上海交大知外科学上血pbl.ppt

Hypertensive Portal Gastropathy Injection of Sclerosant硬化剂 Band Ligation皮圈套扎 Hemoclip止血夹 Laser Application激光止血 Heater Probe加热探针 What Is Your Decision What are the therapeutic options for each common etiology病因 of massive UGIB after initial resuscitation? For Reference Medicine Endoscope Surgery Non-Variceal Bleeding therapeutic endoscope with/without medicine if effective then continue drug therapy eradication of H. pylori mucous protection 2 attempts of endoscopic failure pursue surgery other surgical indications severe life-threatening bleeding not responsive to resuscitation coexisting reason of perforation,obstruction or malignancies second hospitalization of peptic ulcer Variceal Bleeding drug therapy with/without balloon temponade endoscopic binding or sclerotherapy transjugular intrahepatic portosystemic shunt (TIPS) 经颈静脉肝内门体分流术 effective rate 90% rebleeding rate in one year 16-30% shunt disfunction rate in 6 months 50-60% inducing encephalopathy rate 25-35% 30 day mortality rate 14-16% can be used as a temporary method before transplantation Child A B – surgery Child C – transplantation TIPS 8-12mm What Is Your Decision How to perform the operation? For Reference Exploration探查 Hemostasis止血 Radical Operation根治 Exploration Sequence most popular site: stomach duodenum胃十二指肠 cirrhosis or not: liver and spleen肝脾 gallbladder and common bile duct胆道系统 upper portion of jejunum上段空肠 Non-Variceal Bleeding peptic ulcer or stress gastritis消化性溃疡和应激性胃炎 vagotomy迷走神经切除术 gastrectomy胃切除 sewing of bleeding ulcer溃疡缝扎 stomach neoplasm胃肿瘤 gastrectomy胃切除 hemobilia胆道出血 self-limited, seldom needs operation自限性，很少需要手术 Variceal Bleeding emergency: devascularization procedure断流术 splenectomy脾切除 gastroesophageal devascularization胃底食管血管离断 esophageal transection食管下段横断 Child A/B: decompressive shunt分流术 total portal systemic shunt非选择性分流 excellent control of bleeding止血效果好 40-50% encephalopathy肝性脑病发生率高 selective portal systemic shunt选择性分流 maintain portal flow to liver保持门脉入肝血流 10-15% encephalo