呕血便血(诊断学9版-2学时-)

《诊断学》消化系统疾病诊断学呕血：是上消化道疾病或全身性疾病所致的上消化道出血，血液经口腔呕出。Hematemesisisuppergastrointestinalbleedingcausedbyuppergastrointestinaldiseases(digestiveorgansabovetheflexor'sligament,includingesophageal,gastric,duodenal,hepatic,biliary,pancreaticdiseases)orsystemicdiseases.Bloodisvomitedthroughthemouth.定义指Treitz韧带以上的消化器官,包归食管、胃、十二指肠、肝、胆、胰疾病。病因一、上消化道疾病Upperdigestivetractdiseases1、食管疾病：食管炎、食管癌、Mallory-Weiss综合征等。Esophagealdiseases:esophagitis,esophagealcancer,Mallory-Weisssyndromeandsoon.2、胃、十二指肠疾病：消化性溃疡、急性糜烂出血性胃炎、胃癌等。Gastroduodenaldiseases:pepticulcer,acuteerosivehemorrhagicgastritis,gastriccancerandsoon.3、门脉高压:食管胃底静脉曲张破裂或门脉高压性胃病。Portalhypertension:bleedingfromesophagogastricvaricesorportalhypertensivegastropathy.二、上消化道邻近器官疾病：肝胆、胰腺疾病。Upperdigestivetractadjacentorgandiseases:hepatobiliaryandpancreaticdiseases.病因三、全身性疾病Systemicdisease（1）血液病：过敏性紫癜、白血病、凝血机制障碍性疾病等。Hematologicaldiseases:allergicpurpura,leukemia,coagulationdisorders,andsoon.（2）感染性疾病：流行性出血热、钩体病、败血症、爆发性肝炎等。Infectiousdiseases:epidemichemorrhagicfever,leptospirosis,septicemia,fulminanthepatitisandsoon.病因（3）结缔组织病等：系统性红斑狼疮（SLE）、皮肌炎、结节性多动脉炎累及上消化道。Connectivetissuedisease,suchassystemiclupuserythematosus(SLE),dermatomyositis,nodularpolyarteritisinvolvingtheuppergastrointestinaltract.（4）其他：尿毒症、肺心病等。Others:uremia,pulmonaryheartdiseaseandsoon.病因常见病因消化性溃疡Pepticulcer食管胃底静脉曲张破裂Esophagealandgastricvaricesbleeding急性糜烂出血性胃炎Acuteerosivehemorrhagicgastritis胃癌gastriccancer消化性溃疡EGVB急性糜烂出血性胃炎胃癌常见病因Mallory-Weisssyndrome其他病因Dieulafoydisease其他病因其他病因其他病因临床表现1.呕血与黑便Hematemesisandmelena:特征性表现。呕血：可为鲜红色、暗红色或咖啡色（棕褐色）Hematemesis:brightred,darkredorbrown.黑便：血液经肠道排出体外形成黑便（Hb与硫化物结合形成硫化亚铁）。Melena:bloodpassesthroughtheintestinestoformblackstools(Hbcombineswithsulfidetoformferroussulfide).血液在胃内停留时间长，血红蛋白与胃酸作用形成酸化正铁血红蛋白。颜色取决于：出血量、出血部位、出血速度。临床表现2.周围循环血容量不足表现：出血量占循环血量10%以下，无明显表现；10-20%时可有头昏乏力等；20-30%时可有冷汗、四肢厥冷、心慌、脉搏增快等；30%以上时可有周围循环衰竭表现（失血性休克）。Peripheralcirculationinsufficiencymanifestations:theamountofbleedingaccountedforlessthan10%ofthecirculatingbloodvolume,noobviousperformance;10-20%mayhavedizzinessandfatigue;20-30%mayhavecoldsweat,coldlimbs,panic,rapidpulseandsoon;morethan30%mayhaveperipheralcirculationfailure(hemorrhagicshock).临床表现3.血液学变化：Hb降低，早期可无明显血液学改变。Hematologicalchanges:Hbdecreased,buttherewasnoobvioushematologicalchangesintheearlystage.4.氮质血症：血液蛋白的分解产物在肠道被吸收。azotemia：Thedecompositionproductsofbloodproteinsareabsorbedintheintestinaltract.5.发热：吸收热、体温调节中枢调定点上移。fever：Absorptionheatandthermoregulationcentershiftedupward.