Dr. Mabel HM Sihombing, SpPD-KGEH Dr.

Ilhamd SpPD
DIVISION OF GASTROENTERO-HEPATOLOGY DEPARTEMENT OF INTENAL MEDICINE / FACULTY OF MEDICINE, NORTH OF SUMATERA / H. ADAM MALIK HOSPITAL

HEMATEMESIS PSMBA MELENA : (50 ML BLOOD) HEMATOCHEZIA (TRANSIT TIME <<)

LIGAMENTUM TRAITZ HEMATOCHEZIA

PSMBB MELENA (TRANSIT TIME >>)

PENGERTIAN
HEMATEMESIS : MUNTAH DARAH WARNA MERAH KECOKLAT COKLATAN KEHITAM HITAMAN (CAFFEIN) MELENA : BAB WARNA HITAM (TERRY STOOL) HAEMATOCHEZIA : BAB WARNA MERAH TERANG OCCULT BLEEDING : TDK ADA PERUBAHAN WARNA BAB, NAMUN BENZIDINE TEST (+) 10 CC GELAP >50CC DARAH

HASIL :

GAMBARAN PASIEN PSMBA 2 KURUN WAKTU

(MABEL DKK)

1993-1996 Usia Rata2 Wanita/Laki-laki Hematemesis Hematemesis & Melena Melena Kematian Jlh Penderita 54,25 95/168 9/21 (30) 47/72 (119) 39/75 (114) 10/263 (0,04%) 263

1997-2000 52,32 78/142 6/31 (37) 40/69 (109) 30/42 (72) 6/220 (0,03%) 220

HASIL
PENYEBAB PERDARAHAN (MABEL DKK)

1993-1996 Varises esofagus Tukak duodeni Tumor Lambung Tukak Lambung Gastritis Erosiva Gastropati Tumor Esofagus Jumlah 78 51 51 27 24 26 6 263

1997-2000 55 40 45 33 26 17 4 220

Etiologi PSMBA

PENYEBAB PSMBA DITINJAU DARI LOKASI

ESOFAGUS OESOPHAGEAL VARICES MALLORY WEISS TEAR OESOPHAGEAL CARCINOMA REFLUX OESOPHAGITIS FOREIGN BODY LAMBUNG PEPTIC ULCER EROSIONS/GASTRITIS GASTRIC VARICES PORTAL HYPERTENSIVE GASTROPATHY GASTRIC CARCINOMA LYMPOMA LEIOMYOMA ANGIODYSPLASIA (INCLUDING OSLERS DISEASE) DIEULAFOYS EROSION

BERDASARKAN BENTUK KELAINAN

ULCERATIVE, EROSIVE, Peptic Ulcer disease OR INFLAMMATORY Gastro or duodenal ulcer, Z E syndrome, GERD DISEASE Stress Ulcer Infection causes Helicobakter pylori, Cytomegalovirus, Herpes simplex Drug-induced erosions, ulcers Aspirin, NSAIDs, Pil-induced ulcer Anticoagulation therapy TRAUMA Mallory-Weiss Tear, Foreign body ingestion VASCULAR LESIONS Varices, Angiomas, Osler-WR syndrome,Dieulafoy lesion Watermelon stomach,portal hypertensive gastropathy Aortoenteric fistula, radiotion induced telengiectasia Benign Leiomyoma, Lipoma,Polyp, Blue rubber syndrome Malignant Adenocarcinoma, Leiomysarcoma, Lympoma, Kaposis sarcoma,Carcinoid, Melanoma, Metastatic tumor Miscellaneous Hemofilia, Hemosuccus pancreaticus

TUMORS

PENYEBAB TERBANYAK DARI PSMBA DITINJAU DARI PENYAKIT

COMMON ESOPHAGEAL VARICES ESOPHAGOGASTRIC MUCOSAL TEAR (MALLORY-WEISS SYNDROME) GASTRIC EROSIONS GASTRIC ULCER DASTRIC VARICES DUODENAL ULCER ANGIODYSPLASIA (INCLUDING OSLERS DISEASE) DIULAFOYS EROSION

OCCASIONAL ESOPHAGITIS ESOPHAGEAL CARCINOMA GASTRIC DUODENAL NEOPLASMS (CARCINOMA, LYMPHOMA, POLYPS) GASTRIC MUCOSAL VASCULAR ECTASIA ASSOCIATED WITH CIRRHOSIS DUODENITIS ANASTOMIC ULCER SUBMUCOSAL NEOPLASMS (LEIOMYOMA, MOST COMMON) VASCULAR-ENTERIC FISTULA (USSUALY FROM AN AORTIC ANEURYSM GRAFT) RARE NASAL OR PHARYNGEAL BLEEDING HEMOPTYSIS ESOPHAGEAL REPTURE (BOERHAAVES SYNDROMA) HEMOBILIA

