Dr.LEONARDO DAIRY, SpPD – KGEH INTRODUCTION PSCBA (UGI BLEEDING) PSCBB (LGI BLEEDING) OCCULT BLEEDING OBSCURE BLEEDING Gastrointestinal (GI) bleeding is an extremely common clinical problem • resulting in significant morbidity, mortality, and cost. There are over 300,000 hospitalizations annually in the United States for GI bleeding, accounting for 1–2% of all hospital admissions. • A conservative estimate of the overall annual cost of hospital admissions for GI bleeding is $900 million, but the true overall cost, including outpatient endoscopic and radiologic investigations, clinic visits, and work days lost, far exceeds. gastric.duodenal ulcers and gastritis) is the most common cause of upper GI bleeding. This increase cannot be explained by demographics alone. Acid peptic disease (e. and Mallory-Weiss tears in prevalence.g. . gastric and duodenal erosive disease.Upper GI bleeding (UGI) • Incidence of UGI is approximately 100 cases per 100. as the proportion of elderly patients who present with upper GI bleeding has steadily increased. • The elderly appear to be at particular risk. accounting for 50–75% of all cases). .. the predominance of peptic ulcer bleeding has not been affected by the advent of improved acid suppression with medical therapy. Acid peptic disease is followed by variceal bleeding. with persons older than age 60 years accounting for 35–45% of all cases. as increasing age directly correlates with an increased rate of hospitalization for upper gi bleeding. Furthermore.000 population. but it represents only 2–9% of admissions for lower GI bleeding. infectious causes. radiation proctitis. postpolypectomy. maroon stools. and endometriosis . angiodysplasia was the most common diagnosis. accounting for 30%. The rate of hospitalization for LGI bleeding increases more than 200-fold from the third to the ninth decades.g.Lower GI bleeding less common. intussusception. diverticulosis is the most common cause of acute LGI bleeding. colonic varices. iatragenic causes (e. IBDi. or melena. less common etiologies include colorectal neoplasia. around 20–27 per 100. . 80% of patients with GI bleeding pass heme per rectum as bright red blood. The incidence of LGI bleeding is higher in men and elderly . diverticulosis. and so on).Hemorrhoidal bleeding is probably the most prevalent cause of acute GI bleeding in the ambulatory setting. accounting for 42–55% of cases.000 . in one large series of patients with severe. accounting for up to 76% of cases. In most studies. only 24% of all GI bleeding is from a lower GI source. and neoplasia in the elderly. persistent hematochezia. colonic ischemia. Other. angiodysplasia. solitary rectal ulcer syndrome.. However. endoscope trauma. probably because of an increased incidence of the most common etiologies. . Definition • Bleeding derived from any source proximal to the Ligament of Treitz 1 in 1000 in us who experienced upper GI bleeding Men :women 2 : 1 Mortality rate 10% . KEGAWAT-DARURATAN INSIDENS 50 – 100/100. 20. PSCBA PERDARAHAN SEPANJANG SAL.36%. DARI LIG. CERNA PROK. 33% (UK) 80% BERHENTI SPONTAN PERDARAHAN SALURAN CERNA ATAS PERDARAHAN SALURAN CERNA ATAS VARISES PERDARAHAN SALURAN CERNA ATAS NON VARISES .000 PDDK (USA).000 KEMATIAN/TAHUN TINGKAT MORTALITAS 10% .TREITZ. 