伴随症状上腹痛:多为消化性溃疡，中老年人注意胃癌。Epigastricpain:mostlypepticulcer,themiddle-agedandtheelderlypayattentiontogastriccancer.肝脾肿大:肝硬化、肝癌。Hepatosplenomegaly:cirrhosisandlivercancer.皮肤黏膜出血:血液病、败血症、重症肝炎。Mucocutaneoushemorrhage:hematopathy,septicemia,severehepatitis.黄疸、发热、右上腹痛:胆系疾病。Jaundice,fever,rightupperabdominalpain:biliarydiseases.左锁骨上淋巴结肿大:胃癌、胰腺癌。Leftsupraclavicularlymphnodeenlargement:gastriccancerorpancreaticcancer.服用NSAID、饮酒、应急状态：急性糜烂出血性胃炎。TakingNSAID,drinkingandemergency:acuteerosivehemorrhagicgastritis剧烈呕吐后：Mallory-Weiss综合征。Severevomiting:Mallory-Weisssyndrome.伴随症状咯血呕血病因出血前症状出血方式血色血中混有物反应黑便出血后痰的性状咯血与呕血的鉴别消化性溃疡肝硬化急性糜烂出血性胃炎胃癌等肺结核支扩肺癌肺炎肺脓肿心脏病等喉痒胸闷咳嗽等上腹不适恶心呕吐等咯出鲜红痰泡沫碱性咽下后可有常有血痰数日呕出可为喷射状棕黑暗红有时鲜红食物残渣胃液酸性有柏油便可持续数日无血痰概述定义：指消化道出血，血液由肛门排出。Definition:bleedingfromthedigestivetractandblooddrainedfromtheanus.便血颜色可呈鲜红、暗红、黑色。Thecolorofbloodystoolcanbebrightred,darkredandblack.隐血：指少量出血不造成粪便颜色改变，须经隐血试验才能确定者。Occultblood:asmallamountofbleedingthatdoesnotcausechangesinthecolorofthestool.Itcanonlybedeterminedbyoccultbloodtest.病因一、下消化道疾病Lowerdigestivetractdiseases1、小肠疾病Smallintestinaldisease2、结肠疾病Colonicdisease3、直肠肛管疾病Anorectaldiseases4、血管病变Angiopathy二、上消化道疾病Upperdigestivetractdiseases三、全身性疾病Systemicdisease临床表现便血颜色和形式可因出血部位不同、出血量多少以及血液在肠腔内停留时间的长短而异。Thecolourandformofbloodinthestoolcanvarydependingonthesiteofbleeding,theamountofbleeding,andthelengthoftimethebloodstaysintheintestinalcavity.隐血便：消化道出血每日在5ml以下者，无肉眼可见的粪便颜色改变。Occultblood:gastrointestinalbleedingislessthan5mlperday,andnofecalcolorchange.伴随症状1、腹痛abdominalpain：消化性溃疡、胆道出血；细菌性痢疾、阿米巴痢疾、溃疡性结肠炎；急性出血坏死性肠炎、肠套叠、肠系膜血栓或栓塞。Pepticulcer、Biliarytracthemorrhage、Bacterialdysentery、amebicdysentery、Ulcerativecolitis、Acutehemorrhagicnecrotlzingenteritis、intussusception、Mesentericthrombosisorembolism.2、里急后重tenesmus：细菌性痢疾、直肠炎、直肠癌。Bacterialdysentery、Proctitis、rectalcancer.3、发热fever：伤寒、流行性出血热、钩体病、淋巴瘤等。Typhoidfever、epidemichemorrhagicfever、Leptospirosis、Lymphoma,etc.伴随症状4、全身出血倾向Systemicbleedingtendency：过敏性紫癜、流行性出血热、重症肝炎、白血病等。Allergicpurpura、epidemichemorrhagicfever、Severehepatitis、Leukemiaandsoon.5、皮肤改变Skinchange：肝硬化、毛细血管扩张。Cirrhosis、Telangiectasia.伴随症状6、腹部肿块Abdominalmass：结肠癌、淋巴瘤、肠结核、克罗恩病等。Coloncancer、Lymphoma、Intestinaltuberculosis、Crohndisease.伴随症状1、腹泻的定义。Definitionofdiarrhea.2、腹泻根据发生机制分为哪几种？Accordingtothemechanism,whatarethetypesofdiarrhea?3、阿米巴痢疾和细菌性痢疾的血便特点。BloodystoolcharacteristicsofAmiba'sdysenteryandbacillaryysentery.4、洗肉水样大便见于何病？Whatkindofdiseasedoesthestoollooklikemeatwashingwater?复习思考题SEEyou