Diagnosis and examination of gastrointestinal bleeding in the elderly

1. Bleeding, hematemesis, black stool, bloody stool, or vomitus and fecal occult blood test is positive. In any case, if oral or respiratory bleeding or the interference of diet can be ruled out, it can be determined as gastrointestinal bleeding. Those who are only positive for occult blood in stool and have no other bleeding manifestations can be reexamined after three days of vegetarian diet to eliminate dietary interference. Iron and bismuth can make feces black, and some foods can make feces red, which can be identified by fecal occult blood test. Note that some vegetables and fruits (radish, cauliflower, cucumber, carrot, cabbage, potato, pumpkin, grape, fig, etc. ) sometimes make the fecal occult blood test appear false positive. The reverse passive hemagglutination fecal occult blood test was not disturbed, and the specificity was close to 100%.

2. Palpitation, fatigue, hyperhidrosis, dizziness, blackness and tachycardia occurred in a short time. Even if digestive tract diseases have not been found before, the possibility of acute gastrointestinal bleeding, especially massive upper gastrointestinal bleeding, should be considered in diagnosis, and careful examination and close observation should be given. If necessary and possible, gastric juice should be inserted into the stomach tube to help the diagnosis.

3, anemia found no other reasons should be repeated fecal occult blood test, to rule out gastrointestinal bleeding and subsequent occult digestive tract lesions.

(2) Judgment of bleeding volume

1. Roughly estimated, because most bleeding is accumulated in the gastrointestinal tract, it may be far from estimating the amount of bleeding only by hematemesis or blood output. Clinical experience shows that it is feasible to use the following indicators to estimate the amount of bleeding in clinic: when the amount of bleeding is greater than 5 ml (2-20 ml), the fecal occult blood test will be positive; (Upper digestive tract) Bleeding more than 50 ml may lead to melena; More than 300ml can cause hematemesis; There is often no clinical manifestation below 400ml; When the bleeding is 500 ml- 1000 ml, it can produce circulatory compensation (such as palpitation, fast and strong pulse, normal blood pressure or high systolic blood pressure); When the bleeding volume is above 1000ml or the circulating blood volume is lost by more than 20%, there is often circulatory decompensation. Bleeding 1500ml or more, peripheral circulation failure. In addition, the upper gastrointestinal bleeding exceeds about 250ml in a short time, which is prone to hematemesis. In China, a loss of circulating blood of more than 20( 100ml) or a blood loss of more than 30ml (1500ml for adults) is usually considered as severe bleeding. Shoemaker and Nyhks abroad regard blood loss exceeding 30% as massive bleeding. If there are syncope, upright syncope, vomit with blood clots, and black or dark red stool in the medical history, it is a sign of massive bleeding. Signs such as cold limbs, pallor, increased heart rate, decreased blood pressure and other manifestations of shock or compensatory shock are also manifestations of massive bleeding.

2, calculate the shock index shock index = pulse/systolic blood pressure (mmHg), normal is 0.5. 1.0 indicates that the blood loss is 20%-30% of the blood volume; The blood loss of 1.0- 1.5 is 30%-50%, and its reliability is affected by the patient's usual pulse rate and blood pressure.

3. Reaction to changing posture If the patient changes from supine position to supine position, there will be rapid pulse, dizziness, sweating and even syncope, which indicates that more bleeding indicates the need for emergency blood transfusion.

(3) Judging the location and cause of bleeding

1, according to the way of blood discharge and personality.

2. According to the medical history, symptoms and signs, pay attention to whether there is a history of peptic ulcer and cirrhosis. And pay attention to whether there is loss of appetite, weight loss, anemia, etc. in the near future; Pay attention to whether to drink alcohol before bleeding and whether to take aspirin, non-steroidal anti-inflammatory drugs and hormones recently; Whether there are tenderness and lumps in the abdomen and its specific parts. Anal digital diagnosis is of great significance for understanding anorectal diseases and adjacent metastatic tumors.

3. Digestive juice absorption test It is helpful to know whether the upper digestive tract is bleeding by checking the gastric juice absorption through the nasogastric tube. Sometimes, a double-lumen tube with a balloon is used, which is inserted into the balloon after being intubated by pylorus, so that the duodenum creeps into the empty ileum with intestinal peristalsis, and intestinal fluid is sucked out step by step, and the location diagnosis of bleeding is carried out.

4. Endoscopy is the most important method to know the location and causes of gastrointestinal bleeding, and the diagnostic accuracy is as high as 80%-94%. Emergency endoscopy within 24 hours of bleeding is helpful to find acute mucosal lesions, superficial ulcer bleeding and mucosal tear. Endoscopic biopsy can make a pathological diagnosis. Endoscopy can also be used for injection, electrocoagulation and laser hemostasis.

