perdarahan saluran cerna atas dan bawah
TRANSCRIPT
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SRI SOETADI
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PSMBA
PSMBB
HEMATEMESIS
MELENA : (50 ML BLOOD)
HEMATOCHEZIA(TRANSIT TIME <<)
LIGAMENTUM TRAITZ
HEMATOCHEZIA
MELENA (TRANSIT TIME >>)
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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
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PENGERTIAN
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, NAMUN BENZIDINE TEST (+) 10 CC
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PENYEBAB PSMBA DITINJAU DARI LOKASIESOFAGUS OESOPHAGEAL VARICES MALLORY – WEISS TEAR OESOPHAGEAL CARCINOMA REFLUX OESOPHAGITIS FOREIGN BODY
LAMBUNG PEPTIC ULCER EROSIONS/GASTRITIS GASTRIC VARICES PORTAL HYPERTENSIVE GASTROPATHY GASTRIC CARCINOMA LYMPOMA LEIOMYOMA ANGIODYSPLASIA (INCLUDING OSLER’S DISEASE) DIEULAFOY’S EROSION
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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 ingestion
VASCULAR 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
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MEDICAL THERAPYPeptic Ulcer disease
Antisecretory therapy,Antacids,Sucralfate,MisoprostolGastroesophageal varices
Intravenous vasopressin with or without nitroglycerin
Intravenous octreotideBalloon tamponade
ENDOSCOPIC THERAPY
Peptic ulcer diseaseThermal coagulation
Multipolar electrocoagulation,Heater probe,laser ther
Injection therapyEpinephrine, Alcohol
Combination therapy;thermal coagulatuion & injectionGastroesophgeal varices
Injection sclerotherapy,variceal band ligation
Cyanoacrylate injectionCombination
therapy;sclerotherapy &band ligationTumors
Termal 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 THERAPYPeptic ulcer disease
Arterial embolization, Intraarterial vasopressin infusionGastroesophageal varices
Embolization,Transjugular intrahepatic portosystemic shunting
THERAPEUTIC OPTIONS FOR ACUTE UPPER GASTROINTSTINAL HEMORRHAGE
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ACUTE MANAGEMENTPatient stabilization (ABCs)
Respiratory stabilization (intubation etc)Intravenous accessIntravascular volume replacementTransfusions (PRC, FFP, Platelets
Focused history and physical examinationLaboratory data
CBC with platelet count, Coagulation studies (PT/aPTT)Liver enzymes, Chemistries
RadiographicUpright chest x-ray, Abdominal x-ray
ElectrocardiogramLocalization of bleeding siteSurgery consulationGastroenterology consultation for upper panendoscopy
LONG-TERM MANAGEMENT
Treatment of recurrent bleedingRepeat diagnostic and therapeutic endoscopyAngiography, Surgery
Preventive measures for peptic ulcer disease bleedingMaintenance antisecretory therapyHelicobakter pyloru eradicationStrict avoidance of ASA/NSAIDsMisoprostolSurgery
Preventive measures for variceal bleeding BlockersObliterative endoscopic therapyShuntingLiver transplatation
MANAGEMENT APPROACH FOR ACUTE UPPER GASTROINTESTINAL HEMORRHAGE
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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
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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
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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
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CAUSES OF ACUTE LOWER GASTROINTESTINAL BLEEDING
COMMON CAUSESDiverticulaVascular ectasia
UNCOMMON CAUSESNeoplasia (including postpolypectomy)Inflammatory bowel disease
ColitisIschemic RadiationUnspecified
HemorrhoidsSmall bowel sourceUpper gastrointestinal source
No lesion identified
RARE CAUSESDieulafoy’s lesionsColonic UlcerationsRectal Varices
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DIFFERENTIAL DIAGNOSIS OF OCCULT GASTROINTESTINAL BLEEDING
MASS LESIONS VASCULAR
Carcinoma (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
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Variable Guaiac Heme-Porphyrin Immunochemical
Detection characteristics Upper gastrointestinal + ++++ 0
Small bowel ++ ++++ +Right colonic +++ ++++ ++
+ Left colonic ++++ ++++ ++++ Test factors
Bedside availability ++++ 0 +Time to develop 1 minute 1 hour 5 minute to 24 hours
Cost $ 3-5 $ 17 $ 10-20 False positives
Animal hemoglobin ++++ ++++ 0 Dietary peroxidases +++ 0 0False negatives Hemogloblin degredation ++ 0 ++ Storage ++ ++++ ++ Vitamin C ++ 0 0
CHARACTERISTICS OF FECAL OCCULT BLOOD TESTS1
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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
