非静脉曲张性上消化道出血内镜图谱

2020-03-19 MedSci原创 MedSci原创

非静脉曲张性上消化道出血是世界范围内发病率和死亡率的主要原因。尽管治疗方法有所改善,但死亡率仍保持在10%。内镜医生应该知道非静脉曲张性上消化道出血的主要治疗建议。在指南中对患者进行分类和最佳治疗进行

非静脉曲张性上消化道出血是世界范围内发病率和死亡率的主要原因。尽管治疗方法有所改善,但死亡率仍保持在10%。内镜医生应该知道非静脉曲张性上消化道出血的主要治疗建议。在指南中对患者进行分类和最佳治疗进行内镜管理,并应考虑在初始阶段进行多学科管理。内镜治疗是高危病变的重要治疗方法,入院后24~24h内行内镜检查明确诊断及治疗。
 
非静脉曲张性上消化道出血常见原因
 
消化性溃疡    20%~50%
食管贲门黏膜撕裂症  15%~20%
糜烂性炎/十二指肠球炎 10%~15%
食管炎/食管溃疡   5%~10%
恶性肿瘤    1%~2%
血管发育不良/血管畸形   5%
其它     5%
 
内镜下常用治疗技术
 
注射(肾上腺素)     体积效应产生局部填塞
硬化剂   血栓形成
烧灼(热探针)产生局部填塞的机械压力,与热或电流结合,使血管凝固
凝血酶/纤维蛋白/氰基丙烯酸酯胶   在出血部位的主要组织密封
止血夹   物理效应产生压塞
圈套(可拆卸的圈套)物理效应产生压塞
套扎 物理效应产生压塞
OTSC  物理效应产生压塞
APC   电离气体传导电流,导致凝固
 
图1 钛夹 套扎器  OTSC  APC
 
Forrest分级及出血风险
 
图2  Forrest分级及出血风险
 
病例
 
图3 位置变化的重要性。镜检查可见胃内充满血液。(a)当病人处于左侧卧位时,血液聚集在胃底底和大弯。因此,只能看到小弯侧。(b)将病人转右侧卧位,血液便进入胃窦,可见胃体大弯侧的出血性溃疡。(c) 止血夹用于止血。
 
图4 活动性溃疡上有血肿和血块。为了准确有效的内镜下止血,应清除血凝块或血肿。溃疡床上附着着大量的血块。血块清除后,溃疡清晰可见。
 
图5 胃和食管交界处黏膜撕裂出血。胃食管交界处纵向上方可见黏膜撕裂。用多个夹子夹闭黏膜撕裂。内镜止血夹后三个月复查,黏膜撕裂完全愈合。
 
图6 食管贲门黏膜撕裂12点和6点的位置出血,多个夹子夹闭控制出血,1天后,没有进一步出血。
 
图7 食管血肿,2月后复查完全吸收。
 
图8 食管结核纵行溃疡出血,血管造影提示假性动脉瘤、栓塞,抗结核治疗后溃疡愈合。
 
图9 胃体小弯Dieulafoy’s 病出血,钛夹夹闭,5月后复查完全愈合。
 
图10 胃体大弯良性溃疡出血,中间可见血管,钛夹夹闭,5日后复查,溃疡愈合良好,无活动性出血。
 
图11 Forrest Ia出血。胃角良性溃疡伴喷射性出血,多个止血钳夹闭后无进一步出血,复查可见溃疡完全愈合。
 
图12 氩离子凝固术(APC)治疗胃窦血管扩张(西瓜胃)。
 
图13 胃体血管发育不良出血APC治疗。
 
图14 活检后喷射性出血钛夹夹闭治疗。
 
图15 早期胃癌ESD治疗后出血APC治疗,2月后复查溃疡愈合疤痕。
 
图16 DU活动性出血,钛夹治疗。
 
图17 Forrest IIb型十二指肠溃疡出血。发现约1 cm大小的十二指肠溃疡(Forrest类IIb),内镜下止血夹用于血管闭合,5天后,溃疡底部清洁。
 
图18 十二指肠GIST出血,钛夹夹闭,后外科手术切除。
 
图19 吻合口处有活动性出血。患者大约5年前接受了胃次全切除术。吻合口处可见喷血现象。内镜下止血夹装置接近并瞄准出血部位。使用了多枚钛夹,溃疡出血停止。
 
图20 十二指肠降部出血,血管造影提示胰十二指肠下动脉的造影剂渗漏。

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    2021-06-10 ms3000001252867540

    谢谢分享

    0

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    2020-12-06 芬太尼注射液

    好病例,学习了,感谢分享。

    0

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  5. [GetPortalCommentsPageByObjectIdResponse(id=972367, encodeId=c0439e2367f2, content=谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=63, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=2bfe5517980, createdName=ms3000001252867540, createdTime=Thu Jun 10 07:39:08 CST 2021, time=2021-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=905433, encodeId=9b3c905433b3, content=好病例,学习了,感谢分享。, beContent=null, objectType=article, channel=null, level=null, likeNumber=74, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=becf1738887, createdName=芬太尼注射液, createdTime=Sun Dec 06 17:14:26 CST 2020, time=2020-12-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1932074, encodeId=6cfa19320e451, content=<a href='/topic/show?id=5f8799e58f7' target=_blank style='color:#2F92EE;'>#非静脉曲张性上消化道出血#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=41, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=99758, encryptionId=5f8799e58f7, topicName=非静脉曲张性上消化道出血)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=1d01326, createdName=lizhou0204, createdTime=Fri Feb 26 15:54:48 CST 2021, time=2021-02-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1723089, encodeId=99401e230898a, content=<a href='/topic/show?id=0cc01998259' target=_blank style='color:#2F92EE;'>#上消化道#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=19982, encryptionId=0cc01998259, topicName=上消化道)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=b81833366357, createdName=zchen, createdTime=Mon Dec 21 12:54:48 CST 2020, time=2020-12-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1698058, encodeId=2cbe1698058e8, content=<a href='/topic/show?id=f2399910109' target=_blank style='color:#2F92EE;'>#静脉#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=36, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=99101, encryptionId=f2399910109, topicName=静脉)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0bc129907796, createdName=fusion, createdTime=Sun May 03 01:54:48 CST 2020, time=2020-05-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1262169, encodeId=f1a212621691f, content=<a href='/topic/show?id=0ceb30545e0' target=_blank style='color:#2F92EE;'>#内镜#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=30545, encryptionId=0ceb30545e0, topicName=内镜)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c30265, createdName=jiafufeng@yaho, createdTime=Fri Mar 20 23:54:48 CST 2020, time=2020-03-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1464651, encodeId=e8c9146465107, content=<a href='/topic/show?id=32e765e6591' target=_blank style='color:#2F92EE;'>#消化道#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=65765, encryptionId=32e765e6591, topicName=消化道)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7b6e6676048, createdName=changhe715, createdTime=Fri Mar 20 23:54:48 CST 2020, time=2020-03-20, status=1, ipAttribution=)]
    2020-05-03 fusion
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