HISTORICAL FEATURES IMPORTANT IN ASSESSING THE ETIOLOGY OF GASTROINTESTINAL BLEEDING

AGE PRIOR BLEEDING PREVIOUS GASTROINTESTINAL DISEASE PREVIOUS SURGERY UNDERLYING MEDICAL DISORDER (ESPECIALLY LIVER DISEASE ) NON STEROIDAL ASPIRIN ABDOMINAL PAIN CHANGE IN BOWEL HABITS WEIGHT LOSS/ANOREXIA HISTORY OF OROPHARYNGEAL DISEASE ANTI INFLAMMATORY DRUGS /

ADVERSE PROGNOSTIC VARIABLES IN ACUTE UPPER GASTROINTESTINAL BLEEDING

INCREASING AGE INCREASING NUMBER OF COMORBID CONDITIONS CAUSE OF BLEEDING (VARICEAL BLEEDING > OTHERS) RED BLOOD IN THE EMESIS AND/OR STOOL SHOCK OR HYPOTENSION ON PRESENTATION INCREASING NUMBERS OF UNIT OF BLOOD TRANSFUSED ACTIVE BLEEDING AT THE TIME OF ENDOSCOPY BLEEDING FROM LARGE (>2.0 CM) ULCER ONSET OF BLEEDING IN THE HOSPITAL EMERGENCY SURGERY

KLASIFIKASI AKTIFITAS PERDARAHAN MENURUT FORREST

AKTIFITAS PERDARAHAN
Forrest Ia Perdarahan aktif menyembur (spurting) Forrest Ib Perdarahan aktif Forrest II Perdarahan berhenti, tetapi masih disertai kelainan yang nyata Forrest III Perdarahan berhenti, tanpa menunjukkan sisa

KRITERIA ENDOSKOPIK
: perdarahan arteri : Perdarahan merembes (oozing) : Gumpalan darah pada dasar tukak visible vessel : Lesi tanpa tanda sisa perdarahan

TABLE 1 . HEMORRHAGIC CLASSES

HEMORRHAGIC CLASS BLOOD LOSS HEART RATE RESPIRATORY RATE ARTERIAL PRESSURE CAPILLARY FILLING TIME DIURESIS (ML/H) NEUROLOGIC STATUS 35-30 MILDLY 30-25 VERY 25-5 CONFUSED 0 LETHARGIC NORMAL INCREASED INCREASED INCREASED NORMAL 110-80 70-60 <60 15% OR 750 ML <100 14-19 20-25% OR >100 20-29 30-35% OR >120 30-40 40-50% OR >140 >40 I II III IV

1000-1250 ML 1500-1800ML 2000-2500 ML

ANXIOUS ANXIOUS

DIAGNOSTIK
1. PERDARAHAAN
COMMON VOMITING (MENTAL) DYSFAGIA & BB MALLORY WEISS TEAR ? REFLUX ESOFAGITIS ? GASTRIC EROSIVE ? ULKUS PEPTIKUM ? LIVER STIGMATA (CH) VARICES BLEEDING ? STRESS ULCER ? PENYAKIT BERAT (DI ICU) MALIGNANCY PD ESOFAGUS ? HEARTBURN & REGURGITASI

ANAMNESE

RIWAYAT

MAKAN OBAT-OBATAN & ALKOHOL

2. PEMERIKSAAN FISIK : Penilaian status hemodinamik & resusitasi Jaundice & Tanda2 liver stigmata & HT portal Bleeding diathesis : purpura, ekimosis, ptikiae 3. RADIOLOGI Ba. Swallow, Ba. Follow Through, MDF double contras, Kolon in loop. Upper & Lower Abdominal Scanning 4. ENDOSKOPI Gastroduodenoskopi Sigmoidoskopi kolonoskopi Push Enteroskopi

Gambaran Endoskopi : Erosi

Erosi Multipel, warna merah kehitaman,terutama difundus dan korpus

Ulkus
Perdarahan masif bila terkena pembuluh darah Ulkus akut, de novo ,multipel ukuran 0,5-2 cm, di fundus dan korpus dan kadang kadang diduodenum

Forrest III

Forrest I Spurting bleeding

Figure 1. Suggested Diagnostic Procedures in patients with hematemesis. (EGD=esophagogastroduodenoscopy)

HEMATEMESIS HISTORY LABORATORY TESTS AND IMAGING STUDIES LIVER CIRRHOSIS WITH ACTIVE BLEEDING NO URGENT EGD NO LOCALIZATION MASSIVE BLEEDING MODEST BLEEDING LOCALIZATION OF BLEEDING SITE

