PERDARAHAN SALURAN

CERNA BAGIAN ATAS DAN BAWAH

SRI SOETADI
 HEMATEMESIS

PSMBA MELENA : (50 ML BLOOD)

HEMATOCHEZIA
(TRANSIT TIME <<)

LIGAMENTUM TRAITZ

HEMATOCHEZIA

PSMBB

MELENA (TRANSIT TIME >>)

PSMBA DAN PSMBB

 80% BERHENTI SPONTAN

 INSIDENSI PSMBA : 100-150/100000 PDDK
(USA)
 INSIDENSI PSMBB : 20-25/100000 PDDK (USA)
 MORTALITAS : 10-15%
 PSMBA + 5 X LEBIH SERING DARI PSMBB
 LAKI- LAKI > DARI WANITA
 USIA TUA > USIA MUDA
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
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
CAUSES OF ACUTE UPPER GASTROINTESTINAL BLEEDING
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
THERAPEUTIC OPTIONS FOR ACUTE UPPER GASTROINTSTINAL
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
 MANAGEMENT APPROACH FOR ACUTE UPPER
GASTROINTESTINAL HEMORRHAGE
Patient stabilization (ABCs)
ACUTE MANAGEMENT Respiratory stabilization (intubation etc)
Intravenous access
Intravascular volume replacement
Transfusions (PRC, FFP, Platelets
Focused history and physical examination
Laboratory data
CBC with platelet count, Coagulation studies
(PT/aPTT)
Liver enzymes, Chemistries
Radiographic
Upright chest x-ray, Abdominal x-ray
Electrocardiogram
Localization of bleeding site
Surgery consulation
Gastroenterology consultation for upper panendoscopy

Treatment of recurrent bleeding

LONG-TERM Repeat diagnostic and therapeutic endoscopy
MANAGEMENT Angiography, Surgery
Preventive measures for peptic ulcer disease bleeding
Maintenance antisecretory therapy
Helicobakter pyloru eradication
Strict avoidance of ASA/NSAIDs
Misoprostol
Surgery
Preventive measures for variceal bleeding
 Blockers
Obliterative endoscopic therapy
Shunting
Liver transplatation
 HISTORICAL FEATURES IMPORTANT IN ASSESSING
THE ETIOLOGY OF GASTROINTESTINAL BLEEDING

 AGE
 PRIOR BLEEDING
 PREVIOUS GASTROINTESTINAL DISEASE
 PREVIOUS SURGERY
 UNDERLYING MEDICAL DISORDER (ESPECIALLY LIVER DISEASE )
 NONSTEROIDAL 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
CAUSES OF ACUTE UPPER GASTROINTESTINAL BLEEDING
COMMON CAUSES Gastric ulcer
Duodenal ulcer
Esophageal varices Mallory – Weiss tear
LESS FREQUENT CAUSES Dieulafoy’s lesions
Vascular ectasia
Portal hypertensive gastropahty Gastric antral
vascular ectasia (watermelon stomach) Gastric varices
Neoplasia Esophagitis
Gastric erosions
RARE CAUSES Esophageal ulcer
Erosive duodenitis
Aortoenteric fistula Hemobilia
Pancreatic source Cronh’s
disease No lesion indentified
CAUSES OF ACUTE LOWER GASTROINTESTINAL BLEEDING

COMMON CAUSES Diverticula

Vascular ectasia
UNCOMMON CAUSES Neoplasia (including
postpolypectomy) Inflammatory bowel disease
Colitis Ischemic
Radiation
Unspecified Hemorrhoids
Small bowel source Upper
gastrointestinal source No lesion identified
RARE CAUSES Dieulafoy’s lesions
Colonic Ulcerations
Rectal Varices
 DIFFERENTIAL DIAGNOSIS OF OCCULT
GASTROINTESTINAL BLEEDING
MASS LESIONS VASCULAR
Carcinoma (any site)* vascular ectasia (any site)* Large
(>1.5 cm) adenoma (any site) Portal hypertensive gastropathy /
colopathy
MASS LESIONS Watermelon stomach Erosive
esophagitis* Hemangioma Ulcer (any site)*
Dielafoy’s lesion ‡ Cameron lesions †
INFECTIOUS Erosive gastritis Hookworm
Celiac sprue Whipworm
Ulcerative colitis Stronglyoidiasis Crohn’s disease
Ascariasis Colitis (nonspecific) Tuberculous
enterocolitis Idiopathic cecal ulcer Amebiasis
MISCELLANEOUS SURREPTITIOUS
Long-distance running Hemoptysis Factitious
Oropharyngeal (including epistaxis
Pancreaticobiliary source
 CHARACTERISTICS OF FECAL OCCULT BLOOD TESTS1

Variable Guaiac Heme-Porphyrin Immunochemical

Detection characteristics Upper
gastrointestinal + ++++ 0 Small bowel +
+ ++++ + Right colonic +++ ++++
+++ Left colonic ++++ ++++ ++++
Test factors Bedside availability ++++
0 + Time to develop 1 minute 1 hour 5
minute to 24 hours Cost $ 3-5 $ 17 $ 10-20
False positives Animal hemoglobin ++
++ ++++ 0 Dietary peroxidases +++ 0
0 False negatives Hemogloblin
degredation ++ 0 ++ Storage ++
++++ ++ Vitamin C ++ 0 0
PENYEBAB TERBANYAK DARI PSMBA
DITINJAU DARI PENYAKIT

