PERDARAHAN SALURAN CERNA

TERMINOLOGI

1. Hematemesis: muntah darah, merah

kehitaman, endapan bubuk air kopi

2. Melena: BAB seperti, lengket campur darah tua

3. Perdarahan terselubung: warna normal, tes

kimiawi (benzidin tes) ada darah

4. Hematochezia : darah segar melalui rektum

Perdarahan Saluran Makan Bagian Atas

“adalah perdarahan pd saluran makan proksimal dari ligamentum Treitz”

• Perdarahan Saluran Makan Bagian Atas

“adalah perdarahan pd saluran makan proksimal dari ligamentum Treitz”

ETIOLOGI

Upper GI Bleed1. Duodenal Ulcer 30 %2. Gastric Ulcer 20 %3. Varices 10 %4. Gastritis and duodenitis 5-10 %5. Esophagitis 5 %6. Mallory Weiss Tear 3 %7. GI Malignanc 1 %8. Dieulafoy Lesion9. AV Malformation-angiodysplasia

Duodenal Ulcer

Varices

Esophagitis

GI Malignancy

• Esophageal Tumor

GI Malignancy

• Gastric Carcinoma

Angiodysplasia

Waspadai Lower GI Bleed

1. Hematochezia2. Blood in Toilet3. Clear NGT aspirate4. Normal Renal Function5. Usually Hemodynamically stable

Only 1/3 pasien mempunyai hasil (+) orthostatics (tilt test).

Etiology of Lower GI Bleed

Diverticular 20%AVM 10%Malignancy 2-26%Inflammatory Bowel Disease 10%Ischemic ColitisAcute Infectious ColitisRadiation Colitis/ProctitisAortoenteric Fistula

Diverticulosis

Malignancy

• Colon Carcinoma

Colonic Polyps

Hemmorrhoids

PENYEBAB

• Varises esofagus• Gastritis erosif• Tukak peptik• Lesi Mallory-Weiss • Divertikulitis SMBA• Keganasan• Penyakit sistemis (hemofilia dll)

Prosedur Diagnostik

Anamnesa• Penyakit hati• Pedih epigastrium hubungan dg makan• Alkohol, jamu, obat2• Muntah hebat, kmd muntah drh

Pemeriksaan fisik

• Status hemodinamik : HR, BP, tilt test, RR, O2 saturation

• General appearance, Mental status• Vena jugularis (Neck veins), oral mucosa• Skin temperature and color• Pemeriksaan Abdominal • Pemeriksaan Rectal• Stigma of Cirrhosis• NG Tube findings• Urine output

Pemeriksaan Laboratorium

1. Hematologi: Hb, ht, lekosit, eritrosit, trombosit, morfologi darah tepi, gol.drh, faal pembekuan

2. Biokimia darah: faal hati, faal ginjal, gula drh

3. Urin rutin

Management of GI Bleed

• Berikan Oxygen• Berikan IVFD ; tree way

- cairan resusitasi - persiapan transfusi darah.

• Jaga patensi jalan napas (Airway Protection)

• Kaji secara kontinyu gangguan mental dan resiko aspirasi terutama pada pasien dengan perdasarahan massive

Management of GI Bleed

Hubungi ICU bila ada indikasi - perdarahan yang signifikan dg ketidakstabilan hemodynamic

Transfusion- harus berdasarkan status hemodinamik- Cardiopulmonary symptoms-cardiac ischemia or shortness of

breath, decreased pulse oxymetri- 1 unit PRBC increases Hgb by 1 mg/dL and increase Hct by 3 %- FFP for INR greater than 1.5- Platelets for platelet count less than 50K

• Periksa Vital Signs• Adakah riwayat Allergies• Anjurkan pasien untuk Bedrest• Pasang Foley cateter• Diet: NPO

Tindakan Umum1. Resusitasi: penilaian, pemantauan & menjaga

kestabilan status hemodinamika

A. Tanpa Syok: o perdasarah 500 cc

observasi TD, nadi, suhu, kesadaran. Hb/ht berkala untuk transfusi

o perdarahan 500-1000 ccevaluasi kemungkinan transfusi, terpasang kristaloid (RL)

Tindakan Umumo Perdarahan masif >1000 cc

Hb < 8 gr % infus kristaloid dipercepat, menunggu transfusi, pantau tekanan vena sentral.

a) Telentang tanpa bantal, kepala miring kesamping, O2 via kateter hidung 5 l/menit, kateter foley

b) RL 1000 cc dlm 1 jamc) Tetap syok, infus plasma ekpander sambil tunggu

darah, jumlah transfusi tergantung respon hemodinamik: CVP stabil normal, vital baik, diuresis cukup, ht > 30%

