Professional Documents
Culture Documents
The Role of PPI UGI Bleed Final 15 July 2017 C. KONKER PAPDI MALANG PDF
The Role of PPI UGI Bleed Final 15 July 2017 C. KONKER PAPDI MALANG PDF
Neoplasm
Duodenal Acute
Ulcer Gastritis
Arterio-Venous
Malformation
Common Etiologies
None 38 4.5
Others 45 9
Konsensus Nasional Penatalaksanaan Perdarahan Saluran Cerna Atas Non Varises di Indonesia. 2012
Etiology
1993 Malignancy
1% Others
2%
Ulcus
Erosive 1%
Gastritis
19%
Variceal
Bleeding
76%
Others Variceal
Malignancy 15% Bleeding
3% 28%
Ulcus
11%
Erosive
Gastritis
43%
100% Others
80% Malignancy
60%
Ulcus
40%
Er. Gastritis
20%
Var.
0% Bleeding
1993 2006 2007 2008
TUKAK LAMB
TUKAK D
323, 59.05%
KEGANASAN
LAIN2
• Upper or Lower?
– History Freebees
– Digital Rectal Exam These can usually make the diagnosis
– Hemoglobin
• Still bleeding?
– Consider NG Lavage
• What’s the etiology?
– Diagnostic Testing
Diagnostic Testing
Key Points
Stratification the risk of Upper GI
Bleeding and Mortality
• Rockall Score
• Blatchford Score
• Endoscopy
Konsensus Nasional Penatalaksanaan Perdarahan Saluran Cerna Atas Non Varises di Indonesia. 2012
Blatchford admission risk markers
Admission risk marker Score component value
Blood urea (mMol/I)
6.5-8.0 2
8.0-10.0 3
10.0-25.0 4
>25 6
Hemoglobin (g/I) for men
120-130 1
100-120 3
<100 6
Hemoglobin (g/I) for women
100-120 1
<100 6
Systolic blood pressure (mm Hg)
100-109 1
90-99 2
<90 3
Other markers
Pulse>100 per min 1
Presentation with melena 1
Presentation with syncope 2
Hepatic disease 2
Cardiac failure 2 >6
The Rockall risk score scheme
Value Score
0 1 2 3
Age (years) <60 60-79 >80 -
Shock No shock Tachycardia Hypotension -
(systolic BP100, (systolic BP100, (systolic BP<100)
pulse<100) pulse>100)
Comorbidity No major - Cardiac failure, Renal failure,
comorbidity ischemic heart liver failure,
disease, any disseminated
major malignancy
comorbidity
Diagnosis Mallory-Weiss All other Malignancy of -
tear, no lesion diagnoses upper
identified and no gastrointestinal
SRH tract
Major stigmata of None or dark - Blood in upper -
recent spot only gastrointestinal
hemorrhage tract, adherent
clot, visible or
spurting vessel
Maximum additive score prior to diagnosis=7, maximum additive score following diagnosis=11. BP, blood pressure; SRH,
stigmata of recent hemorrhage
ROCKALL Score
http://www.fmed.uniba.sk/uploads/media/Rockall_Score_01.pdf
Skor 0-5: tak butuh intervensi; Skor > 6: butuh intervensi
Risk Factor indicating bad
prognosis in peptic ulcer bleeding
• Age > 60 years old
• Bleeding onset in the hospital
• Comorbid
• Shock or orthostatic hypotension
• Fresh blood in the nasogastric tube
• Coagulopathy
• Ulcer in the upper minor curvatura(near left gastric
artery)
• Posteriof duodenal bulb ulcer(near gastroduodenal
artery)
Konsensus Nasional Penatalaksanaan Perdarahan Saluran Cerna Atas Non Varises di Indonesia. 2012
• Endoscopic findings showed arterial of visible vessel
bleeding.
MANAGEMENT: ACCESS AND VOLUME
• IV Access
– Two large bore peripheral IVs is best
• Volume replacement
– Normal saline
– Blood products
– Consider FFP
Management – Suspected Varices
• Initial stabilization
• Splanchnic Vasoconstricters:
Octreotide/Vasopressin.
• - PPI ??
• TIPS
• Minnesota tube/Blakemoore tube
• Antibiotic prophylaxis
• A whole other talk
Forrest I Active bleeding
Ia Active pulsation 90%
Ib Active oozing 30%
Konsensus Nasional Penatalaksanaan Perdarahan Saluran Cerna Atas Non Varises di Indonesia. 2012
Protective Factors of Gastric Mucous
http://www.intechopen.com/books/gastritis-and-gastric-cancer-new-insights-in-gastroprotection-diagnosis-and-
treatments/protective-effects-of-gastric-mucus
Pharmacokinetic comparison of five PPIs
Pantoprazole shows a significantly higher AUC in comparison to other PPIs
7.0
6.5
6.0 Pantoprazole 40 mg
5.5 Omeprazole 20 mg
Concentration (µmol/l)
5.0
4.5 Esomeprazole 40 mg
4.0
Esomeprazole 20 mg
3.5
3.0 Rabeprazole 20 mg
2.5
2.0
Lansoprazole 30 mg
1.5
1.0
0.5
0.0
0 2 4 6 8 10 12 14 16 18 20 22 24
Hours after dose
Pharmacodynamics
Pantoprazole is the only PPI to also bind
deep within the pump at Cys 822
0 pH = 5.9
20 ADP pH = 6.8
Aggregation (%)
40 pH = 7.4
60
80
100
0 1 2 3 4 5
Time (minutes)
Increase intragastric pH
pH>6.0 for 84-99% of day
http://gastroenterology.jwatch.org/cgi/content/full/2010/219/1
Barkun NA et.al. Ann. Intern Med.2010;152: 101-13
Table 9: Endoscopic Treatment For Non-variceal Upper
Gastrointestinal Bleeding
• Thermal
• Heater probe
• Multipolar electrocoagulation (BICAP,Gold Probe)
• Argon plasma coagulation
• Laser
• Injection
• Adrenaline (1:10000)
• Procoagulants(fibrin glue,human thrombin)
• Sclerosants (ethanolamine, 1% polidoconal)
• Alcohol (98%)
• Mechanical
• Clips
• Band Ligation
• Endoloops
• Staples
• ·utures
• Combination therapy
• Injection plus thermal therapy
• Injection plus mechanical therapy
• Methods rarely used are depicted in italics.