Penatalaksanaan Perdarahan Saluran Cerna Bagian AtasRino A Gani

Departemen Ilmu Penyakit DalamFakultas Kedokteran Universitas IndonesiaRSUPN Cipto Mangunkusumo

Perdarahan Saluran Cerna Bagian AtasMerupakan salah satu kasus emergensiDefinisi : Perdarahan yang terjadi proximal dari ligamentum Treitz sehinga berwarna hitam Cairan hematin (asam chlorida dengan hemoglobin)Hematemesis = muntah cairan hitam Melena = BAB berwarna hitam, cair

Penyebab Paling sering :Pecah varises esofagusGastritis erosifPerdarahan tukak peptikPecah varises gasterJarang :Tumor ganas saluran cernaGangguan pembuluh darah (AVM) dll

Penatalaksanaan Tata Laksana Umum :Nilai tanda-tanda vitalABCPasang jalur intravena besarTata Laksana Khusus :Cari kemungkinan etiologi Tata laksana sesuai etiologi

Penatalaksanaan Perdarahan Varises pada Saluran Cerna Atas

Hipertensi Portal

Peningkatan pada tekanan di sistem porta

Hepatic vein pressure gradient > 12 mmHg.

Peningkatan tekanan intravariseal, porta dan intra-limpa

Fibrous septaRegenerative nodulesIncreased Intra Hepatic Vascular Resistance (IHVR) to portal flow Portal hypertensionDisruption architectureof microcirculation Increased porto-collateralresistanceContraction ofmyofibroblastsSplanchnicvasodilatation Increased portalflowAlcohol, HBV, HCV, autoinmmune, metabolic, Wilsons diseasePathophysiology of Cirrhotic Portal Hypertension.Increased vascular tone REVERSIBLE

Varises Esofagus dengan Red Color Sign

Child-Pugh Class A Varises Kecil Varices Besar Child-Pugh Class B+CVarices Kecil Varices Besar 1 tahun: 5% 1 tahun: 13%

6 tahun :19% 6 tahun : 44%PerdarahanPertama 1 tahun : 16% 1 tahun : 26%

6 tahun : 19% 6 tahun : 66%11% 1 tahun : 22% 2 tahun : 31% B:15% C:50% 1 tahun : 43% 2 tahun : 62%KematianDalam 42 hariPerdarahan UlangINSIDEN dan OUTCOME PERDARAHAN VARISES

Perdarahan Varises Esofagus

Perdahan Aktif Varises Eofagus

Penatalaksanaa Perdarahan Varises Emergensi, Transfusi (50%), Tim, Diagnostik SCBAPenekanan Varises Sengstaken Black More Tube (S-B tube)Obat-obat :Vasopressin / dengan nitroglycerinGlypressin, F- 180SomatostatinOctreotide, Vapreotide, LanreotideEndoskopiLigasi, SclerotherapyHistoacrylPerbaikan HemostasisTIPS / 0LT, Antibiotik, Lactulose

ENDOSCOPIC VARICEAL LIGATION (EVL)

Injeksi Histoacryl pada Varises Gaster

Acute Variceal Bleed : Sclero Vs. BandPatients4143Active bleed1718Control16 (94%)17 (94%)Eradication4042Sessions4.8+0.92.8+0.5*Complications65%2.3%Rebleed14.6%16.2%Recurrence19.5%20.9%ScleroBandFakhry et al. Hepatology 1997;26:137 A , Sarin et al. J Hepatol 1997Shiha et al. Hepatology 1997; 26:136 A (nearly similar results)AA vs. Eth 90% succes GI Endo 2000;51:573

Drugs Vs. Endoscopy In Preventing Rebleeding (Bosch J, Lancet 2003)

Profilaksis Primer Varises EsofagusEVL vs. Control Sarin et al Eur. J. Gastro. Hepatol. 1996EVL vs. Beta-Blocker Sarin et al. New Engl J Med 1999Proportion of Patients Free of Bleeding Follow up in months

