SRI SOETADI

PSMBA

PSMBB

HEMATEMESIS

MELENA : (50 ML BLOOD)

HEMATOCHEZIA(TRANSIT TIME <<)

LIGAMENTUM TRAITZ

HEMATOCHEZIA

MELENA (TRANSIT TIME >>)

PSMBA DAN PSMBB

80% BERHENTI SPONTAN

INSIDENSI PSMBA : 100-150/100000 PDDK (USA)

INSIDENSI PSMBB : 20-25/100000 PDDK (USA)

MORTALITAS : 10-15%

PSMBA + 5 X LEBIH SERING DARI PSMBB

LAKI- LAKI > DARI WANITA

USIA TUA > USIA MUDA

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

PENYEBAB PSMBA DITINJAU DARI LOKASIESOFAGUS 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 diseaseGastro or duodenal ulcer, Z E syndrome,

GERDStress UlcerInfection causes

Helicobakter pylori, Cytomegalovirus, Herpes simplex Drug-induced erosions, ulcers

Aspirin, NSAIDs, Pil-induced ulcerAnticoagulation therapy

TRAUMA Mallory-Weiss Tear, Foreign body ingestion

VASCULAR LESIONS Varices, Angiomas, Osler-WR syndrome,Dieulafo’y lesionWatermelon stomach,portal hypertensive gastropathyAortoenteric fistula, radiotion induced telengiectasia

TUMORS BenignLeiomyoma, Lipoma,Polyp, Blue rubber

syndrome Malignant

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

Hemobilia, Hemosuccus pancreaticus

CAUSES OF ACUTE UPPER GASTROINTESTINAL BLEEDING

MEDICAL THERAPYPeptic Ulcer disease

Antisecretory therapy,Antacids,Sucralfate,MisoprostolGastroesophageal varices

Intravenous vasopressin with or without nitroglycerin

Intravenous octreotideBalloon tamponade

ENDOSCOPIC THERAPY

Peptic ulcer diseaseThermal coagulation

Multipolar electrocoagulation,Heater probe,laser ther

Injection therapyEpinephrine, Alcohol

Combination therapy;thermal coagulatuion & injectionGastroesophgeal varices

Injection sclerotherapy,variceal band ligation

Cyanoacrylate injectionCombination

therapy;sclerotherapy &band ligationTumors

Termal 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 THERAPYPeptic ulcer disease

Arterial embolization, Intraarterial vasopressin infusionGastroesophageal varices

Embolization,Transjugular intrahepatic portosystemic shunting

THERAPEUTIC OPTIONS FOR ACUTE UPPER GASTROINTSTINAL HEMORRHAGE

ACUTE MANAGEMENTPatient stabilization (ABCs)

Respiratory stabilization (intubation etc)Intravenous accessIntravascular volume replacementTransfusions (PRC, FFP, Platelets

Focused history and physical examinationLaboratory data

CBC with platelet count, Coagulation studies (PT/aPTT)Liver enzymes, Chemistries

RadiographicUpright chest x-ray, Abdominal x-ray

ElectrocardiogramLocalization of bleeding siteSurgery consulationGastroenterology consultation for upper panendoscopy

LONG-TERM MANAGEMENT

Treatment of recurrent bleedingRepeat diagnostic and therapeutic endoscopyAngiography, Surgery

Preventive measures for peptic ulcer disease bleedingMaintenance antisecretory therapyHelicobakter pyloru eradicationStrict avoidance of ASA/NSAIDsMisoprostolSurgery

Preventive measures for variceal bleeding BlockersObliterative endoscopic therapyShuntingLiver transplatation

MANAGEMENT APPROACH FOR ACUTE UPPER GASTROINTESTINAL HEMORRHAGE

HISTORICAL FEATURES IMPORTANT IN ASSESSING THE ETIOLOGY OF GASTROINTESTINAL BLEEDING

AGE

PRIOR BLEEDING

PREVIOUS GASTROINTESTINAL DISEASE

PREVIOUS SURGERY

UNDERLYING MEDICAL DISORDER (ESPECIALLY LIVER DISEASE )

NONSTEROIDAL 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

CAUSES OF ACUTE UPPER GASTROINTESTINAL BLEEDING COMMON CAUSES

Gastric ulcerDuodenal ulcerEsophageal varicesMallory – Weiss tear

LESS FREQUENT CAUSESDieulafoy’s lesionsVascular ectasiaPortal hypertensive gastropahtyGastric antral vascular ectasia (watermelon stomach)

