Gastrointestinal bleeding
Introduction
Introduction to gastrointestinal bleeding Gastrointestinal hemorrhage is a common clinical syndrome. The digestive tract refers to the tube from the esophagus to the anus, including the stomach, duodenum, jejunum, ileum, cecum, colon and rectum. The upper gastrointestinal bleeding site refers to the esophagus, stomach, duodenum, upper jejunum, and pancreatic duct and bile duct bleeding above the ligamentous ligament. Intestinal hemorrhage below the ligamentous ligament is called lower gastrointestinal bleeding. Gastrointestinal hemorrhage may be caused by inflammation of the digestive tract itself, mechanical damage, vascular disease, tumor, etc., and may also be caused by lesions of adjacent organs and systemic diseases involving the digestive tract. basic knowledge The proportion of illness: 1% Susceptible people: no specific population Mode of infection: non-infectious Complications: anemia, hemorrhagic shock
Cause
Causes of gastrointestinal bleeding
Gastrointestinal hemorrhage may be caused by inflammation of the digestive tract itself, mechanical damage, vascular disease, tumor, etc., and may also be caused by lesions of adjacent organs and systemic diseases involving the digestive tract.
Upper gastrointestinal bleeding (40%):
1, esophageal disease: esophagitis (reflux esophagitis, esophageal diverticulitis), esophageal cancer, esophageal ulcer, esophageal cardia mucosal tear, device examination or foreign body damage, radiation damage, strong acid and alkali caused chemical damage .
2, stomach, duodenal diseases: peptic ulcer, acute and chronic gastritis (including drug-induced gastritis), gastric mucosal prolapse, gastric cancer, acute gastric dilatation, duodenitis, residual gastritis, residual gastric ulcer or cancer, also There are lymphoma, leiomyoma, polyps, sarcoma, hemangioma, neurofibromatosis, sputum, gastric torsion, diverticulitis, hookworm disease and so on.
3, jejunal ulcer and anastomotic ulcer after gastrointestinal anastomosis.
4, portal hypertension, esophagogastric venous curve rupture, portal hypertensive gastropathy cirrhosis, portal vein occlusion of portal vein or thrombosis, hepatic vein occlusion (Budd-Chiari syndrome).
5. Diseases of organs or tissues adjacent to the upper digestive tract:
(1) Biliary hemorrhage: bile duct or gallbladder stones, biliary ascariasis, gallbladder or biliary tract disease, liver cancer, liver abscess or hepatic vascular disease rupture.
(2) Pancreatic diseases involve the duodenum: pancreatic abscess, pancreatitis, pancreatic cancer, etc.
(3) The thoracic or abdominal aortic aneurysm breaks into the digestive tract.
(4) The mediastinal tumor or abscess breaks into the esophagus.
6, systemic disease manifests bleeding in the gastrointestinal tract:
(1) Blood diseases: leukemia, aplastic anemia, hemophilia, etc.
(2) uremia.
(3) Connective tissue disease: vasculitis.
(4) Stress ulcers: severe infection, surgery, trauma, shock, adrenal glucocorticoid therapy and stress caused by certain diseases, such as cerebrovascular accident, pulmonary heart disease, severe heart failure.
(5) Acute infectious diseases: epidemic hemorrhagic fever, leptospirosis.
Lower gastrointestinal bleeding (40%):
1, anal canal disease: sputum, anal fissure, anal fistula.
2, rectal disease: rectal injury, non-specific proctitis, tuberculous proctitis, rectal tumor, rectal carcinoid, adjacent malignant tumor or abscess into the rectum.
3, colon disease: bacterial dysentery, amoebic dysentery, chronic non-specific ulcerative colitis, diverticulum, polyps, cancer and vascular malformations.
4, small bowel disease: acute hemorrhagic necrotic enteritis, intestinal tuberculosis, Crohn's disease, jejunal diverticulitis or ulcer, intussusception, small intestine tumor, gastrointestinal polyposis, small intestinal hemangioma and vascular malformation.
Prevention
Gastrointestinal bleeding prevention
1. Active treatment of primary diseases such as peptic ulcer and cirrhosis, esophageal inflammation, gastric ulcer, chronic hepatitis, chronic nephritis, and reducing bleeding opportunities under the guidance of a doctor.
2. Life must be regular. Diet should be regular, avoid overeating, avoid alcohol and avoid smoking, do not drink strong tea and coffee. Avoid overwork, sleep should be sufficient, avoid emotional stress, and maintain emotional stability.
3. Pay attention to the use of drugs, should use little or no drugs that are irritating to the stomach, if necessary, should be used to maintain gastric mucosal drugs.
4. Regular physical examination, in order to find early lesions, timely treatment, in the presence of anemia symptoms such as dizziness, should be checked in the morning.
5. Patients with chronic diseases, such as weak body, often take vitamin C, as well as large qi and blood Chinese medicine to improve the body's ability to adapt.
