肠胃科病房常见之问题与处理.ppt

病房常見之消化系問題與處理 馬偕紀念醫院 健檢中心主治醫師 胃腸內科兼任主治醫師 楊安民 GI bleeding Never forget the general principle of internal medicine. Airway, Breathing, Circulation Stabilize vital sign and aggressive resuscitation. Well explanation to the family. Acquire thorough history and past medical history. Differential diagnosis of GI bleeding UGI LGI Make the diagnosis by yourself! Arrange adequate diagnostic procedure. Emperical treatment 消化道出血的間接症狀: dizziness , fainting, tachycardia, cold sweating, shock, abdominal fullness, poor appetite, cons. change 一旦懷疑,利用vital sign評估出血量最重耍 (occult bleeding or overt bleeding) Orthostatic hemodynamic change – 10 to 20% blood loss Drop in systolic pressure 10 mmHg, raise in pulse rate 15/min Supine hypotension – greater than 20% blood loss 定位 UGI or LGI 同時評估 medical treatment or surgical treatment GI bleeding vs Non-GI bleeding: 吐血 vs. 咳血 vs. internal bleeding Study in GI bleeding Digital exam for collect stool NG aspiration for DDx UGI and LGI PES: Panendoscopy or EGD( esophago-gastro-duodenoscopy): should be perform early in the clinical course after vital sign stable or management. Colonoscopy/ rigid sigmoidscopy RBC scan: only in Taipei MMH: 0.1cc/min or 6 cc/hour Angiography: 0.5cc/min or 30 cc/hour Enteroscopy or capsule endoscopy Surgery Why the GI bleeding patient need NPO Not every GI bleeding patient should NPO Prepare for emergency study or management Avoid aspiration GI bleeding 處理原則 Again and again : Check vital sign Evaluate NPO or not If NPO, IVF supply Arrange laboratory study CBC, PT, PTT, Blood group and cross match, liver and renal function. Blood product : Whole blood vs. pack RBC, FFP vs. FP, 代用血漿(ex.6HES) Medication How to arrange the study: NG irrigation, Blood sampling, PES, Angiography, Colonofiberscope, RBC scan Vital sign for GI bleeding Orthostatic hypotension: drop SBP over 10 mmHg, rise in pulse rate over 15 beat/min: blood loose 10-20% Supine hypotension: more than 20% Shock index: SBP/HR1 which hint blood loos