토혈

성균관대학교 의과대학 내과 이준행

http://www.getbetterhealth.com/death-by-stomach-cancer/2009.08.21

Gastrointestinal bleeding

• Hematemesis : vomiting of blood

• Melena : passage of stools rendered black and tarry

• Hematochezia : passage of red blood per rectum

• Occult bleeding : blood in the stool detected by card test for hemoglobin peroxidase

History and Physical

이 준 행

성균관대학교 의과대학 삼성서울병원 소화기내과

토혈 CPX 증례

• 42세 남자가 피를 토하여 응급실로 왔다.

• 혈압 120/72 mmHg

• 맥박 102회/분

• 호흡수 18회/분

• 체온 36.8°C

진료문항 (CPX) 접근 3 axis

• 병력청취

• 신체진찰

• 환자(보호자) 교육

진료문항 (CPX) 접근 3 axis - 토혈

• 병력청취

– 토혈의 양상 및 응급조치가 필요한 증상 확인

– 토혈의 유발 원인 파악

– 건강위험도 및 병적 상태 평가

• 신체진찰

– 토혈의 유발요인과 원인 파악

• 환자(보호자) 교육

– 정보제공

토혈 병력청취 1 - 토혈의 양상 및 응급조치가 필요한 증상 확인

• 토혈 vs 객혈

• 토혈의 양

• 언제부터

• 몇 번

• 색깔: 선홍색, 검붉은 색, 피떡

• 변색깔: 흑색변, 혈변

• 어지럽거나 숨이 차지 않은지?

토혈 병력청취 2 - 토혈의 유발 원인 파악

• 토혈 과거력

• 중요 감별진단에 대하여 질문

– 소화성궤양

– Mallory Weiss

– Varix bleeding

– 위암

– 식도암

토혈 병력청취 3 - 건강 위험도 및 병적 상태 평가

• 흡연

• 혈액응고장애

• 항응고제, 항혈소판제, NSAIDs

History taking in GI bleeding (1)

Identify the probable presence of bleeding

• Hematemesis

• Melena

• Hematochezia

• Hypovolemia (syncope, faintness)

History taking in GI bleeding (2)

Estimate the amount and rapidity of bleeding

• Frequency and volume of stools or emesis

• Symptoms of hypovolemia

• Hematemesis

History taking in GI bleeding (3)

Ask about site and potential causes • Upper gastrointestinal

– Melena and/or hematemesis

– Symptoms of peptic ulcer, varices, esophagitis, Mallory-Weiss tears, and malignancy

• Lower intestinal

– Hematochezia

– Symptoms of arteriovenous malformations, diverticulosis, cancer, hemorrhoids, inflammatory bowel disease, ischemic colitis

History taking in GI bleeding (4)

Determine the presence of diseases or situations having poorer prognosis

• Congestive heart failure or prior myocardial infarction

• Chronic obstructive lung disease

• Cirrhosis

• Renal failure

• Advanced malignancy

• Age over 60 years

Physical examination

• HR, BP, tilt test, RR

• General appearance, mental status

• Neck veins, oral mucosa

• Skin temperature and color

• Abdominal examination

• Rectal examination

• Stigma of cirrhosis

• prn) nasogastric tube findings (upper vs. lower)

Management of upper GI bleeding

1. Restore and maintain normal volume (not necessarily transfusion). Get appropriate access with 2 large bore IVs

2. The site and cause of the bleeding should be established. Knowing the site of bleeding is more important than knowing the cause.

3. A treatment regimen should be planned, based on diagnosis and the condition of the patient .

Initial laboratory studies

• When bleeding is brisk especially if signs of hemodynamic instability are present t is wise to type 4 to 6 units of packed red blood cells.

• CBC with platelet count & differential, blood chemistry, PT (INR) and aPTT, O2 saturation, EKG are always indicated to screen for serious comorbidities as well as specifically additional laboratory work indicated by the initial workup or preexisting conditions.

• Upper endoscopy is the immediately preferred diagnostic & therapeutic modality.