Complication
Gastrointestinal bleeding complications Complications anemia, hemorrhagic shock
Often anemia, severe cases of hemorrhagic shock and so on.
Symptom
Symptoms of gastrointestinal bleeding Common symptoms Upper gastrointestinal bleeding feces black with blood vomiting blood abdominal pain stool black sticky stool green blue intestinal bleeding hemorrhage hypothermia nausea
The clinical manifestations of gastrointestinal bleeding depend on the nature, location, blood loss and speed of the bleeding lesions, and are also related to the patient's age, heart and kidney function and other general conditions. Most of the acute massive hemorrhage is hematemesis. Chronic small amount of hemorrhage is positive for fecal occult blood. When the bleeding site is above the jejunal ligament, the clinical manifestation is hematemesis. For example, blood in the stomach stays for a long time, due to gastric acid. It becomes acidic hemoglobin and is brown. Such as bleeding speed and bleeding volume. The color of hematemesis is bright red. Black feces or tar-like feces indicate that the bleeding site is in the upper gastrointestinal tract, but if the bleeding rate of the lesion in the duodenum is too fast, the residence time in the intestine is short, and the color of the stool becomes purple-red. When the right colon is bleeding, the color of the stool is bright red. Black feces may also be present in small, ileal, and right colonic lesions that cause small amounts of oozing.
Massive bleeding in the upper digestive tract leads to acute peripheral circulatory failure. The amount of blood loss is large, bleeding or treatment is not timely, which can cause the blood perfusion of the body and the lack of oxygen. Furthermore, due to hypoxia, metabolic acidosis and accumulation of metabolites, the surrounding blood vessels are dilated, and the capillaries are extensively damaged, so that a large amount of body fluid stagnates in the abdominal cavity and surrounding tissues, which reduces the effective blood volume and seriously affects the heart. The blood supply to the brain and kidneys finally formed an irreversible shock, leading to death. During the development of circulatory failure around hemorrhage, clinical symptoms such as dizziness, palpitations, nausea, thirst, black sputum or syncope may occur. The skin is gray and wet due to vasoconstriction and insufficient blood perfusion, and appears pale after pressing the nail bed. Recovery has not been seen for a long time. Poor vein filling, body surface veins often collapse. The patient feels tired and weak, and can be further apathetic, restless, even unresponsive, and confused. The elderly have low organ reserve function, and the elderly often have senile underlying diseases such as cerebral arteriosclerosis, hypertension, coronary heart disease, and chronic bronchus. Although the amount of bleeding is not large, it also causes multiple organ failure, which increases the risk factors for death.
First, the general situation
Estimation of blood loss is extremely important for further processing. Generally, the daily blood loss is more than 5ml, and the stool color is unchanged, but the occult blood test can be positive, and black feces appear above 50-100ml. The amount of hematemesis and blood in the stool as the estimated amount of blood loss is often not accurate. Because hematemesis and blood in the stool are often mixed with stomach contents and feces, on the other hand, part of the blood is still stored in the gastrointestinal tract and has not been excreted. Therefore, it is possible to make a judgment based on the change in blood circulation resulting in a change in the surrounding circulation.
The amount of blood loss is small, below 400ml, the blood volume is slightly reduced, and can be compensated by tissue fluid and spleen blood storage. The circulating blood volume can be improved within 1 hour, so there is no symptom. When there are symptoms such as dizziness, palpitation, cold sweat, fatigue, dry mouth, etc., it means that the acute blood loss is above 400ml. If there is syncope, cold limbs, little urine, irritability, it means that the amount of bleeding is large, and the blood loss is at least 1200ml or more. Still continue, in addition to syncope, there are still shortness of breath, no urine, at this time the acute blood loss has reached more than 2000ml.
Second, the pulse
Pulse changes are an important indicator of the degree of blood loss. The acute blood loss in acute gastrointestinal bleeding, the initial body compensatory function is the heart rate is accelerated. Small blood vessels reflect sputum, so that the blood storage in the liver, spleen and skin sinusoids enters the circulation, increases the amount of blood returning to the heart, and adjusts the effective circulation in the body to ensure the blood supply of important organs such as heart, kidney and brain. Once the amount of blood loss is too large and the body's compensatory function is insufficient to maintain effective blood volume, it may enter a state of shock. Therefore, when a large amount of bleeding, the pulse is fast and weak (or weak pulse), the pulse increases to 100-120 times per minute, the blood loss is estimated to be 800-1600ml, the pulse is subtle, and even when it is unclear, the blood loss has reached more than 1600ml.
Some patients have bleeding, blood pressure can be close to normal when lying down, but when the patient is sitting or semi-recumbent, the pulse will increase immediately, dizziness, cold sweat, indicating a large amount of blood loss. If the change in position is not changed, and the central venous pressure is normal, excessive bleeding can be ruled out.
