UPPER

GASTROINTESTINAL
BLEEDING

by
Fajar Yuwanto
SMF Penyakit Dalam
RSUD abdul Moeloek
DEFINITIONS
* HEMATEMESIS : is vomiting fresh red blood
A site of bleeding proximal to the duodenal-
jejunal junction ( Upper Treitz Ligament )
The Colour of vomitus depends on how long
the blood has been in the stomach
* Coffee ground vomiting is vomiting of altered
black blood
* Melena is the passage of black tarry stools
 Causes of Haematemesis
and Melaena
Oesophagus
Oesophageal Varices
Mallory-Weiss tear
Oesophageal carcinoma
Reflux oesophagitis
Foreign body
 Causes of Haematemesis
and Melaena
Stomach
Peptic ulcer
Erosions/ Gastritis
Gastric varices
Portal hypertensive gastropathy
Gastric carcinoma
Lymphoma
Leiomyoma
Angiodysplasia (including Osler’s disease)
Dieulafoy’s erosion
 Causes of Haematemesis
and Melaena
Duodenum/jejunum
Peptic ulcer
Erosions/ Gastritis
Vascular malformations
Haemofilia
Polyps (including Peutz-Jeghers
syndrome and other polyposis syndromes)
Aorto-enteric fistula
Causes of massaive upper
gastrointestinal bleeding

Oesophageal or gastric varices

Gastric ulcer
Duodenal ulcer
Stress ulceration
Dieulafoy’s erosion
Aorto-enteric fistula
 Causes of acute upper gastrointestinal haemorrhage
in Sardjito Hospital 2004

1%1%1%

22%

9%
66%

VE Stress Ulcer Gastritis

Duodenitis Ulkus Peptik Esofagitis

Endoscopic stigmata associated with
high risk of further gastrointestinal bleeding.
Top left : an active, spurting haemorrhage from
a peptic ulcer is associated with an 80% risk of
Continuing bleeding or rebleeding in shocked
patients. Top right : a non-bleeding, visible vessel
Represents either a pseudoaneurysm of an eroded
artery or a closely adherent clot, and 50% of such
patients rebleed in hospital. Left: large varives
with red spots are also strongly associated with bleeding
Risk factors for death after hospital admission
for acute upper gastrointestinal haemorrhage

Advanced age
Shock on admission (pulse rate > 100 beats/min;
systolic blood pressure < 100 mmHg
Comorbidity (particularly hepatic or renal failure and
disseminated cancer)
Diagnosis (worst prognosis for advanced upper
gastrointestinal malignancy)
Endoscopic findings (active, spurting haemorrhage
from peptic ulcer; non-bleeding, visible vessel; large
varices with red spots)
Rebleeding (increases mortality 10-fold)
Faktor resiko varises ruptur
Besar varises  F3 > 5 mm
Tekanan intra varises > 15 mmHg
Warna varises :
Cherry red spot (CRS)
Red wale marking (RWM)
Hemato cystic spot (HCS)
 Blood
Blood tests
tests taken
taken urgently
urgently at
at initial
initial
presentation
presentation

Haemoglobin,
Haemoglobin, platelet
platelet count,
count, and
and white
white
blood
blood cell
cell count
count
Urea
Urea and
and electrolytes
electrolytes
Liver
Liver function
function test
test
Cross
Cross match
match
Prothrombin
Prothrombin timetime
 PENATALASANAAN AWAL
Anannesis & pemeriksaan fisis
Tanda vital, Jalan infus yg sangat besar
Selang nasogastrik Hb, Ht, trombosit,
hemostaisis
Hemodinamik stabil
Tidak ada perdarahan aktif Hemodinamik tidak stabil
Perdarahan aktif
Pengobatan empirik RESUSITASI
Cairan krostaloid, cairan koloid,
Transfusi darah, koreksi
faktor koagulasi

Hemodinamik stabil
Perdarahan berhenti Hemodinamik stabil
Perdarahan tetap berlangsung Obat Vasoaktif
Perdarahan berhenti Octreotide, Somat ostatin,
Vasopressin
Elektif Emergensi atau Dini
Endoskopi SCBA Endoskopi SCBA

Varises esophagus Sumber perdarahan

lambung Tukak Tak tervisualisasi
Skleroterapi Injeksi, Radiologi, Intervensional
Atau ligasi hemostatik Diagnostik & terapeutik
Pengobatan
Bedah Jika Atau “SB tube” Atau bedah segera Atau bedah segera
definitif
gagal
Resuscitation
a. Mild or Moderate Bleed
* Pulse and blood pressure : N
* Hb > 10 mg/ml
* Without comorbidity
* Less than 60 years of age
b. Severe Bleed
Pulse > 100 beats/min
Sistolic blood pressure < 100
mmHg
Hb < 10 mg/ml
Aged > 60 years
 Table 1. Hypovolaemic shock: symptoms, sign, and fluid replacement
Blood loss (ml) <750 750-1500 1500-2000 >2000
Blood loss (%bv) <15% 15-30% 30-40% <40%
Pulse rate <100 >100 >120 >140
Blood pressure Norma Norma Decreased Decreased
Pulse pressure Normal or increased Decreased Decreased Decreased
Respiratory rate 14-20 20-30 30-40 >35
Urine output >30 20-30 30-40 >35
Mental status Slightly anxious Mildly anxious Anxious & confused Confused & letargic
Fluid replacement Crystalloid Crystalloid Crystalloid & blood Crystalloid blood

