Dr.

Mabel HM Sihombing, SpPD-KGEH

Dr.Ilhamd SpPD
DIVISION OF GASTROENTERO-HEPATOLOGY
DEPARTEMENT OF INTENAL MEDICINE /
FACULTY OF MEDICINE, NORTH OF SUMATERA /
H. ADAM MALIK HOSPITAL

HEMATEMESIS

PSMBA MELENA : (50 ML BLOOD)

HEMATOCHEZIA (TRANSIT TIME <<)

LIGAMENTUM TRAITZ

HEMATOCHEZIA

PSMBB

MELENA (TRANSIT TIME >>)

1
PENGERTIAN
HEMATEMESIS :
MUNTAH DARAH WARNA MERAH KECOKLAT COKLATAN

KEHITAM HITAMAN (CAFFEIN)
MELENA :
BAB WARNA HITAM (TERRY STOOL)
>50CC DARAH
HAEMATOCHEZIA :
BAB WARNA MERAH TERANG
GELAP
OCCULT BLEEDING :
TDK ADA PERUBAHAN WARNA BAB, NAMUN BENZIDINE
TEST (+) 10 CC

HASIL :
GAMBARAN PASIEN PSMBA 2 KURUN WAKTU
(MABEL DKK)

1993-1996 1997-2000
Usia Rata2 54,25 52,32
Wanita/Laki-laki 95/168 78/142
Hematemesis 9/21 (30) 6/31 (37)
Hematemesis & Melena 47/72 (119) 40/69 (109)
Melena 39/75 (114) 30/42 (72)
Kematian 10/263 (0,04%) 6/220 (0,03%)
Jlh Penderita 263 220

2
HASIL
PENYEBAB PERDARAHAN (MABEL DKK)

1993-1996 1997-2000
Varises esofagus 78 55
Tukak duodeni 51 40
Tumor Lambung 51 45
Tukak Lambung 27 33
Gastritis Erosiva 24 26
Gastropati 26 17
Tumor Esofagus 6 4
Jumlah 263 220

Etiologi PSMBA

3
PENYEBAB PSMBA DITINJAU DARI LOKASI
ESOFAGUS

OESOPHAGEAL VARICES

MALLORY – WEISS TEAR

OESOPHAGEAL CARCINOMA

REFLUX OESOPHAGITIS

FOREIGN BODY
LAMBUNG

PEPTIC ULCER

EROSIONS/GASTRITIS

GASTRIC VARICES

PORTAL HYPERTENSIVE GASTROPATHY

GASTRIC CARCINOMA

LYMPOMA

LEIOMYOMA

ANGIODYSPLASIA (INCLUDING OSLER’S DISEASE)

DIEULAFOY’S EROSION

BERDASARKAN BENTUK KELAINAN

ULCERATIVE, EROSIVE, Peptic Ulcer disease

OR INFLAMMATORY Gastro or duodenal ulcer, Z E syndrome, GERD
DISEASE Stress Ulcer
Infection causes
Helicobakter pylori, Cytomegalovirus, Herpes simplex
Drug-induced erosions, ulcers
Aspirin, NSAIDs, Pil-induced ulcer
Anticoagulation therapy
TRAUMA Mallory-Weiss Tear, Foreign body ingestion
VASCULAR LESIONS Varices, Angiomas, Osler-WR syndrome,Dieulafo’y lesion
Watermelon stomach,portal hypertensive gastropathy
Aortoenteric fistula, radiotion induced telengiectasia

TUMORS Benign
Leiomyoma, Lipoma,Polyp, Blue rubber syndrome
Malignant
Adenocarcinoma, Leiomysarcoma, Lympoma, Kaposi’s
sarcoma,Carcinoid, Melanoma, Metastatic tumor
Miscellaneous
Hemofilia, Hemosuccus pancreaticus

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PENYEBAB TERBANYAK DARI PSMBA
DITINJAU DARI PENYAKIT
COMMON

ESOPHAGEAL VARICES

ESOPHAGOGASTRIC MUCOSAL TEAR
(MALLORY-WEISS SYNDROME)

