GASTROINTESTINAL BLEEDING
GASTROINTESTINAL BLEEDING
GASTROINTESTINAL BLEEDING
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<strong>GASTROINTESTINAL</strong><br />
<strong>BLEEDING</strong><br />
Sorted by Chen Han-Hsiang M.D.<br />
March 2008
Hematemesis<br />
(1st next)<br />
1 Gastrointestinal Bleeding<br />
2 Perform history and physical exam and stool exam<br />
6 Melena or hematochezia<br />
(2 nd next)<br />
14 Occult blood present<br />
(4th next)<br />
13 Bright red blood per rectum<br />
(BRBPR) (3 rd next)
1 Gastrointestinal Bleeding<br />
•要定位和診斷 GI bleeding 前,病患情形需先穩定,<br />
保持適當血壓.<br />
•有時流血很大量迅速,需要手術定位源頭,而無法作<br />
preoperative evaluation. 這裡是假設病患情形穩定.
2 Perform history and physical exam<br />
and stool exam<br />
•定位 source 最重要因素靠 blood loss 的 nature.<br />
•Hemaiemesis 是因 upper GI bleeding. 而 Stool quality 提<br />
供 blood loss 位置的 clues.<br />
•Stool quality (black, maroon, or bright red) 依’量’,’速度’,’<br />
位置’,’transit time’而定.<br />
•長的’transit time’的血會變成 black (melena),是因 acid<br />
breakdown blood.
•血是一種 cathartic, 大量的血會降低 transit time, 而<br />
stool 會變 maroon (hematochezia) 而不是 black.<br />
•Hematemesis 和 melena 通常因 upper GI bleeding.<br />
而 Hematochezia 可因 either upper or lower GI<br />
bleeding. 而 Bright-red rectal blood (BRBPR) 通常<br />
因 lower GI bleeding.<br />
•解剖上 Treitz ligament 被當作 upper 和 lower GI<br />
bleeding 的區分.
•Black stool 必須作 blood 的 test, 因不同其他物質<br />
也會造成.如攝入 bismuth, charcoal, spinach, 和 iron<br />
均會引起黑便但沒有血.其餘如使用 aspirin,<br />
nonsteroidal antiinflammatory agents (NSAIDs), 和<br />
alcohol 可能有 peptic ulcer 的 clues.<br />
•皮膚檢查有 liver disease 的斑點 (spider angiomas,<br />
palmar erythema) 和腹水,可能有 variceal bleeding
Mallory-Weiss tear<br />
Gastric<br />
Duodenum<br />
Esophagitis<br />
Gastritis<br />
Anastomotic<br />
ulcer<br />
5 Peptic<br />
ulcer<br />
Hematemesis<br />
3 Perform UGI endoscopy<br />
Esophageal<br />
varices<br />
4 Abnormal<br />
Gastric<br />
varices<br />
Gastric<br />
carcinoma<br />
Normal<br />
Lesion not<br />
visualized<br />
GE reflux(next)<br />
Polyps<br />
Arterial-<br />
Intestinal fistula<br />
Angiodysplasia
3 Perform UGI endoscopy<br />
•UGI endoscopy 是診斷 UGI bleeding source 的最<br />
sensitive 和 specific 的檢查.<br />
•Endoscopy 能檢查出 definitive or potential bleeding<br />
site 約 80%. 當流血厲害時會增加檢測率.但當迅速<br />
流血使得 endoscopy不可能看時,考慮作 angiography<br />
來定位.
4 Abnormal UGI endoscopy<br />
•UGI bleeding 最常見的 sources 是 peptic ulcer,<br />
esophageal varices, 和 acute mucosal lesions 如 acute<br />
esophagitis, gastritis, or Mallory-Weiss tears.<br />
•Gasiroesophageal reflux (GER) 不能endoscopic<br />
diagnosis, 但在 lower esophagus 有 mucosal changes<br />
就可懷疑診斷.
