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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

PSMBA

PSMBB

HEMATEMESIS

MELENA : (50 ML BLOOD)

HEMATOCHEZIA (TRANSIT TIME <<)

LIGAMENTUM TRAITZ

HEMATOCHEZIA

MELENA (TRANSIT TIME >>)

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PENGERTIAN

HEMATEMESIS :

MUNTAH DARAH WARNA MERAH KECOKLAT COKLATAN ���� KEHITAM HITAMAN (CAFFEIN)

MELENA :

BAB WARNA HITAM (TERRY STOOL) ���� >50CC DARAH

HAEMATOCHEZIA :

BAB WARNA MERAH TERANG ���� GELAP

OCCULT BLEEDING :

TDK ADA PERUBAHAN WARNA BAB, NAMUN BENZIDINE TEST (+) 10 CC

HASIL :GAMBARAN PASIEN PSMBA 2 KURUN WAKTU

(MABEL DKK)

1993-1996 1997-2000

Usia Rata2 54,25 52,32

Wanita/Laki-laki 95/168 78/142

Hematemesis 9/21 (30) 6/31 (37)

Hematemesis & Melena 47/72 (119) 40/69 (109)

Melena 39/75 (114) 30/42 (72)

Kematian 10/263 (0,04%) 6/220 (0,03%)

Jlh Penderita 263 220

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HASILPENYEBAB PERDARAHAN (MABEL DKK)

1993-1996 1997-2000

Varises esofagus 78 55

Tukak duodeni 51 40

Tumor Lambung 51 45

Tukak Lambung 27 33

Gastritis Erosiva 24 26

Gastropati 26 17

Tumor Esofagus 6 4

Jumlah 263 220

Etiologi PSMBA

�

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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 OSLER’S DISEASE)� DIEULAFOY’S EROSION

ULCERATIVE, EROSIVE,OR INFLAMMATORY

DISEASE

Peptic Ulcer disease

Gastro or duodenal ulcer, Z E syndrome, GERD

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,Dieulafo’y lesion

Watermelon stomach,portal hypertensive gastropathy

Aortoenteric fistula, radiotion induced telengiectasia

TUMORS Benign

Leiomyoma, Lipoma,Polyp, Blue rubber syndrome

Malignant

Adenocarcinoma, Leiomysarcoma, Lympoma, Kaposi’s sarcoma,Carcinoid, Melanoma, Metastatic tumor

Miscellaneous

Hemofilia, Hemosuccus pancreaticus

BERDASARKAN BENTUK KELAINAN

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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 OSLER’S DISEASE)

� DIULAFOY’S 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 (BOERHAAVE’S SYNDROMA)� HEMOBILIA

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HISTORICAL FEATURES IMPORTANT IN ASSESSING THE ETIOLOGY OF GASTROINTESTINAL BLEEDING

���� AGE

���� PRIOR BLEEDING

���� PREVIOUS GASTROINTESTINAL DISEASE

���� PREVIOUS SURGERY

���� UNDERLYING MEDICAL DISORDER (ESPECIALLY LIVERDISEASE )

���� NON STEROIDAL ANTI INFLAMMATORY DRUGS /ASPIRIN

���� ABDOMINAL PAIN

���� CHANGE IN BOWEL HABITS

���� WEIGHT LOSS/ANOREXIA

���� HISTORY OF OROPHARYNGEAL DISEASE

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

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AKTIFITAS PERDARAHAN KRITERIA ENDOSKOPIK

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

: perdarahan arteri

: Perdarahan merembes

(oozing)

: Gumpalan darah pada

dasar tukak

“visible vessel”