Adapted from Grenvick A, Ayres SM, Holbrook PR,

et al. Textbook of critical care. 4th edition. Philadelphia WB Saunders Company; 40-5
Drug Therapy
1. Acid suppressing drugs
2. Somatostatin
3. Antifibrinolytic drugs
 Pasien
Pasien dengan
dengan Perdarahan
Perdarahan Saluran
Saluran
Gastrointestinal
Gastrointestinal Bagian
Bagian Atas
Atas

Singkirkan :
Riwayat penyakit A Hematemesis atau melena C
B Pemeriksaan fisik
Hemoptisis
Epitaksis

Pasien scr hemodinamik tidak stabil Pasien yg scr hemodinamik stabil

Resusitasi : Oksigen, intubasi pm

D Jalur intravena x 2
Hematokrit, gol & skrining darah
Jalur intravena, sifat pembekuan
Gol darah & crossmatch, transfusi
Perbaiki koagulopati, EKG
E Lavase nasogastrik

E Lavase nasogastrik
Positif, Positif, jernih dg
Tidak jernih negatif
Perawatan di ICU <500-1.000 cc
Dg lavase
F Konsultasi dokter ahli Observasi psn 6 jam
Gastroenterologi/bedah
Rawat Hematokrit  Hematokrit stabil
Perub tanda vital Tanda vital stabil

Perdarahan berlanjut Perdarahan berhenti Transfusi pm

G Endoskopi Terapi spesifik Pemeriksaan elektif H Follow-up

Rawat jalan
 Management of bleeding peptic
ulcer
Peptic ulcer

Low risk of rebleeding Active bleeding or high risk of

Rebleeding (shock, visible vessel)

Endoscopic therapy
Monitor

No further bleeding Rebleed Unable to control bleeding

Repeat endoscopic therapy

Rebleed Surgery
Endoscopic treatment for non-variceal bleeding

Thermal
Thermal
Heater
Heater probe
probe
Multipolar
Multipolar electrocoagulation
electrocoagulation
Injection
Injection
Adrenaline
Adrenaline (1:10.000
(1:10.000 to
to 1:100.000)
1:100.000)
Alcohol
Alcohol (98%)
(98%)
Sclerosants
Sclerosants (ethanolamine,
(ethanolamine, 1%1% Polidoconal)
Polidoconal)
Procoagulants
Procoagulants (thrombin,
(thrombin, fibrin
fibrin glue)
glue)
Mechanical
Mechanical
Clips
Clips
Sutures
Sutures
Staples
Staples
Combination
Combination
 Management of non-bleeding varices
Varices present but bleeding

Band ligation

Rebleeding No further bleeding

Repeat band ligation (or sclerotherapy)

Octreotide, 25 ug/hour

Further bleeding No further bleeding Repeat within 1 week

Consider:
•Transcutaneous intrahepatic portosystemic shunt Repeat every 3-4 weeks
•Shunt surgery/liver transplantation Until varices are obliterated
•Withdrawal of therapy
 Management of actively bleeding varices
Actively bleeding varices

Band ligation or injection sclerotherapy

Commence octreotide, 25 ug/hour

Bleeding controlled Bleeding not controlled

Insert Sengstaken-Blakemore
Tube (admit to ICU)

Deflate Sengstaken-Blakemore tube at 24 hours

Attemp band ligation or sclerotherapy

unsuccesful Succesful

Re-inflate Sengstaken-Blakemore tube Consider:

•Transcutanous intrahepatic portosystemic shunt
• Shunt surgery
• Transplantation

Deflate Sengstaken-Blakemore
Tube at 24 hours
Attemp ligation or sclerotherapy
Consider :
•Transcutaneous intrahepatic portosystemic shunt
•Shunt surgery
Unsuccesful •Transplantation
•Withdrawal of therapy
Penanganan
Penanganan Perdarahan
Perdarahan Akut
Akut VE
VE