5 Peptic ulcer<br />
• Peptic ulcer disease 會導致 GI bleeding, 通常是<br />
hematemesis or melena.<br />
• 大部份 gastritis 和 peptic ulcer 是 Helicobacter<br />
pylori infection. 約佔 70% to 90% gastric ulcers,<br />
和 90% to 95% duodenal ulcers.<br />
• NSAIDs 是 peptic ulcer 和 UGI bleeding 另一常見<br />
的原因.
Infectious colitis<br />
Crohn’s colitis<br />
Ulcerative colitis<br />
Colon carcinoma<br />
/ neoplasm<br />
8 Angiodysplasia<br />
Diverticulosis<br />
6 Melena or hematochezia<br />
Perform UGI endoscopy<br />
Lesion not visualized<br />
7 Perform colonoscopy<br />
Abnormal<br />
See 4 endoscopy<br />
abnormal<br />
Lesion not<br />
Seen (Next)<br />
Colonic cancer<br />
Ischemic<br />
bowel<br />
9 Amyloidosis Polyps<br />
Hemorrhoids
6 Melena or hematochezia<br />
• Melena 常起因於 UGI bleeding. 首先要作 upper<br />
endoscopy 評估 melena source.<br />
• Hematochezia 起因於 either upper or lower GI<br />
bleeding. UGI bleeding 的量須超過 1000 ml,才會<br />
發生 hematochezia. LGI bleeding 的量不須多就會<br />
hematochezia.
7 Perform colonoscopy<br />
• Colonoscopic exam 對 active bleeding 可能有困難.如<br />
沒有 active bleeding 且穩定 48 hrs, 雖可以barium<br />
enema 代替,但 CFS 是更 sensitive 和 specific 的檢查.<br />
• BE exam 對 active bleeding 是沒幫助,因 barium 會干<br />
擾 angiography, 並且會妨礙大腸的 endoscopic<br />
visualization.
8 Angiodysplasia<br />
• Angiodysplasia (vascular malformations) 是 LGI<br />
bleeding 較常見的原因.<br />
• 過去右側大腸流血,如果 barium enema 有 diverticula,<br />
可能歸因於 diverticula. 因內視鏡技術進步,現在已<br />
知 angiodysplasia 是更可能. 這強調 lesion 須經<br />
endoscopy or arteriography 確實位置才可 confirm.
9 Amyloidosis<br />
•Primary amyloidosis 引起 connective tissue 和 blood<br />
vessels walls 的 amyloid deposition. 而常見 GI bleeding<br />
且嚴重.
CFS not see lesion<br />
10 Perform small bowel enteroclysis Abnormal<br />
Negative Polyps Tumor<br />
11 Perform angiogram and/or radionuclide imaging<br />
Tumor<br />
Vascular<br />
lesion<br />
Abnormal<br />
Arterial-intestinal<br />
fistulas<br />
Normal<br />
12 Mechel’s<br />
diverticulum<br />
Bleeding<br />
Stopped (next)
10 Perform small bowel enteroclysis<br />
• Small bowel enteroclysis 是把 barium 和 air 打入 small<br />
bowel 和 viewed radiographically.<br />
• 步驟如 air-contrast barium enema, 這可見 small bowel<br />
mucosal lesions, 但無法看見 angioma or<br />
angiodysplasia,因這兩種僅能從 endoscopic 檢查得知.
11 Perform angiogram and/or<br />
radionuclide imaging<br />
• 如 bleeding 持續但 endoscopic exam 無法確定,則<br />
考慮做 angiogram, 它雖無法確認 lesion type, 但<br />
有助於 bleeding site 的定位.<br />
• Radionuclide imaging 能檢測 bleeding 速度在 0.1<br />
to 0.5 mL/min, 與 angiography or colonoscopy,它<br />
是更 sensitive 但較少 specific. 這方法的好處是可<br />
以在 24 hrs 內 rescanned several times.