YES BALOON TAMPONADE URGENT EGD AFTER REMOVAL OF BALLON TAMPONADE ESOPHAGEAL OR GASTRIC VARICES SCLEROTHERAPY

DEFINITIVE TREATMENT: ENDOSCOPIC REPEAT EGD OR (THERMAL ANGIOGRAPHY COAGULATION OR SURGERY INJECTION)OR PHARMACOLOGIC NO LOCALIZATION LOCALIZATION OF BLEEDING SITE WITH RECURRENT OR PERSISTENT BLEEDING

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Figure 2. Suggested diagnostic procedures in patients with melema (EGD=esophagogastroduodenoscopy)

MELENA HISTORY ELECTIVE EGD LOCALIZATION OF BLEEDING SITE (50-70%) NO LOCALIZATION NO ACTIVE BLEEDING RECTOSIGMOIDOSCOPY AND COLONOSCOPY (WHENEVER POSSIBLE) LOCALIZATION OF BLEEDING SITE DEFINITIVE TREATMENT OR OBSERVATION NO LOCALIZATION RADIOISOTOPIC SCAN IF POSITIVE, ANGIOGRAPHY

IN CASE OF RELEVANT BLEEDING ANGIOGRAPHY NO LOCALIZATION SURGERY

PENANGANAN
RESUSITASI (UMUM)

Pasang infus / IVFD Pasang NG Tube Golongan darah / Cross Match Transfusi darah jika perlu Koreksi koagulopati jika perlu

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PERDARAHAN SALURAN CERNA BAGIAN ATAS

HEMATEMESIS / MELENA DENGAN GANGGUAN HEMODINAMIK Syok (baring 50%, duduk 30%) Atasi hipovolemi - NaCl RL, Plasma expander - Transfusi darah biasa / PRC Slang Nasogastrik - Bilas dengan air es sampai jernih Obat hemostatik Monitor Hb/Ht, tensi, nadi, kesadaran Anamnese & Pemeriksaan Fisik Fisik Perdarahan terus Gastroskopi Infus / transfusi sesuai kebutuhan Slang Nasogastrik Bilas air es Obat hemostatik Monitor Hb/Ht, tensi, nadi, kesadaran Anamnese & Pemeriksaan TANPA GANGGUAN HEMODINAMIK

Perdarahan stop

Gastroskopi Dengan varises - Skleroterapi darurat - Slang S-B - Sandostatin& Somastotatin - Terapi konservatif diteruskan (antasid, penghambat H2, hemostatik, laktulose, neomisin) H2,PPI hemostatik) Tanpa varises

+ Gastritis erosif Ulkus Peptikum Mallory Weiss Tumor Konservatif (antasid, penghambat

Perdarahan terus

Perdarahan stop

Operasi

Konservatif

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VARISES BLEEDING MEDICAMENT :

PROFILAKSIS BETABLOKER (PROPANOLOL) TERAPEUTIK : SOMATOSTATIN

SB TUBE
SKLEROTERAPI

ENDOSKOPI ERADIKASI
BINDING LIGASI

TIPSS

ULKUS BLEEDING
1. MEDIKAMEN : ARH2, PPI, Antasida 2. ENDOSCOPIC Therapy : laser elektrokoagulasi heater probe topical sprays injection therapy (adrenalin 1:10.000, alkohol & polidokanol ) 3. RADIOLOGIC Therapy : embolisasi 4. Prophylactic therapy : * eradikasi HP pd TD & TL * empiric therapy jika HP tdk dieradikasi. * Analog PG (misoprostol) utk NSAID + TL * Surgery utk recurent bleeding

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ENDOSCOPIC THERAPY OF UPPER GI BLEEDING

TOPICAL THERAPY -Tissue adhesives -Clotting factors -Collagen -Ferromagnetic tamponade INJECTION THERAPY -Variceal bleeding -Non variceal bleeding - Ethanol - Other sclerosants MECHANICAL THERAPY -Snares -Sutures -Balloons -Hemoclips THERMAL THERAPY -Electrocoagulation - monopoloar - electrohydrothermal bipolar (multipolar) -Heater probe -Laser

THERAPEUTIC OPTIONS FOR ACUTE UPPER GASTROINTESTINAL HEMORRHAGE

MEDICAL THERAPY Peptic Ulcer disease Antisecretory therapy,Antacids,Sucralfate,Misoprostol Gastroesophageal varices Intravenous vasopressin with or without nitroglycerin Intravenous octreotide Balloon tamponade Peptic ulcer disease Thermal coagulation Multipolar electrocoagulation,Heater probe,laser ther Injection therapy Epinephrine, Alcohol Combination therapy;thermal coagulatuion & injection Gastroesophgeal varices Injection sclerotherapy,variceal band ligation Cyanoacrylate injection Combination therapy;sclerotherapy &band ligation Tumors Termal probe, Laser ablation,Thermal balloon cateter Non variceal (ulcer,endoscopic, or mallory-Weiss tear) Variceal Portosystemic shunting,Esophageal transection and devascularization, Liver transplantation Peptic ulcer disease Arterial embolization, Intraarterial vasopressin infusion Gastroesophageal varices Embolization,Transjugular intrahepatic portosystemic shunting

