Gangguan saluran cerna bagian atas

dr. Armon Rahimi SpPD,

KPTI

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

menyembur (spurting)

Forrest Ib – Perdarahan aktif

Forrest II – Perdarahan berhenti,

tetapi masih disertai

kelainan yang nyata

Forrest III – Perdarahan berhenti,

tanpa menunjukkan

sisa

: perdarahan arteri

: perdarahan merembes

(oozing)

: gumpalan darah pada

dasar tukak

“visible vessel”

: lesi tanpa tanda sisa

perdarahan

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 / komabebaskan jalan nafas.

Bila endoskopi belum dpt sumber PSCAangiografi 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 ATASHEMATEMESIS / 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 NasogastrikSlang Nasogastrik Bilas air es- Bilas dengan air es sampai jernih Obat hemostatikObat hemostatik Monitor Hb/Ht, tensi, nadi, Monitor Hb/Ht, tensi, nadi, kesadaran kesadaranAnamnese & Pemeriksaan Fisik Anamnese & Pemeriksaan Fisik

Perdarahan terus Perdarahan stop

G a s t r o s k o p i

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-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

Figure 1 . Management of bleeding peptic ulcer

Peptic ulcer

Low risk of rebleeding Active bleeding or high risk of rebleeding (shock, visible vessel)

M o n i t o r Endoscopic therapy

No further bleeding Rebleed Unable to control bleeding

Repeat endoscopy therapy

Rebleed

Surgery

< 60 thn > 60 thn

Embolisasion therapy

Rebleed

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

Variceal Bleeding

Temporary Measures

Ballon tamponade Vasoconstrictors

Injection Sclerotherapy/Variceal ligation

Haemostatis achieved Continued bleeding

Repeat at 3-4 weeks up to 5-6 session

Repeat injection sclerotherapy / variceal ligation

Continued bleeding

TIPS / Surgery

Figure 2. Schema for the management of bleeding oesophageal Varices

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 :

- Transcutaneous intrahepatic portosystemic shunt - Shunt surgery / liver transplantation - withdrawal of therapy

Repeat every 3-4 weeks until varices are obliterated

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 )

InvestigationInvestigation

•May show angiodysplastic lesions even once bleeding has ceased

•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

ManagementManagement

•If source of colonic bleeding unclear perform a subtotal colectomy and end-ileostomy

•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