Gangguan saluran cerna bagian

atas
Bagian Penyakit Dalam FK UISU
PERDARAHAN SALURAN CERNA BAGIAN ATAS
 common problem & world wide / cosmopolitan
 Emergency / darurat
 Morbiditas / mortalitas 
 Insidensi : * USA 150/100.000 populasi & 10.000 –
20.000 kematian / tahun.
Mortalitas : 5-12 %  manula
cardiovaskular / CHF
hemodinamik instability
COPD
 Klasifikasi aktifitas perdarahan menurut Forrest

Aktifitas perdarahan Kriteria endoskopik

Forrest Ia – Perdarahan aktif : perdarahan arteri

menyembur (spurting)
Forrest Ib – Perdarahan aktif : perdarahan merembes
(oozing)
Forrest II – Perdarahan berhenti, : gumpalan darah pada
tetapi masih disertai dasar tukak
kelainan yang nyata “visible vessel”
Forrest III – Perdarahan berhenti, : lesi tanpa tanda sisa
tanpa menunjukkan perdarahan
sisa
ETIOLOGI

 TD / TL
 Erosi lambung
 Kanker lambung
 Varises esofagus
 Esofagitis, kanker esofagus
 Duodenitis
 Mallory-Weiss syndrome
PSCA : 80 % berhenti spontan, 20 % rebleeding
- Melena : > 60 cc darah
- Darurat  penting status hemodinamik
- significant haemorrhage symptoms : syncope, pucat,
takikardi, TVJ , hipotensi postural.
- Tanda2 syok / perdarahan > 50 % blood volume : TD
sistol < 100 mmHg, takikardi, perifer dingin, Hb <
10 gr%, Ht<30% rendahkan kepala / trendelenburg
IVFD cor : RL / NaCl / Asering
sirosis hati : fresh frozen plasma
+ trombosit
uremik + aspirin :trombosit
hemofili / von willibrand : spesifik?
Resusitasi pd PSCA masif

Pasang infus / IVFD

Pem. Darah
Cross Match
Koreksi koagulopati jika perlu
Transfusi darah jika perlu
DIAGNOSIS :
1. Anamnese
 Identify pre-existing morbid condition
 riwayat PJ iskemik / CHF / aritmia jtg, COPD, GGK,
HT, DM
 riwayat muntah2 hebat : Mallory – weiss synd.
 SH : Varices bleeding & non varices (40 %)
 NSAID
 Stress ulcer  disebabkan perdarahan ulserasi
stress akut / pre-existing peptic ulcer
disease / kondisi patologi lain yg
berhub dgn PSCA
 sering berhub dgn : luka bakar,
trauma mayor, trauma kapitis, multi
organ failure.
2. Pem. fisik :
 Penilaian status hemodinamik & resusitasi
 Tanda2 liver stigmata & HT portal
 Jaundice
 Bleeding diathesis : purpura, ekimosis, ptikiae
3. Endoskopi
 Harus periksa EKG PJK, aritmia !
 Psn gagal nafas / komabebaskan jalan nafas.
 Bila endoskopi belum dpt sumber PSCAangiografi
atau labelled red cell radionuclide scan
TERAPI :
I. ULKUS PEPTIC
1. Farmakologi : ARH2, PPI,
2. Endoscopic therapy :  laser
 elektrokoagulasi
 heater probe
 topical sprays
 injection therapy (adrenalin
1:10.000, alkohol & polidokanol )
3. Radiologic therapy : embolisasi diikuti kateterisasi
4. Prophylactic therapy : * eradikasi HP pd TD & TL
* empiric therapy jika HP tdk
dieradikasi.
* Analog PG (misoprostol)utk
NSAID + TL
* Surgery utk recurrent bleeding
 PERDARAHAN SALURAN CERNA BAGIAN ATAS
HEMATEMESIS / MELENA

DENGAN GANGGUAN HEMODINAMIK TANPA GANGGUAN

HEMODINAMIK
Syok (baring 50%, duduk 30%)

