DIVISION OF GASTROENTERO-HEPATOLOGY

DEPARTEMENT OF INTENAL MEDICINE /

FACULTY OF MEDICINE, NORTH OF SUMATERA /
H. ADAM MALIK HOSPITAL
 HEMATEMESIS

PSMBA MELENA : (50 ML BLOOD)

HEMATOCHEZIA (TRANSIT TIME <<)

LIGAMENTUM TRAITZ

HEMATOCHEZIA

PSMBB

MELENA (TRANSIT TIME >>)

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 (+) ( darah 10 CC )
Incidence
 Upper GI bleed 100/100,000
Above the ligament of Treitz
 Lower GI Bleed 20/100,000
Below the ligament of Treitz
 Both are more common in males and
elderly.
Causes of Upper GI Bleed
 1) Peptic ulcer disease - most common
cause
A) duodenal ulcers 29%
will rebleed in 10% of cases within
24-48h
B) gastric ulcers 16%
more likely to rebleed
C) stomal ulcers <5%
Causes of Upper GI Bleed
 2) Erosive gastritis, esophagitis, duodenitis
some causes are ETOH, ASA, NSAID’s
 3) Esophageal and gastric varices
causes by portal hypertension
 4) Mallory-Weiss syndrome – longitudinal
mucosal tear in the cardioesophageal
region
caused by repeated retching
Causes of Upper GI Bleed

 5) stress ulcers
 6) arteriovenous malformation
 7) malignancy
 8) aortoenteric fistula
Causes of Lower GI Bleeding
 1) Hemorrhoids - most common cause
 2) Diverticulosis – common, painless,
and can be massive
Caused from an erosion into a
penetrating artery from the
diverticulum.
 3) Arteriovenous malformations – common
and seen in people with hypertension and
aortic stenosis
Causes of Lower GI Bleeding

 4) CA/polyps
 5) inflammatory bowel disease
 6) infectious gastroenteritis
 7) Meckel diverticulum
HASIL :
GAMBARAN PASIEN PSMBA 2 KURUN WAKTU
(MABEL DKK)

1993-1996 1997-2000
Usia Rata2 54,25 52,32
Wanita/Laki-laki 95/168 78/142
Hematemesis 9/21 (30) 6/31 (37)
Hematemesis & Melena 47/72 (119) 40/69 (109)
Melena 39/75 (114) 30/42 (72)
Kematian 10/263 (0,04%) 6/220 (0,03%)
Jlh Penderita 263 220
PROPORSI PSMBA BERDASAR JENIS
KELAMIN DAN USIA TAHUN 2009-2010
(Ilhamd dkk)
USIA LAKI-LAKI WANITA

< 16 2

16-20 16 9

21-30 30 19

31-40 48 19

41-50 52 35

51-60 56 25

>60 58 41
JUMLAH 262 148
 HASIL GASTROSKOPI BERDASAR JENIS KELAMIN
TAHUN 2009-2010 (2 TAHUN)
(Ilhamd dkk)
HASIL GASTROSKOPI LAKI-LAKI WANITA total
VARISES ESOFAGUS 69 31 100
ULKUS GASTER 52 26 78
ULKUS DUODENI 34 18 52
GASTRITIS EROSIVA 60 36 96
CA GASTER 8 8
KELAINAN ESOPAGUS NON CA 20 16 36
POLIP GASTER 2 2
CA ESOFAGUS 4 4
VARISES FUNDUS 2 2 4
EGD NORMAL 24 52 76
ADA 22 ORANG DENGAN
>1 JENIS HASIL
GASTROSKOPI
HASIL
PENYEBAB PERDARAHAN (MABEL ,Medan DKK)

1993-1996 1997-2000
Varises esofagus 78 55
Tukak duodeni 51 40
Tumor Lambung 51 45
Tukak Lambung 27 33
Gastritis Erosiva 24 26
Gastropati 26 17
Tumor Esofagus 6 4
Jumlah 263 220
Etiologi PSMBA


