UPPER GASTROINTESTINAL BLEEDINGbySiti Nurdjanah Gastroenterology-Hepatology Division, Internal Medicine, Faculty of Medicine, University of Gadjah Mada, Dr. Sardjito Hospital, Yogyakarta

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* Melaena is the passage of black tarry stools

Causes of Haematemesis and MelaenaOesophagusOesophageal VaricesMallory-Weiss tearOesophageal carcinomaReflux oesophagitisForeign body

Causes of Haematemesis and MelaenaStomach Peptic ulcerErosions/ Gastritis Gastric varicesPortal hypertensive gastropathyGastric carcinomaLymphomaLeiomyomaAngiodysplasia (including Oslers disease)Dieulatorys erosion

Causes of Haematemesis and Melaena

Duodenum/jejunum Peptic ulcer Erosions/ Gastritis Vascular malformations Haemobilia Polyps (including Peutz-Jeghers syndrome and other polyposis syndromes) Aorto-enteric fistula

Causes of massaive upper gastrointestinal bleedingOesophageal or gastric varicesGastric ulcerDuodenal ulcerStress ulcerationDieulatorys erosionAorto-enteric fistula

Aetiology of Non-Variceal Upper Gastrointestinal BleedingOesophagusMallory-Weiss tear, Reflux Oesophagitis, Oesophageal Ulcer, Barrets ulcer, Cameron ulcer within hiatus hernia*, Oesophageal neoplasm* Important causes of obscure UGIBMallory

Aetiology of Non-Variceal Upper Gastrointestinal Bleeding* Important causes of obscure UGIBA gastric ulcer caused by H. pylori

Aetiology of Non-Variceal Upper Gastrointestinal BleedingA duodenal ulcer caused by H pyloriTwo angiodysplasias (arrows) in the duodenum

Aetiology of Non-Variceal Upper Gastrointestinal BleedingSmallbowlStomal ulcer, Diverticulum (including Meckels diverticulum), Vascular malformation, TumorTreatment of a bleeding diverticulum

Endoscopic stigmata associated with high risk of further gastrointestinal bleeding.Top left : an active, spurting haemorrhage froma peptic ulcer is associated with an 80% risk ofContinuing bleeding or rebleeding in shocked patients. Top right : a non-bleeding, visible vessel Represents either a pseudoaneurysm of an erodedartery 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

Klasifikasi V.E.Kl. DegradiKl. Palmer & BrickKl. OmedKl. Perhimpunan Endoskopi GI Jepang

Kl. Perhimpunan Endoskopi GI JepangWarna (colour)Tanda Warna merah (red colour sign)Bentuk (form)Lokalisasi

Warna Colour White (CW)Colour Blue (CB)

Tanda warna merah (red colour sign/RCS)Red Wale Marking (RMW) gambar 1Cherry Red Spot (CRS) gambar 2Hemato Cystic Spot (HCS) gambar 3Diffuse Redness (DR)

(RWM)Red Wale Marking)Gambar 1

(CRS)Cherry Red SpotGambar 2

(HCS)Hemato Cystic SpotGambar 3

(DR)Diffuse RednessGambar 4

BentukTingkat I : VE lurus (straight line varises/F1) gambar 5Tingkat 2 : VE bentuk untaian tasbeh menempati 1/3 lumen (F2) gambar 6Tingkat 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-kelokMenempati lebih dari 1/3 lumen (F3)

LokalisasiVE 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)

LggastricLiinferriorLmmiddleLssuperior

PENATALASANAAN AWAL

Anannesis & pemeriksaan fisisTanda vital, Jalan infus yg sangat besarSelang nasogastrik Hb, Ht, trombosit,hemostaisisPengobatan empirikCairan krostaloid, cairan koloid,Transfusi darah, koreksi faktor koagulasiObat VasoaktifOctreotide, Somat ostatin,VasopressinEmergensi atau DiniEndoskopi SCBAElektifEndoskopi SCBASkleroterapi Atau ligasiAtau SB tubeInjeksi, hemostatikAtau bedah segeraRadiologi, IntervensionalDiagnostik & terapeutikAtau bedah segeraPengobatandefinitifBedah RESUSITASIHemodinamik tidak stabilPerdarahan aktifHemodinamik stabilTidak ada perdarahan aktifHemodinamik stabilPerdarahan berhentiHemodinamik stabilPerdarahan tetap berlangsungPerdarahan berhentiSumber perdarahanTak tervisualisasiTukakVarises esophaguslambungJika gagal

Resuscitation Mild or Moderate Bleed* Pulse and blood pressure : N* Hb > 10 mg/ml* Without comorbidity* Less than 60 years of age

b. Severe BleedPulse > 100 beats/minSistolic blood pressure < 100 mmHgHb < 10 mg/mlAged > 60 years

Adapted from Grenvick A, Ayres SM, Holbrook PR, et al. Textbook of critical care. 4th edition. Philadelphia WB Saunders Company; 40-5

Minnesota tube

Endoscopic treatment of varices. Intravariceal injection of sclerosant (left) and band ligation of oesophageal varices (right)

Endoscopic Treatment For Non-variceal Upper Gastrointestinal BleedingThermal Heater probe multipolar electrocoagulation (BICAP, Gold Probe) Argon plasma coagulation Laserheter probeArgon_plasma_coagulationLaser application for bleeding ulcerHeater probe application for bleeding erosion

Endoscopic Treatment For Non-variceal Upper Gastrointestinal BleedingInjection Adrenaline (1:10000) Procoagulants (fibrin glue, human thrombin) Sclerosants (ethanolamine, 1% polidoconal) Alcohol (98%)Sclerotherapy of bleeding spotAdrenalineUlcer-active_bleeding

Endoscopic Treatment For Non-variceal Upper Gastrointestinal BleedingMechanical Clips Band Ligation Endoloops Staples SuturesMethods rarely used are depicted in italics.Banding of bleeding spotHemoclip application of bleeding erosion

ConclusionEarly upper gastrointestinal Endoscopy ( within 24 hours). Is the cornerstone of management of AUGBEarly Endoscopy has 3 major roles - Diagnosis - Treatment - Risk Stratification