HEMATEMESIScaiqiaoyinDepartmentofGastroenterology,AffiliatedMindaHospitalMedicalCollege,HubeiUniversityforNationalitiesTheGastrointestinalSystemGI tract consists of a hollow muscular tube starting from the oral cavity, going through the rectum and is ended at the anus, where food is expelled. The main function of the GI tract is digestion and absorption of nutrientsThe movement of the smooth muscles in the GI is called peristasis and propels food in the forward directionAccessory organs that assist the tract by secreting enzymes to help break down food into its component nutrients (salivary glands, liver, pancreas and gall bladder) TheGastrointestinalSystemdigestive tract Startsatmouthpharynxesophagusstomachsmallintestinelargeintestinerectumendsatanusdigestive gland salivary glands, liver, pancreas gall bladderTheGastrointestinalSystemDigestiveandabsorptiveprocesstakeplaceintheGItractGastrointestinalProblemsuppergastrointestinaltractdisorderDysphagiaNauseaVomitinghematemesishematocheziamelena.lowerGItracthematochezia.jejunumduodenumsuspensoryligamentofduodenumduodenojejunalflexureuppergastrointestinaltractlowergastrointestinaltract definitionofhematemesisandmelaenahematemesis- isvomitingofblood.whichcanbefreshandred,ordegradedbygastricpepsin,whenitisdarkbrownincolourandresemblescoffeegrounds.melaena-isthepassageoftarry,shinyblackstoolswithacharacteristicodourandresultsfromuppergastrointestinalbleeding.colourofhematemesiscolourofhematemesisdependsontheamountandcharacterofthegastriccontentsatthetimebloodisvomitedandonthelengthoftimethebloodhasbeeninthestomach.brightredblood-thesourceofbleedingisabovethegastroesophagealsphincter,e.g.fromesophagealvarices,activelyvomited.Brightredbloodinthevomitindicatesafreshhemorrhageandlittlecontactofthebloodwithgastricjuicesbrownish/darkbrown(coffee-ground)Gastricacidschangebrightredbloodtoabrownishcolorandthevomitisoftendescribedas“coffee-ground”incolor.colourofmelaenacolourofmelaenaistarry,shinyblackstoolsdistinguishmelaenafromthemattblackstoolsassociatedwithoralironorbismuththerapy.OB(-)hemoglobin 血红蛋白 胃酸作用 转变为 酸化正铁血红蛋白血红蛋白 细菌作用 所含铁转变为硫化铁amountofhematemesisandmelenaEvaluationofbleedingamount5-10mlOB(+)50-100mlMelena250-300mlHematemesis/Hematochezia400-500mlSymptomsofhypovolemicshock(lowcirculatingbloodvolume)dizziness,palecomplexion,coldsweats,acromegalydamp,drymouthdysphoria,lessurine1000mlhemorrhagicshock,SBP90mmHg,P120bpm(20%-30%Systemiccirculationbloodvolume)Causesofhematemesis1.uppergastrointestinaltractdiseasepepticulceresophagitis,gastritis,duodenitisMallory-Weissesphagealtearesophagealvaricesesophagealorgastricmalignancy(cancer)vascularmalfomation.2.others:nosebleedinghematologicalsystemdiseasesuremiaDiseasesofthebodysystemthrombolyticsandanticoagulants.vVarisesVarisesesofagusVarisesfundusDieulafoyhaemangiomasvNonvarisesesofagitis,gastritisduodenitispepticulcerStressulcerMallory-WeisstearTumor/CarcinomaCausesofhematemesisThemostcommoncausesofhematemesisare:pepticulcer,gastritis,esophagealvaricesorlesions,andcancerofthestomach.Benigntumors,traumaticpostoperativebleeding,andswallowedbloodfrompointsinthenose,mouth,andthroatcanalsoproducehematemesis.esophageal varicesMallory-WeisssyndromeMallory-Weisssyndrome:bleedingtearsintheesophagalmucosa,usuallycausedbyprolongedandvigorousretching.esophagal cancerTumorsofesophagus.gastriculcer(GU)Dieulafoydiseasealcoholdrug:NSAID/steroidsHelicobacter pylorihelicobacterpyloriganstriccanceracute erosive and hemorrhagic gastritisalcoholdrugNSAIDsteroidsthrombolyticsandanticoagulantsNSAID-induced hemorrhagic gastritis