Diagnosis dan Tata Laksana

PERDARAHAN SALURAN
CERNA ATAS dan BAWAH
Ari Fahrial Syam
Divisi Gastroenterologi,
Departemen Ilmu Penyakit Dalam, FKUI-RSCM
www.dokterari.com @DokterAri arisyam91@yahoo.com
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 • Keadaan kegawat daruratan
• Dapat menyebabkan kematian jika
terlambat penanganan
• 25 % kasus endoskopi atas karena
perdarahan saluran cerna atas
• Angka kematian 26 % (<2000)à 15 %
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Pengertian Hematemesis Melena

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Table 1. Diagnosis of upper gastrointestinal endoscopy on
indication of hematemesis, melena, or both

Diagnosis Number of patients Percentage

(%)

Varices 280 33.5

Ulcer 225 26.9
Erosive gastritis 219 26.2
Not found 38 4.5
Esophagitis 20 2.4
Portal hypertensive gastropathy**15 1.8
Polyp 11 1.3
Cancer 26 3.1
Miscellaneous* 3* 0.4
Miscellaneous*: Hemangioma, diverticulosis. Portal hypertensive gastropathy**found in
coincidence with esophageal varices in 229 cases (27.4%)
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Syam AF et al. Indones J Of Gastroenterol, Hepatol & Diges Endos, Dec 2005
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Perdarahan karena ulkus
peptikum

n Lesipada mukosa gastroduodenal terjadi karena à

ketidak seimbangan dari faktor agresif dan
defensif mukosa gastroduodenal

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Faktor agresif dan defensif yang mempengaruhi
keutuhan mukosa gastroduodenal
Asam, tripsin,pepsin,
asam empedu, etanol,
aspirin, OAINS dan
infeksi H. pylori.
FAKTOR AGRESIF
aliran darah mukosa, sel
epitel permukaan,
prostaglandin, surfaktan,
musin, bikarbonat dan
motilitas.
FAKTOR DEFENSIF
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Infeksi
H. pylori

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Perdarahan pada sirosis hati

• Varises yang terbentuk ini suatu saat

d a p a t p e c a h d a n m e n i m b u l k a n
perdarahan.
• Perdarahan varises hanya pada 30 % kasus
• Lebih dari 30 % kasus perdarahan pertama
berakibat fatal

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Sistim kolateral vena portae

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 •  Elas>sitas dari varises
Jika terjadi Sirosis Hepatis tekanan 11
vena portae akan meningkat •  Tekanan intra varises
•  Tekanan intraluminal
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Anamnesis

Pemeriksaan Fisik

Hematemesis Hemodinamik
melena? Tanda sirosis
Berapa ha>
banyak?
Seberapa besar
dampaknya ?
Kausa
perdarahan? 13
 Diagnosis

Laboratorium:
Pasang NGT

•  Diagnosis dan •  - Hb, L, Ht.

dekompresi Trombosit
•  - DPL hemostasis
jika curiga DIC
•  - Alb/globulin,
LFT, HbSAg,
An>HCV
•  - Ureum/krea>nin
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Diagnosis

menentukan lokasi perdarahan

Terapi yang tepat dapat

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dilakukan
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Tatalaksana

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RESUSITASI CAIRAN

Minta darah jika

hemodinamik
>dak stabil Packed Red Cell,
Cairan NaCl
Transfusi Fresh Frozen
fisiologis plasma
Plasma
expander
(cairan koloid)

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• T h e t h r e s h o l d f o r b l o o d
transfusion depends on the
underlying condi>on, rate of
bleeding, and vital signs of the
pa>ent, but is generally set at a
hemoglobin level of ≤ 70 g/L
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 Statement A4
Blood transfusions should be administered to a patient with a
hemoglobin level of 70 g/L or less.

Red blood
cell transfusion is rarely indicated when hemoglobin level is
greater than 100 g/L and is almost always indicated when the 20
level is less than 60 g/L.
 History & Physical Exam.;
Vital sign; Large bore iv line;
Nasogastric tube; Laboratory
Hemodynamic stable; No active bleeding Exam.; Hb, Ht, thrombocyte, Hemostasis

Emperical treatment Hemodynamic instability; active bleeding

RESUSCITATION
Crystalloid sollution; Colloid sollution;
Blood Transfusion; Correction for
coagulation factor

Hemadynamic stable; Bleeding stop Hemodynamic instability; Bleeding continued

VASOACTIVE DRUGS
Bleeding stop Ocreotide; Somatostatin
Vasopressin
EMERGENCY or EARLY UGI endoscopy
ELECTIVE UGI endoscopy

Esophageal / gastric Varices Ulcer Bleeding site non-visualized

Schelotherapy or Ligation Hemostatic Interventional diagnostic &
or SB tube injection or therapeutic radiology or
urgent surgery urgent surgery

