinal bleeding or bleeding in the upper and lower digestive tract.
(1) Common: severe infection, cerebrovascular accident, uremia, disseminated intravascular coagulation.
(2) Other:
1 blood disease (allergic purpura, thrombocytopenic purpura, hemophilia, leukemia, etc.).
2 connective tissue disease: systemic lupus erythematosus, nodular polyarteritis.
3 hemorrhagic infectious diseases: epidemic hemorrhagic fever, leptospirosis and so on.
4 stress status: burns, trauma, major surgery, shock, hypoxia, heart failure and so on.
5 Crohn's disease, gastrointestinal tuberculosis, lymphoma, etc.
Pathogenesis
1. Factors that cause bleeding and affect hemostasis
(1) Mechanical damage: such as damage to the esophagus by foreign bodies, abrasion of varicose veins by drug tablets, severe vomiting, tearing of the esophageal cardia and mucosa.
(2) The role of gastric acid or other chemical factors: the latter such as acid and alkali corrosive agents, acid and alkaline drugs.
(3) Decreased mucosal protection and repair function: Aspirin, non-steroidal anti-inflammatory drugs, steroid hormones, infection, stress, etc. can damage the protection and repair function of the digestive tract mucosa.
(4) vascular destruction: inflammation, ulcers, malignant tumors, etc. can destroy arteriovenous blood vessels, causing bleeding.
(5) Local or systemic hemostasis coagulation disorders: The acidic environment of gastric juice is not conducive to platelet aggregation and blood clot formation, anticoagulant drugs, systemic hemorrhagic diseases or coagulopathy disorders can easily cause bleeding in the digestive tract and other parts of the body. .
2. Pathophysiological changes after hemorrhage
(1) Circulating blood volume reduction: the elderly have more heart, arteriosclerosis of vital organs such as brain and kidney, and less severe circulating blood volume can cause obvious ischemic manifestations of these important organs, and even aggravate the original underlying diseases. Causes dysfunction or even failure of one or more important organs; massive bleeding is more likely to cause peripheral circulatory failure and multiple organ failure.
(2) Absorption of blood protein breakdown products: Nitrogenemia can be caused by intestinal absorption of nitrogen-containing decomposition products; it has been thought that absorption of blood decomposition products can cause "absorption of heat", and it is considered that fever and circulating blood volume decrease after gastrointestinal bleeding Caused by thermoregulatory central dysfunction.
(3) Compensation and repair of the body:
1 circulatory system: heart rate is increased, and peripheral circulation resistance is increased to maintain blood perfusion of vital organs.
2 endocrine system: increased secretion of aldosterone and neurohypophysin, reducing water loss to maintain blood volume.
3 Hematopoietic system: bone marrow hematopoietic activity, reticulocyte increased, red blood cells and hemoglobin amount gradually recovered.
Prevention
Prevention of upper gastrointestinal bleeding in the elderly
Actively treat the original lesions, avoid drinking, avoid foods that damage the mucosa of the digestive tract, take medicine, if necessary, apply mucosal protective agents or antacids, esophageal varices, avoid swallowing rough foods, oral medications need to be ground, available Propranolol plus nitrate reduces portal pressure, and patients with sputum and large intestine polyps pay attention to keep the stool soft and smooth.
Complication
Upper gastrointestinal bleeding complications in the elderly Complications, shock anemia, upper gastrointestinal bleeding, blood in the stool
Complications include local ulcers, rebleeding, perforation, shock, anemia, and scarring.
Symptom
Upper gastrointestinal bleeding symptoms in the elderly Common symptoms Repeated bleeding fatigue upper gastrointestinal bleeding weakness blood pressure lower blood pressure low appetite loss irritability blood in the esophagus
Examine
Examination of upper gastrointestinal bleeding in the elderly
Blood picture change
After the upper digestive tract hemorrhage, after a period of time, usually 3 ~ 4h or more, the tissue fluid infiltrates into the blood vessel, so that the blood is diluted, hemoglobin and red blood cells are decreased due to dilution, resulting in anemia, acute hemorrhage is generally positive cells, positive pigmented anemia .
2. Urea nitrogen, liver function, electrolytes, blood type, coagulation mechanism and other tests.
3. Severe bleeding, especially in patients with heart disease, can be determined by central venous pressure to help determine fluid volume and infusion rate.
4. Endoscopy
It is the most important method to understand the location and cause of gastrointestinal bleeding. The diagnostic accuracy rate is as high as 80%~94%. Emergency endoscopy is performed within 24 hours of bleeding, which is helpful for detecting acute gastric mucosal lesions, superficial ulcer bleeding and esophageal cardia mucosal tear. A biopsy can be performed under endoscopic direct vision to make a pathological diagnosis, and corresponding treatment can be performed by endoscopy.
5. X-ray barium angiography
Including gastrointestinal barium meal angiography, small intestinal gas angiography, colonic sputum angiography, etc., suitable for acute bleeding has stopped, or chronic bleeding, to understand the cause, and for various reasons can not be endoscopy, superficial mucosal lesions Easy to miss diagnosis, it is difficult to diagnose vascular malformations.
6. Radionuclide imaging
Scanning of the 99mTc colloid after intravenous injection to detect evidence of vascular overflow from the marker is non-invasive, but must be performed during active bleeding.
7. Selective angiography
Including selective celiac artery and mesenteric angiography, must be performed in active bleeding, bleeding rate > 0.5ml / min, can identify the bleeding site, and can diagnose vascular malformations and other lesions, in the small intestine acute hemorrhage is the preferred method of examination, positive rate 40% to 86%.
8. Surgical exploration
All other methods can not determine the cause and location of the bleeding, and when the situation is urgent, feasible surgical exploration, small intestine hemorrhage endoscopy is difficult, and other methods can not identify the bleeding site and causes, can be performed in the exploration of enteroscopy, It is the most effective method for the diagnosis of small intestinal bleeding, with a success rate of 83% to 100%, which can determine the exact location and cause of small intestinal bleeding.
Diagnosis
Diagnosis and diagnosis of upper gastrointestinal bleeding in the elderly
