Gastrointestinal bleeding
Upper gastrointestinal bleeding
History taking】
1. Etiology.
(1) Bleeding from ulcer disease.
(2) Portal hypertension with bleeding from ruptured varices in the esophagogastric fundus.
(3) Stress ulcer bleeding.
(4) tumor hemorrhage.
(5) biliary bleeding.
(6) Other rare causes, such as Mallory-weiss syndrome, esophageal hiatal hernia, aneurysm penetration into the upper gastrointestinal tract, hemangioma, etc.
2. Medical history.
(1) Carefully inquire about the time of vomiting blood and black stool, the number and volume of blood, whether it is mainly vomiting blood or black stool; whether there is a history of similar vomiting blood and black stool in the past.
(2) Any recent history of dyspepsia, epigastric discomfort, malaise and weight loss.
(3) Any symptoms or history of gastric or duodenal ulcer or acute or chronic gastritis.
(4) History of long-term alcohol consumption; history of hepatitis, schistosomiasis, and hepatomegaly and splenomegaly.
(5) Any history of epigastric pain, fever, jaundice and the temporal relationship to bleeding.
(6) What tests and treatments have been done in the past or after this attack, the results of the tests and the effect of the treatment.
(7) Any history of surgery and postoperative diagnosis.
Physical examination
(1) Pay attention to whether the patient has pale face and lips, yellowish skin and sclera, subcutaneous bleeding spots, spider nevus and liver palm.
2.Measure blood pressure, pulse, respiration, and take body temperature if feverish.
3. presence of abdominal wall varices, hepatosplenomegaly and ascites, and the presence of pressure pain and masses in the upper abdomen.
4. Upper gastrointestinal bleeding suspected to be caused by malignant tumor should be examined by left supraclavicular lymph node and anal finger examination to understand whether there is distant metastasis of cancer.
Auxiliary examination
1.Laboratory examination: blood and urine routine, platelet count, clotting time, blood type, blood albumin and albumin ratio, liver and kidney function and blood ammonia measurement, etc.
2, X-ray examination: chest fluoroscopy or film, barium meal examination of the esophagus and stomach; selective abdominal arteriography, if necessary.
3, fiberoptic gastroscopy and duodenoscopy, which can quickly clarify the site and cause of bleeding.
4.Triple lumen tube examination, inflate and compress the gastric and esophageal balloons, rinse with saline and aspirate the gastric memory blood, without rebleeding, can be considered as ruptured esophageal and gastric fundic variceal bleeding.
Diagnosis】
According to the history, signs and auxiliary examination results, most patients can be diagnosed, and the following analysis should be made for upper gastrointestinal bleeding.
1.Judging the bleeding site.
2.Estimate the amount of bleeding.
3.Analysis of the cause of bleeding.
Treatment principles
1.Non-surgical treatment.
(1) General treatment.
(1) fluid, blood transfusion, correction of shock; maintain blood pressure at 12 kPa and pulse rate below 100 beats per minute.
(2) Patients in shock should have a retention urinary catheter placed, record the hourly urine volume, and measure central venous pressure if necessary.
3) Application of hemostatic drugs.
(4) resting flat, sedation may be given, but note that morphine and barbiturates are prohibited in patients with portal hypertension to avoid inducing hepatic coma.
(2) Three-chamber tube compression to stop bleeding.
(3) hemostasis via fiberoptic endoscopy.
2.Surgical treatment.
(1) Indications for surgery: the key to deciding on surgery is to determine whether the bleeding can stop on its own, but in practice it is difficult to make accurate predictions; the decision can be made based on a comprehensive analysis of the medical history, the size of the bleeding, the speed of bleeding, and the general condition of the patient; rapid bleeding, a large amount of bleeding in a short period of time, early shock, slowing down or suspending blood transfusion will not be able to maintain blood pressure and pulse, and bleeding is not easy to age 60 years or older (2) Surgery should be considered for unexplained hemorrhage, recurrent bleeding and unstable condition after non-surgical treatment.
(2) Selection of surgical procedure: According to the different causes of the disease, the corresponding surgical procedure should be selected, the principle is safe and effective, and overly complicated procedures should not be used for critical patients.
Efficacy criteria
1.Cure: the lesion has been removed by surgery, or the cause of bleeding has been treated accordingly, the postoperative condition is good, no further bleeding, no surgical complications.
2, improved: bleeding stopped after treatment and general condition improved.
3.Not healed: those who have not been treated or the treatment is ineffective.
【Discharge criteria 】
Achieve clinical cure or improvement, incision healing, stable condition.
Blood in stool
History taking】
1.Etiology.
(1) intestinal tumor.
(2) intestinal polyps.
(3) congenital intestinal disorders.
(4) intussusception.
(5) intestinal vascular disorders.
(6) intestinal diverticula.
(7) systemic diseases.
2, medical history.
(1) Pay attention to the time of onset, the number of blood in the stool, the amount and color of blood in the stool, and the presence of pus or mucus.
(2) whether there is abdominal pain, urgency and bleeding in other parts of the body.
(3) Any change in bowel habits, whether the stool is thinner, and whether there are any lumps coming out during stool.
(4) Any previous history of hemorrhoids, anal fissures, intestinal polyps, etc.
Physical examination]
1, pay attention to the general condition of the body, the presence of anemia, the presence of bleeding spots and bruises on the skin and mucous membranes, measurement of blood pressure and pulse.
2, abdominal examination: the presence of abdominal wall varices, the presence of pressure pain, rebound pain and masses, and whether the liver and spleen are enlarged.
3.Anal examination: pay attention to the presence of anal fissures, external hemorrhoids and prolapsed hemorrhoids, polyps or other masses, and the presence of pus, blood and mucus attached to the finger sleeve.
【Auxiliary examination
1.Blood and urine routine examination, platelet count and determination of bleeding and clotting time.
2, stool examination: pay attention to the appearance and nature of the stool, microscopic examination for pus and blood, phagocytosis and intestinal parasitic eggs.
3, barium enema X-ray examination.
4.Selective mesenteric arteriography can be done if necessary.
Diagnostic evaluation
According to the history, signs and auxiliary examination results, most patients can be diagnosed, and the following judgments should be made for blood in stool.
1.Analysis to determine the site of bleeding.
2.Estimate the amount of bleeding.
3.Analysis of the cause of bleeding.
【Treatment principles
1, non-surgical treatment: acute massive blood stool with unknown etiology, first fasting, fluid infusion, replenishment of blood volume, correction of shock, application of sedatives, hemostatic drugs, etc.; general treatment with upper gastrointestinal bleeding.
2.Surgical treatment.
(1) surgical indications: about 90% of cases with blood in stool can stop bleeding within 24 to 48 hours after non-surgical treatment; if bleeding still does not stop after 24 to 48 hours of treatment, emergency exploratory surgery can be performed, the purpose of which is to eliminate the cause of bleeding.
(2) Key points of exploratory surgery.
(1) Exploration of the terminal ileum, cecum, hepatic flexure of the ascending colon, transverse colon, splenic flexure, sigmoid colon, and rectum in turn, paying attention to the presence of inflammation, diverticula, and the presence of unsuspected polyps and tumors.
(2) Deciding the management measures depending on the nature of the lesion.
(3) Selection of operation style: according to the etiology of bleeding, select the corresponding operation style.
【Efficacy criteria
1.Cure: removal of lesions, cessation of bleeding, no complications.
2.Good: bleeding stops and general condition improves.
3.Not cured: untreated or ineffective treatment.
Discharge criteria】
Achieve clinical cure or improvement, incision healing, stable condition, can be discharged.