Perdarahan Saluran Cerna

Oleh : Salman Paris.H

Bagian Penyakit Dalam RSUD Budhi Asih/ Fakultas

Kedokteran UPN Veteran Jakarta
Learning Objectives
• UGIB
– Nonvariceal (PUD) and variceal
– Resuscitation, risk assessment, pre-endoscopy
management
– Role of endoscopy
– Post-endoscopy management
• LGIB
– Risk assessment
– Role and timing of colonoscopy
– Non-endoscopic diagnostic and treatment options
 Pendahuluhan
Dibagi 2 :
1. Perdarahan saluran cerna atas atau upper
gastrointestinal bleeding (UGIB). UGIB: perdarahan
proksimal dari ligament Treitz
a. Perdarahan Varises
b.Perdarahan Non Varises
2. Perdarahan saluran cerna bawah atau Lower
gastrointestinal bleeding (LGIB) : perdarahan distal
dari ligamnet Treitz
Perdarahan saluran cerna atas atau
upper gastrointestinal bleeding (UGIB)
 Penyebab Perdarahan SCBA ( Endoskopi di
RSCM 1996-1988)
Persentase(%)

Pecahnya Varises Esofagus 27.2

Kombinasi 22.1
Gastritis Erosive 19.0
Gastropati HT portal 11.7
Tukak duodenum 5.7
Tukak Lambung 5.5
Pecahnya varises fundus 1.9
Kanker duodenun 1.1
Kanker lambung 0.9
Esofaginitis Erosif 07

Dikutip dari Simadibrata M

Manifestations of Overt GI Bleeding

Symptoms & Signs

Hemetemesis : Vomiting of blood or altered blood ("coffee grounds"
appearance)

Melena
•Black, “tarry”, foul-smelling, (>100 mL blood for 1 melenic stool)
•Blood in GI tract > 14 hours

Hematochezia
•Bright red / maroon stool, bloody diarrhea, clots
•Usually LGI source : UGI source in 10%
Estimating Degree of Blood Loss
RR, HR, and BP can be used to estimate degree of
blood loss/hypovolaemia
Class I Class II Class III Class IV
Volume Loss 0-750 750-1500 1500-2000 >2000
(ml)
Loss (%) 0-15 15-30 30-40 >40
RR 14-20 20-30 30-40 >40
HR <100 >100 >120 >140
BP Unchanged Unchanged Reduced Reduced
Urine Output >30 20-30 5-15 Anuric
(ml/hr)
Mental State Restless Anxious Anxious/conf Confused/
used lethargic
Signs
Klasifikasi Perdarahan
Tatalaksana Perdarahan Varises
1. Resusitasi
2.Terapi Farmakologik
Vasopresin dan analognya( baik tunggal atau
kombinasi dengan nitrogliserin) dan somatostatin
atau analognya.
3.Terapi Endoskopik
Skleroterapi
Ligasi
Tamponade balon
Tips
4. Pembedahan
Predictors of large esophageal
varices
• Severity of liver disease (Child Pugh)
• Platelet count < 88K
• Palpable spleen
• Platelet count/spleen diameter (mm) ratio <909

Gut 2003;52:1200
J Clin Gastroenterol 2010;44:146
J Gastroenterol Hepatol 2007;22:1909
Arch Intern Med 2001;161:2564
Am J Gastroenterol 1999;94:3103
VARICEAL Bleed

• Vasoconstrictor therapy
• Antibiotics
• Resuscitation
• ICU level care
• Endoscopy
• ALternative/Rescue therapies
• Beta blockade
Endoscopy
Variceal Bleed: Prognosis
 Prognosis closely related to severity of underlying chronic liver disease
(Childs-Pugh grading)
 Child-Pugh classification grades severity of liver disease into A,B,C
based on degree of ascites, encephalopathy, bilirubin, albumin, INR

 Mortality 32% Childs A, 46% Childs B, 79% Childs C

Tatalaksan Non Varises

Resuscitation includes fluid administration, blood

transfusion, cardiorespiratory support, and treatment
of significant comorbid diseases, such as sepsis or
coronary artery disease.
In patients who have severe hemodynamic or
pulmonary instability, EGD should be delayed until
the patient is adequately resuscitated and stabilized.
Empiric pharmacotherapy before endoscopy
Proton pump inhibitor (PPI) therapy is recommended
before EGD
Management of Peptic Ulcer Bleeding
Pyramid

Dig Dis 2008;26:291–299.

