Anemia Ec Perdarahan Saluran Cerna

8/19/2019 Anemia Ec Perdarahan Saluran Cerna

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ANEMIA ec PERDARAHAN SALURAN CERNA

General Approach to Anemias

Anemia is present in adults if the hematocrit is < !" #hemo$lo%in < !&'( $)dL *!&(

$)L+, in males or < &-" #hemo$lo%in < !. $)dL *!./ $)L+, in females' 0he most common cause

of anemia is iron deficienc1'

Poor diet ma1 result in folic acid deficienc1 and contri%ute to iron deficienc12 %ut %leedin$ is the

most common cause of iron deficienc1 in adults'

Anemias are classified accordin$ to their pathoph1siolo$ic %asis2 ie2 3hether related to

diminished production #relati4e or a%solute reticuloc1topenia, or to increased production due to

accelerated loss of red %lood cells #reticuloc1tosis, and accordin$ to red %lood cell si5e' A

reticuloc1tosis occurs in one of three pathoph1siolo$ic states6 acute %lood loss2 recentreplacement of a missin$ er1thropoietic nutrient2 or reduced red %lood cell sur4i4al #ie2

hemol1sis,' A se4erel1 microc1tic anemia #mean corpuscular 4olume *MC7+ < 8/ fL, is due

either to iron deficienc1 or thalassemia2 3hile a se4erel1 macroc1tic anemia #MC7 < !.( fL, is

almost al3a1s due to either me$alo%lastic anemia or to cold a$$lutinins in %lood anal15ed at

room temperature'



Gastrointestinal Bleeding

1. Acute Upper Gastrointestinal Bleeding

9eneral Considerations

0here are o4er .(/2/// hospitali5ations a 1ear in the United States for acute upper

$astrointestinal %leedin$2 3ith a mortalit1 rate of :!/"' Appro;imatel1 half of patients are o4er

-/ 1ears of a$e2 and in this a$e $roup the mortalit1 rate is e4en hi$her' 0he most common

presentation of upper $astrointestinal %leedin$ is hematemesis or melena' Hematemesis ma1 %e

either %ri$ht red %lood or %ro3ncoffee $rounds= material'Melena de4elops after as little as (/:

!// mL of %lood loss in the upper $astrointestinal tract2 3hereas hematoche5ia re>uires a loss of

more than !/// mL'

Etiolo$1

Acute upper $astrointestinal %leedin$ ma1 ori$inate from a num%er of sources6

1. Peptic Ulcer Disease



Peptic ulcers account for half of ma?or upper $astrointestinal %leedin$ 3ith an o4erall

mortalit1 rate of -"' Ho3e4er2 in North America the incidence of %leedin$ from ulcers is

declinin$2 perhaps due to eradication of H pylori and proph1la;is 3ith proton pump

inhi%itors in hi$h@ris patients'

2. Portal Hypertension

Portal h1pertension accounts for !/:./" of upper $astrointestinal %leedin$' Bleedin$

usuall1 arises from esopha$eal 4arices and less commonl1 $astric or duodenal 4arices or

portal h1pertensi4e $astropath1' Appro;imatel1 .(" of patients 3ith cirrhosis ha4e medium

to lar$e esopha$eal 4arices2 of 3hom &/" e;perience acute 4ariceal %leedin$ 3ithin a .@

1ear period

3. Mallory-eiss !ears

Lacerations of the $astroesopha$eal ?unction cause (:!/" of cases of upper $astrointestinal

%leedin$' Man1 patients report a histor1 of hea41 alcohol use or retchin$' Less than !/"

ha4e continued or recurrent %leedin$'

". #ascular Anomalies

7ascular anomalies are found throu$hout the $astrointestinal tract and ma1 %e the source of

chronic or acute $astrointestinal %leedin$' 0he1 account for 8" of cases of acute upper tract

%leedin$' 0he most common are angioectasias #an$iod1splasias, 3hich are !:!/ mm

distorted2 a%errant su%mucosal 4essels caused %1 chronic2 intermittent o%struction of

su%mucosal 4eins' 0he1 ha4e a %ri$ht red stellate appearance and occur throu$hout the