GASTRIC EROSIONS

GASTRIC ULCER

DASTRIC VARICES

DUODENAL ULCER

ANGIODYSPLASIA (INCLUDING OSLER’S DISEASE)

DIULAFOY’S EROSION

OCCASIONAL

ESOPHAGITIS

ESOPHAGEAL CARCINOMA

GASTRIC DUODENAL NEOPLASMS
(CARCINOMA, LYMPHOMA, POLYPS)

GASTRIC MUCOSAL VASCULAR ECTASIA
ASSOCIATED WITH CIRRHOSIS

DUODENITIS

ANASTOMIC ULCER

SUBMUCOSAL NEOPLASMS
(LEIOMYOMA, MOST COMMON)

VASCULAR-ENTERIC FISTULA (USSUALY FROM AN
AORTIC ANEURYSM GRAFT)
RARE

NASAL OR PHARYNGEAL BLEEDING

HEMOPTYSIS

ESOPHAGEAL REPTURE (BOERHAAVE’S SYNDROMA)

HEMOBILIA

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 HISTORICAL FEATURES IMPORTANT IN ASSESSING
THE ETIOLOGY OF GASTROINTESTINAL BLEEDING

 AGE
 PRIOR BLEEDING
 PREVIOUS GASTROINTESTINAL DISEASE
 PREVIOUS SURGERY
 UNDERLYING MEDICAL DISORDER (ESPECIALLY LIVER
DISEASE )
 NON STEROIDAL ANTI INFLAMMATORY DRUGS /
ASPIRIN
 ABDOMINAL PAIN
 CHANGE IN BOWEL HABITS
 WEIGHT LOSS/ANOREXIA
 HISTORY OF OROPHARYNGEAL DISEASE

ADVERSE PROGNOSTIC VARIABLES IN ACUTE UPPER

GASTROINTESTINAL BLEEDING
 INCREASING AGE
 INCREASING NUMBER OF COMORBID CONDITIONS
 CAUSE OF BLEEDING (VARICEAL BLEEDING > OTHERS)
 RED BLOOD IN THE EMESIS AND/OR STOOL
 SHOCK OR HYPOTENSION ON PRESENTATION
 INCREASING NUMBERS OF UNIT OF BLOOD
TRANSFUSED
 ACTIVE BLEEDING AT THE TIME OF ENDOSCOPY
 BLEEDING FROM LARGE (>2.0 CM) ULCER
 ONSET OF BLEEDING IN THE HOSPITAL
 EMERGENCY SURGERY

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 KLASIFIKASI AKTIFITAS PERDARAHAN
MENURUT FORREST

AKTIFITAS PERDARAHAN KRITERIA ENDOSKOPIK

Forrest Ia – Perdarahan aktif : perdarahan arteri

menyembur (spurting)
Forrest Ib – Perdarahan aktif : Perdarahan merembes
(oozing)
Forrest II – Perdarahan berhenti, : Gumpalan darah pada
tetapi masih disertai dasar tukak
kelainan yang nyata “visible vessel”
Forrest III – Perdarahan berhenti, : Lesi tanpa tanda sisa
tanpa menunjukkan perdarahan
sisa

TABLE 1 . HEMORRHAGIC CLASSES

HEMORRHAGIC I II III IV
CLASS

BLOOD LOSS 15% OR 20-25% OR 30-35% OR 40-50% OR

750 ML 1000-1250 ML 1500-1800ML 2000-2500 ML
HEART RATE <100 >100 >120 >140
RESPIRATORY 14-19 20-29 30-40 >40
RATE
ARTERIAL NORMAL 110-80 70-60 <60
PRESSURE
CAPILLARY NORMAL INCREASED INCREASED INCREASED
FILLING TIME
DIURESIS (ML/H) 35-30 30-25 25-5 0
NEUROLOGIC MILDLY VERY CONFUSED LETHARGIC
STATUS ANXIOUS ANXIOUS

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DIAGNOSTIK
1. PERDARAHAAN
ANAMNESE
RIWAYAT
COMMON

VOMITING (MENTAL)
MALLORY –WEISS TEAR ?