: Lesi tanpa tanda sisa

perdarahan

KLASIFIKASI AKTIFITAS PERDARAHAN

MENURUT FORREST

HEMORRHAGIC I II III IV

CLASS

BLOOD LOSS 15% OR 20-25% OR 30-35% OR 40-50% OR

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

HEART RATE <100 >100 >120 >140

RESPIRATORY 14-19 20-29 30-40 >40

RATE

ARTERIAL NORMAL 110-80 70-60 <60

PRESSURE

CAPILLARY NORMAL INCREASED INCREASED INCREASED

FILLING TIME

DIURESIS (ML/H) 35-30 30-25 25-5 0

NEUROLOGIC MILDLY VERY CONFUSED LETHARGIC

STATUS ANXIOUS ANXIOUS

TABLE 1 . HEMORRHAGIC CLASSES

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1. PERDARAHAAN ���� ANAMNESE ���� RIWAYAT

COMMON

� VOMITING (MENTAL) � MALLORY –WEISS TEAR ?

� HEARTBURN & REGURGITASI � REFLUX ESOFAGITIS ?

� DYSFAGIA & BB � � MALIGNANCY PD ESOFAGUS ?

� MAKAN OBAT-OBATAN & ALKOHOL �GASTRIC EROSIVE ?

ULKUS PEPTIKUM ?

� LIVER STIGMATA (CH) � VARICES BLEEDING ?

� PENYAKIT BERAT (DI ICU) � STRESS ULCER ?

DIAGNOSTIK

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

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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

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Forrest I

Spurting bleeding

Forrest III

HEMATEMESIS

HISTORY

LABORATORY TESTS AND IMAGING STUDIES

LIVER CIRRHOSIS WITH ACTIVE BLEEDING

YES NO

BALOON TAMPONADE

URGENT EGD AFTER REMOVAL OF BALLON

TAMPONADE

ESOPHAGEAL OR GASTRIC VARICES

SCLEROTHERAPY

URGENT EGD

NO LOCALIZATION

MASSIVE BLEEDING

SURGERY

MODEST BLEEDING

REPEAT EGD OR ANGIOGRAPHY

NO LOCALIZATION

WITH RECURRENT OR PERSISTENT BLEEDING

LOCALIZATION OF BLEEDING

SITE

LOCALIZATION OF BLEEDING

SITE

DEFINITIVE TREATMENT: ENDOSCOPIC (THERMAL

COAGULATION OR INJECTION)OR

PHARMACOLOGIC

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

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MELENA

ELECTIVE EGD

LOCALIZATION OF BLEEDING SITE (50-70%)

NO ACTIVE BLEEDING

RECTOSIGMOIDOSCOPY AND COLONOSCOPY

(WHENEVER POSSIBLE)

DEFINITIVE TREATMENT OR OBSERVATION

RADIOISOTOPIC SCAN

IF POSITIVE, ANGIOGRAPHY

ANGIOGRAPHY

NO LOCALIZATION

SURGERY

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

NO LOCALIZATION

LOCALIZATION OF BLEEDING

SITE

IN CASE OF RELEVANT BLEEDING

NO LOCALIZATION

HISTORY

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 ATASHEMATEMESIS / MELENA

DENGAN GANGGUAN HEMODINAMIK TANPA GANGGUAN

HEMODINAMIK

Syok (baring 50%, duduk 30%)

Atasi hipovolemi Infus / transfusi sesuai

- NaCl RL, Plasma expander kebutuhan

- Transfusi darah biasa / PRC Slang Nasogastrik

Slang Nasogastrik Bilas air es

- Bilas dengan air es sampai jernih Obat hemostatik

Obat hemostatik Monitor Hb/Ht, tensi, nadi,

Monitor Hb/Ht, tensi, nadi, kesadaran kesadaran

Anamnese & Pemeriksaan Fisik Anamnese & PemeriksaanFisik

Perdarahan terus Perdarahan stop

G a s t r o s k o p i

Gastroskopi

Dengan varises Tanpa varises

- Skleroterapi darurat

- Slang S-B + Gastritis erosif

- Sandostatin& Somastotatin Ulkus Peptikum

Mallory Weiss

- Terapi konservatif diteruskan Tumor

(antasid, penghambat H2,

hemostatik, laktulose, neomisin) Konservatif

(antasid, penghambat

H2,PPI

hemostatik)

