*Others: Erosive gastritis, Esophagitis, Polyp, Cancer,

*Syam AF et al. Indones J Of Gastroenterol, Hepatol & Diges Endos, Dec 2005
Hasil pengawasan rutin BPOM Oktober 2012 hingga Oktober 2013.
6
Asam, tripsin,pepsin, asam
empedu, etanol, aspirin,
OAINS dan infeksi H. pylori.
FAKTOR AGRESIF
7
Aliran darah mukosa, sel
epitel permukaan,
prostaglandin, surfaktan,
musin, bikarbonat dan
motilitas.
FAKTOR DEFENSIF
8
9
 The Toronto Consensus for the Treatment of
Helicobacter pylori Infection in Adults- Gastroenterology
July 2016
Syam AF, Miftahussurur M et al, PLOS ONE | DOI:10.1371/ November 23, 2015
Syam AF, Miftahussurur M et al, PLOS ONE | DOI:10.1371/ November 23, 2015
Syam AF, Miftahussurur M et al, PLOS ONE | DOI:10.1371/ November 23, 2015
Syam AF, Miftahussurur M et al, PLOS ONE | DOI:10.1371/ November 23, 2015
Syam AF, Miftahussurur M et al, PLOS ONE | DOI:10.1371/ November 23, 2015
Syam AF, Miftahussurur M et al, PLOS ONE | DOI:10.1371/ November 23, 2015
National Consensus on the Management of Dyspepsia and Helicobacter pylori 2014
If h.pylori is present in the stomach, it will break down the carbon-13 (13C) labeled urea
into ammonia and carbon dioxide. Carbon dioxide is absorbed through the lining of the
stomach into the blood, and it travels to the lungs where it is excreted in the breath.
The samples of exhaled breath are collected to measure the ratio of 13C and 12C.
Referensi:
Gisbert and Calvet, Test-and-Treat for Dyspepsia, Clinical and Translational Gastroenterology, 2013: 4
 Drug Dose Duration
First line:
PPI* 2x1 7-14 days
Amoxicillin 1000 mg (2x1)
Clarithromycin 500 mg (2x1)
Resistance to clarithromycin >20%:
PPI* 2x 7-14 days
Bismuth subsalisilat 2 x 2 tablet
Metronidazole 500 mg (3x1)
Tetracyiclin 250 mg (4x1)
If bismuth is not available
PPI* 2x 7-14 days
Amoxicillin 1000 mg (2x1)
Claritromycin 500 mg (2x1)
Metronidazole 500 mg (3x1)
National Consensus on the Management of Dyspepsia and Helicobacter pylori, 2014
 Second line : if first line eradication failure

PPI* 2x 1 7-14 days

Bismuth subsalisilat 2 x 2 tablet
Metronidazole 500 mg (3x1)
Tetracyclin 250 mg (4x1)
PPI* 2x 7-14 days
Amoxcilin 1000 mg (2x1)
Levofloxacin 500 mg (2x1)
Third line: if second line eradication failure and culture and standard
susceptibility testing is not available.
PPI* 2x1 7-14 days
Amoxicilin 1000 mg (2x1)
Levofloxacin 500 mg (2x1)
Rifabutin 150 mg (2x1)
*PPI yang digunakan antara lain rabeprazole 20 mg, lansoprazole 30 mg, omeprazole 20 mg, pantoprazole 40 mg, esomeprazole 20 mg.
Catatan: Terapi sekuensial (dapat diberikan sebagai lini pertama apabila tidak ada data resistensi klaritromisin) : PPI + amoxicillin selama
5 hari diikuti PPI + klaritromisin dan nitroimidazole (tinidazole) selama 5 hari.
 Penatalaksanaan Perdarahan
Saluran Cerna Atas Non Varises di Indonesia
Juni 2012

26
Tujuan : stabilisasi hemodinamik

1. Resusitasi penderita : ( A – B – C )
2. Nasogastric tube (NGT)
3. Pemberian transfusi darah
Resusitasi penderita : ( A – B – C )
• Pasang infus kiri dan kanan no 16,
• Perbaiki saluran nafas,

• Ambil contoh darah

• (Golongan Darah / Hematokrit - Hb)
• Nadi > 100x/ mnt  infus NS dan/atau colloid.
• Tentukan derajat kehilangan darah
• (nadi, tekanan darah) sistolik BP < 100 mmHg
• Bila perlu persiapkan pemasangan vena dalam
Evaluasi aktivitas perdarahan
• Anamnesis
• Tanda vital : Nadi, Tekanan darah, Pernapasan termasuk
“Postural signs”
• Pemeriksaan fisik : termasuk colok dubur
• Segera pasang infus kateter (vena perifer, vena sentral)
cairan kristaloid / NaCl, darah
• Contoh darah  laboratorium / golongan darah
Pasang NGT
• Bila cairan jernih atau jernih setelah lavage  NGT
dicabut
• Darah/berdarah, lavage  NGT ditinggalkan sementara
untuk monitoring, persiapan endoskopi

Efek samping NGT

 Pemberian transfusi darah segera pada :
• Penderita syok

• Perdarahan terus-menerus

• Gejala-gejala angina pectoris

• Hematokrit < 20%

• Pasien resiko tinggi : (orang tua, CHD, Sirosis hepatis)

 transfusi PRC sampai Ht > 30%)

• Pasien koagulopati  fresh frozen plasma

• Trombositopenia  infus trombosit

• Transfusi  hemodinamik stabil atau Ht 25-30%

 Cohrane meta analysis found :
• Pre-endoscopic PPI therapy
Pre-endoscopic PPI therapy significantly reduced the
may be useful for patients proportion patients with high risk
with high risk stigmata stigmata and the need for
endoscopic therapy vs placebo and
H2RA therapy