93:837–53. Angka morbiditas dan mortalitas juga sangat dipengaruhi oleh bagaimana optimalnya tatalaksana kasus dalam 24-48 jam pertama di sarana pelayanan kesehatan. Chopra KB. . 2009. Sebuah studi meta analisis terapi endoskopi pada PSCBA secara bermakna mengurangi frekuensi perdarahan lanjut. Med Clin N Am. pembedahan dan mortalitas. Sass AD. Portal hypertension and variceal hemorrhage. Hemobilia Pancreatic sources Crohns disease No lesion identified Less Frequent Causes Dieulafoys lesion Vascular ectasia Portal hypertensive gastropathy Gastric antral vascular ectasia Gastric varices Neoplasia Esophagitis Gastric erotions . Duodenal ulcer Esophageal varices Mallory-Weiss tear Rare RareCauses causes Esophageal ulcer.CAUSE OF GI BLEEDING Common causes Gastric ulcer. Erosive duodenitis Aortoenteric fistula. . Gastroenterol Clin N Am. Gastrointestinal bleeding. 2005.o AINS Aspirin Gastric Acid Helicobacter pylori Anti-koagulan Anti-trombotik Merokok Alkohol Penyakit hati kronik Rockey DC. .34:581–8. NAMUN BENZIDINE TEST (+) .CLINICAL PRESENTATION 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. DIAGNOSTIK 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 ? . . ada tidaknya manifestasi gangguan hemodinamik.GAMBARAN KLINIK Hematemesis + Melena PSCBA esofagus & gaster Melena PSCBA duodenum Berat ringannya perdarahan dinilai dari : manifestasi klinik yang ada derajat turunnya kadar hemoglobin. ekimosis. Upper & Lower Abdominal Scanning 4. MDF double contras.2. Ba. Swallow. ptikiae 3. RADIOLOGI Ba. Kolon in loop. PEMERIKSAAN FISIK : Penilaian status hemodinamik & resusitasi Jaundice & Tanda2 liver stigmata & HT portal Bleeding diathesis : purpura. ENDOSKOPI Gastroduodenoskopi Sigmoidoskopi Colonoskopi Push Enteroskopi Capsule Endoscopy . Follow Through. Historical Features Important in Assesing the Etiology of Gastrointestinal Bleeding Age Prior Bleeding Previous gastrointestinal disease Previous surgery Underlying medical disorder (especialy liver disease) Nonsteroidal anti-inflammatory drugs/aspirin Abdominal pain Change in bowel habits Weight loss/anorexia History of oropharyngeal disease . 34:581–8. 2005. .Diagnosis • Pemeriksaan fisik – Tanda vital syok? – Stigmata penyakit hati kronik • • • • • Ikterus Hepatomegali Asites Spider angioma Palmar erythema • Pemeriksaan laboratorium – DPL – Prothrombin time – INR – Fungsi hati Rockey DC. Gastrointestinal bleeding. Gastroenterol Clin N Am. INITIAL PATIENT ASSESMENT hemodynamics Blood loss (%) Severity of bleed (vital signs) (fraction of intravascularvolume) Shock (Resting hypotension) Postural(Orthostatictac hycardia/hypotension) 20-25 Massive 10-20 Moderate Normal <10 Minor . Table : Hemorrhagic Classes HEMORRHAGIC I CLASS 15% OR BLOOD LOSS 750 ML II 20-25% OR III 30-35% OR IV 40-50% OR 2000-2500 ML 1000-1250 ML 1500-1800ML HEART RATE RESPIRATORY RATE ARTERIAL PRESSURE CAPILLARY FILLING TIME DIURESIS (ML/H) NEUROLOGIC STATUS <100 14-19 >100 20-29 >120 30-40 70-60 >140 >40 <60 NORMAL 110-80 NORMAL INCREASED INCREASED INCREASED 35-30 30-25 25-5 CONFUSED 0 LETHARGIC MILDLY VERY ANXIOUS ANXIOUS . 2007. 18th ed. .Aspirasi nasogastrik Membedakan perdarahan saluran cerna atas dan bawah Sensitivitas 79%. spesifisitas 55% Modalitas diagnostik dan terapeutik Townsend: Sabiston Textbook of Surgery. Gastrointestinal bleeding. Gastroenterol Clin N Am.Diagnosis • Esofagogastroduodenoskopi (EGD) – Modalitas utama – Menentukan lokasi & penyebab perdarahan saluran cerna atas: 90% . 