Perdarahan terus Perdarahan stop

Operasi Konservatif

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VARISES BLEEDINGPROFILAKSIS BETABLOKER (PROPANOLOL)

TERAPEUTIK : SOMATOSTATIN

�MEDICAMENT :

�SB TUBE

�ENDOSKOPI�ERADIKASI

�TIPSS

SKLEROTERAPI

BINDING LIGASI

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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TOPICAL THERAPY

-Tissue adhesives

-Clotting factors

-Collagen

-Ferromagnetic tamponade

MECHANICAL THERAPY

-Snares

-Sutures

-Balloons

-Hemoclips

INJECTION THERAPY

-Variceal bleeding

-Non variceal bleeding

- Ethanol

- Other sclerosants

THERMAL THERAPY

-Electrocoagulation

- monopoloar

- electrohydrothermal

bipolar (multipolar)

-Heater probe

-Laser

ENDOSCOPIC THERAPY OF UPPER GI BLEEDING

MEDICAL THERAPYPeptic Ulcer disease

Antisecretory therapy,Antacids,Sucralfate,MisoprostolGastroesophageal varices

Intravenous vasopressin with or without nitroglycerinIntravenous octreotideBalloon tamponade

ENDOSCOPIC THERAPYPeptic ulcer disease

Thermal coagulationMultipolar electrocoagulation,Heater probe,laser ther

Injection therapyEpinephrine, Alcohol

Combination therapy;thermal coagulatuion & injectionGastroesophgeal varices

Injection sclerotherapy,variceal band ligationCyanoacrylate injectionCombination therapy;sclerotherapy &band ligation

TumorsTermal probe, Laser ablation,Thermal balloon cateter

SURGICAL THERAPYNon variceal (ulcer,endoscopic, or mallory-Weiss tear)Variceal

Portosystemic shunting,Esophageal transection and devascularization, Liver transplantation

RADIOLOGIC THERAPY Peptic ulcer diseaseArterial embolization, Intraarterial vasopressin infusion

Gastroesophageal varicesEmbolization,Transjugular intrahepatic portosystemic shunting

THERAPEUTIC OPTIONS FOR ACUTE UPPER GASTROINTESTINAL HEMORRHAGE

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VariableScore

0 1 2 3

Age (yr)

Shock

Comorbidity

Diagnosis

Major SRH

< 60

No Shock

(BP >100

PP <100)

Nil mayor

Mallory weiss

No lesion,

no SRH

None or dark

spot

60-79

Tachycardia

(BP>100,PP>100

All other

diagnosis

>80

Hypotension

(BP<100

PP>100,

CHF,CAD,

Others

Malignancy of

GI tract

Blood in UGI

Clot,visible or

spurting

vessels

Renalfailure,

Liverfailure,

diss.malignancy

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 0%

• Skor 1 3%

• Skor 2 6%

• Skor 3 12%

• Skor 4 24%

•

• Skor 5 36%

• Skor 6 62%

• Skor 7 75%

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PSCA

Monitor status hemodinamik resursitasi

Resiko tinggi (Rockall > 4)Resiko rendah (Rockall < 2)

Endoskopi 12 - 24 jam

Endoskopi segera / urgent

endoskopi terapi Perdarahan ulang (10-20 %)

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PENATALAKSANAAN PERDARAHAN SALURAN CERNAKonsensus Nasional 2003

PB. PERKUMPULAN GASTROENTEROLOGI INDONESIA

• 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 ! !

Manajemen awal

ORDER

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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 µg bolus, infus 250 µg / jam , 3 x 24 jam

Oktreotide 0,05 mg /jam, 3 x 24 jam

NATIONAL CONCENSUS ON UPPER GASTROINTESTINAL BLEEDING

MANAGEMENT IN;

Primary Health Care / Emergency Unit Hospital type D(without specialist and endoscopy facilities)

Indonesian Society of Gastroenterology

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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)

Indonesian Society of Gastroenterology

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TERIMA KASIH