HEMATEMESIS-MELENA ARNELIS Subdivisi Gastroenterohepatologi Ilmu Penyakit Dalam FK UNAND / RS M Jamil Padang

Defenisi : Perdarahan dari saluran cerna, mulai dari esofagus sampai dengan duodenum (Lig Treitz) - Hematemesis : Muntah darah - Melena : Bab yang lembek dengan warna hitam pekat seperti ter (aspal)

Penyebab / sumber perdarahan : Perdarahan SCBA Varises – Varises esofagus – Varises fundus Non varises – Esofagitis – Tukak peptik – Stress ulcer – Mallory-Weiss tear – Duodenitis / esofagitis – Tumor / Carcinoma – Telengectasia herediter – Hemostatic defect – Angiodisplasia – dll

PATOGENESIS Varises esofagus / gastropati kongestif - hipertensi portal NSAID - efek topikal langsung - jalur hambatan prostaglandin Tukak peptik - Hp - aspirin / NSAID - hipersekresi asam lambung - iskemia mukosa

Mallory Weiss - laserasi mukosa esofagogastric junction - ok muntah-muntah Esofagitis - refluk

Gambaran Klinis

Sinkop : takikardia, kepala pusing, melayang Syok : - tekanan darah turun (sistolik < 100 mmHg) nadi cepat (> 100x/ mnt) - muka (kulit, mukosa) pucat - acral dingin

Postural Signs : Prinsip : Kehilangan darah = kehilangan volume intravaskuler : – Kardiak output & tekanan darah menurun – Nadi menjadi cepat – Perdarahan > 1000 cc kompensasi postural tekanan darah dan nadi tidak cukup Cara : Pasien tidur terlentang (ukur tensi & nadi) dudukkan (ukur tensi & nadi) – Jika nadi meningkat > 20 / mnt atau TDS turun > 10 mmHg Kehilangan darah sekitar 20 % (1 Ltr)

PERDARAHAN BERMAKNA Kebutuhan tranfusi 2 unit atau lebih dalam 24 jam sejak MRS Tekanan sistolik < 100 mmHg Penurunan tekanan darah > 20 mmHg dengan perubahan posisi Nadi > 100 x/menit saat MRS

DIAGNOSIS Anamnesis : aspirin / NSAID riwayat tukak peptik obat tradisional penghilang nyeri Pemeriksaan fisik : RT stigmata peny hati kronis diatesis hemoragik NGT Laboratorium Ba meal Endoskopi

Karsinoma esofagus

Perdarahan varises

Acute peptic ulcer Ulcer Epithelial lesions extending through the muscularis mucosae into the submucosa, are defined as ulcers. This ulcer takes the form of a deep mucosal lesion surrounded by a smooth mound, located at the angularis. Reproduced with permission. Freytag et al., Atlas of gastrointestinal endoscopy. www.home.t-online.de/home/afreytag/indexe.htm

Bleeding gastric ulcer Endoscopic investigation of a 71-year-old man with haematemesis revealed a 2 cm ulcer with pulsatile, arterial bleeding. Control of bleeding was achieved by injecting the vessel with epinephrine, followed by bipolar electrocautery. Reproduced with permission. Martin & Lyons, The Atlas of Gastrointestinal Endoscopy. www.mindspring.com/~atlsouthgastro/stul01.html

Duodenal ulcer This view shows a longish duodenal ulcer at the ventral wall of the bulb with regular, rounded edges above and an ulcer base below the normal mucosal surface. The ulcer base is flat and partly covered by fibrin. Reproduced with permission. Freytag et al., Atlas of gastrointestinal endoscopy. www.home.t-online.de/home/afreytag/indexe.htm

Bleeding duodenal ulcer In this duodenal ulcer at the left edge of the figure, there is an oozing, active bleeding. According to the Forrest classification of gastrointestinal haemorrhage of the upper GI tract, this bleeding is graded as Forrest Ib. Reproduced with permission. Freytag et al., Atlas of gastrointestinal endoscopy. www.home.t-online.de/home/afreytag/indexe.htm

NSAID-induced gastropathy Morbidity, mortality, costs in USA Singh. Am J Med. 105:31S–38S, 1998. Total hospitalizations per year – 107,000 Deaths – 16,500 Total annual costs ($10,000 – $15,000 per hospitalization) – >$1 billion

NSAIDs administration

? Virulence Host Environment

PENATALAKSANAAN UMUM Penilaian hemodinamik + resusitasi cairan Penilaian onset dan derajat perdarahan Usaha menghentikan perdarahan Identifikasi sumber perdarahan Mengatasi sumber perdarahan secara defenitif Meminimalisasi komplikasi Mencegah perdarahan ulang

PENATALAKSANAAN Perdarahan SCBA non varises Penatalaksanaan medis - non farmakologis - farmakologis H2RA / PPI, obat hemostatik sitoprotektor, antibiotika - penatalaksanaan khusus terapi hemostatik perendoskopik somatostatin jangka pendek embolisasi arteri daerah ulkus Penatalaksanaan bedah / operasi

Penatalaksanaan perdarahan tukak peptik berdarah Risiko perdarahan rendah Perdarahan aktif / risiko tinggi Perdarahan (syok/visible vessel) Terapi endoskopi Monitor Perdarahan ulang Tidak dapat mengontrol perdarahan Perdarahan berhenti Ulang terapi endoskopi Operasi / bedah Perdarahan ulang

PENATALAKSANAN Perdarahan SCBA oleh varises Penatalaksanaan umum Vasoaktif (vasopresin, somatostatin, octreotide) Antibiotika Pengobatan komplikasi Pengobatan defenitif : SB tube, STE, LVE, TIPS, Profilaksis sekunder : beta bloker, ISMN

Sengstaken-Blakemore tube

SENGSTEKEN BLACKMORE TUBE ( SB TUBE ) 2 1 SENGSTEKEN BLACKMORE TUBE ( SB TUBE ) 2 NG TUBE 3 BALON ESOFAGUS BALON LAMBUNG