2005. .95% Rockey DC.34:581–8. KLASSIFIKASI FORREST PSCBA Forrest class Ia Ib II a II b II c Type of lesion Arterial Spurting Arterial Oozing Visible Vessel Sentinel Clot Haematin covered flat spot Risk of rebleed if untreated (%) 100 17-100 8-81 14-36 0-13 III No Stigmata 0-10 .Tabel 2. MANAGEMENT RESUSCITATION VASCULAR ACCESS INTRAVENOUS FLUIDS BLOOD TESTS TYPING & CROSS MATCHING CORRECT COAGULOPATHY BLOOD TRANSFUSION . visible or spurting vessel Major stigmata of recent bleeding (SRH) None .Rockall scoring system for risk of rebleeding and death Variable 0 point Age (yrs) Shock <60 Systolic BP>100 Pulse <100 None 1 point 60-79 Systolic BP>100 Pulse>100 2 points >80 Systolic BP<100 Pulse>100 Cardiac failure Coronary heart disease Other major co morbidity 3 points Comorbidity Renal failure Hepatic Failure Metastatic cancer Diagnosis MW tear No lesions All other diagnoses Malignancy of upper GI tract Fresh blood Ulcer with adherent clot. Rockall Score Clinical Implication Rockall score ranges 0-11 A total score<3 is associated with an excellent prognosis rebleeding <5% mortality <1% A score>8 is associated with a poor prognosis rebleeding >50% mortality >30% reeburg EM. Tarwee CB. Gut 1999.44:331-5 . Suel P. et al. Usaha menghentikan perdarahan secara umum (stop gap treatment) 4. Mengatasi sumber perdarahan secara defenitif 6. Minimalisasi komplikasi yang dapat terjadi 7. Penilaian hemodinamik disertai resusitasi cairan dan stabilisasi hemodinamik 2. Upaya pencegahan terjadinya perdarahan ulang dalam jangka pendek maupun jangka panjang. . Usaha identifikasi lokasi sumber perdarahan dengan modalitas sarana penunjang yang tersedia 5.PENATALAKSANAAN Prinsip Umum : 1. Penilaian onset dan derajat perdarahan 3. tanda vital. sitoprotektor. obat hemostatik (tranexamic acid. PENATALAKSAAN MEDIK 1. infus cairan parenteral/nutrisi. . transfusi darah dan lain-lain. Penatalaksanaan farmakologis : ARH2 atau PPI. Penatalaksanaan non-farmakologis : memperbaiki keadaan umum. antibiotika. A. adona AC dan somatostatin).PENATALAKSANAAN Penatalaksanaan Penatalaksanaan pada PSCBA terbagi atas penatalaksanaan medik dan penatalaksanaan bedah. 2. Kuipers EJ. Bolus 80 mg IV dilanjutkan dengan infus 8 mg/jam selama 72 jam Menurunkan angka kejadian perdarahan berulang Menurunkan mortalitas Barkun AN. et al. 2010. Mempertahankan pH lambung > 6 Proses koagulasi Agregasi trombosit Pembentukan fibrin Dosis. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. . Ann Intern Med. Hunt RH. Badou M. Sung J.152:101-13. et al. Gastrointest Endosc 2009.70:433- .Seven-day intravenous low-dose omeprazole infusion reduces peptic ulcer rebleeding for patients with comorbidities Ceng H. 3. PENATALAKSANAAN KHUSUS TOPICAL THERAPY -Tissue adhesives -Clotting factors -Collagen -Ferromagnetic tamponade MECHANICAL THERAPY -Snares -Sutures -Balloons -Hemoclips INJECTION THERAPY -Variceal bleeding -Non variceal bleeding .monopoloar .Ethanol .electrohydrothermal bipolar (multipolar) -Heater probe -Laser .Other sclerosants THERMAL THERAPY -Electrocoagulation . polidocanol. • Pada perdarahan saluran cerna atas akibat nonvarises. dan etanolamin. . • Penggunaan sklerosan lebih terbatas karena dapat mengakibatkan ulkus atau striktur iatrogenik.