Hemoragiile digestive superioare

Clasificarea hemoragiilor digestive

Hemoragii digestive superioare (HDS)
Sangerare de la nivelul esofagului pana la nivelul unghiului
Treitz(jonctiunea duodeno jejunala)*ligament Treitz-intre ultima parte a
duodenului si ultima parte a stomacului.
Hemoragii digestive medii (HDM)
nghiul Treitz !alva ileocecala
Hemoragii digestive inferioare (HD")
!alva ileocecala #nus
Hemoragii digestive oculte(prezenta sangelui in scaun,dar fara a fi vazut cu
ochiul liber)
$eactia #dler (%.& ' (.& ml sange in scaun)-reactia de culoare dintre H) si
apa o*igenata+pusa cu un reactive apoiculoare
Hemocult (, & ml sange in scaun)
Hemo-uant-cantitativ o)serva transformarea hemului nonfluorescent in
porfirina fluorescenta.
Importanta HDS
.eneralitati
/recventa - %0 (111 locuitori (2)
Mortalitate %1 3 (recent 4 3)
De ( ori mai frecvente la varste , 51 ani
&1 3 prin 678$ %0 9 #":S(antiinflamatoare nesteroidiene)
4 3 prin !#$"78 % 0 9 D878S
De ce se produc sangerarile digestive?
%)6eziune mucozala
inflamatorie
injurie
()6eziune vasculara
De % si ( -$esponsa)il - tubul digestiv.
9)Deficit al hemostazei
/actori de coagulare
Trom)ocitele
!asele sangvine
4)Deficit al procesului de reparare al injuriei
De 9 si 4 -$esponsa)il ' ficatul.
bordarea unei HDS
Diagnosticul pozitiv
!valuarea gravitatii
Stabilirea efectelor hemodinamice
Diagnosticul etiologic
"ratamentul hemostatic
!tiologia HDS
#eziuni ale tubului digestiv
Patologie esofagiana
o Hemoragie esofagiana ' e*plozie sau eroziune (;&3) ' sunt
hemoragii medii sau severe
o 8sofagita de reflu* ' sunt hemoragii usoare
o Hernie gastrica transhiatala
o lcere esofagiene
o 7ancere esofagiene
o Tumori )enigne esofagiene
Patologie gastrica
o lcer gastric
Mica cur)ura+ unghi gastric+ su) cardial
<repiloric+ fata anterioara 913 sunt severe
o .astrita eroziva
Stress chirurgical+ arsuri intinse
Medicamente (#":S)
HDS moderate
o 7ancer gastric operat ' HDS moderate
o <olipi0polipoze ' HDS usoare
o 7auze rare
#ngiodisplazia gastrica (malformatii vasculare)
Sd. Mallor=->eiss (alcool ? varsaturi)
o Stomac operat
Sutura 0 ulcer 0 cancer gastric
Patologie duodenala
o lcere duodenale mai ales de fata posterioara ' sangerari moderate
sau severe (@13)
o Duodenita acuta ? gastrita acuta hemoragica
o Tumori duodenale ' rar
o 7auze rare
!arice duodenale
<ancreas ectopic
#eziuni la nivelul glandelor ane$e
Patologie hepatica
o Hipertensiune portala
o Hemo)ilia
singe la nivelul cailor )iliare manifestat prin triada
C%#IC & '!#!( & IC"!)
Arigine ' ficat 0 vezicula )iliara 0 cai )iliare 0 pancreas
Patologie pancreatica
o 7auze B)enigneC <#7+ <7$D
o 7ancere pancreatice invazive
o HT< segmentara
Cauze e$tradigestive
Sindroame hemoragipare prinE
7oagulopatii
<urpure
Hemofilie
C#I(IC
Hemoragia
8*teriorizare
Hematemeza
Melena
Hematochezie
Aculte
7onsecinta
Hematologica
Hemodinamica
7auza
*araclinic !DS
/orrest
" F #ctiva
a. jet pulsatil 0 nepulsatil
). panza
"" F Stigmate
a . 7heag
) . !as
""" F potentiale
HDS
#AG
H)+ Ht+ 6
ree
/AGT
$*
#rterio
Hematii marcate *
GA#6# D8 G#H#
7iroa
Hemopatii
7oagulopatii
+ravitate (Smith , -eil)
.soare / 012
3014 ml
5 / 344b6min
" / 74 mmHg
IS 83?