32
Barkun et al. Ann Intern Med. 2010;152:101-113
 100

80
Forrest I* Forrest IIa Forrest IIb Forrest IIc Forrest III

60
55
40 43

20 22

10 5
0
34
Patients with endoscopic or clinical re-bleeding (%)

*Patients did not receive endoscopic therapy Laine L & Peterson WL. N Engl J Med 1994;331:717–27
 Konsensus Nasional Penatalaksanaan
Perdarahan Saluran Cerna Atas Non Varises di Indonesia
Juni 2012

35
• Guideline recommendation to give high-dose continuous
intravenous PPI therapy to patients with PUB with high-risk
stigmata.
• Dosis PPI : Omeprazole/Esome/Panto 80 mg bolus, 8 mg/h
continuous infusion for 72 h
• H. pylori eradication therapy : Testing for H. pylori is
recommended in all patients with PUB. This should be followed
by eradication therapy for those who are H. pylori-positive.

36
 pH
Indikasi
lambung
Penurunan kejadian perdarahan
3.5
karena stress mukosa lambung
Pepsin tidak aktif sebagai faktor
4.5
agresif mukosa lambung
=5 99.9% netralisasi asam
Pencegahan koagulasi dan aggregrasi
<6
platelet darah
Prevention
Penurunan kejadian perdarahan
6 of Ulcer
ulang Rebleeding
8 Penghancuran pepsin
 Esomeprazole iv versus Lansoprazole iv

n = 50 subjek sehat
n = 50 subjek sehat

Esomeprazole i.v meningkatkan pH > 4 baik pada hari -1 dan hari-5

lebih bertahan lama dibandingkan dengan lansoprazole i.v.
 Esomeprazole iv versus Lansoprazole iv

Hari ke-1 Hari ke-5

Eso iv 40 mg
Eso iv 40 mg
Panto iv 40 mg
Panto iv 40 mg
Baseline
Baseline

n =24 subjek sehat

Esomeprazole 40 mg i.v. LEBIH CEPAT dan efektif mencapai pH > 4 serta mampu
mempertahankan pH > 4 LEBIH LAMA dibandingkan pantoprazole 40 mg i.v
 Penelitian Esomeprazol vs Pantoprazole
dalam mempertahankan pH >4

Grafik pH 24-jam intragastrik

Esomeprazole i.v 40 mg

Pantoprazole i.v 40 mg

n = 21 pasien H.pylori
negatif

Esomeprazole 40 mg i.v. lebih mampu mempertahankan pH > 4

lebih lama dibandingkan pantoprazole 40 mg i.v
• RCT, multicenters, internasionally (multi-ethnic), double-
blind, 91 centres in 16 countries.
• Comparison the efficacy of Esomeprazole vs Placebo in PUB
pts. with high risk stigamata. Primary outcome was the rate of
recurrent bleeding within 72 hours. Secondary outcomes:
recurrent bleeding 7 & 30 days, mortality, death, surgery,
endoscopy re-treatment, etc.
• Esomeprazole 376 pts, Placebo 391 pts., consist of 40% NSAID
use, 27% aspirin, 68% H.pylori [+], mostly pts. were Forrest Ib
& IIa ulcer.
Sung JJ, et al. Ann Intern Med 2009;150:455-464
Patients with re-bleeding (%)
esomeprazole iv,
15 80 mg + 8 mg/hour for 3 days
then esomeprazole oral, 40 mg
once daily,
44% 43% 13.6 for 27 days
12 12.9

9
placebo iv for
**
** 3 days then esomeprazole oral,
7.7 40 mg once daily,
6 7.2 for 27 days

**p<0.01
0
Within 7 days Within 30 days

Sung JJ, et al. Ann Intern Med 2009;150:455-464

Total units of blood transfused
(within 30 days)
esomeprazole iv,
1000 80 mg + 8 mg/hour for 3
days then esomeprazole
37% oral, 40 mg once daily,
935 for 27 days
800

600 *
placebo iv for
3 days then esomeprazole
589 oral, 40 mg once daily,
400 for 27 days

200
*p<0.05

Sung JJ, et al. Ann Intern Med 2009;150:455-464

Total number of additional days in hospital
for re-bleeding (within 30 days)
esomeprazole iv,
600 80 mg + 8 mg/hour for 3
days then esomeprazole
500 oral, 40 mg once daily,
43% for 27 days
500
400
placebo iv for
300 ** 3 days then esomeprazole
oral, 40 mg once daily,
284 for 27 days
200

100
**p<0.01
0

Sung JJ, et al. Ann Intern Med 2009;150:455-464

 • Mukoprotektor
• Obat anti asam

MUKOPROTEKTOR OBAT ANTI ASAM

• Misoprostol Penghambat
Antagonis H2 Pompa Proton PPI
• Sukralfat
• Teprenone
• Simetidin • Omeprazole
• Rebamipide • Ranitidin • Lansoprazole
• Roxatidin • Rabeprazole
• Famotidin • Pantoprazole
• Nizatidin • Esomeprazole

47
• ABC’s and appropriate resuscitation critical
• Early risk stratification, including early endoscopy
• Early discharge for very low-risk patients
• Endoscopic hemostasis for high-risk lesions
• High-dose IV PPI are an adjuvant to endoscopic
hemostasis
• Secondary prophylaxis needed for patients
 H. pylori
 NSAIDs / COX2
 ASA / clopidogrel

48
49
50
51