OPTIMIZING MANAGEMENT

DYSPEPSIA AND COMPLICATION OF

UPPER GASTROINTESTINAL
BLEDDING IN PRIMARY CARE AND
HOSPITAL

ABDUL RAHMAN
OVERVIEW

• Dyspepsia affects 20 -40 % of adults

annually
• 7-40% prevalence based on population
studies
• Quality of life impaired: more absent
work days
• Symptoms often short duration and self
limited, but may be chronic
ENDOSCOPY FINDINGS
• 15 % duodenal or gastric ulcer
• 15% oesophagitis → GERD
• 30% Gastritis or duodenitis or
hiatus hernia
• 30% normal = Functional
dyspepsia
 DEFINITION
Dyspepsia is a collective term for any symptoms
thought to originate from the upper gastrointestinal
tract
Epigastric Early
bloating indigestion heartburn
discomfort satiety

Upset
nausea fullness acidy taste vomiting
stomach

queasiness belching
ETIOLOGY
FOOD OR DRUG INTOLERANCE

• Overeating
• Eating too quickly
• Eating high fat foods
• Eating during stressful situations
• Drinking too much alcohol or coffee
• Medications: NSAID, Antibiotics,
Diabetes drugs, etc
FUNCTIONAL DYSPEPSIA
• Most common cause of chronic
dyspepsia
• Three-fourths of patients have no
obvious organic cause
• Symptoms may arise from a complex
interaction: increased visceral afferent
sensitivity, gastric delayed emptying,
impaired accomodation to food,
psychososial stressors
• Although benign, these symptoms may
be chronic and difficult to treat
LUMINAL GASTROINTESTINAL TRACT DYSFUNCTION

• Peptic ulcer disease (PUD)

• Gastroesophageal reflux disease (GERD)
• Gastric or esophageal cancer
• Other causes include gastroparesis
HELICOBACTER PYLORI INFECTION

• Although chronic gastric infection with

H-pylori is an important cause of PUD, it
is an uncommon cause of dispepsia in
the absence of PUD
• The prevalence of H pylori –associated
chronic gastritis in patients with
dyspepsia without PUD is the same as
in the general population
PANCREATIC DISEASE

• Pancreatic carcinoma
• Chronic pancreatitis
BILIARY TRACT DISEAE

• Cholelithiasis or
choledocholithiasis
• Cholecystitis
OTHER CONDITIONS

• Diabetes Mellitus
• Thyroid disease
• Chronic kidney disease
• Myocardial ischemia
• Intra-abdominal malignancy
• pregnancy
DIAGNOSIS
 UPPER GI COMPLAINTS

GERD DYSPEPSIA

NON INVESTIGATED INVESTIGATED

DYSPEPSIA DYSPEPSIA

ORGANIC FUNCTIONAL
DYSPEPSIA DYSPEPSIA

POST PRANDIAL DISTRESS EPIGASTRIC PAIN

SYNDROME SYNDROME
TYPES OF DYSPEPSIA

Organic GERD, PUD, etc

Dyspepsia

Postprandial distress syndrome

Functional
Epigastric pain syndrome
 ROME IV CRITERIA = FUNCTIONAL DYSPEPSIA

Presence of one or more of the following syndroms thought

to originate in the gastroduodenal region

POST PRANDIAL EARLY EPIGASTRIC EPIGASTRIC

FULLNES SATIATION PAIN BURNING

No Evidence Of Structural Disease (ESD) To Explain the Symptoms

Symptoms Present During The Last 3 Months With Onset

At Least 6 Months Before Diagnosis
 WHO NEEDS ENDOSCOPY

❑ GI Bleeding
❑ Unintentional Weight Loss
❑ Dysphagia
❑ Persistent Vomiting
❑ Iron Deficiency Anaemia
❑ Epigastric Mass
❑ > 55 yo with Unexplained Persistant / recent
onset dyspepsia
 DIAGNOSIS H- PYLORI

• Urea breath Test 95% Sensitive & spesific

• Stool Antigen Test 92% Sensitive & Spesific

• Serology 80%Sensitive & Spesific

• Endoscopy – CLO Test 98%Sensitive & Specific

TREATMENT Dyspepsia

Non Investigated Investigated

Dyspepsia Dyspepsia

Symptomatic Organic Functional

Treatment Dyspepsia Dyspepsia

Depend on Depend on
Antacids mucosal damage Fuctional Disorder

PPI

H2RA PUD

Prokinetik Prokinetic
Sitoprotektor Anti Anxiety
(Rebapimide) PPI Anti Depresant
Rebapimide
 H. Pylori Positive H. Pylori Eradication

• PPI BD PO

Ist Line • Clarithromycin 500 gr BD PO For 7- 14 Days

• Amoxicilin 1 gr BD PO

• PPI BD PO

2Sd line • Bismut 120 gr QDS PO

For 7 - 14
Days
• Metronidazol 500 gr TDS PO
• Tetracyclin 250 mg QDS PO
 INVESTIGATIONS OF DYSPEPSIA

Dyspepsia

Are The
“Alarm” Faetures ?