12 Mechel’s diverticulum<br />
• 在 15% to 30% 的 Meckel‘s diverticulum 有 gastric<br />
mucosa, 能被 technetium isotopic scan 得知. 而在<br />
bleeding Meckel’s diverticulum 約一半病例有 gastric<br />
mucosa. 因 gastric mucosa-lined 會分泌 acid, 會導致<br />
ileal mucosal ulceration 和 bleeding.<br />
• 在年輕病患有 GI bleeding, 在 angiography 前,可做<br />
Meckel‘s scan, 在小孩約 50% LGI 是因 Meckel’s<br />
diverticulum, 在年輕病患也很常見.<br />
• Meckel‘s diverticulurn 約佔 populationis 的 2%.
Infectious colitis<br />
Angiodysplasia<br />
Diverticulosis<br />
Hemorrhoid<br />
Polyps<br />
Fissures<br />
13 Bright red blood per rectum (BRBPR)<br />
Perform proctosigmoidoscopy<br />
Abnormal<br />
Inflammatory bowel disease<br />
Crohn’s disease<br />
Normal (Next)<br />
Ulcerative colitis/proctitis<br />
Rectosigmoid<br />
carcinoma<br />
Ischemic colitis
13 Bright red blood per rectum (BRBPR)<br />
• 因 LGI bleeding 的 rectal blood, 最常見的原因是<br />
internal hemorrhoids. 可做 proctosigmoidoscopy,<br />
它是更 sensitive 和 specific.<br />
• 如無法以 sigmoidoscopy 辨認,須做 CFS 來檢測<br />
更 proximal source.
Colonic Ulcer<br />
Crohn’s colitis<br />
Ulcerative colitis<br />
Colonic carcinoma<br />
Angiodysplasia<br />
Diverticulosis<br />
Proctosigmoidoscopy normal<br />
Perform colonoscopy<br />
Abnormal<br />
Ischemic bowel<br />
Hemorrhoid<br />
Negative<br />
Bleeding stopped/<br />
reevaluate<br />
Polyps (next)<br />
Amyloidosis
Crohn’s disease<br />
Ulcerative colitis<br />
Colon carcinoma<br />
Angiodysplasia<br />
Diverticulosis<br />
14 Occult blood present<br />
Perform colonoscopy Normal (next)<br />
Abnormal<br />
Ischemic bowel<br />
Amyloidosis<br />
Hemorrhoids<br />
Colonic ulcer<br />
Polyps
14 Occult blood present<br />
•Routine exam 包括 fecal occult blood tests 篩檢 occult<br />
GI blood loss, 但因可觀的 false-positive 費用,因此須<br />
知 screening sensitivity. (Specificity 也應知道來預防<br />
因false-negative 引起的 morbidity.<br />
•整個 GI 評估前,結合檢查 (如 guaiac test 和<br />
immunologic assay) 能有較高之 sensitivity 和<br />
specificity.
•某些常見 false-positive 的原因要知道,如 Oral iron<br />
supplementation 能使 stool 變黑, 大量 Vitamin C 會<br />
干擾檢查中的 chemical reaction.<br />
•Occult blood 為 positive 時,應測量 hematocrit. 亦可<br />
能任何 source 都會引起 occult blood, 如攝入含血<br />
的東西. 當有 occult blood,須要評估 upper 和 lower<br />
GI tract.
Angiodysplasia<br />
Tumor<br />
Polyps<br />
CFS normal<br />
Perform UGI endoscopy<br />
Normal<br />
Perform small bowel enteroclysis<br />
Abnormal<br />
Angioma<br />
Abnormal<br />
See hematemesis<br />
Normal<br />
15 Follow/repeat hemoccult<br />
and reevaluate at 6 month
15 Follow/repeat hemoccult<br />
and reevaluate at 6 month<br />
• 如評估沒有發現,須在 6 months 內再作 stool<br />
occult blood 和如陽性須作 full endoscopic exam.<br />
• Reevaluation 3 次 (every 6 ms over 18 m period)<br />
後仍為 negative,則不像有明顯 lesion.
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