Las Causas de La Hemorragia Digestiva Alta en Los Adultos

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Los trastornos que causan hemorragia digestiva alta en los adultos

Porque sangrado

manifestaciones

signos y

síntomas

asociados

condiciones o

factores de

riesgo asociados

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Ulcerosa o erosiva

Duodenal y / o úlceragástrica

hematemesis

Melena

Hematoquecia (indicasangrado activo)

la pérdida de sangre

oculta

dolor abdominalsuperior

El dolor asociadocon el consumo(peor cuando laalimentación

sugiere úlceraduodenal, mejoracon la alimentaciónsugiere úlceragástrica)

La dispepsia

infecciones:

Helicobacter pylori

CMV

HSV

Los AINE

úlcera de estrés (porejemplo, en pacientesque están gravementeenfermos)

El exceso de producciónde ácido gástrico (ZES)

idiopática

Úlrdme

Eúr

esofagitis hematemesis

Melena

la pérdida de sangreoculta

La disfagia /odinofagia

dolor retroesternal

impactación de

alimentos

La enfermedad porreflujo gastroesofágico

medicamentos:

tetraciclina

La doxiciclinaclindamicina

Trimetoprim-sulfametoxazol

Los AINE

Los bifosfonatosorales

Cloruro de potasio

quinidina

Los suplementos

de hierroinfecciones:

HSV

CMV

Candida albicans

VIH

Elaees

pec

e

P

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e

Gastritis/gastropathy

Duodenitis/duodenopathy


hematemesis

Melena

La dispepsia Factores de riesgo:

H. pylori

Los AINE

El consumoexcesivo dealcohol

lesión porradiación

m

es

n

s

¶


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estrés fisiológico

La cirugía paraadelgazar

reflujo biliar

Los factores de riesgopara el sangrado:

el uso deanticoagulantes

Las complicaciones de la hipertensión portal

varices esófago-gástrica hematemesis

Melena


Estigmas deenfermedadhepática crónica, en particular,signos dehipertensión portal(esplenomegalia,ascitis,

trombocitopenia)

La hipertensión portaldesde:

Cirrosis

La trombosis de lavena porta

hipertensiónportal no cirrótica

evseg

Lam

h

V

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v

varices ectópicas hematemesis

Melena

Hematoquecia (indica

sangrado activo)

Estigmas deenfermedadhepática crónica, en particular,signos dehipertensión portal(esplenomegalia,ascitis,trombocitopenia)


Cirrosis



evsátgneed

Portal hipertensivagastropatía


hematemesis

MelenaHematoquecia (indicasangrado activo)

Estigmas deenfermedadhepática crónica, en particular,

signos dehipertensión portal(esplenomegalia,ascitis,trombocitopenia)


Cirrosis



Epma

s

cmgefessh

Δ

Δ


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avssmfca

Las lesiones vasculares

angiodisplasia hematemesis

Melena

hematoquecia


Puede tener sangradoactivo

angiodisplasiacutánea enpacientes contelangiectasiahemorrágicahereditaria(síndrome deOsler-Weber-

Rendu)

Enfermedad renal enetapa terminal

Estenosis aórtica

Dispositivo deasistencia ventricularizquierda

telangiectasiahemorrágica hereditaria

enfermedad de vonWillebrand

Terapia de radiación

idiopática

Pmpaphav

ed

lesión de Dieulafoy hematemesis

Melena

Hematoquecia (indicaa paso ligero sangrado,

sangrado es a menudoparticularmente a pasoligero)

etiología desconocida

El sangrado puedeestar asociada conAINE, enfermedadescardiovasculares,hipertensión,enfermedad renalcrónica, diabetes o elabuso de alcohol

Qse(la

elampctg

Pab

múa

Sdheva

L


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ae

Ectasia vascular antralgástrica (DIO)

hematemesis

Melena



En pacientes concirrosis, puedehaber estigmas deenfermedadhepática crónica

, en particular,signos dehipertensión portal(esplenomegalia,ascitis,trombocitopenia)

idiopática

Cirrosis conhipertensión portal

La enfermedad renal /trasplante

Diabetes mellitus

La esclerosis sistémica(esclerodermia)

