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It is only for medical professionals to read for reference.
There are a lot of clinical upper gastrointestinal bleeding cases.
How to distinguish between true and false? Hematemesis is a disease of the upper gastrointestinal tract (the digestive tract above the ligament of flexion, including the esophagus, stomach, duodenum, liver, gallbladder, pancreas, and upper jejunum disease after gastrojejunostomy) or systemic diseases.
Bleeding in the digestive tract, blood vomiting through the mouth
.
It is often accompanied by melena.
In severe cases, it may manifest as acute peripheral circulatory failure
.
In clinical practice, hematemesis and melena are generally treated as upper gastrointestinal bleeding.
Then, is it true that patients with hematemesis and melena at the same time are only seen in upper gastrointestinal bleeding? Let's take a look at the case below
.
Case express delivery patient female, 69 years old
.
Main complaint: hematemesis and black stool for 3 days
.
History of present illness: 3 days ago, the patient began to have hematemesis and melena symptoms, 3 times of vomiting, total vomiting of about 500ml of brown stomach contents, 4 times of melena, self-reported about 500g each time, accompanied by palpitation, anorexia, fatigue , No acid reflux, heartburn, no abdominal pain, abdominal distension, dysphagia, painful swallowing and other discomforts.
Now for treatment, the emergency department admitted to our department with "acute upper gastrointestinal bleeding"
.
Past history: previous cerebral aneurysm for several years, no treatment, 1 year of leg pain, no medication, headache for more than 2 months, oral medication was given in the outpatient clinic (the specific type of medication is prescribed by a private clinic), and the denial of hypertension, diabetes, and coronary History of heart disease, tuberculosis, hepatitis, denial of history of major surgery, trauma, history of blood transfusion and blood donation, history of drug and food allergies, history of vaccination according to local circumstances
.
Physical examination: body temperature: 36.
6℃, pulse: 96 beats/min, respiration: 20 beats/min, blood pressure: 92/65mmHg, weight: 60kg, no pathological murmurs were heard in the auscultation area of each heart valve, breath sounds clear in both lungs, No obvious dry and wet rales, soft abdominal wall, tenderness in the lower abdomen, no rebound pain, no palpability under the liver and spleen ribs, negative Murphy sign, no percussion pain in the liver and kidney area, negative mobile dullness, and normal bowel sounds.
5 times/min, no edema of both lower limbs
.
Auxiliary examination: abdominal CT prompt: consider small stones in the gallbladder
.
Blood test tips: red blood cells (1.
58x1012/L); hemoglobin (46g/L); ABO blood type (positive type) (type A); Rh (D) blood type identification (positive); biochemical tips: albumin (32.
5g/L) ); Creatine kinase (26U/L); Urea (11.
9mmol/L); Chlorine (108.
5mmol/L); Calcium (2.
04mmol/L)
.
Initial diagnosis: acute upper gastrointestinal bleeding; peptic ulcer? Acute gastric mucosal disease? Severe anemia; hemorrhagic shock; cerebral aneurysm
.
The patient has repeated symptoms of blood in the stool.
Where did the bleeding occur? After admission, 80mg of omeprazole for injection was given successively, followed by intravenous infusion at a rate of 8mg/h, and the treatment was given at the same time as hemostasis, correction of anemia, nutritional support, fluid rehydration, etc.
, to complete the painless gastroscopy after proper correction of anemia.
The cause of the bleeding was confirmed, and if necessary, he was treated with gastroscopic hemostasis at the same time.
After admission, the condition was stable and he did not bleed again
.
From the next morning, the patient reappeared with blood in the stool.
Although there was no history of liver disease, the possibility of varicose bleeding and acute bleeding from the vascular stump caused by Dieulafoy’s disease or digestive ulcer could not be ruled out.
Octreotide was given to reduce portal pressure and phenolic For the application of hemostatic drugs such as ethylamine, emergency gastroscopy is recommended.
After communicating with the patient's family about the necessity of emergency gastroscopy and the risks, the family members request that the drug treatment be suspended
.
After the above treatment, the patient still had blood in the stool intermittently, and was given a micro-pituitary pump.
After communicating the condition again, he underwent emergency gastroscopy
.
▌ Gastroscopy: 1.
No hemorrhagic lesions and bloodstains were seen in the gastric cavity; 2.
Multiple ulcers in the duodenal bulb (stage S2) (combined with the patient's medical history, considering the possibility of bleeding in the upper and middle small intestines, further examination is recommended)
.
The result of gastroscopy is due to the large amount of bleeding in the patient, the long time of capsule endoscopy and the need to clean the intestines, which easily increases the risk of bleeding and delays the condition of the patient, and complete the CT+enhanced CT examination of the entire abdomen in the emergency department
.
