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 DARAHHAEMATOCHEZIA :BAB WARNA MERAH TERANG GELAPOCCULT 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 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,

GERDStress 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

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 nitroglycerinIntravenous octreotideBalloon tamponade

ENDOSCOPIC THERAPYPeptic ulcer disease

Thermal coagulationMultipolar electrocoagulation,Heater probe,laser ther

Injection therapyEpinephrine, Alcohol

Combination therapy;thermal coagulatuion & injectionGastroesophgeal varices

Injection 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 GASTROINTSTINAL HEMORRHAGE

ACUTE MANAGEMENT Patient stabilization (ABCs)Respiratory stabilization (intubation etc)Intravenous accessIntravascular volume replacementTransfusions (PRC, FFP, PlateletsFocused history and physical examinationLaboratory dataCBC with platelet count, Coagulation studies (PT/aPTT)Liver enzymes, ChemistriesRadiographicUpright chest x-ray, Abdominal x-rayElectrocardiogramLocalization of bleeding siteSurgery consulationGastroenterology consultation for upper panendoscopy

LONG-TERM MANAGEMENTTreatment of recurrent bleedingRepeat diagnostic and therapeutic endoscopy Angiography, Surgery Preventive measures for peptic ulcer disease bleedingMaintenance antisecretory therapyHelicobakter pyloru eradicationStrict avoidance of ASA/NSAIDsMisoprostolSurgeryPreventive 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

DIFFERENTIAL DIAGNOSIS OF OCCULT GASTROINTESTINAL BLEEDING

MASS LESIONS VASCULARCarcinoma (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

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

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

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

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, 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

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