Tindakan
Tindakan Umum
Umum
Resusitasi
Resusitasi :: cairan
cairan kristaloid
kristaloid
Transfusi
Transfusi darah
darah mengandung
mengandung faktor
faktor pembekuan
pembekuan
darah
darah segar,
segar, whole
whole blood,
blood, fresh
fresh frozen
frozen plasma,
plasma,
pached
pached redred cell
cell
Bilas
Bilas lambung
lambung   NGTNGT
Vitamin
Vitamin KK intramuskuler
intramuskuler :: obat
obat hemostasis
hemostasis (asam
(asam
traneksamat)
traneksamat)
Penyekat
Penyekat reseptor
reseptor HH22
Sterilisasi
Sterilisasi usus
usus :: kanamisin,
kanamisin, neomisin
neomisin oral
oral
Laktulosa
Laktulosa oral
oral // klisma
klisma
Pengobatan
Pengobatan Farmakologis
Farmakologis
Menurunkan
Menurunkan tekanan
tekanan porta
porta   perdarahan
perdarahan
berhenti
berhenti
Vasopresin,
Vasopresin, vasokonstriktor
vasokonstriktor pembuluh
pembuluh darah
darah
splangnik
splangnik   aliran
aliran darah
darah keke Vena porta .
Vena porta .
Dosis 20  dalam
Dosis :: 20 dalam 100100 cccc selama
selama 10-20
10-20 menit
menit
diulang
diulang tiap
tiap 44 jam
jam atau
atau per
per infus 0,2-0,5 /menit
infus 0,2-0,5 /menit
 120
120 menit
menit
Somatostatin.
Somatostatin. Bolus 250 g
Bolus 250 g   infus 250 g/jam.
infus 250 g/jam.
Octeotrid, 100 g
Octeotrid, 100  infus
g  infus 2525 g/jam
g/jam
Nitrat
Nitrat organik,
organik, ISDNISDN 20
20 mgmg (2(2 ampul)
ampul) ++ 500
500 cc
cc
NaCl
NaCl 0,9%
0,9% (detrose
(detrose 5%)5%) perper drip  22 mg/jam
drip  mg/jam
syarat
syarat :: tekanan
tekanan sistolik
sistolik >> 90
90 mmHg,
mmHg, Nadi
Nadi << 90
90
x/mnt.
x/mnt.
Tindakan
Tindakan khusus:
khusus:
•• SB
SBTube
Tube
•• Skleroterapi/ligasi
Skleroterapi/ligasi
Minnesota tube
Endoscopic treatment of varices. Intravariceal injection of sclerosant
(left) and band ligation of oesophageal varices (right)
Traneksamat
Menghambat aktivitas plasminogen dan plasmin

Plasmin
Meningkatkan proses fibrinolisis
Menurunkan aktifitas faktor koagulopati
Meningkatkan permeabilitas pembuluh
darah
Menurunkan agregasi platelet
Figure : Antifibrinolytic Action of Aminocaproic Acid and Tranexamic Acid
N.Engl.J Med. 1998 : 339(4)245-253
 Table 2. Indications for the use the Antifibrinolytic
drugs tranexamic acid and aminocaproic acid in the
treatment of excessive bleeding

Clinical Situation Study Grade of

Evidence*
Primary menorrhagia Bonnar and Sheppard A
Upper gastrointestinal Henry and O’Connell A
bleeding
Dental extraction in patients Walsh et al A
with coagulation disorders Forbes et al
Sinder-Pedersen et al

Bleeding associated with Gardner and Helmer B

thrombocytopenia Bartholomew et al

N.Engl.J.Med. 1998: 339(4)245-253

Klasifikasi V.E.
I. Kl. Degradi
II. Kl. Palmer & Brick
III. Kl. Omed
IV. Kl. Perhimpunan Endoskopi GI
Jepang
 Kl. Perhimpunan Endoskopi GI
Jepang

1. Warna (colour)
2. Tanda Warna merah (red colour sign)
3. Bentuk (form)
4. Lokalisasi
 Warna

Colour White (CW)

Colour Blue (CB)
 Tanda warna merah
(red colour sign/RCS)

Red Wale Marking (RMW)  gambar 1

Cherry Red Spot (CRS)  gambar 2
Hemato Cystic Spot (HCS)  gambar 3
Diffuse Redness (DR)
 (RWM)
Red Wale Marking)

Gambar 1
 (CRS)
Cherry Red Spot

Gambar 2
 (HCS)
Hemato Cystic Spot

Gambar 3
 (DR)
Diffuse Redness

Gambar 4
 Bentuk

Tingkat I : VE lurus (straight line

varises/F1)  gambar 5
Tingkat 2 : VE bentuk untaian tasbeh
menempati 1/3 lumen (F2)  gambar 6
Tingkat 3 : VE yang besar, berkelok-
kelok >1/3 lumen (F3)  gambar 7
Tingkat 1, varises yg lurus
(Straight line varicess/F1)
Tingkat 2, varices berbentuk
untaian manik-manik (rosary like varicess)
yg menempati 1/3 lumen(F2)
Tingkat 3, varices yg besar dan berkelo-kelok
Menempati lebih dari 1/3 lumen (F3)
 Lokalisasi
VE sp diatas bifurkasi trakhea (LS)
VE yg menempati daerah dibawah
bifurkasi trakhea (Lm)
VE yg menempati daerah dibawah 1/3
distal (Li)
VE yang menempati cardia lambung (lg)
 Ls
superior

Lm
middle

Li
inferrior

Lg
gastric