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Dr.

Mabel HM Sihombing, SpPDKGEH

SpPD
DIVISION OFDr.Ilhamd
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) >50CC
DARAH
HAEMATOCHEZIA :
BAB WARNA MERAH TERANG GELAP
OCCULT BLEEDING :
TDK ADA PERUBAHAN WARNA BAB, NAMUN
BENZIDINE TEST (+) ( darah 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

9/21 (30)

6/31 (37)

Hematemesis & Melena

47/72 (119)

40/69 (109)

Melena

39/75 (114)

30/42 (72)

10/263 (0,04%)

6/220 (0,03%)

263

220

Hematemesis

Kematian
Jlh Penderita

PROPORSI PSMBA BERDASAR JENIS


KELAMIN DAN USIA TAHUN 2009-2010
(2 THN) (Ilhamd dkk)
USIA

LAKI-LAKI

WANITA

< 16

16-20

16

21-30

30

19

31-40

48

19

41-50

52

35

51-60

56

25

>60

58

41

JUMLAH

262

148

HASIL
PENYEBAB PERDARAHAN (MABEL ,Medan 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

263

220

Jumlah

HASIL GASTROSKOPI BERDASAR JENIS KELAMIN


TAHUN 2009-2010 (2 TAHUN)
(Ilhamd dkk)
HASIL GASTROSKOPI

LAKI-LAKI

WANITA

VARISES ESOFAGUS

69

ULKUS GASTER

52

ULKUS DUODENI

34

GASTRITIS EROSIVA

60

31
100
26
78
18
52
36
96

CA GASTER

8
8

KELAINAN ESOPAGUS
NON CA
POLIP GASTER

20

16
36

2
2

CA ESOFAGUS

4
4

Etiologi PSMBA

ETIOLOGI PSMBA
1.PENYEBAB PSMBA DITINJAU DARI
LOKASI
2.PENYEBAB PSMBA DITINJAU DARI
BENTUK KELAINAN
3.PENYEBAB PSMBA DITINJAU DARI
JENIS PENYAKIT

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)

CAUSES OF ACUTE UPPER GASTROINTESTINAL


BLEEDING BERDASARKAN BENTUK KELAINAN
ULCERATIVE,
EROSIVE,
INFLAMMATORY
DISEASE

Peptic Ulcer disease


OR
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,Dieulafoy lesionportal
hypertensive gastropathy
Aortoenteric fistula, radiotion induced
telengiectasia

TUMORS

Benign
Leiomyoma, Lipoma,Polyp, Blue rubber
syndrome
Malignant

PENYEBAB TERBANYAK PSMBA


DITINJAU DARI PENYAKIT
COMMON
ESOPHAGEAL VARICES
ESOPHAGOGASTRIC MUCOSAL TEAR
(MALLORY-WEISS SYNDROME)
GASTRIC EROSIONS,ULCER,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 RUPTURE (BOERHAAVES SYNDROMA)

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 ANTI INFLAMMATORY DRUGS /


ASPIRIN

ABDOMINAL PAIN
CHANGE IN BOWEL HABITS
WEIGHT LOSS/ANOREXIA
HISTORY OF OROPHARYNGEAL DISEASE

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

Forrest III

Forrest I
Spurting
bleeding

HEMORRHAGIC CLASSES
HEMORRHAGIC

II

III

IV

15% OR

20-25% OR

30-35% OR

40-50% OR

750 ML

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

CLASS
BLOOD LOSS
HEART RATE

<100

>100

>120

>140

RESPIRATORY

14-19

20-29

30-40

>40

70-60

<60

RATE
ARTERIAL

NORMAL 110-80

PRESSURE
CAPILLARY

NORMAL INCREASED INCREASED INCREASED

FILLING TIME
DIURESIS (ML/H)

35-30

30-25

25-5

NEUROLOGIC

MILDLY

VERY

CONFUSED

LETHARGIC

STATUS

ANXIOUS ANXIOUS

DIAGNOSTIK
1. PERDARAHAAN ANAMNESE RIWAYAT
VOMITING (MENTAL) MALLORY WEISS HEM?
CEPAT/LAMBATLOKASI

HEARTBURN & REGURGITASI REFLUX ESOFAGITIS

DYSFAGIA & BB MALIGNANCY PD ESOFAGUS ?