$astrointestinal tract %ut most commonl1 in the ri$ht colon' !elangiectasias are small2

cherr1 red lesions caused %1 dilation of 4enules that ma1 %e part of s1stemic conditions

#hereditar1 hemorrha$ic telan$iectasia2 CRES0 s1ndrome, or occur sporadicall1' 0he

Dieula$oy lesion is an a%errant2 lar$e@cali%er su%mucosal arter12 most commonl1 in the

pro;imal stomach that causes recurrent2 intermittent %leedin$'

%. Gastric &eoplasms

9astric neoplasms result in !" of upper $astrointestinal hemorrha$es'

'. (rosi)e Gastritis

Because this process is superficial2 it is a relati4el1 unusual cause of se4ere $astrointestinal

%leedin$ #< (" of cases, and more commonl1 results in chronic %lood loss' 9astric mucosal



erosions are due to NSAIDs2 alcohol2 or se4ere medical or sur$ical illness #stress@related

mucosal disease,'

*. (rosi)e (sophagitis

Se4ere erosi4e esopha$itis due to chronic $astroesopha$eal reflu; ma1 rarel1 cause

si$nificant upper $astrointestinal %leedin$2 especiall1 in patients 3ho are %ed %ound lon$@

term'

+. ,thers

An aortoenteric fistula complicates ." of a%dominal aortic$rafts or2 rarel12 can occur as the

initial presentation of a pre4iousl1 untreated aneur1sm' Usuall1 located %et3een the $raft or

aneur1sm and the third portion of the duodenum2 these fistulas characteristicall1 present

3ith a herald none;san$uinatin$ initial hemorrha$e2 3ith melena and hematemesis2 or 3ith

chronic intermittent %leedin$' 0he dia$nosis ma1 %e suspected %1 upper endoscop1 or

a%dominal C0' Sur$er1 is mandator1 to pre4ent e;san$uinatin$ hemorrha$e' Unusual causes

of upper $astrointestinal %leedin$ include hemo%ilia #from hepatic tumor2 an$ioma2

penetratin$ trauma,2 pancreatic mali$nanc12 and pseudoaneur1sm #hemosuccus

pancreaticus,'

nitial ()aluation !reatment

A. /ta0iliation

0he initial step is assessment of the hemod1namic status' As1stolic %lood pressure < !// mm H$

identifies a hi$h@ris patient 3ith se4ere acute %leedin$' A heart rate o4er !// %eats)min 3ith a

s1stolic %lood pressure o4er !// mm H$ si$nifies moderate acute %lood loss' A normal s1stolic

%lood pressure and heart rate su$$est relati4el1 minor hemorrha$e' Postural h1potension and

tach1cardia are useful 3hen present %ut ma1 %e due to causes other than %lood loss' Because the

hematocrit ma1 tae .:8. hours to e>uili%rate 3ith the e;tra4ascular fluid2 it is not a relia%le

indicator of the se4erit1 of acute %leedin$' In patients 3ith si$nificant %leedin$2 t3o !@$au$e or

lar$er intra4enous lines should %e started prior to further dia$nostic tests' Blood is sent for

complete %lood count2 prothrom%in time 3ith international normali5ed ratio #INR,2 serum

creatinine2 li4er en51mes2 and %lood t1pin$ and screenin$ #in anticipation of need for possi%le

transfusion,' In patients 3ithout hemod1namic compromise or o4ert acti4e %leedin$2 a$$ressi4e

fluid repletion can %e dela1ed until the e;tent of the %leedin$ is further clarified' Patients 3ith

e4idence of hemod1namic compromise are $i4en /'" saline or lactated Rin$er in?ection and



crossmatched for .: units of paced red %lood cells' It is rarel1 necessar1 to administer t1pe@

specific or @ne$ati4e %lood' Central 4enous pressure monitorin$ is desira%le in some cases2 %ut

line placement should not interfere 3ith rapid 4olume resuscitation' Placement of a naso$astric

tu%e is not routinel1 needed %ut ma1 %e helpful in the initial assessment and tria$e of selected

patients 3ith suspected acti4e upper tract %leedin$' 0he aspiration of red %lood or coffee