ENDOSCOPIC THERAPY

SURGICAL THERAPY

RADIOLOGIC THERAPY

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Score Variable
Age (yr) Shock

0
< 60 No Shock (BP >100 PP <100) Nil mayor

60-79 >80 Tachycardia Hypotension (BP>100,PP>100 (BP<100 PP>100, CHF,CAD, Others Renalfailure, Liverfailure, diss.malignancy

Comorbidity

Diagnosis

Major SRH

Mallory weiss No lesion, no SRH None or dark spot

All other diagnosis

Malignancy of GI tract Blood in UGI Clot,visible or spurting vessels

Score : < 3 excellent prognosis > 8 poor prognosis SRH : Stigmata of recent Hemorrhage

Interpretasi Rockall Score

Skor > 3 : Risiko mortalitas meningkat Skor > 4 : Perlu dirawat diruang High Care Resusitasi Optimal Kerja sama tim Penyakit Dalam,bedah , anestesi. Mortalitas : Skor 0 Skor 1 Skor 2 Skor 3 Skor 4

0% 3% 6% 12% 24% Skor 5 Skor 6 Skor 7 36% 62% 75%

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PSCA Monitor status hemodinamik resursitasi

Resiko rendah (Rockall < 2)

Resiko tinggi (Rockall > 4)

Perdarahan ulang (10-20 %)

Endoskopi segera / urgent endoskopi terapi

Endoskopi 12 - 24 jam

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PENATALAKSANAAN PERDARAHAN SALURAN CERNA Konsensus Nasional 2003

PB. PERKUMPULAN GASTROENTEROLOGI INDONESIA

Manajemen awal ORDER

O ksigenasi R estore circulating volume D rug Therapy E valuate response to Therapy R emedy underlying cause Prinsip dasar : Ganti kehilangan cairan, Stop perdarahan ! !

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Resusitasi dan Stabilisasi(1)

Pasang jarum ukuran 16 dan 18 untuk infus cairan kristaloid secara cepat; Untuk ekspansi cairan intravaskular 1 L, dibutuhkan cairan kristaloid 3 L NGT untuk diagnostik dan monitoring Terapi antara ( Stop gap treatment): Somatostatin Oktreotide SB tube pada perdarahan varises

Obat supresor asam PPI efektif untuk perdarahan SCBA Evaluasi dan monitor keadaan dan respon terhadap terapi secara klinis, Hematologis, analisa gas darah dan status Metabolik

Resusitasi dan Stabilisasi (2)

Transfusi darah atau komponen darah diberikan bila Hb < 7 g/dl atau bila ada gangguan koagulasi Bila memungkinkan upaya diagnostik secara endoskopik untuk mengetahui dan menghentikan sumber perdarahan perlu segera dilakukan. Perlu dipersiapkan agar pasien dapat ditransfer kepusat rujukan dengan aman Obat Vasoaktif Dopamin,Dobutamin, hanya diberikan pada pasien dengan Syok hemoragik bila sudah diberikan penggantian cairan yang cukup

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Terapi obat pada perdarahan SCBA

Supresi Asam : Pilihan utama Proton Pump Inhibitor (PPI ) Omeprazol : 3 x 40 mg IV atau 40 mg bolus, 8 mg/jam selama 3 x 24 jam Obat Hemostatik; Tranexamic acid; 3 x 500 mg IV Vit K ; 3 x 10mg IV Obat Vasoaktif : Somatostatin : 250 g bolus, infus 250 g / jam , 3 x 24 jam Oktreotide 0,05 mg /jam, 3 x 24 jam

Indonesian Society of Gastroenterology

NATIONAL CONCENSUS ON UPPER GASTROINTESTINAL BLEEDING MANAGEMENT IN; Primary Health Care / Emergency Unit Hospital type D (without specialist and endoscopy facilities)

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Indonesian Society of Gastroenterology

NATIONAL CONCENSUS ON UPPER GASTROINTESTINAL BLEEDING MANAGEMENT IN; Secondary Care / Specialist / Hospital type C ( without endoscopy facilities )

Indonesian Society of Gastroenterology

NATIONAL CONCENSUS ON UPPER GASTROINTESTINAL BLEEDING MANAGEMENT IN; Referral Hospital type A &B (endoscopy facilities are available)

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TERIMA KASIH

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