Gastrointestinal bleeding
Introduction
Introduction Many lesions in the digestive tract can bleed, but most can be explained by a few disease diagnoses. The difference between upper and lower gastrointestinal bleeding depends on its proximal or distal end of the Treitz ligament.
Cause
Cause
Causes of gastrointestinal bleeding:
Upper gastrointestinal bleeding: More than 90% of upper gastrointestinal bleeding is caused by peptic ulcer, erosive gastritis, cardia tear, and esophageal varices.
[Digestive ulcer] Bleeding can occur in the duodenum, stomach, and surgical anastomosis. Patients may have no ulcer pain or indigestion, and bleeding is a symptom of peptic ulcer disease.
[Gastritis] A erosive gastritis that causes bleeding, which can be caused by drinking alcohol or taking non-group anti-inflammatory drugs (NSAIDS) such as aspirin and ibuprofen. Gastric mucosal erosion is also common in critically ill patients such as severe trauma or systemic diseases, burns or head injuries. Severe erosive gastritis often occurs in patients with portal hypertension and causes major bleeding. In order to prevent gastric bleeding in critically ill patients, H 2 blockers should be used to maintain a pH greater than 4 in the stomach. This treatment can reduce the incidence of bleeding, but does not necessarily reduce mortality.
[Responsibility to tear] Cardiac tearing occurs in the mucosa at the junction of the esophagus and the stomach, and the amount of bleeding can be large or small. 50% of these patients have a history of vomiting before vomiting large amounts of blood, but there is no other history of diagnosis. The diagnosis is based on endoscopy, and the treatment is supplemented with Hz receptor blocker.
[Esophageal varices] Esophageal varices bleeding is often large and without aura. The appearance of esophageal varices is due to portal hypertension, which establishes collateral circulation for intestinal venous return. Portal hypertension, including portal vein embolism and schistosomiasis, can cause the same esophageal varices, but the most common cause of esophageal varices bleeding in the United States is alcoholic cirrhosis. Esophageal varices bleeding in patients with cirrhosis is complicated because: (1) patients with varicose veins often suffer from other causes such as gastritis or peptic ulcer; (2) most patients with cirrhosis suffer from repeated bleeding due to long-term portal hypertension. It is necessary to reduce the portal pressure through the door-body shunt. However, the morbidity and mortality of these treatments are high, especially in emergency situations. Therefore, esophageal variceal treatment has become a more standardized therapy; (3) cirrhosis can also cause hepatic encephalopathy, and gastrointestinal bleeding often aggravates hepatic encephalopathy; (4) the liver can not produce enough coagulation factors and Thrombocytopenia caused by hypersplenism may increase gastrointestinal bleeding. For the above reasons, patients with cirrhosis and gastrointestinal bleeding are very difficult to handle.
Other lesions in the upper digestive tract can also cause bleeding, including esophageal cancer, gastric cancer, esophagitis, and catastrophic erosion of the proximal small intestine, especially the artificial arteries implanted in the duodenum.
Lower gastrointestinal bleeding: Lower gastrointestinal bleeding is usually caused by lesions in the anorectal and colon.
[Anal rectal non-neoplastic disease] There is a small amount of bright red blood on the surface of the stool and the toilet paper, most commonly in hemorrhoids, anal fissure or anal. Infectious rectal inflammation is more common in male homosexuals and can cause blood in the stool.
[Colon and new intestines] Intestinal polyps usually present as recessive blood loss, but in the case of acute lower gastrointestinal bleeding. Colon cancer and ulceration form an ulcer.
[ulcerative, bacterial and ischemic colitis] Inflammatory diarrhea with bleeding can be seen in ulcerative colitis, but infectivity caused by Shigella, Campylobacter, lysing entero-ameba, and occasionally Salmonella Diarrhea can also bleed. Usually, these patients have mucus and white blood cells in the feces of diarrhea, and patients with ischemic enteritis, especially the elderly, often have bloody stools.
[colon diverticulum] The colon, especially the sigmoid colon, is common in the United States. However, most of the diverticulum hemorrhage occurs in the proximal colon, which is the most common cause of lower gastrointestinal bleeding. Diverticulitis can cause abdominal pain, but generally does not cause bleeding.
