Dr. Mabel HM Sihombing, SpPD-KGEH

Dr.Ilhamd SpPDDIVISION 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 >>)

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

HASIL :GAMBARAN PASIEN PSMBA 2 KURUN

WAKTU (MABEL DKK)

1993-1996 1997-2000Usia 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

PROPORSI PSMBA BERDASAR JENIS KELAMIN DAN USIA TAHUN 2009-2010 (2 THN) (Ilhamd dkk)

USIA LAKI-LAKI WANITA

< 16 2

16-20 16 9

21-30 30 19

31-40 48 19

41-50 52 35

51-60 56 25

>60 58 41

JUMLAH 262 148

HASILPENYEBAB PERDARAHAN (MABEL ,Medan DKK)

1993-1996 1997-2000Varises 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

HASIL GASTROSKOPI BERDASAR JENIS KELAMIN TAHUN 2009-2010 (2 TAHUN)

(Ilhamd dkk)HASIL GASTROSKOPI LAKI-LAKI WANITA

VARISES ESOFAGUS 69 31 100ULKUS GASTER 52 26 78ULKUS DUODENI 34 18 52GASTRITIS EROSIVA 60 36 96CA GASTER 8 8KELAINAN ESOPAGUS NON CA 20 16 36POLIP GASTER 2 2CA ESOFAGUS 4 4 VARISES FUNDUS 2 2 4EGD NORMAL 24 52 76ADA 22 ORANG DENGAN >1 JENIS HASIL GASTROSKOPI

Etiologi PSMBA

1.PENYEBAB PSMBA DITINJAU DARI LOKASI2.PENYEBAB PSMBA DITINJAU DARI BENTUK KELAINAN3.PENYEBAB PSMBA DITINJAU DARI JENIS PENYAKIT

ETIOLOGI PSMBA

PENYEBAB PSMBA DITINJAU DARI LOKASIESOFAGUS OESOPHAGEAL VARICES MALLORY – WEISS TEAR OESOPHAGEAL CARCINOMA REFLUX OESOPHAGITIS FOREIGN BODYLAMBUNG 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, GERD

Stress UlcerInfection causes

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

Aspirin, NSAIDs, Pil-induced ulcerAnticoagulation therapy

TRAUMA Mallory-Weiss Tear, Foreign body ingestionVASCULAR LESIONS Varices, Angiomas, Osler-WR

syndrome,Dieulafo’y lesionportal hypertensive gastropathyAortoenteric fistula, radiotion induced telengiectasia

TUMORS BenignLeiomyoma, Lipoma,Polyp, Blue rubber

syndrome Malignant

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

Hemofilia, Hemosuccus pancreaticus

CAUSES OF ACUTE UPPER GASTROINTESTINAL BLEEDING BERDASARKAN BENTUK KELAINAN

PENYEBAB TERBANYAK PSMBA DITINJAU DARI PENYAKITCOMMON ESOPHAGEAL VARICES ESOPHAGOGASTRIC MUCOSAL TEAR

(MALLORY-WEISS SYNDROME) GASTRIC EROSIONS,ULCER,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 RUPTURE (BOERHAAVE’S SYNDROMA) HEMOFILIA

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

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

KLASIFIKASI AKTIFITAS PERDARAHAN MENURUT FORREST

Forrest ISpurting bleeding

Forrest III

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 >140RESPIRATORY 14-19 20-29 30-40 >40RATEARTERIAL NORMAL 110-80 70-60 <60PRESSURECAPILLARY NORMAL INCREASED INCREASED INCREASED FILLING TIMEDIURESIS (ML/H) 35-30 30-25 25-5 0NEUROLOGIC MILDLY VERY CONFUSED LETHARGICSTATUS ANXIOUS ANXIOUS

HEMORRHAGIC CLASSES

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 ?

ULKUS PEPTIKUM ? 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

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

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

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

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

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

NO LOCALIZATIO

NLOCALIZATIO

N OF BLEEDING

SITE

IN CASE OF RELEVANT BLEEDING

NO LOCALIZATIO

N

HISTORY

TOPICAL THERAPY-Tissue adhesives-Clotting factors-BILAS EPINEFRIN

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 PROCEDURES 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 diseaseThermal coagulation

Multipolar electrocoagulation,Heater probe,laser therInjection therapy

Epinephrine, AlcoholCombination therapy;thermal coagulatuion & injection

Gastroesophgeal varicesInjection 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

• 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 awalORDER

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 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

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

VARISES BLEEDING PROFILAKSIS BETABLOKER (PROPANOLOL)

TERAPEUTIK : SOMATOSTATIN

MEDICAMENT :

SB TUBE

ENDOSKOPIERADIKASI

TIPSS

SKLEROTERAPI

BINDING LIGASI

ULKUS BLEEDING1. MEDIKAMEN : ARH2, PPI, Antasida2. 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

VariableScore

0 1 2 3

Age (yr)Shock

Comorbidity

Diagnosis

Major SRH

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

Mallory weissNo lesion,no SRHNone or dark spot

60-79Tachycardia (BP>100,PP>100

All other diagnosis

>80Hypotension(BP<100 PP>100,

CHF,CAD,Others

Malignancy ofGI tract

Blood in UGIClot,visible or spurting vessels

Renalfailure,Liverfailure,diss.malignancy

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

Rockall scoring system U REBLEEDING DAN KEMATIAN OK PSMBA

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 536%

• Skor 662%

• Skor 7 75%