MAKAN OBAT-OBATAN & ALKOHOL GASTRIC


EROSIVE ?
PEPTIKUM ?

ULKUS

PENYAKIT BERAT (DI ICU) STRESS ULCER ?

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

Gambaran Endoskopi :
Erosi
Erosi Multipel, warna
merah kehitaman,terutama
difundus dan korpus
Ulkus
Perdarahan masif bila
terkena pembuluh darah
Ulkus ,multipel ukuran
0,5-2 cm, di fundus dan
korpus dan kadang
kadang diduodenum

ULKUS KORPUS ANTRUM

Suggested Diagnostic Procedures in patients with


hematemesis. (EGD=esophagogastroduodenoscopy)
HEMATEMESI
S
HISTORY
LABORATORY TESTS AND IMAGING
STUDIES
LIVER CIRRHOSIS WITH ACTIVE BLEEDING
NO

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

URGENT EGD
LOCALIZATIO
N OF
BLEEDING
SITE
MODEST
MASSIVE
DEFINITIVE
BLEEDING
BLEEDING
TREATMENT:
ENDOSCOPIC
REPEAT EGD OR
(THERMAL
ANGIOGRAPHY
COAGULATION
SURGERY
OR
INJECTION)OR
PHARMACOLOGI
NO LOCALIZATION
LOCALIZATIO
C
N OF
BLEEDING
WITH RECURRENT OR
SITE
PERSISTENT
NO LOCALIZATION

Suggested diagnostic procedures in patients with melema


(EGD=esophagogastroduodenoscopy)
MELENA
HISTORY
ELECTIVE EGD
NO
LOCALIZATIO
LOCALIZATIO
N OF
N
BLEEDING
SITE (50-70%)
NO ACTIVE
IN CASE OF
BLEEDING
RELEVANT
BLEEDING
RECTOSIGMOIDOSCOP
Y AND COLONOSCOPY
ANGIOGRAPHY
(WHENEVER
POSSIBLE)
NO LOCALIZATION
SURGERY

LOCALIZATION
OF BLEEDING
SITE
DEFINITIVE
TREATMENT
OR
OBSERVATION

NO
LOCALIZATIO
N
RADIOISOTOPI
C SCAN
IF POSITIVE,
ANGIOGRAPHY

ENDOSCOPIC PROCEDURES THERAPY


OF UPPERMECHANICAL
GI BLEEDING
THERAPY

TOPICAL THERAPY
-Tissue adhesives
-Clotting factors
-BILAS EPINEFRIN

-Snares
-Sutures
-Balloons
-Hemoclips

INJECTION THERAPY
-Variceal bleeding
-Non variceal bleeding
- Ethanol
- Other sclerosants

THERMAL THERAPY
-Electrocoagulation
- monopoloar
- electrohydrothermal
bipolar (multipolar)
-Heater probe
-Laser

THERAPEUTIC OPTIONS FOR ACUTE UPPER


GASTROINTESTINAL HEMORRHAGE
MEDICAL THERAPY

ENDOSCOPIC
THERAPY

SURGICAL THERAPY

Peptic Ulcer disease


Antisecretory
therapy,Antacids,Sucralfate,Misoprostol
Gastroesophageal varices
Intravenous vasopressin with or
nitroglycerin
Intravenous octreotide
Balloon tamponade

without

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

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 ! !

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

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)

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)

VARISES
BLEEDING
MEDICAMENT :

PROFILAKSIS
BETABLOKER
(PROPANOLOL)
TERAPEUTIK :
SOMATOSTATIN

SB TUBE
SKLEROTERAPI

ENDOSKOPIERADIKASI
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

Variable
Age (yr)
Shock

Comorbidity

Score
1

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

Diagnosis

Major SRH

Mallory weiss
No lesion,
no SRH
None or dark
spot

All other
diagnosis

Score : < 3 excellent prognosis


> 8 poor prognosis
SRH : Stigmata of recent
Hemorrhage

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

Renalfailure,
Liverfailure,
diss.malignancy

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%