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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
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COMMON HEMMORRHOIDS PROCTITIS IBD DIVERTICOLISIS ISCHEMIC COLITIS ANGIODYPLASIA RECTAL OR COLONIC POLYPSOCCASIONAL ANAL FISSURE INFECTIOUS ENTEROCOLITIS CARCINOMA OF THE COLON RADIATION COLITIS MECKEL’S DIVERTICULUM BRISK BLEEDING FROM AN UPPER
GASTROINTESTINAL SOURCE
PENYEBAB TERBANYAK DARI PSMBB DITINJAU DARI PENYAKIT
RARE AMYLOIDOSIS VASCULAR-ENTERIC FISTULA ANTIBIOTIC-ASSOCIATED
COLITIS
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DISEASE OF RECTUM AND COLON DIVERTICULAR DISEASE COLONIC ANGIODYSPLASIA COLITIS (ISCHAEMIA,INFECTIONS,IBD,RADIATION) COLONIC NEOPLASIA/POST-POLYPECTOMY ANORECTAL CAUSES (HAEMORRHOIDS,RECTAL
VARICES)DISEASE OF SMALL BOWEL VASCULAR ECTASIA TUMORS MECKEL’S DIVERTICULUMDISEASE OF UPPER GASTROINTESTINAL TRACT PEPTIC ULCER DISEASE VARICES SIGMOIDOSCOPY
PSMBB DITINJAU DARI SEGI LOKASI
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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
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HEMORRHAGIC I II III IVCLASS
BLOOD LOSS 15% OR 20-25% OR 30-35% OR 40-50% OR750 ML 1000-1250 ML 1500-1800ML 2000-2500 ML
HEART RATE <100 >100 >120 >140
RESPIRATORY 14-19 20-29 30-40 >40RATE
ARTERIAL NORMAL 110-80 70-60 <60PRESSURE
CAPILLARY NORMAL INCREASED INCREASED INCREASED FILLING TIME
DIURESIS (ML/H) 35-30 30-25 25-5 0
NEUROLOGIC MILDLY VERY CONFUSED LETHARGICSTATUS ANXIOUS ANXIOUS
Table 1 . Hemorrhagic Classes
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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
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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
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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
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HEMATEMESIS
HISTORY
LABORATORY TESTS AND IMAGING STUDIES
LIVER CIRRHOSIS WITH ACTIVE BLEEDING
YES NO
BALOON TAMPONADE
URGENT EGD AFTER REMOVAL OF BALLON
TAMPONADE
ESOPHAGEAL OR GASTRIC VARICES
SCLEROTHERAPY
URGENT EGD
NO LOCALIZATION
MASSIVE BLEEDING
SURGERY
MODEST BLEEDING
REPEAT EGD OR ANGIOGRAPHY
NO LOCALIZATION
WITH RECURRENT OR PERSISTENT BLEEDING
LOCALIZATION OF
BLEEDING SITE
LOCALIZATION OF
BLEEDING SITEDEFINITIVE
TREATMENT: ENDOSCOPIC
(THERMAL COAGULATION
OR INJECTION)OR
PHARMACOLOGIC
Figure 1. Suggested Diagnostic Procedures in patients with hematemesis. (EGD=esophagogastroduodenoscopy)
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MELENA
HISTORY
ELECTIVE EGD
LOCALIZATION OF
BLEEDING SITE (50-70%)
NO LOCALIZATIO
N
IN CASE OF RELEVANT BLEEDING
NO ACTIVE BLEEDING
RECTOSIGMOIDOSCOPY AND COLONOSCOPY
(WHENEVER POSSIBLE)
LOCALIZATION OF BLEEDING
SITE
NO LOCALIZATIO
N
DEFINITIVE TREATMENT
OR OBSERVATION
RADIOISOTOPIC SCAN
IF POSITIVE, ANGIOGRAPHY
ANGIOGRAPHY
NO LOCALIZATION
SURGERY
Figure 2. Suggested diagnostic procedures in patients with melema (EGD=esophagogastroduodenoscopy)
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HEMATOCHEZIA
HISTORY
ELECTIVE SIGMOIDOSCOP
Y
LOCALIZATION OF BLEEDING
SITE
NO LOCALIZATION
ELECTIVE TREATMENT
ELECTIVE EGD AND
COLONOSCOPY
PERSISTENT BLEEDING
RADIOISOTOPIC SCAN
IF POSITIVE ANGIOGRAPHY
BLEEDING STOPS
FOLLOW - UP
FOLLOW - UP
Figure 3. Suggested diagnostic procedures in patients with hematochezia (EGD=esophagogastroduodenoscopy)
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PENANGANAN
RESUSITASI (UMUM) VASCULAR ACCESS INTRAVENOUS FLUIDS BLOOD LESTS TYPING & CROSS MATCHING CORRECT COAGULOPATHY BLOOD TRANSFUSION
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VARISES BLEEDINGPROFILAKSIS BETABLOKER (PROPANOLOL)
TERAPEUTIK : SOMATOSTATIN
MEDICAMENT :
SB TUBE
ENDOSKOPIERADIKASI
TIPSS
SKLEROTERAPI
BINDING LIGASI
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ULKUS BLEEDING1. MEDIKAMEN : ARH2, PPI, Antasida
2. 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
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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
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HAEMORRHOID
MEDIKAMENT :
SUPPOSITORIA (+/-) STEROID
DIIT TINGGI SERAT
ANOSCOPI TH/ :
INJ.SKLEROTH / LIGATION, CRYOSURGERI,
PHOTO COAGULATI, ELECTROCOAGULATI
SURGICAL HEMORRHOIDECTOMY
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CA KOLOREKTAL OPERATIF
POLIP KOLON
POLIPEKTOMI
DIVERTIKEL KOLONMEDIKAMEN, INJEKSI EPINEPHRIN, ANALGESIC
OPERATIF KOLEKTOMI
IBD
MEDIKAMEN :
OPERATIF
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