Endoscopy
The prime diagnostic and therapeutic tool for UGIB.
Therapeutic endoscopy generally produces hemostasis
and prevents rebleeding.
The available therapies include injection therapy, such
as : injection of epinephrine; ablative therapy, such as
electrocautery or argon plasma coagulation; and
mechanical therapy, such as endoclips or banding.
When is Endoscopic Therapy
Required?
~80% bleeds spontaneously resolve
Endoscopic stigmata of recent hemorrhage

Stigmata Continued/rebleeding
rate
Active bleeding 55-90%
major
Nonbleeding visible vessel 40-50%

Adherent clot Variable, depending on

underlying lesion: 0-35%

Flat pigmented spot 7-10%

Clean base < 5%

Surgical consultation is recommended
for patients:
Who have ongoing active bleeding
Massive bleeding, recurrent bleeding
Bleeding associated with significant abdominal pain
Acute lower gastrointestinal bleeding
Variceal bleeding
Abdominal findings suggestive of an acute abdomen.
Risk Stratification: Rockall Score
Identifies patients at risk of adverse outcome
following acute upper GI bleed
Variable Score 0 Score 1 Score 2 Score 3
Age <60 60-79 >80 -
Shock Nil HR >100 SBP <100 -
Co-morbidity Nil major - IHD/CCF/major Renal failure/liver
morbidity failure
Diagnosis Mallory Weiss All other GI malignancy -
tear diagnoses
Endoscopic None - Blood, adherent -
Findings clot, spurting
vessel

Score <3 carries good prognosis

Score >8 carries high risk of mortality
Clinical
60%
Rockall Score – Mortality Rates
50%

40%

30%

20%

10%

0%
0 1 2 3 4 5 6 7
-10%
Causes of Mortality in Patients
with Peptic Ulcer Bleeding
• Patients rarely
bleed to death
• Prospective cohort
study >10,000
cases of peptic
ulcer bleed
• Mortality rate
6.2%
• 80% of deaths not
related to
bleeding Am J Gastroenterol 2010;105:84
Causes of Mortality in Patients
with Peptic Ulcer Bleeding
Most common causes of non-bleeding mortality:
Terminal malignancy (34%)
Multiorgan failure (24%)
Pulmonary disease (24%)
Cardiac disease (14%)

Am J Gastroenterol 2010;105:84
Perdarahan saluran cerna bawah atau
Lower gastrointestinal bleeding (LGIB)
Definisi : didefinisikan : sebagai perdarahan yang terjadi
baru saja, yang berasal dari distal ligamen Treitz, yang
menghasilkan ketidakstabilan tanda vital, dengan tanda-
tanda anemia dengan atau tanpa perlu untuk transfusi darah

Insiden :
Sekitar 20-33% dari episode perdarahan saluran cerna.
LGIB < UGIB
Sekitar 20-27 kasus per 100,000 / thn, populasi pada negara-
negara barat.
Sumber perdarahan :
> 95% sampai 97% kasus  kolon
3 sampai 5% sisanya berasal dari usus halus

Gejala :
Mulai dari hematochezia ringan sampai perdarahan masif
yag disertai shock.
Presentation
Lower GI bleeding presents as:
 Dark red blood – more proximal bleeding point (e.g. Distal small
bowel, colon)
 Bright red blood – more distal bleeding point (e.g. rectum, anus)

 PR blood maybe:
 mixed or separate from the stool
 If separate from the stool it maybe noticed in the toilet water or on wiping
 Passed with motion or alone

If blood mixed with stool (as oppose to separate from it)
suggests more proximal bleeding
If bleeding very slow and occult then can present with iron
deficiency anaemia
Causes
Colon Rectum Anus

Diverticular Disease Polyps Haemorrhoids

Polyps Malignancy Fissure

Malignancy Proctitis Malignancy

Colitis

Angiodysplasia
 LGIB – Risk Stratification
00 factors:
factors: ~6%
~6% risk
risk
Predictors of severe* LGIB:
1-3
1-3 factors:
factors: ~40%
~40%
 HR>100
HR>100
 SBP<115
SBP<115 >3
>3 factors:
factors: ~80%
~80%
 Syncope
Syncope
 nontender
nontender abdominal
abdominal examination
examination
 bleeding
bleeding during
during first
first 44 hours
hours of
of evaluation
evaluation
 aspirin
aspirin use
use
 >2
>2 active
active comorbid
comorbid conditions
conditions

