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Pendarahan Varises Akut PDF Hermono

Pendarahan Varises Akut PDF Hermono

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Published by: dr. Titong Sugiharto on Apr 03, 2013
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09/07/2013

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CURRENT MANAGEMENT OFACUTE VARICEAL BLEEDING
HERNOMO KUSUMOBROTO
SURABAYA GASTRO-HEPATOLOGY CENTERAIRLANGGA UNIVERSITY SCHOOL OF MEDICINESUTOMO HOSPITAL SURABAYA
Dibacakan pada :
LOKAKARYA HIPERTERNSI PORTALPGH SURABAYA
Surabaya, 15 Januari 2005
 
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SUMMARY
 Treatment of patients with gastroesophageal varices includes the prevention of theinitial bleeding episode (primary prophylaxis), the control of active hemorrhage, andthe prevention of recurrent bleeding after a first episode (secondary prophylaxis).Many new and exciting therapeutic options for variceal hemorrhage have becomeavailable during the past decade. The management of acute variceal bleeding is a complex process, which includesgeneral supporting measures, resuscitation, cardiorespiratory monitoring, transfusion,treatment of the bleeding itself and prevention of complications.In managing this condition, special care must be exerted in maintaining vital functionsand preventing complications. Combination of endoscopic therapy plus a vasoactivedrug is probably the most effective treatment for variceal bleeding.Blood volume restitution should be done cautiously and conservatively, using PRC tomaintain the hematocrit between 25-30 %, and plasma expanders to maintainhemodynamic stability. The presence of infection should be considered in all patients.Antibiotic prophylaxis is an integral part of therapy and should be instituted fromadmission. Lactulose should be given by mouth, nasogastric tube, or enema to preventhepatic encephalopathy. Balloon tamponade should only be used in massive bleedingas a temporary “bridge” until definitive treatment can be instituted.In suspected variceal bleeding, vasoactive drugs should be started as soon as possible,before diagnostic endoscopy. Even if there is no active bleeding at endoscopy, it isrecommended to perform endoscopic therapy, especially in high risk patients. Drugtherapy may be maintained for up to 5 days to prevent early rebleeding.Endoscopy should be performed as soon as possible after admission (within 12 h),especially in patients with clinically significant bleeding or in patients with featuressuggesting cirrhosis. In mild bleeds, causing neither hemodynamic changes norrequiring blood volume restitution, endoscopy can be done electively.Endoscopic techniques have been used to treat variceal bleeding. Endoscopicsclerotherapy (EST) has been used for many years to treat bleeding varices, butcurrently is not indicated for prophylaxis because of the lack of efficacy. Endoscopicvariceal ligation (EVL) may be better than EST for managing acute variceal bleeding,but it has not been used enough in the prophylactic setting to determine its usefulness. TIPS is very effective in controlling bleeding in patients in whom first-line therapyfails. However patients with severe liver impairment undergoing salvage TIPS facedismally high mortality rates.
 
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CURRENT MANAGEMENT OFACUTE VARICEAL BLEEDING
HERNOMO KUSUMOBROTO
Pusat Gastro Hepatologi SurabayaFakultas Kedokteran Universitas AirlanggaRSUD Dr. Sutomo Surabaya
1. PENDAHULUAN
Perdarahan varises akut merupakan komplikasi yang paling berat dari hipertensi portal.Meskipun banyak cara pengobatan baru telah ditemukan selama beberapa decade terakhirsehingga dapat menekan angka kematian penderita, angka kematian pada 6 minggusetelah perdarahan varises masih tetap berkisar antara 20 – 30 %. Sebagai perbandingan,angka ini sama seperti angka kematian pada infark miokard akut (9, 22, 33).Di Indonesia, sirosis hati merupakan penyebab perdarahan saluran cerna yang palingbanyak ditemukan. Frekuensinya barvariasi antara 25 – 82 %, tergantung di daerah manapemeriksaan dikerjakan. Dari hasil pemeriksaan endoskopi, perdarahan varises esophagusditemukan hampir merata di seluruh Indonesia, dengan frekuensi bervariasi antara 15 –63 % (14, 15, 19).Pengobatan penderita dengan perdarahan varises gastro-esofagus meliputi : prevensiterhadap serangan perdarahan pertama (“primary prophylaxis”), mengatasi perdarahanaktif, dan prevensi perdarahan ulang seteah perdarahan pertama terjadi (“secondaryprophylaxis”). Selama beberapa decade terakhir, banyak modalitas pengobatan baru danyang menarik telah ditemukan untuk perdarahan varises ini (33).Pengelolaan perdarahan varises akut merupakan proses yang sangat kompleks, termasukdi antaranya penanganan secara umum, seperti : resusitasi, monitoring kardio-pulmoner,transfusi, pengobatan terhadap perdarahannya sendiri, dan pencegahan terhadapkomplikasi (9, 14, 15, 22, 33).

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