HEARTBURN & REGURGITASI
REFLUX ESOFAGITIS ?

DYSFAGIA & BB

MALIGNANCY PD ESOFAGUS ?

MAKAN OBAT-OBATAN & ALKOHOL
GASTRIC EROSIVE ?
ULKUS PEPTIKUM ?

LIVER STIGMATA (CH)
VARICES BLEEDING ?

PENYAKIT BERAT (DI ICU)
STRESS ULCER ?

2. PEMERIKSAAN FISIK :
 Penilaian status hemodinamik & resusitasi
 Jaundice & Tanda2 liver stigmata & HT portal
 Bleeding diathesis : purpura, ekimosis, ptikiae
3. RADIOLOGI
 Ba. Swallow, Ba. Follow Through, MDF double
contras, Kolon in loop.
 Upper & Lower Abdominal Scanning
4. ENDOSKOPI
 Gastroduodenoskopi
 Sigmoidoskopi
 kolonoskopi
 Push Enteroskopi

8
Gambaran Endoskopi :
Erosi
• Erosi Multipel, warna
merah kehitaman,terutama
difundus dan korpus
Ulkus
• Perdarahan masif bila
terkena pembuluh darah
• Ulkus akut, de novo
,multipel ukuran 0,5-2
cm, di fundus dan
korpus dan kadang
kadang diduodenum

9
 Forrest III

Forrest I
Spurting bleeding

Figure 1. Suggested Diagnostic Procedures in patients with

hematemesis. (EGD=esophagogastroduodenoscopy)

HEMATEMESIS

HISTORY

LABORATORY TESTS AND IMAGING STUDIES

LIVER CIRRHOSIS WITH ACTIVE BLEEDING

YES NO

BALOON URGENT EGD

TAMPONADE
NO LOCALIZATION LOCALIZATION
URGENT EGD AFTER OF BLEEDING
SITE
REMOVAL OF BALLON
TAMPONADE MASSIVE MODEST
BLEEDING DEFINITIVE
BLEEDING TREATMENT:
ESOPHAGEAL OR ENDOSCOPIC
GASTRIC VARICES REPEAT EGD OR (THERMAL
ANGIOGRAPHY COAGULATION OR
SURGERY INJECTION)OR
SCLEROTHERAPY PHARMACOLOGIC
NO LOCALIZATION LOCALIZATION
OF BLEEDING
SITE
WITH RECURRENT OR
PERSISTENT BLEEDING

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Figure 2. Suggested diagnostic procedures in patients with melema
(EGD=esophagogastroduodenoscopy)
MELENA

HISTORY

ELECTIVE EGD

LOCALIZATION NO
OF BLEEDING LOCALIZATION
SITE (50-70%)
NO ACTIVE BLEEDING
IN CASE OF
RELEVANT BLEEDING
RECTOSIGMOIDOSCOPY
AND COLONOSCOPY
ANGIOGRAPHY (WHENEVER POSSIBLE)

NO LOCALIZATION LOCALIZATION NO
OF BLEEDING LOCALIZATION
SITE
SURGERY
RADIOISOTOPIC
DEFINITIVE SCAN
TREATMENT OR
OBSERVATION
IF POSITIVE,
ANGIOGRAPHY

PENANGANAN

RESUSITASI (UMUM)

Pasang infus / IVFD

Pasang NG Tube
Golongan darah / Cross Match
Transfusi darah jika perlu
Koreksi koagulopati jika perlu

11
 PERDARAHAN SALURAN CERNA BAGIAN ATAS
HEMATEMESIS / 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 Nasogastrik
Slang Nasogastrik Bilas air es
- Bilas dengan air es sampai jernih Obat hemostatik
Obat hemostatik Monitor Hb/Ht, tensi, nadi,
Monitor Hb/Ht, tensi, nadi, kesadaran kesadaran
Anamnese & Pemeriksaan Fisik Anamnese & Pemeriksaan
Fisik