History taking in GI bleeding (1)

Identify the probable presence of bleeding

• Hematemesis

• Melena

• Hematochezia

• Hypovolemia (syncope, faintness)

History taking in GI bleeding (2)

Estimate the amount and rapidity of bleeding

• Frequency and volume of stools or emesis

• Symptoms of hypovolemia

• Hematemesis

History taking in GI bleeding (3)

Ask about site and potential causes • Upper gastrointestinal

– Melena and/or hematemesis

– Symptoms of peptic ulcer, varices, esophagitis, Mallory-Weiss tears, and malignancy

• Lower intestinal

– Hematochezia

– Symptoms of arteriovenous malformations, diverticulosis, cancer, hemorrhoids, inflammatory bowel disease, ischemic colitis

History taking in GI bleeding (4)

Determine the presence of diseases or situations having poorer prognosis

• Congestive heart failure or prior myocardial infarction

• Chronic obstructive lung disease

• Cirrhosis

• Renal failure

• Advanced malignancy

• Age over 60 years

Physical examination

• HR, BP, tilt test, RR

• General appearance, mental status

• Neck veins, oral mucosa

• Skin temperature and color

• Abdominal examination

• Rectal examination

• Stigma of cirrhosis

• prn) nasogastric tube findings (upper vs. lower)

Management of upper GI bleeding

1. Restore and maintain normal volume (not necessarily transfusion). Get appropriate access with 2 large bore IVs

2. The site and cause of the bleeding should be established. Knowing the site of bleeding is more important than knowing the cause.

3. A treatment regimen should be planned, based on diagnosis and the condition of the patient .

Initial laboratory studies

• When bleeding is brisk especially if signs of hemodynamic instability are present t is wise to type 4 to 6 units of packed red blood cells.

• CBC with platelet count & differential, blood chemistry, PT (INR) and aPTT, O2 saturation, EKG are always indicated to screen for serious comorbidities as well as specifically additional laboratory work indicated by the initial workup or preexisting conditions.

• Upper endoscopy is the immediately preferred diagnostic & therapeutic modality.

Common cause of upper GI bleeding

이 준 행

성균관대학교 의과대학 삼성서울병원 소화기내과

Common causes of upper GI bleeding

• Gastric ulcer

• Duodenal ulcer

• Varix

• Mallory-Weiss syndrome

• Gastritis or erosion

• Esophagitis or esophageal ulcer

• Stomach cancer

Clipping Active bleeding

Complication: bleeding (spurting)

Injection Active bleeding

Complication: bleeding (spurting)

MVR후 warfarin 사용 중 출혈이 있어 heat probe coagulation시행

Benign gastric ulcer

Fatal peptic ulcer bleeding

• 71/M with melena

• CHF 환자로 2주전부터 dyspnea 악화되고 general weakness, poor oral

intake로 CCU로 입원.

• Decompensated HF로 manage 중 melena 발생

• Heart failure 진행으로 사망

Duodenal ulcer with exposed vessel

Esophageal varix band ligation

Anatomy of GE junction

대한의사협회 사이버연수원 자료

Mallory Weiss tear

Mallory Weiss Tear - no endoscopic treatment

Clipping for Mallory-Weiss tear

Band ligation for Mallory Weiss tear

RT-induced hemorrhagic gastritis

Esophageal ulcer with bleeding

EGC with bleeding

Singet ring cell carcinoma hematemesis - observation without treatment for 4 years

Hemobilia

Bleeding Dieulafoy ulcer

Dieulafoy lesion - on aspirin after coronary stent 1 week ago

Ia, pumping Ib, oozing IIa, exposed vessel IIb, adherent clot

Rebleeding risk by Forrest classification

Fatal peptic ulcer bleeding

• 71/M with melena

• CHF 환자로 2주전부터 dyspnea 악화되고 general

weakness, poor oral intake로 CCU로 입원.

• Decompensated HF로 manage 중 melena 발생

• Heart failure 진행으로 사망

Treatment for bleeding peptic ulcer

• Electrocauterization

– Bipolar catheter

– Heat probe

– Hot biopsy forcep

• Epinephrine injection treatment

• Endoscopic cliping

• Surgery

Ethanol injection

Coaptive coagulation

Two types of clip application

Timetable for bleeding gastric ulcer

1 2 3 4 5 6 7 8 9 10

PPI

H. pylori eradication treatment (prn)

Initial EGD +/- endoscopic treatment

Follow-up EGD with biopsies for histology and H. pylori

IV oral

Follow-up EGD with histology and H. pylori

결론

• 위장관 출혈의 종류 구분: hematemesis, melena,

hematochezia, occult bleeding

• 상부위장관 출혈의 흔한 원인

• 위장관출혈의 나쁜 예후인자

• Forrest classification

경청해 주셔서 감사합니다.