Dr. Sapto Priatmo, Sp.PD SMF Penyakit Dalam RS BETHESDA STRESS ULCER

Definition of Stress Ulcers Adanya lesi/ perlukaan pada mukosa gaster yang bersifat akut dan disebabkan oleh iskemik pada mukosa gaster

Stress Ulcers Ulserasi Gastrointestinal bagian atas lambung Duodenum Perdarahan makroskopis ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis, AJHP 1999;56(4) 347-379

Epidemiologi Stress ulcer masih sering didapatkan pada pasien ICU (>30% of ICU patients) Pasien < 5% pasien ICU dg perdarahan makroskopik ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis, AJHP 1999;56(4) 347-379 Del Valle, J. Chapter 287 - Peptic Ulcer Disease and Related Disorders , Harrison's Principles of Internal Medicine - 17th Ed. (2008).

Pathophysiologi Stress Ulcers Etiologi complek Berkurangnya pH Gastric Iskemik Produksi mukus gaster berkurang Biasanya terjadi 24 – 48 jam setelah taruma/stres Del Valle, J. Chapter 287 - Peptic Ulcer Disease and Related Disorders , Harrison's Principles of Internal Medicine - 17th Ed. (2008).

FAKTOR RISIKO STRESS ULCER Gagal nafas dan memerlukan ventilator Syok Sepsis berat Gangguan pembukuan darah (DIC) Trauma kepala berat Luka bakar yang luas Gagal multi organ

Morbiditas/Mortalitas Mortalitas pasien : 48.5% dg perdarahan yg bermakn 9.1% tanpa perdarahan yg bermakna Cook DJ, et al. Risk factors for gastrointestinal bleeding in critically ill patients. NEJM 1994;330(6):377-81

Penatalaksanaan awal perdarahan lambung Pengobatan perdarahan ulkus peptikum bertujuan untuk menstabilkan sirkulasi, menghentikan perdarahan yang sedang terjadi dan mencegah perdarahan ulang. Adapun pengobatannya termasuk: Penggantian cairan (tranfusi darah bila diperlukan) Endoskopi dengan endoscopic haemostasis bila dibutuhkan Tindakan bedah, bila perdarahan tidak bisa dikontrol dengan metode diatas Initial management of peptic ulcer bleeding In the initial management of peptic ulcer bleeding, the aims are to stabilize the circulation, stop ongoing bleeding and prevent re-bleeding. Treatment therefore includes: fluid replacement (with blood transfusion if needed) prompt endoscopy, with endoscopic haemostasis treatment if necessary surgery, if bleeding cannot be controlled by the above measures.1 1. Leontiadis GI, et al. Health Technol Assess 2007;11:1–164. Leontiadis GI, et al. Health Technol Assess 2007;11:1–164

Asam lambung menghambat hemostasis pada perdarahan ulkus peptikum Gastric acid inhibits haemostasis in bleeding peptic ulcers The cessation of bleeding from a peptic ulcer is inhibited by gastric acid, which interferes with clot formation, promotes clot lysis and causes on-going tissue damage.1 1. Leontiadis GI, et al. Cochrane Database Syst Rev 2006 Jan 25;(1):CD002094.

pH > 6 diperlukan untuk kestabilan agregasi platelet 20 ADP pH=6,0 Disagregasi=77% 40 60 Buffer pH=6,4 Disagregasi =16% A pH>6 is needed to maintain platelet aggregation The first step in repairing the breach of a blood vessel in the upper GI tract is the development of a platelet plug. These early platelet plugs can achieve initial haemostasis for several hours but will then disintegrate unless they are reinforced by a fibrin clot.1 In vitro data indicate that acid plays an important role in impairing haemostasis and causing clot digestion. In the in vitro experiment shown in this slide, platelet aggregation was promoted by the addition of adenosine diphosphate, followed by the subsequent application of a buffer solution or dilutions of hydrochloric acid. It shows that, at pH 6, there was disaggregation of 77% of previously aggregated platelets. This effect could be overcome by elevating the pH above 6.2 Highly effective acid suppression to elevate the intragastric pH should therefore aid clot formation in upper GI bleeding. 1. Berger S. Can Med Assoc J 1970;102:1271–4. 2. Green FW, et al. Gastroenterology 1978;74:38–43. Slide reprinted from Green FW, et al. Gastroenterology 1978;74:38–43, with permission from Elsevier, Inc. 80 pH=7,3 Disagregasi =0% 100 1 2 3 4 5 Waktu (menit) ADP, adenosine diphosphate Green FW, et al. Gastroenterology 1978;74:38–43

