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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