• Injeksi sklerosan seperti etanol. dapat menyebabkan trombosis pembuluh darah sehingga tercapai hemostasis. efektivitas sklerosan sama dengan adrenalin dalam mencapai hemostasis dan mencegah rekurensi. Pemanasan dengan teknik non-kontak menggunakan laser (neodymium:yttrium-aluminum-garnet) atau argon plasma coagulation. Pemanasan menimbulkan penekanan pada arteri sehingga perdarahan berhenti. Teknik pemanasan menggunakan laser kini jarang digunakan.9% kasus dengan rekurensi pada 5. . Hemostasis pada pemanasan dengan argon tercapai pada 75.7% kasus. Teknik pemanasan dibagi atas non-kontak dan kontak. Kombinasi heater probe thermocoagulation dan injeksi adrenalin dapat mencapai hemostasis pada 98.2%. . Kombinasi elektrokoagulasi bipolar dan injeksi adrenalin dapat menurunkan risiko terjadinya rekurensi. Pemanasan dengan teknik kontak menggunakan elektrokoagulasi bipolar dan heater probe thermocoagulation.6% kasus dengan angka rekurensi sebesar 8. Penggunaan clip dapat mencapai hemostasis pada 100% kasus perdarahan saluran cerna atas dengan rekurensi yang lebih rendah dibandingkan injeksi adrenalin. . clip. dan rubber band ligation merupakan alat yang digunakan untuk menghentikan perdarahan secara mekanik. Endoloop. et al. Gastrointest Endosc.Kombinasi penggunaan hemoclips dan endoloops Perdarahan berhenti Racz I. 2009. . Endoscopic hemostasis of bleeding gastric ulcer with a combination of multiple hemoclips and endoloops. . 68:339-51 .Endoscopic clipping for acute nonvariceal upper-GI bleeding: a meta-analysis and critical appraisal of randomized controlled trials Yuan Y. Gastrointest Endosc 2008. et al. et al. Gastrointest Endosc 2006.Lo C.63Comparison of hemostatic efficacy for epinephrine injection alone and injection combined with hemoclip therapy in treating high-risk bleeding ulcers:767-73 . PENATALAKSAAN BEDAH.Penatalaksanaan B. .OPERASI dilakukan bila perdarahan tetap berlangsung atau sudah masuk dalam keadaan gawat I s/d II maka merupakan indikasi operasi. Varices Esofagus • Ligasi banding • Skeleroterapi • Varices Gaster Injeksi argon plasma . Toubia N. Sanyal AJ. Portal Hypertension and Variceal Hemorrhage. Med Clin N Am 92 (2008) 551–574 . Treatment of Acute Variceal Bleeding. Moller S.•Bendtsen F. Digestive and Liver Disease 40 ( 2008 ) 328-336 . Krag A. TERAPI FARMAKOLOGI 1. TERLIPRESSIN menurunkan tekanan portal sekitar 20 % setelah single dose Dosis 2 mg/4 jam selama 48 jam pertama Dapat dilanjutkan sampai 5 hari dengan dosis yang lebih rendah yaitu 1 mg/4 jam atau 12-24 jam setelah perdarahan berkurang 2. REKOMBINAN faktor VIIa .10 Ocreotide 50 μg diikuti oleh infus 25-50 μg/jam Menurunkan angka rebleeding 3. Diawali dengan 250 μg bolus diikuti oleh infus 250 μg/jam yang dapat dipertahankan sampai 24 jam bebas perdarahan. SOMATOSTATIN DAN ANALOG Somatostatin Mengurangi tekanan portal sekitar 17 % tanpa mempengaruhi hemodinamik sistemik. EST ( Endoskopi Skleroterapi ) 2. EVL ( Endoskopi Variceal Ligation) TIPS ( Transjugular Intrahepatic Portosystemic Shunts ) BALOON TAMPONADE .MANAJEMEN NON FARMAKOLOGI ENDOSKOPI 1. Endoscopic Sclerotherapy Endoscopic Band Ligation . ENDOSCOPIC VARICEAL LIGATION ( EVL) Endoscopy shows two varices in the distal esophagus that have been banded. . The two strings in the right of the field control the trigger device used to deploy the bands. The bands are indicated with the green arrows. BALOON TAMPONADE Linton tube dan Sengstaken-Blakemore