$rounds=confirms an upper $astrointestinal source of %leedin$2 thou$h up to !" of patients

3ith confirmed upper tract sources of %leedin$ ha4e non%lood1 aspiratesFespeciall1 3hen

%leedin$ ori$inates in the duodenum' An aspirate of %ri$ht red %lood indicates acti4e %leedin$

and is associated 3ith the hi$hest ris of further %leedin$ and complications2 3hile a clear

aspirate identifies patients at lo3er initial ris' Er1throm1cin #.(/ m$, administered

intra4enousl1 &/ minutes prior to upper endoscop1 promotes $astric empt1in$ and ma1 impro4e

the >ualit1 of endoscopic e4aluation 3hen su%stantial amounts of %lood or clot in the stomach is

suspected' Efforts to stop or slo3 %leedin$ %1 $astric la4a$e 3ith lar$e 4olumes of fluid are of no

%enefit and e;pose the patient to an increased ris of aspiration'

B. Blood eplacement

0he amount of fluid and %lood products re>uired is %ased on assessment of 4ital si$ns2 e4idence

of acti4e %leedin$ from naso$astric aspirate2 and la%orator1 tests' Sufficient paced red %lood

cells should %e $i4en to maintain a hemo$lo%in of 8: $)dL2 %ased on the patientGs hemod1namic

status2 comor%idities #especiall1 cardio4ascular disease,2 and presence of continued %leedin$' In

the a%sence of continued %leedin$2 the hemo$lo%in should rise appro;imatel1 ! $)dL for each

unit of transfused paced red cells' 0ransfusion of %lood should not %e 3ithheld from patients

3ith massi4e acti4e %leedin$ re$ardless of the hemo$lo%in 4alue' It is desira%le to transfuse

%lood in anticipation of the nadir hematocrit' In acti4el1 %leedin$ patients2 platelets are

transfused if the platelet count is under (/2///)mcL and considered if there is impaired platelet

function due to aspirin or clopido$rel use #re$ardless of the platelet count,' Uremic patients #3ho

also ha4e d1sfunctional platelets, 3ith acti4e

%leedin$ are $i4en three doses of desmopressin #DDA7P,2 /'& mc$)$ intra4enousl12 at !.@hour

inter4als' resh fro5en plasma is administered for acti4el1 %leedin$ patients 3ith a coa$ulopath1

and an INR !'J ho3e4er2 endoscop1 ma1 %e performed safel1 if the INR is < .'(' In the face



of massi4e %leedin$2 ! unit of fresh fro5en plasma should %e $i4en for each ( units of paced red

%lood cells transfused'

. nitial !riage

A preliminar1 assessment of ris %ased on se4eral clinical factors aids in the resuscitation as 3ell

as the rational tria$e of the patient' Clinical predictors of increased ris of re%leedin$ and death

include a$e -/ 1ears2 comor%id illnesses2 s1stolic %lood pressure < !// mm H$2 pulse !//

%eats)min2 and %ri$ht red %lood in the naso$astric aspirate or on rectal e;amination'

1. High ris45 Patients 3ith acti4e %leedin$ manifested %1 hematemesis or %ri$ht red

%lood on naso$astric aspirate2 shoc2 persistent hemod1namic deran$ement despite fluid

resuscitation2 serious comor%id medical illness2 or e4idence of ad4anced li4er disease re>uire

admission to an intensi4e care unit #ICU,' After ade>uate resuscitation2 endoscop1 should %e

performed 3ithin .:. hours in most patients %ut ma1 %e dela1ed in selected patients 3ith

serious comor%idities #e$2 acute coronar1 s1ndrome, 3ho do

not ha4e si$ns of continued %leedin$'

2. 6o7 to moderate ris45 All other patients are admitted to a step@do3n unit or medical

3ard after appropriate sta%ili5ation for further e4aluation and treatment' Patients 3ithout

e4idence of acti4e %leedin$ under$o nonemer$ent endoscop1 usuall1 3ithin . hours'

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Anemia Ec Perdarahan Saluran Cerna