duodenalulcer(DU)Vascularmalfunctionsofthegastrointestinaltract,suchasbleedinggastricvaricesorduodenumvaricespredictionoftheriskofmortalityinpatientswithupperGIbleeding-RockallScorecriterionscoreage:60/60-79/80012shock:none/pulse100bpmSBp100mmHg/SBp100mmHg012comorbidity:none/heartfailure/ischaemicheartdiseaseorothermajordisease/renalfailureordisseminatedmalignancy023endoscopicfindings:Mallory-Weisstearandnovisiblebleeding/allotherdiagnoses/uppergastrointestinalmalignancy012majorstigmataofrecenthaemorrhage:none/visiblebleedingvesseloradherentclot02totalscorepre-endoscopyscore4=25%mortality(maximumscore=7)pre-endoscopypostendoscopyscore8+=40%mortality(maximumscore=11)postendoscopypredictionoftheriskofmortalityinpatientswithupperGIbleeding-RockallScoredifferentialdiagnosishemoptysis-isspittingorcoughingofblood,thebleedinglesionsmaybeanywherefromnosetolung.hemoptysishematemesispathogenesis respiratorytractdiseaseupperGItractdisease(causes) bronchitis/pneumonia)PU/livercirrhosis/cancertuberculosis/carcinomagastritis/esophagealvaricesheartfailurebleedingdisorder complaints larynx(throat)itchabdominaldiscomfortable(beforebleeding)chestpain/distress,coughnasea,vomit style of bleeding spitting/coughingoutvomitingout PH alkline7acidity7melena -+ sputum after bleeding+-+clinicaloccurancesymptoms-historytakingdependontheamountandspeedofbleedingchief complaints:hematemesis/melena/Hematocheziaaccompany complaints:abodominalpain/dizzy/sweat/conscious/shortofbreath/past history:IsthereaprevioushistoryofPUorliverdisease?Isthereahistoryofalcohol,NSAIDorcorticosteroidingestion?Didthevomituscomprisefreshbloodorcoffeeground-stainedfluid?Wasthehnatemesisprecededbyintenseretching?Wasbloodstainningofthevomitusapparentinthefirstvomit?clinicaloccurancephysicalexamination(signs)Vitals:T,P,R,Bp(Tachycardia,hypotension)Skin examinationjaundice/spidernaevi/caputmedusae/palmarerythema/mucotutaneoushemorrhagepallor/hydration/edmapalmarerythemadistendedveinsclinicaloccurancephysicalexamination(signs) Abdominal examinationinspection:scars/swellings/distendedveins/varicesofabdominalwallpalpation:tnderness/hepatomegaly/splenomegalypercussion:ascitesausculation:bowelsounds/bruitsclinicaloccuranceLaboratoryexaminationbloodroutineexamination(RBC/hemoglobin/Hct/WBC/PLTcount)coagulationfunction:PT/APTTliverfunction:TBil(totalbilirubin):directbilirubin(DBIL),indirectbilirubin(IBIL)albuminenzymology(AST/ALT/GGT/ALP)renalfunction:BUNandcreatinineclinicaloccuranceendoscopyexaminationclinicaloccurancediagnosishistorytaking-complaintsphysicalexaimation-signsLaboratoryexaminationendoscopyexaminationClinicalScenario67yoMwithhistoryofHTNandosteoarthritiswhopresentstotheEDwith3episodesofcoffeegroundemesistoday.Noabdominalpain,melenaorhematochezia.Nohistoryofliverdiseaseorcoagulopathy,+occasionalETOHuse.MedicationsincludeHCTZ,Lisinopril,andIbuprofenPRNforjointpainVSonarrival:T37,HR102,BP108/72,similarBPstanding,Pox99%RAExamination:AOx3.Noscleralicterus.Abdomensoft,non-tender,noHSM.Rectalwithdarkbrownstool,guiac+.Labs:Hgb9.8,Plt245,INR1,LFTsnl,BUN28/Cr1.4.Whatisthelikelyetiologyofthebleeding?ClinicalScenarioconculsion67yoMonNSAIDSwith3episodesofcoffeegroundemesis,anemia,andtachycardiaWhatisthelikelyetiologyofthebleeding?Suspectpepticulcerdiseaseorgastritissummary-LearningObjectivesthedefinitionofhematemesis isvomitingofblood.whichcanbefreshandred,ordegradedbygastricpepsin,whenitisdarkbrownincolourandresemblescoffeegrounds.themajorcausesofhematemesisThemostcommoncausesofhematemesisarepepticulcer,gastritis,esophagealvaricesorlesions,andcancerofthestomachevaluationofhematemesisandmelena-colour/amount/accompanycomplaints/pasthistory/physicalexaminationdifferentitationofhematemesisandhemoptysis