Perdarahan terus Perdarahan stop

Gastroskopi

Gastroskopi
Dengan varises Tanpa varises

- Skleroterapi darurat
- Slang S-B + Gastritis erosif
- Sandostatin& Somastotatin Ulkus Peptikum
Mallory Weiss
- Terapi konservatif diteruskan Tumor
(antasid, penghambat H2,
hemostatik, laktulose, neomisin) Konservatif
(antasid, penghambat
H2,PPI
hemostatik)

Perdarahan terus Perdarahan stop

Operasi Konservatif

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VARISES BLEEDING
PROFILAKSIS
BETABLOKER
(PROPANOLOL)

MEDICAMENT :
TERAPEUTIK :
SOMATOSTATIN

SB TUBE
SKLEROTERAPI

ENDOSKOPI
ERADIKASI
BINDING LIGASI

TIPSS

ULKUS BLEEDING
1. MEDIKAMEN : ARH2, PPI, Antasida
2. ENDOSCOPIC Therapy :
laser

elektrokoagulasi

heater probe

topical sprays

injection therapy (adrenalin
1:10.000, alkohol & polidokanol )
3. RADIOLOGIC Therapy : embolisasi
4. Prophylactic therapy : * eradikasi HP pd TD & TL
* empiric therapy jika HP tdk
dieradikasi.
* Analog PG (misoprostol)

utk
NSAID + TL
* Surgery utk recurent bleeding

13
 ENDOSCOPIC THERAPY
OF UPPER GI BLEEDING
TOPICAL THERAPY MECHANICAL THERAPY
-Tissue adhesives -Snares
-Clotting factors -Sutures
-Collagen -Balloons
-Ferromagnetic tamponade -Hemoclips

INJECTION THERAPY THERMAL THERAPY

-Variceal bleeding -Electrocoagulation
-Non variceal bleeding - monopoloar
- Ethanol - electrohydrothermal
- Other sclerosants bipolar (multipolar)
-Heater probe
-Laser

THERAPEUTIC OPTIONS FOR ACUTE UPPER

GASTROINTESTINAL HEMORRHAGE
Peptic Ulcer disease
MEDICAL THERAPY Antisecretory therapy,Antacids,Sucralfate,Misoprostol
Gastroesophageal varices
Intravenous vasopressin with or without nitroglycerin
Intravenous octreotide
Balloon tamponade
Peptic ulcer disease
ENDOSCOPIC THERAPY Thermal coagulation
Multipolar electrocoagulation,Heater probe,laser ther
Injection therapy
Epinephrine, Alcohol
Combination therapy;thermal coagulatuion & injection
Gastroesophgeal varices
Injection sclerotherapy,variceal band ligation
Cyanoacrylate injection
Combination therapy;sclerotherapy &band ligation
Tumors
Termal probe, Laser ablation,Thermal balloon cateter
Non variceal (ulcer,endoscopic, or mallory-Weiss tear)
SURGICAL THERAPY Variceal
Portosystemic shunting,Esophageal transection and
devascularization, Liver transplantation
RADIOLOGIC THERAPY Peptic ulcer disease
Arterial embolization, Intraarterial vasopressin infusion
Gastroesophageal varices
Embolization,Transjugular intrahepatic
portosystemic shunting

14
 Score
Variable 0 1 2 3

Age (yr) < 60 60-79 >80

Shock No Shock Tachycardia Hypotension
(BP >100 (BP>100,PP>100 (BP<100
PP <100) PP>100,
Comorbidity Nil mayor
CHF,CAD, Renalfailure,
Others Liverfailure,
diss.malignancy
Diagnosis Mallory weiss All other Malignancy of
No lesion, diagnosis GI tract
no SRH
Major SRH None or dark Blood in UGI
spot Clot,visible or
spurting
Score : < 3 excellent prognosis
vessels
> 8 poor prognosis
SRH : Stigmata of recent Hemorrhage