[vascular dysplasia] Many people have submucosal arteriovenous malformations, which is called vascular dysplasia. This lesion can cause acute bleeding, and can also be manifested as recessive blood loss. Endoscopic or angiographic examinations often make it difficult to see the lesion. The disease has a tendency to grow with age. Long-term renal failure is predisposed to this disease. This disease may be related to aortic calcification stenosis.
[Intestinal lesions] Tre small intestine lesions beyond the ligament, usually do not cause significant intestinal bleeding, with one exception being the Meckel's diverticulum, which can cause scattered ulcers in the sac or the diverticulum, leading to acute bleeding.
Bleeding tendency
Blood diseases (leukemia, thrombocytopenia), coagulopathy (diffuse intravascular coagulation), vascular malformations (hereditary hemorrhagic telangiectasia), vascular inflammation (Henoch-Schonlein purpura) and connective tissue diseases (elastic leave) Yellow tumors can cause bleeding in the upper or lower digestive tract.
Examine
an examination
Related inspection
Tumor receptor imaging fiber endoscopy small intestine angiography oral small intestine angiography painless gastroscope
Gastrointestinal examination and diagnosis:
Emergency gastroscopy nearly 10 years, emergency gastroscopy has been listed as the preferred diagnostic method for acute upper gastrointestinal bleeding, the diagnostic accuracy rate is as high as 85-94% [1,8], and can distinguish between active bleeding or recent bleeding according to bleeding performance. The former refers to the bloody or oozing blood in the lesion, the latter sees the lesion as a brown base, adhesion blood clots, blood idiots, or bulging small blood vessels; those who see the lesion but have no such manifestations are called non-hemorrhagic lesions. Because of the emergency examination, Deepen the understanding of the cause of bleeding. If there are multiple lesions at the same time, the emergency examination can determine the location of the bleeding. For example, cirrhosis with upper gastrointestinal bleeding for emergency gastroscopy, in addition to the discovery of esophageal varices, often find other causes Hemorrhage, such as erosive gastritis, esophageal mucosal tear, gastroduodenal ulcer, esophagitis, etc. The complications of emergency gastroscopy are no different from conventional microscopy. The main complications are bleeding, perforation, and heart and lung accidents. , drug reactions and infections, etc.
Emergency colonoscopy emergency colonoscopy due to intestinal restriction, the positive diagnosis rate is only 75% [2,7] The method is basically the same as the routine examination, because there is a large amount of blood in the intestinal lumen, affecting observation, only Rinse continuously with water, no need to attract to avoid clogging the pipeline, causing the inspection to fail. Avoid blood clots as much as possible during insertion, so that the lens is placed above the hemorrhage. The entire insertion process is as little as possible. During the inspection, the tube begins. After insertion into the rectum, while observing, slowly advancing, seeing the hemorrhage or finding that there is no blood in the intestine of the insertion site, indicating that the end of the mirror has exceeded the bleeding site, and should stop moving forward and slowly withdraw from the examination. For the diagnosis of hemorrhagic foci, It is most reliable to see active oozing directly under peek. If there are blood clots or old bleeding spots on the lesions, there is also a reference value. Because these patients are generally in poor condition, the condition changes greatly and cannot be tolerated for a long time. Skilled, gentle movement, as long as possible to shorten the examination time. It is generally considered that the complications of emergency colonoscopy are not significantly different from routine examination.
Colonoscopy often uses push-type enteroscopy, which is actually the extension of upper gastrointestinal endoscopy. Preoperative preparation and gastroscopy, most need intravenous injection of 10mg or dulidine 50mg, Jielingling 40mg to maintain sedation and reduction Small bowel peristalsis. After the enteroscopy enters the descending part, straighten the mirror body, send the slide tube into the duodenum, and then use the hook pull method to enter the mirror. When the endoscope reaches 90-100cm, the lens has reached or exceeded. Qu's ligament, which is often the most difficult part, should be skillful to apply the hook pull method to eliminate the acute angle of the intestinal fistula and the curvature of the lens body. By adjusting the angle knob to advance the cavity, less gas injection, generally can smoothly enter the jejunum. After the ligament, the direction of the lens body can be divided into two types: clockwise and counterclockwise. It is easy to insert counterclockwise. The success rate of enteroscopy through the flexor ligament can reach over 95%, but the depth of insertion can only be reached. Upper jejunum, generally 50-80 cm below the ligament of the trochanter. Gutoscopy is the most diagnostic value for gastrointestinal bleeding of unknown cause. Most authors report a 40% diagnosis of distal duodenum and proximal jejunal hemorrhage. Left and right, with arteriovenous malformation The most visible shape [9,10].