Gastric varicesNeoplasiaEsophagitisGastric erosions

RARE CAUSESEsophageal ulcerErosive duodenitisAortoenteric fistulaHemobiliaPancreatic sourceCronh’s diseaseNo lesion indentified

CAUSES OF ACUTE LOWER GASTROINTESTINAL BLEEDING

COMMON CAUSESDiverticulaVascular ectasia

UNCOMMON CAUSESNeoplasia (including postpolypectomy)Inflammatory bowel disease

ColitisIschemic RadiationUnspecified

HemorrhoidsSmall bowel sourceUpper gastrointestinal source

No lesion identified

RARE CAUSESDieulafoy’s lesionsColonic UlcerationsRectal Varices

DIFFERENTIAL DIAGNOSIS OF OCCULT GASTROINTESTINAL BLEEDING

MASS LESIONS VASCULAR

Carcinoma (any site)* vascular ectasia (any site)* Large (>1.5 cm) adenoma (any site)Portal hypertensive gastropathy /colopathy

MASS LESIONS Watermelon stomach Erosive esophagitis* Hemangioma

Ulcer (any site)*Dielafoy’s lesion ‡ Cameron lesions †

INFECTIOUS Erosive gastritisHookworm Celiac sprue

Whipworm Ulcerative colitisStronglyoidiasis Crohn’s

disease Ascariasis Colitis (nonspecific) Tuberculous enterocolitis Idiopathic cecal ulcer Amebiasis MISCELLANEOUSSURREPTITIOUS Long-distance runningHemoptysis Factitious

Oropharyngeal (including epistaxis Pancreaticobiliary source

Variable Guaiac Heme-Porphyrin Immunochemical

Detection characteristics Upper gastrointestinal + ++++ 0

Small bowel ++ ++++ +Right colonic +++ ++++ ++

+ Left colonic ++++ ++++ ++++ Test factors

Bedside availability ++++ 0 +Time to develop 1 minute 1 hour 5 minute to 24 hours

Cost $ 3-5 $ 17 $ 10-20 False positives

Animal hemoglobin ++++ ++++ 0 Dietary peroxidases +++ 0 0False negatives Hemogloblin degredation ++ 0 ++ Storage ++ ++++ ++ Vitamin C ++ 0 0

CHARACTERISTICS OF FECAL OCCULT BLOOD TESTS1

PENYEBAB TERBANYAK DARI PSMBA DITINJAU DARI PENYAKIT

COMMON ESOPHAGEAL VARICES ESOPHAGOGASTRIC MUCOSAL TEAR

(MALLORY-WEISS SYNDROME) GASTRIC EROSIONS GASTRIC ULCER GASTRIC 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 (USSUALLY FROM AN

AORTIC ANEURYSM GRAFT)RARE NASAL OR PHARYNGEAL BLEEDING HEMOPTYSIS ESOPHAGEAL RUPTURE (BOERHAAVE’S SYNDROMA) HEMOBILIA

COMMON HEMMORRHOIDS PROCTITIS IBD DIVERTICOLISIS ISCHEMIC COLITIS ANGIODYPLASIA RECTAL OR COLONIC POLYPSOCCASIONAL ANAL FISSURE INFECTIOUS ENTEROCOLITIS CARCINOMA OF THE COLON RADIATION COLITIS MECKEL’S DIVERTICULUM BRISK BLEEDING FROM AN UPPER

GASTROINTESTINAL SOURCE

PENYEBAB TERBANYAK DARI PSMBB DITINJAU DARI PENYAKIT

RARE AMYLOIDOSIS VASCULAR-ENTERIC FISTULA ANTIBIOTIC-ASSOCIATED

COLITIS

DISEASE OF RECTUM AND COLON DIVERTICULAR DISEASE COLONIC ANGIODYSPLASIA COLITIS (ISCHAEMIA,INFECTIONS,IBD,RADIATION) COLONIC NEOPLASIA/POST-POLYPECTOMY ANORECTAL CAUSES (HAEMORRHOIDS,RECTAL

VARICES)DISEASE OF SMALL BOWEL VASCULAR ECTASIA TUMORS MECKEL’S DIVERTICULUMDISEASE OF UPPER GASTROINTESTINAL TRACT PEPTIC ULCER DISEASE VARICES SIGMOIDOSCOPY