COMMON
 ESOPHAGEAL VARICES
 ESOPHAGOGASTRIC MUCOSAL TEAR
(MALLORY-WEISS SYNDROME)
 GASTRIC EROSIONS
 GASTRIC ULCER
 GASTRIC 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 (USSUALLY FROM AN
AORTIC ANEURYSM GRAFT)
RARE
 NASAL OR PHARYNGEAL BLEEDING
 HEMOPTYSIS
 ESOPHAGEAL RUPTURE (BOERHAAVE’S SYNDROMA)
 HEMOBILIA
PENYEBAB TERBANYAK DARI PSMBB
DITINJAU DARI PENYAKIT
RARE
COMMON
 HEMMORRHOIDS
 AMYLOIDOSIS
 PROCTITIS  VASCULAR-ENTERIC FISTULA
 IBD  ANTIBIOTIC-ASSOCIATED
 DIVERTICOLISIS COLITIS
 ISCHEMIC COLITIS
 ANGIODYPLASIA
 RECTAL OR COLONIC POLYPS
OCCASIONAL
 ANAL FISSURE
 INFECTIOUS ENTEROCOLITIS
 CARCINOMA OF THE COLON
 RADIATION COLITIS
 MECKEL’S DIVERTICULUM
 BRISK BLEEDING FROM AN UPPER
GASTROINTESTINAL SOURCE
PSMBB DITINJAU DARI SEGI LOKASI

DISEASE OF RECTUM AND COLON

 DIVERTICULAR DISEASE
 COLONIC ANGIODYSPLASIA
 COLITIS (ISCHAEMIA,INFECTIONS,IBD,RADIATION)
 COLONIC NEOPLASIA/POST-POLYPECTOMY
 ANORECTAL CAUSES (HAEMORRHOIDS,RECTAL VARICES)
DISEASE OF SMALL BOWEL
 VASCULAR ECTASIA
 TUMORS
 MECKEL’S DIVERTICULUM
DISEASE OF UPPER GASTROINTESTINAL TRACT
 PEPTIC ULCER DISEASE
 VARICES
 SIGMOIDOSCOPY
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
 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 ?
RIWAYAT 
 BAB BERDARAH & KONSTIPASI & ABDOMINAL PAIN 
DIVERTIKULITIS

 BAB BERDARAH & MENETES NETES / MENGALIR 

HAEMMOROID

 BAB BERDARAH (+) DAN DIARE KRONIK  IBD

 BAB BERDARAH (+) USIA LANJUT & BB  & DIARE

KRONIK  MALIGNANCY

 BAB BERDARAH (+) & POST RADIASI  KOLITIS

RADIASI
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
 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
REMOVAL OF BALLON SITE
TAMPONADE MASSIVE MODEST
BLEEDING DEFINITIVE
BLEEDING TREATMENT:
ESOPHAGEAL OR ENDOSCOPIC
GASTRIC VARICES REPEAT EGD OR (THERMAL
SURGERY ANGIOGRAPHY COAGULATION OR
INJECTION)OR
SCLEROTHERAPY PHARMACOLOGIC
NO LOCALIZATION LOCALIZATION
OF BLEEDING
SITE
WITH RECURRENT OR
PERSISTENT BLEEDING
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
Figure 3. Suggested diagnostic procedures in patients with
hematochezia (EGD=esophagogastroduodenoscopy)

HEMATOCHEZIA

HISTORY

ELECTIVE
SIGMOIDOSCOPY

LOCALIZATION OF NO LOCALIZATION
BLEEDING SITE

ELECTIVE EGD AND

COLONOSCOPY

ELECTIVE
TREATMENT
BLEEDING PERSISTENT
STOPS BLEEDING

FOLLOW - UP RADIOISOTOPIC
SCAN

IF POSITIVE
FOLLOW - UP ANGIOGRAPHY
PENANGANAN

RESUSITASI (UMUM)
 VASCULAR ACCESS
 INTRAVENOUS FLUIDS
 BLOOD LESTS
 TYPING & CROSS MATCHING
 CORRECT COAGULOPATHY
 BLOOD TRANSFUSION
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
 Tabel 2. 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
HAEMORRHOID

MEDIKAMENT :
SUPPOSITORIA (+/-) STEROID
DIIT TINGGI SERAT

ANOSCOPI TH/ :
INJ.SKLEROTH / LIGATION, CRYOSURGERI,
PHOTO COAGULATI, ELECTROCOAGULATI

SURGICAL HEMORRHOIDECTOMY
CA KOLOREKTAL
 OPERATIF
POLIP KOLON
POLIPEKTOMI
DIVERTIKEL KOLON
MEDIKAMEN, INJEKSI EPINEPHRIN, ANALGESIC
OPERATIF  KOLEKTOMI
IBD
MEDIKAMEN :
 OPERATIF
TERIMA KASIH