Third, blood pressure
The change in blood pressure, like the pulse, is a reliable indicator of the amount of blood loss.
When the acute blood loss is more than 800ml (accounting for 20% of the total blood volume), the systolic blood pressure can be normal or slightly increased, and the pulse compression is small. Although the blood pressure is still normal at this time, it has entered the early stage of shock, and the dynamic changes of blood pressure should be closely observed. When the acute blood loss is 800-1600ml (20%-40% of the total blood volume), the systolic blood pressure can be reduced to 9.33~10.67kPa (70-80mmHg), and the pulse pressure is small. When the acute blood loss is more than 1600ml (accounting for 40% of the total blood volume), the systolic blood pressure can be reduced to 6.67 ~ 9.33kPa (50 ~ 70mmHg), more severe bleeding, blood pressure can be reduced to zero.
Sometimes, in some patients with severe gastrointestinal bleeding, the blood in the gastrointestinal tract has not been excreted, only in shock, at this time should pay attention to exclude cardiogenic shock (acute myocardial infarction), infectious or anaphylactic shock, and non-digestion Internal hemorrhage (ectopic pregnancy or aortic aneurysm rupture). If the bowel sounds are found to be active and the anus is found to have bloody stools, it is indicated as gastrointestinal bleeding.
Fourth, the blood
Hemoglobin determination, red blood cell count, and hematocrit can help estimate the extent of blood loss. However, in the early stage of acute blood loss, the above values may be temporarily unchanged due to compensatory mechanisms such as blood concentration and blood redistribution. Generally, the tissue fluid needs to be infiltrated into the blood vessel to supplement the blood volume, that is, the hemoglobin declines after 3 to 4 hours, and the hemoglobin can be diluted to the maximum extent on the 32h after the bleeding. If the patient has no anemia before hemorrhage, hemoglobin drops below 7g in a short time, indicating that the amount of bleeding is large, above 1200ml. After 2 to 5 hours after major bleeding, the white blood cell count can be increased, but usually does not exceed 15 × 109 / L. However, in cirrhosis and hypersplenism, the white blood cell count may not increase.
V. Urea nitrogen
A few hours after the upper gastrointestinal hemorrhage, blood urea nitrogen increased, peaked at 1-2 days, and fell to normal within 3-4 days. If bleeding again, the urea nitrogen can be increased again. The increase in urea nitrogen is due to the large amount of blood entering the small intestine and the nitrogenous products are absorbed. When the blood volume decreases and the renal blood flow rate and glomerular filtration rate decrease, not only the urea nitrogen is increased, but also the creatinine can be increased at the same time. If creatinine is below 133 mol/L (1.5 mg%) and urea nitrogen is >14.28 mmol/L (40 mg%), it indicates that upper gastrointestinal bleeding is above 1000 ml.
6. Determine whether to continue bleeding
It is clinically impossible to determine whether bleeding continues by hemoglobin alone or in the stool. Because after a hemorrhage, hemoglobin decline has a certain process, and bleeding 1000ml, tar-like can last 1 to 3 days, fecal occult blood can reach 1 week, bleeding 2000ml, tar-like can last 4 to 5 days, fecal occult blood up to 2 week. With the following performance, it should be considered that there is continued bleeding.
1. Repeated hematemesis, black feces and increased amount, or discharge dark red to cause bright red blood.
2. The gastric tube extract has more fresh blood.
3. Within 24 hours, the blood pressure and pulse can not be stabilized by active infusion and blood transfusion. The general condition has not improved, or the central venous pressure is still decreasing after rapid infusion and blood transfusion.
4. Hemoglobin, red blood cell count and hematocrit continue to decrease, and reticulocyte counts continue to increase.
Examine
Examination of gastrointestinal bleeding
In recent years, clinical research on gastrointestinal hemorrhage has made great progress. In addition to the traditional methods--X-ray barium meal or long-term irrigation examination, endoscopy has been widely applied on the basis of diagnosis and hemostasis has been developed.
(1) X-ray tincture examination: only for patients whose bleeding has stopped and the condition is stable, the positive rate of diagnosis of acute gastrointestinal bleeding is not high;
(2) endoscopy;
(3) angiography;
(4) Radionuclide imaging: In recent years, the radionuclide imaging method has been used to detect the site of active bleeding. The method is to perform abdominal scan after intravenous injection of m colloid to detect evidence of label leakage from blood vessels until preliminary. Orientation.
Diagnosis
Diagnosis and diagnosis of gastrointestinal bleeding
diagnosis
It can be diagnosed based on medical history, clinical symptoms and laboratory tests.
Differential diagnosis
Different from factors other than gastrointestinal bleeding: nose, throat, oral bleeding; hemoptysis; drugs, black feces caused by eating: such as animal blood, carbon powder, iron, tincture, Chinese medicine and so on.