 ETIOLOGI PSMBA

1.PENYEBAB PSMBA DITINJAU DARI

LOKASI
2.PENYEBAB PSMBA DITINJAU DARI
BENTUK KELAINAN
3.PENYEBAB PSMBA DITINJAU DARI JENIS
PENYAKIT
PENYEBAB PSMBA DITINJAU DARI LOKASI
ESOFAGUS
 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
CAUSES OF ACUTE UPPER GASTROINTESTINAL BLEEDING
BERDASARKAN BENTUK KELAINAN
ULCERATIVE, EROSIVE, Peptic Ulcer disease
OR INFLAMMATORY Gastro or duodenal ulcer, Z E syndrome, GERD
DISEASE Stress Ulcer
Infection causes
Helicobakter pylori, Cytomegalovirus, Herpes simplex
Drug-induced erosions, ulcers
Aspirin, NSAIDs, Pil-induced ulcer
Anticoagulation therapy
TRAUMA Mallory-Weiss Tear, Foreign body ingestion
VASCULAR LESIONS Varices, Angiomas, Osler-WR syndrome,Dieulafo’y
lesionportal hypertensive gastropathy
Aortoenteric fistula, radiotion induced
telengiectasia
TUMORS Benign
Leiomyoma, Lipoma,Polyp, Blue rubber syndrome
Malignant
Adenocarcinoma, Leiomysarcoma, Lympoma, Kaposi’s
sarcoma,Carcinoid, Melanoma, Metastatic tumor
Miscellaneous
PENYEBAB TERBANYAK PSMBA
DITINJAU DARI PENYAKIT
COMMON
 ESOPHAGEAL VARICES
 ESOPHAGOGASTRIC MUCOSAL TEAR
(MALLORY-WEISS SYNDROME)
 GASTRIC EROSIONS,ULCER,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 (USSUALY FROM AN
AORTIC ANEURYSM GRAFT)
RARE
 NASAL OR PHARYNGEAL BLEEDING
 HEMOPTYSIS
 ESOPHAGEAL RUPTURE (BOERHAAVE’S SYNDROMA)
 HEMOFILIA
 HISTORICAL FEATURES IMPORTANT IN ASSESSING
THE ETIOLOGY OF GASTROINTESTINAL BLEEDING

 AGE
 PRIOR BLEEDING
 PREVIOUS GASTROINTESTINAL DISEASE
 PREVIOUS SURGERY
 UNDERLYING MEDICAL DISORDER (ESPECIALLY LIVER
DISEASE )
 NON STEROIDAL ANTI INFLAMMATORY DRUGS /
ASPIRIN
 ABDOMINAL PAIN
 CHANGE IN BOWEL HABITS
 WEIGHT LOSS/ANOREXIA
 HISTORY OF OROPHARYNGEAL DISEASE
 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
 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
 HEMORRHAGIC CLASSES
HEMORRHAGIC I II III IV
CLASS