*5C /(
D (diureza)/ (
'edii / 91 2
3:14 ml
5 / 304
"/ 74
IS 83,1
*5C scade
D scade
Severe / 14 2
0144 ml
5 ; 304
" 8 <4
IS ; 3,1
*5C =. scazuta
(.)I! /soc I
"I'* >>>
titudinea terapeutica in HDS
Conditii necesare
<ersonal medical calificat 0 interdisciplinaritateE gastroenterolog+
endoscopist+ anestezist+ chirurg+ asitent medical
7amera de garda ' dotare #T" adecvata
<osi)ilitate de a institui transfuzii sangvine
6a)orator aceesi)il (4 ore din (4
<osi)ilitatea de a efectua 8DS (4 h din (4
8*istenta unor protocoale de inteventie si monitorizare a )olnavilor
#ccesul la serviciul de chirurgie

*rotocol HDS
Diagnostic pozitiv ' hematemeza ? melena ' T$ ? sonda
Da :u acasa
Evaluarea gravitatii
.soara 6 'edie ? pacient J 51 ani+ H),%1+ T# (:)
Sectie )oli interne sau gastroenterologie+ 8DS & zile
+rava ? pacient , 51 ani+ H) J %1+ hipovolemie+ )oli asociate
#T"+ <8!D+ chirurgie
Se determinaE H)+ uree+ grup sg.+ coagulograma+ teste hepatice
Rechilibrare hidroelectrolitica
Detectarea sursei de sangerare
Selectarea tipului de tratament E
Medical
8ndoscopic
"nterventional (T"<S)- Transjugular Intrahepatic Portosystemic Shunt
(TIPS)?
*
7hirugical
*T"<S
Interventional radiologists perform this procedure to treat a condition called portal hypertension.
Portal hypertension occurs most frequently in patients with liver disease such as cirrhosis or
hepatitis. Scarring in the liver creates a restriction to the flow of blood through the liver. The main
vein to the liver is the portal vein. The pressure in the portal vein becomes very high, causing
adjacent veins in the abdomen to become dilated (varices and can potentially rupture and cause
life!threatening internal bleeding. "y lowering the pressure in the portal vein, the ris# of hemorrhage
is greatly reduced.
The TIPS procedure has also been effective in the treatment of ascites secondary to liver disease.
In addition, TIPS has been successfully applied in less common situations including treatment of
"udd!$hiari syndrome, decompression of lower %I and stomal varices, and treatment of malignant
compression of hepatic or portal veins. This procedure is a good alternative to the surgical treatment
of this condition with a shorter recovery time.
The initial TIPS procedure is performed under general anesthesia. The interventional radiologist
threads a thin catheter (tube through a small incision in the nec# and guides it to the blood vessels
in the liver. &nder '!ray guidance a connection between the inflow vein of the liver (portal vein and
the outflow vein of the liver (hepatic vein is made to divert the flow of blood and decompress the
portal vein. The connection is held open by an e'pandable metal tube that remains inside the liver.
(ou may be admitted to the hospital before or directly after the procedure and can potentially be
discharged the following day. )ithin the first year routine follow!up at * month intervals is necessary
to assure that the shunts remain open and adequately functioning. +evisions of the shunt are
performed in a similar manner to the original TIPS procedure but are typically performed as an
outpatient.
Pre-procedure Information
(our doctor will schedule you for a pre!procedure evaluation by the ,ascular - Interventional
+adiology (,I+ service. +eport to .iagnostic Imaging!. (*
rd
floor, %reen /one for your scheduled
appointment. The procedure will be performed on a subsequent day. They will discuss the planned
procedure with you and answer any questions you may have about the procedure, its ris#s and
benefits. Please inform us if you are diabetic, pregnant, or allergic to contrast media (0dye0. )e will
also need to #now if you have a history of heart disease or have respiratory problems.
If additional laboratory or imaging studies are needed prior to your scheduled procedure they will be
arranged during this visit. "ring any outside films ('!rays with you, if you have not already given
them to your physician. Pre!procedural patient wor#!up and preparation includes visuali1ation of
hepatic arterial and venous structures as well as assessing patency of the portal venous system.
This is most commonly performed with .oppler ultrasound but can also be assessed with magnetic
resonance venography. It is critical to aggressively correct a patient2s coagulopathy with vitamin 3,
fresh fro1en plasma, and if necessary, platelets given the high ris# of intraperitoneal bleeding. In
addition, patients receive broad spectrum antibiotic coverage.
Please call (45* 467!5589 (during wor#ing hours if you are unable to #eep your appointment.
Important Instructions
(ou must be accompanied by a responsible adult following your procedure
.o not eat or drin# for a minimum of : hours prior to your procedure
(ou may ta#e your daily medications with sips of water
Discharge Instructions
+est at home and avoid strenuous activities for for a minimum of ;7 hours. (ou should also contact
your doctor if you have a fever of 595 degrees <ahrenheit (*8.* degrees $elsius or higher, or if you
have redness, swelling, bleeding or drainage from the site where the catheter was inserted.
