GASTRO INTESTINAL BLEEDING

dr. Bambang Adi Setyoko, SpPD, FINASIM

RSUD Dr. Loekmonohadi Kudus
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UPPER GI BLEEDING

1. Non Variseal
2. Variseal

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ETIOLOGY

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PATHOGENESIS

Malfertheiner P, et al. Peptic ulcer disease. Lancet 2009;374:1449-61

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STRATIFIKASI RESIKO

SKOR 0-11 POINT,

SKOR 0-2  PROGNOSIS BAIK

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 DEVELOPMENT OF CIRRHOSIS COMPLICATIONS

Dohler KD, Meyer M. Vasopressin analogues in the treatment of hepatorenal syndrome and gastrointestinal haemorrhage. Best Pract Res Clin Anaesthesiol. 2008 Jun;22(2):335-50.
VARICES ESOFAGUS PREVALENCE IN CIRRHOTIC PATIENTS

 Gastrointestinal varices are abnormally dilated

submucosal veins in the digestive tract due to
portal hypertension and can potentially cause life-
threatening bleeding.
 The incidence of esophageal varices in cirrhotic
patients is around 5% at the end of one year and
28% at the end of three years.
 Small varices progress to large varices at a rate of
10% to 12% annually.
 Approximately 50% of all patients with a new
diagnosis of cirrhosis have gastrointestinal
varices.
 Annual risk of variceal bleeding among small and Prevalence of varices increases with the severity of
large varices is 5% and 15% respectively. liver disease (Cirrhosis decompensated):
 The six-week mortality rate among patients with Child-Pugh class A 42.7%, class B 70.7% and class
index variceal bleeding is approximately 20%. C 75.5%).
 Risk of rebleeding without endoscopic
intervention is almost 60% with an increased
mortality rate (33%)

Kovalak M. Endoscopic screening for varices in cirrhotic patients: data from a national endoscopic database. Gastrointest Endosc. 2007 Jan;65(1):82-8.
ACUTE VARICEAL BLEEDING MORTALITY WITHIN 6-WEEKS

178 cirrhosis patients with acute

variceal bleeding 16% patients
died within 6-weeks of index
bleed.

70 cirrhosis patients with acute

variceal bleeding 26% patients
died within 6-weeks of index
bleed.

Reverter E, et al. A MELD-based model to determine risk of mortality among patients with acute variceal bleeding. Gastroenterology. 2014 Feb;146(2):412-19.e3 .
Fortune BE, et al. Child-Turcotte-Pugh Class is Best at Stratifying Risk in Variceal Hemorrhage: Analysis of a US Multicenter Prospective Study. J Clin Gastroenterol. 2017 May/Jun;51(5):446-453.
PATHOGENESIS AND TREATMENT OF PORTAL HYPERTENSION

Garcia-Tsao G, et al. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology. 2017
Jan;65(1):310-335.
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VARICES ESOPHAGUS

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ACUTE VARICEAL BLEEDING TREATMENT TARGET

Prevent 6-week mortality after

Bleeding control
treatment

Reduce bleeding recurrence at 5

days or mortality

Garcia-Tsao G, et al. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology. 2017
Jan;65(1):310-335.
EFFECT OF VASOACTIVE TREATMENT TO OVERALL 7-DAYS
MORTALITY
 The use of vasoactive agents was
associated with a significantly
lower risk of acute 7-day
mortality, and a significant
improvement in haemostasis,
lower transfusion requirements,
and a shorter hospital stay.
 Current guidelines recommend
vasoactive agents should be
initiated as soon as variceal
haemorrhage is suspected and an
EGD, performed with 12h with
either oesophageal variceal
ligation or sclerotherapy.

Wells M, et al. Meta-analysis: vasoactive medications for the management of acute variceal bleeds. Aliment Pharmacol Ther. 2012 Jun;35(11):1267-78.
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RECOMMENDED DOSE AND DURATION OF VASOACTIVE AGENTS IN
ACUTE VARICES BLEEDING TREATMENT

Garcia-Tsao G, et al. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology. 2017
Jan;65(1):310-335.
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LOWER GI BLEEDING

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