Tube . Algorithm for cirrhosis Without Bleeding Algorithm For Cirrhosis Without Bleeding Cirrhosis Established Upper Endoscopy No varices Small or Medium Varices Large Varices (2 – 3 years Evaluation) Observe (1 – 2 years Evaluation) Observe Primary Bleeding Prophylaxis Reguler Interval Usually one week Non Selectne Blockers (and /or Nitrates) Ligation . Algorithm For Bleeding Cirrhotis Resuscitae Begin Octreotide (or Vasopressin) Early endoscopy Esophagel Non-Portal Gastric Varices Portal Varices Hypertensive Cause Hypertensive Gastropathy Treat appropriately Algorithm For Bleeding Cirrhotis Continue octreotide 5 days Begin beta-blocker when stable Band ligation or injection Sclerotheraphy Ballon Tamponade Rebleeding No rebleeding Continue treatment Shunt (Child A) Preventation of Rebleeding TiPSS. or • Pharmacological Treatment Liver transplantation (Child B or C) • Ligation /Sclerotheraphy Reguler Interval Usually one week Eradication Repeated Endoscopy 3 – 6 month Rebleeding Shunt (Child A) TIPSS Or OLT (Child B or C) . multiple co-morbidities .Peptic ulcer hemorrhage • Surgical intervention – Only 10% of patients – Indications – – – – – Failure of endoscopy Significant rebleeding after 1st endoscopy Ongoing transfusion requirement Need for >6 units over 24 hours Earlier for elderly. . Ulcus Pepticum Bleeding . Peptic ulcer hemorrhage • Gastric ulcer – 10% are maliganant – 30% will rebleed with simple ligation • Need Resection » Distal gastrectomy with Bilroth I or II » Subtotal gastrectomy for 10% high on lesser curve . parietal cell vagotomy » If unstable can use meds . ligation of gastroduodenal artery – Anti-secretory procedure » Truncal. four quadrent ligation.Peptic ulcer hemorrhage • Doudenal ulcer – Expose ulcer with duodenotomy or duodenopyloromyotomy – Direct suture ligation. . perdarahan berhenti Perdarahan berhenti Elective endoscopy Varises esofagus EVL. tidak ada perdarahan aktif Terapi Empirik Hemodinamik tidak stabil. ES. NGT Periksa DPL. perdarahan aktif Resusitasi Kristaloid. perdarahan tidak berhenti Obat vasoaktif Ocreotide. somatostatin.Tatalaksana Perdarahan Saluran Cerna Atas Rumah Sakit Tipe A dan B Anamnesis Pemeriksaan tanda vital Pasang IV line. SB tube Hemodinamik tidak stabil. koloid Transfusi darah Koreksi faktor koagulasi Hemodinamik stabil. hemostasis Hemodinamik stabil. vasopressin Emergency endoscopy Ulku s Injeksi hemostasis Bleeding site non-visualized Interventional diagnostic & therapeutic radiology Terapi definitif Bedah Konsensus Nasional Perkumpulan Gastroenterologi Indonesia 2007 . Tatalaksana Perdarahan Saluran Cerna Atas Rumah Sakit Tipe C Anamnesis Pemeriksaan tanda vital Pasang IV line, NGT Periksa DPL, hemostasis Hemodinamik stabil, tidak ada perdarahan aktif Terapi Empirik Hemodinamik tidak stabil, perdarahan aktif Resusitasi Kristaloid; koloid Transfusi darah Koreksi faktor koagulasi Hemodinamik stabil, perdarahan berhenti Perdarahan berhenti Foto abdomen dg kontras Ba atau Rujuk untuk Endoskopi Perdarahan tidak berhenti Perdarahan berhenti Balloon tamponade SB tube Bedah Hemodinamik tidak stabil, perdarahan tidak berhenti Obat vasoaktif Ocreotide, somatostatin, vasopressin Perdarahan tidak berhenti Terapi definitif Konsensus Nasional Perkumpulan Gastroenterologi Indonesia 2007 Summary of consensus Recommendation Management patients with non variceal UGI Bleeding a. Resusitasi, risk assesment, and pre endoscopic management 1. Immediately evaluate and initiate appropriate resusitation. 