Yes No

< 55 Years > 55 Years

Urgent
Endoscopy
Endoscopy

Test For H. Pylori e.g. Srology, stool

Antigen or 13C Urea Breath Test

Positive Negative

H. Pylori Treat
Eradication Symptomatically
Or
Symptoms Symptoms Consider Other
Resolve Persist Diagnoses

No
Endoscopy
Follow-Up
HOW TO DIAGNOSE AND MANAGE
UPPER GASTROINTESTINAL BLEEDING
❑ Uper Gastrointestinal Bleeding
(UGIB) Causes Significant
Morbidity In The US
❑ Associated With Increasing
NSAID Use And H. Pylori
Infection
❑ UGIB Includes Hemorrhage
Originating From The
Esophagus To The Ligament
Of Treitz
❑ Peptict Ulcer Bleeding Causes
> 60% Of UGIB
 CAUSES OF UPPER GASTROINTESTINAL BLEE
DING
Diagnosis Distinguishing features (%)

Peptic ulcer bleeding History of aspirin or nonsteroidal 62

antiinflammatory drug use associated with
abdominal pain, food consumption reduces
pain, nocturnal symptoms, history of peptic
ulcer bleeding or Helicobacter pylori infection

Gastritis and duodenitis Same as peptic ulcer bleeding 8

Esophageal varices History of cirrhosis and portal hypertension 6

Mallory-Weiss tear History of repeated retching or vomiting 4
Arteriovenous malformations Painless bleeding in older patients (older than 10
70 years), history of iron deficiency anemia

Esophagitis or esophageal ulcer Heartburn, indigestion, or dysphagia

Dieulafoy ulcer Painless bleeding, more common in men

Relative Risk of Upper Gastrointestinal Bleeding Associated with NSAIDs

NSAID Relative risk

Ibuprofen 2.7

Diclofenac (Voltaren) 4.0

Meloxicam (Mobic) 4.0

Naproxen (Naprosyn) 5.2

Indomethacin (Indocin) 5.3

Ketoprofen 5.7

Piroxicam (Feldene) 9.3

Ketorolac 14.0

NSAID = nonsteroidal anti-inflammatory drug

DIAGNOSIS
• Diagnosis based on anamnesa, physical
examination, laboratory findings, and
endoscopy
• Take patient history and review of medication
use ( e.g. Aspirin , Clopidogrel or NSAID)
• Important historical information includes the
presence of abdominal pain; coffee-ground–like
emesis; dysphagia; black tarry stools; bright
red blood per rectum; hematemesis; and chest
pain.
• Immediate assessment of hemodynamic status
in patients with prompt intravasculer volume
replacement initially using cristalloid fluids if
hemodynamic instability exists
• Blood transfusions generally should be
administered to those with a hemoglobin level
of 7 g per dL or less;
• Hemoglobin level should be maintained at 9 g
per dL
• A higher target hemoglobin should be
considered in patients with significant
comorbidity e.g. Ischemic cardiovascular
disease
 Stratification the risk of Upper GI
Bleeding and Mortality
● Rockall Score
● Blatchford Score
● Endoscopy

Konsensus Nasional Penatalaksanaan Perdarahan Saluran Cerna Atas Non Varises di Indonesia. 2012
RISK STRATIFICATION
• Risk stratification is based on clinical
assessment and endoscopic findings.
• Clinical assessment includes age, presence of
shock, systolic blood pressure, heart rate, and
comorbid conditions.
• Mortality increases with older age and with
increasing number of comorbid conditions.
• Endoscopic findings, such as the cause of the
bleeding and stigmata of recent hemorrhage,
can be combined with clinical factors to predict
mortality and risk of rebleeding using the
Rockall risk scoring system
Skor 0-5: tak butuh intervensi; Skor > 6: butuh intervensi
http://www.slideshare.net/ssuser57d854/peptic-ulcer-disease-upper-gastrointestinal-tract-bleeding-managemen
t
http://www.slideshare.net/shaffar75/prevention-of-nsaid-related-ulcer-complication
s
PREDICTION VALUE OF FORREST
CLASSIFICATION
 PREVALENCE AND RISK OF REBLEEDING BASED ON ENDOSCOPIC STIGMATA OF
RECENT HEMORRHAGE IN PEPTIC ULCER BLEEDING

Rebleeding Rebleeding rate

rate without with successful
Prevalence Endoscopic Endoscopic
Endoscopic appearance (%) treatment (%) treatment (%)
Active arterial bleeding 12 90 15 to 30
Visible vessel 22 50 15 to 30
Adherent clot 10 33 5
Oozing without stigmata 14 10 NA
Flat spot 10 7 NA
Clean ulcer base 32 3 NA

NA = not available.