▌Complete the abdominal CT+enhanced CT examination: 1.
The left abdominal cavity occupies, considering the possibility of jejunum-derived stromal tumors; 2.
Abdominal and pelvic effusion, the gallbladder volume increases with a small amount of fluid in the gallbladder fossa; 3.
Abdominal aortic atheroma 4.
Exudative lesions of the lungs with bilateral pleural effusion, partial inswelling of the lower lobes of the lungs; 5.
Aorta and coronary atherosclerosis; scoliosis deformities
.
The mystery of the bleeding site of the whole abdomen CT scan + enhanced abdominal CT is revealed, the cause of the bleeding and the bleeding site are identified.
After the intervention department and the gastrointestinal hepatobiliary surgery consultation, the surgical operation is considered as the current best treatment plan, and the transfer to the gastrointestinal hepatobiliary surgery is given Surgical treatment
.
Operation process: Take the midline incision near the middle abdomen, which is about 13 cm long, and cut through the skin and subcutaneous layers into the abdomen in turn
.
Abdominal exploration: light red ascites in the abdominal cavity, part of the small intestine adhered to the greater omentum, and released.
The exploration revealed a small intestine tumor 30cm from the ligament of flexion, 5cm×6cm in size, and the tumor's nourishing blood vessels were thickened, about 50cm from the ileocecal area.
Small intestine diverticulum, about 3cm in length, 150cm from the ileocecal area, there is a small intestinal wall mass, 2cm in diameter, hard, no tumors in the small intestine and colon after exploration, it is decided to perform partial small intestine resection + small bowel tumor resection + small intestinal diverticulum resection
.
Cut off the corresponding mesenteric vessels along the pre-resected small intestine to completely stop bleeding, cut off the small intestine 2 cm from the proximal end of the tumor, and resect the tumor 3 cm from the distal end of the tumor, perform an end-to-side small intestine anastomosis, and close the distal end of the small intestine
.
Local excision of the small intestinal wall mass, horizontal suture of the intestinal wall defect, and seromuscular layer embedding
.
The small intestinal diverticulum was removed, and the stump was reinforced and sutured
.
Postoperative pathology: 1.
Resection of small bowel tumors: spindle cell tumors, considered gastrointestinal stromal tumors, to be further diagnosed by immunohistochemical markers; tumor size 5cm×4.
5cm×3.
5cm; no tumor was seen at the cutting edges of the two cut ends
.
2.
Resection of small intestinal wall mass: small masses of ducts can be seen under the mucosa, some ducts are cystic dilatation, which are considered as ectopic glands, which will be further diagnosed and classified by immunohistochemical markers
.
3.
Resection of small intestinal diverticulum mass: combined with clinical and histological morphology, it conforms to MecKel diverticulum
.
Immunohistochemistry: 1.
(Small intestine spindle cell tumor) immunohistochemical markers, consistent with gastrointestinal stromal tumor; tumor size 5cm×4.
5cm×3.
5cm, mitotic images are not easy to see (<5/50HPF), combined with tumor size, The count of mitotic figures indicates a moderate degree of risk
.
2.
(Small intestine wall mass) There are small masses and cystic enlarged glands under the mucosa.
The immunohistochemical markers are consistent with the dysplastic small intestinal glands.
The interstitial fibrous smooth muscle tissue of the glands proliferates and is accompanied by more adipose tissue.
Combined with histological morphology, it is consistent with small intestinal hamartoma
.
After continuing symptomatic and supportive treatment, the patient improved and was discharged
.
Discussion Gastrointestinal stromal tumors are the most common mesenchymal tissue-derived tumors in the gastrointestinal tract, which are thought to originate from Cajal cells or their precursor cells
.
Gastrointestinal stromal tumors can occur in any part of the digestive tract, and their clinical symptoms are not specific, and are related to the location, size and growth mode.
All gastrointestinal stromal tumors have a malignant tendency, and about 10%-30 % Is malignant tumor
.
The clinical symptoms are often atypical, including gastrointestinal bleeding and secondary anemia, loss of appetite, abdominal distension and abdominal pain
.
Recurrent gastrointestinal bleeding and anemia are the most common clinical manifestations of the disease
.
Most of these patients are diagnosed with gastrointestinal bleeding.
The diagnosis is confirmed by gastrointestinal endoscopy and abdominal enhanced CT.
The treatment is mainly surgery + drug treatment.
At present, low-risk gastrointestinal stromal tumors with a size of 2cm-5cm are also available.