2. Prognostic scales 3. Consider placement of NGT 4. Blood transfution 5. Correction of coagulopathy 6. Promotility agents should not be used 7. Preendoscopic PPI therapy b. Endoscopic management 1. Early endoscopy 2. Endoscopic therapeutic not indicated with low risk stigmata 3. Endoscopic therapy for ulcer with cloth is kontroversial. 4. Endoscopic therapy with high risk stigmata 5. Epinephrine injection sub optimal 6. No single endoscopic thermal is superior 7. Clips thermocoagulation or sclerosan injection alone or combination 8. Endoscopic therapy recommended in rebleeding c. Pharmacologic management 1. H2 RA are not recommended 2. Somatostatin and ocretide are not routine recommended 3. IV bolus followed continuous infusion should be use to the decrease rebleeding and mortality. d. Non endoscopic and non pharmacologic in hospital management 1. Patients with endoscopic therapy should be hospitalized at least 72 hours 2. Surgical consultation if endoscopic therapy failed 3. Percutaneus embolisation can be consider 4. Peptic ulcer bleeding with HP (+) be should eradication therapy 5. HP (-) diagnostic test should be repeat e. Postdischarge, ASA, and NSAID 1. Previous PUB with NSAID, combination PPI and Cox-2 is recommended 2. Previous PUB with NSAID, NSAID plus PPI or cox-2 alone 3. PUB with low dose ASA, ASA therapy ??? 4. Previous PUB who require cardiovascular prophylaxis, clopidogrel alone higher risk than ASA with PPI . LGI hemorrhage • Sites • Colon – 95-97% • Small bowel – 3-5% • Only 15% of massive GI bleeding • Finding the site • Intermittent bleeding common • Up to 42% have multiple sites . Colonic angiodysplasia Bleeding diverticulosis . LGI hemorrhage diagnostics • Colonoscopy • Within 12 hours in stable patients without large amounts of bleeding • Selective viseral angiography • Need >0.5 ml/min bleeding • 40-75% sensitive if bleeding at time of exam • Tagged RBC scan • Can detect bleeding at 0.1 ml/min • 85% sensitive if bleeding at time of exam • Not accurate in defining left vs right colon . Meckel’s Diverticulum Cecal angiodysplasia with extravasation Small bowel ulceration due to NSAIDS . . LGI hemorrhage treatment • Endoscopy – Great for angiodysplasia and polypectomy sites • Angiographic – Selective embolization for poor surgical candidates • Surgery – Ongoing hemorrhage >6 units or ongoing transfusion requirement . 1986). the higher the mortality rate (Larson.• Hemodynamic instability despite vigorous resuscitation (>6 units transfusion) • Failure of endoscopic techniques to arrest hemorrhage • Recurrent hemorrhage after initial stabilization (with up to two attempts at obtaining endoscopic hemostasis) • Shock associated with recurrent hemorrhage • Continued slow bleeding with a transfusion requirement exceeding 3 units/day One of the criteria used to determine the need for surgical intervention is the number of units of transfused blood required to resuscitate the patient. as noted in the following table (Larson. Number of Units Need for Mortality Transfused Surgery. Operative intervention is indicated once the blood transfusion number reaches more than 5 units. % 0 1-3 4-5 >5 4 6 17 57 4 14 28 43 . The more units required. % Rate. 1986).