Atasi hipovolemi Infus / transfusi sesuai

- NaCl, RL, Plasma expander kebutuhan
- Transfusi darah biasa / PRC Slang Nasogastrik
Slang Nasogastrik Bilas air es
- Bilas dengan air es sampai jernih Obat hemostatik
Obat hemostatik Monitor Hb/Ht, tensi, nadi,
Monitor Hb/Ht, tensi, nadi, kesadaran kesadaran
Anamnese & Pemeriksaan Fisik Anamnese & Pemeriksaan Fisik

Perdarahan terus Perdarahan stop

Gastroskopi
 Gastroskopi
Dengan varises Tanpa varises

- Skleroterapi darurat
- Slang S-B + Gastritis erosif
- Pitressin IV 20 U + 200 ml Dextrose 5% Ulkus Peptikum
diberikan 20 menit Mallory Weiss
- Terapi konservatif diteruskan Tumor
(antasid, penghambat H2,
hemostatik, laktulose, neomisin) Konservatif
(antasid, penghambat H2,PPI
hemostatik)

Perdarahan terus Perdarahan stop

Operasi Konservatif
Endoscopic therapy of upper GI bleeding

TOPICAL THERAPY MECHANICAL THERAPY

-Tissue adhesives -Snares

-Clotting factors -Sutures

-Collagen -Balloons

-Ferromagnetic tamponade -Hemoclips

INJECTION THERAPY THERMAL THERAPY

-Variceal bleeding -Electrocoagulation

-Non variceal bleeding - monopoloar

- Ethanol - electrohydrothermal
- Other sclerosants bipolar (multipolar)
-Heater probe

-Laser
Figure 1 . Management of bleeding peptic ulcer

Peptic ulcer

Low risk of rebleeding Active bleeding or high risk of

rebleeding (shock, visible
vessel)

Monitor Endoscopic therapy

No further bleeding Rebleed Unable to control bleeding

< 60 thn > 60 thn

Repeat endoscopy therapy Embolisasion therapy

Rebleed Rebleed

Surgery
II. VARISCES ESOPHAGUS BLEEDING
1. Endoskopi : Skleroterapi & Ligasi
2. Farmakologi: * jika endoskopi tdk dpt dikerjakan.
* Vasopressin + nitrogliserin
3. Balloon Tamponade : Sengstaken – Blakemore,
Linton tube.
4. TIPS ( Transjugular Intrahepatic Porto-systemic
Stent Shunt )
5. Profilaksis : propanolol me tek. V. porta pd SH
Figure 2. Schema for the management of bleeding oesophageal Varices

Variceal Bleeding

Temporary Measures
Ballon tamponade
Vasoconstrictors

Injection Sclerotherapy/Variceal ligation

Haemostatis achieved Continued bleeding

Repeat at 3-4 weeks Repeat injection sclerotherapy /

up to 5-6 session variceal ligation

Continued bleeding

TIPS / Surgery
Figure 3. Management of non bleeding varices

Varices present but not bleeding

Band ligation
Rebleeding No further bleeding

Repeat band ligation (or sclerotherapy)

Further bleeding No further bleeding Repeat within 1 week

Consider : Repeat every 3-4

weeks until varices
- Transcutaneous intrahepatic portosystemic shunt
- Shunt surgery / liver transplantation are obliterated
- withdrawal of therapy
KESIMPULAN :
 Penyebab utama perdarahan disebabkan acid related
disease (erosiva, TD/TL, NSAID, gastropati pd usia
lanjut.
 Di Indonesia varises bleeding mortalitas &
insidensinya tinggi .
 Terapi intervensi gastrointestinal endoskopi semakin
luas digunakan ( ligasi, sklerotarapi, clips, heater
probe, laser dll )
Investigation
•Most patients are stable and can be investigated once bleeding has
stopped
•In the actively bleeding patient consider

•Colonoscopy - can be difficult

•Selective mesenteric angiography
•Requires continued bleeding of >1 ml/minute
•May show angiodysplastic lesions even once bleeding
has ceased
Management
•Acute bleeding tends to be self limiting
•Consider selective mesenteric embolisation if life threatening
haemorrhage
•If bleeding persists perform endoscopy to exclude upper GI cause
•Proceed to laparotomy and consider on-table lavage an panendoscopy
•If right-sided angiodysplasia perform a right hemicolectomy
•If bleeding diverticular disease perform a sigmoid colectomy
•If source of colonic bleeding unclear perform a subtotal
colectomy and end-ileostomy