Tatalaksana Perdarahan Varises Akut : Efikasi selama 5 hari

Terapi Medikamentosa 65-75 %

EVL 70 %

Obat + Endoskopi* 80 %* Recommended approach, Baveno III Consensus Conference

Beta-Blocker Sebagai Profilaksis PrimerPerdarahanKematian Merkel Hepatology 2000

Primary prophylaxis BB Vs. BB+ISMOFree of first bleed: All variceal size025507510012Prop +PlaProp + Is-MNNSPatients at risk 174115 30 Prop + Pla 175118 41 Prop + Is MN

Years(Garicia et al. Hepatology 2003)565 pt, 105 contraindications 28 intolerable

Kegagalan Terapi Endoskopi Obat pada Perdarahan Varises AkutPilihanTIPS OperasiInsiden : 20%Transplantasi Hati

Penatalaksanaan Perdarahan Saluran Cerna Atas Non-Varises

The rationale for the use of acid reducing medication in upper GI bleedingIn vitro studies showed:

Platelet aggregation was inhibited by acid

2. Pepsin activity was highly acid sensitive with a maximal clot lysis at a pH of 2 but limited effect at pH above 5.

3. A gastric pH above 6 is thought to be critical for platelet aggregation.

Green JR FW et al.Gastroenterology 1978

Risiko perdarahan ulang menurut stigmata endoskopikPenemuan Incidens Perdarahan Operasi MortalitasEndoskopik ulang (%) (%) (%) (%)

Clean base 62 5 0.5 2

Flat spot 11 10 6 5

Adherent clot 8 22 10 7

Non-bleeding 11 43 34 11 Visible vessel

Active bleeding 7 55 35 11 Laine L.et.al. N Engl J Med 1994

Dosis tinggi infus PPI* ( omeprazole ) sebelum endoskopi pada perdarahan saluran cerna bagian atas. PPI Plasebo p N= 319 N= 319

Keperluan Th/ endoskopi 19.1% 28.4% 0.007

Rerata jumlah transfusi drh 1.54 units 1.88 units 0.12

Perdarahan ulang 11 psn 8 psn 0.49

Operasi darurat 3 4 1.00

Perdarahan aktif pd endoskopi 12 29 0.01

Ulkus dengan dasar bersih 120 90 0.001

Lau JY et.all .N Engl J of Med 2007* Bolus 80 mg + 8 mg/hour

PPI ( Esomeprazole ) infusion prior to endoscopic procedure in GI bleeding During the last 6 months 7 patients with upper GI bleeding admitted to hospital was treated with PPI (esomeprazole ) infusion with the dose of 7mg/hour.

Endoscopy was performed on the next day. Endoscopic therapy such as adrenalin injection, heat probe or hemoclips was done when bleeding was still going on or the presence of visible vessel.

Esomeprazole infusion was continued up to 3-5 days after endoscopic therapy and then followed with esomeprazole 2 x 40 mg for 2-3 days and maintained with oral 20 mg daily.

Diagnosis endoskopi dan pengobatan Ulkus gaster Ulkus duodenum

Diagnosis 3 4Clean base 3 3On going bleeding - 1Visible vessel 4 2

Th/ Endoskopik :Injection 1 -Hemoclips 2 4

Ulkus ventrikuli dengan visible vessel

Ulkus duodeni dengan perforasi

PPi Infusion for Ulcer BleedingPPI infusion may postpone endoscopic therapy in upper GI bleeding.

In most center where endoscopy is not available high dose PPI ( esomeprazole ) infusion may be considered in upper GI bleeding.

Tindakan EndoskopiInjeksi adrenalinHemoclipHeat probeCoagulasi dengan snareArgon Plasma Coagulation

SimpulanPenanganan perdarahan saluran cerna bagian atas harus dilakukan secara emergensiPeran dokter primer sangat penting baik dalam profilaksis, identifikasi awal, penanganan awal maupun dalam terapi lanjutanKombinasi endoskopi dan medikamentosa sangat diperlukan

Terima KasihBangka, 2008

The advantage of prophylactic antibioticin cirrhotics with GI bleedingA significant decrease in incidence of infection ( 45% in controls vs. 14% in antibiotic treated ), including SBP ( 27% vs. 8% )

A significant improvement in survival ( 24 % in controls vs. 15% in treated patients )

G.G. Tsao, 2003