Please call .iagnostic Imaging!. at (45* 467!5589 (during wor#ing hours or the =... >nderson
?mergency $enter at (45* 46;!*4;; (;7 hours a day.

"ratament medical in HDS
". 7om)aterea efectelor hemodinamice
"". Su)stante vasoactive
""". Tratament hemostatic temporar - 8DS T
"!. Tratament hemostatic definitiv
Combaterea efectelor hemodinamice
I'!DI" CCI I'*)!5I?I@I#
(. S(+!! CCI 'IC)%CI)C.#"I!
'%'!(" )!5!)SI@I#
Scade volemiascade debit incetinire circulatie
Scade volemia Scade vascozitatea creste hematocrit capilar / %)"
'%'!(" I)!5!)SI@I#
Dezo$igenare eritrocit rigidizare %)D
)igidizaregregare plachetara CID
'odalitate
"nlocuire volemica F solutii cristaloide
Sange si A( hiper)ara
!olum
<!7
T#
#!
Substante vasoactive
Doar in soc
Doar la pacientul cu inlocuire volemica
Doar scurt timp
Dopamina+ Do)utamina
"ratament hemostatic AtemporarB / endoscopic
!ariceala
6igatura
Scleroterapie
clips-uri
:onvariceala
"njectare
8lectrocauterizare
6aser
#rgon plasma
HDS non C variceala
"ratamentul HDS nonvariceala
.astrite+ duodenite+ sindroame hemoragipare ' tratament medical
Sindromul Mallor= >eiss ' injectare de alcool
lcer gastric+ cancer gastric ' trat. chirurgical
lcer duodenal
J 41 ani
la prima sangerare ' trat. medical
a doua sangerare ' trat. chirurgical
, 41 ani+ recidiva la 4; ore ' trat. chirurgical
HDS variceala
"ratament HDS variceala
!arice Tratament HDS
Tratament HT<
Tratament 8<HD
"ipul de interventie in HDS variceale
<rofila*ia primei sangerari
8DS
Trat HT<
ntisecretor
<rofila*ia resangerarii
Tratamnetul HT<
ntisecretor
Tratamentul HDS variceale acute
Medical (octreotid0vapreotid+ antisecretor
manevre locale (sonda)
endoscopic
radiologie interventionala (T"<<S)-trans illuminated poKered
phle)ectom= surger=)
chirurgical
*Procedure At A Glance
TIPPS Procedure is intended to reduce varicose and spider veins, and
resurface the skin on the legs by improving blood vessels. This
procedure is likely to be expensive and possibly painful, and also
requires a significant amount of time for an individual to heal. Well
take a closer look.
Procedure In Focus
TIPPS Procedure is a surgery that requires an incision, during !hich
doctors distribute saline solution and insert a suction device to remove
problematic veins. "uring TIPPS Procedure, doctors remove abnormal
veins, allo!ing those that are functioning more blood flo!. #o!ever,
!ith some of the ama$ing products available on the market today, !e
feel TIPPS Procedure seems unnecessary for most. With top quality
products that include ingredients like "iosmin %&', many people are
finding that they may achieve ama$ing skin care !ithout having to
schedule appointments or undergo surgical procedures.
When searching for a skin care formula, !e strongly believe people
should al!ays look for "iosmin %&'. "iosmin %&' is an ingredient
that !as recently made available over the counter, and has sho!n
ama$ing results for addressing varicosity. This ingredient has been
clinically proven to repair blood vessels and rebuild damaged skin
areas. When searching for a skin care product, !e think it is crucial for
individuals to look for this ingredient.
Positives
( )inimally invasive surgery
( Said to reduce varicosity
( *laimed to remove broken veins
Negatives
( "oesnt use "iosmin %&'
( +ather high cost
( +equires time to heal
( ,o refund policy or customer service
Cost
34,444 C 91,444 D 6 !*IS%D HDS 5)IC!#
Sharara A, Roce! D " #e$ Engl % &ed, '(()* +,-* ../ " 0)
Concluzii
%. HDS reprezinta inca o cauza importanta de mor)iditate si mortalitate la
populatia adulta.
(. Modalitatile terapeutice sunt diferite in HDS variceale si non-variceale.
9. Terapia endoscopica a produs modificari majore in mortalitatea prin HDS
indiferent de cauzaL tratamentul antisecretor reprezinta una din cele mai
importante solutii adjuvante ale terapiei endoscopice.
Hemoragie o)scura-apare in scaun dar nu se cunoaste cauza D