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7/18/2019 Pendarahan7df5db5f27
http://slidepdf.com/reader/full/pendarahan7df5db5f27 1/19
Perdarahan saluran cerna
bagian atas
Dr. Rudy Dwi
Laksono
7/18/2019 Pendarahan7df5db5f27
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PERDARAHAN SALURAN CERNA BAGIAN ATAS
common problem & world wide / cosmopoli!n
Emer"enc# / d!r$r!
%orbidi!s / mor!li!s
Insidensi ' USA ()*/(**+*** pop$l!si & (*+*** ,
-*+*** .em!i!n / !$n+
%or!li!s )0(- 1 m!n$l!
c!rdio2!s.$l!r / CH3
emodin!mi. ins!bili# C4PD
7/18/2019 Pendarahan7df5db5f27
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5l!si6i.!si !.i6i!s perd!r!!n men$r$ 3orres
A.i6i!s perd!r!!n 5rieri! endos.opi.
3orres I! , Perd!r!!n !.i6
men#emb$r 7sp$rin"8
3orres Ib , Perd!r!!n !.i6
3orres II , Perd!r!!n bereni9
e!pi m!si diser!i
.el!in!n #!n" n#!!
3orres III , Perd!r!!n bereni9!np! men$n:$..!n
sis!
perd!r!!n !reri
perd!r!!n merembes
7oo;in"8
"$mp!l!n d!r! p!d!
d!s!r $.!.
<2isible 2essel=
lesi !np! !nd! sis!perd!r!!n
7/18/2019 Pendarahan7df5db5f27
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ETI4L4GI
TD / TL
Erosi l!mb$n"
5!n.er l!mb$n"
>!rises eso6!"$s
Eso6!"iis9 .!n.er eso6!"$s
D$odeniis
%!llor#0?eiss s#ndrome
7/18/2019 Pendarahan7df5db5f27
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PSCA @* 1 bereni spon!n9 -* 1 rebleedin"
0 %elen! * cc d!r!
0 D!r$r! penin" s!$s emodin!mi.
0 si"ni6ic!n !emorr!"e s#mpoms s#ncope9 p$c!9
!.i.!rdi9 T> 9 ipoensi pos$r!l+
0 T!nd!- s#o. / perd!r!!n )* 1 blood 2ol$me TD
sisol (** mmH"9 !.i.!rdi9 peri6er din"in9 Hb (* "r19
H*1 rend!.!n .ep!l! / rendelenb$r"
I>3D cor RL / N!Cl / Aserin"
sirosis !i 6res 6ro;en pl!sm!F rombosi
$remi. F !spirin rombosi
emo6ili / 2on willibr!nd spesi6i.
7/18/2019 Pendarahan7df5db5f27
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Res$si!si pd PSCA m!si6
P!s!n" in6$s / I>3D
Pem+ D!r!
Cross %!c
5ore.si .o!"$lop!i :i.! perl$
Tr!ns6$si d!r! :i.! perl$
7/18/2019 Pendarahan7df5db5f27
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DIAGN4SIS
(+ An!mnese
Ideni6# pre0eisin" morbid condiion
riw!#! P is.emi. / CH3 / !rimi! :"9 C4PD9 GG59HT9 D%
riw!#! m$n!- eb! %!llor# , weiss s#nd+
SH >!rices bleedin" & non 2!rices 7* 18
NSAID
Sress $lcer diseb!b.!n perd!r!!n $lser!si
sress !.$ / pre0eisin" pepic$lcer dise!se / .ondisi p!olo"il!in #" ber$b d"n PSCA
serin" ber$b d"n l$.! b!.!r9
r!$m! m!#or9 r!$m! .!piis9m$li or"!n 6!il$re+
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-+ Pem+ 6isi.
Penil!i!n s!$s emodin!mi. & res$si!si
T!nd!- li2er si"m!! & HT por!l
!$ndice
Bleedin" di!esis p$rp$r!9 e.imosis9 pi.i!e
+ Endos.opi
H!r$s peri.s! E5G P59 !rimi! J
Psn "!"!l n!6!s / .om! beb!s.!n :!l!n n!6!s+
Bil! endos.opi bel$m dp s$mber PSCA !n"io"r!6i
!!$ l!belled red cell r!dion$clide sc!n
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TERAPI
I. ULKUS PEPTIC
(+ 3!rm!.olo"i ARH-9 PPI9-+ Endoscopic er!p# l!ser
ele.ro.o!"$l!si
e!er probe
opic!l spr!#s
in:ecion er!p# 7!dren!lin((*+***9 !l.ool & polido.!nol 8
+ R!diolo"ic er!p# embolis!si dii.$i .!eeris!si+ Prop#l!cic er!p# ' er!di.!si HP pd TD & TL
' empiric er!p# :i.! HP d.dier!di.!si+
' An!lo" PG 7misoprosol8
$.
NSAID F TL' S$r"er# $. rec$rren bleedin"
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PERDARAHAN SALURAN CERNA BAGIAN ATAS
HE%ATE%ESIS / %ELENA
DENGAN GANGGUAN HE%4DINA%I5 TANPA GANGGUAN
HE%4DINA%I5 S#o. 7b!rin" )*19 d$d$. *18
A!si ipo2olemi In6$s / r!ns6$si ses$!i
0 N!Cl9 RL9 Pl!sm! ep!nder .eb$$!n
0 Tr!ns6$si d!r! bi!s! / PRC Sl!n" N!so"!sri.
Sl!n" N!so"!sri. Bil!s !ir es
0 Bil!s den"!n !ir es s!mp!i :erni 4b! emos!i.
4b! emos!i. %onior Hb/H9 ensi9 n!di9
%onior Hb/H9 ensi9 n!di9 .es!d!r!n .es!d!r!n
An!mnese & Pemeri.s!!n 3isi. An!mnese & Pemeri.s!!n 3isi.