BLOOD LOSS 15% OR 20-25% OR 30-35% OR 40-50% OR

750 ML 1000-1250 ML 1500-1800ML 2000-2500 ML
HEART RATE <100 >100 >120 >140
RESPIRATORY 14-19 20-29 30-40 >40
RATE
ARTERIAL NORMAL 110-80 70-60 <60
PRESSURE
CAPILLARY NORMAL INCREASED INCREASED INCREASED
FILLING TIME
DIURESIS (ML/H) 35-30 30-25 25-5 0
NEUROLOGIC MILDLY VERY CONFUSED LETHARGIC
STATUS ANXIOUS ANXIOUS
Diagnosis
 Questions to ask in history
 Any hematemesis, coffee-ground emesis, melena, or
hematochezia.
 Any weight loss or changes in bowel habits.
 Any vomiting and retching.
 Any history aortic graft.
 Any history of ASA, NSAID’s, steroids.
 Any ETOH abuse.
 Any history of iron or bismuth which can simulate
melena and beets which can simulate hematochezia.
Note stool guaiac testing will be negative.
Diagnosis
Physical exam
 Vital signs may show hypotension and
tachycardia.
 Cool, clammy skin then in shock.
 Spider angiomata, palmer erythema, jaundice,
and gynecomastia seen in liver disease.
 Petechiae and purpura seen in coagulopathy.
 Careful ENT exam to rule out causes that can
mimic upper GI bleeds.
 Proper abdominal exam and rectal exam.
Diagnosis
Lab
 CBC
 Electrolytes
 Glucose
 BUN/Creatine –BUN will be elevated in upper GI
bleeds
 Coagulation studies
 Liver function studies
 Type and cross-match
Diagnosis
Diagnostic
 ECG
 Abdominal series - not beneficial unless specific
indications
 Angiography - can be diagnostic and therapeutic but
requires a brisk bleed at .5-2ml/min
 Bleeding scans - can only be diagnostic but are more
sensitive then angiography and require a bleeding rate of
only .1ml/min
 Colonoscopy - is diagnostic and therapeutic and more
accurate than bleeding scans and angiography
DIAGNOSTIK
1. PERDARAHAAN  ANAMNESE  RIWAYAT
 VOMITING (MENTAL)  MALLORY –WEISS HEM?
CEPAT/LAMBATLOKASI
 HEARTBURN & REGURGITASI  REFLUX ESOFAGITIS ?
 DYSFAGIA & BB   MALIGNANCY PD ESOFAGUS ?
 MAKAN OBAT-OBATAN & ALKOHOL GASTRIC EROSIVE ?
ULKUS PEPTIKUM ?
 PENYAKIT BERAT (DI ICU)  STRESS ULCER ?
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
Gambaran Endoskopi :
Erosi
• Erosi Multipel, warna merah
kehitaman,terutama
difundus dan korpus
Ulkus
• Perdarahan masif bila
terkena pembuluh darah
• Ulkus ,multipel ukuran
0,5-2 cm, di fundus dan
korpus dan kadang
kadang diduodenum
ULKUS KORPUS ANTRUM
 Forrest III

Forrest I
Spurting bleeding
 Suggested Diagnostic Procedures in patients with hematemesis.
(EGD=esophagogastroduodenoscopy)

HEMATEMESIS

HISTORY

LABORATORY TESTS AND IMAGING STUDIES

LIVER CIRRHOSIS WITH ACTIVE BLEEDING

YES NO

BALOON URGENT EGD

TAMPONADE
NO LOCALIZATION LOCALIZATION
URGENT EGD AFTER OF BLEEDING
SITE
REMOVAL OF BALLON
TAMPONADE MASSIVE MODEST
BLEEDING DEFINITIVE
BLEEDING TREATMENT:
ESOPHAGEAL OR ENDOSCOPIC
GASTRIC VARICES REPEAT EGD OR (THERMAL
ANGIOGRAPHY COAGULATION OR
SURGERY INJECTION)OR
SCLEROTHERAPY PHARMACOLOGIC
NO LOCALIZATION LOCALIZATION
OF BLEEDING
SITE
WITH RECURRENT OR
PERSISTENT BLEEDING
Suggested diagnostic procedures in patients with melema
(EGD=esophagogastroduodenoscopy)
MELENA

HISTORY

ELECTIVE EGD

LOCALIZATION NO
OF BLEEDING LOCALIZATION
SITE (50-70%)
NO ACTIVE BLEEDING
IN CASE OF
RELEVANT BLEEDING
RECTOSIGMOIDOSCOPY
AND COLONOSCOPY
ANGIOGRAPHY (WHENEVER POSSIBLE)