Information from references 17 and 18.

TREATMENT
RESUSCITATION, RISK ASSESSMENT AND PRE-ENDOSCOPY MANAGEMENT

• Immediately evaluate and initiate appropriate

resuscitation
• Early risk stratification: low – high risk categories for
rebleeding and mortality
• Consider placement of a NGT in selected patients
• Blood transfusions should be administered → hb level 7
g% or less
• Patients with acute ulcer bleeding who are at low risk for
rebleeding (clinical and endoscopic criteria ) →
discharged promptly after endoscopy
• Preendoscopic PPI therapy → downstage the endoscopic
lesion and decresased the need for endoscopic
intervention but should not delaye endoscopy
PHARMACOLOGIC MANAGEMENT

• Initiating high dose IV PPI → IV bolus

followed by continuous infusion ( 80 mg
then 8mg /hour) → awaiting upper
endoscopy
• Duration of high dose PPI → 72 hours
• H2 RA are not recommended for patients
with acute ulcer bleeding
• Somatostatin/octreotide are not routinely
recommended
• Patients should be discharged with single
twice daily dose oral PPI
ENDOSCOPIC MANAGEMENT ( IF AVAILABLE)
• International treatment guidelines
recommended an early risk stratification by
immediate endoscopic diagnosis and treatment
• It is associated with a reduction in blood
transfuson and total hospital stay
• Early endoscopy (within 24 hours of hospital
admission
• Endoscopic therapies include epinephrine
injection, thermocoagulation, application of
clips, and banding
PREDICTION VALUE OF FORREST
CLASSIFICATION
Endoscopic
+
Bolus-continuous
PPI therapy
(72hrs)
Konsensus Nasional Penatalaksanaan Perdarahan Saluran Cerna Atas Non Varises di Indonesia. 2012
HELICOBACTER PYLORI
• Patients who have PUD should undergo
endoscopic biopsies of the antrum to test for
this infection
• Patients who have PUD and documented
infection should recieve triple therapy to
eradicate this infection
• Eradication induces ulcer healing and helps
prevent ulcer recurrence
Management of Bleeding Peptic Ulcer(CROTTY B)

Peptic Ulcer

Low-risk bleeding Active or high-risk Bleeding

(shock or visible vessel)

Endoscopic therapy
Monitor

The bleeding stopped Re-bleeding Can not control the

bleeding

Repeat endoscopic therapy

Re-bleeding Surgery
ALGORYTHM FOR ENDOSCOPIC AND/OR PHARMACOLOGIC
TREATMENT

Non-variceal Upper Gastrointestinal

Bleeding

Intravenous PPI infusion(bolus & continuous)

Upper gastrointestinal
Endoscopy

High-risk Stigmata Low-risk Stigmata

Endoscopic therapy + Oral PPI therapy

Intravenous PPI infusion

Triadapafilopoulos G. Aliment Pharmacol Ther 2005; 22(Suppl.3): 53-8

 APPROACH IN MANAGING UGI BLEEDING

Suspected UGIB(hematemesis or coffee-ground–like emesis)

Initial clinical assessment, resuscitation, and stabilization

Admit (usually to intensive care unit) and start proton pump inhibitor infusion

Pre-endoscopy risk assessment

S

Perform urgent EGD

Suspect variceal
hemorrhage (known or
suspected cirrhosis)
Pepptic ulcer AVM Erosive No source
Consider iv octreotide bleeding Mallory weiss tear esophagitis found
(Sandostatin), Dieulafoy ulcer
broad-spectrum
antibiotics, and Endoscopic therapy Continue Consider small
Endoscopic therapy
nonselective beta with epinephrine and proton pump bowel
with epinephrine,
blockers either inhibitor enteroscopy,
thermocoagulation, or
thermocoagulation or therapy capsule
clips
clips endoscopy,
Perform urgent EGD colonoscopy,
with endoscopic arteriography
variceal ligation Bleeding stopped Unable to stop bleeding with
banding embolization, or
tagged red
blood cell study
Rebleeding
No rebleeding Rebleeding
Consider
THANK YOU
CURICULUM VITAE

• Nama : dr Abdul Rahman M, SpPD-KGEH

• Tempat Tugas: RSUD Benyamin Guluh Kolaka
• Pendidikan S1 : Universitas Hasanuddin,
Makassar
• Pendidikan Spesialis Penyakit Dalam :
Universitas Hasanuddin, Makassar
• Pendidikan Konsultan Gastroenterohepatologi:
Universitas Indonesia, Jakarta