Capsule colonoscopy Capsule colonoscopy is a 11×30mm pill-sized wireless colonoscopy consisting of batteries, light sources, imaging systems and conveyors. This non-invasive examination not only achieves the small intestine position that is currently difficult to achieve with endoscopy. And can obtain clear images, providing a new method for the diagnosis of small bowel diseases [11]. Through clinical application, the diagnosis of small bowel lesions by capsule colonoscopy is better than propulsive enteroscopy, especially for those with small amount of bleeding. Recurrent small intestinal bleeding has a good diagnostic value [12]. Capsule colonoscopy currently has the disadvantage of relatively long inspection time, inability to perform microscopic biopsy and treatment, and relatively expensive one-time use.
Intraoperative endoscopy is suspected of intestinal disease. When the laparotomy is difficult to determine the nature and location of the lesion, the enteroscopy can be inserted through the mouth or anus or from the cecal incision on the operating table. The surgeon can put the intestine tube on the endoscope by hand. Observe all small intestinal mucosa and determine the location of gastrointestinal bleeding with unknown cause. If the lesion is found, the thread is marked on the surface of the intestinal serosa. After all the lesions are located, the extent of resection is determined according to the nature and distribution of the lesion [10]. However, patients with recent bleeding and patients who are bleeding during the examination are not satisfied. Artificial intussusception can cause intestinal mucosal damage.
Diagnosis
Differential diagnosis
Gastrointestinal bleeding needs to be distinguished from the following symptoms:
Gastrointestinal congestion: Gastrointestinal congestion is more common in right heart failure caused by various cardiovascular diseases and portal hypertension caused by various causes.
Gastrointestinal symptoms: Gastrointestinal symptoms are nausea, vomiting, abdominal pain and diarrhea, which are caused by the release of histamine and inflammatory mediators. Occasionally, tumor mast cells can also directly infiltrate the gastrointestinal tract.
Gastrointestinal flatulence: Gastrointestinal flatulence is very common in the clinic, often manifested as hernia, abdominal distension, abdominal pain and sagittal (fart).
Emergency gastroscopy nearly 10 years, emergency gastroscopy has been listed as the preferred diagnostic method for acute upper gastrointestinal bleeding, the diagnostic accuracy rate is as high as 85-94% [1,8], and can distinguish between active bleeding or recent bleeding according to bleeding performance. The former refers to the bloody or oozing blood in the lesion, the latter sees the lesion as a brown base, adhesion blood clots, blood idiots, or bulging small blood vessels; those who see the lesion but have no such manifestations are called non-hemorrhagic lesions. Because of the emergency examination, Deepen the understanding of the cause of bleeding. If there are multiple lesions at the same time, the emergency examination can determine the location of the bleeding. For example, cirrhosis with upper gastrointestinal bleeding for emergency gastroscopy, in addition to the discovery of esophageal varices, often find other causes Hemorrhage, such as erosive gastritis, esophageal mucosal tear, gastroduodenal ulcer, esophagitis, etc. The complications of emergency gastroscopy are no different from conventional microscopy. The main complications are bleeding, perforation, and heart and lung accidents. , drug reactions and infections, etc.
Emergency colonoscopy emergency colonoscopy due to intestinal restriction, the positive diagnosis rate is only 75% [2,7] The method is basically the same as the routine examination, because there is a large amount of blood in the intestinal lumen, affecting observation, only Rinse continuously with water, no need to attract to avoid clogging the pipeline, causing the inspection to fail. Avoid blood clots as much as possible during insertion, so that the lens is placed above the hemorrhage. The entire insertion process is as little as possible. During the inspection, the tube begins. After insertion into the rectum, while observing, slowly advancing, seeing the hemorrhage or finding that there is no blood in the intestine of the insertion site, indicating that the end of the mirror has exceeded the bleeding site, and should stop moving forward and slowly withdraw from the examination. For the diagnosis of hemorrhagic foci, It is most reliable to see active oozing directly under peek. If there are blood clots or old bleeding spots on the lesions, there is also a reference value. Because these patients are generally in poor condition, the condition changes greatly and cannot be tolerated for a long time. Skilled, gentle movement, as long as possible to shorten the examination time. It is generally considered that the complications of emergency colonoscopy are not significantly different from routine examination.