Trasplante de médulaósea

hdcirp

qlas

goma de la ampollasíndrome de nevus azul(síndrome de Bean)

hematemesis

Melena


sangrado activo)la pérdida de sangreoculta

Lasmalformacionesvenosas yhemangiomas de

cualquier órgano,incluyendo:

Piel

Sistemanerviosocentral

Hígado

Músculos

linfáticos

intususcepción

nomo

pg

Traumática o iatrogénica

El síndrome de Mallory-Weiss

Hematemesis despuésde un aumento de lapresión intraabdominal

Melena


Dolor epigástrico

Dolor de espalda

Vómitos / náuseas (amenudo relacionadacon el consumo dealcohol)

Esfuerzos al defecar ode elevación

toser

convulsiones

Blunt abdominaltrauma

hernia hiatal puedeaumentar el riesgo dedesarrollar una lágrima

Re

Pslop

Lp

rgc

Esc

ingestión de cuerpoextraño

hematemesis

Melena


san rado activo

La disfagia

odinofagia

Cuello o dolor

abdominal

Desórdenespsiquiátricos

Demencia

Las dentaduras flo as

Lcv(

Δ


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asfixia

sialorrea

plenitudretroesternal

eresp

anastomosisposquirúrgica sangrado (

"úlceras marginales")


hematemesis

Melena


Dolor epigástrico

Náusea

cirugía de Billroth II

Cirugia de banda

gastrica

El uso de AINE

Por H. pylori infección

De fumar

Uf

la

Pospolipectomía /resección endoscópica /esfinterotomíaendoscópica

hematemesis

Melena


Antecedentes de lainstrumentación(puede ser tanlargo como tressemanas antes de

la presentación)

Las lesiones grandes Sdup

Las lesiones de Cameron la pérdida de sangreoculta

hematemesis

Melena


hernia hiatal

La esofagitis por reflujo

úlipmdimd

fístula aortoentéricas hematemesis

Melena


Puede tener un"heraldo" sangraseguido de unahemorragia masiva

Dolor de espalda

Fiebre

Los signos desepsis

masa abdominalpulsátil

Abdominal bruit

aortitis infecciosa(sífilis, tuberculosis)

prótesis aórticaprotésica

aneurisma aórticoaterosclerótica

úlceras penetrantes

La invasión tumoral

Trauma

lesión por radiación

perforación de cuerpoextraño

Lim

pemha

Eeddp

ineuamedd

Los tumores

Los tumores del tracto

hematemesis Pérdida de peso Prácticamente

m


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gas ro n es na super or Melena



Anorexia

Náuseas / vómitos

Saciedad precoz

Dolor epigástrico

Disfagia (para lostumores en elestómago o

esófago proximal)obstrucción de lasalida gástrica

masa palpable

manifestacionesparaneoplásicos:

queratosisseborreicageneralizada

acantosisnigricans

La nefropatíamembranosa

Coagulopathy

cua qu er po e umorpuede sangrar

Los tumores benignos:

Leiomyoma

lipoma

Pólipo(hiperplásico,adenomatosa,

hamartomatoso,inflamatoria)

Tumores malignos:

adenocarcinoma

Los tumores delestromagastrointestinal

linfoma

sarcoma Kaposi

carcinoide

Melanoma

Los tumoresmetastásicos

eo

Egpepn

fllmlopve

Spcmuú

Diverso

hemobilia hematemesis

Melena


sangrado activo)

Cólico biliar

Ictericia(obstructiva)

Sepsis (biliar)

Antecedentes de hígadoy vías biliaresinstrumentación y / olesiones, incluyendo las

siguientes:Biopsia hepatica

colecistectomía

biopsiasendoscópicas ocolocación destents biliares

colocación deTIPS

Angioembolization

Romo o traumaabdominalpenetrante

Los cálculosbiliares

colecistitis

Los tumoreshepáticos obiliares delconducto

Sqad

vsv

Sfocssqc

Cullc


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Los stentsintrahepática

Los aneurismasde la arteriahepática

Los abscesoshepáticos

hemosuccus pancreaticus hematemesis

Melena


Dolor abdominal

La evidenciapasada desíntomas / signosde pancreatitis

La formación deimágenesevidencias depancreatitis (actualo en el pasado)

la amilasa y lalipasa (actual o enel pasado)