* Defined as continued bleeding within first 24 hours (transfusion of 2+ Units, decline in HCT of Arch Intern Med 2003;163:838
20+%) and/or recurrent bleeding after 24 hours of stability Am J Gastroenterol 2005;100:1821
LGIB – Risk Factors for Mortality
• Age
• Intestinal ischemia
• Comorbid illnesses

• Secondary bleeding (developed during admission for a

separate problem)
• Coagulopathy
• Hypovolemia
• Transfusion requirement
• Male gender
Clinical Gastro Hepatol 2008;6:1004
Small-intestinal bleeding

• Vascular ectasias
Treated with endoscopic therapy if possible.
Surgical therapy can be used for vascular ectasias isolated
to a segment of the small intestine when endoscopic
therapy is unsuccessful.
Estrogen/progesterone compounds have been used for
vascular ectasias, but a double-blind trial found no benefit
in prevention of recurrent bleeding.
Isolated lesions, such as tumors, diverticula, or
duplications, are generally treated with surgical resection.
Colonic bleeding

Bleeding colonic diverticula  stop bleeding spontaneously

in approximately 80% of patients.
o If bleeding persists or recurs  segmental surgical
resection
Bleeding colonic polyps  Endoscopic polypectomy,
Colonic tumors typically require surgical resection.

Surgical therapy is generally  required for major,

persistent, or recurrent bleeding from the wide variety of
colonic sources of GI bleeding that cannot be treated
medically or endoscopically.
 Algorithmic Evaluation of Patient with
Hematochezia
Hematochezia

Assess activity
of bleed
active inactive

Prep for
NG lavage
Colonoscopy

Positive Negative
No risk for UGIB
Risk for UGIB
EGD
negative Hemodynamically
Treat lesion positive stable?
Algorithmic Evaluation of Patient with
Hematochezia
Active Lower GIB

Hemodynamically
stable?
No Yes

Angiography
(+/- Tagged RBC
Consider “urgent
scan)
colonoscopy” vs.
Or
traditional approach
Surgery if life-
threatening
Complications

Hypovolemic shock and subsequent end-organ damage

Complications related to blood transfusions, such as
acquired infections or transfusion reaction
Complications related to procedural interventions, such
as perforation and infection
Prognosis
 Upper GI bleeding  Mortality rate of ~5%–10%
 < 1% in patients < 60 years of age in the absence of
cancer or organ failure
GI bleeding
 Increasing age
 Comorbid conditions
 Hemodynamic compromise (tachycardia or hypotension)
 Other poor prognostic signs: coagulopathy,
immunosuppression, presentation with shock, rebleeding,
onset of bleeding in hospital, variceal bleeding, endoscopic
stigmata of recent bleeding
 Prognosis
o Peptic ulcer
Recurrent bleeding  5% and a mortality  2%.
Patients with actively bleeding ulcers at endoscopy have a rebleeding rate -> 50%
and a mortality  10%.

o Mallory–Weiss tears
 Bleeding recurs in 0–5% of patients

o Esophageal varices
Patients with variceal hemorrhage have poorer outcomes than patients with other
sources of upper GI bleeding.
o Stress-related gastric mucosal injury Mortality rate is high because of serious
underlying illness.
• Lower GI bleeding
o Bleeding colonic diverticula
 Approximately 20–25% of patients have episodes of rebleeding.
 Summary
UGIB is a relatively common, potentially life-threatening
condition that requires rapid assessment of clinical
presentation, rapid resuscitative measures, and
appropriate medical triage.
Administration of PPIs is an important adjunctive
measure for NVUGIB.
EGD remains the principal diagnostic, therapeutic, and
prognostic modality for NVUGIB.
TERIMA KASIH
Monitoring
Patients with acute GI bleeding typically require
hospitalization.
Patients with subacute or chronic GI bleeding may
undergo outpatient evaluation if they do not have
significant comorbid conditions.
Patients who present with active GI bleeding require
close monitoring.
Intensive care unit may be indicated for patients with
hemodynamic instability, those requiring blood
transfusions, and those with continued active bleeding.
Monitoring
After endoscopy
o Patients with lower-risk endoscopic findings (clean-
based ulcer) may be discharged on medical therapy.
o Patients with higher-risk endoscopic findings (active
bleeding or visible vessel) require continued inpatient
monitoring for several days.

• After colonoscopy, the level of monitoring may be

determined by whether definitive intervention has
eliminated source of bleeding.