2. Kuras Lambung

1. Pipa nasogastrik2. Aspirasi isi lambung dengan air es 150 cc tiap 2, 4

atau 6 jam tergantung perdarahan3. Air kurasan merah/keruh: masih terjadi, nilai sifat

& macamnya: a. Minimal, terus-menerus, >70 th EKG

abnormal : teruskan kuras dg air es + nor-adrenalin 2 amp/150 cc air es

Kuras Lambung

b. Minimal, terus-menerus. - < 70 th EKG normal: infus vasopresin 0,2 (octapressin,

glypressin) unit/mnt (10 amp @ 10 unit larutkan dlm 500 cc D5 % 20 gtt/m/8 jam), bisa diulang 2 x lagi, bila drh berkurang/stop, teruskan dosis 0,1 unit/m

- EKG abn: vasopresin + nitrogliserin (iv, sub lingual atau transdermal)

Sengstaken-Blakemore tube (SB tube)

c. Masif, usia >70 th EKG abnormal, diduga varises esofagus, farmakologis gagal ----- tamponade

SB tube.

*pneumonia aspirasi, laserasi s/d perforasi, obstruksi

jalan nafas krn migrasi balon kedlm hipofarings

Penilaian tindakan terapi

Penilaian tindakan terapi berdasar:- Penilaian perdarahan akut gawat, bila utk

mempertahankan hemodinamika yg stabil (Hb > 8 gr% & Ht > 30%) perlu transfusi darah 3 unit dalam waktu:

+ 8 jam : perdarahan akut gawat tk.I +24 jam : sda tk.II +48 jam : sda tk.III- Menentukan kapan terapi gagal/berhasil

Nursing diagnosis

• risk for Bleeding related to Active fluid volume loss—hemorrhage

NURSING INTERVENTIONS1. Note color and characteristics of vomitus, nasogastric

(NG) tube drainage, and stools.

• Rationale: The first step in managing bleeding is to determine its location. Bright red blood that does not clear signals recent or acute arterial bleeding, perhaps caused by gastric ulceration; dark red blood may be old blood that has been retained in intestine or venous bleeding from varices. Coffee-ground appearance is suggestive of partially digested blood from slowly oozing area. Undigested food indicates obstruction or gastric tumor. In a rapid upper GI bleed, stool color may be red or maroon because of rapid transit time through the GI tract.

2. Monitor vital signs; compare with client’s normal and previous readings. Take blood pressure (BP) in lying, sitting, and standing positions when possible.

Rationale: Changes in BP and pulse may be used for rough estimate of blood loss; BP less than 90 mm Hg and pulse greater than 110 suggest a 25% decrease in volume, or approximately 1,000 mL. Postural hypotension reflects a decrease in circulating volume.

Note: Heart rate may not rise above normal until up to 30% of total blood volume is lost.

3. Note client’s individual physiological response to bleeding, such as changes in mentation, weakness, restlessness, anxiety, pallor, diaphoresis, tachypnea, and temperature elevation.

• Rationale: Symptomatology is useful in gauging severity and length of bleeding episode. Worsening of symptoms may reflect continued bleeding, inadequate fluid replacement, and shock.

4. Measure central venous pressure (CVP) if available.

• Rationale: Reflects circulating volume and cardiac response to bleeding and fluid replacement. CVP values between 5 and 20 cm H2O usually reflect adequate volume.

5. Monitor intake and output (I&O) and correlate with weight changes. Measure blood and fluid losses via emesis, gastric suction or lavage, and stools.

• Rationale: Provides guidelines for fluid replacement.

6. Keep accurate record of subtotals of solutions and blood products during replacement therapy.

• Rationale: Potential exists for overtransfusion of fluids, especially when volume expanders are given before blood transfusions.

7. Maintain bedrest; prevent vomiting and straining at stool. Schedule activities to provide undisturbed rest periods. Eliminate noxious stimuli.

Rationale: Activity and vomiting increases intra-abdominal pressure and can predispose to further bleeding.

8. Elevate head of bed during antacid gavage.

• Rationale: Prevents gastric reflux and aspiration of antacids, which can cause serious pulmonary complications.

 

9. Note signs of renewed bleeding after cessation of initial bleed.

• Rationale: Increased abdominal fullness and distention, nausea or renewed vomiting, and bloody diarrhea may indicate return of bleeding.

10. Observe for secondary bleeding from nose or gums, oozing from puncture sites, or appearance of ecchymotic areas following minimal trauma

• Rationale: Loss of or inadequate replacement of clotting factors may precipitate development of DIC.