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Upper GI Bleeding and Management. 台大醫院小兒肝膽腸胃科 吳嘉峰醫師 2010/07/25. 定義. 上消化道出血 : 於 Treitz 韌帶以上的消化道出血 吐血 Hematemesis : 鮮紅色的血液自口吐出 咖啡色吐出物 Coffee ground emesis : 鮮血經胃酸作用後呈咖啡色吐出物. To be differentiated … . 吐出物是否真的是來自腸胃道出血 ? 紅色食物染色 (Jello,tomatoes,strawberry)? 藥物 (bismuth, iron)? 流鼻血 ?

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Upper gi bleeding and management

Upper GI Bleeding and Management

台大醫院小兒肝膽腸胃科

吳嘉峰醫師

2010/07/25


定義

  • 上消化道出血:

    於Treitz韌帶以上的消化道出血

  • 吐血 Hematemesis:

    鮮紅色的血液自口吐出

  • 咖啡色吐出物 Coffee ground emesis:

    鮮血經胃酸作用後呈咖啡色吐出物


To be differentiated
To be differentiated…..

  • 吐出物是否真的是來自腸胃道出血?

    • 紅色食物染色 (Jello,tomatoes,strawberry)?

    • 藥物 (bismuth, iron)?

    • 流鼻血?

    • 來自媽媽的血?

    • 呼吸道出血?


如何處理上消化道出血

  • 實驗檢查

    • CBC with differential

    • Reticulocyte count(選擇性)

    • PT, PTT

    • Blood type & cross match

    • Albumin, GOT, GPT, BUN, creatinine

  • 胃液抽取物

    • Gilbert et al. report: bleeding source was identified in 16% of patients with negative gastric aspiration



出血的原因

  • 新生兒

    吞入母血(APT test)

    維生素K缺乏或未施打

    壓力性胃炎或潰瘍

    凝血功能缺陷

    胃酸分泌過多, 藥物

    血管異常

    牛奶蛋白過敏

    病毒感染

Textbook Pediatric Gastrointestinal Disease 4th ed, p259


出血的原因

  • 幼兒(小於三個月)

    • 壓力性潰瘍

    • 胃酸分泌過多

    • 食道炎

    • 血管異常

    • 食道靜脈瘤

    • 十二指腸/胃結構異常

    • 消化道阻塞

Textbook Pediatric Gastrointestinal Disease 4th ed, p259


出血的原因

  • 孩童及青少年

    • 食道撕裂傷

    • 胃酸分泌過多

    • 靜脈瘤

    • 腐蝕性物質誤食

    • 血管炎 (Henoch-Schönlein purpura)

    • 發炎性腸炎

    • 消化道阻塞

    • 凝血功能異常

Textbook Pediatric Gastrointestinal Disease 4th ed, p259


血管異常的病兆

  • 腫瘤

    • 血管瘤 Hemangiomas

    • 血管內皮瘤 Hemangioendotheliomas

  • 結構異常

    • 微血管性 Capillary

    • 靜脈性 Venous

    • 淋巴管性 Lymphatic

    • 動脈性 Arterial/arteriovenous

Textbook Pediatric Gastrointestinal Disease 4th ed, p259


Diagnosis
Diagnosis

  • Radiology

    Plain X-ray, Barium study, Sonography, CT angiography

  • Angiography

    血流量至少0.5mL/min

  • Radio-isotope study

    Technetium-labeled 標記紅血球攝影

  • Endoscope

    Hemoclip, EV Band ligation, ST needle injection (Normal saline, Bosmine, 95% Alcohol, et al)


Management
Management

  • Medical therapy: Drugs

  • Balloon tamponade

  • Endoscopic hemostasis

  • Angiography: embolization or angiocath with Pitressin infusion

  • Surgical hemostasis


Medical therapy
Medical Therapy

  • Gastric acid control

    • Anti-Acid

    • H2 receptor antagonists

    • Proton pump inhibitors

  • Vessel constrictors

    • Octreotide

    • Vasopressin

  • Mucosa protectors

    • Sucralfate

    • Misoprostol

Textbook Pediatric Gastrointestinal Disease 4th ed, p259


Gastric acid control
Gastric Acid Control

  • H2 blockers

    • Famotidine (Gaster 20mg/tab, 20mg/amp)

      • 0.5-1 mg/kg/day (max 80mg/day)

    • Ranitidine (Zantac 150mg/tab, 50mg/amp)

      • 2-4 mg/kg/day BID po (max 300mg/day); iv q6-8hr (max 50mg q6-8hr)

  • Proton pump inhibitors

    • Omeprazole (Losec 40mg/vial)

      • 1mg/kg/day qd to q12h (adult 40mg/day)

    • Lansoprazole (Takepron 30mg/cap)

      • 1-1.2mg/kg/day qd

    • Esomeprazole (Nexium 40mg/tab)

      • 1mg/kg/day qd


Vessel constrictor
Vessel Constrictor

  • Somatostatin (somatosan 3mg/amp)

    • Prevent postprandial hyperemia or reducing portal pressure by vasoactive peptides

    • Few side effect: hyperglycemia, abdominal cramping

    • Stop variceal hemorrhage up to 80%

    • Adult 250-500mcg/hr for 1-5 days for EV (6-12 Amp in N/S 500cc with 20 cc/hr= 250-500mcg/hr )

    • Child 1.5 mcg/kg/hr for 2 days, then up to 3mcg/kg/hr for another 7 days

  • Octreotide (Sandostatin 0.1mg/amp)

    • Synthetic analogues of somatostatin

    • 1-6 mcg/kg/hr (max 50 mcg/hr)


Vessel constrictor1
Vessel Constrictor

  • Vasopressin (Pitressin 20U/1ml/amp)

    • Reduce splanchnic blood flow & portal pressure

    • Short half-life (continuous infusion)

    • Side effect: systemic vasoconstriction (myocardial, mesenteric ischemia/ infarction)

    • Addition of nitroglycerine to improve efficacy

    • Initial 0.002-0.005U/kg/min (max 0.01U/kg/min)

  • Terlipressin (Glypressin 1mg/vial)

    • Synthetic vasopressin analogue

    • Fewer side effect & longer half-life

    • 20-30mcg/kg/dose q6h (adult 1-2 mg q4-6h)


Mucosa protector
Mucosa Protector

  • Sucralfate (Sucrate gel 1g/pk)

    • Aluminum salt of sulfated sucrose forms a paste-like complex adhering to damaged mucosa in the acid PH

    • Adults 1g qid; child 10-20mg/kg/dose qid, AC

    • Antacids should not be taken within one-half hour

  • Misoprostol (Cytotec 200mcg/tab)

    • Synthetic PGE1 analog (gastric antisecretory agent), reduce acid secretion from parietal cell & stimulation of bicarbonate from gastric & duodenal mucosa

    • Adults: 200mcg bid / qid (100mcg qid at 8-16y/o)


Balloon tamponade
Balloon Tamponade

  • Sengstaken-Blakemore tube

  • 常於停止加壓後復發性出血

  • 緊急時使用

  • 等待確定治療的橋樑




Endoscopic hemostasis
Endoscopic Hemostasis

  • Hemoclip: a specific feeding vessel

  • Banding: Esophageal varix

  • ST needle injection: epinephrine, normal saline, 95% Alcohol & sclerosants injection

  • 電燒止血

    • Heater probe, monopolar probe, bipolar electocoagulation (BICAP) probe

  • 雷射止血





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