Antagonis reseptor H2 tidak dapat meningkatkan pH sampai 6 “Tidak ada data pendukung mengenai penggunaan antagonis reseptor H2 (pada perdarahan non variseal), dan obat ini tidak dapat meningkatkan pH > 6 secara konsisten.” Non-variceal upper gastrointestinal haemorrhage: guidelines British Society of Gastroenterology H2-receptor antagonists do not reliably increase gastric pH to 6 The inability of the H2-receptor antagonists to provide an adequate level of pH control for the management of peptic ulcer bleeding is highlighted in the British Society of Gastroenterology guidelines on the management of non-variceal upper gastrointestinal haemorrhage. These state that: “There are no convincing data to support the use of H2-receptor antagonists [in non-variceal bleeding], and these drugs do not reliably or consistently increase gastric pH to 6.” 1. British Society of Gastroenterology Endoscopy Committee. Gut 2002;51(Suppl IV):iv1–iv6. Palmer KR, et al. Gut 2002;51(Suppl IV):iv1–iv6

Guidelines merekomendasikan pemberian PPI iv dosis tinggi untuk pengobatan perdarahan ulkus peptikum “PPI iv bolus dilanjutkan dengan PPI infus efektif dalam menurunkan perdarahan ulang pada pasien yang sudah menjalani terapi endoskopi” Evidence-based management guidelines developed by the multidisciplinary Non-variceal Upper GI Bleeding Consensus Conference Group Guidelines recommend high-dose i.v. PPI therapy for the treatment of bleeding peptic ulcers but no PPI currently has the indication Clinical guidelines on the management of patients with non-variceal upper GI bleeding have been developed by the multidisciplinary Non-variceal Upper GI Bleeding Consensus Conference Group, representing 11 national societies.1 In recognition of the proven benefit of PPIs in preventing persistent or recurrent bleeding of peptic ulcers, they recommend that: “An intravenous bolus followed by continuous infusion proton pump inhibitor is effective in decreasing re-bleeding in patients who have undergone successful endoscopic therapy.” The guidelines also state that H2-receptor antagonists are not recommended for the management of acute upper GI bleeding.1 Based on these guidelines and the available data, i.v. PPIs are widely used off-label for the management of bleeding peptic ulcers, although no PPI currently has the indication. New guidelines on the management of peptic ulcer bleeding are currently being developed, based on a consensus meeting, and should be published during 2009. 1. Barkun A, et al. Ann Intern Med 2003;139:843–57. Barkun AN, et al. Ann Intern Med. 2010;152:101-113.

Guidelines merekomendasikan pemberian PPI oral setelah pemberian sediaan PPI iv Setelah keluar dari rumah sakit, pasien harus diberi PPI oral 1 kali sehari dengan durasi sesuai dengan penyakit penyebabnya Evidence-based management guidelines developed by the multidisciplinary Non-variceal Upper GI Bleeding Consensus Conference Group Guidelines recommend high-dose i.v. PPI therapy for the treatment of bleeding peptic ulcers but no PPI currently has the indication Clinical guidelines on the management of patients with non-variceal upper GI bleeding have been developed by the multidisciplinary Non-variceal Upper GI Bleeding Consensus Conference Group, representing 11 national societies.1 In recognition of the proven benefit of PPIs in preventing persistent or recurrent bleeding of peptic ulcers, they recommend that: “An intravenous bolus followed by continuous infusion proton pump inhibitor is effective in decreasing re-bleeding in patients who have undergone successful endoscopic therapy.” The guidelines also state that H2-receptor antagonists are not recommended for the management of acute upper GI bleeding.1 Based on these guidelines and the available data, i.v. PPIs are widely used off-label for the management of bleeding peptic ulcers, although no PPI currently has the indication. New guidelines on the management of peptic ulcer bleeding are currently being developed, based on a consensus meeting, and should be published during 2009. 1. Barkun A, et al. Ann Intern Med 2003;139:843–57. Barkun AN, et al. Ann Intern Med. 2010;152:101-113.

PENATALAKSANAAN Pasang infus dg cairan kristaloid untuk mempertahankan hemodinamik Bila diperlukan dapat diberi cairan koloid Pasang NGT dan spool air es atau NaCl Puasakan dan segera diberi diit cair setelah NGT jernih Transfusi darah dengan PRC atau WB bila perdarahan banyak Beri PPI (omeprazol, pantantoprazol) iv Sucralfat

PENCEGAHAN Profilaksi dengan PPI, H2RA dan sukralfat pada pasien sakit kritis dapat menurunkan insidensi Stress nulcer 50% Direkomendasikan pemberian profilaksis pada semua pasien dg sakit kritis

Perdarahan saluran cerna Syok Pneumonia Kematian KOMPLIKASI Perdarahan saluran cerna Syok Pneumonia Kematian

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