Endoscopic treatment can be considered, but during the treatment, the lesion should be completely removed at one time and the tumor envelope should be intact.
If the lesion is broken, there may be gastrointestinal implantation and metastasis
.
Lessons learned: 1.
Hematemesis and gastrointestinal bleeding above melena are the most common, but we should also be alert to hemorrhage in the upper jejunum, especially the possibility of bleeding in upper jejunum space-occupying lesions
.
2.
When patients with gastrointestinal bleeding come to the clinic, the gastroscopy should be completed as soon as possible to confirm whether they are diagnosed as upper gastrointestinal bleeding, and endoscopic hemostasis is feasible
.
3.
Massive gastrointestinal bleeding may affect gastroscopy observation due to a large amount of blood accumulation.
In severe cases, it may not be possible to find the bleeding site smoothly, affecting treatment and increasing the risk of gastroscopy.
At this time, it is possible to improve abdominal CT+enhanced CT examination or abdominal angiography as soon as possible.
Early identification of the source of bleeding and whether it is tumor bleeding can effectively save diagnosis and treatment time and reduce risks
.
4.
If bleeding from small bowel tumors is found, surgical treatment should be performed as soon as possible
.
References: [1] Wan Xuehong, Lu Xuefeng, Liu Chengyu, et al.
Diagnostics[M].
People's Medical Publishing House.
2018, 6(9): 29-30.
[2] Digestive Endoscopy Branch of Chinese Medical Association Endoscopy Tunnel Technology Collaboration Group, Chinese Medical Doctor Association Endoscopy Physician Branch, Beijing Medical Association Digestive Endoscopy Branch.
Expert consensus on the diagnosis and treatment of gastrointestinal stromal tumors in China (2020.
Beijing)[J].
China Gastrointestinal Internal Journal of Microscopy.
2020, 7 (4): 176-185.
[3] Gastrointestinal Stromal Tumor Expert Committee of the Chinese Clinical Oncology Association, Gastrointestinal Stromal Tumor Professional Committee of the Chinese Anti-Cancer Association, Gastrointestinal Surgery Branch of the Chinese Medical Doctor Association Professional Committee on Diagnosis and Treatment of Tract Stromal Tumors.
Chinese Expert Consensus on Diagnosis and Treatment of Small Gastrointestinal Stromal Tumors (2020 Edition) Journal of Clinical Oncology.
2020.
25 (4): 349-355.
There are a lot of clinical upper gastrointestinal bleeding cases.
How to distinguish between true and false? Hematemesis is a disease of the upper gastrointestinal tract (the digestive tract above the ligament of flexion, including the esophagus, stomach, duodenum, liver, gallbladder, pancreas, and upper jejunum disease after gastrojejunostomy) or systemic diseases.
Bleeding in the digestive tract, blood vomiting through the mouth
.
It is often accompanied by melena.
In severe cases, it may manifest as acute peripheral circulatory failure
.
In clinical practice, hematemesis and melena are generally treated as upper gastrointestinal bleeding.
Then, is it true that patients with hematemesis and melena at the same time are only seen in upper gastrointestinal bleeding? Let's take a look at the case below
.
Case express delivery patient female, 69 years old
.
Main complaint: hematemesis and black stool for 3 days
.
History of present illness: 3 days ago, the patient began to have hematemesis and melena symptoms, 3 times of vomiting, total vomiting of about 500ml of brown stomach contents, 4 times of melena, self-reported about 500g each time, accompanied by palpitation, anorexia, fatigue , No acid reflux, heartburn, no abdominal pain, abdominal distension, dysphagia, painful swallowing and other discomforts.
Now for treatment, the emergency department admitted to our department with "acute upper gastrointestinal bleeding"
.
Past history: previous cerebral aneurysm for several years, no treatment, 1 year of leg pain, no medication, headache for more than 2 months, oral medication was given in the outpatient clinic (the specific type of medication is prescribed by a private clinic), and the denial of hypertension, diabetes, and coronary History of heart disease, tuberculosis, hepatitis, denial of history of major surgery, trauma, history of blood transfusion and blood donation, history of drug and food allergies, history of vaccination according to local circumstances
.
Physical examination: body temperature: 36.
6℃, pulse: 96 beats/min, respiration: 20 beats/min, blood pressure: 92/65mmHg, weight: 60kg, no pathological murmurs were heard in the auscultation area of each heart valve, breath sounds clear in both lungs, No obvious dry and wet rales, soft abdominal wall, tenderness in the lower abdomen, no rebound pain, no palpability under the liver and spleen ribs, negative Murphy sign, no percussion pain in the liver and kidney area, negative mobile dullness, and normal bowel sounds.