Perd!r!!n er$s Perd!r!!n sop
G ! s r o s . o p i
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G!sros.opi
Den"!n 2!rises T!np! 2!rises
0 S.leroer!pi d!r$r!
0 Sl!n" S0B F G!sriis erosi6
0 Piressin I> -* U F -** ml Derose )1 Ul.$s Pepi.$m
diberi.!n -* meni %!llor# ?eiss
0 Ter!pi .onser2!i6 dier$s.!n T$mor
7!n!sid9 pen"!mb! H-9 emos!i.9 l!.$lose9 neomisin8 5onser2!i6
7!n!sid9 pen"!mb! H-9PPI
emos!i.8
Perd!r!!n er$s Perd!r!!n sop
4per!si 5onser2!i6
7/18/2019 Pendarahan7df5db5f27
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Endoscopic er!p# o6 $pper GI bleedin"
T4PICAL THERAPK
-Tiss$e !desi2es
-Cloin" 6!cors
-Coll!"en
-3errom!"neic !mpon!de
%ECHANICAL THERAPK
-Sn!res
-S$$res
-B!lloons
-Hemoclips
INECTI4N THERAPK
->!rice!l bleedin"
-Non 2!rice!l bleedin"
0 E!nol
0 4er scleros!ns
THER%AL THERAPK
-Elecroco!"$l!ion
0 monopolo!r
0 elecro#droerm!l
bipol!r 7m$lipol!r8
-He!er probe
-L!ser
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3i"$re ( + %!n!"emen o6 bleedin" pepic $lcer
Pepic $lcer
Low ris. o6 rebleedin" Aci2e bleedin" or i" ris. o6rebleedin" 7soc.9 2isible
2essel8
% o n i o r Endoscopic er!p#
No 6$rer bleedin" Rebleed Un!ble o conrol bleedin"
Repe! endoscop# er!p#
Rebleed
S$r"er#
* n * n
Embolis!sion er!p#
Rebleed
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II. VARISCES ESOPHAGUS LEE!I"G
(+ Endos.opi S.leroer!pi & Li"!si
-+ 3!rm!.olo"i ' :i.! endos.opi d. dp di.er:!.!n+
' >!sopressin F niro"liserin
+ B!lloon T!mpon!de Sen"s!.en , Bl!.emore9
Linon $be+
+ TIPS 7 Tr!ns:$"$l!r Inr!ep!ic Poro0s#semic
Sen S$n 8
)+ Pro6il!.sis prop!nolol me
e.+ >+ por! pd SH
7/18/2019 Pendarahan7df5db5f27
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>!rice!l Bleedin"
Tempor!r# %e!s$res
B!llon !mpon!de
>!soconsricors
In:ecion Scleroer!p#/>!rice!l li"!ion
H!emos!is !cie2ed Conin$ed bleedin"
Repe! ! 0 wee.s$p o )0 session
Repe! in:ecion scleroer!p# /2!rice!l li"!ion
Conin$ed bleedin"
TIPS / S$r"er#
3i"$re -+ Scem! 6or e m!n!"emen o6 bleedin" oesop!"e!l >!rices
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3i"$re + %!n!"emen o6 non bleedin" 2!rices
>!rices presen b$ no bleedin"
B!nd li"!ion
Rebleedin" No 6$rer bleedin"
Repe! b!nd li"!ion 7or scleroer!p#8
3$rer bleedin" No 6$rer bleedin" Repe! wiin ( wee.
Consider
0 Tr!nsc$!neo$s inr!ep!ic poros#semic s$n
0 S$n s$r"er# / li2er r!nspl!n!ion
0 widr!w!l o6 er!p#
Repe! e2er# 0wee.s $nil 2!rices
!re oblier!ed
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5ESI%PULAN
Pen#eb!b $!m! perd!r!!n diseb!b.!n !cid rel!ed
dise!se 7erosi2!9 TD/TL9 NSAID9 "!srop!i pd $si!
l!n:$+
Di Indonesi! 2!rises bleedin" mor!li!s &
insidensin#! in""i +
Ter!pi iner2ensi "!sroinesin!l endos.opi sem!.in
l$!s di"$n!.!n 7 li"!si9 s.lero!r!pi9 clips9 e!er
probe9 l!ser dll 8
I i i
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In#estigati$n In#estigati$n
•May show angiodysplastic lesions even once bleeding
has ceased
•Most patients are stable and can be investigated once bleeding has
stopped
•In the actively bleeding patient consider
•Colonoscopy - can be difficult
•Selective mesenteric angiography•Requires continued bleeding of > ml!minute
%
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%anage&ent %anage&ent
•If source of colonic bleeding unclear perform a subtotal
colectomy and end-ileostomy
•"cute bleeding tends to be self limiting
•Consider selective mesenteric embolisation if life threatening
haemorrhage•If bleeding persists perform endoscopy to e#clude upper $I cause
•%roceed to laparotomy and consider on-table lavage an panendoscop
•If right-sided angiodysplasia perform a right hemicolectomy
•If bleeding diverticular disease perform a sigmoid colectomy