La pancreatitis crónica

seudoquistespancreáticos

Los tumorespancreáticos

pseudoaneurisma depáncreas

endoscopia terapéuticadel páncreas o delconducto pancreático:

eliminación de loscálculos depáncreas

esfinterotomíaconductopancreático

drenajepseudoquiste

la colocación destents conducto

pancreático

Sqadvsv

pimdt

rpd

CMV: citomegalovirus; HSV: virus del herpes simple; ZES: el síndrome de Zollinger-Ellison; AINE:antiinflamatorio no esteroideo; VIH: virus de la inmunodeficiencia humana; GI: gastrointestinal;Consejos: derivación portosistémica intrahepática; CPRE:. Colangiopancreatografía retrógradaendoscópica. * Si el sangrado activo o grandes cantidades de sangre residual están presentes, los hallazgosendoscópicos característicos pueden quedar ocultas. ¶ plenitud posprandial, saciedad precoz, dolor epigástrico, o ardorEvidencia Δ de la enfermedad hepática crónica incluye ictericia, esplenomegalia , ascitis, trombocitopenia,eritema palmar, angiomas araña, ginecomastia, atrofia testicular, y la contractura de Dupuytren.

Gráfico 103148 Versión 1.0

Gran úlcera duodenal


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Vista endoscópica de una úlcera relativamente grande y profundo enel duodeno, sin evidencia de un vaso visible o sangrado activo (un

punto negro en la base de la úlcera se puede ver).


úlcera duodenal con un vaso visible

Vista endoscópica de una parte relativamente pequeña úlceraduodenal (flecha) con un gran vaso visible en su parte inferior (puntade flecha).



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esofagitis severa

Vista endoscópica de la esofagitis por reflujo severa en un paciente quepresentó una hemorragia digestiva alta.


Varices esofágicas


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Las imágenes endoscópicas de un paciente con varices esofágicas.Varices puede o no puede tener estigmas de sangrado. Estas váricesson grandes pero no tienen estigmas claras de sangrado, tales comoseñales de columnas rojas.


Sangrado de varices esofágicas activamente

Vista endoscópica de varices esofágicas sangrantes de una formaactiva. La variz fue anillada con éxito, y la hemorragia se detuvo.


variz gástrica


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La imagen obtenida en el momento de la endoscopia revela una lesión típicaGOV (várices gastro-esofágico). La nomenclatura GOV se utiliza para varicesque son continuas desde el esófago hasta el estómago (GOV1 incluyenaquellos que se extienden a menos de 5 cm de la unión GE, mientras queGOV2 se extienden por más allá de esta longitud [esta es una instancia de

GOV2]). La gran estructura en forma de uva parece emanar de la unión GE,típica de las lesiones GOV. varices gástricas también pueden ser aislados, amenudo cuando se presentan como resultado de la trombosis de la venaesplénica.


La evaluación de la hemorragia digestiva alta sospecha


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GI: gastrointestinal; TC: tomografía computarizada; CTA: angiografía por tomografíacomputada; MR:. Resonancia magnética* La presencia de ambos hematemesis y melena sugiere que El sangrado activo está presente.¶ sangrado asociado con signos tales como hipotensión, taquicardia o hipotensión ortostática.Δ considerar la evaluación con un duodenoscopio de visión lateral, si existen factores de riesgo

para hemobilia o hemosuccus pancreaticus; considerar CTA (seguido de la enteroscopia depulsión si el CTA es negativo) en los pacientes en riesgo de una fístula aortoentéricas. Laangiografía convencional transvenoso se lleva a cabo normalmente si el paciente se encuentrahemodinámicamente inestables a pesar de los intentos de reanimación. ◊ Los pacientes que se

presentan con hematemesis no necesita someterse a una colonoscopia, ya que hematemesissugiere que el sangrado es proximal al ligamento de Treitz. Deben proceder directamente a unaevaluación para el sangrado del intestino delgado. § Si el paciente se vuelve inestablehemodinámicamente después de la reanimación inicial, la angiografía convencional transvenosose puede realizar. Los pacientes que se presentan con hematemesis no necesitan someterse auna colonoscopia y se puede omitir este paso en la evaluación porque hematemesis sugiere que