NO LOCALIZATION LOCALIZATION NO
OF BLEEDING LOCALIZATION
SITE
SURGERY
RADIOISOTOPIC
DEFINITIVE SCAN
TREATMENT OR
OBSERVATION
IF POSITIVE,
ANGIOGRAPHY
Treatment
 Large-bore intravenous lines with fluid
replacement.
 Class I + II hemorrhage replace with crystalloid.
 Class III + IV hemorrhage replace with
crystalloid and blood.
 NG tube should be placed and can determine
upper GI from lower GI but not 100%. Also NG
tubes will not worsen varice bleeds.
 Foley catheter for hypotension patients to
monitor output.
Treatment
 Proton-pump inhibitor
 Endoscopy
 Somatostatin, octretide for varices
 Balloon tamponade
 Surgery
 Must get early consultation with
gastroenterologist and general surgeon for
significant GI bleeds.
PENANGANAN

RESUSITASI (UMUM)

Pasang infus / IVFD

Pasang NG Tube
Golongan darah / Cross Match
Transfusi darah jika perlu
Koreksi koagulopati jika perlu
 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
- Sandostatin& Somastotatin Ulkus Peptikum
Mallory Weiss
- Terapi konservatif diteruskan Tumor
(antasid, penghambat H2,
hemostatik, laktulose, neomisin) Konservatif
(antasid, penghambat
H2,PPI
hemostatik)

Perdarahan terus Perdarahan stop

Operasi Konservatif
VARISES BLEEDING
PROFILAKSIS
BETABLOKER
(PROPANOLOL)
 MEDICAMENT :
TERAPEUTIK :
SOMATOSTATIN

 SB TUBE
SKLEROTERAPI

 ENDOSKOPIERADIKASI
BINDING LIGASI
 TIPSS
ULKUS BLEEDING
1. 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
 ENDOSCOPIC PROCEDURES THERAPY
OF UPPER GI BLEEDING
TOPICAL THERAPY MECHANICAL THERAPY
-Tissue adhesives -Snares
-Clotting factors -Sutures
-BILAS EPINEFRIN -Balloons
-Hemoclips

INJECTION THERAPY THERMAL THERAPY

-Variceal bleeding -Electrocoagulation
-Non variceal bleeding - monopoloar
- Ethanol - electrohydrothermal
- Other sclerosants bipolar (multipolar)
-Heater probe
-Laser
 THERAPEUTIC OPTIONS FOR ACUTE UPPER
GASTROINTESTINAL HEMORRHAGE
Peptic Ulcer disease
MEDICAL THERAPY Antisecretory therapy,Antacids,Sucralfate,Misoprostol
Gastroesophageal varices
Intravenous vasopressin with or without nitroglycerin
Intravenous octreotide
Balloon tamponade
Peptic ulcer disease
ENDOSCOPIC THERAPY Thermal coagulation
Multipolar electrocoagulation,Heater probe,laser ther
Injection therapy
Epinephrine, Alcohol
Combination therapy;thermal coagulatuion & injection
Gastroesophgeal varices
Injection sclerotherapy,variceal band ligation
Cyanoacrylate injection
Combination therapy;sclerotherapy &band ligation
Tumors
Termal probe, Laser ablation,Thermal balloon cateter
Non variceal (ulcer,endoscopic, or mallory-Weiss tear)
SURGICAL THERAPY Variceal
Portosystemic shunting,Esophageal transection and
devascularization, Liver transplantation
RADIOLOGIC THERAPY Peptic ulcer disease
Arterial embolization, Intraarterial vasopressin infusion
Gastroesophageal varices
Embolization,Transjugular intrahepatic
portosystemic shunting
Rockall scoring system U REBLEEDING DAN KEMATIAN OK PSMBA