If fail

DEFINITIVE TREATMENT Surgery

PANDUAN PENATALAKSANAAN PERDARAHAN VARISES PADA

SIROSIS HATI
PERKUMPULAN GASTROENTEROLOGI INDONESIA
(PGI)-2007 21
 INITIAL ASSESSMENT
History & Physical Exam.;
Vital sign; Large bore iv line;
Nasogastric tube; Laboratory
Hemadynamic stable;
Exam.; Hb, Ht, thrombocyte, Hemostasis
No active bleeding
Empirical treatment
Vit. K; Antisecretory Hemodynamic instability; active bleeding
drugs; Antacida;
Sucralfate RESUSCITATION
Crystalloid sollution; Colloid sollution;
Blood Transfusion

Hemadynamic stable; Bleeding stop Hemodynamic instability; Bleeding continued

BP > 90 / 60 mmHg; Pulse < BP < 90 / 60 mmHg; Pulse >
100/m; Hb >9 g%; Tilt test (-) 100/m; Hb < 9 g%; Tilt test (+)

VASO-ACTIVE DRUGS
Ocreotide; Somatostatin
Vasopressin

Bleeding stop Bleeding continued

Baloon tamponade/SB tube

ELECTIVE EVALUATION
UGI Barium Radiography or
Referral for Upper GI Bleeding stop Bleeding continued
Endoscopy

Urgent surgery

DEFINITIVE TREATMENT

PANDUAN PENATALAKSANAAN PERDARAHAN VARISES PADA

SIROSIS HATI
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PERKUMPULAN GASTROENTEROLOGI INDONESIA (PGI)-2007

Hemadynamic stable; No active bleeding
INITIAL ASSESSMENT
History & Physical Exam.;
Vital sign; Large bore iv line;
Nasogastric tube; Laboratory
Exam.; Hb, Ht, thrombocyte, Hemostasis

Emperical treatment
Vit. K; Antisecretory Hemodynamic instability; active bleeding
drugs; Antacida;
RESUSCITATION
Sucralfate
Crystalloid sollution; Colloid sollution;
Transfusion: PCR +/- FFP

Hemadynamic stable; Bleeding stop Hemodynamic instability; Bleeding

BP > 90 / 60 mmHg; Pulse < BP < 90 / 60 mmHg; Pulse >
100/m; Hb >9 g%; Tilt test (-) 100/m; Hb < 9 g%; Tilt test (+)

VASO-ACTIVE DRUGS
Ocreotide; Somatostatin
Vasopressin

Referral system for STABILIZATION

ELECTIVE EVALUATION
Fluid resuscitation; Blood
UGI Barium Radiography or transfusion; Coagulation factors
Referral for Upper GI
Endoscopy

DEFINITIVE TREATMENT REFERRAL in Stable hemodynamic

NATIONAL CONCENCUS ON UPPER GASTROINTESTINAL BLEEDING MANAGEMENT IN; Primary

Health Care / Emergency Unit Hospital type D (without specialist and endoscopy facilities) 23
PERDARAHAN SALURAN CERNA 24

BAWAH
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Clinical Manifestation
•  Rectal bleeding, pain, and diarrhea
•  Proctitis

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Colonoscopy Findings
Colonoscopy may be normal or may show
telangectasias or friable mucosa.

Early or acute changes include microscopic

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damage to mucosal and vascular epithelial
cells.

One typical histologic feature is the presence of

atypical fibroblasts.

Late changes commonly involve fibrosis with

oblitera>ve endarteri>s resul>ng in chronic
ischemia, stricture forma>on, and bleeding.
Colonoscopy Findings

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Penonjolan pembuluh darah ke
anal kanal Piles
Ambeien
Anatomi hemoroidal cushion

Ø D orongan dan

m e n g e d a n

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m e m b u a t
pembuluh darah
ini keluar ke anal
canal
Manifestasi klinis
•  BAB darah menetes
•  Ada benjolan keluar dari
anus

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•  Nyeri pada anus
•  Panas pada dubur
•  Anemia (occult bleeding)
Diagnosis
•  Anamnesis
•  Pemeriksaan fisik : Inspeksi pada anus, Rectal Toucher
•  Anuscopy

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KlasiFikasi Hemoroid
•  Grade 1 :pelebaran dengan bleeding terlihat
dengan anuskopi
•  Grade 2# : keluar dan masuk secara spontan
•  Grade 3 : keluar dan perlu bantuan untuk
dimasukan lagi
•  Grade 4 keluar >dak bisa dimasukan lagi.

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SKIN
TAG

ANOREKTAL
ULSERASI
Pengobatan non surgery
•  Non-surgical “destruc2ve” techniques :
- Rubber band liga2on
- Sclerotherapy

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Kesimpulan
Perdarahan saluran
cerna bagian atas dan Anamnesis dan
bawah sering dijumpai Pemeriksaan fisik yang
pada praktek sehari- tepat
hari

Tahapan tatalaksana:
Endoskopi untuk resusitasi cairan, obat-
evaluasi sumber obatan dan
perdarahan pengobatan per 41
endoskopi