el sangrado es proximal al ligamento de Treitz. ￥ Si la evaluación endoscópica inicial fueinsuficiente (por ejemplo, regular o mala visualización, la falta de alcanzar el ciego), el examende repetición se debe considerar antes de iniciar una evaluación para el sangrado del intestinodelgado. Consulte la revisión de tema UpToDate sobre supuestos casos de sangrado delintestino delgado para más detalles. ‡ Si no lo ha hecho. Si el paciente permanecehemodinámicamente estable y no tiene evidencia de sangrado agresivo (por ejemplo,hematoquecia en curso), realizar una CTA o enteroscopia de pulsión (CTA es la prueba deelección inicial si hay preocupación por una fístula aortoentéricas). Si el paciente se vuelveinestable hemodinámicamente después de la reanimación inicial o tiene signos de sangradoagresivo, realizar la angiografía convencional transvenoso. † Si no lo ha hecho, se puedenobtener angiografía o CTA. Si la angiografía o la CTA se ha realizado y se identifica ninguna


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uen e, exp orac n e ec e se e e o ener en os pac en es m s venes con emorrag amanifiesta, a no ser que la única manifestación de sangrado fue hematemesis. La exploraciónquirúrgica es apropiada si no hay otros estudios han revelado una fuente y un sangradosignificativo continúa o si hay alta sospecha de una pequeña neoplasia intestinal. ** Si laprofundidad enteroscopia del intestino delgado era incompleta, se debe obtener un estudio de lacápsula endoscópica de vídeo, seguido de entero-entero-TC o RM si la cápsula endoscópica esnegativo.


lesión de Dieulafoy

Vista endoscópica del estómago muestra una lesión de Dieulafoysangrado.

Cortesía de Roma Jutabha, MD.


La lesión de Dieulafoy gástricas


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sangrado activo por lesión de Dieulafoy un gástrica (A) a lo largo de la paredproximal antro / anterior. El sangrado se controló con la terapia decombinación endoscópica consiste en: Terapia de inyección con un 10 FrancésInyector-Gold Probe (Microvasive Corp) usando 1: 10.000 epinefrina (B),seguido de electrocoagulación bipolar a los 12 vatios x 10 seg / pulso x 4impulsos usando presión firme taponamiento (C), a continuación,

hemoclipping x 1 (Olympus Corp) (D). Después se realizó la India tatooing detinta (E) para marcar el sitio de tratamiento en el caso de nuevas hemorragiasy facilitar la localización si es necesaria una intervención quirúrgica (porejemplo, resección en cuña).



ectasia vascular antral gástrica (estómago sandía)


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La endoscopia en un paciente con ectasia vascular antral gástrica(DIO) muestra el antro y el píloro (centro) con franjas radiales

eritematosas se asemejan a la cáscara de una sandía. El pacientepresentó anemia por deficiencia de hierro.

Cortesía de Laurence Bailén, MD.


ectasia vascular antral gástrica

Luz micrografía de ectasia vascular antral gástrica muestra ectasiavascular, proliferación de células fusiformes, y fibrohyalinosis.

Cortesía de Roma Jutabha, MD y Dennis M Jensen, MD.


ectasia vascular antral gástrica (estómago sandía)


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imágenes endoscópicas en serie de ectasia gástrica antral vascular ("estómago sandía"), que ha sido tratada con plasma de argón. La filasuperior muestra el aspecto original de las lesiones, y su aparicióndespués del tratamiento inicial. La fila central muestra el aspectodespués de la primera sesión de tratamiento y después de la segundasesión de tratamiento. La tercera fila muestra la notable mejora traslas dos primeras sesiones de tratamiento, y la aparición después deuna tercera sesión de tratamiento.

Cortesía de Eric D Libby, MD.


la coagulación térmica de ectasia vascular antral

gástrica

El aspecto endoscópico después de sonda bipolar de coagulación

térmica de ectasia vascular antral ástrica estóma o sandía . La


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coagulación bipolar con la sonda finalmente borró la ectasia vascular.

Cortesía de Roma Jutabha, MD y Dennis M Jensen, MD.


tumor gástrico

Vista endoscópica de un adenacarcinoma gástrica ulcerada.


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Las Causas de La Hemorragia Digestiva Alta en Los Adultos

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