Score
Variable 0 1 2 3
Age (yr) < 60 60-79 >80
Shock No Shock Tachycardia Hypotension
(BP >100 (BP>100,PP>100 (BP<100
PP <100) PP>100,
Comorbidity Nil mayor
CHF,CAD, Renalfailure,
Others Liverfailure,
diss.malignancy
Diagnosis Mallory weiss All other Malignancy of
No lesion, diagnosis GI tract
no SRH
Major SRH None or dark Blood in UGI
spot Clot,visible or
spurting
Score : < 3 excellent prognosis
vessels
> 8 poor prognosis
SRH : Stigmata of recent Hemorrhage
Interpretasi Rockall Score

• Skor > 3 : Risiko mortalitas meningkat

• Skor > 4 : Perlu dirawat diruang High Care
Resusitasi Optimal
Kerja sama tim Penyakit Dalam,bedah , anestesi.
• Mortalitas :
• Skor 0 0%
• Skor 1 3% • Skor 5 36%

• Skor 2 6% • Skor 6 62%

• Skor 3 12%
• Skor 7 75%
• Skor 4 24%
•
PENATALAKSANAAN
PERDARAHAN SALURAN CERNA
Konsensus Nasional 2003

PB. PERKUMPULAN
GASTROENTEROLOGI INDONESIA
 Manajemen awal
ORDER

• O ksigenasi

• R estore circulating volume

• D rug Therapy

• E valuate response to Therapy

•R emedy underlying cause

Prinsip dasar :
Ganti kehilangan cairan, Stop perdarahan ! !
Resusitasi dan Stabilisasi(1)

• Pasang jarum ukuran 16 dan 18 untuk infus cairan kristaloid

secara cepat; Untuk ekspansi cairan intravaskular 1 L,
dibutuhkan cairan kristaloid 3 L

• NGT untuk diagnostik dan monitoring

• Terapi antara ( Stop gap treatment):

• Somatostatin
• Oktreotide
• SB –tube pada perdarahan varises

• Obat supresor asam PPI efektif untuk perdarahan SCBA

• Evaluasi dan monitor keadaan dan respon terhadap terapi

secara klinis, Hematologis, analisa gas darah dan status
Metabolik
Resusitasi dan Stabilisasi (2)

• Transfusi darah atau komponen darah diberikan

bila Hb < 7 g/dl atau bila ada gangguan
koagulasi
•Bila memungkinkan upaya diagnostik secara
endoskopik untuk mengetahui dan menghentikan
sumber perdarahan perlu segera dilakukan.
• Perlu dipersiapkan agar pasien dapat ditransfer
kepusat rujukan dengan aman
• Obat Vasoaktif Dopamin,Dobutamin, hanya
diberikan pada pasien dengan Syok hemoragik
bila sudah diberikan penggantian cairan yang
cukup
Terapi obat pada perdarahan SCBA
• Supresi Asam : Pilihan utama Proton Pump Inhibitor (PPI )
Omeprazol : 3 x 40 mg IV atau
40 mg bolus, 8 mg/jam
selama 3 x 24 jam
•Obat Hemostatik;
• Tranexamic acid; 3 x 500 mg IV
• Vit K ; 3 x 10mg IV
• Obat Vasoaktif :
• Somatostatin : 250 μg bolus, infus 250 μg / jam , 3 x 24
jam
Oktreotide 0,05 mg /jam, 3 x 24 jam
Indonesian Society of
Gastroenterology

NATIONAL
CONCENSUS ON
UPPER
GASTROINTESTINAL
BLEEDING
MANAGEMENT IN;

Primary Health Care /

Emergency Unit
Hospital type D
(without specialist and
endoscopy facilities)
Indonesian Society of
Gastroenterology

NATIONAL CONCENSUS
ON
UPPER
GASTROINTESTINAL
BLEEDING
MANAGEMENT IN;

Secondary Care /
Specialist / Hospital
type C
( without endoscopy
facilities )
Indonesian Society of
Gastroenterology

NATIONAL CONCENSUS
ON
UPPER
GASTROINTESTINAL
BLEEDING
MANAGEMENT IN;

Referral Hospital type A

&B
(endoscopy facilities are
available)
TERIMA KASIH