PSMBB DITINJAU DARI SEGI LOKASI

Klasifikasi aktifitas perdarahan menurut Forrest

AKTIFITAS PERDARAHAN KRITERIA ENDOSKOPIK

Forrest Ia – Perdarahan aktif menyembur (spurting)Forrest Ib – Perdarahan aktif

Forrest II – Perdarahan berhenti, tetapi masih disertai kelainan yang nyataForrest III – Perdarahan berhenti, tanpa menunjukkan sisa

: perdarahan arteri

: perdarahan merembes (oozing): gumpalan darah pada dasar tukak “visible vessel”: lesi tanpa tanda sisa perdarahan

HEMORRHAGIC I II III IVCLASS

BLOOD LOSS 15% OR 20-25% OR 30-35% OR 40-50% OR750 ML 1000-1250 ML 1500-1800ML 2000-2500 ML

HEART RATE <100 >100 >120 >140

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

ARTERIAL NORMAL 110-80 70-60 <60PRESSURE

CAPILLARY NORMAL INCREASED INCREASED INCREASED FILLING TIME

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

NEUROLOGIC MILDLY VERY CONFUSED LETHARGICSTATUS ANXIOUS ANXIOUS

Table 1 . Hemorrhagic Classes

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

RIWAYAT

BAB BERDARAH & KONSTIPASI & ABDOMINAL PAIN

DIVERTIKULITIS

BAB BERDARAH & MENETES NETES / MENGALIR

HAEMMOROID

BAB BERDARAH (+) DAN DIARE KRONIK IBD

BAB BERDARAH (+) USIA LANJUT & BB & DIARE

KRONIK MALIGNANCY

BAB BERDARAH (+) & POST RADIASI KOLITIS

RADIASI

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

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 SITEDEFINITIVE

TREATMENT: ENDOSCOPIC

(THERMAL COAGULATION

OR INJECTION)OR

PHARMACOLOGIC

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

MELENA

HISTORY

ELECTIVE EGD

LOCALIZATION OF

BLEEDING SITE (50-70%)

NO LOCALIZATIO

N

IN CASE OF RELEVANT BLEEDING

NO ACTIVE BLEEDING

RECTOSIGMOIDOSCOPY AND COLONOSCOPY

(WHENEVER POSSIBLE)

LOCALIZATION OF BLEEDING

SITE

NO LOCALIZATIO

N

DEFINITIVE TREATMENT

OR OBSERVATION

RADIOISOTOPIC SCAN

IF POSITIVE, ANGIOGRAPHY

ANGIOGRAPHY

NO LOCALIZATION

SURGERY

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

HEMATOCHEZIA

HISTORY

ELECTIVE SIGMOIDOSCOP

Y

LOCALIZATION OF BLEEDING

SITE

NO LOCALIZATION

ELECTIVE TREATMENT

ELECTIVE EGD AND

COLONOSCOPY

PERSISTENT BLEEDING

RADIOISOTOPIC SCAN

IF POSITIVE ANGIOGRAPHY

BLEEDING STOPS

FOLLOW - UP

FOLLOW - UP

Figure 3. Suggested diagnostic procedures in patients with hematochezia (EGD=esophagogastroduodenoscopy)

PENANGANAN

RESUSITASI (UMUM) VASCULAR ACCESS INTRAVENOUS FLUIDS BLOOD LESTS TYPING & CROSS MATCHING CORRECT COAGULOPATHY BLOOD TRANSFUSION

VARISES BLEEDINGPROFILAKSIS BETABLOKER (PROPANOLOL)

TERAPEUTIK : SOMATOSTATIN

MEDICAMENT :

SB TUBE

ENDOSKOPIERADIKASI

TIPSS

SKLEROTERAPI

BINDING LIGASI

ULKUS BLEEDING1. 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

Tabel 2. Endoscopic therapy of upper GI bleeding

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

HAEMORRHOID

MEDIKAMENT :

SUPPOSITORIA (+/-) STEROID

DIIT TINGGI SERAT

ANOSCOPI TH/ :

INJ.SKLEROTH / LIGATION, CRYOSURGERI,

PHOTO COAGULATI, ELECTROCOAGULATI

SURGICAL HEMORRHOIDECTOMY

CA KOLOREKTAL OPERATIF

POLIP KOLON

POLIPEKTOMI

DIVERTIKEL KOLONMEDIKAMEN, INJEKSI EPINEPHRIN, ANALGESIC

OPERATIF KOLEKTOMI

IBD

MEDIKAMEN :

OPERATIF