PENATALAKSANAAN

PEMERIKSAAN AWAL PADA PERDARAHAN

SALURAN CERNA

Menentukan beratnya perdarahan status hemodinamik

TD dan nadi posisi baring Perubahan ortostatik TD dan nadi ada/ tidaknya vasokontriksi perifer (akral dingin) Tingkat kesadaran Produksi urin

HEMODINAMIK TIDAK STABIL

Perdarahan > 20 % volume intravaskular
Hipotensi ; TD < 90/60 mmHg, nadi > 100/ menit Diastolik ortostatik turun > 10 mmHg atau sistolik turun > 20 mmHg Nadi ortostatik meningkat . 15/menit Akral dingin Kesadaran menurun Anuria atau oliguria (produksi urin < 30 ml/jam)

*PERDARAHAN SALURAN CERNA BAGIAN ATAS*

HEMATEMESIS / MELENA DENGAN GANGGUAN HEMODINAMIK TANPA GANGGUAN HEMODINAMIK Syok (baring 50%, duduk 30%) Atasi hipovolemi - NaCl RL, Plasma expander - Transfusi darah biasa / PRC Slang Nasogastrik - Bilas dengan air es sampai jernih Obat hemostatik Monitor Hb/Ht, tensi, nadi, kesadaran Anamnese & Pemeriksaan Fisik Fisik Perdarahan terus Gastroskopi Infus / transfusi sesuai kebutuhan Slang Nasogastrik Bilas air es Obat hemostatik Monitor Hb/Ht, tensi, nadi, kesadaran Anamnese & Pemeriksaan

Perdarahan stop

Gastroskopi Dengan varises - Skleroterapi darurat - Slang S-B - Pitressin IV 20 U + 200 ml Dextrose 5% diberikan 20 menit - Terapi konservatif diteruskan (antasid, penghambat H2, hemostatik, laktulose, neomisin) Tanpa varises

+ Gastritis erosif Ulkus Peptikum Mallory Weiss Tumor Konservatif (antasid, penghambat H2, hemostatik)

Perdarahan terus
Gawat I / II / III Operasi

Perdarahan stop

Konservatif

Management of bleeding peptic ulcer

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

Monitor

Endoscopic therapy

No further bleeding

Rebleed

Unable to control bleeding

Repeat endoscopy therapy

Rebleed

Surgery

Management of actively bleeding varices

Actively bleeding varices
Band ligation or injection sclerotherapy, commence ocreotide 25 g/hour

Bleeding controlled
Continue as figure 1

Bleeding not controlled

Insert Sengstaken-Blakemore tube (admit to ICU) Deflate Sengstaken-Blakemore tube at 12-24 hours and attempt band ligation or sclerotherapy Successful

Unsuccessful

Reinflate Sengstaken-Blakemore tube, consider

Transjuguler intrahepatic portosystemic shunt surgery - Transplantation

Continue as figure 1
Successful

Deflate Sengstaken-Blakemore tube at 24 hours Attempt ligation or sclerotherapy Unsuccessful

consider Transjuguler intrahepatic portosystemic Shunt surgery , Transplantation , withdrawal of therapy

Management of non bleeding varices (figure 1)

Varices present but not bleeding
Band ligation Rebleeding Repeat band ligation (or sclerotherapy) Ocreotide 25 g/hour

No further bleeding

Further bleeding
Consider :

No further bleeding

Repeat within 1 week

Repeat every 3-4 weeks until varices are obliterated

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

SKEMA PENANGANAN PSCB MASIF

Massive rectal bleed Resuscitation & Physical Examination Laboratory Studies

Proctosigmoidoscopy

Lesi (-)

Lesi (+)

Strong suspicion of upper GI bleed OR blood/coffee ground naso-gastric aspirate Upper GI endoscopi

RX

Lesion indentified

Lesion not found

Kolonoskopi

Lesion indentified

Lesion not found

Bleeding stops Push enteroskopi

Bleeding continues

Lesion indentified

Lesion not found Angiography (With optional radionuclide)

Lesion indentified

Lesion not found

Surgery