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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

slide2
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?
slide4
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
slide6
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

slide7
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

slide8
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

slide9
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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