Interpretasi Rockall Score

• Skor > 3 : Risiko mortalitas meningkat

• Skor > 4 : Perlu dirawat diruang High Care
Resusitasi Optimal
Kerja sama tim Penyakit Dalam,bedah , anestesi.
• Mortalitas :
• Skor 0 0%
• Skor 1 3% • Skor 5 36%

• Skor 2 6% • Skor 6 62%

• Skor 3 12%
• Skor 7 75%
• Skor 4 24%
•

15
 PSCA
Monitor status hemodinamik
resursitasi

Resiko rendah (Rockall < 2) Resiko tinggi (Rockall > 4)

Endoskopi segera / urgent

Perdarahan ulang (10-20 %) endoskopi terapi

Endoskopi 12 - 24 jam

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 PENATALAKSANAAN
PERDARAHAN SALURAN CERNA
Konsensus Nasional 2003

PB. PERKUMPULAN
GASTROENTEROLOGI INDONESIA

Manajemen awal
ORDER

• O ksigenasi

• R estore circulating volume

• D rug Therapy

• E valuate response to Therapy

•R emedy underlying cause

Prinsip dasar :
Ganti kehilangan cairan, Stop perdarahan ! !

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Resusitasi dan Stabilisasi(1)

• Pasang jarum ukuran 16 dan 18 untuk infus cairan kristaloid

secara cepat; Untuk ekspansi cairan intravaskular 1 L,
dibutuhkan cairan kristaloid 3 L

• NGT untuk diagnostik dan monitoring

• Terapi antara ( Stop gap treatment):

• Somatostatin
• Oktreotide
• SB –tube pada perdarahan varises

• Obat supresor asam PPI efektif untuk perdarahan SCBA

• Evaluasi dan monitor keadaan dan respon terhadap terapi

secara klinis, Hematologis, analisa gas darah dan status
Metabolik

Resusitasi dan Stabilisasi (2)

• Transfusi darah atau komponen darah diberikan

bila Hb < 7 g/dl atau bila ada gangguan
koagulasi
•Bila memungkinkan upaya diagnostik secara
endoskopik untuk mengetahui dan menghentikan
sumber perdarahan perlu segera dilakukan.
• Perlu dipersiapkan agar pasien dapat ditransfer
kepusat rujukan dengan aman
• Obat Vasoaktif Dopamin,Dobutamin, hanya
diberikan pada pasien dengan Syok hemoragik
bila sudah diberikan penggantian cairan yang
cukup

18
 Terapi obat pada perdarahan SCBA
• Supresi Asam : Pilihan utama Proton Pump Inhibitor (PPI )
Omeprazol : 3 x 40 mg IV atau
40 mg bolus, 8 mg/jam
selama 3 x 24 jam
•Obat Hemostatik;
• Tranexamic acid; 3 x 500 mg IV
• Vit K ; 3 x 10mg IV
• Obat Vasoaktif :
• Somatostatin : 250 µg bolus, infus 250 µg / jam , 3 x 24
jam
Oktreotide 0,05 mg /jam, 3 x 24 jam

Indonesian Society of
Gastroenterology

NATIONAL
CONCENSUS ON
UPPER
GASTROINTESTINAL
BLEEDING
MANAGEMENT IN;

Primary Health Care /

Emergency Unit
Hospital type D
(without specialist and
endoscopy facilities)

19
Indonesian Society of
Gastroenterology

NATIONAL CONCENSUS
ON
UPPER
GASTROINTESTINAL
BLEEDING
MANAGEMENT IN;

Secondary Care /
Specialist / Hospital
type C
( without endoscopy
facilities )

Indonesian Society of
Gastroenterology

NATIONAL CONCENSUS
ON
UPPER
GASTROINTESTINAL
BLEEDING
MANAGEMENT IN;

Referral Hospital type A

&B
(endoscopy facilities are
available)

20
TERIMA KASIH

21