5 times/min, no edema of both lower limbs
.
Auxiliary examination: abdominal CT prompt: consider small stones in the gallbladder
.
Blood test tips: red blood cells (1.
58x1012/L); hemoglobin (46g/L); ABO blood type (positive type) (type A); Rh (D) blood type identification (positive); biochemical tips: albumin (32.
5g/L) ); Creatine kinase (26U/L); Urea (11.
9mmol/L); Chlorine (108.
5mmol/L); Calcium (2.
04mmol/L)
.
Initial diagnosis: acute upper gastrointestinal bleeding; peptic ulcer? Acute gastric mucosal disease? Severe anemia; hemorrhagic shock; cerebral aneurysm
.
The patient has repeated symptoms of blood in the stool.
Where did the bleeding occur? After admission, 80mg of omeprazole for injection was given successively, followed by intravenous infusion at a rate of 8mg/h, and the treatment was given at the same time as hemostasis, correction of anemia, nutritional support, fluid rehydration, etc.
, to complete the painless gastroscopy after proper correction of anemia.
The cause of the bleeding was confirmed, and if necessary, he was treated with gastroscopic hemostasis at the same time.
After admission, the condition was stable and he did not bleed again
.
From the next morning, the patient reappeared with blood in the stool.
Although there was no history of liver disease, the possibility of varicose bleeding and acute bleeding from the vascular stump caused by Dieulafoy’s disease or digestive ulcer could not be ruled out.
Octreotide was given to reduce portal pressure and phenolic For the application of hemostatic drugs such as ethylamine, emergency gastroscopy is recommended.
After communicating with the patient's family about the necessity of emergency gastroscopy and the risks, the family members request that the drug treatment be suspended
.
After the above treatment, the patient still had blood in the stool intermittently, and was given a micro-pituitary pump.
After communicating the condition again, he underwent emergency gastroscopy
.
▌ Gastroscopy: 1.
No hemorrhagic lesions and bloodstains were seen in the gastric cavity; 2.
Multiple ulcers in the duodenal bulb (stage S2) (combined with the patient's medical history, considering the possibility of bleeding in the upper and middle small intestines, further examination is recommended)
.
The result of gastroscopy is due to the large amount of bleeding in the patient, the long time of capsule endoscopy and the need to clean the intestines, which easily increases the risk of bleeding and delays the condition of the patient, and complete the CT+enhanced CT examination of the entire abdomen in the emergency department
.
▌Complete the abdominal CT+enhanced CT examination: 1.
The left abdominal cavity occupies, considering the possibility of jejunum-derived stromal tumors; 2.
Abdominal and pelvic effusion, the gallbladder volume increases with a small amount of fluid in the gallbladder fossa; 3.
Abdominal aortic atheroma 4.
Exudative lesions of the lungs with bilateral pleural effusion, partial inswelling of the lower lobes of the lungs; 5.
Aorta and coronary atherosclerosis; scoliosis deformities
.
The mystery of the bleeding site of the whole abdomen CT scan + enhanced abdominal CT is revealed, the cause of the bleeding and the bleeding site are identified.
After the intervention department and the gastrointestinal hepatobiliary surgery consultation, the surgical operation is considered as the current best treatment plan, and the transfer to the gastrointestinal hepatobiliary surgery is given Surgical treatment
.
Operation process: Take the midline incision near the middle abdomen, which is about 13 cm long, and cut through the skin and subcutaneous layers into the abdomen in turn
.
Abdominal exploration: light red ascites in the abdominal cavity, part of the small intestine adhered to the greater omentum, and released.
The exploration revealed a small intestine tumor 30cm from the ligament of flexion, 5cm×6cm in size, and the tumor's nourishing blood vessels were thickened, about 50cm from the ileocecal area.
Small intestine diverticulum, about 3cm in length, 150cm from the ileocecal area, there is a small intestinal wall mass, 2cm in diameter, hard, no tumors in the small intestine and colon after exploration, it is decided to perform partial small intestine resection + small bowel tumor resection + small intestinal diverticulum resection
.
Cut off the corresponding mesenteric vessels along the pre-resected small intestine to completely stop bleeding, cut off the small intestine 2 cm from the proximal end of the tumor, and resect the tumor 3 cm from the distal end of the tumor, perform an end-to-side small intestine anastomosis, and close the distal end of the small intestine
.
Local excision of the small intestinal wall mass, horizontal suture of the intestinal wall defect, and seromuscular layer embedding
.
The small intestinal diverticulum was removed, and the stump was reinforced and sutured
.
Postoperative pathology: 1.
Resection of small bowel tumors: spindle cell tumors, considered gastrointestinal stromal tumors, to be further diagnosed by immunohistochemical markers; tumor size 5cm×4.