5.x-ray barium radiography includes gastrointestinal barium radiography, small intestine double barium radiography and colon barium enema. Suitable for acute bleeding has stopped, or chronic bleeding needs to know the cause, because of various reasons can not be endoscopic examination. X-ray barium radiography is easy to miss the diagnosis of superficial mucosal lesions, and it is difficult to diagnose vascular malformation, but it has great diagnostic value only for space-occupying lesions, so we should pay attention to its false negative.

6. Radionuclide imaging Radionuclide imaging is to mark radionuclides on red blood cells or colloidal particles, inject them into the body through veins, reach the bleeding point with blood circulation, leak blood vessels, and show radioactive concentration areas locally, thus locating diagnosis. It can detect bleeding, and the bleeding rate is only 0.05-0. 1 ml per minute. Its sensitivity is 10 times that of angiography, and 3ml/h bleeding can be detected. Non-traumatic, it must be performed when there is active bleeding. It is used to locate gastrointestinal bleeding without diagnosis and to find the cause of melena or chronic anemia.

7. Selective visceral arteriography Selective visceral arteriography can accurately obtain diagnostic information such as the location, shape and anatomical abnormality of the bleeding focus, and can also be used for drug perfusion or embolization to stop bleeding. Or create favorable conditions for medical and surgical treatment. At present, this technique has become the first choice for severe lower gastrointestinal bleeding, especially small intestinal bleeding. It is also an important auxiliary treatment for endoscopic diagnosis of upper gastrointestinal bleeding. Active bleeding rate >; 0.5 ml/min is the best indication. Acute massive hemorrhage of small intestine is the first choice, and the positive rate is 40%-86%. Selective visceral arteriography is sensitive to the diagnosis of arterial hemorrhage and capillary hemorrhage, but it is difficult to determine the bleeding location for venous hemorrhage. Although the bleeding site can not be determined for portal hypertension complicated with esophageal varices bleeding, it is often used to exclude arterial bleeding and provide anatomical information for portal vein shunt surgery in the future. Emergency arteriography should be performed as soon as possible for patients with massive hemorrhage whose bleeding focus can not be clearly defined by endoscopy, or patients whose bleeding continues after endoscopic treatment, or patients whose bleeding has stopped for a short time because of the great influence. Abdominal artery, left gastric artery or gastroduodenal artery are the first choice for upper gastrointestinal bleeding. Superior mesenteric artery is the first choice for small intestinal bleeding and left colon bleeding. However, selective celiac arteriography is a traumatic examination, which should not be used for a long time or listed as the first choice. The bleeding is static.

8, surgical exploration of various other methods can not be clear about the cause and location of bleeding, and in an emergency, surgical exploration is feasible. Endoscopic examination of small intestinal bleeding is difficult, and other methods can not determine the location and cause of bleeding. It is the most effective method to diagnose small intestinal bleeding during exploration, and the success rate is 83%- 100%, which can determine the exact location and cause of small intestinal bleeding.

(4) judging whether the bleeding stops.

1, palpitation, dizziness and fatigue in peripheral circulation, which means that symptoms are relieved, pulse rate and blood pressure are improved, suggesting that bleeding slows down or stops. For example, patients show irritability, cold sweat, rapid pulse and blood pressure fluctuation. Although the blood volume is replenished as soon as possible after blood transfusion or transfusion, the blood pressure and central static pressure are still lower than the normal level, indicating that bleeding is still happening.

2. In the case of frequent hematemesis and hematochezia, if hematemesis and hematochezia stop and the peripheral circulation improves, it means that the bleeding slows down or stops, and the fecal occult blood test continues to be negative, which means that the bleeding stops; If the bleeding amount is about 1000ml, the positive stool occult blood test may last about 1 week; if the bleeding amount exceeds 1000ml, the positive stool occult blood test lasts for a long time, and the time to turn negative is related to the bleeding amount and the speed of stool excretion. If the patient continues to feel nausea and vomiting, or even vomits blood or draws new blood from the stomach tube, the amount and frequency of discharging tar-like black feces will increase, or the feces will be dark red or bright red, suggesting that gastrointestinal bleeding is still going on.

3. Other factors such as excessive bowel sounds, excluding intestinal infections or drugs, usually lead to continuous bleeding; ② Blood urea nitrogen continued to increase again; Excluding pre-renal factors and renal factors usually leads to persistent bleeding; ③ The red blood cell count, hemoglobin and red blood cell volume decreased continuously, suggesting continuous bleeding; ④ The gastric occult blood test was negative, suggesting that the gastrointestinal bleeding above pylorus stopped.