5cm×3.
5cm; no tumor was seen at the cutting edges of the two cut ends
.
2.
Resection of small intestinal wall mass: small masses of ducts can be seen under the mucosa, some ducts are cystic dilatation, which are considered as ectopic glands, which will be further diagnosed and classified by immunohistochemical markers
.
3.
Resection of small intestinal diverticulum mass: combined with clinical and histological morphology, it conforms to MecKel diverticulum
.
Immunohistochemistry: 1.
(Small intestine spindle cell tumor) immunohistochemical markers, consistent with gastrointestinal stromal tumor; tumor size 5cm×4.
5cm×3.
5cm, mitotic images are not easy to see (<5/50HPF), combined with tumor size, The count of mitotic figures indicates a moderate degree of risk
.
2.
(Small intestine wall mass) There are small masses and cystic enlarged glands under the mucosa.
The immunohistochemical markers are consistent with the dysplastic small intestinal glands.
The interstitial fibrous smooth muscle tissue of the glands proliferates and is accompanied by more adipose tissue.
Combined with histological morphology, it is consistent with small intestinal hamartoma
.
After continuing symptomatic and supportive treatment, the patient improved and was discharged
.
Discussion Gastrointestinal stromal tumors are the most common mesenchymal tissue-derived tumors in the gastrointestinal tract, which are thought to originate from Cajal cells or their precursor cells
.
Gastrointestinal stromal tumors can occur in any part of the digestive tract, and their clinical symptoms are not specific, and are related to the location, size and growth mode.
All gastrointestinal stromal tumors have a malignant tendency, and about 10%-30 % Is malignant tumor
.
The clinical symptoms are often atypical, including gastrointestinal bleeding and secondary anemia, loss of appetite, abdominal distension and abdominal pain
.
Recurrent gastrointestinal bleeding and anemia are the most common clinical manifestations of the disease
.
Most of these patients are diagnosed with gastrointestinal bleeding.
The diagnosis is confirmed by gastrointestinal endoscopy and abdominal enhanced CT.
The treatment is mainly surgery + drug treatment.
At present, low-risk gastrointestinal stromal tumors with a size of 2cm-5cm are also available.
Endoscopic treatment can be considered, but during the treatment, the lesion should be completely removed at one time and the tumor envelope should be intact.
If the lesion is broken, there may be gastrointestinal implantation and metastasis
.
Lessons learned: 1.
Hematemesis and gastrointestinal bleeding above melena are the most common, but we should also be alert to hemorrhage in the upper jejunum, especially the possibility of bleeding in upper jejunum space-occupying lesions
.
2.
When patients with gastrointestinal bleeding come to the clinic, the gastroscopy should be completed as soon as possible to confirm whether they are diagnosed as upper gastrointestinal bleeding, and endoscopic hemostasis is feasible
.
3.
Massive gastrointestinal bleeding may affect gastroscopy observation due to a large amount of blood accumulation.
In severe cases, it may not be possible to find the bleeding site smoothly, affecting treatment and increasing the risk of gastroscopy.
At this time, it is possible to improve abdominal CT+enhanced CT examination or abdominal angiography as soon as possible.
Early identification of the source of bleeding and whether it is tumor bleeding can effectively save diagnosis and treatment time and reduce risks
.
4.
If bleeding from small bowel tumors is found, surgical treatment should be performed as soon as possible
.
References: [1] Wan Xuehong, Lu Xuefeng, Liu Chengyu, et al.
Diagnostics[M].
People's Medical Publishing House.
2018, 6(9): 29-30.
[2] Digestive Endoscopy Branch of Chinese Medical Association Endoscopy Tunnel Technology Collaboration Group, Chinese Medical Doctor Association Endoscopy Physician Branch, Beijing Medical Association Digestive Endoscopy Branch.
Expert consensus on the diagnosis and treatment of gastrointestinal stromal tumors in China (2020.
Beijing)[J].
China Gastrointestinal Internal Journal of Microscopy.
2020, 7 (4): 176-185.
[3] Gastrointestinal Stromal Tumor Expert Committee of the Chinese Clinical Oncology Association, Gastrointestinal Stromal Tumor Professional Committee of the Chinese Anti-Cancer Association, Gastrointestinal Surgery Branch of the Chinese Medical Doctor Association Professional Committee on Diagnosis and Treatment of Tract Stromal Tumors.
Chinese Expert Consensus on Diagnosis and Treatment of Small Gastrointestinal Stromal Tumors (2020 Edition) Journal of Clinical Oncology.
2020.
25 (4): 349-355.
